Every finding on record at Landmark of Cicero Rehabilitation and Nursing Cent

Based on observation, interview, and record review, the facility failed to ensure water temperatures for staff and visitors were at safe temperatures, failed to ensure dryer lint traps were clean to provide a safe environment for the residents and staff, and failed to provide clean homelike environment in the dining room and two community shower rooms on the fourth floor. These failures have the potential to affect all 238 residents residing at the facility and an indeterminate number of staff and visitors.Findings include: Facility census (7/13/2026) documents 238 residents reside in the facility. 1. On 7/13/26 at 10:25AM, the fourth-floor dining room was observed with V16(Scheduler/Transport Staff). V16 stated, I'm the Guardian Angel here watching residents in the dining room. The following were observed with V16: The dining room floor had visible accumulated dirt/dust on the floor closer to the wall all around the whole front area of the dining room. V16 stated that she(V16) would notify the housekeeper. There was peeling paint on the walls and the door of the dining room. 2.On 7/13/26 at 10:40AM during observation on the fourth floor with V38(CNAs/Certified Nurse Assistant), the following were observed: The east side community shower room was observed with accumulated dust on the ceiling vent return, and a shower rod was found on the floor. The west side community shower room had rusted pipes close to the ceiling, and some of the ceiling tiles were falling off; there was brownish black visible dirt on the floor of the first shower stall, which V36(Floor Technician) stated was from the backflow from the drain that happened earlier in the morning. V36 stated 'I told them to rod it out'. V37(Housekeeper) stated, This morning, the drain came up and was all over; we cleaned it, but maybe it backed up again. I will do it now. One toilet commode was observed to be covered in black plastic, and V37 stated the toilet water was backing up from the toilet, and it is not available for use. V36 stated that Maintenance is aware, and they said they would fix everything. 3. On 7/13/2026 at 11:50 AM, V31 (Laundry Aide) and surveyor observed the three clothes dryers. V31 stated the dryer lint traps are cleaned every two hours. V31 stated, It is important because we don't want lint to accumulate and cause a fire. V31 stated the lint traps for all three dryers were last cleaned about an hour ago. Dryer number 1 (farthest from the laundry room entrance) had a lint trap ripped across the entire top edge of the trap. V31 stated, It is not supposed to be ripped, but it has been like that for a while. Lint was visible at the base and on the sides of the lint trap. Dryer number two and dryer number three had lint on the trap and balls of lint on the floor/base on the dryer lint trap area. V31 stated lint places the facility at risk of fire. On 7/13/2026 at 12:10 PM V28 (Central Supply Manager/Covering Housekeeping Manager) observed the lint traps for dryers one, two and three. V28 stated the first dryer's lint trap has a rip across the entire top of it. V28 stated lint traps are not effective if they are ripped. V28 and surveyor observed lint on the floor in front of the dryers and in dryer one, dryer two, and dryer three lint trap areas. V28 stated lint should not be visible in or around the dryers. Lint can cause a fire. On 7/15/2026 at 11:02 AM, V4 (Assistant Director of Nursing/Infection Preventionist) stated V4 was not aware of issues with the laundry dryers. V4 and surveyor observed dryer number one where the lint trap was observed to be unsecured on the right side and hanging down with lint on the bottom and side of the lint trap and behind the lint trap. V4 stated, That can cause a fire. On 7/15/2026 at 11:32 AM, V5 (Maintenance Director) observed dryer number one lint trap with V4 (Infection Preventionist), V31 (Laundry Aide) and surveyor. V5 observed the lint trap and stated, That should be secured. Otherwise, the lint can get behind the lint trap. V5 stated, I can fix that by securing the lint trap on the left side. V5 stated the risk of the lint trap as observed is that it can create a fire. On 7/15/2026 at 1:06 PM V31 (Laundry Aide) stated, They are in there fixing that dryer lint trap now. Facility policy titled Guidelines for Linen Handling/Storage/Transport dated 8/17/2023 stated dryer lint removal should take place every laundry shift. 3. On 7/14/2026 at 11:10 AM, surveyor washed hands in the handwashing sink in the kitchen. The hot water was painful to the touch and observed hands begin to turn pink. V6 (Dietary Manager) obtained a thermometer and confirmed the thermometer had been calibrated. V6 placed the thermometer probe into the water and obtained a temperature reading of 127.7 degrees F. V6 affirmed water temperature was too hot for staff to wash their hands. On 7/14/2026 at 11:58 AM, V5 (Maintenance Manager) turned on the hot water to the first-floor bathroom outside of the conference room near the administrative offices. V5 placed the thermometer probe into the water and obtained a temperature reading of 121 degrees F. V5 explained the first-floor kitchen, staff administrative areas, bathrooms, and laundry rooms were on the same water loop and the resident shower rooms/areas were on another water heater. V5 affirmed staff and visitors use the sinks that are serviced by the first-floor water heaters. 4. On 7/14/2026 at 12:19 PM, observed the east side shower room on the 8th floor with V5. One shower was missing a handle and was unable to be used, one shower had a missing shower head. Only one shower was functioning out of three total available showers. V5 affirmed the showers were in disrepair and needed to obtain supplies (showerhead, new handle, etc.) to fix the shower. Review of V12 (Housekeeping Supervisor) job description titled Director of Housekeeping job description with no effective date stated under the direction of V1 (Administrator), the Director of Housekeeping is responsible for the daily operations of the housekeeping department including staffing, supply ordering and supervision. Supervised staff and assists with all aspects of cleaning and maintaining the facility interior and grounds, ensures resident rooms are safe, comfortable and maintained in an attractive manner. Facility's policy titled General Cleaning Policies and Procedures subtitled Tubs and Showers states: To maintain a clean and attractive environment which reduces the likelihood of cross contamination and enhances the image of the facility. Clean the Tubs and Showers: Apply cleaner to the interior surfaces of the fixture including the curtain or door tracks, doors, doors, walls, soap dish, faucets and shower head; allowing the proper contact time. Facility's Policy titled Maintenance Department dated 05/01/17 states: To assure proper maintenance of the physical plant. #iii C states: Leaks and areas of moisture should be fixed promptly, and drywall, ceiling tiles and other materials should be replaced, using guidelines as above. Facility policy titled Maintenance Department (undated) documents the maintenance department is responsible for maintaining the facility's ventilation systems and temperature control.

Based on observation, interview, and record review, the facility failed to implement its abuse prevention policy by: 1) failing to immediately protect R16 and all other residents after an allegation of staff-to-resident physical abuse was presented to facility administration; 2) failing to establish coordination between the facility's Quality Assurance and Performance Improvement (QAPI) program and the facility's abuse prevention program by tracking data of potential indicators of abuse; and 3) failing to develop plans of care for identified offenders that included recommendations made by the state police. These failures affect 3 residents (R16, R37, R63) in a sample of 68 residents. These failures have the potential to affect all 238 residents that reside in the facility and place all residents at risk for abuse. Findings include: Facility census (7/13/2026) documents 238 residents reside in the facility. 1) R16's face sheet documents R16 is a [AGE] year-old resident with diagnoses including chronic obstructive pulmonary disease, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, asthma, cannabis use, and suicidal ideations. R16's Minimum Data Set (4/28/2026) documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R16 is cognitively intact. R16's care plan (6/27/2026) documents R16 has have factors that may increase R16's susceptibility to abuse/neglect. R16 demonstrates: Behavior that might be characterized as provoking, antagonizing, disrespectful, angry, insensitive, &/or annoying., Current or H/O Conflict between/with roommate(s), Delusions/Hallucinations, Diagnosis of Mental Illness I am observed/monitored to mitigate potential risk towards becoming a recipient or perpetrator of abuse/neglect or further trauma. Additionally, R16's care plan (6/17/2026) documents R16 frequently threatens to call the state survey agency, ombudsman, police, and attempting to justify offensive behaviors and interventions include assure me that staff are more than willing to address legitimate concerns and involving state survey officials, the police or the EMS will likely only result in more frustration and negative consequences for him/her personality (i.e., a monetary fine for abuse of the EMS) (6/12/2026). On 7/14/2026 at 1:15 PM, the resident council voiced concerns the security staff do not treat the residents with dignity and respect. The council expressed security staff often bark/yell at residents, demand for them to do things, and handle residents roughly, often hitting residents/using corporal punishment. The council understands the residents can be irate or physically aggressive with staff based on their mental illness but does not excuse the staff's behavior for hitting residents or yelling at residents. On 7/16/2026 at 10:31 AM, V89 (Security Guard) was sitting in a chair facing the west hallway. R16 was pacing in the east hallway and appeared in distress. R16 stated V89 had been threatening R16 to make R16 stay in his room. R16 recalled on 7/7/2026 in the afternoon, They moved me and put me on 1:1 (monitoring) for no reason. I was mad. I tried to leave my room and (V89) told me to get the f*** back into my room. (V89) kept coming at me and he choked me. I got him off and (V89) kept talking s***. Then, (V89) was hitting me, threating me that (V89) was gonna (sic) hit me with the fan in my room. (V89) continued to bully me since then. Man, I'm afraid. That's why I called the cops because (V89) choked me. I felt suicidal because I felt so unsafe. I been telling everyone they all know. I have schizophrenia so no one will believe me that it happened. I feel like I have to defend myself from him, like (V89) might try to do it again. (V89) is working on this unit now. On 7/16/2026 at 10:37 AM, V1 (Administrator) affirmed V1 was already aware of an allegation. V1 explained V1 was aware R16 was suicidal and was sent to the hospital for suicidal ideation. V1 was alerted by V91 (Case Manager, Registered Nurse) of an allegation, but V91 told V1 R16 said nothing happened. V1 stated V91 could be contacted for more information. When R16 came back from the emergency department visit, V1 recalled asking R16 if R16 had any problems with any staff members. R16 denied any issues and was more concerns about cigarettes, so V1 laid the issue to rest. On 7/16/2026 at 10:49 AM, V89 was on R16's floor. V89 denied the incident occurred and stated R16 frequently makes allegations up when things don't go R16's way. R16 will call police to get him out of situations. V89 denied V89 was suspended pending investigation or that an investigation occurred. V89 affirmed V89 has worked multiple days since the incident. V89's time keeping payroll records (7/2026) document V89 worked on 7/7/2026 from 8:30 AM to 5:00 PM, 7/8/2026 from 3:45 PM to 11:00 PM, 7/9/2026 from 8:00 AM to 4:15 PM, 7/13/2026 from 3:30 PM to 10:15 PM, 7/14/2026 from 7:00 AM to 3:15 PM, 7/15/2026 from 3:00 PM to 11:45 PM, and 7/16/2026 from 8:00 AM to 11:15 AM. Email chain, dated 7/8/2026, documents V91 emailed V1 and V2 at 3:52 PM stating, I am following up regarding a phone call I received from (R16). During the call, (R16) reported an allegation that a staff member identified as (V89) choked (R16) in his room and subsequently threatened to hit (R16) with a fan. (R16) stated that he called 911 to report the incident to law enforcement. (R16) further reported that following the incident, (R16) was transported to the hospital for evaluation. I know (R16) has behaviors of allegations in the past but was this investigated at all? Thank you! . On 7/8/2026 at 6:33 PM, an email replied from V2 (Director of Nursing)'s email stating, Hey (V91)!! That's actually not true. (R16) was caught smoking marijuana and his pass was revoked due to contraband. (R16) called 911 and told them he was suicidal. When the officer arrived (R16) told the officer the same thing and we then sent him out. (R16) does this every time his pass is taken away. On 7/16/2026 at 3:15 PM, V2 (Director of Nursing) stated V2 was unaware of any allegation between V89 and R16. Email chain between V91, V1, and V2 was reviewed with V2. V2 denied any recollection of reading the email. V2 affirmed V4 (Infection Preventionist) has access to V2's email and may have responded. V2 stated choking is a serious allegation of physical abuse. V2 affirmed V89 should have been suspended pending investigation. V2 explained the purpose of suspending the staff member is to assure no further contact can be made between the staff and the resident. By not suspending V89, V2 asserted V89 had continued access to R16 and all other residents in the facility. V2 stated all residents of the facility have complex psychiatric issues, and all are at risk for abuse. On 7/20/2026 at 10:34 AM, V4 (Infection Preventionist) recalled V1 couldn't get a hold of V2 (Director of Nursing) so V1 called V4 asking V4 to check V2's email because there was an email from R16's case manager (V91). The email said R16 reported to V91 that R16 had been choked by V89. V4 affirmed a staff member choking someone is an allegation of physical abuse. V4 explained choking is when someone intentionally cuts of someone's airway and ability to breathe. Choking can cause damage to the airway, loss of consciousness or if long enough, can result in the resident's death. V4 confirmed V4 replied to the email. V4 denied knowledge of any abuse allegation, reviewing/collecting any statements or any other investigative/reporting processes prior to replying and was told it was a behavior. V4 denied knowledge if V89 was ever suspended pending an investigation. V4 stated, (V1) is the Abuse Prevention Coordinator and is typically responsible for obtaining statements. (V1) was aware, if (V1) chose not to investigate it or report it, that's on (V1), that's not on me. On 7/21/2026 at 10:51 AM, V1 (Administrator) confirmed V1 is the Abuse Prevention Coordinator. V1 confirmed there were no other abuse allegations completed that involved R16 prior to 7/16/2026. V1 stated the first time V1 heard the allegation was on 7/16/2026 from the surveyor (this statement contradicts V1's statement on 7/16/2026). V1 explained V1 saw an email from an insurance case manager and deferred it to the nursing department. V1 could not get a hold of V2 (Director of Nursing), so V1 called V4. V4 said R16 was having behaviors, was saying R16 was suicidal, and knew what was going on. V1 denied V4 said anything about an abuse allegation (choking or threatening) to V1. V1 stated if V1 knew there was an allegation of choking, V1 would have suspended V89 right away. V1 affirmed the abuse policy requires the facility to suspend staff pending an investigation. V1 stated V89 continued to work after the allegation was submitted to the facility on 7/8/2026, and had continued access to R16 and all other residents which could harm the other residents. 2) R37's face sheet documents R37 is a [AGE] year-old resident with diagnoses including type 2 diabetes mellitus, paranoid schizophrenia, and hypertension. R37's background check (5/20/2024) documents R37 had been convicted of battery, criminal damage to property, and resisting a peace officer. R37's Criminal History Analysis Security Recommendation Report (5/21/2024) from the Illinois Department of Public Health Identified Offenders Program indicates recommendations that R37 is a high-risk offender with psychiatric conditions, ongoing acts of verbal aggression, refusal of psychiatric treatment, high risk supervision status is recommended. High risk- The resident requires a single room in close proximity to the nurses station to permit ongoing monitoring. Regular R37's identified offender care plan (3/27/2026) documents, I am an adult living with medical and mental health comorbidities. I have a criminal felony background. I have been screened through the admission process and am expected to acclimate safely in this setting. My criminal history includes: : Battery & Criminal Damage Property. I am aware that I must comply with Finger Printing in order to remain in this setting and my risk level will be determined by representatives from IL State Police. ISP has conducted an interview and determined my risk level to be High (private room) . The requirement of R37's needing a room in close proximity to the nurse's station to permit ongoing monitoring is not identified within R37's care plan. R63's face sheet documents R63 is a [AGE] year-old resident with diagnoses including unspecified psychosis, generalized anxiety disorder, paranoid schizophrenia, and generalized muscle weakness. R63's background check (9/8/2025) documents R63 had been convicted of theft, possession of a controlled substance, criminal sexual assault, aggravated sexual abuse, and is a convicted sex offender. R63's Criminal History Analysis Security Recommendation Report (10/6/2025) from the Illinois Department of Public Health Identified Offenders Program indicates recommendations that staff should assure R63 is consistently taking psychiatric medication as prescribed and should not be allowed contact with individuals under [AGE] years old in the facility without direct and constant staff supervision. R63's identified offender plan of care (12/18/2025) documents, Identified Offender: I am an adult living with medical and mental health comorbidities. I have a criminal felony background. I have been screened through the admission process and am expected to acclimate safely in this setting. My criminal history includes: (No criminal history is identified) I am aware that I must comply with Finger Printing in order to remain in this setting and my risk level will be determined by representatives from IL State Police. My risk analysis determined to be Low (Private Room). A yellow pass is granted with family and friends due to risk assessment from IDPH. The recommendation that R63 should not be allowed contact with individuals under [AGE] years old in the facility without direct and constant staff supervision is not identified within R63's care plan. On 7/21/2026 at 10:51 AM, V1 (Administrator) confirmed V1 is the Abuse Prevention Coordinator. V1 reviewed the facility's abuse prevention policy and confirmed the policy indicates the facility shall incorporate recommendations into the identified offender's plan of care. V1 affirmed V1 expects staff to follow the abuse prevention policy. 3) Facility Quality Assurance and Performance Improvement (QAPI) documentation (3/2026-6/2026) does not indicate the facility reviewed/collected data regarding grievance reports, missing item reports, and safety committee reports and assessed for possible trends of suspicious bruising, unexplained accidents, or other occurrences that may indicate abuse, neglect exploitation, misappropriation, or a crime against a resident. The last time the facility tracked grievance reports and missing item reports was March 2026 (data for February 2026). 07/16/2026 at 11:14 AM, V1 (Administrator) affirmed V1 is responsible for the QAPI programming and the QAPI committee activities. Reviewed QAPI documentation and data with V1. Surveyor inquired if the QAPI committee was tracking any data related to the abuse prevention program. V1 stated V1 tracks abuse allegations, reportable, like how many visits the facility has had from the State Survey Agency. V1 confirmed the data was not available during the interview for review and stated V1 had to revamp the whole (QAPI) book, so V1 would have to find the data. On 7/21/2026 at 10:51 AM, V1 (Administrator) confirmed V1 is the Abuse Prevention Coordinator. V1 explained V1 could not find any documentation that indicates the QAPI committee reviewed/collected data regarding missing item reports, and safety committee reports and assessed for possible trends of suspicious bruising, unexplained accidents, or other occurrences that may indicate abuse, neglect exploitation, misappropriation, or a crime against a resident and completed analysis of the reports/data. V1 was not aware of the requirement that establishes coordination with the abuse prevention program and the QAPI program. V1 was not aware the abuse prevention policy required the committee to review/collect data regarding grievance reports, accident reports, incident reports, missing item reports, and safety committee reports to assess for possible trends of suspicious bruising, unexplained accidents, or other occurrences that may indicate abuse, neglect exploitation, misappropriation, or a crime against a resident. V1 stated, I'm assuming if you're asking me, it's in there (the abuse policy). No one's ever asked me that before. No further documentation was presented that indicates the QAPI committee reviewed/collected data regarding grievance reports, missing item reports, and safety committee reports and assessed for possible trends of suspicious bruising, unexplained accidents, or other occurrences that may indicate abuse, neglect exploitation, misappropriation, or a crime against a resident. Facility abuse prevention policy (revised 1/2019) documents it is the policy of the facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility. The policy identifies verbal abuse as any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families or within their rearing distance to describe residents, regardless of their age, ability to comprehend or disability. Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also involves controlling behavior through corporal punishment. Mental abuse is defined as humiliation, harassment, threats of punishment, or withholding of treatment or services. If abuse is suspected, the policy instructs staff to separate the alleged perpetrator and assure all residents safety and notify the administrator or director of nursing immediately. Staff members accused of abuse or misconduct shall immediately (regardless of time left on shift) be barred from any further contact with residents of the facility and suspended from duty, pending the outcome of investigation, prosecution, or disciplinary action against the employee. For residents who are identified offenders, the facility shall incorporate the identified offender report and recommendations report into the identified offender's plan of care. At least quarterly, the Quality Assurance Performance Improvement committee will review concern reports, grievance reports, accident reports, incident reports, missing item reports, safety committee reports to assess for possible patters or trends of suspicious bruising of residents, unexplained accidents or other occurrences that may constitute abuse, neglect, exploitation, misappropriation or a crime against the resident. Based on an assessment of the reports, the Quality Assurance Performance Improvement committee will further investigate and/or determine whether a change in facility practices is warranted.

Based on observation, interview, and record review, the facility failed to provide a linens for resident beds, failed to provide a safe environment, failed to ensure baseboards were free of holes and secured to the wall, failed to provide a clean environment in the resident's room that was free from debris, and failed to provide safe functioning air conditioners in resident rooms. These failures affected 11 residents (R2, R5, R12, R36, R38, R56, R65, R203, R218, R219, and R238) in a sample of 68 residents reviewed for home-like environment.Findings Include: 1.R12's Face sheet documents R12 is a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include Parkinsonism, Bipolar, Vascular dementia, and Personality Disorder. R12's Minimum Data Set (MDS) on 5/25/2026 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R15 is cognitively intact, and R15 requires moderate assistance for bathing with supervision/touch assistance for toileting and dressing. On 7/13/2026 at 11:16AM, R12 reported she was having difficulty opening her door. Surveyor pushed with excessive force in order to get the door open enough to enter the room. V15 (Assistant Maintenance Director) examined the door and affirmed the door was a safety hazard. V15 returned to the room to shave down the bottom of the door so it would open and close easily. 2.R5's Face sheet documents R5 is a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include in part Parkinsons, unspecified dementia, weakness, unsteadiness on feet, schizophrenia, and bipolar. R5's Minimum Data Set (MDS) on 6/3/2026 documents a BIMS (Brief Interview for Mental Status) score of 8, indicating R5 has moderate cognitive impairment, and R5 is dependent for toileting and bathing, and needs substantial/maximum assistance for dressing. On 7/14/2026 at 9:30AM, Surveyor attempted to open R5's door and noted much resistance against the floor. Door was eventually opened with forceful pushes. R5 was asleep in the bed, unharmed. V15 (Assistant Maintenance Director) examined the door and affirmed the door was a safety hazard. V15 returned to the room to shave down the bottom of the door so that it would open and close easily. R5 was unable to be interviewed regarding the door and room/baseboards. On 7/16/2026 at 9:44AM, Surveyor noted in R5's room the metal baseboard along the wall with the window was sticking out approximately 4 inches at one end of the baseboard, creating a fall or injury hazard. On 7/16/2026 at 11:00AM, V4 (Maintenance Director) confirmed this finding and stated, Yes, this should be secured to the wall so that it is not sticking out. 3.R203's Face sheet documents R203 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses include in part Dementia, Epilepsy, and Chronic Obstructive Pulmonary disease. R203's Minimum Data Set (MDS) on 4/22/2026 documents a BIMS (Brief Interview for Mental Status) score of 10, indicating R203 is moderately cognitively impaired, and R203 requires supervision/touch assistance for all activities of daily living. R203 was unable to be interviewed about the condition of the room/baseboards. On 7/16/2026 at 9:20AM, R203's baseboard of the wall was missing, approximately the length of four floor tiles. To the right of the area with the missing baseboard, there was another split/gap in the baseboard with a hole burrowed directly above the baseboard. On 7/16/2026 at 11:00AM, V4 (Maintenance Director) confirmed this finding and stated, I see the hole there, and that is something we can cover. 4.R219's Face sheet documents R219 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses include in part Cerebral infarction, unspecified dementia, and schizoaffective disorder. R219's Minimum Data Set (MDS) on 5/7/2026 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R219 is cognitively intact, and R219 requires partial/moderate assistance for bathing, toileting, and dressing. On 7/16/2026 at 9:25AM, an electric wall plate was hanging halfway off the wall in R219's room, exposing a hole leading into the wall and exposing access to electric source. On 7/16/2026 at 11:00AM, V4 (Maintenance Director) confirmed this finding and stated, Yes, this should be covered for safety, it is an electric outlet. 5.R65's Face sheet documents R65 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses include in part Cerebral Infarction, Unspecified Dementia, Repeated Falls, and Diabetes. R65's Minimum Data Set (MDS) on 5/6/2026 documents a Staff Assessment for Mental Status of 2, indicating R65 is moderately cognitively impaired, and R65 is dependent for toileting and dressing, while requiring maximum assistance for bathing. R65 was unable to be interviewed about the condition of the room/baseboards. On 7/16/2026 9:37AM, a burrowed hole was in one of a baseboards to the right of the air conditioning unit in R65's room. On 7/16/2026 at 11:00AM, V4 (Maintenance Director) confirmed this finding and stated, Yes, this should be covered to prevent rodents from entering into the room through the walls. 6.R218's Face sheet documents R218 is a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include in part Heart Failure and Paranoid Schizophrenia. R218's Minimum Data Set (MDS) on 5/19/2026 documents a BIMS score of 15, indicating R218 is cognitively intact, and R218 requires partial/moderate assistance for toileting, dressing, and hygiene. R218 was unable to be interviewed about the condition of the room/baseboards. On 7/16/2026 at 9:52AM, R218's room had a metal baseboard along the wall near the head of the bed that had separated from the wall approximately 4 inches, creating a fall or injury hazard. On 7/16/2026 at 11:00AM, V4 (Maintenance Director) confirmed this finding and stated, Yes, this should be secured to the wall so that it is not sticking out. 7.On 7/16/2026 at 10:00AM, an unoccupied room on the 4th floor had a rusty nail that was securing the baseboard and had come out of the wall. Despite the room not having a resident, this posed a safety risk as the door was open, and the room was accessible to all residents walking in the hallway. On 7/16/2026 at 11:00AM, V4 (Maintenance Director) affirmed this risk and said, We (maintenance) will take care of it right away. 8.On 7/13/26 at 10:15AM, R36 was observed lying directly on the mattress without any bed sheets. R36 stated he wanted a sheet on his bed, but they said there were no sheets available. R238 was also observed without a bedsheet on his bed, and R238 went to ask V38(CNAs/Certified Nurse Assistant) for a bedsheet. V38 stated hey were still waiting for clean linen to be brought up from the laundry. V38 was asked why there were no bed sheets for R36 and R238. V38 responded they brought up some linen this morning, but they were not enough to go round all the residents, and she was waiting for more linen from the laundry. On 7/14/26 at 10:13am, V31(Laundry Aide) stated there's enough linen for all the floors. As long as the CNAs put the dirty linen in the laundry chute in a timely manner, she would wash the linen and bring them back to the floors. V31 showed the surveyor the laundry chute and the clean linen she was putting together to send to the 8th floor. 9.On 07/13/2026 at 9:30 AM, the air conditioner in a resident's room was leaking, with towels on the ground by the air conditioning unit. R38 stated it has been leaking for the past 6 months, staff are aware, they tried to fix it, but it is still leaking. V19 (Registered Nurse/RN) affirmed the air condition unit is leaking water. 10. On 07/14/2026 at 11:02AM, R56 had a large area in the room by the window, behind the resident's dresser with all the baseboard out from the wall exposing a pipe. There was a lot of dirt and debris in the area. R56 said the room is all broken, they complain but the staff do not do anything. 11.On 7/14/2026 at 11:10AM, R2's air conditioner in the room was leaking with a puddle of water in the middle of the floor. On 7/14/2026 at 11:30AM, V15 (Assistant maintenance director) was notified of observations and affirmed these issues need to be addressed. V15 stated, We are working on it; we do need more hands to fix everything. Facility's Laundry Policies and Procedures for Laundry Personnel states, under Clean Linen: Clean linen is to be delivered to the appropriate locations at designated times. Clean linen should be transported and stored by methods that minimize microbial contamination from surface contact and airborne deposit. Clean linen should be transported in containers used exclusively for this purpose. The clean linen cart/container should be kept completely covered during transport. Facility's admission Packet on Resident Rights states the facility provides housekeeping and laundry services to residents. Environmental Care policy revised 6/7/20222 state: GENERAL CLEANING POLICIES AND PROCEDURES RESIDENT ROOM – CLEAN.PURPOSE:To provide a clean, attractive and safe environment for residents, visitors and staff.PROCEDURE: 1. Always knock, announce yourself (HOUSEKEEPING) and then enter the room carefully. c. Greet the residents and their family or visitors in a friendly, courteous manner, identify yourself and explain why you are there. General Inspection: a. Survey the area and pick up loose trash. c. Inspect room and report all damage including to walls, furniture, cubical and window curtains (note cleanliness), resident belongings and sinks. Facility policy Maintenance Department (undated) documents, It is the policy of this facility that equipment and facility is maintained to prevent the spread of infection.

Based on interview and record review, the facility failed to complete assessments accurately and failed to complete the Minimum Data Set accurately in accordance with RAI guidelines. These failures affected four residents (R1, R2, R5, & R6) in a sample of 64. Findings include: 1) R5 is a [AGE] year-old female resident with diagnoses including: Parkinson's disease, type 2 diabetes mellitus, unspecified dementia, schizoaffective disorder, bipolar disorder, autistic disorder, major depressive disorder, anxiety, and cognitive communication deficit. R5's Minimum Data Set (MDS) (6/3/2026) documents R5 used a other physical restraint less than daily in the lookback period, and R5's chair preventing rising was not assessed. R5's physician orders do not document any current, discontinued, or cancelled physical restraint active during the lookback period of the minimum data set. R5's progress notes do not document any use of a physical restraint during the lookback period of the minimum data set. R5's care plan does not identify any current, discontinued or cancelled physical restraint use in the lookback period of the Minimum Data Set. On 7/15/2026 at 11:13 AM, V8 (Restorative Director) affirmed V8 is responsible assessing and managing restraint use in the facility. V8 denied R5 ever used any restraints since admission to the facility. V8 reviewed R5's Minimum Data Set (6/3/2026) and affirmed the MDS was coded incorrectly. On 7/15/2026 at 11:16 AM, V14 (Minimum Data Set Coordinator, Licensed Practical Nurse) explained the purpose of the Minimum Data Set is to identify care needs for the resident and drives the care plan. V14 affirms the facility uses the resident assessment instrument to guide coding of the Minimum Data Set. CMS' RAI (Resident Assessment Instrument) Manual 3.0 (10/2025) documents coding instructions for physical restraints and instructs staff to identify all physical restraints that were used at any time (day or night) during the 7-day look back period. After determining whether or not an item listed in (P0100) is a physical restraint and was used during the 7-day look-back period, code the frequency of use: Code 0, not used: if the item was not used during the 7-day look-back period or it was used but did not meet the definition. Code 1, used less than daily: if the item met the definition and was used less than daily during the observation period. Code 2, used daily: if the item met the definition and was used on a daily basis during the look-back period. 2) R1's FRI (Facility Reported Incident), dated 4/27/26, documents, Resident (R1) who is ambulatory without assistance was observed on the floor in the men's bathroom sitting upright. Upon assessment, resident (R1) complained of pain to the right lower extremity. Physician was notified and provided orders to obtain X-ray of the right lower extremity. Upon receipt of the X-ray results, the resident (R1) was noted to have a right acute intertrochanteric proximal femur fracture. The on-call provider was notified and transferred to hospital for further evaluation and treatment. Conclusion: Based on the findings, it was determined that the resident's (R1) right hip fracture was sustained as a result of an unwitnessed fall occurring during independent ambulation in the bathroom, during which the resident (R1) lost balance and was observed seated on the floor. The resident (R1) is ambulatory without assistance and has a history of cognitive impairment, which may impact safety awareness. Review of the resident's (R1) care plan confirmed that appropriate interventions were in place at the time of the incident, consistent with the resident's (R1) baseline functional status. The resident (R1) was transferred to the hospital for further evaluation and treatment, where he (R1) underwent hip surgery. The resident (R1) has since returned to the facility and will follow up with orthopedics in three weeks. R1's face sheet documents an original admission date of 7/16/24 and diagnoses that include but are not limited to weakness, abnormal posture, dementia, lack of coordination, attention and concentration deficit, slowness and poor responsiveness, cognitive communication deficit, epilepsy, depression, and schizoaffective disorder. R1's BIMS (Brief Interview for Mental Status) score, dated 6/10/26, is 5 which indicates R1's cognition is severely impaired. R1's MDS (Minimum Data Set) section GG, dated 4/10/26 (prior to fall on 4/26/26), per V52 (Assistant Restorative Directive/Registered Nurse), documents R1 requires supervision or touching assistance with both toilet transfers and walking 10 feet. R1's Fall Risk Review, dated 4/26/26 (completed after fall on 4/26/26), documents a score of 10, which indicates R1 is at high risk for falls. Upon review of R1's Fall Risk Review, dated 4/26/26, question 3. Does the resident have a history of falls within the last 3 months? was answered inaccurately with no, and question 7. Ambulation is answered as independent. R1 fell on 4/26/26 indicating R1 has a history of falls. R1's MDS (Minimum Data Set) section GG, dated 4/10/26 (prior to fall on 4/26/26), documents R1 requires supervision or touching assistance with both toilet transfers and walking 10 feet indicating R1 does not ambulate independently. R1 was unable to be interviewed due to altered mental status. On 7/14/26 at 2:54PM, V8 (Restorative Director) affirmed R1 requires supervision and/or one touch assistance during ambulation and ADLs (toileting). V8 affirmed R1 is not ambulatory without assistance. 3) R6's FRI (Facility Reported Incident), dated 5/20/26, documents, Resident (R6) was seated in dining room chair during meal service, removed protective helmet, and began eating. Resident (R6) subsequently slid from dining chair to the floor and struck the right side of head against chair during descent. Immediate assessment initiated. Resident (R6) observed with small open area to right side of head. Physician notified with new order to transfer resident to hospital for further evaluation and treatment. Conclusion: The facility completed a comprehensive investigation regarding the resident's fall incident during meal service. Based on the findings, it was determined the resident (R6) experienced a self-initiated slide from the dining room chair to floor after removing his (R6) protective helmet while seated for breakfast. During the decent, the resident (R6) struck the right side of his (R6) head against the chair, resulting in a small open area to the scalp. The resident (R6) has since returned from the hospital with a diagnosis including a fractured scapula and 3 staples to the scalp area related to the injury sustained during the fall. Review of the investigative findings determined the fall was accidental in nature and related to the resident's (R6) self-initiated movement while seated during meal service. R6's face sheet documents an admission date of 1/29/26 and diagnoses that include but are not limited to dementia, paranoid schizophrenia, dyskinesia, osteoarthritis, and chronic obstructive pulmonary disease. R6's BIMS (Brief Interview for Mental Status) score, dated 6/8/26, is 6, which indicates R6's cognition is severely impaired. R6's Fall Risk Review, dated 5/14/26 (after R6's fall on 5/14/26), is 1. Question 3. Does the resident have a history of falls within the last 3 months? was answered inaccurately with no. R6 fell on 5/14/26. Question 4. Is resident receiving a medication that affects awareness, judgement or safety? (e.g. Anti-Anxiety, Antibiotics, Anticoagulants, Antihistamines, Anti-hypertensives, Anti-Parkinson, Anti-seizure, Diuretics, Narcotics, Psychotropics, Sedative/Hypnotics) was answered inaccurately with no. Record review of R6's Medication Administration Record (MAR), dated May 2026, documents R6 was receiving Zyprexa, Divalproex Sodium, Trazadone, and Oxcarbazepine at the time of the fall. R6's Fall Risk Review, dated 5/20/26, is 9. Question 4. Is resident receiving a medication that affects awareness, judgement or safety? (e.g. Anti-Anxiety, Antibiotics, Anticoagulants, Antihistamines, Anti-hypertensives, Anti-Parkinson, Anti-seizure, Diuretics, Narcotics, Psychotropics, Sedative/Hypnotics) was answered inaccurately with no. Record review of R6's Medication Administration Record (MAR), dated May 2026, documents R6 was receiving Zyprexa, Divalproex Sodium, Trazadone, and Oxcarbazepine at the time of the fall. R6 was unable to be interviewed due to altered mental status. On 7/16/26 at 3:13PM, V2 (Director of Nursing/DON) said Absolutely, V2 expects the fall resident's fall risk assessments to be filled out accurately. V2 said, Fall assessments tell you how much a resident's risk level is for potentially falling and determine what to put in place to reduce risk of falling. When answering the question of a fall in past 3 months, when I do it, I don't count day of. Should I be? I look to see if a fall happened before that current day. V2 affirmed R1's fall assessments were not answered correctly because R1 does not ambulate without assistance (question #7) and R6 is on medications that affect awareness, judgement or safety (question #4). 4) R2 is a [AGE] year-old female with a past medical history of post-traumatic stress disorder (PTSD) bipolar disorder, borderline personality disorder, schizophrenia, alcohol abuse, suicidal ideations, anxiety disorder, vitamin D deficiency, obesity, alcohol abuse, HTN, anxiety disorder, etc. Minimum data Set (MDS) assessment, dated 4/7/2026, (Quarterly) section C (cognitive) scored R2 with a Brief Interview for Mental Status score of 14, indicating R2 is cognitively intact; section GG (functional of the same assessment documented R2 requires supervision for all activities of daily living (ADL) care needs including ambulation. R2 had a fall on 6/15/2026 while smoking in the patio. Fall risk assessment, dated 6/15/2026, documented the following: Reason for review-other, Does the resident have a history of fall in the last 3 months-No, Fall history-No, Ambulation-independent, Gait/balance- normal. Record review of facility policy titled, Guidelines for Incidents/Accidents/Falls, dated 6/30/23, documents, Policy: It is the policy of the facility to ensure that any incident/accident to include falls is reported immediately to the nurse or appropriate person designated to be in charge. After the resident has had immediate attention and their safety is established, a written report will be entered into Risk Management (usually Risk Management section of PCC). The facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated and resolved. The facility will create a database related to incidents/accidents as part of the QAPI process to enable trending and tracking. This information will be used to implement corrective actions to include any needed training to prevent reoccurrences when possible. It will be part of the QAPI (Quality Assurance—monthly meeting) Agenda. If the incident/accident is significant and requires outside emergency intervention/treatment, the Administrator and DON will be notified immediately that emergency services were called and what the circumstance were that required that intervention. Other required notifications will occur as well. A trigger call will be held with the members of the Regional Team if the incident/fall meets trigger call criteria. All falls will have a site investigation by appropriate staff in an effort to define the root cause of the fall. This will help provide information to enable staff to roll out interventions to prevent another similar occurrence. Note: Each fall needs a new care plan intervention rolled out. Therapy should be involved to some degree in all post fall reviews to offer any input or to determine if a screen or being added to therapy case load is appropriate. Residents are assessed for Fall Risk upon admission, -admission, quarterly and when there is a change of condition. The resident has a care plan put into place with interventions, based on their individual risk factors at the time of the Falls Assessment. When evaluating residents for fall potential or post fall—the list below needs to be considered for the need of interventions to prevent further falls. Any incident/accident/fall that meets the reporting criteria of the state/federal regulations will be reported timely and accurately, to include the initial as well as the follow up report. Any incident/accident that meets criteria to be reported to the authorities (police), Ombudsman, Adult Protection Services will be reported. This will be documented within the investigation file. Based on the results of the incident/accident/fall, the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place. Record review of facility policy titled, Policy and Procedure of Comprehensive Care Plans, dated July 2022, documents, Policy: Comprehensive Care Plans are to be done with every New admission, Annual, Significant change in status and every Quarterly. Comprehensive Care Plan will be developed for each resident that includes; problem/need of the resident, measurable objectives and interventions to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the Comprehensive Assessment. The facility interdisciplinary team, in conjunction with the resident, resident's family, surrogate, or representative, as appropriate, will develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the Comprehensive assessments and the CAAs. The Comprehensive Care Plans will be reviewed and updated every quarter (90 days) at minimum. The facility may need to review the care plans more frequently based on changes in the resident's condition and/or newly developed health/psychosocial well-being issues. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based on interview and record review, to provide adequate supervision and interventions for a resident, R2, assessed as a smoker. This failure resulted in R2 sustaining a fall while unsupervised. Findings include: R2 is a [AGE] year-old female with a past medical history of post-traumatic stress disorder (PTSD) bipolar disorder, borderline personality disorder, schizophrenia, alcohol abuse, suicidal ideations, anxiety disorder, vitamin D deficiency, obesity, hypertension, anxiety disorder, etc. 07/13/2026 11:15AM, R2 was in bed, awake and alert, stated she is doing okay. R2 was noted with a cast to her left leg. R2 was asked what happened, and she said she fell on the patio and twisted her ankle. R2 was outside for a smoke break, she smoked an e-cigarette (vape) and a regular cigarette, then became lightheaded and fell. Staff were available and they called the nurse. On 07/14/2026 11:10AM, R2 said she purchased it, not by herself, she gave staff (V49) $20.00, and the staff bought it for her. 07/14/2026 11:42 AM, V49 (Certified Nursing Assistant/CNA) said she is familiar with R2 before she moved to another floor. Resident stays by herself and smokes sometimes. R2 does not go out on a pass, she buys cigarettes from the facility. V49 denied ever purchasing an e-cigarette for R2, she said she probably got it from other residents. Some residents can buy stuff and sell it to other residents though they are not supposed to do that. Minimum Data Set (MDS) assessment, dated 7/7/2026, section C (cognitive) scored R2 with a Brief Interview for Mental Status score of 12, indicating R2 is somewhat cognitively intact, section GG (functional) of the same assessment documented R2 requires supervision for all activities of daily living (ADL) care needs. Smoking risk assessments, dated 10/10/2024, 4/4/2025, 7/4/2025, 10/3/2025 and 1/5/2026, all documented R2 is a nonsmoker and is not at risk of injury to herself or others. Active physician order for R2 indicates she is currently taking the following medications: Risperidone 1mg PO BID (Dx. Schizophrenia Ix. Delusions) Fluphenazine [DATE]mg IM q4weeks (Dx. Schizophrenia, Ix. Psychosis) Quetiapine 500mg PO at bedtime (Dx. Schizophrenia) Lamotrigine 25mg PO BID (Dx Schizophrenia. Ix. mood instability) Doxepin 6mg PO at bedtime, (Dx. BPD, Ix. depressive symptoms) Trazodone 75mg PO at bedtime (Dx. Insomnia, Ix. Difficulty at falling asleep) Zolpidem 5mg PO at bedtime (Dx. Insomnia, Ix. Sleep disturbances) Melatonin 5mg PO at bedtime (Dx. Insomnia Ix. Sleep Disturbances) Benztropine for 5mg every 12 hours for EPS. R2 does not have any physician orders to smoke. Smoking care plan, initiated 6/26/2926, stated: I have the potential for safety hazard and/or injury related to smoking. Goal: I will not cause injury to self/others or cause damage to property related to smoking through next review. Interventions: Assess my smoking abilities quarterly and as needed, educate me as needed, provide me with copy of facility smoking policy, Smoking apron if needed, etc. 07/14/2026 11:15AM, V18 (Social services) said she can only go to the store to purchase cigarettes for residents if the facility does not sell it. Facility does not sell vaping cigarettes. V18 is not sure if residents are allowed to vape; vaping may require more caution than regular cigarettes. On 7/16/2026 at 9:46AM, V76 (Attending Physician) said he is very familiar with R2 and aware the resident had a fall recently, could not remember exactly what they told him resident was doing before the fall. V76 was informed the resident said she smoked an e-cigarette and then smoked a regular cigarette before she became lightheaded and lost her balance, and that R2 was assessed as nonsmoker according to facility smoking risk assessment. V76 was asked if R2 should be smoking an e-cigarette and at the same time smoke a regular cigarette considering her medical diagnosis and all the medications she takes and he said, Theoretically, no, but practically, it could be difficult to monitor what every resident is doing, there are usually about 50 residents with one person monitoring them. V76 was asked if R2 did not smoke an e-cigarette and a regular cigarette at the same time, would she have not gotten lightheaded and the fall could have been avoided. V76 said, I will say 50/50, it is hard to say but (R2) should not be smoking both cigarettes at the same time. The smoke monitor who gave her both an e-cigarette and a regular cigarette was not doing his job well. V76 added that he will speak to the facility and put R2 on a nicotine patch, her smoking risk assessment needs to be redone, and if the resident insists on smoking after the nicotine patch, V76 said he will suggest staff taking her out in a wheelchair and monitoring her closely so she will not fall again. On 7/15/2026 at 1:14PM, V67 (Smoke Monitor) via phone said he usually does not monitor smoking on the 5th floor but had to go up to that floor the day R2 had a fall. R2 had a vape in the cigarette cart, V67 gave it to her, and she went and plugged it in the nursing station for it to charge. V67 gave R2 a cigarette which she smoked while the e-cigarette was charging. R2 then smoked the e-cigarette while she was sitting at the corner. R2 tried to stand up and got lightheaded, lost her balance, and fell. V6 said that was the first time he gave an e-cigarette to R2. V67 does not know how the resident got it, but her name was on it, and he gave it to her. R2 does not go out on a pass as far as V67 knows. V67 was asked if the smoke monitors review resident's risk assessment before giving them cigarettes and he said no. V67 could not catch R2 before she fell and did not touch her, he just called the nurse. On 7/16/2026 at 1:16PM, V39 (Social Worker) said she is familiar with R2 and completed her smoking risk assessments. (R2) smokes occasionally. The purpose of the smoke risk assessment is to know residents who smoke and determine the level of supervision they need during smoke breaks. If a resident say they do not smoke during the assessment and later decide to smoke, then a new assessment will be completed. V39 added the last assessment R2 had, dated 1/5/2026, indicated she is a smoker. V39 was presented with the same assessment that indicated R2 is a nonsmoker, and V39 said, Based on this assessment, (R2) should not be smoking then. Guideline for smoking (undated) documented: Policy: There will be no smoking permitted inside the facility. Smoking will be allowed for residents, staff and visitors in designated areas only. Smoking must be at least 15 feet (or as dictated by any State/Local laws/mandates), from any doorway, window, or vent system of the facility. All residents' smoking materials will be kept by the facility in a secure location. Purpose: To provide a healthy and safe smoke environment as possible for all residents, staff and visitors to include those who smoke and those who do not smoke. Also, determine if a resident is an independent smoker or an At-Risk smoker before the resident exercises the privilege to smoke while residing in the facility. Further, to establish Smoking Guidelines for all residents that desire to smoke at the facility. Procedure: 6. Residents will be assessed for safe smoking behavior prior to smoking at the facility. This assessment is found on PCC. The residents will be further assessed for smoking quarterly, annually, after an unsafe smoking episode and after a change of condition. Any resident who has been a non-smoker and who decides to take up smoking will be assessed as a newly admitted resident who is a smoker would be assessed (as per assessment periods or indications). Note: Based on the results of the smoking assessment, education will be documented for the resident, their representative as well as any appropriate staff. The care plan and CNA assignment sheets will be reflective of the resident's needs as far as safe smoking. The residents will need a physician's order permitting them to smoke.

Based on observation, interview, and record review, the facility failed to maintain one of six crash carts in the facility, with non-expired supplies and failed to stock the items in the crash cart checklist so the crash cart was complete and ready for emergency use. This failure has the potential to affect all forty residents on the eighth floor. Findings:On [DATE] at 10:38 AM, V26 (Licensed Practical Nurse) the eighth floor crash cart was reviewed. V26 explained the nurse may direct staff to get the crash cart during a medical emergency with a resident or staff. V26 stated the crash cart is checked daily by the night shift nurse to make sure that it remains unopened. The nurse documents daily the lock number and the nurse's signature signifying the lock is intact. The lock check also signifies that everything that is supposed to be in the crash cart is accounted for, and nothing is expired. V26 was asked how staff know that nothing is expired in the crash cart. V26 did not know and called V4 (Assistant Director of Nursing/Infection Preventionist) who V26 explained maintains the crash carts. Review of the Crash Cart signature log shows no signature/crash cart check for [DATE] and shows the same lock number from [DATE] through [DATE]. The crash cart checklist outlined what should be in each drawer of the crash cart. When V4 presented to the unit, V4 stated V4 checked the crash cart last week to make sure that all items on the crash cart check list were present, and nothing was expired. When surveyor pointed out that the lock number was identical from [DATE] through [DATE], V4 stated I don't remember when I checked it then. V4 confirmed the crash cart should have been checked on [DATE], but there was no signature that it was checked. V4 also stated everything on the crash cart checklist should be in the crash cart and not expired. V4 opened the crash cart and no intravenous fluids (one liter 0.9 normal saline and 2 liters of D5W) were found as noted on the crash cart checklist. V4 stated, They should be in the crash cart. I don't know why they aren't. A suction catheter that expired [DATE] and suction connecting tubing that expired [DATE] were also on the cart. V4 stated during an emergency, everything should be in the crash cart and within reach to give the patient the best and the quickest care. V26 stated this lack of supplies and expired supplies means the forty residents on the unit today could be potentially affected if they needed the crash cart and it was not stocked or expired supplies were used to care for a resident. On [DATE] at 10:07 AM, V4 (Assistant Director of Nursing/Infection Preventionist) stated there are a total of six crash carts in the facility.On [DATE] at 10:41 AM, V2 (Director of Nursing) stated, The expectation is the crash carts are checked nightly by the night supervisor. If the crash cart is not checked, the risk is that there will be missing or expired supplies in the crash cart. If there are expired supplies in the crash cart, the risk is that an expired supply would be used on a resident or staff. If there are missing supplies, the supplies are not available during a code or emergency situation, and it risks the resident or staff safety. Intravenous fluids are no longer stored in the crash cart. If the crash cart check list includes intravenous fluids, we are using the wrong crash cart checklist.Facility policy titled Crash Cart, dated [DATE], stated the crash cart will be stocked with emergency supplies as defined by the Crash Cart Checklist. The crash cart will be locked at all times to ensure that all emergency supplies are available during the event of a medical emergency requiring intervention, conforming with resident(s) Advance Directive.Facility policy titled Cardiopulmonary Resuscitation (CPR) with no date stated CPR equipment includes: Ambu-bag, board, mouth screen, suction machine with tubing, collection bottle, sterile normal saline, extension cord, oxygen with cannula or mask, oxygen tubing.

Based on observation, interview, and record review, the facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse. This failure affected one resident (R16) in a sample of 68 residents. Findings include:R16's face sheet documents R16 is a [AGE] year-old resident with diagnoses including chronic obstructive pulmonary disease, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, asthma, cannabis use, and suicidal ideations. R16's Minimum Data Set (4/28/2026) documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R16 is cognitively intact. R16's care plan (6/27/2026) documents R16 has have factors that may increase R16's susceptibility to abuse/neglect. R16 demonstrates: Behavior that might be characterized as provoking, antagonizing, disrespectful, angry, insensitive, &/or annoying., Current or H/O Conflict between/with roommate(s), Delusions/Hallucinations, Diagnosis of Mental Illness I am observed/monitored to mitigate potential risk towards becoming a recipient or perpetrator of abuse/neglect or further trauma. Additionally, R16's care plan (6/17/2026) documents R16 frequently threatens to call the State Survey Agency, ombudsman, police, and attempting to justify offensive behaviors and interventions include assure me that staff are more than willing to address legitimate concerns and involving state survey officials, the police or the EMS will likely only result in more frustration and negative consequences for him/her personality (i.e., a monetary fine for abuse of the EMS) (6/12/2026). On 7/16/2026 at 10:31 AM, V89 (Security Guard) was sitting in a chair facing the west hallway. R16 was pacing in the east hallway and appeared in distress. R16 stated V89 had been threatening R16 to make R16 stay in his room. R16 recalled on 7/7/2026 in the afternoon around 3 o'clock, They moved me and put me on 1:1 (monitoring) for no reason. I was mad. I tried to leave my room and (V89) told me to get the f*** back into my room. (V89) kept coming at me and he choked me. I got him off and (V89) kept talking s*** . Then, (V89) was hitting me, threating me that (V89) was gonna (sic) hit me with the fan in my room. (V89) continued to bully me since then. Man, I'm afraid. That's why I called the cops because (V89) choked me. I felt suicidal because I felt so unsafe. I been telling everyone they all know. I have schizophrenia so no one will believe me that it happened. I feel like I have to defend myself from him, like (V89) might try to do it again. (V89) is working on this unit now. On 7/16/2026 at 10:37 AM, V1 (Administrator) affirmed V1 was already aware of an allegation. V1 explained V1 was aware R16 was suicidal and was sent to the hospital for suicidal ideation. V1 was alerted by V91 (Case Manager, Registered Nurse) of the allegation but V91 told V1 R16 said nothing happened. V1 stated V91 could be contacted for more information. When R16 came back from the emergency department visit, V1 recalled asking R16 if R16 had any problems with any staff members. R16 denied any issues and was more concerned about cigarettes, so V1 laid the issue to rest. V1 denied there was any further investigation completed into the allegation. On 7/16/2026 at 10:49 AM, V89 was on R16's floor. V89 denied the incident occurred and stated R16 frequently makes allegations up when things don't go R16's way. R16 will call police to get him out of situations. V89 denied V89 was suspended pending investigation or that an investigation occurred. On 7/16/2026 at 1:25 PM, V91 (Case Manager, Registered Nurse) affirmed V91 is R16's managed care case manager assigned from the insurance company. V91 expressed R16 and V91 have a close relationship and R16 regularly calls V91. V91 explained on 7/8/2026, R16 called V91 and stated he went to the hospital because he was feeling suicidal. R16 reported to V91 that V89 had choked him and threatened to hit him with a fan. V91 affirmed R16 had made false allegations in the past but emailed the facility's Administrator and Director of Nursing to report the allegation and ensure someone was looking into it. V91 affirmed choking someone is a form of physical abuse and threatening someone is a form of mental abuse. V91 affirmed the Director of Nursing stated it was a behavior from getting V91's smoking pass taken away, so V91 did not pursue it further. Email chain dated 7/8/2026, documents V91 emailed V1 and V2 at 3:52 PM stating, I am following up regarding a phone call I received from (R16). During the call, (R16) reported an allegation that a staff member identified as (V89) choked (R16) in his room and subsequently threatened to hit (R16) with a fan. (R16) stated that he called 911 to report the incident to law enforcement. (R16) further reported that following the incident, (R16) was transported to the hospital for evaluation. I know (R16) has behaviors of allegations in the past but was this investigated at all? Thank you! . On 7/8/2026 at 6:33 PM, an email replied from V2 (Director of Nursing)'s email stating, Hey (V91)!! That's actually not true. (R16) was caught smoking marijuana and his pass was revoked due to contraband. (R16) called 911 and told them he was suicidal. When the officer arrived (R16) told the officer the same thing and we then sent him out. (R16) does this every time his pass is taken away. On 7/16/2026 at 2:47 PM, V97 (Social Worker) denied participating in an investigation completed by the facility's administration regarding the alleged abuse between R16 and V89. V97 was not aware if an investigation was completed. On 7/20/2026 at 10:34 AM, V4 (Infection Preventionist) recalled V1 couldn't get a hold of V2 (Director of Nursing) so V1 called V4 asking V4 to check V2's email because there was an email from R16's case manager (V91). The email said R16 reported to V91 that R16 had been choked by V89. V4 affirmed a staff member choking someone is an allegation of physical abuse. V4 confirmed V4 replied to the email. V4 denied knowledge of any abuse allegation, reviewing/collecting any statements or any other investigative/reporting processes prior to replying and was told it was a behavior. V4 denied knowledge if V89 was ever suspended pending an investigation. V4 stated, (V1) is the Abuse Prevention Coordinator and is typically responsible for obtaining statements. (V1) was aware, if (V1) chose not to investigate it or report it, that's on (V1), that's not on me. On 7/21/2026 at 10:51 AM, V1 (Administrator) confirmed V1 is the Abuse Prevention Coordinator. V1 confirmed there were no other abuse allegations completed that involved R16 prior to 7/16/2026. V1 affirmed there was no evidence that could be produced to indicate an investigation was completed after the email from V91 on 7/8/2026. V1 denied V90 told V1 about any allegation of R16 being choked. V1 stated the first time V1 heard the allegation was on 7/16/2026 from the surveyor (this statement contradicts V1's statement on 7/16/2026). V1 explained V1 saw an email from an insurance case manager, deferred it to the nursing department, and didn't really read it. V1 could not get a hold of V2 (Director of Nursing) so V1 called V4. V4 said R16 was having behaviors, was saying R16 was suicidal, and knew what was going on. V1 denied V4 said anything about an abuse allegation (choking or threatening) to V1. V1 stated if V1 knew there was an allegation of choking, V1 would have completed an investigation. No further documentation was produced by facility staff that indicates an investigation was completed after V91 reported the allegation on 7/8/2026 Facility abuse prevention policy (revised 1/2019) documents it is the policy of the facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility. The policy identifies verbal abuse as any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families or within their rearing distance to describe residents, regardless of their age, ability to comprehend or disability. Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also involves controlling behavior through corporal punishment. Mental abuse is defined as humiliation, harassment, threats of punishment, or withholding of treatment or services. If abuse is suspected, the policy instructs staff to separate the alleged perpetrator and assure all residents safety and notify the administrator or director of nursing immediately. When an allegation or suspected case of abuse or neglect is reported to the administrator, or the Director of Nursing in the administrator's absence, the facility will notify the following persons immediately . 1. State Licensing and Certification Agency (ie. IDPH). All incidents, allegations or suspicions of abuse, neglect exploitation, will result in an abuse investigation and will be documented. The final investigation report will be completed within five working days of the reported incident. The final report shall include facts determined during the process of the investigation, review of medical records, personnel files, and interviews of witnesses. The final investigation shall include a conclusion of the investigation based on known facts. The administrator will review the report and be responsible for forwarding a final written report of the result of the investigation and of any corrective action taken to the Department of Public Health within five working days of the reported incident.

Based on observation, interview, and record review, the facility failed to report allegations of abuse to the State Survey Agency within regulatory reporting requirements and failed to report allegations of abuse to the Abuse Prevention Coordinator. These failures affected three residents (R16, R140, R204) in a sample of 68 residents.Findings include: 1) R16's face sheet documents R16 is a [AGE] year-old resident with diagnoses including chronic obstructive pulmonary disease, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, asthma, cannabis use, and suicidal ideations. R16's Minimum Data Set (4/28/2026) documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R16 is cognitively intact. On 7/16/2026 at 10:37 AM, V1 (Administrator) was notified of R16's allegation against V89. V1 affirmed V1 was already aware of the allegation. V1 explained V1 was aware R16 was suicidal and was sent to the hospital for suicidal ideation. V1 was alerted by V91 (Case Manager, Registered Nurse) of the allegation but V91 told V1 R16 said nothing happened. V1 stated V91 could be contacted for more information. When R16 came back from the emergency department visit, V1 recalled asking R16 if R16 had any problems with any staff members. R16 denied any issues and was more concerns about cigarettes, so V1 laid the issue to rest. V1 affirmed allegations of abuse are required to be reported to the State Survey Agency within 2 hours. On 7/16/2026 at 1:25 PM, V91 (Case Manager, Registered Nurse) affirmed V91 is R16's managed care case manager assigned from the insurance company. V91 expressed R16 and V91 have a close relationship and R16 regularly calls V91. V91 explained on 7/8/2026, R16 called V91 and stated he went to the hospital because he was feeling suicidal. R16 reported to V91 that V89 had choked him and threatened to hit him with a fan. V91 affirmed R16 had made false allegations in the past but emailed the facility's Administrator and Director of Nursing to report the allegation and ensure someone was looking into it. V91 affirmed choking someone is a form of physical abuse and threatening someone is a form of mental abuse. V91 affirmed the Director of Nursing stated it was a behavior from getting V91's smoking pass taken away, so V91 did not pursue it further. Email chain obtained from V91, dated 7/8/2026, documents V91 emailed V1 and V2 at 3:52 PM stating, I am following up regarding a phone call I received from (R16). During the call, (R16) reported an allegation that a staff member identified as (V89) choked (R16) in his room and subsequently threatened to hit (R16) with a fan. (R16) stated that he called 911 to report the incident to law enforcement. (R16) further reported that following the incident, (R16) was transported to the hospital for evaluation. I know (R16) has behaviors of allegations in the past but was this investigated at all? Thank you! . On 7/8/2026 at 6:33 PM, an email replied from V2 (Director of Nursing)'s email stating, Hey (V91)!! That's actually not true. (R16) was caught smoking marijuana and his pass was revoked due to contraband. (R16) called 911 and told them he was suicidal. When the officer arrived (R16) told the officer the same thing and we then sent him out. (R16) does this every time his pass is taken away. On 7/20/2026 at 10:34 AM, V4 (Infection Preventionist) recalled V1 couldn't get a hold of V2 (Director of Nursing) so V1 called V4 asking V4 to check V2's email because there was an email from R16's case manager (V91). The email said R16 reported to V91 that R16 had been choked by V89. V4 affirmed a staff member choking someone is an allegation of physical abuse. V4 confirmed V4 replied to the email. V4 denied knowledge of any abuse allegation, reviewing/collecting any statements or any other investigative/reporting processes prior to replying and was told it was a behavior. V4 stated, (V1) was aware, if V1 chose not to investigate it or report it, that's on (V1), that's not on me. Record review of police report (7/7/2026) documents R16 called the police and reported staff choked him. The offender's name is not listed, but physical description matched V89's appearance. The front desk staff told the officer R16 had lost his smoking privileges and when R16 loses smoking privileges, he makes allegations of misconduct. R16 told the officer someone had choked him and did not elaborate on who did it. R16 did not have visible marks consistent with being choked. V90 (Licensed Practical Nurse) denied any staff member had battered R16. V90 told the officer R16 admitted he was suicidal and police requested paramedics to transport R16 to the hospital for a psychiatric evaluation. On 7/20/2026 at 10:46 AM, V90 (Licensed Practical Nurse) affirmed V90 took R16 downstairs after R16 called 911. V90 called the officers questioning R16 and R16 asking if R16 could smoke. R16 wanted to change his mind about being suicidal, but the officer told him he had to go to the hospital. V90 denied the police officer asked V90 any questions. V90 denied R16 told anyone he was choked but later stated R16 told the police officer a guy choked me. The officer didn't ask who choked him and R16 didn't say. V90 denied V90 told the police no one choked or battered R16 and affirmed V90 never spoke with the officer. V90 explained V90 did not report the allegation because residents, especially R16, make things up. V90 affirmed residents have to be consistent with their allegation for the allegation to be reported. V90 denied anyone interviewed V90 about the incident. On 7/21/2026 at 10:51 AM, V1 (Administrator) confirmed V1 is the Abuse Prevention Coordinator. V1 confirmed there were no other abuse allegations completed that involved R16 prior to 7/16/2026. V1 denied V90 told V1 about any allegation of R16 being choked. V1 stated the first time V1 heard the allegation was on 7/16/2026 from the surveyor. V1 explained V1 saw an email from an insurance case manager, deferred it to the nursing department, and didn't really read it. V1 could not get a hold of V2 (Director of Nursing) so V1 called V4. V4 said R16 was having behaviors, was saying R16 was suicidal, and knew what was going on. V1 denied V4 said anything about an abuse allegation (choking or threatening) to V1. V1 stated if V1 knew there was an allegation of choking, V1 would have reported the incident to the State Survey Agency. 2) R204's progress notes indicate on 7/14/2026 at 4:16 PM, V18 (Social Worker) documented R204 presented with manipulative and combative behavior toward staff and peers. After, R204 pulled the fire alarm. R204 provided education and placed R204 on smoking restrictions per the facility policy. On 7/21/2026 at 1:05 PM, V18 (Social Worker) recalled the incident with R204 having combative behavior towards peers. V18 described R204 as someone who uses people and antagonizes people that are more vulnerable than her. V18 heard yelling and saw R204 on the unit cursing out R140. R204 was yelling at R140, calling her a b****, telling her f*** you, and threatening to hit R140 and was going to slap R140. V18 separated the residents and placed R204 on one-to-one monitoring. V18 checked on R140 and recalled R140 didn't seem upset. V18 explained R140's baseline is cognitively impaired and mumbles, so R140 might not process the situation as a cognitively intact person would. V18 affirmed yelling at a resident, threatening residents, are verbal/mental abuse. V18 affirmed when a staff member witnesses abuse or receives an allegation of abuse, the staff member is to notify their supervisor and the administrator. V18 denied V18 told anyone about the incident between R140 and R204. V18 stated, I only told (V17, Assistant Administrator) about (R204) pulling the fire alarm the following day. On 7/21/2026 at 1:51 PM, V17 affirmed V18 notified V17 about R204 pulling the fire alarm but did not tell V17 about R204 and R140's altercation. V17 explained threatening and yelling at someone is considered verbal/mental abuse and can progress to physical abuse if not addressed. When staff witness abuse, they are to report it to V1 (Administrator) so V1 can complete an investigation and report to the State Survey Agency. Facility initial report (7/21/2026) completed by V1 (Administrator) of the incident between R204 and R140 documents on 7/14/2026, V18 documented R204 exhibiting manipulative and combative behaviors. On a subsequent interview with V18 on 7/21/2026, V18 disclosed R204 made verbal and physical threats to R140. V18 acknowledged the allegation of resident-to-resident abuse was not reported to facility Administration until 7/21/2026 and was suspended pending investigation. Facility abuse prevention policy (revised 1/2019) documents it is the policy of the facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility. The policy identifies verbal abuse as any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families or within their rearing distance to describe residents, regardless of their age, ability to comprehend or disability. Mental abuse is defined as humiliation, harassment, threats of punishment, or withholding of treatment or services. If abuse is suspected, the policy instructs staff to separate the alleged perpetrator and assure all residents safety and notify the administrator or director of nursing immediately. When an allegation or suspected case of abuse or neglect is reported to the administrator, or the Director of Nursing in the administrator's absence, the facility will notify the following persons immediately . 1. State Licensing and Certification Agency (ie. IDPH).

Based on observation, interview, and record review, the facility failed to keep residents free from verbal/mental abuse. This failure affected three residents (R49, R140, R204 ) in a sample of 68 residents reviewed for abuse. Findings include: 1)R204's face sheet documents R204 is a [AGE] year-old female resident with diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder, bipolar disorder, cocaine abuse and alcohol abuse. R204's Minimum Data Set (7/7/2026) documents a Brief Interview for Mental Status (BIMS) score of 11, indicating R204 has cognitive impairment. R204's care plan (revised 7/8/2025) identifies R204 has risk factors that make R204 susceptible to abuse/neglect including current or history of conflict between roommates/staff, aggression, depression, history of drug and or alcohol abuse. R204's goal of care is to be treated with respect and dignity while in the facility. R49's face sheet documents R49 is a [AGE] year-old male resident with diagnoses including type 2 diabetes mellitus, unspecified dementia without behavioral disturbance, schizoaffective disorder, acute kidney failure, heart failure, arthritis, and glaucoma. R49's Minimum Data Set, dated [DATE], documents Brief Interview for Mental Status (BIMS) score of 14, indicating R49 is cognitively intact. R49's care plan (revised 6/30/2026) identifies R49 has a history of aggressive, inappropriate, attention-seeking and or maladaptive behavior. History includes acting impulsively, erratically and making loud outbursts while in the milieu. R49's goal of care is to behave in a manner consistent with resident conduct policies through the next review. On 7/20/2026 at 1:28 PM, V92 (Security) was on the telephone at the front desk, with residents lined up down the hallway adjacent to the side of the front desk. R204 screamed SHUT UP! and R49 replied, No, you b****. No staff was observed intervening. R204 stated R49 was bothering her and didn't want to talk about it. R49 continued to make comments towards R204 and R49 yelled SHUT UP! again at R49. R49 replied, You know what b****, I'm gonna beat your a**. V92 told R204 and R49 to stop and instructed them to go to opposite sides of the hallway. R49 stated, Yeah, I'm going to beat her ass because I gave her two dollars, she ain't pay me back (sic). R204 yelled back and V92 instructed both residents to go out and smoke. R204 and R49 walked with the other residents to go smoke;V92 did not separate residents. On 7/20/2026 at 1:32 PM, observed R49 and R204 on the smoking patio with other residents. The smoking patio was being monitored by V28 (Central Supply Manager/Security Manager). R204 was still agitated and calling R49 an as*****. R204 stated, Yeah you don't care about that, you don't care about anything. You don't even care about yourself!. Staff did not intervene. Both residents went to the smoking cart to retrieve cigarettes and began to smoke. R204 shouted loudly to the group, He's just mad because no one wants to f*** him!. Staff did not intervene. R49 went back into the building unsupervised. R204 went back in with V28 (Central Supply Manager/Security Manager). V28 went into the housekeeping office and R204 entered the elevator. On 7/20/2026 at 1:40 PM, V28 (Central Supply Manager/Security Manager) recalled observing R204 and R49 slinging words back and forth to one another while smoking. V28 couldn't recall exactly what they were saying. On 7/20/2026 at 1:42 PM, V92 (Security) recalled V92 was at the front desk when he heard R204 and R49 getting into it prior to the yelling. V92 asked what the issue was. R204 said R49 was bothering her and R49 said R204 was bothering him. V92 told them to be quiet and stop. V92 could not hear what exactly was yelled between R204 and R49 as V92 was on the phone and the caller was asking V92 questions. V92 did not want to be rude and hang up. After the yelling, V92 recalled telling them to go smoke. V92 explained V92 did not separate the residents because they were already separated and on other sides of the hallway. On 7/20/2026 at 1:47 PM, V28 in V1's (Administrator) office. V1 inquired if surveyor was here to report the verbal altercation between R204 and R49. V1 affirmed V1 was told by V28. V1 stated the incident was going to be investigated. 2) R204's progress notes indicate on 7/14/2026 at 4:16 PM, V18 (Social Worker) documented R204 presented with manipulative and combative behavior toward staff and peers. After, R204 pulled the fire alarm. R204 was provided education and placed R204 on smoking restrictions per the facility policy. On 7/21/2026 at 1:05 PM, V18 (Social Worker) recalled the incident with R204 having combative behavior towards peers. V18 described R204 as someone who uses people and antagonizes people that are more vulnerable than her. V18 heard yelling and saw R204 on the unit cursing out R140. R204 was yelling at R140, calling her a b****, telling her f*** you, and threatening to hit R140 and was going to slap R140. V18 separated the residents and placed R204 on one-to-one monitoring. V18 checked on R140 and recalled R140 didn't seem upset. V18 explained R140's baseline is cognitively impaired and mumbles, so R140 might not process the situation as a cognitively intact person would. V18 affirmed yelling at a resident and threatening residents are verbal/mental abuse. R140's face sheet documents R140 is a [AGE] year-old resident with diagnoses including osteoarthritis, schizoaffective disorder, unspecified psychosis, unspecified convulsions, drug-induced tremors, and cognitive communication deficit. R140's Minimum Data Set (5/1/2026) documents a Brief Interview of Mental Status (BIMS) score of 4, indicating R140 has severe cognitive impairment. R140's care plan (7/8/2026) documents R140 has a history of suspected abuse, neglect, exploitation, past trauma and/or other factors that may increase R104's susceptibility to abuse/neglect. On 7/21/2026 at 1:25 PM, R140 was resting in bed. R140 affirmed residents have yelled and threatened her while R140 has been at the facility. R140 could not recall who the resident was. R140 stated being yelled at and threatened made (R140's) heart beat real fast. R56 (R140's Roommate) affirmed R204 was the resident that yells at R140 and threatens her. R56 stated R204 yells and threatens to hurt and hit R140 often. R56's face sheet documents R56 is a [AGE] year-old resident with diagnoses including schizophrenia, psychoactive substance abuse, drug induced subacute dyskinesia, moderate intellectual disabilities, and trichomoniasis. R56's Minimum Data Set (5/8/2026) documents a Brief Interview of Mental Status score of 13, indicating R56 is cognitively intact. On 7/21/2025 at 1:30 PM, R153 (R140's other roommate) explained R140 and R240 constantly don't get along, they are like oil and water. R153 recalled R204 frequently cursing at R153, calling her names like b****and threatening to knock her lights out. R153 stated R204 yells and threatens R153 at least twice a week and sometimes R140 will threaten her back. R153 affirmed the incidents usually happen in the dining room, and staff are aware because they tell them to stop. R153 could not recall which staff have intervened. R153's face sheet documents R153 is a [AGE] year-old resident with diagnoses including bipolar disorder manic with psychotic features, schizoaffective disorder, type 2 diabetes mellitus, peripheral vascular disease, and chronic kidney disease. R153's Minimum Data Set (7/9/2026) documents a Brief Interview of Mental Status (BIMS) summary score of 14, indicating R153 is cognitively intact. Facility abuse prevention policy (revised 2019) documents it is the policy of the facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility. The policy identifies verbal abuse as any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families or within their rearing distance to describe residents, regardless of their age, ability to comprehend or disability. Mental abuse is defined as humiliation, harassment, threats of punishment, or withholding of treatment or services. If abuse is suspected, the policy instructs staff to separate the alleged perpetrator and assure all residents safety and notify the administrator or director of nursing immediately.

Based on interview and record review, the facility failed to ensure trauma screenings were documented as recommended and/or failed to conduct/document required abuse risk assessments per regulatory requirements for three of three residents (R1, R2, R3) reviewed for abuse/misappropriation of property.Findings include:R1's diagnoses include bipolar disorder and unspecified psychosis. R2's diagnoses include schizoaffective disorders. R3's (5/2/26) facility concern form states resident misplaced $40. R3's diagnoses include paranoid schizophrenia.On 6/23/26, the surveyor reviewed facility assessments via EMR (Electronic Medical Records) however required abuse risk assessments were not documented for R1, R2, and R3.On 6/24/26 at 11:16am, V2 (ADON/Assistant Director of Nursing) presented trauma screenings for R1, R2, and R3 - not abuse risk assessments (as requested) and stated they use the trauma screen for the abuse risk assessment. The trauma screening form was reviewed and states risk measure for likelihood for psychiatric, behavioral and/or physical symptomatology related to trauma - risk for abuse is excluded. Surveyor inquired why abuse risk assessments were not conducted/documented for R1, R2 and R3. V2 responded, The Social Services Department said that everybody gets this screening; the title is a trauma screening, but they assess abuse risk for everybody. Abuse risk assessments for R1, R2, and R3 were not received during this survey.R1's (10/30/25) trauma screening determined a score of 4 (minimal trauma-related symptomatology). R2's (12/5/25) trauma screening determined a score of 5 (significant trauma-related symptomatology); therefore, assessments are recommended quarterly.R3's (1/8/24) trauma screening determined a score of 2 (minimal trauma-related symptomatology).On 6/24/26 at 2:35pm, V10 (Social Service) was asked if abuse risk assessments should be documented for each resident. V10 (Social Service) stated, Yeah, they should be done for each resident. V10 was asked when abuse risk assessments are required. V10 responded, Quarterly. V10 was asked why abuse risk assessments were not documented quarterly for R1, R2, and R3. V10 replied, I didn't believe that specific one, is one that we have, that was not something that we have. On 6/24/26 at 3:25pm, V2 (ADON) stated, We don't have a policy for abuse risk assessments. The screening assessment to determine the presentation of trauma factors including abuse and/or neglect policy (revised 6/24/26) states this nursing facility assesses each person to learn (to the extent possible) if there is any history of trauma/traumatic events. The purpose of this assessment tool is to screen residents to learn about any history of trauma and identify persons who have a history of mistreatment and/or to determine if factors exist making the person more susceptible or vulnerable to mistreatment. This information will be integrated into their comprehensive treatment plan assuring delivery of appropriate medical and mental health services. The assessment will be used to help identify persons who may present with a greater than normal risk for mistreatment in a residential setting. Persons assessed as low risk should be reassessed, as necessary, but during a significant change assessment is recommended, if moderate or high risk the frequency recommended is quarterly. Numerical scoring will indicate the risk measure for the likelihood for psychiatric, behavioral and/or physical symptomology related to trauma.

Based on interview and record review, the facility failed to ensure comprehensive care plans include risk for abuse with preventive interventions for three of three residents (R1, R2, R3) reviewed for abuse/misappropriation of funds.Findings include:R1 was admitted to the facility on [DATE] with diagnoses which include bipolar disorder and unspecified psychosis. On 6/8/26, IDPH (Illinois Department of Public Health) received allegations that R1 was a victim of misappropriation of property. On 6/23/26, R1's care plan was reviewed, however, risk for abuse and preventive interventions were excluded.R2 was admitted to the facility on [DATE] with diagnoses which include schizoaffective disorders. On 6/22/26, IDPH received allegations that R2 was a victim of physical abuse. On 6/23/26, R2's care plan was reviewed, however, risk for abuse and preventive interventions were excluded.R3 was admitted to the facility on [DATE] with diagnoses which include paranoid schizophrenia.R3's (5/2/26) facility concern form states resident misplaced $40. On 6/23/26, R3's care plan was reviewed, however, risk for abuse and preventive interventions were excluded.On 6/24/26 at 11:16am, V2 (Assistant Director of Nursing) was asked if R1's comprehensive care plan includes risk for abuse. V2 (Assistant Director of Nursing) reviewed R1's care plan and replied, I'm not seeing the abuse or neglect in this (referring to R1's care plan) right now. V2 was asked if R2's comprehensive care plan includes risk for abuse. V2 reviewed R2's care plan and stated, I'm seeing the manipulative behaviors, resisting care, aggressive/inappropriate behaviors and identified offender but that particular one, I didn't see. V2 was asked if R3's comprehensive care plan includes risk for abuse. V2 reviewed R3's care plan and stated, I didn't see a risk for abuse.On 6/24/26 at 2:35pm, V10 (Social Service) was asked about the requirements for developing/implementing resident care plans. V10 (Social Service) stated, I'm making sure that I go through the PASRR (Pre admission Screening Resident Review) and inputting certain things that need to be put in for the Social Services. V10 was asked if risk for abuse should be included in resident care plans. V10 responded, Yes. V10 was asked who is responsible for abuse risk care plans? V10 replied, Social service is responsible. V10 was asked when comprehensive care plans were reviewed and/or revised. V10 replied, They get updated every quarter and if a behavior pops up, we (staff) add the behaviors.The abuse prevention program policy (revised 01/2019) states as part of the social history evaluation and MDS (Minimum Data Set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches which would reduce the chances of mistreatment for these residents. The comprehensive care plan policy (revised July 2022) states comprehensive care plans are to be done with every new admission, annual, significant change in status and quarterly. Comprehensive care plans will be developed for each resident that includes problem/need of the resident, measurable objectives and interventions to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plans will be reviewed and updated every quarter (90 days) at minimum. The facility may need to review the care plans more frequently based on changes in the residents' condition and/or newly developed health/psychosocial well-being issues.

Based on interview and record review, the facility failed to provide a decision maker for a resident with severely impaired mental status. This failure affected one (R1) resident reviewed for residents' rights in the total sample of 4 residents. Findings include:R1's admission Record documented R1's diagnoses include but are not limited to epilepsy, bipolar disorder, and hypertensive heart disease. R1's contact information include only himself as responsible party. R1's census list documented R1 was initially admitted to the facility on [DATE].R1's (02/02/2026) Minimum Data Set documented, Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 03. Indicating R1's mental status as severely impaired. Section I: Active Diagnoses: Medically complex conditions, heart failure, hypertension, psychotic disorder and, schizophrenia.R1's (09/30/2025) Minimum Data Set documented, Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 03. Indicating R1's mental status as severely impaired.R1's (12/19/2025) Report of Physician documented, IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, PROBATE DIVISION. Case No. (BLANK). Estate of: (Blank). Calendar: (blank). Alleged Person with a Disability: (blank). (V20 - Medical Doctor), a licensed physician, submits the following report on (R1), an alleged person with disability. Note: The evaluations upon which this Report is based must have been performed within three (3) months of the date the Petition for guardianship is filed. The following is a description of the nature and type of the Respondent's disability' and an assessment of how the disability impacts on the ability of the Respondent to make decision or to function independently, including an underlying diagnosis and a description of the manifestation of the disability: patient suffers from schizoaffective disorder which impairs ability to make decision and function independently. The following is my opinion as to whether guardianship is needed, the type and scope of the guardian ship needed, and the reasons for my opinion, including whether the respondent is totally or only partially incapable of making personal then financial decisions and if only partially, the kinds of decisions which the respondent can and cannot make: full guardianship is needed as patient is totally incapable of making personal or financial decisions.R1's (03/31/2026) Hospital discharge summary documented, GI Progress Note. No family available for consent, awaiting public guardian. Internal Medicine Progress Note: Legal Guardianship would then be pursued after discharge at the nursing home. R1'S (03/12/2026) Change in Condition documented, 1. Signs and symptoms identified. 3. Altered mental status. 3. Resident Representative Notification. 1. Name of family/resident representative Notification. SELF. R1's (09/04/2025) Progress Notes documented, Resident observed sitting on the floor inside the room. No family member contact on face sheet. Will continue with resident status care as needed. The (04/03/2026) email correspondence with V2 documented, I (V2) have reached out to the facility attorney regarding the guardianship (for R1), and I will let you know as soon as I get something. Facility failed to provide documentation the facility lawyer initiated guardianship for R1.On 04/02/2026 at 11:35am inside R1s' room with V13 (Licensed Practice Nurse), R1 was lying on bed, mumbling, and vocalizing 'haaaaa'. R1 did not nod nor turn his head left and right when this surveyor's inquired if he was wet. V13 stated he cannot communicate or hold a conversation. R1 has no POA (Power of Attorney) on his clinical record. V13 stated he should have one because he is not able to make a decision. V13 stated the importance of having a decision maker is to ensure the resident is getting proper care that suit his needs. The guardian can make the decision for him in the best interest of the resident. On 04/02/2026 at 11:46am, V5 (Social Services/Memory Care Coordinator) stated R1 mumbled, and V5 could not tell what R1 was saying. V5 stated he was in charge of completing the BIMS (Brief Interview for Mental Status) of the resident. V5 stated R1 has a BIMS of 3, meaning his mental status is severely impaired. V5 stated when it was determined the resident has severely impaired mental status, the facility should have initiated the process of getting a guardian or surrogate for R1. V5 stated on day of admission, it was determined that R1 was appropriate to be admitted on his current floor which was a dementia floor; he was initially admitted from a different floor, and he was moved to his current floor on 09/04/2025. V5 stated he is responsible for reviewing the resident admission packet; he probably reviewed the admission packet and might have missed one or few things including R1's guardianship. V5 stated he did not initiate guardianship for R1. V5 stated the importance of guardianship or surrogacy is to ensure someone is advocating for the resident; to ensure the resident is properly taken care of. V5 stated if he did not have a guardian or surrogate decision maker; the effect, potentially, his needs are not being met. On 04/02/2026 at 1:09pm, V9 (Admissions Director) stated the staff in charge of making sure the resident has the capacity to make a decision during admission or couple of days after admission is the Social Services. V9 stated she only reviews the referral packet for financial background of the resident, mainly for insurance purpose only. On 04/02/2026 at 2:14pm, V14 (Assistant Social Services Director) stated Section C of the MDS (Minimum Data Set) would tell the staff whether a resident is capable of making a decision. V14 stated if R1 has a BIMS of 3, it means the resident could not answer certain things correctly, indicating his mental status as severely impaired and cannot make a decision. V14 stated the resident should have a surrogate or guardian; and the process of getting one should start right after it was determined he could not make a decision; ask family members to see if they are willing to step in as the resident's decision maker. V14 stated the importance of having a decision maker for a resident who cannot make a decision for himself so there is someone they can contact in case of emergency or with any changes in condition who can make a decision for the resident. On 04/02/2026 at 4:30pm, V2 (Director of Nursing) stated if the resident did not have anyone on file as decision maker, Social Services should have initiated the process of asking the family for surrogacy and if that did not work, start the process of guardianship. It has to be initiated when the BIMS assessment is completed, Social Services should have investigated if he has a family; or check if guardianship is initiated. V2 stated there is a failure in getting a decision maker for him and the purpose of getting a decision maker for him is to make sure his needs are being met. On 04/06/2026 AT 9:33am, V19 (Guardian Representative - Office of the State Guardian) stated the person should be assessed by the doctor to make a determination the person needs guardianship; if no family is willing to take guardianship, the facility has to submit a referral to the State for guardianship. V19 stated R1's name is not on their file for guardianship.On 04/06/2026 at 3:41pm, V2 affirmed R1 has no decision maker on R1's clinical record. The (undated) Facility Policy on Adult Guardianship in the State documented, Background. It is the policy of this nursing facility to work with residents, family members and significant others to help residents receive appropriate representation and advocacy, as necessary, based upon their medical and mental health conditions. Guardianship for an adult in a long-term care facility may be necessary for an individual who is unable to make and communicate responsible decisions regarding personal care or finances due to a mental, physical or developmental disability. Courts ultimately determine the necessity of a legal guardian based on a thorough clinical evaluation and report. Guardianship is typically initiated by the Attending Physician or Psychiatrist. This individual will be responsible for completing the court mandated evaluation explaining the person's deficits/inability to provide self-care (in [NAME] County this is the CCP-211). Residents of LTC/SMHRF facilities should not have outside persons/entities soliciting them for matters of guardianship. This process needs to commence with a determination and discussion with the Physician(s). The facility will reach out upon admission to Guardian, including the identified representative of OSG or OPG (Cook County Office of Public Guardian). The Guardian's contact information shall be identified in the clinical record along with documents proving guardianship.The (undated) Your Rights and Protections as a Nursing Home Resident documented, What are my rights in a nursing home? As a nursing home resident, you have certain rights and protections under Federal and state law that help ensure you get the care and services you need. You have the right to be informed, make your own decisions, and have your personal information kept private. The nursing home must tell you about these rights and explain them in writing in a language you understand. They must also explain in writing how you should act and what you're responsible for while you're in the nursing home. This must be done before or at the time you're admitted , as well as during your stay. You must acknowledge in writing that you got this information. Get Proper Medical Care: You have the following rights regarding your medical care: Family members can also help with your care plan with your permission. To access all your records and reports, including clinical records (medical records and reports) promptly (on weekdays). Your legal guardian has the right to look at all your medical records and make important decisions on your behalf. Have Your Representative Notified: The nursing home must notify your legal representative or an interested family member when the following occurs: Your physical, mental, or psychosocial status starts to get worse. Your treatment needs to change significantly.

Based on interview and record review, the facility failed to ensure a resident's refusal of medications was care planned. This failure affected one (R2) resident reviewed for care plan in the total sample of 10 residents. Findings include:R2's admission Record documented that R2's diagnoses include but are not limited to bipolar disorder, restlessness and agitation, and anxiety disorder.R2's (02/10/2026) Minimum Data Set documented, Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15., indicating R2's mental status as cognitively intact. On 03/02/2026 at 11:50am, R2 stated V3-Licensed Practice Nurse kept giving her the antipsychotic medication even though she informed her she was allergic to it. V3 told her she was going to document she was refusing the medication.On 03/03/2026 at 3:43pm, V3 statedR2 did not only refuse her antipsychotic medication, R2 also refused her anti-depressant almost every time she worked on her (R2) floor. V3 stated she was sure she informed the Social Service Department so she could counsel her.On 03/03/2026 at 3:28pm, V20 (Assistant Social Services Director) stated she was in charge of completing R2's behavior, history of substance, suicidal ideation, community access, and refusal of medication care plan.On 03/03/2026 at 3:30pm, V20 checked R2's care plan using her personal phone and stated R2 did not have a care plan for refusal of medications. V20 stated, If she has 3 or more refusal of medications, she should be care planned, so we can put intervention on the refusal. V20 was shown R2's February MAR (Medication Administration Record) and 'code 2 - drug refused' was documented on R2's anti-depressant medication. V20 stated she did not review the MAR (Medication Administration Record), she ran the 24-hour report and reviewed it for any behavior. R2's (02/2026) MAR (Medication Administration Record) had a code '2 -Drug refused' on medications C******b 200mg on 2/10, 2/14, 2/15, 2/16, and 2/25; and C*****m on 2/12, 2/13, 2/18, 2/19, 2/20, and 2/25.R2's (02/16/2026) Behavior charting documented, Resident continues to curse at nurse and refused ice and morning medication from nurse.R2's (02/25/2026) Nurses notes documented, Resident refused medication. Educated about medication refusal and resident stated I don't care to take medication from you or anyone.R2's (provided on: 03/02/2026) entire care plan was reviewed. R2 was not care planned for refusal of medications.R2's (03/03/2026) care plan documented, Focus: Refusal: exhibit the symptoms of resisting care which is related to: These behavioral symptoms are manifested by: Refusing/resisting medications. Goal: comply with treatment plan through the next review. Intervention: Conduct an evaluation of the behavioral symptom(s) to determine what strengths or needs are communicated via the behavior (e.g., resisting care often communicates the emotion of fear & need for control). Of note, this care plan was added during the survey. The (undated) Guidelines for Resident Refusal of Treatment/Services/Medications documented, Facts: Refusal of one service does not absolve a facility from providing other care. Facility staff are expected to try to determine the cause of the refusal and address the concern if possible. Attempting to determine why the resident is refusing care should include whether a resident who is unable to verbalize their needs is refusing care for another reason (such as pain, fear of a staff member or other person, etc.). If a treatment or service is declined, the service that otherwise would be provided must be documented in the resident's medical record and must be in the resident's comprehensive care plan.The (07/2022) Policy and Procedure of Comprehensive Care Plans documented, Policy: Comprehensive Care Plans are to be done with every New admission, Annual, Significant change in status and every Quarterly. Comprehensive Care Plan will be developed for each resident that includes; problem/need of the resident, measurable objectives and interventions to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the Comprehensive Assessment. The facility interdisciplinary team, in conjunction with the resident, resident's family, surrogate, or representative, as appropriate, will develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the Comprehensive assessments and the CAAs. Procedure: 5. The Comprehensive Care Plans will be reviewed and updated every quarter (90 days) at minimum. The facility may need to review the care plans more frequently based on changes in the resident's condition and/or newly developed health/psychosocial well-being issues. 6. The facility MDS/Care Plan Coordinators and ancillary MDS staff will attend the department head meeting with in-depth review of the 24-hour report and will establish a new plan of care and/or make revisions to existing care plans to address any acute condition changes or exacerbation of chronic issues that may need revisions to the problem, goals and/or interventions.

Based on observation, interview, and record review, the facility failed to have an effective pest control program to prevent and eliminate rodents/mice from the kitchen's dry storage area. This failure has the potential to affect all 266 residents in the facility. Findings include: Facility census (1/5/2025) documents 266 residents reside within the facility. On 1/5/26 at 10:26am during observation of the dry storage area of the kitchen with V7(Dietary Manager), the floor was observed with visible dirt, spilled dried grits, and about 22 pieces of mice droppings were observed on the floor by the wall under the bottom shelve. V7 was asked what kind of rodents' waste/droppings were on the floor; V7 stated, They are mice droppings. V20 (Regional Director of Operations) also observed the dry storage area. V20 stated the facility has problems with mice because the alley is very close to the kitchen (pointing at the left side that leads to the alley). V20 got a broom and dustpan and tried to sweep the droppings and stated the Pest control company comes regularly to the building. On 1/6/2025 at 10:45 am, the resident council unanimously agreed that pest control, including rodents and roaches, is an ongoing concern within the facility. R267 stated R267's room has rats and mice that run through it a few days a week, and R267 last saw rodents in the facility yesterday. On 1/7/26 at 10:20am, V7 was asked why there were so many mice droppings and why the person who took food items to cook breakfast in the morning did not clean the dirty floor including the mice droppings. V7 stated she was off work on Thursday, Friday, and the weekend, and she just returned to work on Monday, and the kitchen floor should be cleaned every day by staff. Facility's undated policy titled Pest Policy states: It is the policy of the facility to ensure that an effective pest control program is in place. An effective pest control program is defined as measures to eradicate and contain common household pests. #2: The maintenance staff and all the staff will be cognizant of the necessity to maintain a clean, safe, and comfortable homelike environment that is free of pests or rodents.

Based on observation, interview, and record review, the facility failed to ensure the facility assessment was developed in accordance with all required information. This failure has the potential to affect all 266 residents that reside within the facility. Findings include:Facility census (1/5/2025) documents in part that 266 residents reside within the facility. On 1/5/26 at 1:39pm, V17, Registered Nurse, was asked about the current (4th floor) staffing. V17 (Registered Nurse) stated, It's just 2 Nurse's, sometimes they (residents) have a CNA and sometimes they don't. V17 was asked if any of the 4th floor residents require assistance. V17 responded Most of them (residents) need supervision. On 1/6/25 at 1:17pm, V32 (Assistant Director of Nursing) was asked why there was not a CNA assigned to 4th floor on 1/5/26 (dayshift). V32 (Assistant Director of Nursing) stated she was unsure and stated, On 4th and 8th floor most of them are independent. We have psych techs and security cover those floors because of the behaviors. We want to schedule all the floors with a (1) CNA and on 3rd and 6th floor in the morning they get 4 or 5. On 1/6/25 at 1:44pm, V2 (Director of Nursing) stated, We had multiple call-off yesterday (1/5/26), so we pulled people. We had a CNA on 4th floor and pulled them to 3. (V12/Security Director) is a CNA so he was sent to 4th floor. Surveyor inquired about dayshift staffing in the facility V2 responded, We have 2 nurses on every floor except for 5th floor there's one nurse. We have 5 on 3 and 6th and one CNA on 4, 5, and 8. Review of the facility assessment (dated 12/18/2025) was completed. The facility assessment lacked the following required information: A) The governing body (V4) participated in the development of the facility assessment B) Any direct care staff were involved in the completion of the facility assessment C) The residents/representatives participated in development of the facility assessment D) Direct care staffing (CNA) needs by unit and shift E) a recruitment and retention plan for direct care staffing. On 1/5/2026 at 11:09 am, the facility assessment was reviewed with V1 (Administrator). V1 stated the facility assessment was developed by V1, V2 (Director of Nursing), V9 (Chief Nursing Officer), and the Medical Director. V1 confirmed no direct care staff, residents or their representatives were included in the development of the facility assessment, and the facility assessment does not have documentation direct care staff, the residents, or representatives were involved in the development of the facility assessment. V1 confirmed CNA needs are not broken down by unit and shift and stated, No, I didn't do that. Surveyor inquired the facility's plan for recruitment and retention of staff within the facility assessment. V1 (Administrator) reviewed the facility assessment again and affirmed there is no plan for recruitment or retention of direct care staff. V1 affirmed the missing elements are required under the regulation and explained the purpose of the facility assessment is to ensure all resident needs can/are being met and summarizes the care the facility is able to provide.Facility policy titled, Facility Assessment documents, A facility assessment is conducted annually to determine and update the capacity to meet the needs of and competently care for residents during day-to-day operations (including nights and weekends) and emergencies . 2. The team responsible for conducting, reviewing, and updating the facility assessment includes the following: 1. leadership and management, including the: 1. administrator. 2. representative of the governing body. 3. medical director. 4. director of nursing services; and 5. other department heads (as needed). 2. direct care staff, including: 1. RNs. 2. LPNs/LVNs. 3. nursing assistants; and 4. representatives of the direct care staff (if applicable). 3. residents, representatives, and family members. 1. Input from residents, resident representatives, and family members may be obtained by methods such as questionnaires, surveys, and suggestion boxes prior to the facility assessment . 11. The facility assessment is used to identify current or potential gaps in care or services due to misalignment or lack of appropriate resources .13. The facility assessment is used to inform staffing decisions. 1. The facility assessment is used to ensure there is enough staff with appropriate competencies and skill sets to meet the needs of the residents identified through the review of resident assessments and plans of care. 1. Staffing needs are considered for each unit and adjusted as necessary based on changes in the resident population. 2. Staffing needs are considered for each shift, including day, evening, and night shifts, and adjusted as necessary based on changes in the resident population. 2. The facility assessment is used to develop and maintain a direct-care staff recruitment and retention plan .

Based on observation, interview, and record review, the facility failed to ensure that 2 of 3 outside dumpsters garbage disposal were covered with the lids. This failure has the potential to harbor rodents which could cause infection and affect all 266 residents in the facility.Findings include:On 1/5/26 at 9:10am, 2 of 3 outside dumpsters were observed to be open without lids. On 1/5/26 at 11:10am during kitchen observation with V7(Dietary Manager), the same dumpsters were observed without covers. V7 stated leaving dumpsters open could cause rodents to come around the building, and the 2 dumpsters left open are mostly used by the Housekeeping and Laundry departments. V7 added she would notify their supervisors to remind staff to close the dumpsters. On 1/7/26 at 9:30am, V1(Administrator) stated she would speak with the laundry and housekeeping staff. V1 added, There's no reason to leave the dumpsters open because they have covers.Facility's policy and procedure manual titled Garbage and Refuse Disposal, dated 9/17/23, states: All garbage and refuse will be stored and disposed of daily in a sanitary manner. Garbage and refuse will be deposited in sealed dumpsters to prevent the harborage and feeding of rodents and pests.

Based on observation, interview, and record review, the facility failed to ensure the dish machine had the correct concentration of chlorine to sanitize dishes, trays, and utensils; failed to ensure the floor of the dry storage room was kept clean and free of visible debris, mice droppings, and spilled grits. These failures have the potential to affect all 266 residents that receive oral food from the facility's kitchen. Findings include:On 1/5/26 after the entrance conference, V1(Administrator) presented the facility census as 266.On 1/6/26 at 2:56pm, V1 stated tall 266 residents receive oral foods from the kitchen and those who have gastrostomy tubes still eat kitchen food for pleasure feeding.On 1/5/26 between 10:05am and 10:20am during observation of the kitchen with V7(Dietary Manager), V7 stated the kitchen uses a low temperature dish machine with chlorine sanitizer. V7 showed the color code for the chlorine sanitizer. V7 dipped the test strip and found it to be less than 10 parts per million(ppm). V7 tested it the second and the third time dipping the test strip in different parts of the dish machine each time, but the test strip still did not change color. V7 stated the sanitizing solution should be 50 ppm, and the color of the test strip should be purple. The chlorine chemical container was empty, and staff replaced the chemical container. V7 stated the test strip did not change because the container that dispensed the chemical was empty, and now it will dispense from the full chemical container.The floor of the Dry Storage Area of the kitchen was observed with visible accumulated dust, visible dirt, spilled dried grits, and about 22 pieces of mice droppings were observed on the floor by the wall under the bottom shelf. V7 stated the floor of the whole kitchen is supposed to be cleaned daily. V7 was asked what kind of rodents' waste/droppings were on the floor. V7 stated they are mice droppings. V20 (Regional Director of Operations) stated the facility has problems with mice because the alley is very close to the kitchen (pointing at the left side that leads to the alley).Facility's policy titled Food Safety & Sanitation- Machine Dishwashing, dated 9/17/23, states: The Facility will clean and sanitize food service utensils, dishes, and tableware using approved equipment. Before dishes are washed, the sanitation temperature or level of chemical sanitizer in the dish machine should be tested with the correct test strip. (ii) Low temperature using sanitizer: Temperature should be 120-150 degrees. Dip the appropriate chemical sanitizer test strip in the water on the drain board nearest to the opening at the clean end of the dish machine. The test strip should turn the appropriate color to indicate 50 to 100 parts per million for chlorine or 200 parts per million for quaternary ammonium sanitizer.Facility's Policy titled Food Safety & Sanitation-Cleaning Schedule, dated 9/22/23, states: The food service department will be cleaned and sanitized on a routine basis according to written cleaning schedules. #5 states: The dietary manager will review cleaning schedules to evaluate the results and look for unsatisfactory areas or items.Facility's Policy titled Food Safety & Sanitation-Storage of Dry Foods/Supplies- The facility will have a room/area designated for storage of dry goods such as single serve items, canned goods, packaged foods. The area will be clean, lighted, well ventilated, dry, free from contaminants and kept at room temperature around 70 degrees. Routine cleaning and pest control procedures are followed. Areas are free from garbage or other waste.

Based on interview and record review, the facility failed to develop and implement comprehensive, person-centered, and individualized fall care plans for four residents (R2, R8, R230, R253) with a history of falls. These failures have the potential to affect four residents (R2, R8, R230, and R253) reviewed for care plans in the total sample of 59 residents. Findings include: 1.R2's face sheet documents, diagnoses that include but are not limited to fracture of right hand, all on same level from slipping, tripping and stumbling without subsequent striking against object, and dementia.R2's BIMS (Brief Interview for Mental Status) score, dated 10/14/25, is 14, which indicates R2 is cognitively intact.R2's Fall Risk Review, dated 2/19/25, documents a score of 13, which indicates R2 was at high risk for falls, and also documents, Does the resident have a history of falls within the last 3 months? Yes. R2's progress note, dated 10/08/25, documents, Resident (R2) c/o (complain) pain on her right wrist. Writer asked resident (R2) what happened, resident (R2) stated that she (R2) had fallen in her (R2) room. Resident (R2) stated that, she (R2) was reaching for her (R2) coffee cup and lost her (R2) balance and fell. Resident c/o pain in her (R2) right wrist. Resident (R2) was observed from head to toe. VS (vital signs) checked, Resident (R2) was noted to have swelling to her (R2) right wrist and c/o pain. Ordered a STAT Xray to the right wrist. R2's hospital records, dated 10/09/25, documents, Presenting after a fall, found to have right distal radial and ulna fracture. Orthopedics consulted and will reduce, splint.R2's Fall care plan, dated 4/13/2021, documents, Goal: (R2) will have a safe environment maintained thru the next review. 2.R8's face sheet documents diagnoses that include but are not limited to history of falling, epilepsy, acquired absence of right leg below knee, acquired absence of left leg above knee, dementia, and altered mental status. R8's BIMS (Brief Interview for Mental Status) score, dated 12/23/25, is 13, which indicates R8 is cognitively intact. R8's Fall care plan, dated 8/21/2024, documents, Goal: (R8) will have a safe environment maintained through next review. 3.R230's face sheet documents an admission date 3/22/2023.R230's face sheet documents diagnoses that include but are not limited to nondisplaced intertrochanteric fracture of right femur (onset date 11/10/25), dementia, schizoaffective disorder, and low back pain.R230's BIMS (Brief Interview for Mental Status) score, dated 11/11/25, is 10, which indicates R230's cognition is moderately impaired.R230's progress note, dated 10/27/25 at 11:46am, per V21 (Registered Nurse/RN), documents, Resident (R230) alert oriented x2 in the dining area sitting in a chair, repeatedly attempting to throw himself out of the chair, staff monitoring area. Will continue plan of care. R230's progress note, dated 10/27/25 at 12:58pm, per V21 (Registered Nurse/RN), documents, Resident (R230) noted sitting in dining area in chair, resident leaped onto floor, resident doesn't know why he threw himself onto floor, Resident assessed. Resident assisted to chair, with staff, monitoring dining area. No enhanced or one-to-one supervision was implemented prior to the fall.R230's Fall care plan, dated 3/23/2023, documents, Goal: (R230) will have a safe environment maintained through next review.4.R253's face sheet documents, diagnoses that include but are not limited to generalized arthritis, chronic pain, pain in left knee, syncope and collapse, weakness, and unspecified fall.R253's BIMS (Brief Interview for Mental Status) score, dated 12/05/25, is 15, which indicates R253 is cognitively intact.R253's Fall Risk Review, dated 1/04/26, documents a score of 14, which indicates R253 is at high risk for falls.R253's progress note, dated 8/21/25 at 5:30am, per V16 (Registered Nurse/RN), documents, Resident (R253) observed laying on floor in right lateral position, when asked what happened the resident stated I tried to get in my chair, and I fell.R253's Fall care plan, dated 1/18/2020, documents, Goal: (R253) will have a safe environment maintained thru the next review.On 1/06/26 at 12:28pm, V24 (MDS) Coordinator stated goals for care plans should be measurable and want to be specific to the resident. V24 further explained the fall goal, will have a safe environment maintained thru the next review, was system-generated and stated, It generates the goal, and we (staff) need to customize it, but acknowledged the goal as written was broad and general. V24 stated goals depend on the type of clientele and should be related to the need of the resident and measurable. V24 stated the fall goal was just a broad statement, better to be safe, and stated, I'd have to look at all the interventions, indicating the goal itself did not clearly define resident-specific, measurable outcomes.On 1/06/26 at 12:44pm, V41 (Restorative Nurse Consultant) stated, We (facility staff) care plan everyone to have a safe environment through next review for falls and explained the goal was to keep them safe. V41 said, I think it's a measurable goal, but also acknowledged goals should be measurable and should be person-centered or I-centered. V41 further stated the residents' care plan goals should be tailored to each resident specific and acknowledged the goal, will have a safe environment maintained thru the next review, was probably general, and not person-centered. V41 further stated, I don't find anything wrong with it (goal), but also stated if there is a fall, we (facility staff) should update the goal for them, indicating that the existing goal did not include resident-specific, measurable outcomes related to the individual's fall risk.Review of facility policy titled, Care Plan Policy and Procedure, undated, documents, Each resident will have a comprehensive assessment completed that will assist in the development of an individualized plan of care that will include goals and interventions aimed to improve or maintain the residents highest level of function, prevent decline, decrease risk of complications of medical conditions, medications and diagnosis, decrease risk of injury or to promote comfort ant end of life. Each resident will have a comprehensive assessment completed by the Interdisciplinary team upon admission, quarterly and with significant changes and an individualized care plan will be developed and updated as needed with quarterly assessments, re-admissions, and changes in condition. Residents care plans will be reviewed and updated as needed with re-admissions, quarterly re-assessments, annually, and with any significant changes in condition. Review of facility policy titled, Fall Prevention and Management Program, undated, documents, Strategies/Interventions list may be used to identify appropriate interventions. Approaches/Interventions should focus of risk factors identified. Review of facility policy titled, Incidents/Accidents/Falls, undated, documents, The CNA information sheet will be updated as indicated to reflect the plan of care. Review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.Facility job description titled, MDS (Minimum Data Set) Coordinator, undated, documents, The primary purpose of this position is to coordinate, plan, organize, develop, evaluate and take part in, and to assure the quality of all facility services relating to the HCF A Minimum Data Set Assessment Instrument (MDS) and resident care planning (MDC/Care Planning); to safeguard the health, safety and welfare of all residents of the facility; to assure that all MDS/Care Planning is carried out in accordance with the facility's established policies and procedures, applicable federal and state laws and regulations, and the directions of your supervisors, who include the Administrator, Medical Director, and other members of the facility's management to whom such persons report; to do all things required of an MDS/Care Plan Coordinator; to implement the MDS/Care Planning policies established by, and assist in providing MDS. Conducts periodic review to ensure all documentation is informative and descriptive of nursing care and of the resident's response to that care.

Based on observation, interview, and record review, the facility failed to identify maintenance concerns, failed to document maintenance concerns/repairs, and failed to repair damaged ceilings/heater, for 54 (4th floor) residents reviewed for home-like environment.Findings include:The (1/4/26) facility census includes 54 (4th floor) residents. The 4th floor is a men's unit.On Monday (1/5/26) at 10:26am, R213's (metal) baseboard heater was falling off and severely bent away from the wall. Surveyor asked about concerns with the heater in R213's room. V13 (LPN/Licensed Practical Nurse) stated, That I'm not sure. V13 subsequently inspected the heater and responded, I could call maintenance; it's bent its metal.On (1/5/26) at 10:38am, the 4th floor shower/bathroom was inspected; large gaping holes were observed in the ceiling of both showers. Surveyor asked about concerns in the shower. V13 (LPN) stated, It's a hole in the ceiling. Upon further inspection, a blanket and toilet paper were observed on the floor in the toilet stall. On (1/5/26) at 10:45am, the hinge on R40's closet door (to lock the closet) was broken. Surveyor asked about concerns with the closet lock. R40 responded, It broke off. On (1/5/26) at 11:12am, R200 stated, My cabinet is broken and pointed to the closet door. R200 subsequently opened the left closet door, and it was dangling from the top bracket. The bottom bracket was observed to be broken.On (1/7/26) at 12:15pm, V8 (Maintenance Director) stated, We have 6 maintenance employees, one for each floor. Surveyor asked if V8 was aware of the large holes on the 4th floor shower ceiling. V8 stated, Yes ma'am; it was a plumbing issue. The p-trap was leaking, and we had to repair it. We got that covered up Monday (1/5/26). On (1/7/26) at 12:38pm, V8 presented the maintenance tablet. Surveyor requested to see the 4th floor shower ceiling work order request. V8 stated, We found it but honestly I didn't enter it. V1 (Administrator) responded, You (V8) should have entered it. Surveyor asked if the 4th floor broken closet doors and/or locks were entered in the maintenance tablet. V8 replied, Not on the 4th floor. The (undated) general maintenance policy includes purpose: to ensure that the nursing home environment is safe, sanitary, functional, and comfortable for residents, staff and visitors, in compliance with Illinois Department of Public Health rules and regulations, applicable life safety codes, and the Nursing Home Care Act. The facility shall maintain all buildings, systems, and equipment in good repair and safe operating condition at all times.The (undated) Physical plant - daily inspections policy states buildings are to be inspected daily. As areas needing repair or attention are identified, they should be dealt with immediately.

Based on observation, interview, and record review, the facility failed to ensure meals were served timely and failed to ensure dining room seating was available for four of 59 residents (R102, R108, R213, R241) in the sample reviewed for resident rights. Findings include:The facility meal-time schedule affirms the (4th floor) lunch is scheduled for 12:15pm-12:30pm.1.On 1/5/26 at 12:53pm, lunch was delivered to the 4th floor dining room via steam table. At 1:38pm V17 (Registered Nurse) affirmed R102, R108, and R241 had not received lunch. Most of the residents had completed their meal and had already left the dining room. R102, R108, and R241 had requested the alternate meal: hamburgers (per dietary cards). At 1:39pm, R241 inquired about lunch. V18 (Activity Aide) responded, We're waiting on hot burgers; they haven't come yet. At 1:45pm, hamburgers were delivered to the 4th floor dining room.2.On 1/5/26 at 1:25pm, R213 was served lunch on a tray at the steam table. He proceeded to carry the tray throughout the dining room to find a seat, however, no chairs were available. R213 stood in the dining room while holding the meal/tray and proceeded to eat half of a grilled cheese sandwich before staff provided a chair.On 1/7/26, surveyor requested the 4th floor dining room seating chart. At 1:52pm, V32 (Assistant Director of Nursing) presented a drawing with tables numbered 1-15, however, resident names were excluded. Surveyor inquired if the facility has a seating chart for each dining room to ensure that adequate seating is available. V32 responded, No, not with the resident names.The order of meals served policy (revised April 2022) states the Nursing Department will provide the Food Service Department with a seating chart for dining rooms. Every effort is made for the meals to be passed to the residents per table so everyone eating together receives their food together. Dining rooms that have open dining will serve the resident in a timely manner (after) being seated.

Based on interview and record review, the facility failed to ensure a cognitively impaired resident on an altered diet did not have access to a regular consistency sandwich. This failure resulted in R5 who was found choking and subsequently died . These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when R5 experienced a choking episode and dying at the hospital on [DATE]. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 9:44 AM. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on [DATE]; however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R5 is a [AGE] year-old male admitted to the facility on [DATE] with terminal illness under hospice services with diagnoses of frontotemporal neurocognitive disorder, dementia, diabetes, bipolar schizophrenia. Per facility assessment dated [DATE], R5's BIMS (Brief Interview for Mental Status) score was 7 which means R5 has severe cognitive impairment. The same assessment showed R5 was in need of supervision when eating and R5 is up and ambulatory independently. Physician Order Sheet (POS) dated ,d+[DATE] showed R5's diet order as: no added salt and no concentrated sweets diet, pureed texture, nectar consistency. R5's progress note dated [DATE] timed at 7:45 PM, documents: at approximately 7:40 PM showed staff reported that resident appeared to be choking, Heimlich Maneuver performed, 911 arrived and took over Heimlich maneuver. Resident left via emergency services with a pulse and was breathing. R5's progress note dated [DATE] timed at 8:20 PM, showed a call as received from the local hospital ER (emergency room ) that the resident had expired. Resident was pronounced dead at 7:48 PM, cause of death recorded as hypoxic cardiopulmonary arrest. R5's incident report dated [DATE] by V8 (License Practical Nurse-LPN) showed observed resident standing struggling for breath appeared to be choking as he was trying to cough .attempted Heimlich maneuver and when resident continued to be SOB [shortness of breath], we sat him down on his buttocks and continued Heimlich [maneuver]. I had already instructed staff to call 911. When 911 arrived, they continued Heimlich [maneuver] no food removed and then placed him on cart to hospital. Emergency Medical Services (EMS Police Dept) report dated [DATE] showed, summoned for [AGE] year old male unresponsive. Upon arrival patient was found at the nursing home being held up sitting up by nursing staff. Per the staff on scene they state that the patient was eating a sandwich when he began choking. Heimlich maneuver was not being performed by nursing staff. Patient continued choking and [the] crew initiated Heimlich maneuver on the patient. Patient was unresponsive with agonal respirations, crew initiated ventilations on the patient. Patient was transferred to the ambulance where crew continued patient care . Patient became pulseless and initiated ACLS [Advanced Cardiac Life Support] protocols. Patient arrived at the receiving ED [Emergency Department] nursing staff. R5's ED hospital records dated [DATE] showed, Patient was found choking at nursing home called EMS. Upon EMS arrival at the nursing home, patient was unresponsive but had a pulse. said they performed Heimlich maneuver and was transported to ER. On the way patient arrested and intubated patient for airway protection. EMS said after intubation patient arrested .CPR [Cardiopulmonary Resuscitation] was performed. Upon arrival to ER, patient was actively vomiting with ET [endotracheal tube] tube in mouth, information from nursing home showed he was hospice and DNR [Do Not Resuscitate]. CPR was terminated. Confirmed deceased at 7:48PM ([DATE]). On [DATE] at 3PM, V20 (Medical Legal Investigator (Local County)) said R5's cause of death was: Immediate-asphyxiation-choked on food bolus, Secondary-neuro cognitive disorder manner of death- accident. An autopsy was performed on R5. On ,d+[DATE]/ 24 at 8:53 AM, V21 (Medical Examiner (Local County)) said he performed an external autopsy on R5. External autopsy result showed R5 was found with solid foods on his distal trachea. V21 also said that a police report showed that facility staff V8 (License Practical Nurse-LPN) and V12 (Certified Nursing Assistant-CNA) both informed the police responders that R5 grabbed a turkey sandwich and ate the sandwich. (R5 was on pureed diet.) On [DATE] at 10:42 AM, V12 (Certified Nursing Assistant-CNA) said it was after dinner approximately around 7PM. V12 said he was coming out from the dining room after having break. He saw R5 by the elevator wearing just an incontinent brief with no gown on. V12 said he went to R5 to redirect him to his room. We made few steps then he suddenly stopped, put his head down so I asked him, 'Are you ok?' He did not respond gasped for air, so I called the nurse. The Nurse (V22 LPN) came and did the Heimlich maneuver. On [DATE] at 8:28 AM, V22 (LPN) said he was by the nurses' station when he heard V12 (CNA) calling for help. V22 said he ran to R5. R5 was clutching his throat. R5 was trying really hard to cough. V22 said he tried to open R5's mouth and R5's mouth was full of saliva. V22 said he cannot recall if he did a mouth sweep. Heimlich maneuver was done and 911 was called R5 was sent to the emergency room . On [DATE] at 1:30 PM, V8 (LPN) said she was R5's nurse last [DATE]. At around 6:30ish on [DATE], she was in the nurses' station with the other nurse when they were alerted by V12 that R5 appeared to be choking. V8 said she ran by the elevator where R5 and V12 were. R5 was short of breath, gasping for air and not talking. R5 was tall, so R5 was lowered to the floor, the Heimlich maneuver was done, back blows, and abdominal thrust. No food was coming out, did a mouth sweep did not feel any food. 911 was called. Paramedics came and also performed Heimlich maneuver then R5 was brought to the ER. Later, got a call from the ER and asked for his code status. R5 was a DNR. R5 coded on his way to the ER. V8 said she was informed R5 passed away shortly. V8 said R5 is up and able to ambulate independently. R5 has dementia and was on pureed diet. V8 said she does not recall telling the paramedics about R5 having a sandwich. V8 said residents with pureed diets should not have regular sandwich. On [DATE] at 11:15 AM, V13 (CNA) said she was R5's CNA for the day and PM shift last [DATE]. R5's dinner was pureed food. R5 ate 100%. After dinner V13 walked with R5 to his room because he needed to be changed. R5 was provided bedtime care. R5 was left in his room lying in bed with gown and clean incontinent brief. V13 said he later learned R5 was sent to ER due to possible choking. R5 might have gotten up from bed after he was provided bedtime care. R5 was able to walk around independently. On [DATE] at 3:23 PM V23 (CNA) said she was one of the CNAs working on [DATE] PM shift. She was in one of the residents room taking care for another resident when she heard what happened to R5. V23 said the incident happened around 7PM. V23 said she had taken care of R5 in the past. R5 is a tall, large guy, able to walk, he can come out in his room, walks around the hallways then goes back to his room. V23 said bedtime snacks come around that time. R5 gets apple sauce. Other resident gets either PBJ or turkey sandwich. On [DATE] at 10:15 V16 (Dietary Manager) said she was at the facility that time [DATE] during the evening meal. The kitchen was short of staff, so dinner trays were prepared in the kitchen instead of the usual steam table. The menu on [DATE] evening meal was grilled cheese sandwich, tossed salad and pudding. V16 said R5 was served pureed diet. After dinner was when bedtime snacks were served that consisted of deli sandwiches- turkey sandwich and peanut butter and jelly sandwich. Residents on puree diets cannot have regular sandwich On [DATE] at 1:10 PM V18 (Assistant Director of Nursing (ADON)) said she was on call ([DATE]) and that evening, she was informed code blue was called on R5. Not sure what happened or how R5 choked. Staff performed Heimlich maneuver and was sent to the hospital via 911. R5 expired that same evening. R5 has behaviors of paces and wanders, R5 had declined in cognition that was why he was on hospice. On [DATE] at 2:35 AM V2 (Director of Nursing) said she was informed that on Saturday [DATE], R5 was in distress and was sent to the ER via 911. V2 said she was told the incident happened around 7PM when dinner was already done. Dinner was at 5:30ish (PM) V2 said she was told that V12 (CNA) was the first staff who noticed R5 was having SOB. R5 was trying to talk and cannot talk so he called for the nurses (V8 and V22 both LPN) who performed Heimlich on R5. V2 said R5 was on pureed diet, ambulatory on hospice due to dementia. V2 said V3 (Chief Nursing Officer) did the investigation. On [DATE] at 9:30 AM, V3 (Chief Nursing Officer) said she was the one who did R5's possible choking episode investigation. R5 was able to feed himself on pureed diet. R5 was ambulatory, on hospice services due to dementia and was DNR. V3 said her investigation showed that none of the staff could tell her what happened. V3 said the coroner has an ongoing investigation regarding R5's death. The updated policy and procedure dated [DATE] showed: -Supervision of Residents on Puree diets; residents that are on pureed diet require supervision that they are not able to get non pureed foods as it relates to their swallowing ability as determined by a speech therapist. Delivery of food to the Nursing Units; To ensure that food, such as snacks and meals is always under supervision. The dietary department will ensure that the food delivered is handed to the nursing department or dietary staff are serving the food. During this investigation, R5's police report and death certificate were requested, but both were unavailable as of [DATE]. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: The facility respectfully submits this abatement plan today, [DATE]. The facility requests that this abatement plan is accepted today, [DATE] and requests that the immediacy be removed. Actions taken by the facility -On [DATE], the facility did the following: -Assessed the residents on a pureed diet and ensured that they cannot obtain food that is not on their pureed diet; -Speech therapy is currently reevaluating all 4 residents who are on a pureed diet to ensure that it is still the most appropriate diet for them; In-servicing has been initiated which included all Nursing, dietary and activity staff regarding residents on Pureed diets and supervision of the residents on pureed diets that they do not have access to other food. In servicing is on-going and will continue until all staff in serviced. -In regards to delivery of bedtime snacks and all snack deliveries, dietary staff must get a signature from nursing for the snacks that were delivered. All snacks delivered to the floors will be held in the locked Nutrition Room on each floor. -An audit tool was created to supervise residents on pureed diets - auditing will be conducted 5 times a week for 2 weeks, 2 times a week for 2 weeks and 1time a week for 2 months. -Emergency QAPI (Qaulity Assurance and Perfomance Improvement) Meeting informed Medical Director of the citation as it relates to an IJ called for F689 on [DATE] at 0944 (am). Medical Director reviewed the abatement plan and approved it. IDT (Interdisciplinary Team) has been notified of the IJ 689 as well in the emergency ad hoc QAPI meeting held today, [DATE]. The following was reviewed in the emergency ad hoc QAPI meeting held today: Policy and Procedure/System Revision 1) Food delivery 2) Care of residents on pureed diets. QAPI is held on a monthly basis and the DON, ADON and Dietary Manager will be responsible for reporting on the on-going audit tools. Education: In-servicing began today, [DATE], and is on-going. The following staff are included in the in-servicing: Licensed nursing staff, certified staff, dietary staff, restorative staff, social services, and activity staff. In-servicing topics are as follows: New Policy and Procedures as it relates to providing Pureed diet to those residents that are on a Pureed diet and safeguarding that they do not have access to regular foods. 1) QAPI Plan The IDT Team have been educated on the IJ that was [DATE]. Topic: New Policy and Procedures relating to pureed diets/supervision as it relates to IJ. Education, Audits, and Plan: -New Policy Resident Access to food. -Care of residents on Pureed Diets.

Based on interview and record review the facility failed to follow physician referral orders for unilateral inguinal hernia. Failed to follow orders and schedule gastroenterologist appointment for rectal bleeding for six months. Failed to complete a comprehensive assessment after complaint of rectal bleeding, failed to test for occult stool. This affected one of three residents (R2) reviewed for quality of care. This failure resulted in R2 having a delay in evaluation of rectal bleeding and hernia repair surgery, from 4.14.23 to 10.19.23. On 10.19.23 R2 was sent to the local hospital to be evaluated, treated for hernia repair. R2 secondary diagnosis was diagnosed with 5.0 cm rectal tumor with metastasis to the regional lymph nodes, liver, and lungs. Findings include: R2 face sheet shows diagnosis of malignant neoplasm of rectum, cognitive communication deficit, weakness. On 11.1.23 at 2:38pm R2 observed in his room, resting in bed, R2 observed to be in good spirits, R2 said he had surgery, and he has staples in his stomach (abdomen). R2 said he has never refused to go for the surgery referral, he has never refused to have surgery for his hernia. R2 said he never refused to go to appointment to see why he was rectal bleeding, R2 said he wanted to know what was going on with him. R2 said he had blood coming from his rectum when he pooped, R2 said he did tell the nurse at the facility. R2 was not able to recall name of nurse. R2 progress notes dated 3.22.23 denotes resident observed this morning when taking shower with scrotal swelling and bleeding from rectum area. MD (medical doctor) made aware and instructed to schedule resident for Urologist. Appointment scheduler made aware. R2 progress notes dated 4.8.23 denotes in-part the patient approached the nursing station with complaint of bleeding hemorrhoids after a bowel movement. V19 (Medical Doctor) paged this AM to inform and receive further orders, awaiting a return call. Endorsed to morning shift nurse, please follow up with MD for further orders. R2 progress note dated 4.14.23 denotes resident went to Neurology appointment. Resident came back with referral for surgery to (hospital name noted) due to scrotum hernia. R2 after summary visit dated 4.14.23 denotes in-part surgery referral, expires 7.14.23, referred to (hospital name) hospital affiliated (physician name noted). R2 referral script dated 4.14.23 denotes in-part R2 name, address of nursing home, surgery referral, associated diagnosis, unilateral inguinal hernia without obstruction or gangrene, recurrence not specified. Instructions: referred to (hospital name) affiliated provider (physician name noted). R2 progress note dated 8.7.23 denotes in-part staff informed writer resident noted with blood on clothing. Writer asked resident has he had any bleeding or hurt anywhere resident stated I am not hurt; I have been bleeding when I move my bowels for a few days now. Writer informed resident to call staff in washroom next time has a bowel movement to collect specimen. Np (nurse practitioner) informed with new orders CBC, occult blood at this time. Resident up ambulating throughout unit without difficulty, no apparent difficulty, no apparent distress/discomfort noted. Resident compliant with medication regimen, good appetite at mealtimes, hydrated well. Writer will continue to monitor resident status at this time, needs met. R2 evaluation for hernia report dated 10.18.23 denotes in-part examination: the abdomen is soft and flat with well healed vertical midline incision. Examination of the groins revealed budging on the right side fairly large but reducible with the patient lying flat clearly contains viscus. No obvious hernia on the left side, penis and testicle is normal. No peripheral edema. assessment non recurrent unilateral inguinal hernia without obstruction or gangrene, at least a right inguinal hernia containing bowel. Once the patient left, I was able to retrieve his old records including a CT from 2020 when he had his perforated appendicitis. There was clear right inguinal hernia at that time with intestine in it. There was a fat containing inguinal hernia on the left said at the same time. At this point even the patient verifies his only complaint is on the right side and the left inguinal hernia is not necessarily clinically apparent. I would certainly recommend repair of the right inguinal hernia and consideration the left at the same time. The patient per records at the hospital at least is non distension all and I have called and left a message with his mother hopefully she will call me back I would recommend an open repair because of his extensive lower abdominal surgery in the past, given his history as well. Review of R2 progress from all discipline presented by V5 (Director of nursing) from 3.22.23 through 10.18.23, there is no documentation noted that R2 refused to have hernia surgery, there is no documentation that R2 refused to go to gastrointestinal consult appointment. R2 physician order sheet (POS) dated 4.14.23 denotes in-part Urologist consult for swollen scrotum and rectal bleeding. POS dated 8.7.23 denotes CBC, occult blood. POS dated 9.11.23 denotes order for Urologist consult for swollen scrotum. GI consult rectal bleeding. Surgical consult hernia (hospital name noted). POS dated 9.21.23 occult blood stool specimen. POS dated 10.4.23 denotes stool specimen for low hemoglobin, repeat CBC 10.18.23. Review of R2 care plan, there is no plan of care in place for R2 refusal for hernia surgery, no plan of care for R2 refusal to go to surgery referral consult. Review of R2 progress notes, there is no documentation noted from 3.22.23 to 10.19.23 denoting that R2 refused hernia surgery. On 11.7.23 at 10:50am V21 (appointment scheduler) said she was aware that R2 needed an appointment for surgery in April 2023, but she couldn't get to schedule the appointment because she had so many appointments to be made, she had 200 appointments. V21 said she doesn't have documentation that she needed to schedule 200 appointments in April 2023. V21 said she was made aware in September 2023 that R2 needed another appointment for surgery, and she scheduled the appointment for 10.26.23 but R2 went out to the hospital and had surgery, so he missed that appointment. V21 said she should schedule all recommended appointments for the residents. V21 said she did not inform V5 (Director of Nursing) that she needed help scheduling appointments for the 200 residents that needed appointment in April 2023. V21 said V5 is her direct supervisor. V21 said she supposed to prioritize scheduling surgery appointment, V21 said she didn't get to schedule R2's appointment before she was terminated from her position in May 2023. V21 said her last day of work was at the end of April. On 11.1.23 at 12:28pm V5 (Director of nursing) said R2 went to see the surgeon on 10.18.23, V5 said that was R2's first appointment for surgery referral, V5 said they found a facility that takes same day appointments. V5 verified that R2 was referred to see the surgeon for hernia repair on 4.14.23. V5 said the physician gave orders on 9.11.23. V5 was asked why wasn't R2's appointment scheduled on 9.12.23, 9.13.23, 9.14.23 etc., if the clinic takes same day appointments. V5 did not give a response. V5 said R2's appointment was made on 10.18.23. V5 said she is not aware of R2 refusing to go for surgery or surgery consult or GI consult/appointment. V5 said R2 complained of his hemorrhoids bleeding, V5 was asked, if R2 had a diagnosis of hemorrhoids, V5 reviewed R2's factsheet and said, no. V5 was asked who assessed R2 to determine if he had hemorrhoids. V5 did not give response. V5 was asked what's the treatment plan was if R2 complained of having hemorrhoids. V5 was asked was R2 assessed to determine what was he describing as hemorrhoids. V5 did not give a response. R2's face sheet reviewed with V5, R2 did not have diagnosis of hemorrhoids. On 11.3.23 at 11:45am V5 said R2's scrotal ultrasound was not completed. V5 said R2's occult stool test was not completed on 8.7.23, 9.21.23, and 10.4.23. V5 said one of the occult tests was done but it wasn't valid, and it was not repeated by staff. V5 said the nurse did not document and she can't make them document. On 11.7.23 at 1:11pm V5 said V21 should prioritize appointments, scheduling surgeries and emergency dental appointments first. V5 said V21 did not have 200 appointments to be scheduled in April 2023. On 11.1.23 at 3:10pm V9 (Medical Director) said he has tried to get R2 to go to his appointment/consult several times and R2 refuses. V9 said R2's swollen scrotum was down to R2's knee. V9 said he did not document R2's refusal any of those times. V9 said he doesn't know how many times R2 refused. V9 said the plan was to get R2's family involved when he refused. V9 said he did not document the plan to get R2's family involved when R2 refused. V9 said he did not get R2's family involved in March when R2 refused. V9 said R2's family was involved in October and that's who took R2 to the hospital. V9 was asked who discussed risk and benefits of surgery with R2, and risk and benefits of going to GI appointment with R2. V9 said R2 would not understand because of his mental illness. V9 was asked if they tried to get R2's family involved in March since R2 would not understand. V9 was asked if he got the nurse, the director of nursing, the assistant director of nursing, or the social worker involved to assist with documenting R2's multiple refusals, and to get R2's family involved since R2's swollen scrotum was down to R2's knees and needed surgery. V9 said he forgot to document, it's all on him, he was responsible. On 11.3.23 at 1:36pm V6 (social services) said R2 was on his caseload prior to R2's readmission on 10.28.23, V6 said he was never made aware that R2 refused surgery or refused to go to GI appointment or GI referral. V6 said no one told him R2 needed surgery and he refused in April, or October. V6 said no one informed him that R2's family needed to be contact or involved because R2 is refusing surgery or GI consult. R2's hospital records dated 10.19.23 denotes in-part R2 present to ED (emergency department) via walk in with daughter from City View. V9 (Medical Director) instructed patient to come to ED for hernia surgery. R2 hospital records dated 10.19.23 denotes active diagnosis rectal bleed and s/p (status post) hernia repair 10.20.23, CT chest abdomen pelvis with contrast final result, impression preparation of colon was fair, rectal mass 5.0 cm (centimeters) from anal verge, likely malignant partially obstructing tumor in the proximal rectum in the mid rectum and in the distal rectum. Biopsied. CT impression rectal bleeding and partially obstructing rectal tumor with metastasis to regional lymph nodes, liver, and lungs. Facility policy titled physician/physician assistant/ nurse practitioner/clinical nurse specialist visits with review date of 2.5.23 denotes in-part the purpose to ensure that all residents receive the care and services that meet their medical and psychosocial needs. To ensure that all residents are seen regularly by attending physician, physician assistant, nurse practitioner or clinical nurse specialist for review of the resident medical condition, corresponding drug regimen, and overall medical management of the resident. Facility care plan policy and procedures denotes in-part each resident will have a comprehensive assessment completed that will assist in the development of an individualized plan of care that will include goals and interventions aimed to improve or maintain the resident's highest level of function, prevent decline, decrease risk of complications of medical conditions, medication, and diagnosis, decrease risk of injury or to promote comfort and end of life. The resident rights for people in the long-term care denotes in-part your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source. You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually. Your facility must provide services to keep your physical and mental health, at their highest practical levels. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You may be informed, in advance, of changes to the plan of care. You should receive the services and/or items included in the plan of care.

Based on observation, interview and record review the facility failed to utilize appropriate CPI technique by using excessive force while attempting to deescalate resident's behaviors and failed to prevent a resident-to-resident physical assault. This affected four of four residents (R1, R4, R3 R5) reviewed for abuse. This failure resulted in R1 being forced to the ground during CPI and R1 sustaining a right tibial plateau fracture. This failure also resulted in R5 being struck in the face by R3 with a closed fist unprovoked. Findings include: 1.R1 is [AGE] years old with diagnosis including but not limited to Major Depressive Disorder, Bipolar Disorder, Post Traumatic Stress Disorder, Schizoaffective Disorder, and Restlessness and Agitation. R1 is 67 inches tall and 148 pounds on 10/5/23. R1's cognitive assessment dated [DATE] indicates he is cognitively intact. R1's Behavior assessment indicates he has suffered from hallucinations and delusions. On 11/1/23 at 11:10AM R1 was seen in the facility. R1 had been readmitted to the facility on the evening of 10/31/23. R1 seen his bed with right leg brace on. R1 was mumbling non-audible words. V4, R1 Family, at bedside. V4 said to the surveyor, R1 told me that they (staff) attacked him because they wouldn't let him go smoking. On 10/31/23 at 10:31AM V1, Security, said on 10/29/23 we were in the lobby, right in front of the desk. V1 said R1 was close enough to the desk and the structure post. V1 said R1 wanted to go for a smoke, smoke time was done. V1 said we was trying to redirect R1. V1 said he was going smoke, I said no don't go. V1 said V2, Security, saw R1 get aggressive. V1 said R1 jumped on my back, on my face, I was trying to shake him off my back. V1 said R1 stumbled and fell . V1 said then we secured him until [V15, Licensed Practical Nurse,] came down. V1 said R1 was on the floor on his back, V2 grabbed an arm and was holding R1's arms. R1 was still on the floor, swinging on the floor. V1 said R1 was kicking and V2 held R1's arm. V1 said I had to call V15 to come because R1 was not listening to us. V1 said R1 is laying on the floor and then when V15 came we sat R1 down. V1 said I didn't speak to V15, LPN. V1 said he helped lift R1 and put him in a chair. V1 said I had scratches on my back, they are gone now (10/31/23). V1 said I didn't want to go to a doctor. V1 said R1 was poking my eyeball. (During interview R1 had no visible injury or scratch on his face.) V1 said R1 was not trying to get up. V1 said he heard R1 say his leg hurts while he was sitting in the chair. V1 said R1 had been out on that smoke break already. On 10/31/23 at 10:45AM V2, Security, said I used Critical Prevention Interventions (CPI) on Sunday (10/29/23). V2 said V1 and I were trying to redirect R1. V2 said R1 got verbally aggressive and as V1 went to walk away R1 attacked him. V2 said they were stumbling and fell to the floor, both went down to the ground. V2 said R1 was on the floor, and we tried to reach for his hands. V2 said I went for R1's left hand. V2 said V15 got called after R1 calmed down and was released from CPI. V2 said I went to the washroom and when I came back, he asked V13, LPN, to help get R1 up. V2 said R1 was sitting in a lobby chair. V2 said R1 kept saying he wanted a smoke. V2 was asked why he was holding R1's arm while R1 was on the floor and V2 said I thought that was what I was supposed to do. V2 said there is no other witness, we were the receptionist that day. On 10/31/23 at 11:27AM V5, Director of Nursing, said I was told R1 was coming for a smoke break. V5 said only 2 security no one else was in the lobby. V5 said R1 was aggressive with V1, he was verbally aggressive, just talking and cussing at him. V5 said it was not R1's time to smoke he had to wait until it was his time. V5 said the residents were down here, lining up to go smoke. V5 said it happened at the front desk. V5 said she reported to the state agency what she was told, that R1 was walking backwards and fell . V5 said R1 got in front of everyone in line and R1 came to the desk. V5 said V1 was trying to redirect R1, V2, Security, seen it and stepped in to intervene. R1 grabbed V1 from behind. V2 stepped in to have R1 let V1 go. V5 said they stumbled back, and they fell back. V15, Nurse supervisor, LPN, came down to assess R1. V15 said R1 was having pain, they got R1 into a wheelchair to further assess. V5 said they notified me later that R1 went to the ER for the fracture. V5 said I did not watch the security video footage because it was a witnessed fall. V5 said I have been assigned to this investigation. V5 said when R1 was on the floor, he was still agitated, and they had to use CPI to calm him down. On 10/31/23 at 11:49AM V15, Nurse Supervisor/LPN, said I was doing my rounds and I was coming to the first floor and saw two security guards on the floor. V15 said R1, V1, and V2 were all on the floor. V15 said V1 and V2 were holding R1 on the floor. V15 said I did not receive a page or a phone call. V15 said either of V1 or V2 was yelling for help. V15 said there were no residents in the area or in smoke line. V15 said I told security to leave him alone and R1 complained of right leg pain. V15 said R1 was sitting on the floor, he wanted to get up, but R1 could not get up. V15 said I called for another nurse to get me a wheelchair. V15 said during assessment I noticed R1 was not able move his right knee, he usually moves around. V15 said I reported to V5, Director of Nursing, and V11, Chief Nursing Officer, that I saw 2 security holding R1 on the floor. V15 said V13, LPN, and I put R1 in the wheelchair. V15 said V13 and I lifted R1 to a wheelchair, then I took R1 to the unit, and we put R1 in the bed and EMTs picked him up. V15 said the hospital called and said R1 had a fracture right tibia. On 10/31/23 12:13PM V11, Chief Nursing Officer, said I did not watch the surveillance camera footage for R1's incident on 10/29/23. V11 said, from investigation, R1 jumped on a security guard. V11 said R1 fell backward, and security had him so he would not attack again. V11 said V15 heard them yelling and saw them sitting. V11 told security to step away, R1 was unable to stand up due to the pain in the leg, R1 was sent out for evaluation, and he has a fracture. V11 said everyone is trained on CPI. On 10/31/23 at 11:01AM the surveyor requested to view the surveillance camera footage from R1's fall on 10/29/23 and on the same day told by V7, Administrator, it was not available. On 10/31/23 at 1:29PM V13, LPN, said I was coming from my break, and I saw R1 sitting on the floor with security V1 and V2. V13 said V1 and V2 said R1 jumped on one of them. V13 said R1 said he could not go upstairs because of his leg. V13 said V15 was called to come and assess R1. V13 said when he saw R1 he was sitting up against a wall, (pointing to the wall on the east side of the desk). V13 said I don't remember where V1 and V2 were in position to R1. V13 said I don't know if R1 fell or was knocked down. V13 said if an individual is knocked down then another individual was involved. V13 said if a resident falls it, is an accident. V13 said when I left the floor R1 was on the floor and V15 was with him. On 11/1/23 at 10:08AM V17, CPI Instructor, said I teach all staff CPI, Crisis Prevention Intervention. V17 said I teach holds and decision making with role playing exercises. V17 said the purpose of CPI is to manage and minimize the harm from the behavior and the care, safety, and welfare of all involved. V17 said the 2 techniques I teach are standing and seated (V17 showed the surveyor the techniques from the training book). I only teach hold and stabilize. V17 provided the surveyor with portions of the CPI book. Included V17 pointed out on page 59 the Holding Skills he teaches. Holdings are seated, in a chair, and Standing positions, no skill for on the floor is shown. On 11/1/23 V14, CNA, said I have been trained on CPI. V14 said I would not hold a resident in a hold if he was on the floor, flat on his back. V14 said code [NAME] are called for when resident behaviors are bad and not calming or behaviors escalating. V14 said with CPI we don't want to hurt anyone; we just want to manage the situation properly. V14 said if CPI is done properly, we should not fall during CPI. V14 said if the patient fell , and is on the floor, there would be no need for more CPI. 11/7/23 11:47AM V9, Medical Director, (listed as primary on R1's face sheet) I saw R1 in the hospital. V9 said the kind of fracture R1 has is caused by falling on the knee. V9 said I was told he had an unwitnessed fall. V9 said R1 fell forward on the knee to cause a knee fracture, like his. V9 said R1 could not have fallen backwards to fracture the knee like this. V9 said I was not informed that CPI was performed on R1 the same day of the injury. R1's progress notes dated 10/29/23 at 5:00PM states writer made aware R1 at front desk lobby and without provocation started to punch a security guard. Progress note states R1 was walking backwards and fell on to the floor. No visible injury. R1 unable to bare weight on right knee. The facility Initial Incident Report dated 10/29/23 documents R1 was walking backwards, and he fell to the floor. R1 admitted to the hospital with Right Tibia Fracture. The final report dated 11/3/23 indicates R1 fell to the floor with V1. Report stated family and MD notified of the outcome of the investigation. R1's hospital Emergency Department Notes dated 10/29/23 documents R1 brought by EMS with right knee pain after a ground level fall. Patient state that he was thrown to ground by a security guard. However, he is an unreliable historian. Per EMS the fall was unwitnessed. R1's CT of the lower right extremity indicates right tibial plateau fracture. Impression: comminuted fracture of the proximal tibia extending to the articular surface involving the medial and lateral tibial plateaus as well as the tibial eminence. There is a comminuted intra-articular fracture involving the tibial eminence extending into the medial and lateral tibial plateaus. Additionally, there is an additional comminuted fracture through the proximal tibial metadiaphysis without significant displacement. There is a moderate suprapatellar effusion. Document from CPI instruction book provided by the facility titled Safety Interventions Holding Skills, page 59, includes images for Principals of Holding in a seated position and Principle of holding in a standing position. Additionally, document from the book titled The CPI Crisis Development Model states 3. Safety interventions: Definition restrictive strategies to maximize safety and minimize harm. Initial incident report provided to state agency: 2. R4 diagnosis include but are not limited to Schizophrenia, Schizoaffective Disorder, Anxiety Disorder, and Delusional Disorder. According to the facility Report sent to the state agency on 10/22/23 R4 had a physical altercation with a peer (R6). R4 was placed on one-to-one supervision with staff. On 11/1/23 at 1:17PM V3, Security, said I was assigned to one-to-one supervision with R4. V3 said I used CPI on R4. V3 said we call a code Gray when they have a behavior episode we can't control. V3 said we always have a second staff to assist with CPI. V3 said I had to do CPI with R4. V3 said R4 launched his arm and he hit me. V3 said I had to put him on the ground. V3 said assistance came after R4 was on the floor. Progress notes R4 engaged in physical aggression with staff. The top of the progress note provided by the facility in light blue ink states Staff Member V20, Security, arm hold. 3. R3 is [AGE] years old with diagnosis including but are not limited to Schizoaffective Disorder, Psychosis, and Anxiety. R5 is [AGE] years old with diagnosis including but are not limited to Schizoaffective Disorder, Bipolar type, Conduct Disorder, On 10/31/23 at 10:45AM V2, Security, said I used CPI on R3 on Thursday (10/26/23). On 11/1/23 at 10:59AM R3 seen in his room but R3 would not speak to the surveyor. On 11/1/23 at 11:01AM V12, Nurse, said I didn't see anything with R5. V12 said all I saw was security escorting R5 out of the dining room. On 11/1/23 the surveyor met R5 in his room. R5 alert with confusion or delusions. R5 was not able to give interview related to the incident on 10/26/23 with R4. On 11/1/23 at 1:17PM V3, Security, said the incident with R3 and R5 started at breakfast, we heard a commotion. V3 said I saw R3 was using both fists, throwing punches, but not hitting hard, on R5's face. V3 said R3 made contact with R5's face. V3 said I saw R3 hit R5 like 4 hits in the face, before we intervened. Progress notes dated 10/26/23 documents R3 was in the dining room and made physical contact with his peer at the table. Progress Notes dated 10/26/23 for R5 documents resident was sitting in the dining room and peer came into physical contact with him. R5 states his peer brushed up against him. R5 and his peer was separated. Administrator and Director of Nursing notified. On 11/1/23 at 2:19PM V7, Administrator, said a Code Gray is called when a resident behavior cannot be de-escalated. V7 said after CPI is used myself, social services and the Director of Nursing need to be made aware that CPI was used so we can determine if we need to investigate further. V7 said with R3 a code was not called. I was in the building. V7 said the incident for CPI was something about a chair. V7 said R3 did not hurt anyone staff intervened before he could do anything. V7 said I was told no physical contact with a peer was made. V7 said I would have reported it as an alleged incident to report if contact had been made. The facility undated Crisis prevention Intervention (CPI) Policy and Procedure states staff are trained on core principles of the class. A. Care: Demonstrating respect, dignity, and empathy. B. Welfare: acting in the person's best interest. C. Safety: protecting rights, safeguarding vulnerable people, reducing, or managing risk to minimize injury or harm. D. Security: maintaining safe, effective, harmonious, and therapeutic relationships that rely on collaboration. The facility Abuse Policy dated 6/27/23 states the facility is doing all that is within its control to prevent and reduce the risk of abuse incidences to the residents of City View Multi Care Center. Staff shall have ongoing training on the Abuse Policy. The facility has developed and operationalize policies and procedure for protection of residents and prevention of abuse. Identification, investigation, and reporting of abuse, neglect, and mistreatment. Train employees such as CPI.

Based on observation, interviews and record review, the facility failed to prevent an incident of resident-to-resident physical assault that resulted in injury and psychosocial harm to R2, as the facility failed to follow their abuse policy by preventing physical abuse for one resident as a result of a physical attack by a peer (R1). This failure resulted in R2 sustaining swelling and bruising to his left upper lip and right eye, along with a cut to the bridge of his nose and caused psychosocial harm to R2 as he verbalized fear and feeling scared of another peer attacking him, which makes him not feel safe at the facility. Findings include: On 10/07/2023 at 10:03 AM, observed R2 lying in bed at this time. Observed mild swelling and purple colored bruising to his left upper lip, a small, scabbed area to the bridge of his nose, and light purple-blue bruising to entire right eye area (upper and lower lids), noted several dried reddish brown colored stains to R2's pillowcase. Resident said that two nights ago (Thursday 10/5/23), he was lying on his bed when his roommate at that time (R1), came over to the side of his bed and punched him (R2) very hard to the side of his head. R2 added that he sustained the facial injuries because of the attack from R1. R2 then stated that after it happened, a staff member took him (R1) out of the room and moved him to a different room on a different floor. R2 also stated he did not receive any medical attention until last night when they came and x-rayed me. R2 then stated that he was fearful of another attack and would like to transfer to another facility because he does not feel safe here. R2's Nursing Progress Note by V6 (RN) dated 10/5/2023 15:43 indicated, during visit with [Nurse Practitioner] resident states he had pain around his eye area and [pain medication] was given. [Nurse Practitioner] ordered x-ray to facial structures and skull. Nursing Progress Note dated 10/6/2023 21:41 indicated, x-ray of facial structure/skull was done results pending. No documentation found regarding incident with R1 and R2. Facility provided risk assessment report dated 10/05/2023 12:59 PM that indicated R1 had a verbal disagreement with co-peer and R1 was observed with a scratch to bridge of nose and discoloration under right eye. Ice applied. Medical doctor made aware. No orders noted. Monitor. R2's face sheet indicated resident admitted to facility on 02/14/2023 and has a past medical history of major depressive disorder, schizoaffective disorder, delusional disorders, osteoarthritis, weakness, and lack of coordination. R2's care plan last reviewed 7/11/2023 indicated resident has the potential for abuse due to history of suspected abuse, neglect, exploitation, past trauma and/or other factors that may increase resident's susceptibility to abuse/neglect; denies any past trauma yet assessment reveals factors including diagnosis of mental illness, aggression, and denial. R2's Trauma Screening dated 10/04/2023 indicated resident scored five which indicated significant trauma-related symptomology. On 10/07/2023 at 11:38 AM, when asked how R2 sustained the facial injuries, V2 (Director of Nursing) who appeared to be unaware of R2's facial injuries stated, R2 had a verbal altercation with his roommate R1 two days ago (Thursday morning). V2 then corrected herself and said, it was a disagreement not an altercation then said she noticed a small scratch to the bridge of his nose and a little red dot under his right eye. She added that V1 initiated an investigation on the day of incident. V2 (DON) then stated R1 was moved to a different room because of the disagreement and because he had voiced wanting to move to another room due to R2's loudness which disturbed his sleep. When asked how R2 sustained facial injuries from a verbal disagreement with R1, V2 (DON) gave no response. On 10/07/2023 at 12:15 PM, V1 (Administrator) stated regarding the alleged incident between R1 and R2, there was a verbal disagreement regarding the air conditioner and R1 got upset with R2 because he thought R2 was making too much noise which disturbed his sleep. V1 added that an investigation was initiated for the verbal disagreement. When informed to the extent of R2's facial injuries, V1 appeared to be unaware to the extent of his facial injuries. On 10/07/2023 at 12:26 PM, V2 (Director of Nursing) stated they had immediately removed the residents then initiated an investigation. She added that she briefly spoke to R2 around 12:30 PM on the day of the incident. When she asked what was happening between him and his roommate, R2 said they don't get along and R1 came to his side of the room telling him what he can/cannot do which made him upset which led to a disagreement. R2 told her that a staff member then entered their room and removed R1. V2 (DON) said she saw R2 again yesterday (10/06/2023) and noted no new injuries to his face. On 10/07/2023 at 1:29 PM, V5 (Certified Nursing Assistant) stated she asked R1 why he was moved to the fourth floor and R1 told her, He couldn't understand it himself. V5 added that she felt like R1 knew why he was moved but didn't want to say and she didn't want to pressure him about it. On 10/07/2023 at 1:36 PM, V6 (Registered Nurse) stated she worked the day of the incident between R1 and R2 which had occurred in the morning towards the end of third shift. She was told after the incident, that R1 was moved to another floor. V6 then stated that same morning, R2 was seen by the Nurse Practitioner who did not report any facial injuries to R2 but had ordered x-rays due to his complaint of pain to the eye area. V6 added that she doesn't know the full story regarding the incident and was told by previous nurse (V4) that everything was taken care of and she did see a bruise to R2's eye and did a pain assessment then administered pain medication. She added that she did not report the injury because she was told everything was taken care of. On 10/07/2023 at 2:04 PM V2 (Director of Nursing) now stated that R2's injury was not a red dot but rather red discoloration that was only to a small area of his eye area. When asked if she noted any blueish purple bruising to the area, she stated the color of bruising is described differently by different people. V2 also stated after re-interviewing both residents today, R1 stated he approached R2 at the side of his bed and told him (R2) about what he does that aggravates him. R1 is now stating that R2 swung at him, and he swung his hand back at him (R2). R1 then stated he made physical contact with R2 that was not intentional. V2 (DON) stated when she interviewed R2, he said they had a disagreement and R1 came to the side of his bed, got agitated and he (R1) swung his hand at R2. When asked what the protocol was for an injury of unknown origin, V2 stated nurses are to call her then she initiates an investigation. V2 then said when staff first saw the injury to R2's face, it was not reported because it was not intentional then added that the conclusion was made today after she reinterviewed both residents, that R1 was the cause of R2's facial injuries so V1 submitted an initial report to public health. When asked how it was determined on the day of the incident that the physical contact was not intentional when she was just informed today by both residents that there was physical contact made, V2 offered no explanation. On 10/07/2023 at 2:24 PM, V4 (Licensed Practical Nurse) stated the incident between R1 and R2 happened after she was already gone. V4 added that there was no visible injury to R2's face nor did an incident occur between him and roommate before she left at approximately 7:15 AM Thursday morning (10/05/23). V4 then stated when she came to work on Friday (10/06/23) for the afternoon shift, she saw R2 on the elevator and saw a bruise underneath his right eye that was purple in color. R2 stated he got into a little fight with his roommate, and that's all he said about it. V4 stated she did not report R2's injury because she assumed it was known. On 10/07/2023 at 2:40 PM V7 (Certified Nursing Assistant) stated she worked Wednesday night into Thursday morning on the fifth floor and no incidents had occurred between R1 and R2 and believed the incident occurred Thursday (10/05/23) after she left. She then stated when she came into work on Thursday night, V4 (Licensed Practical Nurse) told her there was an altercation between R1 and R2, that R1 hit R2 in the face so they moved R1 to a different room. V7 added that she had worked on the fifth floor Thursday night and saw a purple-colored bruise to his eye but didn't recall which one. She also stated that she did not report the bruise because she assumed it was already known. On 10/07/2023 at 2:51 PM V8 (Nurse Practitioner) stated when she assessed R2 on the afternoon of 10/05/2023, she observed blueish-purple bruising to his right eye and right cheekbone area with minimal swelling. V8 stated she asked the nurse (V6) if they were aware and what had happened, was told that R2 was punched by another resident. V8 stated she assessed R2 for visual changes and pain, then she ordered x-rays be done. Surveyor informed V8 that no progress note was found indicating her assessment. At 3:00 PM, V8 stated the note was documented under an incorrect resident, will correct, and add to R2's electronic record. Reviewed R2's corrected Physician Progress Note dated 10/5/2023 15:02 that reads in part, he is noted with bruising to the right orbital wall/cheekbone. He explains that he was punched this morning by another resident. He reports mild discomfort, however, denies changes in vision or headache. On 10/07/2023 at 3:47 PM, V1 (Administrator) stated her expectations of staff regarding an injury of unknown origin is to report the injury immediately and to follow policy and procedures to investigate. Reviewed R1's electronic medical records with the following noted: R1's face sheet indicated resident admitted to the facility on [DATE] and has a past medical history not limited to schizoaffective disorder, anxiety, restlessness and agitation, and suicidal ideations. R1 was out on pass and unavailable for interview. R1's current Screening Assessment for Indicators of Aggressive and/or Harmful Behavior dated 07/11/2023 reads in part, resident at this time is minimal risk for aggression. Assessment was not completed, showed in progress upon review. Reviewed R1's progress notes for last thirty days with no documentation found regarding alleged incident with R2. R1's care plan last reviewed 07/19/2023 reads in part requires psychotropic medication to help manage and alleviate schizoaffective bipolar anxiety disorders and aggressive behavior, depression, behavior with depressive features, mood swings, mood liability, and anxiety; history of demonstrating noncompliance with medications; Identified Offender has a history of criminal behavior. According to the available history, he has been arrested & convicted of Battery in 2009. The state agency performed a criminal history analysis and determined the resident to be a moderate risk; resident has a history of presenting with physically aggressive behavior towards his grandmother; resident has experienced periods of delusions and believes his family is practicing witchcraft, that his grandmother is possessed by the devil. R1's active physician orders showed the following medications ordered day of incident: Haloperidol Tablet 5 milligram (mg) by mouth every six hours as needed for agitation related to schizoaffective disorder (start date 10/05/2023), Haloperidol Lactate Injection Solution 5 mg/ml (milliliter) intramuscularly every six hours as needed for agitation related to schizoaffective disorder (start date 10/05/2023), Chlorpromazine HCl Injection Solution 50 mg intramuscularly every six hours as needed for agitation related to schizoaffective disorder (start date 10/05/2023). R1's census report indicated resident moved to room [ROOM NUMBER]-A on 10/5/2023. R1's Notification of Room Change dated 10/05/2023 indicated that resident transferred from room [ROOM NUMBER]-A to 401-A for reason indicated as other. Resident Choice/Compatibility was not selected. Abuse Prevention Policy 01/2022 reads in part: Policy: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a third party. Screen-Train-Report-Identify-Investigate-Protect-Prevent (STRIIPP) Procedure: II. Pre-Admission Screening of Potential Residents: This facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal convictions. Within 24 hours after admission of a new resident to the facility, the facility will: initiate a criminal history background check according to the facility identified offender policy and procedure. While results are pending, the facility shall take the necessary steps to ensure the safety of residents. III. Orientation and Training Employees: During orientation of new employees, the facility will cover at least the following topics: Staff obligations to prevent and report abuse, neglect, exploitation, mistreatment, any crime against the resident, what constitutes abuse (physical, mental, sexual, verbal) .and an employee's obligation under the law (Elder Justice Act) for reporting a suspected crime to the facility, the state survey agency, and local law enforcement, the time frames for reporting, and management's obligation to prohibit retaliation against anyone who makes a report. V. Identification of Allegations/Internal Reporting Requirements: Employees are required to immediately report any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment, or a crime against a resident they observe, hear about, or suspect to the Administrator is available or an immediate supervisor who must immediately report it to the administrator. The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruises, lacerations, or other abnormalities 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 in the absence to the director of nursing. VI. Investigation: All incidents, allegations or suspicion of abuse, neglect, exploitation, misappropriation of property, or a crime against a resident will be documented. Any incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident will result in an abuse investigation. An injury should be classified as an Injury of Unknown Origin when both of the following conditions are met: source of injury was not observed by any person or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury or the location of the injury (the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. If there is an Injury of Unknown Origin, the person gathering facts will complete an incident report. Abuse and Crime Reporting policy last revised 01/2019 reads in part: Policy: This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends, or other individuals. All personnel must promptly report any incident or suspected incident of resident abuse, mistreatment, neglect, or exploitation including injuries of unknown origin. An injury should be classified as an injury of unknown origin when the source of the injury was not observed or known by any person, and the initial skin tear/bruise investigation could not determine the cause of injury.

Based on observation, interview and record review, the facility failed to promptly identify and intervene for an acute change in a resident's condition related to resident not eating and failed to identify and have a treatment in place for a resident's pressure ulcer. This failure affected one resident (R105) who was transferred to the hospital and was admitted with a diagnosis of sepsis, dehydration, and UTI, R105 was also noted to have a stage 3 sacral decubitus ulcer. Findings include: R105 is a [AGE] year-old female who was admitted to the facility on [DATE] with past medical history of cerebral infarction, chronic obstructive pulmonary disease, dementia, type 2 diabetes, bipolar disorder, anxiety disorder, schizoaffective disorder, major depressive disorder, essential primary hypertension, etc. 7/23/23 10:35 AM, R105 was observed in her room in bed, awake and alert but unable to answer any interview questions, noted lying on an air loss mattress that was set at 400. V10 (LPN) was in the room with surveyor and was asked if the resident have any pressure ulcer, V10 said that he thinks so, but he is not sure, he is not the assigned nurse for the resident. 07/24/23 11:00AM, went to resident's room for follow-up observation, resident was not in her room, staff reported that resident was sent out to the hospital yesterday, surveyor asked why and V10 (LPN) said that resident has not been eating, this has been happening for a couple of days now, resident is sent out for failure to thrive. Minimum data set assessment (MDS) dated [DATE] section G (functional) documented that resident requires extensive assistance with one-person physical assist for all Activities of Daily Living (ADL), including, eating, dressing, toilet use and personal hygiene. Hospital record for R105 dated 7/25/2023 documented a primary impression of sepsis, dehydration, abdominal mass, disposition, inpatient admission, departure date and time 7/24/2023 -0035. Same document recorded a chief complaint adult fever, nurses note at 18:15 states in part, patient arrived via EMS from nursing home, elite reported nursing home requested patient to go to a different hospital but was diverted to the nearest ED, patient very hot to touch, moans to pain eyes open upon arrival. History and physical section of the hospital report states in part, patient is a [AGE] year-old female .presents from nursing home, staff reports that for the past three days patient has not been eating much and has seemed more withdrawn than usual. RN reports she has been eating <25% of all her meals, RN also reports for the past three days, they have noted patient has been slightly tachycardic as well. Review of R105's facility medical record did not show any documentation of any changes in resident's condition or that family or physician was notified of such. Further review of resident's medical record showed the following progress note dated 7/12/2023: Resident noted with left upper buttocks skin tear as reported by CNA during care. Wound care nurse notified. Wound care MD to f/up tomorrow. Resident on new air mattress, maximum ADL care provided. Denies pain currently. Closed dressing with dry gauze applied. Turned and reposition. All concerned authorities notified. 4/23/2023, Alteration in skin integrity observed by staff while assisting with ADL care for resident. Upon assessment, the resident has signs of skin degradation to sacrum. No evidence of pain/distress observed. Area cleaned with NSS. Medi honey and sterile gauze applied. MD and emergency contact, made aware via voicemail. ADON made aware. The resident has been turned to her left side. Bed locked and in lowest position, HOB elevated and call light within reach. Resident referred to TX nurse for follow up care. 4/25/2023, Wound care Nurse informed of ulcer to sacrum. Patient seen by wound care nurse and physician. Small wound observed to sacrum. Dressing done. Wound cleaned and covered. 07/24/23 01:41 PM, spoke to V24 (LPN/Wound care nurse) who stated that resident does not have any wounds, the nurse who first saw her made a wrong assessment, it was reported to her and she assessed it as an MASD, resident does not have any pressure ulcer or open wounds, she is just getting zinc oxide and foam dressing as a protective treatment, she has not been seen and is not being followed by the wound doctor. Per hospital record assessment, resident was noted with a sacral decubitus ulcer stage 3, and urine culture was positive for urinary tract infection (UTI). 7/26/2023 at 3:05PM V2 (DON) said that staff are supposed to notify the physician or dietician when a resident refuses to eat for 1 day, R105 has been having a decrease in appetite for a couple of days, the doctor should have been notified earlier prior to the time resident was sent out. A document provided by V2 (DON) titled change in resident's condition (undated) states that it is the policy of the facility to ensure the resident's attending physician and representative are notified of changes in resident's condition or status. Under procedure, the policy states in part that the nurse will notify the resident's attending physician when there is a significant change in resident's physical, mental or psychosocial status, the resident repeatedly refuses treatment or meds (two times consecutively or three times in a 7-day period). Note: if a treatment or med is given weekly or monthly, then one refusal will be considered as meeting criteria for physician notification. 44570 Based on observation, interview, and record review, the facility failed to 1. provide necessary supplies for a resident who has a urostomy, 2. Failed to follow their wound and skin care policies by not providing weekly assessments and skin treatments as ordered and 3. Failed to follow their change of condition policy which affected 4 residents (R59, R91, R105 and R215) of 66 reviewed. These failures resulted in 1. R91 exhibiting feelings of anger and sadness contributed by having to stay in his room due to the facility not providing urine ostomy bags; 2. R59 exhibiting anger and despair due to not receiving wound care as required; R215 not receiving skin assessments as evidenced by reopening of a healed wound; and 3. Not recognizing medical decline in a resident with an open wound who was transferred to an acute care hospital and subsequently diagnosed with a decubitus ulcer, sepsis and failure to thrive. Findings include: R91 was admitted to the facility 2/2/23 with diagnoses that included anxiety disorder and history of malignant neoplasm of bladder and obstructive and reflux uropathy. On 7/23/23 at 10:38AM R91 was observed sitting on the side of the bed, adjusting a urine ostomy bag. A strong odor of urine was noticed inside the room and there were several puddles of yellowish liquid on the floor. R91 was alert and oriented when the Surveyor approached and R91 pointed to the ostomy bag. R91 said angrily, they won't give me new urine bags. I used to change them every day myself and now that I live here I can't because I have to wait for them to give them to me. They told me that they are out of them, and I don't know what to do. They are always out of them. They gave me these other bags but there is nothing to attach it to! Surveyor observed a clear collection bag that appeared to be missing the stoma attachment. R91 pointed to the bag in use and said, I have had this bag on for over a week and its not sticking anymore so the urine leaks out and all around, making me get covered in urine. Urine all over my clothes and my bed, sometimes on the floor. I have to stay here in my room because they can't give me the things that I need and its humiliating. I can't walk around like this. I can't go to the dining room or make my phone calls. Can you help me please? I've tried everything, but I can't get it to stay on my skin, so all the urine just comes out. This is no way to live. I know how to take care of it, I've had this condition since the 1970's. I don't even need them to change it I just need the bags since they won't let me keep them. They want me to beg for them like I'm a dog or something. Tearfully, R91 showed the Surveyor that the ostomy pouch was unable to adhere to the skin. R91 was wearing an elastic belt to try and hold it in place, but it was not effective. R91 was wearing a disposable brief covered in urine. The ostomy bag was attached to a large drainage bag that contained dark brownish/red urine. At 10:56 AM V11 LPN (Licensed Practical Nurse) went in to speak with R91, told them that there were no ostomy bags available at the moment and told them door needed to be closed. He is in his room, because it wouldn't be sanitary for him to walk around without the ostomy bag. The ostomy is on right side of his stomach and urine can't be caught by a disposable brief. At 10:57AM V11 was interviewed and said, we don't currently have the ostomy bags and I have to find out where we can get some more. I don't know how long he has not had them. I came down to I closed the door because R91 doesn't have a shirt on, and the room does smell. On 7/24/23 at 1:30PM R91 was noticed in room lying down. The urinary drainage bag had still not been changed. At 1:35PM V11 said, I was able to get a new bag, but R91 refused it because he prefers the 2 piece attachment, and this is only 1 piece with the wafer adhesive. When I was here last Wednesday (5 days prior) someone from Supplies told me it would be ordered, but it hasn't come yet. I noticed that the drainage bag had dark colored reddish urine, but I haven't called the doctor about it yet. On 7/26/23 at 2:15PM, V2 DON said, I was aware R91 was out of urine ostomy bags, and I helped order new ones. We should not have let it get to the point where we didn't have any because we supply them, and it is his choice to use the device he is most comfortable with. The drainage bags should be changed by the nurse whenever there is sediment or unusual drainage. Any unusual drainage should be referred to the physician as soon as possible and communicated as a change of condition. On 7/25/23 at 12:35PM, R91 was observed dressed and sitting in the dining room waiting for lunch. R91 called the Surveyor over to where they were sitting and was smiling. R91 said, they finally got me what I needed and now I can come out of my room, I feel great. R215 is a [AGE] year old male who transferred from skilled nursing home to this facility on 2/4/23 with diagnoses that include Paraplegia, and Heart Failure. He was admitted to this facility with a wound on the sacrum and the anterior and lateral right ankle. During his stay at this facility, R215 required hospitalization for an acute illness. Progress notes dated 2/15/23 state that R215 returned from the hospital with a wound on the left posterior lower leg with a dressing intact. During this survey, the Weekly Wound Evaluation notes were reviewed and the last time the nursing department documented on the left lower leg (rear) was 4/10/23-including measurements of 6.5cm in length, 1cm width with a depth of 0.1cm. According to Wound care physician notes, the left posterior lower leg wound resolved on 6/1/23. On 7/25/23 at 12:00PM R215 was observed lying in bed, alert and oriented. R215 said that he had been getting wound care to his sacral and ankle wounds, but that he had not been getting dressings or treatment to the left leg anymore. R215 went on to say that although he does receive dressing changes most days, the dressing changes are later in the evening and because of this, the staff does not get him up out of bed during the day. R215 said, because he requires the use of a mechanical lift, the nursing staff tells him that it doesn't make sense to get him out of the bed before his dressings are changed and he has not been out of bed for about two weeks. R215 said that he is saddened that he can't even get out of bed during the day and can only lay there and watch television. R215 also said that since he is not able to reposition himself due to the condition of paraplegia, he needs staff to assist in changing positions in bed which does not happen regularly. At 1:00PM a skin observation was conducted with V43 RN and V44 CNA. V24 Wound Care Nurse arrived shortly after the observation began. R215's skin appeared very dry and scaly. V24 said, that she was only providing treatments to the sacrum and right ankle and that the wound on the left leg was healed. R215's lower legs were positioned flaccidly resting on foam boots and when V43 lifted the left leg, an area of skin was detached from the leg and remained on the foam. The skin on the foam appeared black with an odor, and the opened area on the leg was bloody. R215 said, because he is unable to distinguish any feeling below his waist, he would not be able to determine that the wound was there. V44 CNA said that she was assigned to R215 since 7AM and had not provided any care to R215 until this observation because he has a urinary catheter and not need to be changed regularly. V24 said, I would classify this as a skin tear, because it was healed before. On 07/26/23 at 12:12PM V28 Wound Doctor said when you have a wound that resolves it is prone to injury because the skin will never be the same as it was before the wound. It would not be classified as a skin tear. Depending on the circumstances, it would be classified as reopening or pressure wound depending on the characteristics on assessment. V2 DON (Director of Nursing) was interviewed immediately after this observation and said since R215 requires extensive assistance with turning, re-positioning, and bathing, I would have expected the nursing staff to have identified this skin issue before today. R215 should be repositioned at least every 2 hours to prevent new wounds from occurring and relive the pressure of any existing wounds. Skin should be checked during showers or bed baths which the nurse has to confirm, and it is expected that V24 conduct weekly skin assessments on Residents who are receiving wound care treatments, because they are susceptible for developing new wounds. Weekly wound care notes for R215 were not documented or provided for the months of June or July 2023. Care plan for alteration in skin integrity initiated and revised 7/4/23 stated I am at increased risk for alteration in skin integrity and at risk for additional and/or worsening of skin integrity issues Interventions include weekly measurements and documentation. Reposition resident frequently when in bed/chair/gerichair and/or Wheelchair. Any skin integrity issues/concerns ill be conveyed to the Charge Nurse for further evaluation and/or treatment changes/new interventions and the MD will be called [as needed]. R59 was admitted to the facility from an acute care hospital on 5/31/23 with diagnoses that included chronic venous hypertension with ulcers of the bilateral lower extremities. Hospital transfer and discharge notes document R59 was admitted to the emergency room with a chief complaint of bilateral lower extremity pain and purulent drainage. R59 stated to the hospital staff that he has chronic venous stasis, had been changing his dressings normally but had been unable to do so. The wounds were noted to be foul smelling with drainage and R59 received intravenous antibiotics for treatment of cellulitis. emergency room Physician Assessment and plan included the following statements: patient will need aggressive wound care and case management spoke with patient in [emergency room ] and will likely need placement in a skilled nursing facility On 7/23/23 at 11:48PM, R59 was observed alert and oriented lying in bed. Surveyor noted that both legs were wrapped in roll gauze that had areas of dried reddish brown stains that were also noticed on the bed sheets toward the foot of the bed. The bottom of the dressings on the feet were black from dirt. An odor was noted. R59 said, I hate being in this place, I don't belong here, and they neglect everybody in here including me. I have wounds on both of my legs, and I haven't had the bandages changed in about two weeks. I can't take a shower unless somebody takes them off and they have to put them back on when I'm done. I would change them myself, but I have to walk with a cane now because my legs are so weak. I have pain in both legs that has gotten worse, so I have to ask for medication which helps, but they are not getting any better because I don't get regular treatments. What am I even here for, if they are not going to help me?! TARs (Treatment Administration Record) for June and July 2023 were reviewed. An order was not placed for wound care of the lower extremities until 6/16/23, which was 16 days after R59 was admitted to the facility. Treatments ordered on 6/16/23: Xeroform to left and right lower legs after cleansing with normal saline solution or wound cleanser every Monday, Wednesday, Friday and as needed. Treatments were not signed out as ordered for June or July and there is no indication of refusal documented in TAR or progress notes. On 7/24/23 at approximately 1:45PM V2 DON said, the nursing staff should be following the orders as written for all treatments. If the resident came to the facility with an indication that they needed treatment, I would have expected the wound care nurse to complete a skin check on admission and get orders from the doctor. If the treatment was not signed out, we can assume that it wasn't completed. On 07/24/23 at 12:10 PM V23 Wound Care Nurse was observed during a dressing change for R59. R59 was noted with the same dressings in place from the previous day and V23 applied wound cleanser spray to detach the bandages as they were dry and attached to the skin. As V24 removed the dressings, she initiated a confrontation with R59 saying that he often refuses wound care, to which R59 became angry, yelling, and responded why would you lie on me!? I have been asking to have my dressings changed, I don't want to lay here like this! When V24 removed the dressings, the odor became more prominent. Areas of the skin was mottled, with some darker blackish brown and pink areas, and open sores that were draining. V24 said, the odor was not there before, and I don't know what it would indicate. I don't know how long ago this dressing was changed or if I was the last person to change it. I don't remember when I changed it last. R59 is not followed by the Wound care doctor because I didn't think he needed it because he is not being treated for pressure sores, so I didn't put him on the list to consult. I was using the xeroform to provide moisture to the legs because they crack and have drainage sometimes. I document on R59's skin condition weekly. On 07/24/23 01:53 PM V39 CNA said, R59 is fully alert and oriented. When I am here, I work with R59, and I notice that V23 is the only person who would do wound care- but not every day. I have never known him to refuse care or showers. 07/24/23 02:47 PM V24 Wound Care nurse said, I wrote an order today for wound care physician to see R59 on the next visit. Weekly wound care notes for R59 were not documented or provided for the months of June or July 2023. No Wound care Physician notes were documented for provided for R59 from admission to current. R59 did not have any assessments or care plans for refusal of care in the health record upon review. On 07/26/23 at 12:12PM V28 Wound Doctor said I round weekly at the facility with the wound care nurse who coordinates the residents that I need to see. I care for residents with venous, arterial and pressure wounds. I don't conduct any skin assessments as that is a nursing responsibility. I have never seen or consulted with R59. Policy and Procedure Wound Care Program revised 1/2/23 states in part; Policy: The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure as well as, non-pressure related wounds. Procedure: 2. Weekly skin checks will be conducted by the licensed nurse. This will be documented in the resident's Electronic Medical Record (EMR) 3. Daily, during routine care, the Certified Nursing Assistant (CNA) will observe the resident's skin. When abnormalities are noted, this will be communicated to the licensed nurse and the licensed nurse will proceed as mentioned in step 2 and complete a skin check. The nurse will notify the Wound Care Nurse and DON (Director of Nursing). Policy and Procedure Treatment/Services to Prevent/Heal Pressure and Non-Pressure wounds Effective 11/2/22 states in part; Policy: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. Procedure: 1. The facility will ensure that based on the comprehensive Assessment of a resident: 1a: A resident receives care, consistent with professional standards of practice, to prevent pressure and non-wounds and does not develop pressure or non- pressure wounds unless the individual's clinical condition demonstrates that they were unavoidable as documented by the wound care specialist. 1b.: A resident with pressure ulcers or non-pressure wounds receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new wounds from developing.

Based on observation, interviews and record reviews, the facility failed to provide adequate supervision and monitoring in preventing falls for one (R288) of ten residents in the sample of 70 reviewed for accidents and supervision. This deficiency resulted in R288 found lying on the floor, was sent to the emergency room and sustained an acute cervical myofascial strain, minor head injury and scalp contusion. Findings include: R288 is a [AGE] year old, male, admitted in the facility on 12/22/2022 with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side; Secondary Malignant Neoplasm of Unspecified Lung; Secondary Malignant Neoplasm of Brain; Major Depressive Disorder, Recurrent, Unspecified; Bipolar Disorder, Current Episode Manic Severe With Psychotic Features; Schizoaffective disorder, Bipolar Type; Unspecified Psychosis not Due to a Substance or Known Physiological Condition; Headache, Unspecified; and Anxiety Disorder, Unspecified. On 07/24/23 at 9:45 AM, surveyor went to the fourth-floor dining room to observe, and found R288 lying on the floor, in a supine position. No staff was observed present, supervising, and monitoring residents in the dining room at the time. R288 was wearing flat shoes. The shoes were observed not worn properly. He was wearing it like a slipper. V30 (Registered Nurse, RN) came to the dining room, assisted R288 to sit in the chair and assessment was conducted. R288 was asked regarding fall incident. R288 replied, I did hit my head. I was trying to put my tray there in the cart, but I slipped and fell . V30 was asked regarding staff supervision. V30 stated, We have a CNA (Certified Nursing Assistant) monitoring the dining room. There should be a staff in the dining room at all times. As far as I know, CNA was there. Some of the residents put their trays and put it in the cart but not all. Some residents can do this, or they can wipe tables or clean the dining area but R288 is not one of them. There should be supervision. V31 (CNA) was asked regarding monitoring and supervision of residents in the dining room. V31 verbalized, I am supposed to be here in the dining room, but I need to go get a milk from the refrigerator. I am the only one working as a CNA. R288 was sent out to the emergency room for further evaluation and management as ordered. Incident report dated 07/24/23 documented: R288 was observed in the dining room laying in supine position. Was asked what happened, R288 stated, I was trying to put my tray up and lost my balance. No injuries observed at time of incident. Hospital records dated 07/24/23 recorded the following: Seen today for: Fall from ground level Acute cervical myofascial strain Minor head injury without loss of consciousness Scalp contusion On 07/25/23 at 10:09 AM, V9 (Restorative Director) was asked regarding R288's fall. V9 replied, He had a fall incident on 07/24/23. He was observed lying in a supine position in the dining room at 9:45 AM. He had been sent out and was admitted . I know him very well. He is alert, oriented, answers simple questions. He can walk but with unsteady gait. He uses a rollator. Sometimes he believed that he could do things independently. Based on my own assessment, he needs constant supervision when he is walking. Dining room should be supervised and monitored by CNAs at all times when there are residents. V2 (Director of Nursing/Fall Coordinator) was also interviewed on 07/25/23 at 3:11 PM regarding R288's fall incident on 07/24/23. V2 stated, His fall could have been prevented if there were staff monitoring and supervising residents in the dining room. There should be a staff in the dining room at all times. At the time of incident, he said he lost his balance when he was trying to put his tray up in the dining. He should also be monitored that he wear his shoes properly. Sometimes he wear his shoes like a slipper. R288's care plans documented the following: ADL (Activities of Daily Living): Self-Care Deficit (initiated 12/24/22) Interventions/Tasks: Ambulation - usually require supervision and set-up support for walking (verbal cues and set-up assistance) Locomotion on unit - usually require supervision and set-up support for locomotion on unit (verbal cues and set-up assistance) Fall (initiated 12/26/22): Interventions/Tasks: Follow the facility fall protocol Ensure R288 is wearing appropriate footwear that provide stability and good traction when ambulating or mobilizing in wheelchair and during transfers. On 07/26/23 at 1:52 PM, V33 (Physician) stated during interview that there should be staff supervising residents in the dining room. V1 (Administrator) also stated during interview on 07/26/23 at 2:14 PM, In my psych units, there are psych technicians, security, CNAs and nurses on the floors. I have enough people to supervise but I don't know how fall happened. R288 is a resident in one of the psych floors in the facility. Facility's policy titled Fall Prevention and Management Program dated 08/03/17 stated in part but not limited to the following: This facility is committed to safety and maximizing each resident's physical, mental, and psychosocial well-being. Benefits of Preventing and Managing Falls This facility uses a Safety First approach for falls prevention Though an interdisciplinary approach, this facility will provide fall prevention assessment, implement interventions to prevent falls as much as possible, and manage post-fall treatment. Facility's policy titled Supervision of Residents dated 2/1/2022 documented in part but not limited to the following: Policy: Supervision is an intervention and a means of mitigating accident risk. We will provide adequate supervision to reduce the risk and the prevention of accidents. Adequacy of supervision is defined by type and frequency, based on the individual resident's assessed needs, and identified hazards in the resident environment. Procedure: 3) Facility staff will monitor and assess the residents throughout their day and determine if a resident will benefit from increased supervision. 34071 Based on observations, interviews, and record reviews, the facility failed to follow their policy for use of extension cords as evidenced by observation of extension cords in resident's rooms and unit bathrooms on the 5th and 6th floors. This failure has the potential to affect all 109 total residents on the 5th and 6th floors. Findings include: On 07/23/23 at approximately 12:30 PM, 5th floor observed orange extension cords in resident rooms and in resident bathrooms with water on the floor. There were no staff present when the extension cords were observed in use. On 07/24/23 at approximately 9:15 AM, 6th floor observed orange extension cords in resident rooms and in resident bathrooms with water on the floor. There were no staff present when the extension cords were observed in use. On 07/25/23 at 9:23 AM, interview conducted with V13 Maintenance Director regarding concerns with extension cords being used in resident areas. V13 stated, Extension cords should not be used at all. The Physical Plant Monthly Inspections policy states in part: Multi Gang Outlets and Power Strips: Multi gang outlets and power strips are prohibited in the facility. The only exceptions are if the facility needs to protect electronic equipment (i.e., computers, stereos, televisions, etc.) then the facility is allowed to utilize surge protectors only for connecting this equipment together to an electrical wall outlet. 44570 Based on interview and record review, the facility failed to assess for self-harm behaviors and failed to ensure resident care areas were free of disposable razors. This failure applied to one (R56) of one resident reviewed for supervision and resulted in R56 finding a disposable razor in a resident room and using it to cut her wrists requiring immediate hospitalization . Findings include: R56 was admitted to the facility 1/20/22 with diagnoses that include bipolar disorder and major depressive disorder. According to Facility reported incident on 7/07/23, a fell ow Resident alerted the nurse on duty that R56 was cutting their wrists in the bedroom. R56 was found by staff with a laceration to the left wrist, rendered first aid, and was subsequently sent to the hospital for psychiatric evaluation. R56 returned to the facility 7/13/23 with sutures to the wrist. On 07/26/23 at 10:07 AM R56 was alert, oriented and presenting appropriately to situation. R56 said, I wasn't trying to kill myself. I cut myself so that I could transfer to another nursing home. I was in my friends' room upstairs and saw that she had a disposable razor that was left on the floor. I picked it up and bust it open to take the razor out and cut my wrists with it. I went to the hospital, and they did a medication adjustment and review for 6 days. We are allowed to shave our legs but [nurses] are supposed to watch us in the shower. We aren't supposed to have them. We use them and give them right back for them to throw away. On 07/26/23 10:19 AM V12 Assistant. Social Services Director said, I was informed R56 cut her wrists and was told that we needed to place her on 1:1 and group sessions. I'm not sure why this group was not provided to R56 prior to this incident. When the incident happened, I updated the care plan and the self-harm assessments. Prior to that, I am not sure when it was updated, but it should be whenever there is an incident or quarterly. This is not the first time R56 has inflicted self-harm and it has happened at least once since I have been working in this facility, so yes there is a history of self-harm. Residents are not allowed to have razors without supervision to prevent harm from happening to them. On 7/26/23 at 2:20PM V2 DON (Director of Nursing) said, R56 told me that she found a razor on the floor of her co-peer who was in the hospital at the time. I asked the other roommate who was in the room at the time, and they said that they didn't know where the razor came from and that they just noticed R56 bleeding. The residents are not allowed to have razors. This incident occurred during the day where most of the staff was on duty. Either the staff didn't properly confiscate or dispose of the razor after a shower, or a resident brought it in from the outside. Either situation put residents at risk for harm and in this case R56 was able to cut her wrists. Initially the wound looked superficial because the bleeding was minimal. When we were notified from the hospital that the wound required sutures, we initiated an investigation to report to IDPH. Care Plans and Assessments were reviewed in the Electronic Medical Record, however the facility failed to provide copies of the documents requested during this survey. Care Plan: Self Harm revised 1/26/2023: R56 demonstrated self-harmful behavior of superficial cutting/scratching. When interviewed, expressing episodes of Depression and poor coping skills. Interventions 1/7/2023: o Sent out to hospital for further evaluation. o As warranted, conduct: behavior monitoring of the resident. o As warranted, conduct a room check/search & remove: any sharp objects or similar contraband (razor blades, razors) o Intervene when any self-injurious behavior is observed. Counsel and Communicate assertively that the resident is responsible for exercising control over impulses & behavior. ASSESSMENTS: Self Harm/suicidal ideation o 1/7/23: Resident demonstrating episode of depression leading to suicidal ideation/self-harm with a plan. Resident placed on close monitoring. Sent out to hospital for further evaluation. o 7/7/2023 14:48 Resident has a history of suicidal ideation behavior. o 7/14/2023 10:39 Resident at this time is low to moderate risk and had a previous attempt. will continue to follow up with resident and document accordingly. No assessments or updates to the care plan were conducted between 1/7/23 and 7/7/23.

There are multiple deficient practice statements. Based on interviews and records reviewed the facility failed to prevent an incident of staff to resident inappropriate sexual behavior. This affected 1 of 3 residents (R2) reviewed for staff to resident sexual abuse. This failure resulted in V7 being observed receiving oral sex from R2 and V7's finger observed inserted in or on R2's exposed vagina. The Immediate Jeopardy began on 6/6/2023 when V7 was observed naked engaging in an inappropriate sexual act with R2. V4 (Co-Administrator) was notified of the Immediate Jeopardy and the Immediate Jeopardy template was presented on 06/27/2023 at 11:04AM. The survey team confirmed by observation, interview and record the Immediate Jeopardy was removed on 06/28/2023, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan. The findings include: 1. R2 is a [AGE] year-old with diagnosis include but not limited to bipolar disorder with psychotic features, schizoaffective disorder, bipolar type, personal history of traumatic brain injury, auditory hallucinations, and post-traumatic stress disorder. R2 is alert and oriented to person, place, time, and situation. On 6/16/23 at 11:20 R2 stated I had relations with my baby daddy in the facility. R2 stated they (the staff) accuse me of all sorts of things. During a second interview on 6/20/23 at 10:30AM R2 was shown a picture of V7 from his employee file. R2 responded I recognize him from the facility. R2 stated we talked before about life, goals, and futures. R2 stated he told me I looked nice. R2 stated I don't know his name. On two phone interviews on 6/16/23 at 1:37PM and 3:07PM V11 Certified Nursing Assistant (CNA), stated I was sitting at the nurse's station and saw V7 Psych Tech, enter the floor from the stairs. V11 stated V7 came to the floor around 11:00PM. V11 stated I did not see him enter R2's room. V11 stated the evening shift nurses had left and the night shift nurses had not arrived, I was on the floor alone. V11 said I got up to do my rounds and went to R2's room. V11 stated I saw R2 giving him (V7) head (oral sex) and he (V7) was fingering R2's exposed vagina. V11 said she told V7 to leave several times and he just stared at me. V11 said V7 would not leave. V11 said I think because he had no clothes on, he didn't want me to see him. V11 said R2 never said nothing to her but was mad and agitated after V7 left. V11 said R2 left the floor like 5-7 minutes after she told him (V7) to leave. V11 stated V15 Supervisor came to the floor, but V7 had left. V11 stated she saw V7 go to the stairs and leave. V11 said all of R2's roommates slept thru everything and never woke up. V11 stated R2 lied to the police and to V15 and said no one was in her room and then she told V15 that a staff member was on the floor. V11 state this is my first time I am talking to anyone about this. V4 Co-Administrator and V20 Administrator, did not talk to me about this. V11 stated I gave V15 a written witness statement and she said she put it in V8's Director of Nursing, mailbox. V11 stated she recognized the male as staff when he came to the floor. V11 stated V7 should not be doing this because he is staff, and it is not right. V11 stated the facility tells us we can't do that, there is no sleeping with the residents. V11 stated this would be abuse, sexual abuse. On a follow up, in person interview on 6/20/23 at 3:20PM V11 stated I notified V15 that the guy in R2's room was naked. V11 stated I never spoke with V4 Assistant Administrator, V20 Administrator, or a V23 Chief Nursing Officer. V11 stated you are the only one that has called me about this incident. V11 stated I knew I had seen the staff member on social media, so I pulled up his picture and showed it to the police. V11 stated I gave the police my statement that night. On 6/16/23 at 1:43PM V19 Social Services Director, stated he heard R2 was flirting with security. V19 stated staff spoke with R2 and let her know that sex with a staff person is inappropriate and V19 said R2 said she consented to it. V19 said R2 is alert and oriented times four. V19 said it is inappropriate because this is her home and R2 is here for a reason. On 6/16/23 at 2:23PM V12 Security/Psych Tech/ Central Supply Manger stated V7 was usually assigned to the 3rd or 6th floor. V12 stated I know V7 was terminated for a policy violation, and he was not where he was supposed to be while on duty. V12 stated on 6/6/23 V20 called me at night and told me to remove V7 from the schedule pending investigation. V12 stated I tried to call V7 to tell him, and he did not answer his phone. On a follow up interview on 6/20/23 at 12:56PM V12 stated I never had the chance to ask V7 anything about R2 because he never answered my calls. On 6/16/23 at 3:02PM the surveyor requested to see camera footage from V13 Maintenance Director. V13 said he calls the company to obtain a code to watch the security camera footage. V13 said the footage is available for 24 hours. No footage was available to view from 6/6/23 or 6/7/23. On 6/20/23 at 10:37AM V8 Director of Nursing, stated she was made aware that a male entered a resident room and V11 told him to come out of the room. V11 said all I know is R2 was going to be sent out for evaluation and that R2 refused evaluation and was returned to the facility. V8 stated she had a statement in her mailbox from V11.V8 said I gave the written statement to V4 Co-Administrator. On 6/20/23 during a phone interview from 11:05AM until 11:28PM V7 Psych Tech, stated I worked at the facility as a psych tech. V7 stated on 6/6/23 I was assigned to the 5th floor. V7 said I was terminated by phone on 6/7/23 for not following the rules. V7 stated I was not on my assigned floor. V7 said I have not been asked anything about R2 by anyone at the facility. V7 said not being on my assigned area means I was in R2's room. V7 said we were just talking and then R2 began removing her clothes. V7 said R2 said she wanted to do something. V7 said staff saw me standing over R2, in her bed without clothes, and her legs open. The surveyor asked if V7 was clocked in when this occurred and V7 said yes. V7 stated this was like at 11:00PM. V7 said after the staff saw me, I went down the stairs, punched out, and left the facility. V7 said the interaction with R2 started off friendly, we were just talking, then it went left. V7 elaborated and said it went left when the nurse walked in on us. V7 said I got no training on what to do if a resident makes sexual advances or flirts with me. V7 stated I had no training on not having sex with a resident. On 6/20/23 during a phone interview at 11:05AM until 11:2AM V20 Administrator stated I started the investigation as soon as I was notified in the night hours of 6/6/23. V20 said she had V15 take the phone to R2's room but R2 was not cooperative and refusing to be examined. V20 stated the allegation was that V11 was in R2's room and should not be on the unit and the staff saw him in R2's room. V11 stated they weren't sure what happened V15 did not see anything. V11 stated I never spoke with V11 or V7. V20 stated V12 spoke with V7 and V7 told V12 nothing happened in R2's room. V20 stated inappropriate friendships with staff and residents should not happen and V7 was terminated because he was in an inappropriate location in the building. V20 stated I reviewed camera footage and saw V7 go down the hall, on the unit and go into R2's room. V20 stated V7 left R2's room and went thru the stairwell, and V20 state she watched V7 leave the building. V20 stated on the camera footage she saw V11 at the nurse's station, get up, and go to R2's room. V20 stated my conclusion of the investigation is that the allegation cannot be substantiated. On 6/20/23 at 12:11PM thru 12:21PM during a phone interview, V21 R2's Guardian, stated R2 is upset right now because I told her she can't be having sex in her room while the room mates are present. V21 stated R2 does not understand boundaries. V21 said R2 interprets niceness as an advance, and she is needing male attention. On 6/20/23 at 3:00PM V4 Assistant Administrator, stated we don't have a statement from V11, I checked. On 6/21/23 at 9:05AM V15 RN Supervisor, stated on 6/6/23 V11 reported that R2 observed an inappropriate interaction between a male staff and a patient. V11 stated it was of a sexual nature. V15 stated I was instructed by V20 to get a statement from V11. V20 stated I took V11's statement and put it in V8's box. V11 stated I did not see anything or the male staff person. V15 stated I did call the police. V15 stated there were no witness everyone was asleep. R2's care plan includes identification that R2 is sexually active and is a trauma survivor. R2 has diagnosis and history of severe mental illness, and poor ability to control impulses. R2's PASRR (preadmission screening and resident review) denotes R2 was admitted to the hospital on 8/15/22 from a shelter, you were not taking your medications, using drugs, and engaging in high risk sexual behavior. You have a court appointed guardian ad litem. You have been ordered by the court for placement in a nursing facility. You state that you do not need your medication. You are homeless. When manic the patient has a history of engaging in risky sexual behaviors and self-neglect. R2's trauma screening dated 9/26/22 and 6/7/23 both denote a score of 1. V11's timecard record identifies he punched in on 6/6/23 at 3:00PM and his end of shift was 11:00PM. The facility investigation incident date 6/7/23 denotes It was reported by staff that V7 was inappropriate towards R2. Conclusion: Facility conducted a thorough investigation and interviewed staff and residents. (Per V20 and V11, V11 was not interviewed.) Final sentence in the reports denotes abuse is not substantiated. R2's Hospital records dated 6/7/23 denote R2 refused assault/rape kit. Records note R2 reported to hospital staff that she has been in a romantic relationship with the security guard for a while now. Police Report obtained dated 6/7/2023 denotes officer responded to the facility for an alleged criminal sexual assault. Allegedly V11 reported to V15 that V11 walked in on a staff member with R2 engaged in sexual acts. V15 stated R2 did confirm a male staff member was in the room with her but refused to answer any other questions. V11 told officer she observed a male psych tech who she did not know by name naked in R2's bed and was getting head (receiving oral sex) from R2 while he fingered her. The facility Resident Rights document states You must not be abused by anyone- physically, verbally, mentally, financially, or sexually. The Immediate Jeopardy that began on 06/06/23 was removed on 06/28/23 when the facility took the following actions to remove the immediacy confirmed by the survey team onsite observation, interview, and record review. Policy and Procedure/System Revision 1) Abuse policy revision to include that staff understand inappropriate sexual behaviors/acts or prevention of staff manipulation of residents for sexual gratification. 2) The residents will be educated by the social service team on Sexual Practices within the facility. 3) Residents with known sexual abuse (Trauma Screening Assessment reviewed in electronic medical record) will be encouraged to attend a group with the focus on Trauma survival and support placing boundaries and safe sexual practices. R2 was reassessed for Trauma on 6/7 and was identified as high risk for abuse. The care plan was updated with revised interventions on 6/7/23. Her state guardian was made aware. Education 1) Abuse quiz revision and all facility staff will be reeducated and quiz completion by CNO, Administrator, or Co Administrator. The education of all facility started on 6/28/23 and will continue until all staff have a face-to-face meeting. Staff that are on FMLA or have extended vacations if they have capacity to connect to a zoom meeting, we will complete education in that manner). No employee will be on schedule until they have completed abuse in servicing on new policy and quiz. Completion date June 29, 2023. 2) The new employee orientation program will include face to face meetings with their specific department supervisor and administrative staff to evaluate their job policy. These meetings will occur weekly for 1 month, biweekly for 1 month, then monthly until staff and administration are ensured of employee's confidence/comfort level within their job and knowledge of the facility abuse policy. Current employees will meet with their direct supervisor and administrative staff to evaluate their job performance, how comfortable they are with resident interaction, reassessment of abuse policy. 3) Social Service will be adding on a group or individual meetings for those residents who have been evaluated as significant Trauma as per their trauma screening. Those residents with significant passed trauma will have a new trauma assessment completed. Those cognitively impaired residents will be assessed for signs and symptoms of abuse. 4) V7 is no longer working at this facility 5) Qapi Plan The qapi plan as follows has been initiated with the following as written on 6/27/23: Topic: Abuse F600 IJ Abuse Data collected: This information was provided on 6/27/23. Education, Audits, and Plan: 1) Abuse policy Revision 2) Abuse Quiz Revision 3) Staff follow up Meetings for New Hires and Current employees, the meeting will discuss job performance comfort level understanding of policies and job description as well as abuse. A) New employees will meet with Department Head and Administration person 1 time/week for 4 weeks, 2times/month for 1 month, then 1 time a month until Employee and Department head and administration feel they are confident in their job and have a clear understanding of abuse. B) Current employees will have an initial meeting and they department head and administration as well as the employee are knowledgeable on all topics listed above evaluations minimally yearly and attendance at in-services for abuse. 4) On going staff education, face to face meetings with the department heads and administration staff, social service, and nursing monitoring of R2 and all residents for any signs and symptoms of abuse, charting accordingly with any follow up concerns to administration. 5) Team members responsible for following up on the items listed in the plan: Administration, CNO, DON, Social Service, and Interdisciplinary Team. 6) Audit tool 7) R2 was provided wellbeing checks and individual consoling she continues to be monitored and encouraged to attended or meet individual with social service. State guardian has continued to be updated. 2. Based on observation, interview, and record review the facility failed to ensure staff does not physically harm residents during Crisis Prevention Intervention (CPI) technique. This affected one (R30) of nine residents reviewed for physical abuse. This failure resulted in R30 being observed with a bump on left side of face, lips swollen, and facial bruises after an incident with V69 (Security). The findings include: R30's diagnosis include anxiety, bipolar disorder, major depressive disorder, lack of coordination, schizoaffective disorder and weakness. R30's cognitive assessment dated [DATE] indicates a score of 13 (cognitively intact). On 7/7/23 at 1:50PM the surveyor was escorted to R30's room by V37 Licensed Practical Nurse (LPN). R30 observed in gown and underwear on (no pants or shirt) gown open in the front. R30's arms, chest, belly exposed. Surveyor saw no bruises or marks on R30's, neck, belly, chest, arms, or hands. R30 has three purple bruises about the size of a quarter on the right side R30's forehead/temple region. R30 has one round purple bruise along R30's lower left chin. All three bruises same color and similar shape. R30 said the guy beat me up for no reason. R30 said he said to me you think you hard a** then he attacked me. R30 said this happened yesterday. R30 said he broke my fingers. R30 said he works here, his name is [derogatory slur]. R30 stated I told the police the same thing I just told you. R30 said my hand and jaw hurts. R30 was unable to say who V37 was by name. R30 became agitated during conversation and surveyor ended interview. On 7/7/23 at 2:07PM in R5's room. R5 said I saw V69 Security Guard, go into R30's room, right next door, and the door was closed. R5 said I was in the hall and heard noises. R5 said I peeked in the room and saw V69 punch R5 in the face. R5 said I saw V69 and R30 standing face to face with each other hands on each other, close to each other, they were standing by the bed. R5 said I waited outside the room and then saw V69 come out, it went on for like 3-5 minutes. R5 said V69 came out the doorway and said, I F*** people up. R5 stated I have pictures and showed the surveyor two pictures on his personal broken screen phone. R5 showed two blurry pictures and one picture has R30 holding a white cloth to his face, bright red blood on a white cloth. R5 said I saw V69 hit R30 two or three times. R5 said when V69 came out of the room he was wearing black gloves, like baseball gloves on his hands and was taking them off, he carries them in his pocket. R5 said I saw both, V37 and V69, carrying bloody towels and sheets. On 7/7/23 at 1:48PM V37 Licensed Practical Nurse (LPN) stated I approached R30 on 7/6/23 because he needed assistance, he wasn't dressed properly, and R30 became aggressive. V37 stated I called V69 to assist. I then left the facility for an appointment. V37 stated I did not see the altercation, but I was told about it when I returned. V37 stated in the morning while I was here R30 had no bruises on his face, but when I returned in the afternoon, I saw the bruises on R30's face. V37 stated R30 is alert and oriented times two, he has confusion, and he may have some delusions and hallucinations. On a follow up interview on 7/8/23 at 9:25AM V37 stated V69 approached R30 saying Mr. (R30) follow me and R30 followed V69 to R30's room. V37 stated V69 then called V37 to look at the mess in R30's room. V37 stated I went to see and there was a mess of linens. V37 stated I did not see blood anywhere at that time. V37 stated R30 was standing in the room with V69 and R30 was not saying anything. V37 stated I did not see V69 with a ripped pocket and no bleeding. V37 stated I left the facility around 10:00AM on 7/6/23 and returned at 4:00PM. V37 stated I did not punch out when I left, because my appointment is related to a facility injury. V37 stated I called V68 Nurse, to notify her I was leaving, and she said she was coming to the unit. V68 said V69 and V57 Scheduler, were on the floor when I left. V37 stated V69 did not report to me the incident that occurred with R30. V37 stated V69 should have told me or to the administrator when it happened. On 7/7/23 at 2:52PM during a phone interview, V69 Security, stated R30 was argumentative at the nurses' station. V69 stated R30 then grabbed me by the neck and scratched my neck. V69 said I tried to de-escalate the situation by myself, and I did not call for help or a code gray. I didn't think of it. V69 stated after R30 got his clothes, linens, and shower - everything he wanted R30 calmed down. V69 stated I never put my hands on R30. V69 stated R30 didn't fall. R30 was never on the ground. R30 was trying to grab me by the neck. V69 stated I was in the room for 3-5 minutes. During follow up call on 7/11/23 at 10:20AM V69 stated I didn't tell anyone after the incident. I should have reported but V37 was gone. V69 stated I used proper CPI (crisis prevention institute). I didn't touch R30's face. V69 stated R30 only had me in a bear hug from the front he never came at me from behind. On 7/11/23 at 10:03AM V71 Director of Customer Experience, stated I was doing my rounds and R5 pulled me to the side and showed me some pictures on his phone, and stated the resident had been beat up by a staff member. V71 said this was reported to him a little before 10:00AM. V71 said R5 was holding his phone with a picture in which he saw a man's face and some blood, and his face was down. V71 gave the room number and R30's name as the man in the picture R5 was showing him. V71 stated R30's face should not look like that. You don't engage in CPI and his face should not look like that. V71 said you need to call a code and get out the room when behaviors are coming like that. V71 described R30's face as swollen and said V30 said the [derogatory name] did it. V71 said I have seen V69 with black motorcycle gloves at work. On 7/7/23 at 2:58PM by phone, V68 (Nurse) stated she received a call from V37 (Nurse) around 10:00AM that she was to cover the floor, while he was out to an appointment. V68 stated she went to the unit shortly after 10:00AM. V68 stated she did not stop on any other unit. V68 said it was around 12:00-12:30PM when V4 (co-administrator) arrived on the unit and asked V49 to come with her because there was an allegation. V68 stated they went to R30's room. V68 stated that R30 reported he got into it with a male security guard. V68 said she did a head-to-toe assessment on R30, and she observed R30's forehead was swollen and R30's lip was swollen. V68 said the inside of R30's lip was swollen, too. V68 requested the surveyor read the incident report that she completed. V68 said she asked R30 what happened to his forehead and lip, R30 replied, the male security guard did it, I told the nurse. V68 said she and V4 went toward V69 he was sitting by the elevator. V68 said V69 said no, no, the resident was aggressive. V68 said she observed V69's shirt pocket was ripped and V69 pointed out very minor scratches to his neck. On 7/7/23 at 4:21PM by phone, V12 Security Supervisor, stated a code gray is called when a resident is combative. V12 said if a resident puts their hands on you, that should be a reason to call a code gray. V12 said if you are using CPI to get the resident's hands off your neck the technique would not involve touching the resident's head or face. V12 said the code is called to prevent the situation from escalating and to show the resident they are outnumbered. I did not respond to a code gray involving V69 on 7/6/23. V12 said I did not hear the code gray, I was outside. V12 stated I was called by V20 Administrator, about 12:30PM and told to watch the security footage. I watched the video about 12:45PM. V12 said on the video, I saw R30 at the nurses' station and V37 waving for someone. V12 said I only saw footage at the nurses' station not the hallway. V12 said I was told that R30 said he was hurt. V12 said when I went into the video room, I watched the video alone. V12 said I didn't talk to V69, and I didn't see him before he left. On 7/8/23 at 1:40PM V4 Co-Administrator, stated I was notified by V71 Director of Customer Service, there was an incident where a resident alleged a staff member was inappropriate. V4 said I went to speak with R30 sometime in the morning of 7/6/23. V30 said she went to the floor and when she got there the first place, she went was to R30's room. V4 said R30 reported he and staff possibly had some kind of altercation. V4 said R30 said a staff member had physical contact with him. V4 said R30 described the person as having military fatigue, clean cut, and the color of his uniform was black, R30 gave no name. V4 said I asked R30 for a description of the altercation and he seemed disorganized and confused, he cognitively was coming in and out, and seemed tired. V4 said from the description of the staff person R30 gave it was V69. V4 said V68 Nurse, was present during R30's interview. V4 said I obtained R30's written statement before he left. V4 said V69 said he had redirected R30 back to his room. V4 said V69 said that Crisis Prevention Interventions (CPI) was utilized. V4 said generally CPI requires a party of two, but maybe done with one person. V4 said I would expect the incident to be reported if one person CPI technique was used, right after the situation occurred. V4 said the nurse would document in a progress note if CPI occurred. V4 said I am not trained to see if I saw on injury on R30. V4 said I did not see blood. V4 said I read V68's progress note where she reported R30 had some possible skin discolorations. V4 said CPI is verbal de-escalation of a situation, physical techniques are a last resort, and the holds are nonaggressive. V4 said R5 reported to her that V69 was in R30's room. V4 said R5 had said he was standing in the hallway. V4 said R5 said he opened the door to R30's room, looked inside, and he possibly witnessed they were having a disagreement and closed the door. V4 said R5 said there was a possibility that V69 was using CPI on R30. V4 said R5 is alert and oriented times four. V4 said it sounds like the CPI used could have been verbal and possible holds. V4 said the investigation is not yet completed. On 7/7/23 at 3:12PM V20 Administrator, said I was not in the facility, but I was told by V12 that V69 grabbed R30 from the back. V20 said I did not watch the security video; I was not in the facility on 7/6/23. On 7/8/23 at 12:40PM the surveyor inquired if the facility has a specific code gray policy, other than the Facility Codes Policy. V20 replied there is no other policy for code gray. Facility incident report dated 7/6/23 at 11:30AM completed by V68 denotes in-part incident location- resident room, resident location- (room number). Resident (R30) alleged staff member was inappropriate towards him. Head to toe assessment completed, resident noted with bloody lips, and swelling to forehead, ice applied. Co-Administrator (V4) made aware; investigation initiated. Injury type- swelling, right forehead. No witness found. R30 plan of care dated 04/05/2023 denotes in-part that R30 comprehensive assessment reveals a factor that may increase my susceptibility to abuse/neglect. The resident demonstrates: Diagnosis of Mental Illness The resident will be treated with/ respect, dignity & reside in the facility free of mistreatment (i.e., abuse/neglect) (on-going). Review assessment information. Emphasize treatment of causal factors &/or interventions designed to moderate/reduce symptoms, make treatment of compulsive behavior, substance abuse, anger & mental health issues available to the resident, as indicated. Assure the resident that he/she is in a safe & secure environment with/ caring professional. Explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse, CNA, peer) & by verbalizing thoughts, needs & feelings. Assure the resident that staff members are available to help & department heads maintain an open door policy. R30's plan of care dated 04/10/2023 denotes in-part has a Self-Care Deficit with impaired dressing and grooming abilities and would benefit from participation in a dressing/grooming restorative nursing program as evidenced by the following risk factors and potential contributing diagnosis: bipolar disorder, requires one person assist with dressing and grooming, schizophrenia and/or schizoaffective disorder. R30 will be able to dress self-up and comb hair with staff provided ones daily for clean appearance/hygiene potential with no more than supervision assists times one staff, six- seven days weekly to help improve and/or maintain current level of function, unless disease process causes unavoidable deterioration through next review. Explain all tasks prior to performing R30 dressing and grooming assistance. Use task segmentation and verbal cues as needed. Gather all of R30 clothing and grooming supplies prior to assisting me with restorative dressing and grooming program. Notify MD (Medical Director) for significant decline in dressing and grooming status and request an order for skilled PT/OT (physical therapy/ occupational therapy) evaluation and TX (treatment) as indicated. Praise R30 efforts in dressing and grooming program. MDS (Minimum Data Set) dated 4/10/23 denotes in-part R30 requires limited assist with one-person physical assist with dressing. Progress Notes include documentation by V37 between 10:08AM and 10:10AM, 5 entries. V37's written statement dated 7/6/23 denotes he was sitting at the nurse's station when R30 presented partially naked. V37 wrote R30 became agitated. V69 came back to nurse and reported the condition of R30's room. V69 said he provided towels for R30 and then left for his appointment. V69's written statement signed 7/6/23 denotes between 10:00AM and 10:30AM R30 spoke very rudely to the nurse. R30 got aggressive, and the nurse called for security. V69 wrote he instructed R30 to go to his room and wait for the nurse when R30 tried to pull V69 to the floor. Security try to back up but R30 kept trying to get on top of security while scratching security face. R5 has a cognitive score of 15, intact, dated 6/16/23. Facility abuse policy with last revision date of 6/28/2023 (a different version that what had been presented prior to 7/6/23) denotes in part the purpose of the policy is to ensure that the facility is doing all that is within its control to prevent and reduce the risk of abuse incidences to the residents of city view multicenter. The types of abuse include neglect, exploitation, mistreatment, sexual, involuntary seclusion, and misappropriation of property. Staff and other relevant ancillary personnel shall have ongoing training on the abuse policy. The education consist of the following: procedure for reporting incidents of abuse, dementia management, abuse prevention, inappropriate staff relationships with the residents, and CPI (crisis prevention intervention). The facility Abuse Policy dated 6/28/23 (a different version that what had been presented prior to 7/6/23) states staff will be trained on the procedures for reporting incident of abuse including CPI. Prevention includes identifying inappropriate behavior including rough handling. Facility Codes Policy and Procedure dated 1/2/23 mentions the code gray is used for behavioral health emergency. No instruction for use given. 38796 Based on observation, interview, and record review the facility failed to prevent incidents of resident-to-resident physical assault, and staff to resident mental abuse. This affected 5 of 9 (R11, R14, R9, R24, and R6) residents reviewed for physical and mental abuse. This failure resulted in R14 hitting R11 with a chair. R1 sustained a facial laceration and multiple left orbital fractures. R24 assaulted R9 with a food tray sustaining a laceration to mouth, and V2 CNA challenging R6 to a fight. Findings include: R11's face sheet shows in-part that R11 has diagnosis of cognitive deficits, lack of coordination, weakness, personal history of traumatic brain injury. Facility incident report to the department with date of incident 6/7/2023 denotes in-part, reported by V8 (Director of Nursing), resident (R11) observed with laceration/slight swelling below left eye. Head to toe assessment completed. Area cleaned with NS (normal saline) and ice pack applied to left eye. Resident denies pain. MD (Medical Doctor) made aware and order to send to ER (emergency room ) for further evaluation. Resident remains in the hospital. Family made aware. Investigation initiated. After investigation resident was sitting on patio when another resident accidental picked up a chair and it hit R11 in his facial area. This as per resident (R11) was not intentional and did not have initial discomfort. Resident was sent to the hospital with preliminary report of fracture to orbital and jaw. Resident remains in the hospital currently, and we do not have any conformation of hospital interventions currently. If we need to add an addendum we will send as soon as he returns. Final report. R11 emergency room record dated 6/7/23 denotes in-part stated complaint, left face injury, eye emergency, priority 4, assault- left eye trauma, epistaxis, epistaxis due to trauma, blow out fracture of orbital floor, assault, zygomatic fracture -left s[TRUNCATED]

A. Based on interview, and record review the facility failed to follow their notification of change policy and notify the physician of changes in condition to include fall incident, complaints of pain, and significant weight loss. This affected 2 of 3 (R12, R3) residents reviewed for notification of changes. This failure resulted in the facility staff failing to notify the physician of a fall incident and complaints of pain for R12 for over 8 hours. R12 subsequently was admitted to the hospital for right hip fracture. This failure also resulted in the facility staff not notifying the physician of R3 experiencing an insidious weight loss of 18 pounds (17.5%) in a 6-week period. B. Based on interview, and record review the facility failed to follow their policy and conduct a comprehensive assessment after an unwitnessed fall with complaints of not being able to move the leg/legs for over 6 hours. This affected 1 of 3 residents (R12) reviewed for comprehensive assessment. This failure resulted in over a six-hour delay in treatment and services for R12 who was subsequently sent to hospital for treatment of a right hip fracture. Findings include: R12 face sheet shows diagnosis of osteoporosis without current pathological fractures, COPD (chronic obstructive pulmonary disease), multiple fractures of ribs, right side sequela, other hyperlipidemia, dementia unspecified severity with other behavioral disturbance, pathological fracture hip, presence of right artificial hip joint, difficulty walking, and abnormal posture. R12's facility final report to the department completed by V8 (Director of Nursing) with sent date of 6/11/2023, incident date 6/6/23 denotes in-part resident c/o (complaints of) pain to right hip. Head to toe assessment completed BP (blood pressure) 128/69, PR (pulse rate) 59, RR (respiration) 18, T(temperature) 97.7, spo2 97%, and 8/10 pain scale. PRN (as needed) pain medication administered. MD (medical doctor) made aware, and resident transferred to hospital. Resident remains in hospital for evaluation. Resident is her own responsible party. Investigation initiated. After completing the investigation, it was determined the resident had indicated that she had a fall while in the bathroom the night before and got up went to bed and then early the next morning c/o pain to the hip. The nurse completed an assessment, notified PCP and resident was transferred to hospital for evaluation that determined she had a right hip stress fracture. Resident has returned to the facility and new orders and care plan have been updated with orders. Resident is aware, PCP (primary care physician) aware she has returned to facility. This was an isolated incident for the resident. R12 facility incident report completed by V8 (Director of Nursing) dated 6/6/23 at 8:00AM denotes in-part fall, incident location, residents' bathroom. Resident complaint of pain to the right hip. Resident stated that she had a fall in the bathroom and fell on her buttocks. Resident assessed, VS (vital sign) stable, pain 8/10, PRN pain medication given. MD made aware with orders to send to ER for evaluation. No injuries observed at time of incident. Level of pain;8, alert, ambulatory without staff assistance. Alert to periods of, orient to place, orientated to person. No injuries observed post incident, predisposing situation factors; toileting needs. Witnesses V60 (Nurse) I did not get report that resident had a fall. V32 (Nurse), per nurse during rounds, resident was complaining of pain to right hip. Nurse assessed resident with no visible injuries. Pain medication was given, and MD called with orders to send to ER. R12, I had a fall last night while in the bathroom. I fell on my buttocks. V27 (Nurse) the resident did not report a fall to me. V28 (CNA) I am not aware of any fall. V26 (CNA) resident complaint of pain and I told the nurse. I do not know about the resident fall. V41 (physician) notified on 6/6/23 at 8:14AM. IDT (interdisciplinary team) met to discuss fall and put in place interventions. Reported to the State Agency. After completion of investigation resident had an unwitnessed fall while in the bathroom on her buttocks and went back to bed. Intervention, wheelchair initiated, abductor to be placed in between legs for proper alignment when in bed. Refer to therapy for safety transfers. Review of facility incident report there is no statement noted from V18 (Nurse). R12's emergency room records dated 6/6/23 denotes in-part patient is a [AGE] year-old white female with history of COPD (chronic obstructive pulmonary disease), and psychosis presents from SNF/NF (skilled nursing facility/nursing facility) to hospital following a fall. Patient was noted to have right lower extremity rotated. Patients X-ray showed acute angular fracture of femoral neck. Patient was treated with morphine and zofran, pre-op labs, EKG (electrocardiogram), CXR (chest X-ray) obtained at local hospital, transferred to another hospital for ortho procedure with doctor. On 6/21/23 at 11:13AM R12 observed sitting in wheelchair in dining room. R12 agreed to interview. R12 was escorted to her room for interview, at 11:15AM R12 observed to be alert to person, place, and situation. R12 said she fell in the bathroom. R12 said she couldn't get up or move her legs. R12 said she called out for help when she was on the floor. R12 said the next day she went to the hospital and her right hip was fractured. R12 said V26 picked her up and the nurse helped V26 (CNA). R12 does not know the nurse's name that helped V26 pick her up. R12 said at the time she fell ; she was able to go to the bathroom by herself. R12 said now she's in the wheelchair. R12 said she was using the pink wedge noted in her room but that has stopped. R12 said she has an ortho appointment tomorrow. R12 stated she does have discomfort. R12 stated she wanted something for pain. R12 pressed her call light, V32 (Nurse) arrived. R12 requested pain medicine for her leg. V32 informed R12 that she recently had pain medication and it was not time right now. R12 stated she was walking and taking herself to the bathroom before the fall. On 6/21/23 at 3:17PM V26 (CNA-Certified Nursing Assistant) stated he was doing 1 to 1 with another resident when he heard R12 yelling. V26 stated he went to where the yelling was coming from and saw R12 on the bathroom floor. V26 said it was him, V27 (Nurse) and V42 (unknown female CNA) that picked R12 up. V26 stated he went and got the wheelchair for R12. V26 was asked who had the upper body and who held R12's lower body? V26 stated he really doesn't remember all those details. V26 stated he left the facility after that. V26 stated he did not let the next CNA know R12 fell and was picked up off the floor. On 6/28/23 at 2:36PM V42 CNA stated she was sitting at the nurse's station when V26 came and got her and to assist with picking R12 up from the bathroom floor. V42 stated when V26 approached the nurse's station he said to V27 (Nurse) R12 was on the floor if you want to come and look. V42 stated V27 was on the phone, and she was not sure if V27 heard V26. V42 said when she got to the bathroom R12 was sitting on the floor on her buttocks. V42 said the wheelchair was in the bathroom already, and she and V26 picked R12 up and put her in the wheelchair. V42 stated she left the bathroom after that. V42 said she doesn't know what V26 did after picking R12 up from the floor. V42 stated she went to clean up a spill in the dining room. V42 said she did not report R12's fall to anyone. V42 stated she did not report the fall because V26 reported the fall to V27. Follow up to V42 statement of she doesn't think V27 heard V26, V42 then said she doesn't know if V27 heard V26 or not but V26 told V27. V42 stated V8 (Director of Nursing) did not contact her regarding R12's fall and she has not been interviewed regarding R12's fall. V42 stated, surveyor was the only one to ask her about R12's fall. On 6/21/23 at 12:16PM V27 (Nurse) stated she was the nurse working with R12 on the 3PM-11:00PM shift. V27 denied knowing about R12 having a fall. V27 denied helping V26 pick R12 up from the floor. V27 stated around 9:30PM R12 approached her in a wheelchair and asked for pain medication because her right knee was hurting. V27 stated she gave R12 tylenol. V27 stated she did not ask R12 about her pain level. V27 stated she did not assess R12's right knee nor did she ask R12 any questions about her right knee pain. V27 stated R12 has arthritis but she doesn't know if R12 has arthritis of the right knee. V27 stated R12 is alert and orient and she knows if she's in pain or not. V27 stated she has always seen R12 use a wheelchair. V27 stated she went on break after that, and she doesn't know what time she returned from break. V27 said she worked a double and at 11:00PM she went upstairs to work her next assignment. On 6/22/23 at 4:09PM V18 (Nurse) stated she was the nurse responsible for R12's care on 6/5/23 11PM-7:00AM shift. V18 stated she did not get a report from V27 or V26 that R12 had a fall. V18 said she was doing rounds and R12 informed her that she was in pain, and that she had fallen in the bathroom and V26 picked her up from the floor. V18 said she gave R12 something for pain, but she did not assess R12 at that time. V18 said not too long after that another resident approached her for medications and mentioned that R12 needed to see her. V18 said when she went to see R12, R12 was asking for pain medications again. V18 stated she thought that was strange since she'd given R12 something for pain not too long ago. V18 stated that's when she asked R12 more questions and wanted to assess R12's legs. V18 said when she touched R12's leg, R12 was in severe pain and didn't want to move her leg. V18 said she immediately called V8 (Director of Nursing) and informed her that R12 stated she had a fall and V26 picked her up. V18 said she called V8 because she didn't want the incident to be blamed on her or that it happened on her shift. V18 stated V8 did not give her any directives. V18 said she called the doctor after speaking to V8 that morning. V18 stated the doctor ordered an X-ray. V18 stated she put the order in as routine but when she called the radiology company, she told them it was a STAT order. V18 stated the radiology company had not completed the X-ray by the time she left completed her shift. V18 was adamant that she spoke to V8 and informed V8 that R12 had a fall on the 3-11 shift and that R12 stated V26 picked her up from the floor. On 6/22/23 at 1:40PM V8 (Director of Nursing) stated she conducted the investigation for R12's unwitnessed fall. V8 stated R12 had an unwitnessed fall in the bathroom and got herself up and went back to bed. V8 stated the root cause of R12's fall was that R12 was unassisted to the restroom. V8 initially said R12 was independent with toileting. V8 then stated R12 needs one person assist with toileting V8 stated that R12 needs someone to be there just in case R12 needs help. V8 stated when she talked to R12 that morning, R12 said she had fallen in the bathroom on the 3PM-11:00PM shift, that's it. V8 stated R12 did not tell her that she got up from the floor by herself and got back in bed. V8 stated she assumed that R12 got up by herself and so that's what she documented in her investigation report. V8 stated she did not review the facility video surveillance because she did not find anything suspicious with the investigation. V8 said the nurse should be made aware of an unwitnessed fall and that the CNA should not pick a resident up before the nurse completes a head-to-toe assessment of the resident. V8 stated the physician should be notified immediately when the resident has a physical change in condition. V8 stated R12 had a physical change in condition when she was not able to move her legs after her fall. V8 stated R12 is ambulatory. On 6/28/23 at 10:31AM V8 stated she saw the documentation that V18 (Nurse) got an order for an X-ray for R12, but she didn't think to talk to V18 during her investigation to gather more information regarding R12's fall. V8 stated she helped the morning nurse by completing the incident report and when she saw R12's right leg she did not see any bruising or rotation. On 7/11/23 at 1:40PM V41 (Doctor) stated he is familiar with the incident with R12. V41 stated he was made aware that R12 had a fall and got back in bed independently. V41 was made aware of the investigation findings that V26 (CNA) stated he picked R12 up after the fall in the bathroom and put R12 in bed. V41 was made aware that R12 stated she did walk to the bathroom independently and had a fall. V41 stated the CNA should have reported the fall to the nurse and the facility needs to in-service all the CNAs about falls, injuries, and head injuries. V41 was made aware that V18 (Nurse) stated R12 reported to her that she fell and V26 picked her up and put her (R12) back in bed. V41 stated the nurse should have called him right away and he would have ordered an X-ray. V41 stated he should have been called/notified, and that he answers his phone at all hours. V41 stated he remembers the facility calling him that morning and he ordered to send R12 out to the hospital for evaluation. Review of R12 progress notes and medication administration record, there is no documentation denoting that V18 gave R12 pain medication. Review of R12 progress notes and medication administration record, there is no documentation denoting that V27 gave R12 pain medication. Review of R12 POS (physician order sheet) it is denoted that V18 put order in electronic record for R12's X-ray on 6/6/23. On 6/27/23 at 2:43PM V43 (Radiology company rep) stated V18 ordered the X-ray for R12 on 6/6/23 at 7:14AM, V43 stated the X-ray was for right hip with pelvis STAT and it was cancelled at 2:43PM by the facility on 6/6/23. Facility policy titled change in resident condition or status dated 6/26/2011 denotes in-part to ensure that the resident attending physician and representative is notified of change in the resident's condition and/or status. The nurse will notify the resident attending physician when the resident is involved in any accident or incident resulting in any injury including injuries of unknown origin. There is significant change in the resident physical, mental and psychosocial status. Deemed necessary or appropriate in the best interest of the resident. A significant change in the resident condition is a decline or improvement in the resident status will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. The nurse will record in the resident's medical record any changes in the resident's medical condition or status. Facility Fall prevention and management policy version date 8/3/2017 denotes in-part this facility is committed to safety and maximizing each resident physical, mental, and psychosocial well-being. The purpose of our fall prevention and management program is to provide our residents with an interdisciplinary approach to assess risk of falls. Provide appropriate interventions to prevent falls. Ensure that in the event a fall occurs, the fall will be investigated, appropriate emergency treatment will be provided, and additional interventions will be implemented to prevent another fall from occurring as much as possible. This facility will achieve this goal through an individualized fall risk assessment, interventions that are implemented based upon the identified risk factors, immediate response to residents who fall including assessment for any injuries and the emergency management of any injuries. Reassessment of risk after a fall with modifications and /or additional interventions as appropriate. 40066 2. On 6/27/23 at 9:54AM V8 Director of Nursing, stated I didn't see R3's weight loss triggered until about a month ago. V8 stated R3 usually eats about 100% of her meals. V8 said I contacted V38 Registered Dietician, about R3's weight on June 12. V8 stated on 6/6/23 V33 Nurse Practitioner, misunderstood what the nurse said about R3. V38 stated V33 was wanting to send R3 out for masturbation but V41 physician, stated to not send R3 out. V38 said I didn't know that psych was contacted about R3. V38 stated the nurse did not document that the order was discontinued. On 6/22/23 at 1:21PM V33 stated I saw R3 on 6/6/23 for psychiatric deterioration. V33 stated they told me R3 has not been eating and that she has been masturbating at night. V33 stated I spoke to R3's psych doctor and we decided to send her out for evaluation. V33 said I told the staff to send R3 out for an evaluation because she was manic. V33 stated to my knowledge R3 had not been losing weight. V33 stated on my next visit to the facility, a different day than 6/6/23, I was told R3 refused to go to the emergency roiagnom on [DATE]. V33 stated I don't have my calendar out, so I am not sure what date that was, but it was after 6/6/23. V33 state if I had known on 6/6/23 that R3 refused, I would have told the staff to send R3 out by petition. V33 said I don't recall being notified of R3's weight loss. V33 stated I don't know the results of R3's calorie count. V33 said if they called the doctor instead of me, it should be documented. V33 stated everything should be documented. R3's weight May 8, 2023, was 103 pounds, May 22, 2023, was 99.5 pounds, and June 12, 2023, was 90 Pounds. R3's weight dated 6/19/23 was 85 Pounds. R3's weight report identifies weight loss consistently since May 8, 2023. R3's progress notes dated 6/6/23 written by V33 documents a conversation with psychiatrist who discussed an evaluation and plan of care was discussed with the staff. R3's notes dated 6/6/23 denotes R3 refused to go to the hospital and Director of Nursing was notified. Review of R3's progress notes from 5/31/23 until 6/23/23 do not have documentation of physician notification of weight loss. Progress notes do not include physician notification. The facility policy for Change in Resident's Condition or Status dated 6/26/11 denotes the nurse will notify the resident's attending physician when the resident repeatedly refuses treatment or medications. The facility policy Weight Management dated 1/2/23 denotes the physician and the resident or resident representative will be notified by the resident's nurse of any significant unexpected and or unplanned with changes. The nurse will document the notification in the resident's medical record.

Based on interview and record review the facility failed to implement fall prevention interventions to reduce the risk of falling. This affected 2 of 3 residents (R8 and R4) reviewed for fall prevention. This failure resulted in R8 being involved in a fall incident being sent to the hospital for treatment for swelling to the right eye, concussion, and minor brain injury, and R4 being involved in a fall incident resulting in a fracture of the right inferior pubic ramus. The findings include: R8's face sheet indicates diagnosis including but not limited to cerebral vascular disease, hypertension, type 2 diabetes, atrial fibrillation, GERD (gastroesophageal reflux disease), anemia, bipolar disorder, hyperlipidemia, schizophrenia, constipation, anxiety, drug induced subacute dyskinesia, delusional disorders, altered mental status, essential tremors, vitamin D deficiency, pain in leg, and lack of coordination. R8's facility incident report dated 6/19/2023 completed by V50 (Nurse) denotes in-part incident location; resident (R8) room. Writer went to resident to bring him a milk supplement and he was observed on the floor. Resident (R8) stated he was trying to get out of bed. Head to toe assessment, right eye swollen, resident denied pain. PRN (as needed) acetaminophen administered, and ice pack applied to eye. V/S (vital signs) stable. MD (Medical Doctor) called. Resident sent out to hospital per facility protocol. No injuries observed at time of incident. R8 in wheelchair alert and orientated to place, Predisposing physiological factors-decreased safety awareness, involuntary movements. Witnesses V52 (CNA) I (V52) was doing rounds and found him (R8) on the floor. V50 (Nurse) I was bringing resident his supplement when I observed him on the floor. I (V50) had just seen resident minutes prior to the fall. Notes: IDT met to discuss fall and put in place interventions; resident was in room when he attempted to get up causing him to fall to the floor. Resident moved closer to nurse station. On 6/29/23 at 9:43AM V50 (Nurse) stated she was the nurse working with R8 on 6/19/23 when R8 was observed on the floor. V50 stated R8 was not unresponsive. V8 stated R8 had just received a bed bath and change of clothing. V50 stated R8 had asked for a milk shake (nutritional supplement). V50 stated when she went back to give R8 the supplement she observed R8 on the floor. R8's head was up as if he was trying to get up. V50 stated R8 was laying straight out on the floor in between the two beds. R8's head was at the foot of the bed. V50 said she asked R8 what happened? What was he trying to do? V50 stated she couldn't determine what R8 was saying because R8 has communication deficits. V50 stated she observed swelling above R8's right eyebrow. V50 stated she don't know what R8 hit his right eye on. V50 stated she doesn't know if R8 hit his right eye on the floor or the bed frame. V50 stated she did her assessment, and she and two other staff members lifted R8 up and put R8 in the wheelchair. V50 stated R8 needs 2-person assist with transfers, she believes. V50 stated she always sees R8 in his wheelchair and she never had to assist with transferring R8. V50 stated she called the physician and did not get a response. V50 stated she called V8 (Director of Nursing) and informed V8 that R8 was going to be sent to the hospital and V8 agreed. V50 stated she called the state guardian and did not speak to anyone. V50 said she did not complete an incident report as she was not familiar with the PCC (point click care) electronic medical record system. On 6/29/23 at 11:16AM V52 (CNA) stated she was working on the 6th floor; she was not assigned to work with R8. V52 stated she was serving dinner in the dining room, and she noticed R8 was not there. V52 stated she went to R8's room and observed R8 on the floor. V52 stated she summoned V50 and the other nurse to the room. V52 stated it was her, V50 and V54 that picked R8 up from the floor. V52 stated R8 had scraped his knee. V52 said V54 was R8's CNA. On 6/29/23 at 11:34AM V54 (CNA) stated she was assigned to work with R8 on 6/19/23. V54 said she last saw R8 in the bed just before dinner trays had arrived. V54 stated V52 is the CNA that found R8 on the floor. V52 stated V52 was going to see why R8 hadn't come for dinner. V54 said R8 had on regular black socks when they picked R8 up off the floor. V54 stated that was her second time working with R8. V54 stated R8 needs help with getting in and out of the bed. V54 stated R8 will transfer himself in and out of bed. V54 stated she provides weight bearing support and pivots R8 in and out of the bed by putting her arms under R8 arms, bringing R8 to a standing position and then pivoting R8 to the wheelchair or bed. V54 stated R8 cannot come to a full standing position. On 6/29/23 at 12:09PM R8 observed in wheelchair self-propelling throughout the unit purposefully. R8 observed with constant involuntary movement to the upper extremities, however, R8 continues to able to self-propel in the wheelchair. R8 communicated with surveyor about going to the dentist. R8 observed to be wearing black crew socks. On 6/29/23 at 12:24PM V5 CAN stated R8 self-propels in the wheelchair. V5 stated R8 needs help getting in and out of the bed. V5 stated she got R8 dressed this morning and R8 assisted by raising his arms when putting on the shirt. V5 stated R8 can also assist with pulling up his pants. V5 stated she put the black socks on R8 this morning. V5 stated those are the socks that R8's family provided and so she used them. V5 stated R8 should have on skid free socks. V5 said the skid free socks helps to prevent falls. V5 stated R8 is a fall risk. V5 stated R8's room was recently moved closer to the nurse station because R8 had a fall. When V5 was asked how do you know who needs skid free socks? V5 asked surveyor is it the resident's that's a fall risk?. V5 was asked does she know who to ask? V5 replied the nurse. V5 denied R5 refused assistance with care this morning. On 6/30/23 at 11:30AM V8 stated R8 should have on skid free socks. V8 stated its to prevent falls when R8 tries to stand up. V8 stated R8 has unsteady gait/balance. V8 stated the skid free socks is a fall prevention intervention for R8. V8 stated if the family brings regular socks, the staff must continue to put on skid free socks for R8. V8 stated the restorative aide knows what fall preventions the resident's need and they should be checking daily that the fall interventions are in place. V8 stated the restorative aides should inform the aides of what fall interventions the resident needs. V8 said the aides have not been provided any in-service on fall interventions that are in place, specifically skid free socks. V8 stated she will follow up with surveyor regarding how she is ensuring the restorative aides are informing CNAs of what fall interventions that are needed and who has fall interventions in place. V8 then stated there's a binder on the unit and inside the binder is a list of resident's fall interventions. V8 stated she will follow up with surveyor regarding how she's ensuring that the CNA's know about the binder and the fall interventions that are inside the binder. V8 was made aware that on 6/30/23 at around 12:09PM R8 was observed not wearing skid free socks and that the staff dressed R8 that morning and did not put skid free socks on R8. Review of R8 plan of care dated 4/24/23 denotes in-part R8 is at risk for falls as evidenced by the following risk factors and potential contributing diagnosis: diabetes mellitus, general weakness, use of anti-seizure medication(s), use of hypoglycemic agents, use of psychotropic medications. R8 will have a safe environment maintained through next review. Interventions dycem applied to wheelchair. R8 sent to the ER for treatment/evaluation, upon return on 5/19/2023 R8 is educated to call for assistance when in need of transfer. R8 sent to hospital for treatment/evaluation, upon return on 6/22/2023. R8 is moved closer to nurses' station for increased monitoring. Keep bed in the lowest position. Nursing staff will complete a fall risk assessment per facility fall protocol. Follow the facility fall protocol. Place R8 call light within reach and encourage me to use it for assistance as needed. Ensure that R8 is wearing appropriate footwear that provide stability and good traction when ambulating or mobilizing in w/c (wheelchair) and during transfers. Staff to anticipate and meet R8 needs. Pharmacy consults to evaluate R8 medications. Check to see that R8 bed brakes are locked prior to transferring. Commode placed over toilet/grab bars to make standing up easier. R8 has a self-care deficit with impaired dressing and grooming abilities and would benefit from participation in a dressing/grooming restorative nursing program as evidenced by the following risk factors and potential contributing diagnosis: bipolar disorder, diabetes mellitus, psychiatric disease process, requires 1-person assist with dressing and grooming. R8 requires extensive assist with dressing, requires extensive assist with grooming, schizophrenia and/or schizoaffective disorder, unsteady gait, and balance. R8 will assist as much as possible with dressing/grooming, donning/doffing, pants/shirt, shoes/socks daily with limited 1-staff for hygiene potential thru next review each day and as needed unless the disease process causes unavoidable deterioration, until next review. Provide assistance with all ADL's (activity of daily living) as required per R8 dependence needs eating, transferring, bed mobility, bathing, dressing, personal hygiene, ambulation, and personal hygiene. R8's ER (emergency room record) dated 6/19/23 denotes in-part patient presents to the ER via ambulance with a c/o (complaint of) unwitnessed fall at city view nursing home, patient has swelling to the right eye, patient presents in gown, patient placed on cardiac monitor, labs collected and sent, patient given cold pack to the right eye. Discharge diagnosis- concussion and minor head injury. R8 fall risk assessment dated [DATE] denotes in-part score of 15, high risk for falls, no history of falls in past 3 months, yes for resident receiving medications that affects awareness, judgment, or safety. Altered level of consciousness- behaviors present-fluctuates. Adequate vision, ambulation with assist, elimination; incontinent. Balance problems, change in gait pattern when walking, requires use of assistive devices, 1-2 health conditions that predispose resident to be at risk for falls. Total score 15. Facility Fall prevention and management policy version date 8/3/2017 denotes in-part this facility is committed to safety and maximizing each resident's physical, mental, and psychosocial well-being. The purpose of our fall prevention and management program is to provide our residents with an interdisciplinary approach to assess risk of falls. Provide appropriate interventions to prevent falls. Ensure that in the event a fall occurs, the fall will be investigated, appropriate emergency treatment will be provided, and additional interventions will be implemented to prevent another fall from occurring as much as possible. While preventing all incidents including falls is not possible, this facility is committed to act in a practical manner to identify those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. This is accomplished through the fall program. This facility will achieve this goal through an individualized fall risk assessment, interventions that are implemented based upon the identified risk factors, immediate response to residents who fall including assessment for any injuries and the emergency management of any injuries. Reassessment of risk after a fall with modifications and /or additional interventions as appropriate. Facility titled baseline care plan assessment/ comprehensive care plans with last update of 11/25/2017 denotes in-part, policy; the comprehensive care plan will further expand on the resident's risk, goals and interventions using the person-centered plan of care approach for each resident that includes measurable objectives and timetables t meet the residents medical, nursing, physical functioning, mental and psychosocial needs. These needs will be defined from observation, interviews, clinical medical record reviews and through assessments and CAAs (care area assessments). 40066 2. R4 is a [AGE] year-old with diagnosis including but not limited to diabetes, major depressive disorder, delusional disorder, history of traumatic brain injury, altered mental status, syncope and collapse, dementia, osteoarthritis, and vitamin d deficiency. According to assessment dated [DATE] R4 is severely cognitively impaired with a score of 4. On 6/15/23 at 11:59AM R4 observed in her room ambulating, no staff with her, not wearing a helmet. On 6/22/23 at 12:20PM R4 observed ambulating, no helmet, and staff walking next to her without their hands on her. On 6/22/23 at 1:53PM V32 Registered Nurse (RN), stated R4 takes her helmet off. V32 said we keep R4 with us staff to watch her. V32 stated R4 is alert times one and she is usually walking. On 6/21/23 at 3:27PM V26 Certified Nursing Assistant (CNA), stated R4 is supposed to be a 1:1 monitoring. V26 stated R4 is total care except for ambulation. V26 said you must watch R4 she is confused. V26 stated R4 must be under supervision when we have available staff. On 6/28/23 V44 CNA, said R4 can walk by herself but she needs redirection, she has dementia, she is confused and wanders. V44 stated I was in the dining room, yesterday (6/27/23) and R4 was walking back and forth. V44 stated I was sitting at the table in the dining room, R4 was near the TV (television) in the dining room (surveyor observed TV is on the other side of the room from V44). V44 stated I could not see R4 because she was behind the post in the dining room. V44 stated I was looking down, charting, and I heard the other residents saying no, no. V44 stated when she looked up, she saw R25 holding a chair. R25, had pushed R4 and she was sitting on her on the floor. V44 stated she and V32 picked R4 up and took her to the nurses' station. V44 stated R4 is not walking today she is sitting in a wheelchair at the nurses' desk. V44 said R4 was a 1:1 for monitoring about a month or two ago. V44 stated R4 was a 1:1 because of her falling. V44 said sometimes R4 responds to redirection. V44 said R4 is supposed to wear a helmet, but she won't' keep it on. (The surveyor was not shown a helmet and did not see staff attempting to put the helmet on or offering it to R4). On 6/28/23 at 2:04PM V8 Director of Nursing, stated R4's baseline is wandering, and she needs redirection and close monitoring. V8 stated we provide R4 with close monitoring and redirect when walking. V8 stated R4 was in the dining room yesterday (6/27) and her and another resident had their hands on a chair. V8 stated when V44 looked up due to the commotion R4 was on the floor. V8 said V44 was charting. V8 stated R4 has a fracture and went to the hospital today (6/28). V8 stated the interventions were not effective in preventing a fall and injury for R4. V8 stated R4 was not in sight of the staff. V8 stated R4 had a fracture on 1/26 caused by osteopenia. V8 stated the doctor said R4's walking and weakness caused that fracture. On 6/29/23 at 11:11AM V8 stated R4 is only alert to her name and can't make decisions. On 6/29/23 at 1:12PM V40 Director of Rehab, stated on 6/9/23 R4 was discharged from therapy, and she had mild balance impairments and 100% cognitive impairments. V40 stated R4 was educated on safety techniques while in therapy. V40 stated R4 is possibly not able to retain that education due to her cognition. R4's Fall Risk Review dated 12/28/22 identifies R4's category of high fall risk. R4's incident reports reviewed and are as follows: Fall on 9/6/22 obtained laceration on the top of her head. Fall on 11/22/22 obtained a bruise on her left arm. Fall on 11/28/22 obtained hematoma to forehead. Fall on 12/22/22 laceration on head. Fall on 1/5/23 discoloration to right inner thigh. Right hip X-ray performed without fracture. Review of R4's progress notes and X-ray results denote X-ray due to pain and inability to walk dated 1/26/23. X-ray results denote pelvis and left hip fracture presumable acute. Fall on 6/27/23 R4 obtained a skin tear on her chest and X-ray denotes fracture right inferior pubic ramus. R4's Functional Status assessment dated [DATE] denotes she required extensive physical assistance from staff for walking, bed mobility, and transfer. R4's balance is noted to not be steady and only able to stabilize with staff assistance. R4's care plan denotes she is at risk for falls related to cognitive impairment, weakness, and use of psychotropic medications. Interventions include monitoring, wheelchair for mobility, labs reviewed, helmet, and redirection by staff. R4's progress notes dated 6/8/23 denotes Gait dysfunction - continue to work with PT (physical therapy) to improve balance. Fall Prevention and Management Program, version 08/03/17, denotes the purpose of the program is to provide appropriate interventions to prevent falls. The program will decrease the incidence of falls and falls with injuries.

Based on interview, and record review the facility failed to follow their policy and conduct a comprehensive assessment after an unwitnessed fall with complaints of not being able to move the leg/legs for over 6 hours. This affected 1 of 3 residents (R12) reviewed for comprehensive assessment. This failure resulted in over a six-hour delay in treatment and services for R12 who was subsequently sent to hospital for treatment of a right hip fracture. Findings include: R12 face sheet shows diagnosis of osteoporosis without current pathological fractures, COPD (chronic obstructive pulmonary disease), multiple fractures of ribs, right side sequela, other hyperlipidemia, dementia unspecified severity with other behavioral disturbance, pathological fracture hip, presence of right artificial hip joint, difficulty walking, and abnormal posture. R12's facility final report to the department completed by V8 (Director of Nursing) with sent date of 6/11/2023, incident date 6/6/23 denotes in-part resident c/o (complaints of) pain to right hip. Head to toe assessment completed BP (blood pressure) 128/69, PR (pulse rate) 59, RR (respiration) 18, T(temperature) 97.7, spo2 97%, and 8/10 pain scale. PRN (as needed) pain medication administered. MD (medical doctor) made aware, and resident transferred to hospital. Resident remains in hospital for evaluation. Resident is her own responsible party. Investigation initiated. After completing the investigation, it was determined the resident had indicated that she had a fall while in the bathroom the night before and got up went to bed and then early the next morning c/o pain to the hip. The nurse completed an assessment, notified PCP and resident was transferred to hospital for evaluation that determined she had a right hip stress fracture. Resident has returned to the facility and new orders and care plan have been updated with orders. Resident is aware, PCP (primary care physician) aware she has returned to facility. This was an isolated incident for the resident. R12 facility incident report completed by V8 (Director of Nursing) dated 6/6/23 at 8:00AM denotes in-part fall, incident location, residents' bathroom. Resident complaint of pain to the right hip. Resident stated that she had a fall in the bathroom and fell on her buttocks. Resident assessed, VS (vital sign) stable, pain 8/10, PRN pain medication given. MD made aware with orders to send to ER for evaluation. No injuries observed at time of incident. Level of pain;8, alert, ambulatory without staff assistance. Alert to periods of, orient to place, orientated to person. No injuries observed post incident, predisposing situation factors; toileting needs. Witnesses V60 (Nurse) I did not get report that resident had a fall. V32 (Nurse), per nurse during rounds, resident was complaining of pain to right hip. Nurse assessed resident with no visible injuries. Pain medication was given, and MD called with orders to send to ER. R12, I had a fall last night while in the bathroom. I fell on my buttocks. V27 (Nurse) the resident did not report a fall to me. V28 (CNA) I am not aware of any fall. V26 (CNA) resident complaint of pain and I told the nurse. I do not know about the resident fall. V41 (physician) notified on 6/6/23 at 8:14AM. IDT (interdisciplinary team) met to discuss fall and put in place interventions. Reported to the State Agency. After completion of investigation resident had an unwitnessed fall while in the bathroom on her buttocks and went back to bed. Intervention, wheelchair initiated, abductor to be placed in between legs for proper alignment when in bed. Refer to therapy for safety transfers. Review of facility incident report there is no statement noted from V18 (Nurse). R12's emergency room records dated 6/6/23 denotes in-part patient is a [AGE] year-old white female with history of COPD (chronic obstructive pulmonary disease), and psychosis presents from SNF/NF (skilled nursing facility/nursing facility) to hospital following a fall. Patient was noted to have right lower extremity rotated. Patients X-ray showed acute angular fracture of femoral neck. Patient was treated with morphine and zofran, pre-op labs, EKG (electrocardiogram), CXR (chest X-ray) obtained at local hospital, transferred to another hospital for ortho procedure with doctor. On 6/21/23 at 11:13AM R12 observed sitting in wheelchair in dining room. R12 agreed to interview. R12 was escorted to her room for interview, at 11:15AM R12 observed to be alert to person, place, and situation. R12 said she fell in the bathroom. R12 said she couldn't get up or move her legs. R12 said she called out for help when she was on the floor. R12 said the next day she went to the hospital and her right hip was fractured. R12 said V26 picked her up and the nurse helped V26 (CNA). R12 does not know the nurse's name that helped V26 pick her up. R12 said at the time she fell ; she was able to go to the bathroom by herself. R12 said now she's in the wheelchair. R12 said she was using the pink wedge noted in her room but that has stopped. R12 said she has an ortho appointment tomorrow. R12 stated she does have discomfort. R12 stated she wanted something for pain. R12 pressed her call light, V32 (Nurse) arrived. R12 requested pain medicine for her leg. V32 informed R12 that she recently had pain medication and it was not time right now. R12 stated she was walking and taking herself to the bathroom before the fall. On 6/21/23 at 3:17PM V26 (CNA-Certified Nursing Assistant) stated he was doing 1 to 1 with another resident when he heard R12 yelling. V26 stated he went to where the yelling was coming from and saw R12 on the bathroom floor. V26 said it was him, V27 (Nurse) and V42 (unknown female CNA) that picked R12 up. V26 stated he went and got the wheelchair for R12. V26 was asked who had the upper body and who held R12's lower body? V26 stated he really doesn't remember all those details. V26 stated he left the facility after that. V26 stated he did not let the next CNA know R12 fell and was picked up off the floor. On 6/28/23 at 2:36PM V42 CNA stated she was sitting at the nurse's station when V26 came and got her and to assist with picking R12 up from the bathroom floor. V42 stated when V26 approached the nurse's station he said to V27 (Nurse) R12 was on the floor if you want to come and look. V42 stated V27 was on the phone, and she was not sure if V27 heard V26. V42 said when she got to the bathroom R12 was sitting on the floor on her buttocks. V42 said the wheelchair was in the bathroom already, and she and V26 picked R12 up and put her in the wheelchair. V42 stated she left the bathroom after that. V42 said she doesn't know what V26 did after picking R12 up from the floor. V42 stated she went to clean up a spill in the dining room. V42 said she did not report R12's fall to anyone. V42 stated she did not report the fall because V26 reported the fall to V27. Follow up to V42 statement of she doesn't think V27 heard V26, V42 then said she doesn't know if V27 heard V26 or not but V26 told V27. V42 stated V8 (Director of Nursing) did not contact her regarding R12's fall and she has not been interviewed regarding R12's fall. V42 stated, surveyor was the only one to ask her about R12's fall. On 6/21/23 at 12:16PM V27 (Nurse) stated she was the nurse working with R12 on the 3PM-11:00PM shift. V27 denied knowing about R12 having a fall. V27 denied helping V26 pick R12 up from the floor. V27 stated around 9:30PM R12 approached her in a wheelchair and asked for pain medication because her right knee was hurting. V27 stated she gave R12 tylenol. V27 stated she did not ask R12 about her pain level. V27 stated she did not assess R12's right knee nor did she ask R12 any questions about her right knee pain. V27 stated R12 has arthritis but she doesn't know if R12 has arthritis of the right knee. V27 stated R12 is alert and orient and she knows if she's in pain or not. V27 stated she has always seen R12 use a wheelchair. V27 stated she went on break after that, and she doesn't know what time she returned from break. V27 said she worked a double and at 11:00PM she went upstairs to work her next assignment. On 6/22/23 at 4:09PM V18 (Nurse) stated she was the nurse responsible for R12's care on 6/5/23 11PM-7:00AM shift. V18 stated she did not get a report from V27 or V26 that R12 had a fall. V18 said she was doing rounds and R12 informed her that she was in pain, and that she had fallen in the bathroom and V26 picked her up from the floor. V18 said she gave R12 something for pain, but she did not assess R12 at that time. V18 said not too long after that another resident approached her for medications and mentioned that R12 needed to see her. V18 said when she went to see R12, R12 was asking for pain medications again. V18 stated she thought that was strange since she'd given R12 something for pain not too long ago. V18 stated that's when she asked R12 more questions and wanted to assess R12's legs. V18 said when she touched R12's leg, R12 was in severe pain and didn't want to move her leg. V18 said she immediately called V8 (Director of Nursing) and informed her that R12 stated she had a fall and V26 picked her up. V18 said she called V8 because she didn't want the incident to be blamed on her or that it happened on her shift. V18 stated V8 did not give her any directives. V18 said she called the doctor after speaking to V8 that morning. V18 stated the doctor ordered an X-ray. V18 stated she put the order in as routine but when she called the radiology company, she told them it was a STAT order. V18 stated the radiology company had not completed the X-ray by the time she left completed her shift. V18 was adamant that she spoke to V8 and informed V8 that R12 had a fall on the 3-11 shift and that R12 stated V26 picked her up from the floor. On 6/22/23 at 1:40PM V8 (Director of Nursing) stated she conducted the investigation for R12's unwitnessed fall. V8 stated R12 had an unwitnessed fall in the bathroom and got herself up and went back to bed. V8 stated the root cause of R12's fall was that R12 was unassisted to the restroom. V8 initially said R12 was independent with toileting. V8 then stated R12 needs one person assist with toileting V8 stated that R12 needs someone to be there just in case R12 needs help. V8 stated when she talked to R12 that morning, R12 said she had fallen in the bathroom on the 3PM-11:00PM shift, that's it. V8 stated R12 did not tell her that she got up from the floor by herself and got back in bed. V8 stated she assumed that R12 got up by herself and so that's what she documented in her investigation report. V8 stated she did not review the facility video surveillance because she did not find anything suspicious with the investigation. V8 said the nurse should be made aware of an unwitnessed fall and that the CNA should not pick a resident up before the nurse completes a head-to-toe assessment of the resident. V8 stated the physician should be notified immediately when the resident has a physical change in condition. V8 stated R12 had a physical change in condition when she was not able to move her legs after her fall. V8 stated R12 is ambulatory. On 6/28/23 at 10:31AM V8 stated she saw the documentation that V18 (Nurse) got an order for an X-ray for R12, but she didn't think to talk to V18 during her investigation to gather more information regarding R12's fall. V8 stated she helped the morning nurse by completing the incident report and when she saw R12's right leg she did not see any bruising or rotation. On 7/11/23 at 1:40PM V41 (Doctor) stated he is familiar with the incident with R12. V41 stated he was made aware that R12 had a fall and got back in bed independently. V41 was made aware of the investigation findings that V26 (CNA) stated he picked R12 up after the fall in the bathroom and put R12 in bed. V41 was made aware that R12 stated she did walk to the bathroom independently and had a fall. V41 stated the CNA should have reported the fall to the nurse and the facility needs to in-service all the CNAs about falls, injuries, and head injuries. V41 was made aware that V18 (Nurse) stated R12 reported to her that she fell and V26 picked her up and put her (R12) back in bed. V41 stated the nurse should have called him right away and he would have ordered an X-ray. V41 stated he should have been called/notified, and that he answers his phone at all hours. V41 stated he remembers the facility calling him that morning and he ordered to send R12 out to the hospital for evaluation. Review of R12 progress notes and medication administration record, there is no documentation denoting that V18 gave R12 pain medication. Review of R12 progress notes and medication administration record, there is no documentation denoting that V27 gave R12 pain medication. Review of R12 POS (physician order sheet) it is denoted that V18 put order in electronic record for R12's X-ray on 6/6/23. On 6/27/23 at 2:43PM V43 (Radiology company rep) stated V18 ordered the X-ray for R12 on 6/6/23 at 7:14AM, V43 stated the X-ray was for right hip with pelvis STAT and it was cancelled at 2:43PM by the facility on 6/6/23. Facility policy titled change in resident condition or status dated 6/26/2011 denotes in-part to ensure that the resident attending physician and representative is notified of change in the resident's condition and/or status. The nurse will notify the resident attending physician when the resident is involved in any accident or incident resulting in any injury including injuries of unknown origin. There is significant change in the resident physical, mental and psychosocial status. Deemed necessary or appropriate in the best interest of the resident. A significant change in the resident condition is a decline or improvement in the resident status will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. The nurse will record in the resident's medical record any changes in the resident's medical condition or status. Facility Fall prevention and management policy version date 8/3/2017 denotes in-part this facility is committed to safety and maximizing each resident physical, mental, and psychosocial well-being. The purpose of our fall prevention and management program is to provide our residents with an interdisciplinary approach to assess risk of falls. Provide appropriate interventions to prevent falls. Ensure that in the event a fall occurs, the fall will be investigated, appropriate emergency treatment will be provided, and additional interventions will be implemented to prevent another fall from occurring as much as possible. This facility will achieve this goal through an individualized fall risk assessment, interventions that are implemented based upon the identified risk factors, immediate response to residents who fall including assessment for any injuries and the emergency management of any injuries. Reassessment of risk after a fall with modifications and /or additional interventions as appropriate.

Based on interviews and record reviews, the facility failed to determine the cause of one resident's major injury of unknown origin. This affected 1 of 3 (R3) reviewed for injury of unknown origin. This failure resulted in R3 complaining of left hip pain, subsequently resulting in an acute displaced fracture of the proximal left femur with superior displacement. R3 was sent to the local hospital and treated for hemiarthroplasty. The facility also failed to prevent resident to resident physical assault. This affected 4 of 6 residents (R5-R8). reviewed for physical abuse. This failure resulted in R7 being punched in the face by R8 multiple time and R7 sustaining superficial abrasions to the left temporal area and an abrasion to right upper eye. This failure also resulted in R5 being punched in the face by R6 and sustaining a laceration under the left eyebrow. Findings Include: Facility reported incident, initial report dated 1/27/23 reads in part: R3 observed with pain to the left hip and knee. X-ray ordered and revealed abnormalities. Physician notified with order to send to emergency room for further evaluation and treatment. Final incident report reads in part: R3 had a fall on 1/5/23 which an x-ray was ordered that had no abnormal findings other than osteopenia. R3 was ambulating without difficulty until 1/25/23 when R3 appeared to have difficulty with ambulation at which time PCP ordered x-ray of the hip and it was noted there was a fracture of the hip, and R3 was sent to emergency room for conclusive diagnosis. R3 admitted in the hospital with diagnosis of hip fracture. R3 has many co morbidities which place R3 at risk for fracture and the fact that the X-ray indicated osteopenia, R3's normal daily activities and weakened bones could have resulted in the fracture. Hospital record reviewed with arrival date of 1/26/23, documented: There is no report of fall or any other trauma. Physical exam: pain with ROM (Range of Motion) left hip. R3 presents with left hip pain and was found to have a fracture. Despite the fact that there is no report of trauma a workup for possible fall is indicated as there is no clear etiology of the fracture. Hospital record with admitted [DATE] documented that Ortho and ID on consult for further evaluation and treatment. Surgery tomorrow 7am, left hip hemiarthroplasty. On 5/19/23 at 2pm, V23 (Nurse) stated that R3 was observed able to ambulate without difficulty after the fall on 1/5/23. On 5/19/23 at 11am, V2 (Director of Nursing) stated that they investigated R3's injury of unknown origin and reported it to IDPH (Illinois Department of Public Health). V2 stated that the facility concluded that R3's fracture is due to diagnosis of Osteopenia, this is a fracture caused by the osteopenia diagnosis and weakened bone. R3 had a fall on 1/5/23 and nothing else after that. There is no fall incident reported to me by any staff for R3. R3's complaint of pain to left leg on 1/25/23. On 1/25/23, R3 walked into another resident's room and the staff found R3 standing in the room, the staff was about to escort R3 out of that room, R3 stated pain, pain pointing at her leg. Staff did not report any fall incident for R3. Nurse received order for X-ray to be done in the facility. X-ray result received and it showed left hip fracture. R3 was sent to hospital for further evaluation. R3 was admitted for left hip fracture and had left hip surgery. On 5/24/23 at 11am, V55 (Ortho Medical Assistant) stated that For anyone with such fracture like R3 had, would most likely have difficulty walking and might have severe discomfort. They may not be able to bear weight on that leg due to discomfort. The fact that R3 came in the hospital and was scheduled for a hip surgery, it is something that needed to be corrected at that time. Any residents with this kind of hip fracture can still ambulate with sever discomfort and difficulty. V55 stated it was very unlikely for R3 to walk long because of the pain due to left hip fracture. This kind of fracture comes from a trauma such as a fall incident. V55 stated an osteopenia diagnosis alone would not just cause a hip fracture, it needed an underlying medical condition such as bone cancer for example. R3's record reviewed and the only fall incident documented was dated 1/5/23. Facility provided a January 2023 fall incident list and R3 had a fall on 1/5/23, one fall incident for R3 for the month of January 2023. Facility policy for Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property dated 2/1/2022 reads on part: The purpose is to assure that the facility is doing all that is within their control to reduce the risk of occurrences of abuse, exploitation, misappropriation of property, mistreatment, or neglect. Identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse, and to determine the direction of the investigation. Investigate different types of incidents. R7 was admitted to the facility on [DATE] with a diagnosis of schizophrenia, asthma, seizures, post-traumatic stress disorder, hypertension, delusional disorders, and weakness. R7's BIMS dated 4/4/23 documents a score of 14/15 which indicates cognitively intact. R7's progress notes dated 4/11/23 documents: Report given from DON that resident received physical aggression while in the elevator; resident states peer threw a cup that almost hit her while in the elevator and hopped out of his wheelchair and hit her in the face; Both residents were immediately separated, head to toe assessment performed, resident noted with small laceration to left side forehead and swelling to right eye, bleeding controlled, ice pack applied, and vital signs within normal limits. The resident denied any pain or discomfort. R7's change in condition form dated 4/11/23 documents: physical aggression received. Under skin status evaluation laceration. On 5/18/23 at 11:09am, R7 who was alert and oriented stated she and R8 were on the 2nd floor entering onto the elevator at the same time which resulted in a verbal exchange. R7 stated R8 threw a cup of water at her and then stood up from his wheelchair while they were on the elevator. R7 stated she thought R8 was going to hit her, so she put her foot up to him to block him. R8 then started punching R7 in the face and staff eventually separated them. R7 stated she was bleeding from her head and went to the hospital. On 5/23/23 at 3:45pm, R7 who was alert and oriented relayed the same events about the incident. On 5/24/23 at 9:37AM, V50 (escort) stated she was waiting for the elevator on the 1st floor when the elevator doors opened, she observed R8 punching R7. R7 was not fighting back and was trying to get off the elevator. R7's hospital records dated 4/11/23 documents: Resident presents to emergency room after altercation with another nursing home resident. Patient was hit in the face multiple times on the left side of her head and to her right eye. She shows superficial abrasion to left temporal area and an abrasion to the right upper eye. R8's change in condition evaluation dated 4/11/23 documents under behavioral status: physical aggression; patient punched another residents in the head. Under pain documents: pain in right hand that was used to punch resident. No injuries seen. R8's height dated 3/20/23 documents 75.0 inches and weight dated 4/18/23 304 pounds. Facility reportable dated 4/17/23 documents: On 4/11/23 facility investigated an allegation of a peer-to peer incident between R8 and R7. R8 was interviewed and reported that he and R7 were trying to enter the elevator at the same time which caused a disagreement about who should first enter the elevator. Per R8, he and R7 finally entered the elevator, and as the elevator was moving, R7 attempted to make physical contact with him by raising her leg up towards his waist, he then attempted to block her and she started flailing her arms towards his face, and he started flailing his arms and hands back at her towards her face, he and R7 then made physical contact as the elevator door opened on the first floor. Staff then entered the elevator and separated he and R7. R8 was escorted to his floor and assessed by the Nurse. R8 was noted with pain to his left hand with no visible injuries and no skin discolorations. R7 was interviewed and reported that she was attempting to enter the elevator and R8 was trying to get on the same time and a disagreement ensued between them. After they entered the elevator, R8 started swinging his arms in a flailing motion and she started flailing her arms, and they both made physical contact on the elevator. Once the elevator arrived at the 1st floor, a staff member intervened and separated them. R7 was escorted to her room and assessed by the nurse. R7 was noted with swelling of the right eyelid and discoloration of the right eyelid, and some bruising to the left side of head. Facility abuse policy dated 2/1/22 documents: The purpose is to assure that the facility is doing all that is within their control to reduce the risk of occurrences of abuse, mistreatment, and neglect. Abuse is the willful infliction of injury, intimidation or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, pulling, and kicking. R5 was admitted to the facility on [DATE] with diagnoses of parkinson's, schizoaffective disorder, dementia, weakness, lack of coordination, hypothyroidism, and dehydration. On 5/19/23 at 12:55PM, V23 (Nurse) stated she saw R5 in the hallway with a cut to his face. V23 stated she spoke to R6 at that time who admitted to hitting R5. V23 stated R6 said R5 did not hit him back. R5's progress note dated 4/10/23 documents: R5 has a small laceration under left eyebrow. First aide done. Facility abuse reportable dated 4/10/23 documents: R6 reported that R5 entered his room rummaging through his belongings R6 stated R6 attempted to redirect R5. Per R6, R5 did not respond, so he approached R5 to escort him away from his belongings and R5 put his arms up in flailing motion. R6 then put up his arms to redirect R5s arms and that is when he and R5 made physical contact. R5 had a small opening under his left eye. Facility abuse policy dated 2/1/22 documents: The purpose is to assure that the facility is doing all that is within their control to reduce the risk of occurrences of abuse, mistreatment, and neglect. Abuse is the willful infliction of injury, intimidation or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, pulling, and kicking. 39340 R7 was admitted to the facility on [DATE] with a diagnosis of schizophrenia, asthma, seizures, post-traumatic stress disorder, hypertension, delusional disorders, and weakness. R7's BIMS dated 4/4/23 documents a score of 14/15 which indicated cognitively intact. R7's progress notes dated 4/11/23 documents: Report given from DON that resident received physical aggression while in the elevator; Resident states peer threw a cup that almost hit her while in the elevator and hopped out of his wheelchair and hit her in the face; Both residents were immediately separated, head to toe assessment performed, resident noted with small laceration to left side forehead and swelling to right eye, bleeding controlled, ice pack applied, and vital signs within normal limits. The resident denied any pain or discomfort. R7's change in condition form dated 4/11/23 documents: physical aggression received. Under skin status evaluation laceration. On 5/18/23 at 11:09am, R7 who was alert and oriented stated she and R8 were on the 2nd floor entering onto the elevator at the same time which resulted in a verbal exchange. R7 stated R8 threw a cup of water at her and then stood up from his wheelchair while they were on the elevator. R7 stated she thought R8 was going to hit her, so she put her foot up to him to block him. R8 then started punching R7 in the face and staff eventually separated them. R7 stated she was bleeding from her head and went to the hospital. On 5/23/23 at 3:45pm, R7 who was alert and oriented relayed the same events about the incident. On 5/24/23 at 9:37am, V50 (escort) stated she was waiting for the elevator on the 1st floor when the elevator doors opened, she observed R8 punching R7. R7 was not fighting back and was trying to get off the elevator. R7's hospital records dated 4/11/23 documents: Resident presents to emergency room after altercation with another nursing home resident. Patient was hit in the face multiple times on the left side of her head and to her right eye. She shows superficial abrasion to left temporal area and an abrasion to the right upper eye. R8's change in condition evaluation dated 4/11/23 documents under behavioral status: physical aggression; patient punched another resident in the head. Under pain documents: pain in right hand that was used to punch resident. No injuries seen. R8's height dated 3/20/23 documents 75.0 inches and weight dated 4/18/23 304 pounds. Facility reportable dated 4/17/23 documents: On 4.11.23 facility investigated an allegation of a peer-to peer incident between R8 and R7. R8 was interviewed and reported that he and R7 were trying to enter the elevator at the same time which caused a disagreement about who should first enter the elevator. Per R8, he and R7 finally entered the elevator, and as the elevator was moving, R7 attempted to make physical contact with him by raising her leg up towards his waist, he then attempted to block her and she started flailing her arms towards his face, and he started flailing his arms and hands back at her towards her face, he and R7 then made physical contact as the elevator door opened on the 1st floor. Staff then entered the elevator and separated he and R7. R8 was escorted to his floor and assessed by the Nurse. R8 was noted with pain to his left hand with no visible injuries and no skin discolorations. R7 was interviewed. R7 reported that she was attempting to enter the elevator and R8 was trying to get on the same time and a disagreement ensued between them. After they entered the elevator, R8 started swinging his arms in a flailing motion and she started flailing her arms, and they both made physical contact on the elevator. Once the elevator arrived at the first floor, a staff member intervened and separated them. R7 was escorted to her room and assessed by the nurse. R7 was noted with swelling of the right eyelid and discoloration of the right eyelid, and some bruising to the left side of head. Facility abuse policy dated 2/1/22 documents: The purpose is to assure that the facility is doing all that is within their control to reduce the risk of occurrences of abuse, mistreatment, and neglect. Abuse is the willful infliction of injury, intimidation or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, pulling, and kicking. R5 was admitted to the facility on [DATE] with a diagnosis of parkinson's, schizoaffective disorder, dementia, weakness, lack of coordination, hypothyroidism, and dehydration. On 5/19/23 at 12:55PM, V23(Nurse) stated she saw R5 in the hallway with a cut to his face. V23 said she spoke to R6 at that time who admitted to hitting R5. V23 stated R6 said R5 did not hit him back. R5's progress note dated 4/10/23 documents: R5 has a small laceration under left eyebrow. First aide done. Facility abuse reportable dated 4/10/23 documents: R6 reported that R5 entered his room rummaging through his belonging and attempted to redirect R5. Per R6, R5 did not respond, so he approached R5 to escort him away from his belonging and R5 put his arms up in flailing motion. R6 then put up his arms to redirect R5s arms and that is when he and R5 made physical contact. R5 had a small opening under his left eye. Facility abuse policy dated 2/1/22 documents: The purpose is to assure that the facility is doing all that is within their control to reduce the risk of occurrences of abuse, mistreatment, and neglect. Abuse is the willful infliction of injury, intimidation or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, pulling, and kicking.

Based on observations, interviews and record reviews, this facility failed to consistently monitor and implement pressure relieving interventions to promote healing and prevent a community acquired wound from worsening. This affected 1 of 4 residents (R11) reviewed for pressure sore prevention protocols. This failure resulted in R11's preexisting stage 3 wound worsening into a preventable stage 4. Findings include: On 5/18/23 at 11:15am, R11 was observed to have a low air loss mattress with setting for 360-pound resident. R11 was observed to have bilateral heel protectors on. The inside of these boots was covered with dry flakes of skin and several quarter size spots of dried brown substance. On 5/18/23 at 11:40am, this surveyor observed V31 perform wound care treatment for R11. R11 was observed to have a stage 4 right ischium (buttock) pressure ulcer. Wound measured 4cm (centimeters) x 0.7cm x 0.3cm. Wound with 90% granulation tissue and 10% slough (yellow tissue). V31 cleaned R11's wound with wound cleanser, packed wound with calcium alginate and then covered wound with a dry dressing. On 5/18/23 at 12:35pm, this surveyor observed V27 CNA and V33 CNA provide care to R11. R11 was observed to have a large soft bowel movement. The proximal and medial sides of right ischium dressing were observed to be not adhering to R11's skin and bowel movement was observed on the inside and the outside of R11's dressing. On 5/18/23 at 4:05pm, this surveyor observed the CNA remove R11's incontinence brief. R11's right ischium dressing appears to be the same dressing as at 12:35pm. There is dried bowel movement on dressing. The proximal and medial sides of dressing are rolled under dressing and touching R11's wound. On 5/18/23 at 11:15am, R11 stated that R11's wound dressings are changed every Monday, Wednesday, and Friday by V31. R11 stated that V31 was not present in the facility yesterday so his dressings were not changed until this morning. R11 stated that he gets out of bed once in a blue moon. R11 does not recall the last time he got out of bed. R11 stated that R11 weighs 180 pounds. On 5/18/23 at 12:00pm, when questioned does having the mattress setting on 360 pounds affect R11's wounds, V3 DON replied there would be a decline in wound or R11 could develop new pressure ulcer. On 5/18/23 at 12:00pm, V31 stated that staff bump into the knob that controls the weight setting for the air mattress causing the setting to change. V31 was observed pushing R11's nightstand into the controls on the air mattress. This surveyor observed the weight control knob did not move. On 5/18/23 at 12:45pm, V33 CNA stated that residents should receive incontinence care every two hours and as needed. V33 stated that if a resident has a dressing that becomes soiled during care, the nurse should be notified to change the resident's dressing. On 5/19/23 at 9:40am, V31 stated that all wound care treatments are documented in the resident's TAR (treatment administration record). V31 stated that the nurse should change the dressing if it becomes soiled. On 5/19/23 at 11:15am, V3 DON stated that all wound care orders have orders for scheduled and as needed dressing changes. V3 stated that the nurse is expected to change the resident's dressing(s) when soiled. V3 stated that all dressing changes are documented on the resident's TAR. On 5/23/23 at 2:30pm, V22 RN stated that V22 was assigned to R11 yesterday and today. V22 stated that R11's dressings are changed every Monday-Wednesday-Friday by V31. V22 stated that R11's dressings were changed yesterday by V31. V22 stated that the CNA is expected to notify the nurse if a resident's dressing falls off or is soiled. V22 stated that V31 will do as needed dressing changes for soiled dressings if V31 is not present at the facility, otherwise the floor nurse will do dressing change. V22 stated that the CNA did not inform her that R11's dressing needed to be changed today. Review of R11's medical record notes R11 was admitted to this facility on 2/4/23 with diagnoses including paraplegia, peripheral autonomic neuropathy, chronic indwelling catheter, heart failure, chronic obstructive pulmonary disease, and anemia. R11 was transferred from this facility to the hospital on 2/4/23. R11 was readmitted to this facility on 2/15/23. Review of R11's transfer medical record, dated 2/2/23, R11 had a facility acquired stage 3 right hip pressure ulcer. R11's wound was 10% deep maroon tissue and 90% bright pink/red tissue, periwound with redness and maceration. R11's wound measured 3.5cm (centimeters) x 1.5cm x 4.5cm. Review of R11's wound care documentation, dated 2/22/23, notes R11 with a right hip stage 3 pressure ulcer measuring 4.7cm x 1.6cm x 1cm. R11's wound care documentation, dated 4/11/23, notes R11 with a stage 4 right hip pressure ulcer, measuring 2.5cm x 0.3cm x 0.1cm. R11's wound care documentation, dated 5/1/23, notes R11's stage 4 right hip pressure ulcer measures 3cm x 0.6cm x 0.3cm. R11's wound care documentation, dated 5/15/23, notes R11's stage 4 right hip pressure ulcer measures 3.5cm x 1cm x 0.3cm. Review of R11's POS, dated 2/16/23, notes an order to apply calcium alginate to right ischium (buttock) cover with a foam dressing daily and as needed after wound cleansed with normal saline or wound cleanser. This order was discontinued on 4/10/23. Review of R11's MAR (medication administration record) notes the following: February 2023, R11's dressing was changed on the 2/27. March 2023, R11's dressing was changed on 3/3 and 3/17. April 2023, there is no documentation noting R11's dressing was changed. Review of R11's POS, dated 4/12/23, notes an order to apply hydrocolloid dressing to right ischium (buttock) every Monday-Wednesday-Friday and as needed after cleansing wound with normal saline or wound cleanser. Review of R11's MAR notes the following: April 2023, R11's dressing was changed on 4/26 and 4/28. May 2023, R11's dressing was changed on 5/1, 5/3, 5/5, 5/8, 5/10, 5/17, 5/22, and 5/24. There is no documentation found in R11's medical records noting R11 received all scheduled wound care treatments for February, March, April, and May. Review of R11's alteration in skin integrity care plan, dated 2/27/23, notes R11 is at risk for additional and/or worsening of skin integrity related to incontinence of bowel. Intervention identified includes to administer wound care treatments per physician orders. Review of this facility's treatment/services/heal pressure and non-pressure wounds policy, dated 11/2/2022, notes a resident with pressure ulcers will receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new wounds from developing.

Based on interview and record review, the facility failed to prevent and deescalate a verbal altercation from becoming physical to prevent an avoidable accident. This failure affected 2 of 3 residents (R1, R28) reviewed for supervision of behaviors. The facility also failed to implement effective fall prevention interventions to prevent or reduce the risk of falling. This failure affected 2 of 3 (R14, R24) residents reviewed for fall prevention. This failure resulted in R1 standing up from his wheelchair taking a swing at R28. R1 lost his balance and fell to the floor sustaining a right hip dislocation. Findings include: On 5-25-23 at 9:30am, R1 (via translator) stated at 3:00am, two residents opened his door and was looking into his room. R1 was able to identify R28 and the other resident was not identified. R1 stated he shouted at the residents and the residents closed the door and went away. At 9:00am, during R1's smoke break on the 2nd floor, R1 stated he saw R28, and he warned R28 not to go to his room. R1 stated R1 and R28 were yelling at each other. R1 stated he did not want to fight R28, and the staff had to separate R1 and R28. R1 stated he went upstairs to the 4th floor. R1 stated around 9:30am, R1 was in the day room receiving his medications and R28 confronted R1. R1 stated the other resident instigated a fight with R1. R1 stated he stood up to swing at the other resident, lost his balance, and fell on his side. R1 stated he had pain to his right hip and told the nurse. R1 is deaf however is able to communicate by reading lips. On 5-25-23 at 12:09pm, V2 state R1 and R28 had an altercation. V2 stated V2 was informed R1 and R28 had a peer-to-peer altercation. V2 stated this occurred in the 2nd floor smoke room V2 and PRSA (psychiatric rehabilitation service aide) separated R1 and R28. R28 reported R1 was making comments against R28. R1 and R28 were having a verbal disagreement then R28 reported R1 grabbed him. V2 stated the PRSA intervened and separated R1 and R28. On 5-26-23 at 9:54am, V2 stated cannot substantiate abuse. R1 mentioned R28 was coming to his room. No staff was aware of R28 going to his room. R28 was making inappropriate comments to R1. R1 and R28 made physical contact. They grabbed each other. R1 and R28 have psych diagnoses. The PRSA separated R1 and R28. R1 reported he stood up in his room and sat back down. R1 reported standing in smoke room during altercation, lost balance, and fell back into his wheelchair. V2 state R1 is noncompliant with his non-weight bearing status. R1 admitted he stood up on his own. On 5-25-23 at 2:38pm, V3 (DON) stated R1 is alert, oriented x3-4, and able to make his needs known. V3 stated she is not aware of any aggressive behaviors previous to the current incident with R28. V3 is not aware of R1 and R28 having any issues. V3 (DON) stated R28 is alert, oriented x3, and able to make his needs known. V3 is not aware of R28 having any aggressive behaviors towards resident or staff or R1. V3 stated she was informed R1 and R28 had a disagreement and R1 was complaining of hip pain after a recent hip resection. R1 was sent out and diagnosed with a hip dislocation (same affected side). V3 stated she is not aware of the incident. On 5-25-23 at 1:03pm, V59 (RN) stated V59 was the primary nurse for both R1 and R28 during AM shift. V59 stated R28 is alert oriented x2-3 and able to make his needs known. V59 stated she was on the unit while R1 and R28 were in the 2nd floor smoking room. R28 told V59 R1 was kicking and cursing at R28. V59 stated R28 has history of aggressive behavior when it comes to smoking. V59 stated R1 is alert oriented x3 and able to make needs known. R1 has history of physical and verbal aggression towards his peers. V59 stated R1 stated R28 was kicking and cursing at R1. R1 told V59 and Activity Director R1 grabbed R28 because he was being made fun of. V59 stated R1 and R28 were tussling. V59 stated R28 can walk and R1 can stand up. V59 stated no staff reported R1 or R28 falling to the floor. V59 stated R1 complained of unbearable pain to right hip and rated pain 9 out of 10 and recent hip arthroplasty. V59 sent R1 out to hospital and hospital found right hip dislocation. V59 stated R28 tried to attack R1 but security stopped the attack on the 4th floor. V59 stated no physical contact occurred on the 4th floor. V59 stated security removed R28. On 5-25-23 at 1:16pm, V24 (social services) stated R1 is alert oriented x4, able to make his needs known. R1 has history of physical and verbal aggression towards peers. V24 is not aware of R1 and R28 having previous altercation or incidents. V24 stated R28 is alert, oriented x2-3 (fluctuates) and able to make his needs known. V24 stated R28 has history of verbal aggression. V24 stated R1 stated something R28 didn't like, and this led to a physical fight. V24 stated R28 could not recall what R1 stated to him, and this occurred in the 2nd floor smoke room. On 5-25-23 at 2:07pm, V18 (PRSA) stated R1 is alert oriented and able to make his needs known. V18 stated R28 is alert, oriented, and able to make his needs known. V18 is aware of R28 having verbal aggression towards smoking monitors. V18 stated V18 had to remove R28 from the smoking area due to his aggressive behaviors (in the past) however, V18 is not aware of any physical aggression towards staff. V18 stated he was present on the 2nd floor and heard commotion. V18 saw R1 and R28 holding each other in an aggressive manner. R1 and R28 were bear hugging each other. R1 and R28 were standing on their feet. V18 stated he did not see R1 or R28 have any fall or injury. V18 split R1 and R28 immediately. V18 stated he instructed R28 to sit down while V18 escorted R1 to the 4th floor. V18 informed the nurse that R1 was in an altercation and V18 went back down to the 2nd floor. V18 went to R28 and removed him from the smoking floor and escorted him to the elevator. V18 is not aware of what floor R28 went to because V18 had a meeting to attend. V18 stated he is not aware of any further altercation between R1 and R28. Progress note dated 5/22/23 documents: Informed by staff resident was involved in physical aggression with peer R1 in smokeroom on second floor. When asked what happened the resident stated, he was bothering me, calling me out of my name disrespecting me, so I grabbed him. Resident immediately separated, assisted to assigned unit. No new injuries/bruising noted from event. Resident complained of right hip pain 9 out of 10 given prn (as needed) pain medication, tolerated well. Resident assisted to bedroom, management informed, administration informed, police department aware report completed, MD aware, send resident to Hospital for medical evaluation at this time. Progress note dated 5/22/23 documents: Informed by staff resident was involved in physical aggression with peer R28 in the smokeroom on second floor. When asked what happened the resident stated, he was talking to me in any kind of way, so I talk to him the same way and he grabbed me. Resident immediately separated, assisted to assigned unit. No new injuries/bruising noted from event. Resident denies any complaints of pain/discomfort at this time. Resident assisted to bedroom, management informed, administration informed, police department aware report completed, MD aware, responsible for self. Resident has in-house transfer to room transfer at this time. R1's Hospital Record dated 5-22-23 documents: History of Present Illness: Initial Comments: [AGE] year-old male sent from nursing home for right hip pain. He was in an altercation and felt a sudden pain and can't stand due to right hip pain. He denies any other injuries. Denies head injury or loss of consciousness. Physical Exam: Extremities: right leg held in flexion, internal rotation, and shortened. Progress Notes: This patient presents with a right hip dislocation approximately one month after right hip replacement. No other injuries reported. Radiology Impressions: Impression: Redemonstration of a right total hip arthroplasty with overlying skin staples consistent with recent surgery. Soft tissue air has improved since prior. However, there is now a complete right hip dislocation. Primary Impression: Hip dislocation, right. Initial Reportable dated 5-22-23 documents: Brief Description of Incident: Facility received report that resident R1 and resident R28 was involved in a peer-to-peer incident. Immediate Action Taken: Residents were separated by staff and placed on monitoring. Both residents were assessed by nursing staff with no visible injuries or skin discolorations. Facility initiated an investigation. Police Department notified, and both residents MD was notified. Final Reportable was not completed at the time this was written. 41758 R14 has diagnoses of rhabdomyolysis and lack of coordination. R14's MDS section C (cognitive patterns) dated 12/15/22 documents a score of fifteen which indicates cognitive intact. Section G (functional status) documents: R14 requires extensive assistance with toileting with one-person physical assist. Moving from seated to standing position, on and off toilet-not steady, only able to stabilize with staff assistance. R14 also requires limited assistance with transfers with one-person physical assist. Fall event report dated 3/11/23 documents: Resident (R14) was observed with walking difficulty while getting his medication. R14 states he fell the other day unwitnessed. Mobility: Ambulatory without staff assistance. On 5/19/23 at 1:39pm, V21 (nurse) stated, R14 walked to the nursing station limping. R14 reported he had a fall the night before. R14 complained of lower back, bilateral knee pain and the middle of R14's nose was swollen. R14 reported he fell on his face. R14 had an unwitnessed fall. On 5/19/23 at 2:54pm, R19 (R14's roommate) who was assessed to be alert and orient to person, place and time, stated, R14 slipped and fell on some water by the bathroom. R14 laid on the floor for hours. R14 had a bloody nose. I helped clean R14's blood up with paper towels. R14's nose was swollen. R14 complained of back and leg pain. I helped R14 up off the floor. I went to get help, but the nurse and security tech were sleep. I did not disturb them. No CNA was available. On 5/23/23 at 11:42am, R14 who was assessed to be alert and orient to person, place and time, stated, I went to the bathroom, slipped on some water and fell face down on the floor around 2:00am on 3/10/23. R19 tried to help me up but I fell again hitting the back of my head. My nose was bleeding a lot, I had two black eyes. I damaged my spinal cord. I hurt my back and leg. R19 was finally able to help me off the floor to my bed. I stayed in bed for the rest of the night/early morning due to the pain. I reported the incident to the nurse the next morning. I'm currently in a wheelchair. I can't walk. No staff was available to help. Staff on my floor usually sleep around 2am-3am. I had a clock in my room. Nursing note dated 3/11/23 documents: at approximately 6:00am resident (R14) observed walking with difficulty, resident complaint pain on his back and states that he fell the other day unwitnessed. Hospital paperwork dated 3/11/23 documents: Patient (R14) presented with blunt head trauma after a mechanical trip and fall with complaints of sacral back pain. R14 was diagnosed with subarachnoid hematoma within the medial aspect of the right frontal lobe and a nasal bone fracture and a small occipital scalp hematoma. Fall policy dated 8/2017 did not apply R24 was diagnosed with schizoaffective disorder, lack of coordination, difficult in walking, extrapyramidal and movement disorder and repeated falls. R24's MDS section C (cognitive pattern) dated 1/18/23 documents: cognitive skill for daily decision-making documents moderately impaired. Section G (functional status) dated 5/8/23 documents: R24 requires extensive assistance with one-person physical assist with bed mobility, transfers, walk in room/corridor, locomotion on/off unit and toilet use. Balance during transition and walking (moving from seated to standing, walking, turning around, moving on/off toilet and surface to surface transfer) not steady, only able to be stabilized with staff assistance. R24's BIMS dated 5/25/23 documents a score of five which indicates severe cognitive impairment. Fall risk review dated 2/11/23 documents: gait/balance requires use of assistive device- Conclusion: A score of ten or above represent high risk. R24 had a total score twelve. R24's Care plan initiated 12/06/22 documents: R24 is non-complaint with interventions put in place to reduce the risk of injury and falls as evidence by removing helmet not using wheelchair refusing to let staff assist. Intervention-staff to anticipate and meet R24's needs Fall event dated 4/5/23 documents: Resident (R24) was observed on the common bathroom floor. R24 stated, she was trying to go to the bathroom. R24 did not have her wheelchair. Injury: face laceration, predisposing physiological factors: confused and gait imbalance predisposing physiological factors: decreased strength/endurance, predisposing situation factors: incident during unassisted self-transfer, not using wheelchair. Nursing note dated 4/5/23 documents: approximately 1:05am resident (R24) was observed on the bathroom floor in between the stalls, on her left side in a sitting position. Blood was observed running down the left side of her face which resident was holding and crying. Upon assessment a small laceration noted with continuous bleeding. R24 returned with four stitches to left side of face near eye. Swelling noted. Nursing note dated 4/8/23 documents: noted four stitches to the left side of face near eye, with blue black ecchymosis and swelling. Care plan intervention dated 4/5/23 documents: Toileting program initiated for every 2 hours. Labs, refer to therapy. Wheelchair seat belt (it's not considered as restraint). Date initiated 4/6/23 documents: Restorative toileting program (every two-hour voiding pattern). Restorative Nurse note dated 4/6/23 documents: R24 was given an attached wheelchair seat belt which could be released on voice command, it is not considered a restraint. On 5/25/23 at 1:04pm, V3 stated, R24 had a fall on 4/5/23. R24 was at the nursing station and went to the bathroom by herself. The CNA went to do something, and the nurse turned her back for a minute. R24 was alert and orient to name (aox1). R24 sustained a laceration above the left eye. R24 was placed on a toileting program, given a seat which she could release, referred to therapy and medication modification. Restorative would toilet R24 during the day. Fall event dated 4/11/23 documents: Staff alerted writer resident had a fall, upon assessment, resident noted in sitting position on floor in resident's room. Resident noted with open area with blood at the back of resident's head. R24 was alert to person. R24 has some difficulty communicating due to current psych issues. Predisposing Physiological factors: gait imbalance and decrease safety awareness. Nursing note dated 4/11/23 documents: Staff alerted writer resident (R24) on floor, upon assessment, resident noted in sitting position on floor in room. Resident noted with open area and bleeding from back of skulls. Nursing note dated 4/12/23 documents: Resident went out due to a fall resulting in laceration of occipital region of scalp. Resident returned with orders to f/u (follow up) with her PCP (primary care physician) in ten days to have staples removed. Care plan intervention dated 4/11/2023: Bilateral floor mats. Care plan intervention dated 5/9/23 documents: R24 is non-compliant with helmet and attached seat belt on wheelchair. On 5/25/23 at 1:04pm, V3 stated, R24 was found on the floor in her room. R24 got out the bed stood up and fell back. R24 had a helmet but would remove the helmet. R24 was redirected by restorative staff to keep the helmet on. The redirection worked sometimes but not all the time. We gave R24 bilateral floor mats. Fall event dated 5/22/23 documents: R24 stated, she had a fall. Injury: bruise. Predisposing physiological factor: gait imbalance, decreased safety awareness, impulsive. Predisposing situation factors: not using wheelchair. Non-complaint with wheelchair. Resident is non-complaint with wheelchair and know how to get self-off of the floor if fall occurs. Nursing note dated 5/22/23 documents: Resident (R24) stated she had a fall. Purple/reddish discoloration noted to right side chest, right side armpit, and right side. Care plan dated 5/22/2023 documents: R24 was sent to emergency room . R24 is non-compliant with helmet and attached seat belt on the wheelchair On 5/25/23 at 1:04pm, V3 (don) stated, R24 reported she had a fall. We haven't determined the root cause of R24 bruises. Our investigation is on-going. On 5/25/23 at 1:23pm, R24 was called at the hospital. R24 was not able to converse in comprehendible verbiage. R24 was not alert. Verbiage did not consist of any words. On 5/25/23 at 1:36pm, V36 (rehab director) stated, R24 was a fall risk, used a wheelchair and had poor safety awareness. I saw bruising on R24's [NAME] and chest area. I reported it to nursing. R24 was able to transfer and walk with physical therapy. R24 could not walk by herself. On 5/25/23 at 3:10pm, V61 CNA stated, R24 stumbles when she walks. R24 tries to get up and walk at least three times on my shift. If R24 hops up out of her wheelchair fast she would stumble. R24 was not on a toileting program. I've never seen restorative toilet R24. I would see R24 going to the bathroom, I would go behind her. R24 would walk behind her wheelchair pushing it. I didn't witness R24 fall. Hospital paperwork dated 5/22/23 documents: Patient (R24) was sent for an unwitnessed fall. Found on the floor by nursing home staff. R24 had bruising in various stages of healing on the face and body. Extensive ecchymosis to the right side (chest wall, breast, axilla (underarm), shoulder, upper back and hip with upper thoracic tenderness, bilateral knees and left shoulder. Baseline alert and oriented times one (Aox1). Mumbles in response to question, unable to discern words. Diagnosis: fall, ecchymosis. Fall policy dated 8/2017 did not apply.

Based on interview and record review, the facility failed to follow their nutrition at risk policy by not monitoring weekly weights and ordering labs for one resident. This affected 1 of 3 residents (R7) reviewed for adequate nutrition. This failure resulted in R7 experiencing an unplanned severe weight loss of 11.3% in 90 days. Findings include: On 5/18/23 at 11:09am, R7 alert and oriented stated she was not trying to lose weight and was not on any prescribed weight loss regimen. R7 stated she just started losing weight and had requested for lab work to be done but was never completed. R7 was unable to recall the last time her blood was drawn. R7 stated she was weighed a few weeks ago and the facility has not been weighing her weekly. On 5/19/23 at 12:31pm, V38 stated he is unsure if he was notified of R7's weight loss. V38 stated if a resident experiences weight loss, they should notify himself or the nurse practitioner. V38 stated the resident would be evaluated by the dietician and follow their recommendations. V38 stated Labs would be ordered to monitor for any changes. V38 stated all of his patients have a standing order for labs to be drawn every 3 months and was unsure why labs had not been ordered. V38 stated the facility should have been weighing R7 weekly to monitor weights. On 5/23/23 11:54AM, V44 (dietary tech) stated restorative is responsible for conducting the weekly weights and V44 will upload the weights in the computer under vitals. V44 was unaware of weekly weights for R7 and was unable to find any documentation of weekly weights for R7. On 5/23/23 at 2:01PM, V3 stated weekly weights should be done be restorative. V3 was unable to find weekly weights for R7. V3 stated she did not see any recent lab results or orders for R7. R7's weights dated: 2/7/23: 204 pounds; 3/6/23: 201 pounds; 4/12/23: 185 pounds; 5/8/23:181 pounds. 11.3% weight loss of 23 pounds compared to weight on 2/7/23. R7's medical record did not document any other weights or weekly weights. R7's dietary progress notes dated 4/22/23 documents: Weight loss triggering for significant weight changes x (times) 30, 90 days. No reported edema. No recent hospitalization / infection. Weekly weights/nutrition at risk review. Advise weight maintenance. Staff supervision at meals, monitor p.o. (by mouth) intake, weights, labs, skin, reassess as needed. R7's medical record did not document any recent lab results. R7 labs results for Complete Blood Count, Thyroid level, lipid panel and Comprehensive Metabolic Panel were drawn on 8/17/22. Facility policy titled Nutrition at Risk revised 9/2018 documents: The facility will have a systematic interdisciplinary effort to identify, track, intervene and monitor residents that are high risk for weight loss, dehydration, and pressure ulcers. Residents are reviewed based on the following criteria: has experienced significant weight loss (5% in one month, 7.5% in 3 months or 10% in 6 months).

Based on interview and record review the facility failed to have an effective plan to monitor/supervise residents with known history of physical aggression to prevent resident to resident physical assaults. This affected 3 of 3 (R10, R1, and R4) residents reviewed for supervision. These failures resulted in R11 physically assaulting R10, R10 sustained a left orbital fracture requiring 10 facial sutures, this failure also resulted in R4 physically assaulting R3 and R3 sustained a black eye Findings include: On 10/5/22 at 10:34am, R10 stated that on 9/18/22, R11, R13 (R10's roommate), and V24 (security) were in R10's room. R10 stated that V24 was breaking the lock off R13's dresser because R13 locked keys in the dresser. R10 stated that R10 was lying in bed at this time. R10 stated that R11 started yelling and cursing at R10. R10 stated that R13 and V24 exited the room and R11 hit R10 repeatedly in the face. R10 stated that the previous day, 9/17/22, R11 brought a bottle of alcohol into R10 and R13's room. R10 stated that R10 and R11 had an argument. R10 stated that when staff came into R10's room, everyone was on R10's side of the room; R11 and R13 informed staff that the alcohol belonged to R10. R10 stated that staff told R10 he would have to go to the disciplinary floor as a result of having alcohol; staff never transferred R10. R10 stated that R13 came back into R10's room and hit R10 in the face. R10 stated that R10 informed a staff member of this. R10 stated that R10 had only been at this facility for a short time and does not remember who the staff member was. On 10/5/22 at 2:30pm, V24 (security) stated that V24 was present on 9/18/22 from 2:00pm until 10:00pm. V24 stated that when V24 came in to work that day, he was told to cut R13's lock off. V24 stated that R13 was present in the room at that time, R10 was present in room with curtain closed, and R11 was outside of R10's room. V24 stated that V24 left R10 and R13's room after cutting the lock on R13's dresser. V24 stated that V24 heard a door slam, V24 turned around and saw R10 standing in the hall bleeding and R10 stated that he was attacked. On 10/5/22 at 1:09pm, V26 LPN stated that V26 was R11's nurse on the evening shift on 9/18. V26 stated that V26 does not know what happened. V26 stated that V24 (security) told her that R10 was bleeding; R10 had blood gushing from his face and V26 gave R10 a towel. V26 stated that there was blood on floor; trail of blood between R10's bed and the hallway. V26 stated that R11 denied hitting R10. V26 stated that R11 did acknowledge that R11 and R10 had a verbal altercation the night before. V26 stated that neither resident gave any specific details regarding incident on 9/17. V26 stated that V26 did not see any alcohol in R10's room nor did R10 or R11 appear intoxicated. Review of this facility's fourth floor nursing unit census, dated 9/17/22 and 9/18/22, notes there were 67 residents residing on this unit. Review of this facility's staffing sheets for the fourth-floor nursing unit, dated 9/17/22 evening shift, notes there were two nurses, zero CNAs (certified nurse aides), and zero security working. Review of this facility's staffing sheets for the fourth-floor nursing unit, dated 9/18/22 evening shift, notes there were two nurses, zero CNAs, and one security staff working. Review of R10's medical record notes R10 was admitted to this facility on 8/23/22 with diagnoses including major depressive disorder and [CONDITION(S)] disorder. Review of R10's BIMS (brief interview of mental status) score, dated 9/2/22, notes R10's score is 15 out of 15. Review of R10's screening assessment for aggressive/harmful behavior, dated 8/23/22, notes R10 is minimal risk for aggression at this time. Review of R10's medical record notes: on 9/18 at 6:00pm, V19 LPN (licensed practical nurse) noted: staff observed R10 in hallway leaning forward. When asked R10 what happened R10 alleged that R11 made physical contact with R10. R10 and R11 were immediately separated. Immediate head to toe assessment completed. Left upper eyebrow area with open area pressure applied. No change in level of consciousness. R10 denied blurred vision headache at that time. Neurological checks at baseline. V1 (administrator) and V4 DON notified. R10 transported to the hospital via 911 EMS (emergency medical services). Review of R10's hospital record, dated 9/18/22, notes R10 presented to the emergency room for a chief complaint of left head injury. R10 stated that while he was lying in bed another individual struck R10 3-4 times in the left side of R10's face. R10 stated that R10 has left head/facial pain. Physical exam noted facial swelling, eye pain, headache, bruising, and two lacerations above left eye. Neurological exam noted R10 was alert and oriented x 3. Psychiatric exam noted R10's behavior normal. CT (computerized tomography) scan of R10's head noted: acute left lamina papyracea blowout fracture with 5-millimeter medial herniation of the infraorbital fat into the ethmoidal air cells. The medial rectus muscle is approaching the fracture site. Left periorbital soft tissue contusion. Laceration: there were two 1.5-centimeter lacerations to the left eyebrow. Both lacerations were cleaned and approximated with 5 sutures each. Review of R11's medical record notes R11 was admitted to this facility on 6/13/22 with diagnoses including [CONDITION(S)] disorder, major depressive disorder, [CONDITION(S)] disorder, [CONDITION(S)], and auditory hallucinations. Review of R11's BIMS score, dated 9/20/22, notes R11's score is 15 out of 15. Review of R11's screening assessment for aggressive/harmful behaviors, dated 6/15/22 and 9/20/22, notes R11 is at moderate risk for aggression. Review of R11's medical record notes: On 9/17/22 at 4:10pm, V27 LPN noted: R11 arguing with R10. At the time of the incident R11 was visiting R13 in R10 and R13's room. Interventions attempted: R11 and R10 separated, therapeutic communication. Effectiveness of the interventions: stable currently. On 9/18 at approximately 6:00pm, nurse was notified by V24 (security) that while going to cut a lock off, R10 stated that R11 came into R10's room and hit R10 unprovoked. R11 stated that R11 didn't hit R10. Nurse notified V1 and V4. On 10-1-22 at 10:58 AM, R3 stated R4 hit him because R3 owed R4 two cigarettes and did not have any when asked. R4 hit R3's eye with his fist. On 10-2-22 at 10:17 AM, V1 (administrator) stated R4 is [CONDITION(S)] with [CONDITION(S)] disease. Even with medication and constant behavioral monitoring, R4 has had aggressive behavior in the past. R4 is on the 7th floor which is a male psychiatric unit. All psych patients can have unpredictable changes in behavior. V1 was informed by staff about V4 abruptly hitting V3 in the eye. R3 sustained and swollen eye. Psychiatric patients have no impulse control and will react first before thinking things through. On 10-1-22 at 12:40 PM, V4 (director of nursing) stated R4 is alert, oriented x 3, can be verbally and physically aggressive (re-directable), and can be agitated. On 9-14, R4 was verbally aggressive towards staff. R4 was placed on social service wellbeing checks for 72 hours. Staff will monitor resident every hour alternating with nurse, CNA, and security. Residents are monitored to make sure they are calm, stable, and not any change in condition or concerns. V4 was informed V4 and V3 were in an altercation. R4 hit R3 in the eye and sustained discoloration to right eye. Staff immediately separated R3 and R4. R4 was placed on 1:1 supervision for a couple of days (minimum of 72 hour). R3 was moved to the 4th floor. On 10-1-22 at 10:01 AM, V5 (social worker) state R4 is known to be psychotic and delusional. V5 stated R4 was throwing things at staff on 12-27-21. R4 was delusional and called 911 one time. On 9-14-22, R4 was verbally aggressive toward staff. R4 was started on well-being checks. R4 was rambling off topic. V5 stated she was not on duty at the time of the incident. V5 stated she was told by staff about R4 hitting R3 resulting in a right black eye with no other injury noted. V5 continued with R4's well-being checks. V5 is not aware of R4's previous altercations with R3. R4 can be easily agitated. R4 requires more frequent monitoring every 15 minutes. R4 was noted disorganized with thoughts on 9-14 and 9-15. On 10-1-22 at 11:23 AM, V3 (LPN) stated R4 is alert, oriented x 1-2. with confusion, delusions, and hallucinations. R4 is impulsive and unpredictable. R4 is delusional and will talk about things that nobody understands. R4 can come off as intimidating and aggressive by his peers. V3 stated staff saw R3 with a black right eye on 9-15-22. R3 stated R4 attacked him. V3 stated R3 has a history of entering others, rooms and taking things. R4 told staff R3 took his belongings. R4 admitted to hitting R3. Facility is not able to determine what time this incident took place. V3 stated there is more staff on 7th floor to monitor the residents. R4 requires monitoring more frequently. On 10-2-22 at 10:46 AM, V6 (LPN) stated R4 is alert, oriented x 2, confused, and delusional. V6 stated he thinks R4 has hallucinations. R4 is unpredictable and impulsive. R4 has verbal and physical aggression. R4 can be unpredictable and may require close monitoring. V6 saw R3 with discoloration to right eye on 9-15-22. R3 told V6 that he was hit by R4. R3 could not tell V6 why R4 hit him. V6 talked to R4 and told V6 that R3 took his[OBSCENITY] R4 refused to discuss further with V6. R4 admitted to hitting R3 but no specific reason was given. On 10-2-22 at 11:09 AM, V10 (security guard) stated he was on duty 9-15-22 and was situated in the middle of the main hallway near the elevators and not in clear view of R3 and R4's rooms. V10 did not see the altercation between R3 and R4. V10 heard a commotion coming from R3 and R4's wing and he went to see what was happening. V10 saw R3 walking rapidly towards the nurse station. R3 was seen blinking his right eye. R3 was talking to the nurse. R3 did not give any information to security. Security is not aware of any staff observing this altercation occur. Security does their rounding every hour. R4's MDS- ARD 8-26-22- documents BIMS= 14, Active Diagnoses (not limited to): [CONDITION(S)] disorder, unspecified, and [CONDITION(S)]. R4's Progress note dated 9-14-22 documents: Behavior Charting Describe Behavior/Mood: Verbal aggression. What was the resident doing prior to or at the time of behavior/mood: Sitting in room? Interventions attempted: Verbal redirection. Education. Effectiveness of the interventions: Stable R4's Progress note dated 9-15-22 documents: Approx. 8:20 am, resident alleged that another resident had physical contact with him. Approximately 8:20 am, the resident alleged that he got into physical contact with another. Immediately, head to toe assessment performed and revealed alert/oriented x 2, verbal, skin, dry and warm, but not intact, skin discoloration on right eye noted, lungs clear, normal bowel sounds audible in all 4 quadrants, abdomen soft and non-tender, ROM (range of motion) performed on all 4 extremities and tolerated to the resident's baseline, besides skin discoloration on left eye, no visible injuries noted, Resident transferred to another room, MD (medical doctor) notified, new order: monitor for change condition and update, x-ray of face ordered, administrator notified, [NAME] police dept. notified, report filed, contact information on file invalid, social services notified to update information, will continue to monitor. Initial Reportable dated 9-15-22 documents: Brief Description of Incident: R4 abruptly swung and hit R4 in the eye. Immediate Action Taken: Staff immediately intervened and separated both residents. R4 placed on 1:1 supervision. First aide was rendered to R3. Discoloration of eye noted. R3 placed on social service and nursing well-being checks. Local police notified. MD and families of residents notified. Investigation initiated and is ongoing. Final Reportable dated 9-19-22 documents: Facility conducted a thorough investigation and interviewed both staff and residents. R4 thought R3 took his shirt. R4 became agitated and abruptly swung and accidentally hit R3 in the eye. R4 was counseled on more appropriate ways to express frustration. His plan of care was updated and remains on social service well-being checks. R3 remains on social service well-being checks and states he feels safe at the facility. There have been no further incidents between the 2 residents. Abuse Policy (no date) documents: The purpose is to assure the facility is doing all that is within its control to reduce the risk of occurrences of abuse, exploitation, misappropriation of property, mistreatment, or neglect. R4's Aggression Behavior Care Plan (initiated 11-22-21) documents a history of R4's aggressive behavior. Surveyor requested the police report and was not on hand at this time.

Based on interview and record review the facility failed to follow their abuse policy to prevent resident to resident physical assaults. This affected 3 of 3 (R11, R2, and R3) residents reviewed for abuse. These failures resulted in R11 physically assaulting R10, R10 sustained a left orbital fracture requiring 10 facial sutures, this failure also resulted in R4 physically assaulting R3 and R3 sustained a black eye. Findings include: On 10/4/22 at 2:00pm, V4 DON (director of nursing) stated that R10 did not exhibit any behaviors while residing at this facility. V4 stated that based on interviews with staff and residents, it was concluded that R10 fell and hit his eye on the dresser. R10's fall incident report, dated 9/18/22, reviewed with V4. Incident description noted R10 observed with open area to left eyebrow. R10 refused to give description of fall. When questioned what 'other' means in sections: predisposing environmental, physiological, and situation factors, V4 responded that V4 did not know. V4 was not able to elaborate on R10's left eye swelling, bruising, blowout fracture, or how R10 had two lacerations to eyebrow from a fall on level surface. On 10/5/22 at 10:34am, R10 stated that on 9/18/22, R11, R13 (R10's roommate), and V24 (security) were in R10's room. R10 stated that V24 was breaking the lock off R13's dresser because R13 locked keys in the dresser. R10 stated that R10 was lying in bed at this time. R10 stated that R11 started yelling and cursing at R10. R10 stated that R13 and V24 exited the room and R11 hit R10 repeatedly in the face. R10 stated that the previous day, 9/17, R11 brought a bottle of alcohol into R10 and R13's room. R10 stated that R10 and R11 had an argument. R10 stated that when staff came into R10's room, everyone was on R10's side of the room; R11 and R13 informed staff that the alcohol belonged to R10. R10 stated that staff told R10 he would have to go to the disciplinary floor as a result of having alcohol; staff never transferred R10. R10 stated that R13 came back into R10's room and hit R10 in the face. R10 stated that R10 informed a staff member of this. R10 stated that R10 had only been at this facility for a short time and does not remember who the staff member was. On 10/5/22 at 2:30pm, V24 (security) stated that V24 was present on 9/18/22 from 2:00pm until 10:00pm. V24 stated that when V24 came in to work that day, he was told to cut R13's lock off. V24 stated that R13 was present in room at that time, R10 was present in room with curtain closed, and R11 was outside of R10's room. V24 stated that V24 left R10 and R13's room after cutting the lock on R13's dresser. V24 stated that V24 heard a door slam, V24 turned around and saw R10 standing in the hall bleeding and R10 stated that he was attacked. On 10/5/22 at 1:09pm, V26 LPN stated that V26 was R11's nurse on the evening shift on 9/18. V26 stated that V26 does not know what happened. V26 stated that V24 (security) told her that R10 was bleeding; R10 had blood gushing from his face and V26 gave R10 a towel. V26 stated that there was blood on the floor; and a trail of blood between R10's bed and the hallway. V26 stated that R11 denied hitting R10. V26 stated that R11 did acknowledge that R11 and R10 had a verbal altercation the night before. V26 stated that neither resident gave any specific details regarding the incident on 9/17. V26 stated that V26 did not see any alcohol in R10's room nor did R10 appear intoxicated. On 10/6/2022 at 2:00pm, V31 (emergency room manager) stated that blowout fractures are typically seen in physical altercations. On 10/6/22 at 3:23pm, V31 called this surveyor. V31 stated that V31 reviewed R10's hospital record with physician. V31 stated that EMS (emergency medical services) noted R10 was being transported from facility to hospital due to battery. On 10/6/22 at 5:20pm, V23 (housekeeping) stated that V23 does recall having to clean R10's room after incident. V23 stated that V23 noted some blood on the floor. V23 stated that V23 checked all of R10's furniture (bed frame, dresser, and nightstand) and did not find any blood. V23 stated that R10 had a tall dresser. When asked to clarify how tall the dresser was, V23 stated that V23 is 67 inches tall, and the dresser is taller than that. Review of R10's medical record notes R10 is 65 inches tall. R10 was admitted to this facility on 8/23/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R10's BIMS (brief interview of mental status) score, dated 9/2/22, notes R10's score is 15 out of 15. Review of R10's screening assessment for aggressive/harmful behavior, dated 8/23/22, notes R10 is minimal risk for aggression at this time. Review of R10's medical record notes: On 9/17 at 4:10pm, V27 LPN (licensed practical nurse) noted: R10 and R11 arguing. R10 was in R10's room at the time of this behavior. Interventions: R10 and R11 were separated, therapeutic communication. Effectiveness of the interventions: stable. On 9/17 at 4:57pm, V4 DON noted: R10 observed with incoordination, and mood and behavior changes. R10 assessed, vital signs stable. No signs/symptoms of distress noted. R10's room checked, and empty bottles of alcohol recovered. Physician made aware. Social service made aware. R10 will be monitored. On 9/18 at 6:00pm, V19 LPN noted: staff observed R10 in hallway leaning forward. When asked R10 what happened R10 alleged that R11 made physical contact with R10. R10 and R11 were immediately separated. Immediate head to toe assessment completed. Left upper eyebrow area with open area pressure applied. No change in level of consciousness. R10 denied blurred vision headache at that time. Neurological checks at baseline. V1 (administrator) and V4 DON notified. R10 transported to the hospital via 911 EMS (emergency medical services). Review of R10's hospital record, dated 9/18/22, notes R10 presented to the emergency room for a chief complaint of left head injury. R10 stated that while he was lying in bed another individual struck R10 3-4 times in the left side of R10's face. R10 stated that R10 has left head/facial pain. Physical exam noted facial swelling, eye pain, headache, bruising, and two lacerations above left eye. Neurological exam noted R10 was alert and oriented x 3. Psychiatric exam noted R10's behavior normal. CT (computerized tomography) scan of R10's head noted: acute left lamina papyracea blowout fracture with 5-millimeter medial herniation of the infraorbital fat into the ethmoidal air cells. The medial rectus muscle is approaching the fracture site. Left periorbital soft tissue contusion. Laceration: there were two 1.5-centimeter lacerations to the left eyebrow. Both lacerations were cleaned and approximated with 5 sutures each. Review of R11's medical record notes R11 was admitted to this facility on 6/13/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R11's BIMS score, dated 9/20/22, notes R11's score is 15 out of 15. Review of R11's screening assessment for aggressive/harmful behaviors, dated 6/15/22 and 9/20/22, notes R11 is at moderate risk for aggression. Review of R11's medical record notes: On 8/17/22, nurse noted: R11 was involved in a physical altercation with peer in dining room before staff could intervene. Both residents immediately separated. V1 (administrator) and V4 DON notified, and a police report filed. On 9/17/22 at 4:10pm, V27 LPN noted: R11 arguing with R10. At the time of the incident R11 was visiting R13 in R10 and R13's room. Interventions attempted: R11 and R10 separated, therapeutic communication. Effectiveness of the interventions: stable currently. On 9/18 at approximately 6:00pm, nurse was notified by V24 (security) that while going to cut a lock off, R10 stated that R11 came into R10's room and hit R10 unprovoked. R11 stated that R11 didn't hit R10. Nurse notified V1 and V4. Review of R11's change in condition/evaluation form, dated 9/18/22 notes R11 with behavioral symptoms. R11's physician paged, has not called back yet. There is no documentation found in R11's medical record noting R11's physician called the facility or that staff made any further attempts to contact physician after this incident. On 10/1/22 at 11:40am, R2 stated that R1 hit R2 because he thought R2 had taken R1's snacks. R2 stated that R1 and R2 were in the social services office at the time R1 hit R2. On 10/1/22 at 1:32pm, V5 (social services) stated that V5 was in her office with R2, R2 was sitting next to the door. V5 stated that R1 came in unprovoked and hit R2 on the left upper back and shoulder area. V5 stated that V5 immediately separated R1 and R2. V5 stated that R1 was escorted back to R1's room by security and placed on 1:1 monitoring until R1 was no longer a threat. V5 stated that R1 has a history of aggressiveness and delusions. V5 stated that earlier same day, R1 was restless and had thrown a television and broke it. V5 stated that V5 kept some snacks from R1's family in V5's office. V5 stated that R1 thought R2 was eating R1's snacks; R2 was not eating at all in V5's office. On 10/1/22 at 3:30pm, V9 RN (registered nurse) stated that V9 is familiar with R1. V9 stated that R1 exhibits aggressive behaviors frequently. V9 stated that on 9/13/22, R1 destroyed a television in another resident's room and then slammed a water jug in the hallway on ground and broke it. V9 stated that when V9 questioned R1, R1 stated that R1 didn't like what was being said on the television. V9 stated that R1 was able to be calmed down. V9 stated that R1 hit R2 later that same day because R1 was upset that R2 was taking all of the snacks. Review of R1's medical record notes R1 was admitted to this facility on 6/9/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's MDS (minimum data set), dated 9/16/22, notes R1's BIMS score is 15 out of 15. R1 is able to make needs known. Review of R1's screening assessment of aggressive and/or harmful behavior, dated 6/10/22, notes R1 at moderate risk for aggression. R1 comes with history of aggressive behavior. Review of R1's medical record, dated 6/12/22, notes R1 unpredictable, physical and verbal aggression toward staff, hard to re-direct, destruction of property. Interventions attempted: redirection and close monitoring; interventions ineffective. On 6/21/22, notes R1 made physical contact with another resident. R1 came out of his room and went to the dining room and pushed another resident without any provocation. Both residents were separated and redirected to their respective rooms and assessed and put under close monitoring. On 6/21/22, social services noted: Resident seen in relation to alleged physical aggression towards peer. At the time of visit he was noted with some restlessness and responding to internal stimuli. Resident provided with reorientation and redirection. During visit he was asked about alleged behavior for which he was disorganized with his thoughts, delusional saying he was hearing voices of people telling him different things. On 7/26, R1 exhibited physical aggressive behaviors. On 7/27, V5 (social services) noted: R1 seen in relation to alleged physical aggression towards peer. At the time of visit he was noted responding to internal stimuli. On 8/12, V5 noted: R1 was demonstrating restlessness and delusional thought process with various topics. On 9/13 at 3:24pm, V9 RN noted: property destruction. On 9/13 at 4:37pm, V5 (social services) noted: R1 seen to further discuss behavior episode towards R2 while on the unit. R1 at the time removed from area and provided with education on the importance of safety and getting along with others in a positive manner in order to avoid any injuries or further problematic situations. R1 to continue to be monitored. On 9/14, V5 noted R1 noted to be responding to internal stimuli. Review of R2's medical record notes R2 was admitted to this facility on 6/20/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] 9/13/22, R1 made physical contact towards R2. Complete head to toe assessment initiated, R2 sustained no injuries as a result of this incident. Skin intact. Range of motion within normal limits, neurological checks within normal baseline. V1, physician, and responsible party notified. Review of R2 BIMS score dated 9/13/22, notes R2's score is 15 out of 15. Review of this facility's abuse policy, undated, notes to identify, correct, and intervene in situations in which abuse is more likely to occur. The deployment of staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual residents' care needs. The assessment and monitoring of residents with needs and behaviors which might lead to conflict, such as residents with a history of aggressive behavior. On 10-1-22 at 10:58 AM, R3 stated R4 hit him because R3 owed R4 two cigarettes and did not have any when asked. R4 hit R3's eye with his fist. On 10-2-22 at 10:17 AM, V1 (administrator) stated R4 is [CONDITION(S)] with [CONDITION(S)] disease. Even with medication and constant behavioral monitoring, R4 has had aggressive behavior in the past. R4 is on the 7th floor which is a male psychiatric unit. All psych patients can have unpredictable changes in behavior. V1 was informed by staff about V4 abruptly hitting V3 in the eye. R3 sustained and swollen eye. Psychiatric patients have no impulse control and will react first before thinking things through. On 10-1-22 at 12:40 PM, V4 (director of nursing) stated R4 is alert, oriented x 3, can be verbally and physically aggressive (re-directable), and can be agitated. On 9-14, R4 was verbally aggressive towards staff. R4 was placed on social service wellbeing checks for 72 hours. Staff will monitor resident every hour alternating with nurse, CNA, and security. Residents are monitored to make sure they are calm, stable, and not any change in condition or concerns. V4 was informed V4 and V3 were in an altercation. R4 hit R3 in the eye and sustained discoloration to right eye. Staff immediately separated R3 and R4. R4 was placed on 1:1 supervision for a couple of days (minimum of 72 hour). R3 was moved to the 4th floor. On 10-1-22 at 10:01 AM, V5 (social worker) state R4 is known to be psychotic and delusional. V5 stated R4 was throwing things at staff on 12-27-21. R4 was delusional and called 911 one time. On 9-14-22, R4 was verbally aggressive toward staff. R4 was started on well-being checks. R4 was rambling off topic. V5 stated she was not on duty at the time of the incident. V5 stated she was told by staff about R4 hitting R3 resulting in a right black eye with no other injury noted. V5 continued with R4's well-being checks. V5 is not aware of R4's previous altercations with R3. R4 can be easily agitated. R4 requires more frequent monitoring every 15 minutes. R4 was noted disorganized with thoughts on 9-14 and 9-15. On 10-1-22 at 11:23 AM, V3 (LPN) stated R4 is alert, oriented x 1-2. with confusion, delusions, and hallucinations. R4 is impulsive and unpredictable. R4 is delusional and will talk about things that nobody understands. R4 can come off as intimidating and aggressive by his peers. V3 stated staff saw R3 with a black right eye on 9-15-22. R3 stated R4 attacked him. V3 stated R3 has a history of entering others, rooms and taking things. R4 told staff R3 took his belongings. R4 admitted to hitting R3. Facility is not able to determine what time this incident took place. V3 stated there is more staff on 7th floor to monitor the residents. R4 requires monitoring more frequently. On 10-2-22 at 10:46 AM, V6 (LPN) stated R4 is alert, oriented x 2, confused, and delusional. V6 stated he thinks R4 has hallucinations. R4 is unpredictable and impulsive. R4 has verbal and physical aggression. R4 can be unpredictable and may require close monitoring. V6 saw R3 with discoloration to right eye on 9-15-22. R3 told V6 that he was hit by R4. R3 could not tell V6 why R4 hit him. V6 talked to R4 and told V6 that R3 took his[OBSCENITY] R4 refused to discuss further with V6. R4 admitted to hitting R3 but no specific reason was given. On 10-2-22 at 11:09 AM, V10 (security guard) stated he was on duty 9-15-22 and was situated in the middle of the main hallway near the elevators and not in clear view of R3 and R4's rooms. V10 did not see the altercation between R3 and R4. V10 heard a commotion coming from R3 and R4's wing and he went to see what was happening. V10 saw R3 walking rapidly towards the nurse station. R3 was seen blinking his right eye. R3 was talking to the nurse. R3 did not give any information to security. Security is not aware of any staff observing this altercation occur. Security does their rounding every hour. R4's MDS- ARD 8-26-22- documents BIMS= 14, Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Progress note dated 9-14-22 documents: Behavior Charting Describe Behavior/Mood: Verbal aggression. What was the resident doing prior to or at the time of behavior/mood: Sitting in room? Interventions attempted: Verbal redirection. Education. Effectiveness of the interventions: Stable R4's Progress note dated 9-15-22 documents: Approx. 8:20 am, resident alleged that another resident had physical contact with him. Approximately 8:20 am, the resident alleged that he got into physical contact with another. Immediately, head to toe assessment performed and revealed alert/oriented x 2, verbal, skin, dry and warm, but not intact, skin discoloration on right eye noted, lungs clear, normal bowel sounds audible in all 4 quadrants, abdomen soft and non-tender, ROM (range of motion) performed on all 4 extremities and tolerated to the resident's baseline, besides skin discoloration on left eye, no visible injuries noted, Resident transferred to another room, MD (medical doctor) notified, new order: monitor for change condition and update, x-ray of face ordered, administrator notified, [NAME] police dept. notified, report filed, contact information on file invalid, social services notified to update information, will continue to monitor. Initial Reportable dated 9-15-22 documents: Brief Description of Incident: R4 abruptly swung and hit R4 in the eye. Immediate Action Taken: Staff immediately intervened and separated both residents. R4 placed on 1:1 supervision. First aide was rendered to R3. Discoloration of eye noted. R3 placed on social service and nursing well-being checks. Local police notified. MD and families of residents notified. Investigation initiated and is ongoing. Final Reportable dated 9-19-22 documents: Facility conducted a thorough investigation and interviewed both staff and residents. R4 thought R3 took his shirt. R4 became agitated and abruptly swung and accidentally hit R3 in the eye. R4 was counseled on more appropriate ways to express frustration. His plan of care was updated and remains on social service well-being checks. R3 remains on social service well-being checks and states he feels safe at the facility. There have been no further incidents between the 2 residents. Abuse Policy (no date) documents: The purpose is to assure the facility is doing all that is within its control to reduce the risk of occurrences of abuse, exploitation, misappropriation of property, mistreatment, or neglect. R4's Aggression Behavior Care Plan (initiated 11-22-21) documents a history of R4's aggressive behavior. Surveyor requested the police report and was not on hand at this time.

Based on interview and record review, the facility failed to develop a plan to monitor and supervise a resident with a history of [CONDITION(S)] and self-injurious behaviors. The facility also failed to have a plan to monitor and supervise residents with physical aggression. These failures affected 4 of (R22, R23, R27, R28) 4 residents reviewed for supervision. This failure resulted in R23 being found in the dining room attempting to hang himself from a pipe with a belt around his neck. R23 was taken down and sent to the local hospital for a psychiatric evaluation. Findings Include: R23 was admitted with [CONDITION(S)] disorder. R23's brief interview for mental status (BIMS) dated 7/21/22 documents a score of 9 which indicates moderately impaired and disorganized thinking. The facility placement assessment summary dated 4/14/21 documents: R23 is a high level for self-injurious behavior both recent and remote. R23 has a history of wanting to hurt himself. Screening assessment for evaluation self-harm/suicide risk and indicators of aggressive and/or harmful behavior dated 7/21/22 documents: R23 was a moderate risk. On 8/30/22 at 4:36PM, V35 (nurse) stated, I heard R29 screaming at 6:30AM. I ran to the dining room. R23 was hanging from a pipe with a belt tightly around his neck and the other end around the pipe. The belt gave away from the pipe causing R23 to fall to the ground. R23 was unresponsive. At the time of the incident the dining room was not being monitored by staff. On 8/31/22 at 10:52AM, V17 psychiatric rehabilitation service director (PRSD) stated, the facility placement assessment summary is used to determine psychosocial needs. R23's high level for self-injurious behavior both recent and remote and a history of wanting to hurt himself should have been a red flag. I would have processed R23 to determine if his self- injurious behavior was active or passive. Moderate risk on the screening assessments dated 7/21/22 would indicate R23 needed close observation which entails a staff member within R23's area to visually watch/monitor R23. There aren't any nursing notes that document R23 was being monitored closely. R23 was at risk for self-harm due to a history of self-destructive behavior including suicidal thought and suicidal actions, severe mental illness and recent aggressive/agitated behaviors. V17 stated residents should not be in the dining room without supervision. On 9/1/22 at 9:58AM, R29 stated, I saw R23 hanging from the pipe with a belt around his neck. R23 fell to the floor. I called the staff to hurry to come into the dining room. We did not have a monitor in the dining room. On 9/1/22 at 10:02AM, R31 and R32 where observed in the dining room, sitting without staff supervision. Nursing note dated 7/31/22 documents: 6:40AM resident alerted this nurse to come in the dining room. Upon entering resident was noted with his belt wrapped around his neck on one end and the other around a pipe in the ceiling. R23 fell to the floor. Standard supervision and monitoring dated 2/2/22 documents: This guideline emphasizes a proactive intervention promoting enhanced physical and psychosocial well-being. The facility recognizes supervision and guidance to the resident is an essential part of nursing care in which standard approaches are successful in meeting the resident's physical and psychosocial needs R27 has the diagnosis of violent behavior. Care plan initiated on 7/21/22 documents: R27 displayed conflictual, difficult behavior with other persons related to severe mental illness ([CONDITION(S)] and delusion disorder) and [CONDITION(S)] (audio, visual hallucination and disorganized delusion thoughts). Behavior: symptoms are manifested by impulsivity and unprovoked expressions of anger towards staff and peers. R27 demonstrates behavioral distress related to being challenged by mental illness. Problems: are manifested by verbal and physical abusive behaviors when agitated, alleged behavior towards peers. On 8/31/22 at 10:55AM, V17 (PRSD) stated, R27 has poor boundaries, difficulty redirecting, and refusal to process with staff. R27 is impulsive and actions where all of sudden. On 9/7/22 at 3:32PM, V21 (nurse) stated, R27 has a mental illness, unpredictable thoughts and actions and sometimes things happen with the residents that are out of our/staff control. The incident with R27 and R36 was unpredictable. I was called by staff (unable to recall which staff) to assess the situation. Incident report dated 7/21/22 documents: R36 allegedly received physical contact from peer (R27). No witnesses. Final Reportable dated 7/25/22 documents: R27 had physical contact towards her co-peer (R36). On 8/24/22 at 3:41PM, R26 (R4's roommate) who was assessed to be alert and oriented to person place and time, stated R27 entered our room, standing at R4's bedside. R4 asked R27 to get out. R27 hit R4 in the face and head multiple times. R4 tried to fight back. R27 stopped hitting R4 on her own and left our room. On 8/24/22 at 3:21PM, V17 psychiatric rehabilitation director (PRSD) stated, R27 was impulsive and difficult to deescalate. R27 has a history of being impulsive and physically/verbally aggressive. R27 became physically aggressive without any warning towards R4. On 8/24/22 at 3:30PM, V20 (assistant administrator) stated, R27 was standing at R4's bedside. R4 was trying to redirect R27. R27 made physical contact with R4. Incident report dated 7/29/22 documents: R4 received physical contact from co-peer (R27). R27 was physically aggressive towards peer (R4). Witness R26. Standard supervision and monitoring dated 2/2/22 documents: This guideline emphasizes a proactive intervention promoting enhanced physical and psychosocial well-being. The facility recognizes supervision and guidance to the resident is an essential part of nursing care in which standard approaches are successful in meeting the resident's physical and psychosocial needs. R28 has diagnoses of dementia and disorganized [CONDITION(S)]. R28's brief interview for mental status dated 7/8/22 documents cognitive skill for decision making is severely impaired. Care plan initiated 11/04/20 and 8/11/21 documents: R28 has a history of being a target of aggression from peers. Redirect when roaming into peers' rooms to decrease and avoid any problematic situations. R28 has wandering behaviors in the hallway, dining room and other peer's room. On 8/30/22 at 3:56PM, V57 (cna) stated, R28 wanders and requires constant supervision. I have to sit outside R28's room in this chair to prevent R28 from wandering into other resident's room. On 9/1/22 at 9:09AM, R28 was observed coming out of co-peer R9's room. R9 who was assessed to be alert and orient to person, place and time stated, R28 just came in my room and sat on that bed. I did not ask R28 to come into my room nor did I want R28 in my room. Social service note dated 8/17/22 documents: R28 was seen due to being a target of physical aggression of peer R16. (R16) made physical contact with resident (R28) without provocation. Incident report dated 8/17/22 documents: another peer (R16) made physical contact with resident (R28). No witnesses. Reportable dated 8/21/22 documents: R16 was physically aggressive toward co-peer (R28) when R28 was found wondering into R16's room taking some of R16's personal belongings. R28 was noted with injury to the left side of his face. Facility reported incident dated 7/14/22 reads in part: R22 was physical towards co-peer R33. Conclusion: Per staff, they witnessed R22 wandering the dining room during mealtime and as staff was trying to redirect R22 to his table, R22 was swinging his hands and accidentally bumped into R33. R22 has diagnoses not limited to [CONDITION(S)] disorder [CONDITION(S)] type and dementia without behavioral disturbances. R22's Care Plan review date 1/6/21 with revision date of 7/8/22, reads in part: Socially inappropriate behavior. Resident has presented with inappropriate personal boundaries manifested by inappropriately touching peers and staff, screaming and yelling in the hallway. Interventions: Staff will continue to re-direct and offer assistance when resident is on the floor (date initiated 4/5/2021). Staff will provide redirection and place resident on close monitoring when suspected or any reports of inappropriate behavior (Revised 1/6//21). Staff will provide redirection when observed entering others room or personal area (Revision on 1/6/21). R22 is care planned for aggressive behavior with initial date of 1/6/21 and revision date on 7/8/22). The resident has a history of aggression (physical and verbal), inappropriate, and attention-seeking. R22's history includes conflicts/altercations with others, threatening behavior, verbal /physical aggression. Interventions: Place resident on 72-hour well-being checks in order to monitor any mood and behavior changes and document accordingly (1/6/21). Remove resident from triggering environment. Motivate resident to exercise safety (initiated 11/27/21, revision on 8/31/22). Staff will monitor for aggressive behavior and redirect as necessary. Abuse and Neglect indicates: Resident is noted to have been the target of aggression from peers and to display inappropriate behaviors and aggression such as throwing things while in on the unit. These behaviors are unprovoked and unpredictable (initial date of 1/6/21 and revision on 5/12/22).Interventions: Staff will remain available for any behavioral changes (initiated 8/20/22 and revision 8/31/22). Place on 72-hour wellbeing checks when the target of aggression to further monitor any changes (imitated 11/11/21 and revision on12/5/21). Remove resident from triggering environment. Motivate resident to exercise safety. Place on 1:1 supervision (date initiated 8/20/22 and revision on 8/31/22) Staff will immediately intervene if observing resident and see signs of abuse/neglect (initiated 1/11/21 and revision on 11/22/21). On 8/26/22 at 9:45AM, V20 (Assistant Administrator) stated that V20 investigated the incident. V20 stated that V20 asked the nurse assigned on the floor what happened. The nurse reported to V20 that R22 was walking around the unit pacing and accidentally bumped into R33. R22 was walking with his hands flaring and hit R33. The nurse immediately attended to the situation. The nurse separated the residents immediately. The nurse completed an assessment on R33, no injury or pain noted. R22 was placed on one-to-one monitoring immediately. The incident was reported to [NAME] police. V20 stated the incident was physical altercation, and it was part of the 7 types of abuse, and it is the residents right to be free from abuse. V20 stated we did our diligence on our part to report and investigate the incident. R22 is noted to have the behavior of flaring his hands. V20 stated R33 was in a wheelchair in the hallway and R22 passed by and accidentally hit R33. R22 has history of accidentally hitting other residents, I cannot recall how many but more than one incident. During this incident, other staff were providing care to other residents and did not witness the resident-to-resident physical altercation. Only the nurse observed this incident. Prior to this incident, R22 was placed on one-to-one monitoring multiple times because of R22's aggressive behavior. When V20 was questioned about the location conflicts (reported to the state agency (SA)) and interview. V20 stated that incident happened in the hallway, V20 stated I apologize, if the final report says dining room, then that was where the incident happened. We have lots of incidents and I probably confused it with another incident. On 8/26/22, V23 (Dementia Care Coordinator) stated I was in the facility the day of the incident. I believe it was the nurse that informed me that R33 reported to the nurse that R22 hit him. R33 is able to report if someone hit him. I believe R22 has a history of hitting other residents. I know we do close monitoring for R22 because of R22's aggressive behavior. The incident happened it the hallway, around the corner from R33's room. If someone hit R33, I know R33 is able to report it to staff. This is the first time I heard R33 report that a resident hit him. R33 did not have any other physical abuse allegation except for this incident. R33 was not hurt, no injuries and no reported pain. We are closely monitoring R22 and redirecting R22. Sometimes R22 has the tendency to swing R22's arms and hit others unintentional and unprovoked. On 8/30/22 at 12:20PM, R33 stated that 3 months ago someone hit him on the back of the head. Per R33, he was watching television in the dining room, near the television. R33 noticed R22 walking in the dining room, then R22 got close to R33, and before the staff could get to R22, R22 had already hit me (R33). R22 was just walking everywhere, and no one was watching R22 at the time. R33 stated that R33 was not expecting that R22 would hit R33. R22 hit me in the head and my ear was warm for a while and painful at the time of the incident but the pain went away. Since the incident R33 has not been close to R22. On 9/7/22 at 12:45PM, V2 (Director of Nursing) stated I was not part of the investigation. An abuse allegation usually goes to the administrator. R22 is a wanderer. If R22 is having behaviors such as not redirectable or altercation with someone either verbal of physical, or if R22 becomes aggressive with staff we will do a one-to-one supervision. We will keep R22 on one-to-one monitoring for as long as R22 presents aggressive behaviors. On 8/26/22 at 2:15PM, V50 (LPN) stated I was doing rounds in the morning and R33 met me in front of R33's room and reported to me while pointing at R22 who at the time was coming out of the washroom. R33 stated R22 hit me in the head and I asked R22 what happened, R22 just muffled and walked away. I assessed R33, no pain and no injury were noted. I assessed R33 and then reported it to the administrator immediately. I observe R22 wandering on the unit majority of the time but have not seen R22's hand swinging when walking. I am not aware of any history of R22 hitting another resident prior to this incident R33 is alert and oriented and able to report if something happens to R33. It was shift change at the time the incident happened, and I am pretty sure the other staff were doing patient care, there are no witnesses. On 9/2/22 at 11:00AM, R22 was observed to be ambulating the hallway. R22 was observed walking from the dining room area to the end of the hallway where R22's room is located. R22 stayed in the hallway, paused for a short period of time and went back into the dining room. There was no staff member redirecting the resident or monitoring R22 at that time. Other residents are observed in the hallway and dining room area. One staff member observed in the nurse's station, sitting in front of a computer. On 9/6/22 at 1:00PM, R22 was observed again walking from the dining room to the end of the hallway. R22 observed would pausing for a short time then started walking back to the dining room. Other residents observed walking the hallway also. There are no staff to visually monitor the resident at the end of the hallway, close to R22's room.

Based on interviews, and record reviews, the facility failed to follow their abuse policy and prevent incidents of sexual assault and resident to resident physical assault. This failure affected 6 residents (R11, R33, R4, R36, R23, R28) of 8 reviewed for abuse. These failures resulted in R11 making an allegation of rape being sent to the local hospital to be assessed and diagnosed with multiple external rectal tears and dark redness with impending bruising to distal vaginal opening. Findings Include: Facility reported incident dated 6/15/22 reads in part: R11 alleged inappropriate contact by R21. Conclusion: R11 stated that R11 went into R21's room to watch television and did not anticipate having sexual intercourse with R21. R11 stated that R11 and R21 began kissing and that they had intercourse in R21's bed. R11 stated she did not want to have intercourse with R21. R11 informed staff the next morning that R11 did not want to have intercourse with R21. R11 was sent out for medical evaluation and returned the same day with no new orders. R21 was interviewed and denies having sexual intercourse with R11. The facility is unable to substantiate the allegation made by R11. R11's Progress note dated 6/15/2022 at 9:00AM, reads in part: resident reported this AM to staff alleged abuse received from peer. Per resident I was in peers' room last night and was touched inappropriately. Hospital records reviewed and read in part: stated complaint: possible sexual assault. 6/15/22 at 12:12PM body assessment reads in part: abrasions to anus, redness to vaginal area, sexual assault 6/14/22, type of assault-anal penetration, last voluntary intercourse/sexual activity: last year, contraceptive used by penetration: no, skin inspection: abrasion, genital inspection: abrasion. 6/15/22 at 1:39PM reads in part: upon examination redness noted to vaginal area, small tears noted to rectal area in internal and external area, small blood noted on swab when anus was swabbed. 6/15/22 emergency room : pelvic exam shows dark redness to impending bruising to distal vaginal opening, also has multiple external rectal tears without bleeding. Police report dated 6/15/22 at 12:05PM, reads in part: Criminal Sexual Assault Investigation. V59 (Nurse) related that R11 claimed R11 was raped by R21. R11 related that R11 had messaged R21 and asked R21 if R21 wanted R11 to go to his room. Once inside R21's room, the two sat on the bed and R21 allegedly began kissing R11 on the mouth. R21 then removed R11's shorts and underwear and vaginally penetrated R11 with R21's penis. R11 did not say to stop or put up any resistance. R21 then began to anally penetrate R11 causing R11 pain where R11 then stated for R21 to stop. R11 stated R11 did not tell R21 to stop or prior to R21 penetrating R11 sexually. R11 stated R11 was once raped when R11 was younger so R11 just froze and did not say anything because R11 did not want R21 to hurt R11 physically. R21 stated that R11 agreed to go to R21's room to watch TV and further stated that R21 and R11 only watched television and that they did not have sex. R21 also stated that they did not kiss or did anything sexually. Sexual assault kit picked up by the local police and turned into the lab. Results are still pending. Results not yet available at this time. On 9/7/22 at 12:00PM, V59 (nurse) stated that V59 remembers the time when R11 reported the incident that happened on 6/14/22. V59 cannot remember the complete details but remembers that R11 reported to her that R11 was raped by R21. On 8/26/22 at 1:30PM, V1 (Administrator) stated that R11 reported to the nurse that R11 was raped and stated it was a black man, and then mentioned the name of R21. Before the police came and before sending R11 out to the hospital, R11 was able to give more details about watching television and kissing with R21. Further investigation R11 reported that she went to R21's room, watched television, but it was not R11's intention to have sex with R21. R11 and R21 are both not available for interview. Both residents have been discharged . Facility reported incident dated 7/14/22 reads in part: R22 was physical towards co-peer R33. Conclusion: Per staff, they witnessed R22 wandering the dining room during mealtime as staff was trying to redirect R22 to his table, R22 was swinging his hands and accidentally bumped into R33. R22 is care planned for aggressive behavior with initial date of 1/6/21 and revision date of 7/8/22). The resident has a history of aggression (physical and verbal), inappropriate, and attention-seeking. R22's history includes conflicts/altercations with others, threatening behavior and verbal/physical aggression. R22's care plan interventions: Place resident on 72 hours well-being checks in order to monitor any mood and behavior changes and document accordingly (1/6/21). Remove resident from triggering environment. Motivate resident to exercise safety (initiated 11/27/21, revision on 8/31/22). Staff will monitor for aggressive behavior and redirect as necessary. O n 8/26/22 at 9:45AM, V20 (Assistant Administrator) stated that V20 investigated the incident. V20 stated that V20 asked the nurse assigned on the floor what happened. The nurse reported to V20 that R22 was walking around the unit pacing and accidentally bumped into R33. R22 was walking with his hands flaring and hit R33. The nurse immediately attended to the situation. The nurse separated residents immediately. The nurse completed an assessment on R33, no injury or pain noted. R22 was placed on one-to-one monitoring immediately. The incident was reported to [NAME] police. The incident was a physical altercation, and it was part of the seven types of abuse, and it is the resident rights to be free from abuse. We did our diligence in our part to report and investigate the incident. R22 has the behavior of flaring his hands. R33 was in a wheelchair, in the hallway when R22 passed by and accidentally hit R33. R22 has history of accidentally hitting other residents. V20 stated I cannot recall how many but more than one incident. During this incident, other staff were providing care with other residents and did not witness the resident-to-resident physical altercation. Only the nurse observed this incident. Prior to this incident, R22 was placed on one-to-one monitoring multiple times because of R22's aggressive behavior. When V20 was questioned about the location of the conflicts (reported to the state agency (SA)) V20 stated the incident happened in the hallway. V20 then stated I apologize, if the final report says dining room, then that was where the incident happened. We have lots of incidents and I probably confused it with another incident. On 8/26/22, V23 (Dementia Care Coordinator) stated I was in the facility the day of the incident. I believe it was the nurse that informed me that R33 reported to the nurse that R22 hit him. R33 is able to report if someone hit him. I believe R22 has a history of hitting other residents. I know we do close monitoring for R22 because of R22's aggressive behavior. This incident happened it the hallway, around the corner from R33's room. If someone hit R33, I know R33 is able to report it to staff. This is the first time I heard R33 report that a resident hit him. R33 did not have any other physical abuse allegation except for this incident. R33 was not hurt, no injuries and no reported pain. We are closely monitoring R22. V23 stated R22 has the tendency to swing R22's arms and hit others unintentional and unprovoked. On 8/30/22 at 12:20PM, R33 stated that 3 months ago someone hit him on the back of the head. Per R33, he was watching television in the dining room. R33 noticed R22 walking in the dining room, then R22 got close to R33, and before the staff can get to R22, R22 already hit R33. R22 was just walking everywhere, and no one was watching R22 at the time. R33 stated that R33 was not expecting that R22 would hit R33. R33 stated R22 hit me in the head and my ear was warm for a while and painful at the time of the he hit me, but the pain went away. Since the incident R33 have not been close to R22. On 8/26/22 at 2:15PM, V50 (LPN) stated I was doing rounds in the morning and R33 met me in front of R33's room and reported to me while pointing at R22 who at the time was coming out of the washroom. R33 stated R22 hit me in the head and I asked R22 what happened, R22 just muffled and walked away. I assessed R33, no pain and no injury. I monitored R33 then reported the incident to the administrator immediately. R22 wanders on the unit majority of the time, but I have not seen R22's hand swinging when walking. I am not aware of any history of R22 hitting another resident prior to this incident R33 is alert and oriented and able to report if something happens to R33. It was shift change at the time the incident happened, and I am pretty sure the other staff were doing patient care, there are no witnesses. Abuse Prevention Program with a revised date of 3/1/21, reads in part: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party. R4 has the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Brief Interview for Mental Status dated 8/15/22 documents a score of zero which indicates severe impairment. R4's care plan initiated and revised on 2/21/22 documents: Comprehensive assessment reveals past trauma and or other factors that may increase R4's susceptibility to abuse/neglect. R4 presents with an alteration in ability to communicate related to mental illness as evidenced by being selective with when and who she will communicate with. On 8/24/22 at 3:40PM, R4 was unable to report any physical abuse occurred. On 8/24/22 at 3:41PM, R26 (R4's roommate) who was assessed to be alert and oriented to person place and time, stated R27 entered our room, standing at R4's bedside. R4 asked R27 to get out. R27 hit R4 in the face and head multiple times. R4 tried to fight back. R27 stopped hitting R4 on her own and left our room. I informed staff. On 8/24/22 at 3:21PM, V17 psychiatric rehabilitation service director (PRSD) stated, R27 was impulsive and difficult to deescalate. Both R4 and R27 have cognitive delays and were unable to report what happen. R27 has a history of being impulsive and physically/verbally aggressive. R27 became physically aggressive without any warning towards R4. On 8/24/22 at 3:30PM, V20 (assistant administrator) stated, R27 was standing at R4's bedside. R4 was trying to redirect R27. R27 made physical contact with R4. Nursing Note dated 7/29/22 documents: Resident (R4) received physical contact from her co-peer (R27) inside her room as per witness by roommate (R26). Observed resident (R4) had a small superficial scratch on her face.Incident report dated 7/29/22 documents: R4 received physical contact from co-peer (R27). R27 was physically aggressive towards peer (R4). Witness R26. Abuse Prevention Program revised 3/1/21 documents: It is the policy of this facility to prohibit and prevent resident abuse, neglect and exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility. #4 Physical Abuse: Hitting, slapping, punching and kicking. R36 has the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R36's brief interview for mental status dated 8/29/22 documents a score of fifteen which indicates cognitively intact. On 8/24/22 at 3:32PM, V17 (PRSD) stated, R27 is impulsive, physically and verbally aggressive. On 9/7/22 at 2:36PM, R36 was unable to articulate what happened related to the altercation with R27. On 9/7/22 at 3:16PM, V61 psychiatric rehabilitation services coordinator (PRSC) stated, I did a wellbeing check on R36. I asked R36 if she was ok, related to an alleged physical altercation with a co-peer (R27). On 9/7/22 at 3:32PM, V21 (nurse) stated, R27 was supposed to have hit R36. R27 has mental illness, unpredictable thoughts and actions. Sometimes things happen with the residents that is out of our/staff control. The incident with R27 and R36 that was unpredictable. I was called by staff (unable to recall who) to assess the situation. V21 stated use my charting as my factual statement. I assessed both R36 and R27 after an alleged physical altercation for alterations in skin. Incident report dated 7/21/22 documents: R36 allegedly received physical contact from peer (R27). No witnesses. Nursing note dated 7/21/22 documents: R36 observed within bedroom allegedly received physical contact from R2.7 Reportable dated 7/25/22 documents: R27 had physical contact towards her co-peer (R36). On 8/26/22 at 11:56AM, R23 who was assessed to be alert to person, place and time stated, I was hit by a staff member who was tall, ball head and black. I was sleeping and he (unknown staff) hit me. He monitored the hallway. On 8/30/22 at 3:14PM, V20 (assistant administrator) stated, R23 is alert and orient to person, place and time. R23 reported to V53 (nurse) that someone came into his room and hit him in the eye. R23 was unable to report who hit him and did not give a description. R23 has never accused anyone of hitting him prior to this incident. R23 has never hit himself. On 9/1/22 at 9:45AM, V53 (nurse) stated, I saw R23 come out his room with a black eye. R23's injury was consistent with being hit. R23 did not have any other injuries Nursing note dated 7/24/2022 documents: Resident (R23) was noted with swelling and discoloration to left side of his face. Resident (R23) was unable to recall events that led to the swelling. R28 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R28's brief interview for mental status dated 7/8/22 documents cognitive skill for decision making is severely impaired. Care plan initiated 11/04/20 and 8/11/21 documents: R28 has a history of being a target of aggression from peers. Redirect when roaming into others rooms to decrease and avoid any problematic situations. R28 has wandering behaviors, R28 wanders in the hallway, dining room and other peer's room. Social service note dated 8/17/22 document: Without provocation, R16 made physical contact with another peer (R28). R28 was seen due to being a target of physical aggression. Another peer (R16) made physical contact with resident (R28). Incident report dated 8/17/22 documents: another peer (R16) made physical contact with resident (R28). No witnesses. Reportable dated 8/21/22 documents: R16 was physically aggressive toward his co-peer (R28) when R28 was found wondering into R16's room taking some of R16 personal belongings. R28 was noted to have an injury to the left side of his face.

Based on interview and record review the facility failed to have a method or system in place that detects when a resident has unauthorized medications or contraband in her possession, failed to have individualize care plan interventions to monitor for behavior changes, failed to provide therapeutic programming for a resident with mental illness to prevent self-harm and failed to follow their policy and ensure that all residents belongings are accounted for. This applies to 1 of 4 residents (R1) reviewed for supervision. As a result, R1 was discovered to have taken an unspecified amount of previously prescribed medications that she had in her possession while admitted in the facility. This was identified as an immediate jeopardy situation that began on [DATE] and was removed on [DATE]. V10 (Administrator) was informed of the immediate jeopardy on [DATE] at 12:20 p.m. However, the deficiency remains at a level 2 harm until the facility can evaluate the effectiveness of the in-services given to the facility staff members. Findings include: Findings include: 1. According to the face sheet R1 a [AGE] year-old resident was admitted to the nursing facility on [DATE]. R1 face sheet also indicated R1 had diagnosis of [CONDITION(S)] current episodes mixed, moderate, Major Depressive Disorder recurrent, unspecified [CONDITION(S)], type 2 Diabetes, [CONDITION(S)], Lumbago with Sciatic, [CONDITION(S)], Hypertension, other Psychoactive Substance Abuse with unspecified Psychoactive Substance Induced Disorder, [CONDITION(S)] unspecified. R1's death certificate dated [DATE] listed R1's cause of death as [MEDICATION(S)] and probable [MEDICATION(S)] and [MEDICATION(S)] toxicity, manner of death is suicide with the date of injury [DATE], place of injury shows nursing home, description of how injury occurred is ingested combined drugs, dated pronounced is [DATE]. R1's POS (Physician Order Sheet) dated [DATE] included physician orders for Acetaminophen tablet give 650 milligrams by mouth every 4 hours as needed for pain, [MEDICATION(S)] tablet 20 milligrams give 1 tablet by mouth at bedtime for Cholesterol, [MEDICATION(S)] tablet 10 milligrams give 1 tablet by mouth two times a day for Spasm, [MEDICATION(S)] capsule delayed release particles 30 milligrams ([MEDICATION(S)]) give one capsule one time a day related to Major Depression recurrent unspecified, [MEDICATION(S)] tablet 2 milligram give 1 tablet by mouth two times day related to type 2 Diabetes, [MEDICATION(S)] HCI tablet 25 milligrams give 1 tablet by mouth in the morning for Hypertension, [MEDICATION(S)] tablet 30 milligrams give one tablet by mouth one time a day for Hypertension, [MEDICATION(S)] Suspension 2400/milligrams/10 milliliters give 30 milliliters by mouth every 24 hours as needed for Constipation, [MEDICATION(S)] HCI tablet 500 milligrams give 1 tablet by mouth two times a day for DM2 ( Diabetes type 2), [MEDICATION(S)] Suspension [DATE] milligrams/5 milliliters (Aluminum Hydroxide & [MEDICATION(S)]-[MEDICATION(S)]) give 30 milliliters by mouth every 4 hours as need for Dyspepsia, and [MEDICATION(S)] tablet 200 milligram give one tablet by mouth two times a day for behavior disturbance. R1's POS does not show physician orders for [MEDICATION(S)] medications. Review of R1's MAR (Medication Administration Record) dated [DATE]-[DATE], does not show any documentation of May keep at bedside Facility policy Titled Medication Storage in the Facility with no date noted showed in-part that medication and biological are stored safely and properly following the manufacture or supplier recommendations. The medication supply is assessable only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Facility policy Titled Medication Self-Administration no date noted shows in-part the purpose is to provide procedures for determining if the resident can safely self-administer and store medication in their room. Bedside storage of prescription and non-prescription drugs is permitted when the assessment demonstrate the practice is safe. Non-prescription drugs, bearing the manufactures label which may be stored in the resident room include Petroleum Jelly, Talcum Powder, toothpaste, cold cream, lip balm, make-up, and baby oil. Non- prescription medication stored in resident room will be documented on the medication record. Prescription medications stored in the resident room should be written on the medication record May keep at bedside. 2. R1's progress notes dated [DATE] at 2:20 p.m. documented by V1(nurse) indicated: resident noted to be lethargic and slowly to respond with generalized weakness. Resident observed snoring in postictal state but doesn't have history of Seizures. Vitals taken V/S (Vital Signs) T-96.8, P-63, R-20, BP-,d+[DATE]. Spo2 (oxygen saturation) 94% on Room Air. Nurse Practitioner informed and received order to transfer resident out to hospital for medical evaluation. V6 (Director of Nursing) informed, family contact informed and spoke to son. Ambulance Service called for pick up and given 1-hour ETA (Expected time of Arrival). Will continue to monitor. R1 progress notes dated [DATE] documented by V2 shows at 2:35p.m resident in bed, with head of bed up. SPO2 95% with oxygen at 2L. V/S (vital signs), BP (blood pressure) ,d+[DATE], T (temperature) 97.0, P (pulse) 68, R (Respirations) 20. Resident responsive to verbal stimuli, will continue to monitor closely with staff on hand. Awaiting ambulance. At 2:50p.m resident remains in bed. Continues to respond to verbal and tactile stimuli but sleeping and snoring. Head of bed at 45 degrees. No sob noted. SPO2 ,d+[DATE]% oxygen at 2L. V/S, T 96.7, P 60, R 20. Staff on hand. Awaiting ambulance pick up. At 3:05p.m resident closely monitored by staff. Resident continues to be lethargic. V/S ,d+[DATE], T 96.7, P 60, R 22. Resident appears stable. SPO2 94% with O2 at 2L. At 3:20p.m resident observed sleeping and snoring. O2 (oxygen) ongoing. SPO2 91%. V/S, BP ,d+[DATE], T 97.3, P 58, R 22. CNA assigned to stay by resident. Will continue to monitor. At 3:40p.m called Elite ambulance, spoke with representative regarding past ETA and nurse was informed resident will be picked up in 45 minutes. Resident SPO2 85% with oxygen at 2 liters, and heart rate dropping from 45 to 35. Oxygen increased to 3 Liters. At 3:50p.m resident SPO2 85% with oxygen at 2 liters, and heart rate dropping from 45 to 35. Oxygen increased to 3 Liters, and SPO2 increased to 91% and heart rate continues to drop to 26. 911 called. Resident still lethargic and slow to respond, and snoring. Awaiting paramedics. Staff by bedside. Elite ambulance cancelled. At 4:10 p.m., 911 team here, report given. Resident taken to hospital. At 11:00p.m called hospital for status. Resident admitted to ICU (Intensive Care Unit) with diagnosis of Overdose. Supervisor notified. Belongings packed. On [DATE] at 11:01a.m. V1 (Nurse) said she was covering for V2 (Nurse) when she was summons to R1's room because something was wrong with R1 V1 said she observed R1 sitting on the side of the bed, when she asked R1 how she was doing R1 responded I'm okay V1 said R1 spoke in a very slow manner. V1 said R1 then tried to stand up however R1 went sat back down on the bed and she assisted R1 into a lying position. V1 said R1 began to fall asleep and snore very loudly at a regular pace. R1 present in a postictal state as if she'd had a [CONDITION(S)], however when she checked R1 records R1 did not have any medical history of seizures disorder. V1 said she assessed R1 vital signs, and they were stable, V1 said she called V5 (Nurse Practitioner) and made him aware of her assessments, R1 vitals and R1 current condition. V1 said when V2 (Nurse) came back from her break and assessed R1, she mentioned R1 was not at her base line. V1 said she has seen R1 with her purse, R1 would have her purse in the bottom of her walker (walker that had basket at bottom). V1 said she last saw R1 about an hour prior to being summons to R1's room. On [DATE] at 11:53a.m. V2 (Nurse) said on [DATE] when she came back from her lunch break, V1 reported R1 condition to her. V2 said when she assessed R1, R1 was laying in the bed, R1 would open her eyes when her name was called, but was not verbal, V2 said R1 would move her leg a little when asked. V2 said she continued to assess R1 vital signs while waiting for the ambulance to transport R1 to the hospital. V2 said R1 vital signs were stable initially. V2 said after one hour of waiting for the ambulance, she followed up and that's when she was given another hour for the ETA. V2 said she continued to assess R1 vital signs and when she noticed R1 heart rate drop from 45 to 35 that's when she called 911 for emergency care. V2 said she was not aware that R1 had diagnosis of [CONDITION(S)]. R1's progress notes dated [DATE] at 2:20 p.m., documented by V1(Nurse) indicated: resident noted to be lethargic and slow to respond with Generalized Weakness. Resident observed snoring in Postictal state but doesn't have history of Seizures. vitals taken V/S (Vital Signs): T (Temperature) 96.8, P (Pulse) 63, R (Respirations) 20, BP (Blood Pressure) ,d+[DATE], Spo2 (Oxygen Saturation) 94% on Room Air. Nurse Practitioner informed and received order to transfer resident out to hospital for medical evaluation. V6 (Director of Nursing) informed, family contact informed and spoke to son. Ambulance Service called for pick up and given 1-hour ETA (Expected time of Arrival). Will continue to monitor. R1's progress notes dated [DATE], documented by V2 (Nurse), shows at 2:35p.m. resident in bed, with head of bed up. SPO2 95% with oxygen (O2) at 2L. V/S: BP-,d+[DATE], T-97.0, P-68, R-20. Resident responsive to verbal stimuli, will continue to monitor closely with staff on hand. Awaiting ambulance. At 2:50 p.m. resident remains in bed, continues to respond to verbal and tactile stimuli but sleeping and snoring. Head of bed at 45 degrees. No SOB (shortness of breath) noted. SPO2 ,d+[DATE]% oxygen at 2L, V/S: T-96.7, P-60, R-20, staff on hand awaiting ambulance pick up. At 3:05 p.m. resident closely monitored by staff. Resident continues to be lethargic. V/S: BP-,d+[DATE], T-96.7, P-60, R-22, resident appears stable. SPO2 94% with O2 at 2L. At 3:20 p.m. resident observed sleeping and snoring, O2 ongoing, SPO2 91% V/S: BP-,d+[DATE], T-97.3, P-58, R-22, CNA (Certified Nursing Assistant) assigned to stay by resident. Will continue to monitor. At 3:40 p.m. called Elite Ambulance, spoke with representative regarding past ETA and nurse was informed resident will be picked up in 45 minutes. Resident SPO2 85% with oxygen at 2 liters, and heart rate dropping from 45 to 35. Oxygen increased to 3 Liters. At 3:50 p.m. resident SPO2 85% with oxygen at 2 liters, and heart rate dropping from 45 to 35. Oxygen increased to 3 Liters, and SPO2 increased to 91%, heart rate continues to drop to 26. 911 called. Resident still lethargic and slow to respond and snoring. Awaiting paramedics. Staff by bedside. Elite ambulance cancelled. At 4:10 p.m., 911 team here, report given. Resident taken to hospital. At 11:00 p.m., called hospital for status. Resident admitted to ICU (Intensive Care Unit) with diagnosis of Overdose. Supervisor notified; belongings packed. From the documentation in R1's medical record it took the staff from 2:20 p.m. to 4:10 p.m. to get medical emergency team to the facility to evaluate and transport R1 to the hospital after the identification of R1's change of condition. 3. R1's hospital records date of [DATE] at 7:39 p.m., documented in-part: patient endorsed SI (Suicidal Ideation). Patient reports taking ,d+[DATE] tabs of [MEDICATION(S)] of unknown dosage. Patient states the [MEDICATION(S)] is her medication that's in her purse and had it before going to the NH (Nursing home). MD (Medical Doctor) and Pharmacy aware, poison control being contacted. At 8:42 p.m., in brief, patient [AGE] year-old female patient with PMH (Past Medical History) of [CONDITION(S)], Major Depression, [CONDITION(S)], type 2 Diabetes, [CONDITION(S)], HLD ([CONDITION(S)]), [CONDITION(S)] (Hypertension) who presented to ED (Emergency Department) after she was found to be altered at the nursing home. Upon arrival to the ED there was questionable concerns that the patient had taken another residents medication. She was given [MEDICATION(S)] for possible Opioids use and started on IV fluids as her BP (Blood Pressure) was ,d+[DATE]. At the time of ED (Emergency Department) arrival, per ED nurse and attending, minimal information was obtained from the patient as she was drowsy but still arouse-able to tactile stimulation. Upon examination, patient was more alert although drowsy throughout my encounter. When asked for purpose of her ED visit, she stated that she wanted to kill herself. When asked how she tried to do so she mentioned she had taken about 20 pills of [MEDICATION(S)]. ED Nurse and attending were notified. After further questioning she mentioned that she had these pills before arriving to the nursing home in her purse. (R1) ED H&P (History & Physical) assessment showed: Acute Toxic [CONDITION(S)] secondary to ingestion of multiple tablets of [MEDICATION(S)], suicide attempt from [MEDICATION(S)] overdose, shock most likely secondary to Cardiogenic from [MEDICATION(S)] overdose, [CONDITION(S)] possibly secondary to Atypical Pneumonia versus Pulmonary [CONDITION(S)] from fluid resuscitation, Electrolyte Imbalance, and type 2 Diabetes with [CONDITION(S)]. 4. On [DATE] at 2:23 p.m. V3 (Social Worker) stated R1 was on her caseload, and she has never seen R1 with a purse however when R1's family picked up R1's belongings, she observed some clothing, a black purse, and a laptop, V3 also stated R1 had a debit card while at the facility but does not know if the debit card was with R1's belongings. On [DATE] at 3:26 p.m. V8 (Laundry Aide) stated she did the inventory of R1's items (V8 reviewed the 2 inventory documents and verified her signature). V8 stated the process is that residents' belongings come to laundry first, V8 stated if contraband is found she would get the nurse or security involved, if there's medication she would notify the nurse, if there's sharps, glass, weapons or anything a resident can use to hurt themselves or others she would notify security. V8 reviewed R1's inventory sheet and stated there is no purse or medication documented on the 2-inventory sheets there must wasn't one in R1's belongings. V8 stated she only gets the bags of belongings, if a resident has something on their person, she will not inventory those items, and she would not see those items because it would go to the unit with the resident and the nurse would inventory the items. On [DATE] at 4:01p.m V12 (Nurse) said he was the nurse that assessed R1 upon her admission and it's been a while since the admission, but he does not think he saw a purse. On [DATE] at 11:50a.m V9 (Activity Director) stated she has seen R1 with a purse, and R1 keeps her purse at the bottom of her walker (walker that has a basket at the bottom). On [DATE] at 2:23p.m. V3 (Social Worker) stated R1 was on her caseload, and she has never seen R1 with a purse however when R1's family picked up R1 belongings, she observed some clothing, a black purse, and a laptop, V3 also stated R1 had a debit card while at the facility but does not know if the debit card was with R1 belongings. Review of R1's inventory personal items, dated [DATE] and [DATE], there is no documentation of R1's purse noted nor is there documentation of the pills that R1 admitted to having in her purse. On [DATE] at 8:50a.m V6 (R1's Family member) stated the facility contacted him on [DATE] and informed him that R1 would be sent to the hospital because her blood pressure was low and R1's sugar was high. V6 stated while at the hospital R1 told the doctor that she took pills that she had in her purse, V6 stated R1 expired on [DATE], V6 stated R1 was not supposed to have those pills because she was a danger to herself and R1 was also diagnosed with [CONDITION(S)], [CONDITION(S)] and Depression. V6 stated R1's belongings were picked up from the facility and in R1's black purse was a pill bottle along with some receipts, V6 also stated in R1's belongings were her gray laptop and some clothing items. V6 stated the pill bottle was empty. Review of the picture that V6 submitted of pill bottle dated [DATE] shows in-part R1's name, a Chicago address, [MEDICATION(S)]-HTCZ ,d+[DATE] milligram, take 1 tablet by mouth daily. Facility policy titled Resident personal Clothing and Belongings Handling dated [DATE] shows in-part that policy is to ensure that all residents clothing is identified, stored, and laundered appropriately. Procedure upon admission, personal belongings are to be listed on the Belongings List in the resident chart. New items brought to the facility other that during the admission process, should be added to this list. Upon discharge CNA (Certified Nursing Assistant) assigned to the resident unit will pack residents' belongings and notify housekeeping, housekeeping will move resident belongings to the storage area, residents' belongings will be marked with residents name during storage, social services will contact the family regarding belongings left at the facility, belongings will be stored for 30 days after resident permanent discharge. Facility Policy Titled Contraband Materials, Inspection of rooms, safe storage and use of recording Devices, no date noted shows in-part Introduction: This organization reserves the right to conduct inspections if there is reason to suspect/believe that a resident has contraband items/ materials in his/her possession. These items include but are not limited to alcohol, illicit (street or over the counter) drugs, weapons (including any sharp objects/ ammunition) and smoking materials (if the individual has assessed as dangerous and irresponsible with smoking related items). The individual may also be appropriately checked to look for suspected lost or stolen property, if reasonable suspicion exits. No over the counter medication may be kept by the resident. These items must be turned over to facility personnel immediately upon arrival. The origination will try balance individual rights against the safety needs of peers, visitors and staff members in making decisions about further investigation of contraband. In situations where illegal activity appears to have taken place appropriate authorities will be notified. Again, safety and security are of the utmost concern. Policy; the following items are not allowed in resident's rooms at any time and are not allowed on the resident's person unless permission has been granted from administration and supervision is being provided: lighters matches, cigarettes, drugs, over the counter medication, drug paraphernalia, glass bottles, toaster oven, hot plates, coffee makers, rice cookers, microwave oven, silverware, knives, fire arms and ammunition of any type, alcohol, razors, razor blades, caffeinated beverages, needles, safety pins, housekeeping, laundry supplies, staplers, staples, candles, incense. 5. R1 Nursing Facility Placement Assessment Summary Information dated [DATE] indicated in-part, R1's mental status and presenting behaviors where, adequate concentration, poor memory, absent motivation, cooperative, unremarkable thought disorder, sad facial expression, average intelligence, depressed mood, orientated, no impairment with physical sensory, withdrawn, and speech and voice was appropriate. The narrative summary shows screening completed via phone due to COVID-19. Patient is a [AGE] year-old hospitalized for Depression Symptoms, endorsing SI (Suicidal Ideation), AH (Auditory Hallucinations). Patient was alert and orient during screening, denies current SI/ HI (Suicidal Ideation/ Homicidal Ideations). Denies AVH (Auditory-Visual Hallucinations). Ongoing medication non-compliance, limited insight, history of substance abuse, currently homeless, and denies legal issues. Patient referred to FDDP for assessment. Based on medical records and patient presentation during PAS, there is a reasonable basis to believe the patient will benefit from NF (Nursing facility) level of care. We recommend reassessment for TCM/ communication reintegration within ,d+[DATE] months or upon Psychiatric Stabilization, poor judgement placing self or others at risk and recent medication non-compliance. R1's Nursing Facility Placement PAS/MH level 2 notice of determination dated [DATE] shows in part the following information is a summary of the findings of your pre-admission screen: special services; professional observation (MD/RN) for medication monitoring, adjustment and stabilization, instrumental activities of daily living training/ reinforcement, mental health rehabilitation activities, illness self-management and community survival activities. V7 (Assistant Director of Social Service) said he was not aware of R1's history of [CONDITION(S)], he was made aware last week. R's care plan with target date of [DATE] shows in-part that R1 requires [CONDITION(S)] medication to help manage and alleviate: Depression, behavior with depressive features, Mood swings, mood liability. The ff. class (es) of medication are prescribed: Antipsychotic. The ff. class (es) of medication are prescribed: Antidepressant. R1 will be maintained on the lowest therapeutic medication dosage and engaged in counseling/behavioral programming to facilitate maximum functioning and well-being through: R1 [CONDITION(S)] medication will be therapeutically reduced if warranted. Assure that the resident's diagnosis corresponds with the medication prescribed, Complete [CONDITION(S)] evaluation and assessment consistent with protocol. Carry out the medication management regiment as prescribed. Report changes, complications to the doctor., Assess the side effects and complication such as abnormal involuntary movements (i.e., tremors, shaking, pacing, lip/tongue movement, rigidity, stooped posture, etc.) and anticholinergic symptoms (blurred vision, poor balance, [CONDITION(S)], constipation, dry mouth, etc.), Offer behavioral counseling and intervention to help the resident cope with mood and/or behavioral distress and dysfunction., Teach the resident coping strategies to enable him/her to compensate for hallucination and/or delusions., If behavioral symptoms are observed, record and document on Behavior Tracking Form. Report abnormalities to MD. R1's care plan with initiation date of [DATE] shows Auditory Hallucinations: Resident has a history of having Auditory Hallucinations. Resident will experience a decrease in Auditory Hallucinations as evidenced reported by staff through next review date, [DATE]. Staff will provide reality-orienting counseling. Staff will provide redirection as needed. R1's care plan with initiation date of [DATE] shows mood Depression: Resident presents with periods of Depression evidenced by resident scoring a 13 on the PHQ-9. Resident stated Depressive symptoms in regard to being isolated in the facility at this time. Resident stated she has trouble sleeping and does not like the status in health. Resident stated while in the hospital she did not like the environment. Resident will share concerns and demonstrate a decrease in symptoms as evidenced by improved indicators identified PHQ9 and in Depression Scale through the next review date [DATE]. Encourage Resident to seek staff when having any distress or moods leading to Depression. Staff will discuss and offer Resident to participate in Marriage and or 1:1 counseling as needed. R1's care plan with initiation date of [DATE] shows Substance Abuse, R1 has a history of polysubstance abuse which includes alcohol and Benzoates. The resident will refrain from using non-prescribed substances through the next review [DATE]. Staff will discuss the negative impacts of using illicit substances as needed, Staff will make resident aware of rules prohibiting use of alcohol, illicit substances & intoxication. R1 care plan with initiation date of [DATE] shows [CONDITION(S)], resident with a history of [CONDITION(S)] with no plan. Resident will immediately report any Suicidal Ideation or thoughts of self-harm to staff, as evidenced by staff reports through the next review date of [DATE]. Staff will monitor for any mood and behavior changes, and staff will provide counseling as needed. The surveyor confirmed via observation, record review and interview facility did the following to remove the immediacy: Policy and Procedure/System Revision 1. Inventory of Resident Belongings 2. Therapeutic Programming for Resident with Mental Illness 3. Individualize Care Plans to monitor and check for Behavioral Changes 4. Plan to monitor for Mood and Behavior Education Provided Immediate education was provided on [DATE] and completed [DATE]th (ADDENDUM COMPLETION DATE 11.17.2021) by: Regional Director of Operations Provided education on the following topics and staff. Front Desk Staff: Inservice Included the following: The following process will be conducted by 2 staff members on a 24hour basis, 7 days a week. 1. Search of any bags i.e., Plastic bags, purses, wallets, suitcases brought into the facility by residents or family members. 2. When items are found that are considered contraband they will be confiscated and placed in a bag with inventory sheet attached and secured in a safe until Administrator/Assistant Administrator can retrieve. 3. Any clothing will go to laundry for inventory and labelling. 4. If purses and wallets are deemed clear (no contraband) they can be sent up to unit to be placed on an inventory by nursing staff. 5. Visitors are subject to being searched upon entry into the facility by front desk staff. Searches to include, but not limited to, grocery bags, book bags, totes, luggage etc. 6. Auditing will be completed by Administrator or Designee 7. Front Desk training completed on [DATE]. 8. New hires will be trained on this policy/procedure during new hire orientation. Regional Nurse Consultant provided education to Director of Nursing and staff on the following topics: 1. Reviewed facility and Policy and Procedure on Self - Administration of medications. 2. Nurse Managers were educated on the above process relating the front desk search of resident belongings. 3. Responsibility of nurses upon arrival of resident to the floor to inventory all other belongings. Education regarding this was conducted initially by Regional Nurse Consultant on [DATE] and was continued by the Directors of Nursing. Additionally, in-services regarding this were completed on [DATE] to nursing staff to include all active nurses on payroll by either in-service in person or over the phone. Education regarding this will continue for new hires by DON's. The administrator provided education to all Interdisciplinary Department Team (IDT) on the following topic: 1. The IDT was educated on searching of rooms and belongings for contraband and an immediate search of all residents' rooms was conducted on [DATE] to include 274 residents. The Administrator will be responsible for ensuring that searches take place. If resident refuse to be searched upon entering the facility the physician will be notified and residents will receive orders to be sent out to the hospital. Social Service Consultant educated Social Service staff on the following policies and procedures: 1. Resident will be monitored for mood and behavior Monday-Friday for 30 days and weekly thereafter. 2. The IDT will review resident's medical record prior to admission sent via a referral packet identifying potential risk of the following DX SI, Major Depression, [CONDITION(S)], [CONDITION(S)], Substance abuse and poor judgement and other mental illness diagnosis and develop a plan of care. 3. Residents with the diagnosis consisting of any mental illness admitted to the facility will have self-harm assessment Completed-[DATE] 4. Self-harm assessment will be completed quarterly thereafter, and upon any new incident moving forward. 5. Individualized care plans will be resident specific to monitoring for known history of SI, Major Depression, [CONDITION(S)], [CONDITION(S)], Substance abuse and poor judgement and mental illness- completed- [DATE] 6. Programming to include supportive counseling 1:1 and/or groups: 1:1 psychotherapy session-monthly Group therapy-weekly 1:1 Psychotherapy Session with Social Services-weekly Social Service groups: Medication education-weekly Socialization-weekly Symptom management/ Coping skills-weekly Community re-entry-weekly Intimacy and relations-weekly Smoking Cessation-weekly Anger Management-weekly Substance Abuse-weekly Mood and Depression-weekly

Based on interview and record review the facility failed to call 911 to get emergency medical assistance in a timely manner, for a resident with a continuous decline in his/her physical status which lead to a drastic change after having a change in condition. This applies to 1 of 1 resident (R1) who experienced a change in condition. This failure put R1's life in danger and was identified as an immediate jeopardy situation that began on 10/19/2021 and was removed on 11/15/2021. V10 (Administrator) was informed of the Immediate Jeopardy on 11/10/21 at 12:09 p.m. However, the deficiency remains at a level 2 harm until the facility can evaluate the effectiveness of the in-services given to the facility staff members. Findings include: 1. R1's face sheet indicated R1 was a [AGE] year-old resident who was admitted to the nursing facility on 09/05/2020. R1's face sheet also indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's progress notes dated 10/19/21 at 2:20 p.m., documented by V1(Nurse) indicated: resident noted to be lethargic and slow to respond with Generalized Weakness. Resident observed snoring in Postictal state but doesn't have history of Seizures. vitals taken V/S (Vital Signs): T (Temperature) 96.8, P (Pulse) 63, R (Respirations) 20, BP (Blood Pressure) 96/60, Spo2 (Oxygen Saturation) 94% on Room Air. Nurse Practitioner informed and received order to transfer resident out to hospital for medical evaluation. V6 (Director of Nursing) informed, family contact informed and spoke to son. Ambulance Service called for pick up and given 1-hour ETA (Expected time of Arrival). Will continue to monitor. R1's progress notes dated 10/19/2021, documented by V2 (Nurse), shows at 2:35p.m. resident in bed, with head of bed up. SPO2 95% with oxygen (O2) at 2L. V/S: BP-98/61, T-97.0, P-68, R-20. Resident responsive to verbal stimuli, will continue to monitor closely with staff on hand. Awaiting ambulance. At 2:50 p.m. resident remains in bed, continues to respond to verbal and tactile stimuli but sleeping and snoring. Head of bed at 45 degrees. No SOB (shortness of breath) noted. SPO2 94-95% oxygen at 2L, V/S: T-96.7, P-60, R-20, staff on hand awaiting ambulance pick up. At 3:05 p.m. resident closely monitored by staff. Resident continues to be lethargic. V/S: BP-98/61, T-96.7, P-60, R-22, resident appears stable. SPO2 94% with O2 at 2L. At 3:20 p.m. resident observed sleeping and snoring, O2 ongoing, SPO2 91%V/S: BP-96/61, T-97.3, P-58, R-22, CNA (Certified Nursing Assistant) assigned to stay by resident. Will continue to monitor. At 3:40 p.m. called Elite Ambulance, spoke with representative regarding past ETA and nurse was informed resident will be picked up in 45 minutes. Resident SPO2 85% with oxygen at 2 liters, and heart rate dropping from 45 to 35. Oxygen increased to 3 Liters. At 3:50 p.m. resident SPO2 85% with oxygen at 2 liters, and heart rate dropping from 45 to 35. Oxygen increased to 3 Liters, and SPO2 increased to 91%, heart rate continues to drop to 26. 911 called. Resident still lethargic and slow to respond and snoring. Awaiting paramedics. Staff by bedside. Elite ambulance cancelled. At 4:10 p.m., 911 team here, report given. Resident taken to hospital. At 11:00 p.m., called hospital for status. Resident admitted to ICU (Intensive Care Unit) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . From the documentation in R1's medical record it took the staff from 2:20 p.m. to 4:10 p.m. to get medical emergency team to the facility to evaluate and transport R1 to the hospital after the identification of R1's change of condition. 2. The following staff members were interviewed regarding R1's change of condition on 10/19/2021: On 10/27/2021 at 11:01a.m., V1 (Nurse) said she was covering for V2 (Nurse) when she was summons to R1's room because something was wrong with R1. V1 stated she observed R1 sitting on the side of the bed, when she asked R1 how she was doing R1 responded I'm okay. V1 stated R1 spoke in a very slow manner. V1 said R1 then tried to stand up, however, R1 sat back down on the bed and she assisted R1 into a lying position. V1 stated R1 began to fall asleep and snore very loudly at a regular pace. R1 presented in a postictal state as if she had a [CONDITION(S)], however, when she checked R1's records, R1 did not have any medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 stated she assessed R1's vital signs and they were stable. V1 stated she called V5 (Nurse Practitioner) and made him aware of her assessments, R1's vitals, and R1's current condition. V1 stated when V2 (Nurse) came back from her break and assessed R1, she mentioned R1 was not at her base line. V1 stated she has seen R1 with her purse, R1 would have her purse in the bottom of her walker (walker that had basket at bottom). V1 stated she last saw R1 about an hour prior to being summons to R1's room. On 10/27/2021 at 11:53 a.m., V2 (Nurse) stated on 10/19/21 when she came back from her lunch break, V1 reported R1's condition to her. V2 stated when she assessed R1, R1 was laying in the bed, R1 would open her eyes when her name was called, but was not verbal, V2 stated R1 would move her leg a little when asked. V2 said she continued to assess R1's vital signs while waiting for the ambulance to transport R1 to the hospital. V2 stated R1's vital signs were stable initially. V2 stated after one hour of waiting for the ambulance, she followed up and that's when she was given another hour for the ETA. V2 stated she continued to assess R1's vital signs and when she noticed R1's heart rate drop from 45 to 35 that's when she called 911 for emergency care. V2 stated she was not aware that R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/28/21 at 2:02p.m., V5 (Nurse Practitioner) stated he received one call and the nurse stated that R1 was lethargic but was still moving her head or something like that, and also R1's vitals were a little below her base line, and that's why he gave the order to send to CF hospital. V5 stated he did not receive a follow up call related to R1's status. V5 stated the nurse did not inform him that R1's oxygen saturation dropped, he did not give an order to place R1 on oxygen, and he was not made aware that R1's heart rate had dropped. V5 was not made aware that R1 presented in a postictal state. V5 stated if he was made aware of all the changes in condition for R1, he would have sent her out 911 for further medical evaluation for the decline. V5 continued to say he only received one call, but maybe the collaborating physician was notified. 3. R1's hospital records date of 10/19/2021 at 7:39 p.m., documented in-part: patient endorsed SI (Suicidal Ideation). Patient reports taking 20-30 tabs of [MEDICATION(S)] of unknown dosage. Patient states the [MEDICATION(S)] is her medication that's in her purse and had it before going to the NH (Nursing home). MD (Medical Doctor) and Pharmacy aware, poison control being contacted. At 8:42 p.m., in brief, patient [AGE] year-old female patient with PMH (Past Medical History) of [CONDITION(S)], Major Depression, [CONDITION(S)], type 2 Diabetes, [CONDITION(S)], HLD ([CONDITION(S)]), [CONDITION(S)] (Hypertension) who presented to ED (Emergency Department) after she was found to be altered at the nursing home. Upon arrival to the ED there was questionable concerns that the patient had taken another residents medication. She was given [MEDICATION(S)] for possible Opioids use and started on IV fluids as her BP (Blood Pressure) was 76/52. At the time of ED (Emergency Department) arrival, per ED nurse and attending, minimal information was obtained from the patient as she was drowsy but still arouse-able to tactile stimulation. Upon examination, patient was more alert although drowsy throughout my encounter. When asked for purpose of her ED visit, she stated that she wanted to kill herself. When asked how she tried to do so she mentioned she had taken about 20 pills of [MEDICATION(S)]. ED Nurse and attending were notified. After further questioning she mentioned that she had these pills before arriving to the nursing home in her purse. (R1) ED H&P (History & Physical) assessment showed: Acute Toxic [CONDITION(S)] secondary to ingestion of multiple tablets of [MEDICATION(S)], suicide attempt from [MEDICATION(S)] overdose, shock most likely secondary to Cardiogenic from [MEDICATION(S)] overdose, [CONDITION(S)] possibly secondary to Atypical Pneumonia versus Pulmonary [CONDITION(S)] from fluid resuscitation, Electrolyte Imbalance, and type 2 Diabetes with [CONDITION(S)]. 4. On 11/02/2021, a phone conference with E1 (Administrator) was held to discuss the survey teams concerns for the late response to act on R1's change of condition. After the discussion the facility provided documentation from V16 (Physician) dated 11/02/2021 indicating he was in direct contact with V5 (Nurse Practitioner) as it was reported 14:20 hours (2:20 p.m.). V16 (Physician) documented: I was notified of the initial assessment and vitals for the patient and was in agreement with sending the patient to a local medical center as the patient's condition at the initial assessment did not warrant a 911 emergency call. I was contacted (no time given) by the nurse (not named) at the facility that there was a deviation from the initial assessment that was provided to my Nurse Practitioner and then I gave the order for the resident to be sent to the hospital 911. This second, contact with the medical doctor was not documented in the resident's medical record. On 11/9/2021 at 10:35 a.m., V16 (Physician) stated V5 (Nurse Practitioner) received the initial call regarding R1 change in condition. V16 stated V5 communicated with him and they agreed that R1 should be sent to CF hospital for evaluation. V16 said he informed V5 that he would be the contact person for R1 at that point. V16 said the nurse did contact him several times before the 911 call at 3:50p.m, V16 stated he does not remember specific times. V16 stated 911 should be called when a resident has a drastic change of condition. V16 described a drastic change in condition could be when a person's pulse is going below 40, oxygen very low of 75% to 80% and blood pressure of 70/50. V16 said R1's condition at 2:20p.m was not drastic, that's why R1 was going to be transported to CF hospital. R1's progress notes dated 10/19/21 at 3:20p.m, V16 stated oxygen saturation of 91% is okay for a patient that smokes, he would be concerned if the oxygen saturation was 70%-75% for someone that smokes. V16 said heart rate of 58 is okay. R1's progress notes date 10/19/21 at 3:40p.m reviewed with V16, V16 said oxygen saturation of 85% could indicate multiple things, one could possibly be an intracerebral bleed and a heart rate of 35 is bad but not drastic, V16 stated that's why he gave orders to send R1 to hospital so that she could be evaluated, but the ambulance took their time. V16 stated at 3:40 p.m., he was informed of R1's condition and he directed the nurse to keep him informed, if the resident condition does not improve to call 911, and at 3:50 p.m. the nurse called 911 because the heart rate dropped to 26. V16 stated the nurses did a marvelous job, V16 stated it was okay for the nurse to wait for Elite Ambulance to transport a resident to the hospital for evaluation unless the patient has a drastic change and R1 had a drastic change at 3:50 p.m. and that's when the nurse called 911. When asked does he expect the nurse to call 911 at 3:40 p.m. when the heart rate is 35 and oxygen saturation is 85%, V16 stated the nurse cannot call 911 unless the physician gives directives. V16 stated at 3:40 p.m. he gave directives to the nurse to keep him informed and if R1's condition does not improve to call 911 and that's when the nurse called 911 at 3:50 p.m. Facility policy Titled Change in Resident's Condition or Status dated 06/26/2011 shows in-part the purpose is to ensure that the resident's attending physician and representative is notified of change in resident's condition and/ or status. The nurse will notify resident's attending physician when there is a significant change in the resident's physical, mental and psychosocial status. Deemed necessary or appropriate in the best interest of the resident. A significant change of condition is a decline or improvement in the resident status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions, impact more than one area of the resident health status, and review and revision to the care plan. Except in medical emergencies, notification will be made within 24 hours of a change occurring in the resident condition or status. During medical emergencies such as unstable vital signs, respiratory distress, uncontrolled bleeding and unresponsiveness 911 will be notified for transport to the hospital. The surveyor confirmed via observation, record review and interview facility did the following to remove the immediacy: Education: Will be provided by Regional Nurse Consultant's and Medical Director. Immediate Notification to MD, NP, or 911 Education that has been Provided 1) Medical Director did in-service relating to changes in condition, professional standards of care responsibility and expectations of the licensed and registered nursing staff. 11/10/21 2) In-service Licensed and Registered Nurses on calling 911 services. 3) In-service the Licensed and Registered Nurses on utilizing their professional nursing judgement in relation to changes in condition and continued decline. 4) DONs will In-service the staff who are directly involved in care of residents, CNA's, psych techs ,social service staff and nurses on changes in condition relating to the residents' baseline. This is ongoing to be Completed by Monday, [DATE] 5) DON's provided separate in-service relating to 911 use and changes of conditions notification to Physicians professional judgement. This is Ongoing completed by Monday 11/15/21 Policy and Procedure 1) Change of Condition Current 2) Utilization of 911 services this is not a new policy it is an education that was enhanced to give direction to Nurses relating to 911 criteria: Immediate Notification to 911 then to MD for continuity of care Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and: A Marked Change (i.e., more severe) in relation to usual symptoms and signs, or Unrelieved by measures already prescribed Non-Immediate Notification to MD or NP New or worsening symptoms that do not meet above criteria

Based on interview and record review the facility failed to ensure staff provided the identified level of assistance to prevent a fall for 1 (R4) of 3 residents reviewed for falls. In addition, the facility failed to implement their care planned safety interventions for 1 (R4) of 3 residents reviewed for safety. Findings include: R4 is [AGE] years old with diagnoses including but not limited to [CONDITION(S)] and [CONDITION(S)], Diabetes Mellitus, [CONDITION(S)] Disease, [CONDITION(S)], Hypertension, need for assistance with personal care, visual loss, difficulty walking, and Dementia. R4's care plan notes documents: she requires extensive assist for ambulation and one person assistance for transfer, has Dementia with periods of forgetfulness, and is at risk for falls due to her decreased safety awareness. On 9/8/21 at 12:58 PM R4 observed sitting in her wheelchair in the dining room. R4's wheelchair observed with no extenders on wheelchair with an empty plastic cup hanging upside down from the wheelchair brake handle on the left side. R4 stated she gets herself up from bed and into bed every day. R4 said she does not call the staff to help her. R4 stated she fell last month in the bathroom she didn't get injured and got herself up. On 9/8/21 at 1:05 PM V6, Certified Nursing Assistance (CNA), said R4 is able to transfer by herself, she does not let me do anything for her. She is in the wheelchair when I get here at 7:00 AM and in it when I leave. I don't know when she goes to the bathroom, because she does not tell me. On 9/8/21 at 1:18 PM V7, Restorative Nurse, stated R4 is on restorative programs for walking and assisted range of motion (AROM). V7 statedR4 has bilateral weakness in her legs and she is not safe to stand and transfer independently. V7 stated on 8/5/21 R4 said she fell while she was trying to go to the bathroom. V7 stated R4 should have someone with her when transferring on and off the toilet. V7 stated her initial concern related to R4's fall on 8/5/21 was R4 locking her wheelchair. V7 stated to address this concern she placed an order for wheelchair brake extenders. V7 said I requested these I know they were ordered. V7 was unable to provide documentation that the item was ordered. V7 stated R4 is able to lock the wheelchair. On 9/9/21 at 9:31 AM V10 Licensed Practical Nurse (LPN) stated, the night shift CNA reported that R4 was in the bathroom. V10 said when she went to R4's room R4 told me she had fallen, but she was now sitting in her wheelchair in the bathroom. V10 said R4 said she had missed the toilet and fell . V10 said it is usual for R4 to get up unassisted. V10 said R4 does accept assistance from staff when offered. On 9/9/21 at 1:16 PM V16 Director of Therapy stated, R4 has brake extender devices on her wheelchair to use when she stands. V16 stated we evaluated R4 after her fall on 8/5/21 and she was unchanged from the last time we worked with her. V16 stated whatever the care plan instructed her transfer status to be is what she was. On 9/9/21 at 1:35 PM V17 nurse stated, if a resident is 1 assist, they should not be left alone in the bathroom because they need assistance. If the resident got themselves into the bathroom then staff should stay with them to prevent a fall. On 9/9/21 at 1:50 PM V7 stated a clamp was applied to R4's wheelchair to assist her with locking it. I put the device on R4's wheelchair today. V7 stated, according to R4's Functional Status assessment dated [DATE] she requires 1 person hands on assist for transfers, toilet use, and personal hygiene. V7 stated based on this assessment dated [DATE] R4 is not safe to transfer herself. V7 stated on 8/5/21 R4 should not have self-transferred and today R4 should not be self-transferring. V7 stated R4 should not be left alone in the bathroom, because she needs 1 person assist and she will transfer herself alone. On 9/9/21 at 2:24 PM by phone interview V21 CNA stated on 8/5/21 R4 pulled the call light and was sitting in the wheelchair. V21 stated R4 said she fell . V21 stated I don't know how she got into the wheelchair. V21 stated before the fall she saw R4 in her bed. V21 said R4 gets up by herself around 5:30 to 6:00 AM, she is independent. V21 said R4 does not ask for help. V21 said a 1 assist can't be left along in the bathroom. On 9/10/21 at 10:24AM V2, Director of Nursing (DON), said she expects staff to follow the care plan interventions. V2 said the interventions are put into place to provide consistent care and maintain the safety of the residents. R4's care plan dated 2/17/20 notes educate resident to lock wheelchair before sitting/standing with wheelchair, therapy to screen for proper use of wheelchair. R4's care plan dated 2/18/20 notes refer to therapy for safe transfers and redirect resident to lock wheelchair prior to sitting. R4's care plan dated 8/5/21 notes resident received floor change, brake extenders placed on wheelchair, and staff provided education on proper wheelchair locking, therapy screen. Progress Note dated 8/5/21 written by V10 notes resident was sitting on bathroom floor did not have breaks on wheelchair locked. R4 said I was trying to use the bathroom and fell . Falls & Accident / Incident Resident Management Review dated 8/5/21 notes facility identified during the investigation that resident has impulsiveness. Order to be placed for break extenders if it is appropriate upon therapy assessment. Functional Status assessment dated [DATE] notes extensive assistance of 1 person is required for transfers, toilet use, and personal hygiene.

Based on interview and record review, the facility failed to follow their abuse policy by not preventing resident to resident assault against 1 of 3 residents (R5) reviewed for physical abuse. This failure resulted in R5 being physically assaulted by a co-peer (R12), R5 sustained a fracture to the left nasal bone, large periorbital soft tissue hematoma, and a 3cm laceration that required 4 sutures. Findings Include: R5 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Minimum Data Set (MDS) dated [DATE] under Brief Interview For Mental Status (BIMS) documents a score of 15/15 which indicates cognitively intact. R5's progress note dated 12/12/20 documents: At 2:50 pm resident was on the unit, alert and oriented and in no distress. Around 3:10 pm writer was informed by another peer that the resident allegedly received physical aggression from another male resident in the male bathroom. Writer rushed down to check on him. He was bleeding in his left eye and refused treatment from nurse, denies pain stated he's ready to go to the emergency room . Facility's abuse reportable dated 12/18/2020 documents: R12 made physical contact with R5. Under conclusion documents, R12 admitted to making contact with peer. Staff noted witnessing R5 and R12 going into restroom and R5 exiting with skin laceration. On 9/8/21 1:19 pm, R5 who is alert and oriented at time of interview said he was punched in the face by another resident in the common washroom. R5 said he had limited vision to his left eye before the incident and is now no longer able to see from his left eye. On 9/10/21 at 9:59 AM, R5 who was alert and oriented said R12 punched him in the face a few times and he fell to the ground. R5 was unable to provide any further details. R5 stated he did not hit R12. Local hospital record dated 12/12/2020 documents: R5 presented to emergency room with head laceration after assault. R5 states he got into an argument with another resident, was hit in the head and suffered a brief loss of consciousness. Notes under physical exam documents: laceration over left eyebrow approximately 3 cm. there is significant soft tissue swelling around the left periorbital region. Notes under results documents: Computerized Tomography (CT) head and facial bones findings; There is an oblique fracture of the left side nasal bones, increased density is seen in left globe, possible hemorrhage with disruption. Large left periorbital soft tissue hematoma. Under procedure note documents; simple laceration repair to forehead total length 3cm. Four sutures were utilized. Facility abuse prevention program revised 3/26/21 documents: It is the policy of this facility to prohibit and prevent resident abuse, neglect, mistreatment and misappropriation of resident property and a crime against a resident in the facility. The facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff, other residents, consultants, volunteer, family members, legal guardians or other individuals. Abuse is the willful infliction of injury with resulting harm or pain or mental anguish or deprivation by an individual. Physical abuse is hitting, slapping, pinching kicking etc. R12 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's preadmission screening dated 10/18/2018 documents under physical assault injury, a moderate behavior level. Note under description documents: Patient was hospitalized with suicidal and homicidal ideations. He had been noncompliant with his medications and was agitated and felt like hurting someone or hurting himself. R12's progress note dated 12/12/20 documents: Resident initiated physical aggression towards another resident in the male bathroom around 3:10 pm, he denies the allegation but in house camera was able to point him out. R12's progress note dated 12/12/20 at 15:20 documents: Day 1/3 Physical Aggression towards peer social service made aware that resident was allegedly physically aggressive towards peer. Upon meeting with resident, he denies actions stating, I didn't do anything, I stayed away from him after you told me to. After, further investigation and being presented with information R12 admitted to staff that he hit peer. R12 then expressed his dislike for his behavior towards staff earlier. Resident was encouraged to not intervene in situations that do not pertain to him and allow staff to take care of any difficulties. Resident educated on the importance of maintaining safety and a positive relationship with others. Resident able to verbalize understanding. Nurse on duty contacted Doctor for further instructions and possibility of sending to hospital for further evaluation. Resident will continue to be monitored. Resident aggression assessment and care plan updated. Social services will continue to follow up. R12's care plan dated 9/11/2020 documents: R12 is an identified offender with moderate risk. Interventions dated 9/11/20: Staff will do appropriate supervision/observation, regular monitoring, attention to behavior changes, visual monitoring if warranted and reassessment. Facility abuse prevention program revised 3/26/21 documents: It is the policy of this facility to prohibit and prevent resident abuse, neglect, mistreatment and misappropriation of resident property and a crime against a resident in the facility. The facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff, other residents, consultants, volunteer, family members, legal guardians or other individuals. Abuse is the willful infliction of injury with resulting harm or pain or mental anguish or deprivation by an individual. Physical abuse is hitting, slapping, pinching kicking etc.

Based on observation, interview and record review, the facility failed to monitor and supervise residents to prevent unsupervised smoking in the building and to prevent contraband smoking material(s) from coming into the facility (R8, R23), failed to provide a safe environment by leaving electrical wires exposed and maintain safe electrical outlets in resident's room (R27, R28, R29, R30, R32, R33, R34, R35, R36, R37), and allowed residents to put foil into electrical outlets to ignite a spark to light smoking materials (R8 R23, R31). This was previously identified as an immediate jeopardy during another complaint investigation and the immediacy was removed prior to the exit of the Annual Survey. Findings include: R8 was admitted on [DATE] with a diagnosis of [CONDITION(S)]. R8's progress notes dated 7/12/21 documents: resident noted with broken electric cables attempting to ignite fire to light a cigarette butt. R8's progress note dated 7/26/21 documents: using improvised devices to light fire in the bedroom, danger to self and others. Transferred to hospital. R8's petition dated 7/26/21 documents: using electrical cables to set fire in the bedroom. R8's hospital record dated 7/26/21 documents: R8 stated, I was trying to use the electrical cords to light toilet paper so I can smoke weed and crack. Hospital record dated 7/27/21 documents positive finding of cannabis. On 7/26/21, R8 said he was trying to light a cigarette by using the electrical wires from the over the bed light in his room. R8 said he removed the wires but unable to describe how he removed the wires. R8 said he put the wires into the electrical outlet and had toilet paper near the outlet to catch fire to light his cigarette. R8 said he had a cigarette from a previous smoke break. R8 then demonstrated how he lit the cigarette, R8 sat on the floor near electrical outlet and pulled the privacy curtain near the outlet. R8 put his face near the outlet to catch the flame. R8 said this time the privacy curtain was too close to outlet and set on fire. R8 had to put it out with his hands and wet towel. On 8/10/21 at 3:21pm, R8 said he called a suppler (R8 refused to give name or description) who would meet him in the common outside patio, where he would receive marijuana. R8 said he would return into the building and was never searched or questioned. On 8/3/21 at 3:30pm, R8's previous room was observed with black soot around one outlet. The electrical outlet was observed with an object sticking out which was confirmed by V11 (Maintenance Director) to be a piece of foil. V11 and V35(Maintenance) said they were unaware of any concerns related to the electrical outlets in R8's room, but residents in the building will stick things in the outlets to ignite a spark so they can light a cigarette. No observation of privacy curtain in room. R8's smoking assessment dated [DATE] documents: May not be capable of handling/carrying any smoking materials and requires supervision when smoking. R23 was admitted on [DATE] with a diagnosis of [CONDITION(S)] Disorder, [CONDITION(S)] and Asthma. R23's smoking assessment dated [DATE] documents: May not be capable of handling/carrying any smoking materials and requires supervision when smoking. R23's care plan dated 12/24/20 documents: R23 as an identified offender with history of aggravated arson 1996 and considered high risk. R23's progress notes dated 7/26/21 and 7/27/21 document had no unsafe use of electrical wire by V37(nurse). R23's progress note dated 8/8/21: R23 using cables to light cigarettes in R29-30's room. On 8/10/21 at 4:30pm, V37 said R23 was in the room when the incident with R8 happened on 7/26/21 but unable to provide any other information related to incident. R23 was unable to provide any additional information about incidents and denied any involvement. On 8/5/21 at 4:45pm, R23's room was observed with black soot around one outlet in the room. The hospital bed in the room was observed with a cord that had been cut with exposed wires. V11(maintenance director) said the outlet had black soot around it which indicates that something was placed in the outlet causing a spark. V36 (maintenance) said that this behavior is happening all over the building and residents are using foil from food deliveries to stick in the outlets to light cigarettes. On 8/6/21 at 12:34 pm, R27-28 room had two over the bed light frames on the wall, within the frame of the lightening device there were two electrical outlet plugs that had black soot on them. At 12:44pm, R29-R30's room was observed with two exposed wires from the over the bed the light and one electrical outlet with black soot. At 12:51pm, R31's room had one outlet with black soot and small piece of foil observed along with exposed wires from the over the bed light. At 1:06pm, V11 confirmed that it was a piece of foil in the outlet in R31's room. At 1:12pm, R35's room had exposed wires from one of the over the bed lights. At 1:14pm. R32-33's room had paper stuffed into the electrical outlet and exposed wires from one of the over the bed lights. At 1:15pm, R34's room was observed with four exposed wires from the over the bed light and one electrical outlet with black soot. At 1:20pm, R36-37 had two exposed wires from the over the bed light. On 8/10/21 at 2:04pm, R29-30's room had an outlet blackened with soot with a small object within the outlet. On 8/19/21 10:50am, R27-R28's room was observed with soot covered outlets to two lightening fixtures over the bed which had been previously observed on 8/6/21. At 11:02am R29-R30's room had new observations of foil and an unknown object protruding from one ceiling outlet. On 8/5/21 at 1:47pm, V11 (Maintenance) said he has been at facility for about 2 months. V11 said about a month ago residents removed fire lights in the bathroom on the 5th floor and staff does not report when these incidents occur. V11 stated maintenance staff will find outlets burnt or cut electrical cords from televisions or over the bed lights randomly. V11 said they do not do any daily inspections because there is not enough staff. V11 said he has replaced about 20 outlet covers in 2 months but unable to provide any record of replacements or what they replaced. On 8/10/21 at 10:00am, V11 said he was aware that there was a concern related to residents placing cords/foil in the outlets. There is a possibility of fire if the breaker does not cut the power supply to the outlet. It is possible to get an electrical shock from the outlet if placing objects into the wall but V11 states he has not seen or heard of anyone getting hurt. V11 said they have not done any audits of the rooms but claimed to be placing wall plates over the outlets since June. When asked what rooms they were placed in, V11 was unable to recall specific rooms and unable to produce a log of replacements or receipts of purchases of items. V11 said he has replaced on cover on 8/6/21 on the seventh floor. On 8/10/21 at 10:25am, V35(Maintenance) said he has not placed any wall plates on outlets but replaced the outlet cover in R29's room on 8/3/21. On 8/10/21 at 10:34am, V36(Maintenance) said he has only placed one wall cover on the 8th floor. On 8/11/21 at 204PM, V55 (Electrician) said he has never heard of foil being placed in outlets and is not sure what will happen. V55 stated if there are observations of blackened areas around the outlet, it indicates there was some kind of fire near the outlet. In most cases the circuit breaker will trigger which will turn off the power supply to prevent fires or electrocution but there is always a chance that someone could be injured. Facility policy titled: Physical plant weekly inspections undated documents under electrical inspections: All receptacles and switches shall be inspected for cracks, condition of cover plates and any signs of shorts. 8/6/21 at 2:14pm, V4(APRSD) said all smoking materials are held by staff and no resident is allowed to smoke independently. Facility policy titled smoking policy undated documents: There will be no smoking permitted inside the facility. All resident smoking material will be kept by the facility in a secure location. All smoking remnants will be discarded into approved receptacle by staff or under staff supervision. Residents will have no smoking materials in their possession. Facility policy titled Search and Confiscation Policy undated documents: The facility has right to search belongings and person if there is reasonable suspicion that contraband is being brought into the facility. Items that are considered harmful or unsafe for the resident will be destroyed. Prohibited items include but not restricted to the following list: cigarettes, cigars, loose tobacco, lighters, sharps, razors, scissors, knifes or items considered a possible danger. B. Based on observation, interview, and record review the facility failed to have an effective 1:1 monitoring system in place, failed to implement their crisis prevention intervention protocol to de-escalate an incident of self-injurious behavior for 1 of 1 resident (R1) reviewed for supervision. This failure resulted in R1 being able to pry off a heating vent and stab herself in the abdomen while under 1:1 supervision by facility staff resulting in R1 to be sent to the local hospital for treatment. This was previously identified as an immediate jeopardy during another complaint investigation and the immediacy was removed prior to the exit of the annual survey. Findings include: R1 admitted to facility on 5/12/21 with a diagnosis of [CONDITION(S)] Disorder, Major Depressive Disorder, [CONDITION(S)], Unspecified [CONDITION(S)], Paranoid Personality, Delusional Disorder, Auditory Hallucinations, and Post Traumatic Disorder. R1's plan of care dated 6/12/2021 shows R1 has a history of self-harmful & self-mutilation ideation (thoughts) and/or behavior. Interventions dated 6/7/21 include: As warranted, conduct, random room safety checks, personal wellness checks, and behavior monitoring of resident. Interventions dated 5/21/21 include conduct appropriate assessments upon admission. Review transfer record, including screening to determine any history of self-harm; encourage resident to seek help of staff when in distress. Facility incident report dated 5/21/2021 documents: An incident occurred in R1's room, R1 admitted to stabbing herself with a pen. A complete body assessment revealed pen stuck in resident stomach, 911 called. No witnesses found. Facility incident report dated 6/4/2021 documents: An incident happened in R1's room. R1 observed with open area to abdomen and small amount of bleeding noted. R1 had broken pieces of pencil in her hand. R1 stated she stuck a pencil in her stomach. Facility incident report dated 6/17/2021 documents: An incident occurred in R1's room, call to room by CNA, R1 stated she swallowed a key. No witnesses. Facility incident report dated 6/30/2021 at 12:54 AM documents: An incident occurred in R1's room. R1 was noted with self-inflicted skin tears on left wrist and lower abdomen with plastic spoon. R1 stated, I do not want to be here, just take me to the hospital.911 called. No witnesses found. Progress note dated 7/14/21 documents: R1 was readmitted to the facility from local hospital around 1:00PM. Progress notes dated 7/14/2021 at 17:32 documents: V8 (Nurse) was doing petition to send R1 to the hospital. R1 stated she was giving V8 ten minutes to get R1 out of the building. I sent V5 (CNA) to closely monitor. V5 (CNA), yelled for (V8) to come to R1's room. V8 observed blood coming from R1's abdomen. R1 had a sharp object in her hand. V8 stated I tried to get R1 to give it to me, R1 tried to cut me with the object. I called security to get the object. A facility incident report dated 7/14/2021 documents: At 4:45pm, V8 (Nurse) was preparing petition to send R1 to the hospital, V5 (CNA-Certified Nursing Assistant) placed at room to closely monitor R1. Witnesses' statement from V5 documents: R1 grabbed a sharp object when I tried to take the object R1 started to cut at me with it. Then R1 took the object and cut her stomach. Witness statement from V8 documents: Observed R1 with blood coming from her stomach. R1 had a sharp object when I tried to take it from her, the resident tried to cut me with it and said she will cut my throat with it. On 7/20/21 at 5:04p.m. V5 (CNA) said she was told by the nurse that R1 needed 1 to 1 monitoring, V5 said, she was in the room standing behind R1 when R1 pulled the vent off the radiator in the room, R1 then turned to V5 and began to wave the object in front of V5's face while saying I will cut you. V5 said, she yelled out for help and was asking R1 to put the object down and or give her the object. V5 said, R1 did not give her the object but then took the object and cut herself in the abdomen area. V5 said, R1 then dropped the object. V5 said, the nurse arrived and stayed with R1 while she went to call a code gray. V5 said, R1 needed 1 to 1 observation because R1 harmed herself in the past, by swallowing a key and cutting herself with a plastic spoon. On 7/21/2021 at 1:28PM, V5 (CNA) said, when she was monitoring R1, R1 walked to the nurse station, R1 stated, to V8 (Nurse) you have 10 minutes, V5 said, she did not know what R1 was talking about. V5 said, V8 told her to watch R1 closely as she continued to follow R1 to her room. V5 said, while in R1's room, V5 was sitting in a chair, she saw R1 standing at the window, R1 was leaning forward a bit. V5 said, she saw R1 hands moving near the radiator vent. V5 said, she stood up and walked toward R1's back, R1 continued to have hand movement while leaning toward the radiator vent. V5 said, she never asked R1 what she was doing, nor did she redirect R1 at that time. V5 said, she heard a click sound and that's when R1 turned around toward V5, R1 had the radiator vent in her hand and began to wave it at V5, while saying I will cut you b####. V5 said, she then asked R1 to put the object down and give it to her (V5). V5 said, R1 then raised her shirt and cut herself in the stomach area. V5 said that's when she yelled for help. V5 said, she did not yell for help prior to R1 cutting herself and she did not call code gray when she saw R1 by the window doing something with her hands When asked if R1 was trying to remove the radiator vent when V5 observed R1 moving her hands near the radiator vent V5 would not respond. On 7/20/21 at 1:20PM, V8 (Nurse) said, she arrived at the facility for her shift around 3:00pm on 7/14/2021, as she got on the elevator, V8, R1 and V5 got on with her. V8 said, she was informed by V5 that R1 needed 1 to 1 monitoring, V8 said, once on the 8th floor, she informed V5 to closely monitor R1 when they got off the elevator. V8 said, close monitoring and 1:1 observation is the same thing. V8 said, close monitoring and/ or 1 to 1 observation is when the staff keep an eye on the resident, the staff can sit outside the room or the staff can go in the room as long as they watch the resident. V8 said, maybe 15 minutes after 3:00pm, R1 and V5 approached the nurse station and R1 said you have 10 minutes to get me out of here or I will hurt myself V8 said, she told R1 okay, I'm working on it and you don't have to do that. V8 said, R1 and V5 returned to R1's room. V8 said she does not know if V5 was inside the room with R1 or standing on the outside of the door of R1's room. V8 said, she placed a call to the physician and the physicians plan was to petition R1 for evaluation and she was preparing the involuntary petition. V8 said, about 15 minutes later she heard V5 yelling out for help. V8 said when she went to R1's room, she observed R1 bleeding from the stomach area. V8 said R1 was bleeding bad there was a lot of blood, V8 said, she observed blood on R1's shirt, pants and the floor. V8 said, she saw a horizontal laceration to R1's stomach however she did not complete an assessment of the wound because R1 would not allow her to. V8 said, she then informed V5 to get help, and she heard V5 announce a code gray. V8 said, R1 would not put the sharp object down when she asked R1 to put the object down. V8 said, R1 waved the object in her face stating, I will cut you. V8 said, R1 did not put the sharp object down until the two male staff arrived and that's when R1 handed the object to V12 (Security). V8 said, R1 would not allow anyone from the facility to assess her injuries or render first aide, R1 continued to say do not touch me V8 said, she left the room and called 911. V8 said, the paramedics arrived and put R1 on the stretcher. V8 said, she does not know if the paramedics rendered first aide to R1. On 7/20/21 at 1:20PM V8 (Nurse) said, she knew R1 required 1 to 1 monitoring because she was informed of this and also, she used her judgement to determine R1 needed 1 to 1 monitoring because R1 has harmed herself about 3 times when she worked with R1. V8 said, R1 does not want to be in the facility, and she hurts herself when she wants to go back to the hospital. V8 said, she did not call code gray when R1 said, she was going to hurt herself. R1's local police report dated 7/14/2021 at 4: 47p.m. documents: Police were dispatched to a call of psychological evaluation at the facility. Local police dispatch advised that a resident cut herself in her stomach with a razor and still had it in her hand. Upon arrival, along with the local paramedics went to the eighth floor where the resident was located standing near security. The resident was identified as R1. V5 (CNA) advised that R1 had been discharged from hospital on the above date and was admitted to the facility. V5 stated that R1 appeared to be distraught upon arrival and aggressive. V5 advised that while in her room R1 began cutting herself with a razor. V5 provided the said razor, which in fact was an air vent from the room. The officer was able to locate the A/C unit in the room with the missing vent. As V5 walked into R1's room, she observed her cutting her lower stomach area and yelled at V5 to leave her alone. The air vent was ultimately removed from R1's hand before the police arrived. V5 further added that R1 has an extensive history in harming herself, as she was said to have swallowed pills, keys, and cut herself in the past. The officer took eight digital photographs of R1's room, the observed blood, air vent used to self-harm and A/C unit with missing vent. The photographs have been attached to the incident report. R1 was transported to local hospital for further medical treatment. On 7/20/21 at 5:50PM, the surveyor observed one picture in the police report of the object that R1 used to cut her abdomen. The picture showed a rectangular object which looked like the vent cover that was observed in the facility. The vent cover was noted to have coagulated blood near one corner of the surface which covered approximately a fourth of the vent cover. On 7/20/21 at 1:53 PM. while accompanied by V11 (Maintenance Director), the surveyor observed the radiator unit in R1's room listed on the incident report, there was a gray radiator /air conditioner unit noted in front of the window. The unit had 6 vents in place on top of the unit, there was an opening noted to the right of the unit (front facing). V11 said, there was a vent missing from the radiator/ air conditioner unit, V11 said, there's six vents and it should have seven vents on top, also there should be a door where the open area is on the unit. R1's Local hospital record dated 7/15/21 documents: R1 was admitted due to self-inflicted stab wound to abdomen with piece of furnace to a previous stab-wound site on abdomen. Under abdomen documents: 8cmx 2 cm x 3cm depth. On 7/20/21 at 4:34p.m V3 (Social Service Director) said 1 to 1 observation and close monitoring are two different types of observations. V3 said 1 to 1 observation (monitoring) is used when a resident threatens harm to self or others. V3 said, during 1 to 1 observations staff should be within arm's length of the resident. V3 said the staff should have visual control of the resident, they should be able to see what the resident is doing with their hands, staff must accompany the resident at all times and if the staff needs a relief, the staff must wait for coverage, staff should never leave the resident alone. V3 said close monitoring are frequent rounds, staff does not have to stay with the resident at all times. V3 said he does not know how often staff should conduct rounds during close monitoring observations. V3 said staff is trained in CPI (Crisis Prevention Intervention), CPI is a non-violent crisis intervention used to deescalate a situation with a resident. V3 said CPI is used when the resident is past the point of de-escalation, when resident physically act out towards others, when residents try to harm themselves or others. V3 stated when a resident says they will hurt themselves, staff should seek help from the social worker, the social worker will then counsel the resident, and the social worker would get the nurse involved to contact the physician for orders. V3 said R1 has known behaviors of hurting herself. V3 said R1 required 1 to 1 observation because of her behaviors of self-harm. V3 said he was not there when the incident occurred but what he understands is that R1 was on 1:1 observation when R1 removed an object from the A/C unit in her room and cut her abdomen with the object. V3 said the facility failed R1 during this 1 to 1 observation because R1 cut herself while she was on a 1 to 1 observation. V3 said R1 should not have any sharp objects in her room or in her possession, nor can she have any objects that she can use to inflict harm to herself with. V3 said R1 is a danger to herself and others. On 7/21/21 at 11:19a.m V3 said it is difficult for the facility to conduct assessment on R1's behaviors, triggers and manage her because R1 usually is discharged shortly after her admissions to the facility. V3 said the 8th floor where R1 resides has not had a social worker for 2 months, V3 said he just acquired that unit along with his assistant. V3 said R1 is managed with 1 to 1 observation. V3 said the facility has given R1 a 30-day notice. On 7/20/21 at 12:30PM V4 (Social Service Assistant) said he was informed that R1 cut herself with a sharp object that she removed from the air conditioning unit in her room. V4 said R1 has behaviors of self-harm. V4 said R1 requires 1 to 1 observation at all times because of her behavior of self-harm. On 7/20/21 at 3:15p.m V10 (ADON- Assistant Director of Nursing) said the facility does not have a policy for 1 to 1 observation. V10 said, 1 to 1 monitoring/observation are for residents that are at risk for self-harm or harm to others. V10 said when a resident is on 1 to 1 observation the staff should be within arm's length of the resident, the staff should be in eye view of the resident and be able to see what the resident is doing with their hands, V10 said the staff should be able to touch, grab and intervene if something happens. V10 said 1 to 1 observation are conducted to prevent the resident from harming themselves and others. V10 said when V5 saw R1 standing at the window and moving her hands near the radiator vent she would have expected V5 to redirect R1, ask R1 what she was doing and also to redirect her to stop what she was doing, V10 said she would not have expected V5 to call a code gray unless R1's behavior was escalating. R1's hospital record dated 7/14/21 at 920AM documents under psychiatric progress note history R1 more towards baseline. She does have 2 sitters because she's very impulsive. Under short term goals dated 7/13/21 documents: Self injury-R1 seems to be injuring herself for strategic purposes that are unrelated to any suicide attempts or gestures. R1 purposely injures herself to this extent. Under 1:1 (monitoring) sitters- R1 has two sitters for 1:1 (monitoring), the physician has allowed her to use paper cups. Under contracting for safety- R1 is cooperative and pleasant but continues to behave in this manner and will remain on 1:1(monitoring) for safety precaution. R1's electronic records showed no documentation of a completed screening assessment for evaluating of self-harm/suicide risk and screening assessment for indicators of aggressive and/or harmful behavior from the initial date of admission on 5/12/21 to current admission of 7/14/21. On 7/21/2021 at 12:45p.m V3 (Social Service Director) said upon admission and readmission residents have a screening assessment for evaluating self-harm/suicide risk and for indicators of aggressive and/or harmful behavior. V3 said he did not observe an assessment conducted for R1. Facility undated policy titled, Guidelines for Handling and Addressing Behavioral Emergencies noted, in part the first step involves recognizing and handling the behaviors in the earliest stages, assess whether the anger/acting out is related to mental illness, dementia or other probable and perhaps transient factors. The escalating resident, staff need to be aware of how likely a resident is to lose control and exhibit a behavior- especially a behavior that might escalate- this comes from knowledge obtained on resident assessment as well as the care plan. It will need to be clear which staff member will be in-charge of escalation of behavior- the staff will follow the lead of the designated staff member in charge. Residents displaying a behavior need to have a staff member with them from time of the onset of the behavior until it is resolved or managed. This supervision maybe able to be reduced to lesser supervision such as every 15 minutes checks, depending on the ability of those involved to provide successful care and interventions to resolve the behavior. The duration of 1:1 supervision or every 15 minutes checks will be based on each individual resident/situation. Determine and define if there is history of aggressive and/ or unpredictable behavior. Attempts need to be made to quantify (measure) the resident level of upset or anger. Is the resident making threats or exhibiting motions that suggest they intend to inflict harm towards another person (s)? Immediately approaches, If the resident does not seem to start to calm down quickly call for assistance. If it appears that the resident is likely to harm themselves or others call a Code Gray This will alert available staff to come to assist as needed and also this notification lets staff know to deter residents from going to this area as well as alerting staff not to take any residents to that area. Remember there should be adequate staff dealing directly with the resident. Every resident behavior will be assessed and addressed individually. There is no standing program for behavior prevention. Be sure that the assessment and care planning and medication reviews as well as the individualized activity programs for residents with behavior issues are done accurately and timely. Facility policy titled Standard Supervision and Monitoring dated 6/10/20 noted in part these guidelines emphasize a proactive intervention promoting enhanced physical and psychological well-being. The facility recognizes supervision and guidance to the resident is an essential part of nursing care in which standard approaches are successful in meeting the resident's physical and psychosocial needs. At any time that the resident is being supervised or redirected during, the direct care staff member may need to redirect the resident through verbal and physical guidance and or care. If the resident cannot be guided, supervised, or redirected during intervals of rounds the resident may require 30-minute, 15-minute, or 1:1 supervision. The physician/ psychiatrist will be notified for further evaluation and treatment to further assess and treat the resident if increased supervision and guidance is required.

Based on interview and record review, the facility failed to prevent a cognitively impaired resident (R2) from being coerced by another resident (R3) to perform an oral sex act on him, failed to prevent a female resident (R11) from being inappropriately touched by a male resident (R12) and failed to prevent a resident (R6) from being physically and mentally abused by facility's security staff members (V38, V39), as outlined in the facility's abuse policy. This applies to 3 of 6 residents (R2, R6, R11) reviewed for abuse. As a result, R2 was allowed to engage in a sexual act without knowing the consequence of her actions, R11's was forced to experience a violation of her personal space and body and R6 was pushed, threatened and subjected to the use of inappropriate language. Findings include: R2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Brief Interview for Mental Status (BIMS) dated 7/3/21 documents a score of five which indicates severe cognitive impairment. R2's Care Plan dated 7/16/21 documents: R2 demonstrated cognitive impairment related to mental illness. Nursing note dated 7/3/21 documents: Approximately 9:45pm, R2 was observed in room with a co-resident. R2's face was toward R3's private area. On 8/4/21 at 1:15pm, R2 who was assessed to be confused was unable to report, or even answer questions about the incident dated 7/3/21. On 8/6/21 at 2:14pm: V4 (Social Service Assistant) said, R2 is confused and cannot make her own decisions. On 8/10/21 at 12:13am, V1 (Administrator) said, V5 (Certified Nurse Aide/CNA) walked into R2's room, observed R2 looking at R3's private area. I spoke with R3 who said, R2 performed oral sex on R3. We substantiated the allegation of abuse. On 8/13/21 at 1:31pm, V51 (PRSC) said, R2 is not able to make decision for herself. R2 is not able to give consent for sexual activities nor would I call R2's family for consent for R2 to have sex. A BIMS score determines the cognitive level of a resident. A BIMS score of 00-07 requires full assistance with decision making. The decision making is done by the Power of Attorney (POA)/Guardian. Facility reportable incident sent to IDPH dated 7/3/21 documents: R2 was observed in the room with R3 with face towards R3's private area. Hospital paperwork dated 7/3/21 document: R2 was discharged to the hospital for inappropriately touching a male resident. R3 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Brief Interview for Mental Status dated 6/8/21 documents a score of fifteen which indicates cognitively intact. Care plan dated 7/20/21 documents: R3 exhibits sexually inappropriate behaviors manifested by attempting to take advantage of peers who lack ability to consent. R3 who was observed and assessed to be alert to person, place and time during the investigation. On 8/3/21 at 11:56am, R3 said, I put my penis in R2's mouth. It was consensual. R2 performed oral sex on me. Transfer form dated 7/3/21 documents: Behavior- R3 touched co-resident inappropriately, placed on 1:1, R3 sent to hospital for evaluation. Hospital paperwork dated 7/4/21 documents: R3 was sent to the hospital for inappropriate touching another female resident. Police report dated 7/15/21 documents: R3 admitted to allegedly having sexual contact with a co-resident (R2) on 7/3/21. Reportable Incident dated 7/3/21: Addendum 7/15/21: R3 reported that he had allegedly had a consensual sexual relationship with R2. R11 was admitted to facility on 2/12/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's Brief Interview for Mental Status dated 7/29/21 documents a score of 15/15 which indicates cognitively intact. R11's progress note dated 7/13/21 documents: R11 was in the dining area wiping off tables when she was touched inappropriately by a peer. On 8/3/21 at 11:10 am, R11 who was alert and oriented at time of interview said, a male resident touched her buttocks while she was in the dining room. R11 said anyone that touched her inappropriately without her consent is in violation of her personal space. On 8/4/21 at 2:40pm, V17 (Psych Tech) said, he witnessed R11 in common dining room and R12 touched her buttocks. V17 said he separated the residents and informed nurse. Facility's final abuse report dated 7/18/21 documents under conclusion: It was reported R12 allegedly touched R11 in an inappropriate manner. R12 stated he did not want to talk about it. R11 stated R12 tapped her on the behind as he was walking past. Staff that was present also stated that he tapped her as he was walking past R11 and that R12 was redirected immediately. Under witness statement for R12 documents: R12 stated he doesn't know why he touched R11's behind when walking past her. R12 said he was very sorry. R12 was admitted to facility on 4/14/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's Brief Interview for Mental Status dated 7/28/21 documents a score of 15/15 which indicates cognitively intact. R12's progress note dated 7/13/21 documents: R12 was observed by staff touching female peer on buttocks in dining room. Per R12 I need some p****. Resident separated for safety. On 8/3/21 at 4:01pm, R12 who was alert and oriented to self, said he grabbed a resident's butt on the 4th floor, and she slapped him. R12 refused to give any further details. On 8/4/21 at 2:40pm, V17 (Psych Tech) said he witnessed R11 in common dining room and R12 touched her buttocks. V17 said he separated the residents and informed nurse. R12's local hospital record dated 7/13/21 documents under patient notes: When asked why R12 was sent to the hospital, R12 stated I touched other patients butt and I regret what I did. I did not know why I did it. Facility's final abuse report dated 7/18/21 documents under conclusion: It was reported R12 allegedly touched R11 in an appropriate manner. R12 stated he did not want to talk about it. R11 stated R12 tapped her on the behind as he was walking past. Staff that was present also stated that he tapped her as he was walking past R11 and that R12 was redirected immediately. Under witness statement for R12 documents: R12 stated, he doesn't k now why he touched R11's behind when walking past her. R12 said, he was very sorry. R6 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Minimal Data Set (MDS) dated [DATE] Brief Interview for Mental Status documents a score of thirteen which indicated cognitively intact. Nursing note dated 7/27/21 documents: R6 alleged he was verbally abused in the elevator by staff. R6 reported staff used swear words at him. On 7/30/21 at 2:37pm, R6 who was assessed to be alert to person, place and time said, I was getting on the elevator, when V39 (Security) pushed me and said, get your as* off the elevator. V38 (Security) stepped off the elevator and said, Nigg** I'm going to beat your as*. We stood in a fighting stance face to face. On 8/10/21 at 12:13pm, V1 (Administrator) said, V38 was terminated for verbal abuse toward R6. On 8/17/21 at 2:26pm, V39 (Security) said, I did not speak inappropriately to R6. V38 (Security) got off the elevator and told, R6 he would whip his as*. V38 (Security) stood face to face with R6 in a fight stance. Final reportable incident dated 7/27/21 documents: V38 and V39 spoke inappropriately to R6. R6 was concerned with V38 who appeared to be aggressive. V39 said, V38 spoke inappropriately to R6. V39 was allowed to return to work and will be assigned to a different floor than R6. V38 will not be returning to the facility. Employee Disciplinary Action Form dated 8/3/21 documents: V38 (Security) failed to follow employee handbook category 1 number 1 stating resident abuse (verbal or physical) for incident that happened on 7/27/21. Employee will be terminated without any privileges to be rehired. Employee handbook documents: Category 1 offenses are most serious and subject to the employee's immediate discharge without rehire privileges. The following are category 1 offenses: #1. Resident abuse (verbal or physical). V38 was unable to be reached during this survey. Facility policy titled Abuse prevention program revised 9/17/21 documents: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility. Abuse: The willful infliction of injury. Unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Verbal Abuse: any use of oral, written or gestured language that included disparaging and derogatory terms to resident or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability.

Based on observation, interview and record review, the facility failed to monitor and supervise residents to prevent unsupervised smoking in the building and to prevent contraband smoking materials from coming into the facility (R8, R23), failed to provide a safe environment by leaving electrical wires exposed and maintain safe electrical outlets in resident's room (R27, R28, R29, R30, R32, R33, R34, R35, R36, R37), and allowed residents to put foil into electrical outlets to ignite a spark to light smoking materials (R8, R23, R31). On 8/12/21 this was identified as an immediate jeopardy situation that began on 08/03/21 and was removed on 08/20/21. V1 (Administrator) was informed of the immediate jeopardy on 08/12/21. The immediacy was removed on 08/20/21, but the deficiency remains at a level 2 harm, until the facility can evaluate the effectiveness of the interventions implemented. Findings include: R8 was admitted on [DATE] with a diagnosis of [CONDITION(S)]. R8's progress note dated 7/12/21 documents: resident noted with broken electric cables attempting to ignite fire to light a cigarette butt. R8's progress note dated 7/26/21 documents: using improvised devices to light fire in the bedroom, danger to self and others. Transferred to hospital. R8's petition dated 7/26/21 documents: using electrical cables to set fire in the bedroom. R8's hospital record dated 7/26/21 documents: R8 stated, I was trying to use the electrical cords to light toilet paper so I can smoke weed and crack. Hospital record dated 7/27/21 documents positive finding of cannabis. On 7/26/21, R8 said he was trying to light a cigarette by using the electrical wires from the over the bed light in his room. R8 said he removed the wires but was unable to describe how he removed the wires. R8 said he put the wires into the electrical outlet and had toilet paper near the outlet to catch fire to light his cigarette. R8 said he had a cigarette from a previous smoke break. R8 then demonstrated how he lit the cigarette, R8 sat on the floor near the electrical outlet and pulled the privacy curtain near the outlet. R8 put his face near the outlet to catch the flame. R8 said this time the privacy curtain was too close to the outlet and was set on fire. R8 had to put it out with his hands and wet towel. On 8/10/21 at 3:21pm, R8 said he called a suppler (R8 refused to give name or description) who would meet him in the common outside patio, where he would receive marijuana. R8 said he would return into the building and was never searched or questioned. On 8/3/21 at 3:30pm, R8's previous room was observed with black soot around one outlet. The electrical outlet was observed with an object sticking out which was confirmed by V11 (Maintenance Director) to be a piece of foil. V11 and V35(Maintenance) said they were unaware of any concerns related to the electrical outlets in R8's room but residents in the building will stick things in the outlets to ignite a spark so they can light a cigarette R8's smoking assessment dated [DATE] documents: May not be capable of handling/carrying any smoking materials and requires supervision when smoking. R23 was admitted on [DATE] with a diagnosis of [CONDITION(S)] Disorder, [CONDITION(S)], and Asthma. R23's smoking assessment dated [DATE] documents: May not be capable of handling/carrying any smoking materials and requires supervision when smoking. R23's care plan dated 12/24/20 documents: R23 as an identified offender with history of aggravated arson 1996 and considered high risk. R23's progress notes dated 7/26/21 and 7/27/21 document had no unsafe use of electrical wire by V37(Nurse). R23's progress note dated 8/8/21: R23 using cables to light cigarettes in R29-30's room. On 8/10/21 at 4:30pm, V37 said R23 was in the room when the incident with R8 happened on 7/26/21, but was unable to provide any other information related to incident. R23 was unable to provide any additional information about incidents and denied any involvement. On 8/5/21 at 4:45pm, R23's room was observed with black soot around one outlet in the room. The hospital bed in the room was observed with cord that had been cut with exposed wires. V11(Maintenance Director) said the outlet had black soot around it which indicates that something was placed in the outlet causing a spark. V36 (Maintenance) said that this behavior is happening all over the building and residents are using foil from food deliveries to stick in the outlets to light cigarettes. On 8/6/21 at 12:34 pm, R27-28 room had two over the bed light frames on the wall. Within the frame of the lightening device there were two electrical outlet plugs that had black soot on them. At 12:44pm, R29-R30's room was observed with two exposed wires from the over the bed the light and one electrical outlet with black soot. At 12:51pm, R31's room had one outlet with black soot and small piece of foil, observed along with exposed wires from the over the bed light. At 1:06pm, V11 confirmed that it was a piece of foil in the outlet in R31's room. At 1:12pm, R35's room had exposed wires from one of the over the bed lights. At 1:14pm. R32-33's room had paper stuffed into the electrical outlet and exposed wires from one of the over the bed lights. At 1:15pm, R34's room was observed with four exposed wires from the over the bed light and one electrical outlet with black soot. At 1:20pm, R36-37 had two exposed wires from the over the bed lights. On 8/10/21 at 2:04pm, R29-30's room had an outlet blackened with soot with a small object within the outlet. On 8/19/21 10:50am, R27-R28's room was observed with soot covered outlets and two lightening fixtures over the bed which had been previously observed on 8/6/21. At 11:02am R29-R30's room had new observations of foil and an unknown object protruding from one ceiling outlet. On 8/5/21 at 1:47pm, V11 (Maintenance) said he has been at facility for about 2 months. V11 said about a month ago residents removed fire lights in a bathroom on the 5th floor. V11 stated staff do not report when these incidents occur. Maintenance staff will find outlets burnt or cut electrical cords from televisions or over the bed lights randomly. V11 said they do not do any daily inspections because there is not enough staff. V11 said he has replaced about 20 outlet covers in 2 months but unable to provide any record of replacements or where they were replaced. On 8/10/21 at 10:00am, V11 said he was aware that there was a concern related to residents placing cords/foil in the outlets. V11 stated there is a possibility of fire if the breaker does not cut the power supply to the outlet. It is possible to get an electrical shock from the outlet if placing objects into the wall but V11 states he has not seen or heard of anyone getting hurt. V11 said they have not done any audits of the rooms but claimed to be placing wall plates over the outlets since June. When asked what rooms they were placed in, V11 was unable to recall specific rooms, unable to produce a log of replacements or receipts of purchases of items. V11 said he has replaced a cover on 8/6/21 on the seventh floor. On 8/10/21 at 10:25am, V35(Maintenance) said he has not placed any wall plates on outlets but replaced the outlet cover in R29's room on 8/3/21. On 8/10/21 at 10:34am, V36(Maintenance) said he has only placed one wall cover on 8th floor. On 8/11/21 at 204PM, V55 (Electrician) said he has never heard of foil being placed in outlets not sure what will happen. If there are observations of blackened areas around the outlet, it indicates there was some kind of fire near the outlet. In most cases the circuit breaker will trigger which will turn off the power supply to prevent fires or electrocution but there is always a chance that someone could be injured. Facility policy titled: Physical plant weekly inspections undated documents under electrical inspections: All receptacles and switches shall be inspected for cracks, condition of cover plates and any signs of shorts. 8/6/21 at 2:14pm, V4(APRSD) said all smoking materials are held by staff and no resident is allowed to smoke independently. Facility policy titled smoking policy undated documents: There will be no smoking permitted inside the facility. All resident smoking material will be kept by the facility in a secure location. All smoking remnants will be discarded into approved receptacle by staff or under staff supervision. Residents will have no smoking materials in their possession. Facility policy titled Search and Confiscation Policy undated documents: The facility has right to search belongings and person if there is reasonable suspicion that contraband is being brought into the facility. Items that are considered harmful or unsafe for the resident will be destroyed. Prohibited items include but not restricted to the following list: cigarettes, cigars, loose tobacco, lighters, sharps, razors, scissors, knifes or items considered a possible danger. On 08/19/21 the surveyors verified by observations, record review and interview that the facility implemented the following to remove the immediacy: A Resident who has a history of behaviors that may potential place themselves or others at risk by placing items electrical outlets for the purpose of starting fires to ignite contraband will have interventions put in place to prevent these behaviors. Social Service will conduct a smoking risk review of those residents in the facility that are smokers. Psychiatrist/Psychologist/ Psychiatric Nurse Practitioner (NP) will assess resident R8 and R23 to determine if the resident can be managed safely in the facility. Resident R23 was sent to the hospital relating to behaviors on 8/13/21 and remains in the hospital at this time. Resident R8 has been evaluated by Psychiatric NP on 8/13/21. One to One monitoring will remain in place for R8 and R23 until they are determined to no longer be a threat to themselves or others. The IDT (Interdisciplinary Team) members which includes Administrator, DON (Director of Nursing) ADON (Assistant Director of Nursing), NP (Nurse Practitioner), PCP, Psychiatrist and Social Service Team determine when one to one monitoring can be decreased, or hospitalization is required. On 8/24/21 the surveyor verified by observation, record review and interview that the facility implemented the following to remove the immediacy: The system revisions initiated on 8/12/21: Residents that are smokers in the facility will have a smoking risk review completed by the social service team under the guidance and assistance of the social service consultant. This will be completed by the Social Service Team members. The smoking risk assessment has been initiated immediately today 8/12/21 and will be completed by 8/13/21. R8 and R23 have had a care plan revision and interventions put in place on 8/12/2021. The facility instituted one to one to for R8 and R23 until residents have been assessed to no longer display these maladaptive behaviors and if unable to maintain their safety or others safety they will be assessed if hospitalization is appropriate. There have been 5 other residents identified that have displayed the maladaptive behaviors of using wires to light their contraband. The residents that display this maladaptive behavior have been placed in 2 designated rooms with group supervision. They are being overseen by the psychological team to monitor and address the behavior. The 7 residents identified will meet with Social Service and the Administrator to review the Smoking Policy and Smoking Contract. Maintenance Director has replaced outlets to 20-amp Tamper resistant Outlets for the rooms that R8 and R23 are located. The facility will continue to replace the outlets on the 7th floor which has higher risk behavioral residents. The 7th floor audit of the sockets and exposed wires was completed on 7/28/21. The number of sockets that have been replaced are 29 as of 8/13/21. The Maintenance Department is currently completing an entire facility audit to assess for any further socket's requiring replacement and light fixtures with exposed wires. This audit will continue until [DATE]. All the fixtures and sockets in the rooms are being evaluated as well and replaced with tamper resistant outlets. The striping or removing the wires has not been identified yet for those residents displaying this behavior as they are unwilling to cooperate with the investigation. A few residents are utilizing their teeth as seen with marks on plastic coating and no one has indicated what else they are using. The residents also refuse to indicate how the wires are stripped. All nursing staff which includes Licensed Nurses, Registered Nurses, Certified Nursing Assistants and other facility staff such as: Social Service Team members, Escorts, Psych Techs, Security, Resident Assistants, Activity Aides, Smoke Monitors, Administrators and Assistant Administrators will be in serviced on one-to-one policy by the Regional Nurse Consultant, DON, and ADON. In-service on one-to-one policy began 7/29/21 and will be completed by 7/30/21.Staff that are not able to attend in person in-service will be in-serviced via phone and next day return to work will sign off on the in-service. Newly hired employees will be trained on One-to-One policy and CPI registration as part of new employee training. Evaluation on understanding of One to One see attached quiz The entire team as listed above is responsible for assisting with providing one to one understanding the process of why a one to one may be required for some residents. The team members are also responsible for identifying behaviors that residents maybe displaying and bringing it to the attention of an IDT member. Behavioral programming will include the following with emphasis on maladaptive behaviors relating to safety. The resident has a psychiatric diagnosis (es) and may benefit from skills training. The resident requires attention in the priority skill areas: Symptom management - symptom monitoring, increased self-knowledge, self-awareness, understanding personal stressors, coping strategies, stress management, impulse control, medication management, self-medication, and relapse prevention. The resident will engage in skills training behavior as evidenced by participation in supportive group programming via groups, 1:1 licensed therapeutic counseling, psychiatric follow up and compliance with medication regimen inventions to be implemented 1. Conduct an appropriate skill needs/level of functioning. 2. Teach skill development addressing socially inappropriate and/or maladaptive/ disruptive via group and/or individual formats (i.e.: licensed counselor and psychiatrist) on a routine, schedule frequency. 3. Use skill generalization techniques in which new skills are introduced gradually, explained clearly and participants are enabled to practice each skill. 4. Intervene when I am observed to display any inappropriate behavior. Communicate that I am responsible for exercising control over my own impulses and behavior (Social Skills training). 5. As warranted conduct: Random room safety checks, personal wellness check, mouth check during medication pass, behavior monitoring, evaluation of mental status, mood state and thought content. 6. Provide me with initial psychiatric management to monitor my psycho-active medications, provide support and enhance structure. Inform my psychiatrist of progress, stabilization, or regression. These group and individual programs will be conducted by the outside psychologist group and in-house social service team. Newest updates from 8/19/21: Updates specific to the Outlets. The RDO (Regional Director of Operations) has created the floor plan grid specific to all outlets in the rooms corridor and is systematically checking off on floor plan what outlets have been completed. The priority floor is the 7th floor where residents with these behaviors are currently located. There is a specific employee who is designated to being responsible for assigning the one-to-one monitors or group monitor for the facility. There has been a Monitoring Tech Job Description created which staff assigned to this position will be educated on the expectations of the job. Newest Updates from 8/24/21: Updates specific to the entire 7th floor and 5th floor The light sockets that were identified on 8/19/21 identified to be obstructed with debris was removed on 8/19/21. The 7th floor sockets have been replaced and/or covered with plate covers as 8/20/21 All outlets on the 7th floor unit have been secured. Residents noted with the maladaptive behaviors have been identified and have been placed on group monitoring, this was completed on 8/20/21. Based on observation, interview, and record review the facility failed to have an effective 1:1 monitoring system in place, failed to implement their crisis prevention intervention protocol to de-escalate an incident of self-injurious behavior for 1 of 1 residents (R1) reviewed for supervision. This failure resulted in R1 being able to pry off a heating vent and stabbing herself in the abdomen while under 1:1 supervision by facility staff and R1 to being sent to the local hospital for treatment. On 7/28/2021 this was identified as an immediate jeopardy situation that began on 07/14/21 and was removed on 07/30/21. V1 (Administrator) was informed of the immediate jeopardy on 07/28/21. The immediacy was removed on 07/30/21, but the deficiency remains at a level 2 harm, until the facility can evaluation the effectiveness of the interventions implemented. Findings include: R1 admitted to facility on 5/12/21 with diagnoses of [CONDITION(S)] Disorder, Major Depressive Disorder, [CONDITION(S)], Unspecified [CONDITION(S)], Paranoid Personality, Delusional Disorder, Auditory Hallucinations, and Post Traumatic Disorder. R1's plan of care dated 6/12/2021 shows R1 has a history of self-harmful & self-mutilation ideation (thoughts) and/or behavior. R1's interventions dated 6/7/21 include: As warranted, conduct, random room safety checks, personal wellness checks, and behavior monitoring of resident. Interventions dated 5/21/21 include conduct appropriate assessments upon admission. Review transfer record, including screening to determine any history of self-harm; encourage resident to seek help of staff when in distress. Facility incident report dated 5/21/2021 documents: An incident occurred in R1's room, R1 admitted to stabbing herself with a pen. A complete body assessment revealed pen stuck in resident stomach. 911 called. No witnesses found. Facility incident report dated 6/4/2021 documents: An incident happened in R1's room. R1 observed with open area to abdomen and small amount of bleeding noted. R1 had broken pieces of pencil in her hand. R1 stated she stuck a pencil in her stomach. Facility incident report dated 6/17/2021 documents: An incident occurred in R1's room, call to room by CNA, R1 stated she swallowed a key. No witnesses. Facility incident report dated 6/30/2021 at 12:54 AM documents: An incident occurred in R1's room. R1 was noted with self-inflicted skin tears on left wrist and lower abdomen with plastic spoon. R1 stated, I do not want to be here, just take me to the hospital.911 called. No witnesses found. Progress note dated 7/14/21 documents: R1 was readmitted to the facility from local hospital around 1:00PM. Progress notes dated 7/14/2021 at 17:32 documents: V8 Nurse was doing petition to send R1 to hospital. R1 stated she was giving V8 ten minutes to get R1 out of the building. I sent V5 (CNA) to closely monitor. V5 (CNA), yelled for (V8) to come to R1's room. V8 observed blood coming from R1's abdomen. R1 had a sharp object in her hand. V8 stated I tried to get R1 to give me the object, R1 tried to cut me with the object. I called security to get the object. A facility incident report dated 7/14/2021 documents: At 4:45pm, V8 was preparing petition to send R1 to the hospital, V5 (CNA-Certified Nursing Assistant) placed at room to closely monitor R1. Witness statement from V5 documents: R1 grabbed a sharp object when I tried to take the object R1 started to cut at me with it. Then R1 took the object and cut her stomach. Witness statement from V8 documents: Observed R1 with blood coming from her stomach. R1 had a sharp object when I tried to take it from her, the resident tried to cut me with it and said she will cut my throat with it. On 7/20/21 at 5:04p.m. V5 said she was told by the nurse that R1 needed 1 to 1 monitoring, V5 said, she was in the room standing behind R1 when R1 pulled the vent off the radiator in the room, R1 then turned to V5 and began to wave the object in front of V5 face while saying I will cut you. V5 said, she yelled out for help and was asking R1 to put the object down and or give her the object. V5 said, R1 did not give her the object but then took the object and cut herself in the abdomen area. V5 said, R1 then dropped the object. V5 said, the nurse arrived and stayed with R1 while she went to call a code gray. V5 said, R1 needed 1 to 1 observation because R1 harmed herself in the past, by swallowing a key and cutting herself with a plastic spoon. On 7/21/2021 at 1:28PM, V5 said, when she was monitoring R1, R1 walked to the nurse station, R1 stated, to V8 you have 10 minutes, V5 said, she did not know what R1 was talking about. V5 said, V8 told her to watch R1 closely and she continue to follow R1 to her room. V5 said, while in R1's room, V5 was sitting in a chair, she saw R1 standing at the window, R1 was leaning forward a bit. V5 said, she saw R1 hands moving near the radiator vent. V5 said, she stood up and walked toward R1's back, R1 continued to have hand movement while leaning toward the radiator vent. V5 said, she never asked R1 what she was doing, nor did she redirect R1 at that time. V5 said, she heard a click sound and that's when R1 turned around toward V5, R1 had the radiator vent in her hand and began to wave it at V5, while saying I will cut you b####. V5 said, she then asked R1 to put the object down and give it to her (V5). V5 said, R1 then raised her shirt and cut herself in the stomach area. V5 said that's when she yelled for help. V5 said, she did not yell for help prior to R1 cutting herself and she did not call code gray when she saw R1 by the window doing something with her hands When asked if R1 was trying to remove the radiator vent when V5 observed R1 moving her hands near the radiator vent V5 would not respond. On 7/20/21 at 1:20PM, V8 said, she arrived at the facility for her shift around 3:00pm on 7/14/2021, as she got on the elevator, V8, R1 and V5 got on with her. V8 said, she was informed by V5 that R1 needed 1 to 1 monitoring, V8 said, once on the 8th floor, she informed V5 to closely monitor R1 when they got off the elevator. V8 said, close monitoring and 1:1 observation is the same thing. V8 said, close monitoring and/ or 1 to 1 observation is when the staff keeps an eye on the resident, the staff can sit outside the room or the staff can go in the room as long as they watch the resident. V8 said, maybe 15 minutes after 3:00pm, R1 and V5 approached the nurses' station and R1 said you have 10 minutes to get me out of here or I will hurt myself V8 stated, she told R1 okay, I'm working on it and you don't have to do that. V8 said, R1 and V5 returned to R1's room. V8 said she does not know if V5 was inside the room with R1 or standing on the outside of the door of R1's room. V8 said, she placed a call to the physician and the physicians plan was to petition R1 for evaluation as she was preparing the involuntary petition. V8 said, about 15 minutes later she heard V5 yelling out for help. V8 said when she went to R1's room, she observed R1 bleeding from the stomach area. V8 said R1 was bleeding bad there was a lot of blood, V8 said, she observed blood on R1's shirt, pants and the floor. V8 said, she saw a horizontal laceration to R1's stomach however she did not complete an assessment of the wound because R1 would not allow her to. V8 said, she then informed V5 to get help, and she heard V5 announce a code gray. V8 said, R1 would not put the sharp object down when she asked R1 to put the object down. V8 said, R1 waved the object in her face stating, I will cut you. V8 said, R1 did not put the sharp object down until the two male staff arrived and that's when R1 handed the object to V12 (Security). V8 said, R1 would not allow anyone from the facility to assess her injuries or render first aide, R1 continued to say do not touch me V8 said, she left the room and called 911. V8 said, the paramedics arrived and put R1 on the stretcher. V8 said, she does not know if the paramedics rendered first aide to R1. On 7/20/21 at 1:20PM V8 said, she knew R1 required 1 to 1 monitoring because she was informed of this and also, she used her judgement to determine R1 needed 1 to 1 monitoring because R1 has harmed herself about 3 times when she worked with R1. V8 said, R1 does not want to be in the facility, and she hurts herself when she wants to go back to the hospital. V8 said, she did not call code gray when R1 said, she was going to hurt herself. R1's local police report dated 7/14/2021 at 4: 47p.m. documents: Police were dispatched to a call of psychological evaluation at the facility. Local police dispatch advised that a resident cut herself in her stomach with a razor and still had it in her hand. Upon arrival, along with the local paramedics went to the eighth floor where the resident was located standing near security. The resident was identified as R1. V5 devised that R1 had been discharged from hospital on the above date and was admitted to the facility. V5 related that R1 appeared to be distraught upon arrival and aggressive. While in her room, V5 advised that R1 began cutting herself with a razor. V5 provided the said razor, which in fact was an air vent from the room. Officer was able to locate the A/C unit in the room with the missing vent. As V5 walked into R1's room, she observed her cutting her lower stomach area and yelled at V5 to leave her alone. The air vent was ultimately removed from R1's hand before the police arrival. V5 further added that R1 has an extensive history of harming herself, as she was said to have swallowed pills, keys, and cut herself in the past. Officer took eight digital photographs of R1's room, the observed blood, air vent used to self-harm and A/C unit with missing vent. The photographs have been attached to the incident report. R1 was transported to local hospital for further medical treatment. On 7/20/21 at 5:50PM, the surveyor observed one picture in the police report of the object that R1 used to cut her abdomen. The picture showed a rectangular object which looked like the vent cover that was observed in the facility. The vent cover was noted to have coagulated blood near one corner of the surface which covered approximately a fourth of the vent cover. On 7/20/21 at 1:53 PM. while accompanied by V11 (Maintenance Director), the surveyor observed the radiator unit in R1's room listed on the incident report, there was a gray radiator /air conditioner unit noted in front of the window. The unit had 6 vents in place on top of the unit, there was an opening noted to the right of the unit (front facing). V11 said, there was a vent missing from the radiator/ air conditioner unit, V11 said, there's six vents and it should have seven vents on top, also there should be a door where the open area is on the unit. R1's Local hospital record dated 7/15/21 documents: R1 was admitted due to self-inflicted stab wound to abdomen with piece of furnace to a previous stab-wound site on abdomen. Under abdomen documents: 8cmx 2 cm x 3cm depth. On 7/20/21 at 4:34p.m V3 (Social Service Director) said 1 to 1 observation and close monitoring are two different types of observations. V3 said 1 to 1 observation (monitoring) is used when a resident threatens harm to self or others. V3 said, during 1 to 1 observations staff should be within arm's length of the resident. V3 said the staff should have visual control of the resident, they should be able to see what the resident is doing with their hands, staff must accompany the resident at all times and if the staff need a relief, the staff must wait for coverage, staff should never leave the resident alone. V3 said close monitoring are frequent rounds, staff does not have to stay with the resident at all times. V3 said he does not know how often staff should conduct rounds during close monitoring observations. V3 said staff is trained in CPI (Crisis Prevention Intervention), CPI is a non-violent crisis intervention used to deescalate a situation with a resident. V3 said CPI is used when the resident is past the point of de-escalation, when the resident is physically acting out towards others, when residents try to harm themselves or others. V3 said when a resident says they will hurt themselves, staff should seek help from the Social Worker, the Social Worker will then counsel the resident, and the Social Worker would get the nurse involved to contact the physician for orders. V3 said R1 has known behavior of hurting herself. V3 said R1 required 1 to 1 observation because of her behaviors of self-harm. V3 said he was not there when the incident occurred but what he understands is that R1 was on 1:1 observation when R1 removed an object from the A/C unit in her room and cut her abdomen with the object. V3 said the facility failed R1 during this 1 to 1 observation because R1 cut herself while she was on a 1 to 1 observation. V3 said R1 should not have any sharp objects in her room or in her possession, nor can she have any objects that she can use to inflict harm to herself with. V3 said R1 is a danger to herself and others. On 7/21/21 at 11:19a.m V3 said it is difficult for the facility to conduct an assessment on R1's behaviors, triggers and manage her because R1 usually is discharged shortly after her admissions to the facility. V3 said the 8th floor where R1 resides has not had a social worker for 2 months, V3 said he just acquired that unit along with his assistant. V3 said R1 is managed with 1 to 1 observation. V3 said the facility has given R1 a 30-day notice. On 7/20/21 at 12:30PM V4 (Social Service Assistant) said he was informed that R1 cut herself with a sharp object that she removed from the air conditioning unit in her room. V4 said R1 has behaviors of self-harm. V4 said R1 requires 1 to 1 observation at all times because of her behavior of self-harm. On 7/20/21 at 3:15p.m V10 (ADON- Assistant Director of Nursing) said the facility does not have a policy for 1 to 1 observation. V10 said, 1 to 1 monitoring/observation are for residents that are at risk for self-harm or harm to others. V10 said when a resident is on 1 to 1 observation the staff should be within arm's length of the resident, the staff should be in eye view of the resident and be able to see what the resident is doing with their hands, V10 said the staff should be able to touch, grab and intervene if something happens. V10 said 1 to 1 observations are conducted to prevent the resident from harming themselves and others. V10 said when V5 saw R1 standing at the window and moving her hands near the radiator vent she would have expected V5 to redirect R1, ask R1 what she was doing and also to redirect/stop what she was doing, V10 said she would not have expected V5 to call a code gray unless R1's behavior was escalating. R1's hospital record dated 7/14/21 at 920AM documents under psychiatric progress note history: R1 more towards baseline. She does have 2 sitters because she's very impulsive. Under short term goals dated 7/13/21 documents: Self injury- R1 seems to be injuring herself for strategic purposes that are unrelated to any suicide attempts or gestures. R1 purposely injures herself to this extent. Under 1:1 (monitoring) si [TRUNCATED]

Based on interview and record review, the facility failed to prevent a cognitively impaired resident (R2) from being coerced by another resident (R3) to perform an oral sexual act on him, failed to prevent a female resident (R11) from being inappropriately touched by a male resident (R12) and failed to prevent a resident (R6) from being physically and mentally abused by facility's security staff members (V38, V39), as outlined in the facility's abuse policy. This applies to 3 of 6 residents (R2, R6, R11) reviewed for abuse. As a result, R2 was allowed to engage in a sexual act without knowing the consequence of her actions, R11 was forced to experience a violation of her personal space and body and R6 was pushed, threatened and subjected to the use of inappropriate language. Findings include: R2 had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Brief Interview for Mental Status (BIMS) dated 7/3/21 documents a score of five which indicates severe cognitive impairment. R2's Care plan dated 7/16/21 documents: R2 demonstrated cognitive impairment related to mental illness. Nursing note dated 7/3/21 documents: Approximately 9:45pm, R2 was observed in room with a co-resident. R2's face was toward R3's private area. On 8/4/21 at 1:15pm, R2 who was assessed to be confused and unable to report, or even answer questions about the incident dated 7/3/21. On 8/6/21 at 2:14pm: V4 (Social Service Assistant) stated, R2 is confused and cannot make her own decisions. On 8/10/21 at 12:13am, V1 (Administrator) said, V5 (Certified Nurse Aide/CNA) walked into R2's room, observed R2 looking at R3's private area. I spoke with R3 who stated, R2 performed oral sex on R3. We substantiated the allegation of abuse. On 8/13/21 at 1:31pm, V51 (PRSC) said, R2 is not able to make decision for herself. R2 is not able to give consent for sexual activities nor would I call R2's family for consent for R2 to have sex. A BIMS score determines the cognitive level of a resident. A BIMS score of 00 -07 requires full assistance with decision making. The decision making is done by the Power of Attorney (POA)/Guardian. Facility reportable incident sent to IDPH dated 7/3/21 documents: R2 was observed in the room with R3 with face towards R3's private area. Hospital paperwork dated 7/3/21 document: R2 was discharged to the hospital for inappropriately touching a male resident. R3 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Brief Interview for Mental Status dated 6/8/21 documents a score of fifteen which indicates cognitively intact. Care plan dated 7/20/21 documents: R3 exhibits sexually inappropriate behaviors manifested by attempting to take advantage of peers who lack ability to consent. R3 who was observed and assessed to be alert to person, place and time during the investigation. On 8/3/21 at 11:56am, R3 said, I put my penis in R2's mouth. It was consensual. R2 performed oral sex on me. Transfer form dated 7/3/21 documents: Behavior- R3 touched co-resident inappropriately, placed on 1:1, R3 sent to hospital for evaluation. Hospital paperwork dated 7/4/21 documents: R3 was sent to the hospital for inappropriately touching another female resident. Police report dated 7/15/21 documents: R3 admitted to allegedly having sexual contact with a co-resident (R2) on 7/3/21. Reportable Incident dated 7/3/21: Addendum 7/15/21: R3 reported that he had allegedly had a consensual sexual relationship with R2. R11 was admitted to facility on 2/12/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's Brief Interview for Mental Status dated 7/29/21 documents a score of 15/15 which indicates cognitively intact. R11's progress note dated 7/13/21 documents: R11 was in the dining area wiping off tables when she was touched inappropriately by a peer. On 8/3/21 at 11:10 am, R11 who was alert and oriented at time of interview said, a male resident touched her buttocks while she was in the dining room. R11 said anyone that touched her inappropriately without her consent is in violation of her personal space. On 8/4/21 at 2:40pm, V17 (Psych Tech) said, he witnessed R11 in common dining room and R12 touched her buttocks. V17 said he separated the residents and informed nurse. Facility's final abuse report dated 7/18/21 documents under conclusion: It was reported R12 allegedly touched R11 in an inappropriate manner. R12 stated he did not want to talk about it. R11 stated R12 tapped her on the behind as he was walking past. Staff that was present also stated that he tapped her as he was walking past R11 and R12 was redirected immediately. Under witness statement for R12 documents: R12 stated he doesn't know why he touched R11's behind when walking past her. R12 said he was very sorry. R12 was admitted to facility on 4/14/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's Brief Interview for Mental Status dated 7/28/21 documents a score of 15/15 which indicates cognitively intact. R12's progress note dated 7/13/21 documents: R12 was observed by staff touching female peer on buttocks in dining room. Per R12 I need some p****. Resident separated for safety. On 8/3/21 at 4:01pm, R12 who was alert and oriented to self, said he grabbed a resident's butt on the 4th floor, and she slapped him. R12 refused to give any further details. On 8/4/21 at 2:40pm, V17 (Psych Tech) said he witnessed R11 in common dining room and R12 touched her buttocks. V17 said he separated the residents and informed nurse. R12's local hospital record dated 7/13/21 documents under patient notes: When asked why R12 was sent to the hospital, R12 stated I touched other patients butt and I regret what I did. I did not know why I did it. Facility's final abuse report dated 7/18/21 documents under conclusion: It was reported R12 allegedly touched R11 in an appropriate manner. R12 stated he did not want to talk about it. R11 stated R12 tapped her on the behind as he was walking past. Staff that was present also stated that he tapped her as he was walking past R11 and that R12 was redirected immediately. Under witness statement for R12 documents: R12 stated, he doesn't k now why he touched R11's behind when walking past her. R12 said, he was very sorry. R6 was admitted to the facility with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimal Data Set (MDS) dated [DATE] Brief Interview for Mental Status documents a score of thirteen which indicated cognitively intact. Nursing note dated 7/27/21 documents: R6 alleged he was verbally abused in the elevator by staff. R6 reported staff used swear words at him. On 7/30/21 at 2:37pm, R6 who was assessed to be alert to person, place and time said, I was getting on the elevator, when V39 (Security) pushed me and said, get your as* off the elevator. V38 (Security) stepped off the elevator and said, Nigg** I'm going to beat your as*. We stood in a fighting stance face to face. On 8/10/21 at 12:13pm, V1 (Administrator) said, V38 was terminated for verbal abuse toward R6. On 8/17/21 at 2:26pm, V39 (Security) said, I did not speak inappropriately to R6. V38 (Security) got off the elevator and told, R6 he would whip his as*. V38 (Security) stood face to face with R6 in a fight stance. Final reportable incident dated 7/27/21 documents: V38 and V39 spoke inappropriately to R6. R6 was concerned with V38 who appeared to be aggressive. V39 said, V38 spoke inappropriately to R6. V39 was allowed to return to work and will be assigned to a different floor than R6. V38 will not be returning to the facility. Employee Disciplinary Action Form dated 8/3/21 documents: V38 (Security) failed to follow employee handbook category 1 number 1 stating resident abuse (verbal or physical) for incident that happened on 7/27/21. Employee will be terminated without any privileges to be rehired. Employee handbook documents: Category 1 offenses are most serious and subject to the employee's immediate discharge without rehire privileges. The following are category 1 offenses: #1. Resident abuse (verbal or physical). V38 was unable to be reached during this survey. Facility policy titled Abuse prevention program revised 9/17/21 documents: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility. Abuse: The willful infliction of injury. Unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Verbal Abuse: any use of oral, written or gestured language that included disparaging and derogatory terms to resident or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability.

Based on interview and record review, the facility failed to protect R2's right to be free from physical abuse as evidenced by R2 being transferred to an acute care hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure applies to one (R2) of four residents reviewed for physical abuse. Findings include: R2 was in the hospital at the time of this survey. 6/22/2021 at 12:51 PM, a telephone interview was conducted with R2 regarding the incident that took place at the facility on the night of 6/20/21-6/21/21. R2 stated, I was new there, only 2 days. I didn't know nobody there. The man was sitting behind the desk, he was African American with brown skin. He hit me in the stomach with his face. Then twisted my wrist and fractured it. Nobody saw it, it was only him and me. He was mad at me the day before because I said I didn't want to stay there. I pushed the button on the wall to call 911. I didn't get his name. None of the people had name tags on or it was turned around. It happened about 2 or 3 in the morning. When I got up the next day to tell someone he was gone already. I talked to two women who were behind the desk. When I told them, they called 911? I'm not going back there. R2 was very confused about the timeframe of the events and could not give a clear time as to when incident occurred or specific time of when he actually reported the incident. Nursing progress note documents that V8 LPN (Licensed Practical Nurse) received report from R2 on 6/20/21 at 10:30 PM stating someone hit him and told him to stay in his room. V8 LPN completed a head to toe assessment observing discoloration to the right rib cage and swelling to the right hand and wrist. R2 complained of pain to hand and wrist but refused pain medication. V8 LPN notified R2's physician; order received for stat portable x-rays. Police report filed by V8 on 6/20/21 at 11:50 PM; reviewed, family notified. Progress notes from 6/21/21 at 02:48 AM indicate: V8 LPN notified R2's physician with the x-ray results. Mild distracted oblique fracture in the distal diaphysis of the ulna and mildly displaced right lateral 10th rib fracture. Received orders to send R2 to the hospital. Review of R2's care plan indicates he was not assessed at risk for abuse. 6/23/21 at 1:18 PM V5 ADON was interviewed regarding the abuse investigation. V5 ADON stated, Our investigation is still open, we are still interviewing staff that was on the floor. We have not identified the alleged perpetrator, but we have suspended a staff V3 LPN due to the description of the allegation. It is still under investigation. Review of R2's hospital records indicate: Review of the 6/21/21 CT (Computed Tomography) Scan of the wrist indicates: isolated distal ulnar fracture with minimal displacement. Review of the 6/21/21 x-ray of the rib's bilateral chest indicates fracture of the left anterolateral seventh rib. Review of the 6/21/21 x-ray of the right wrist indicates fracture of the distal ulna. 6/23/21 at 2:01 PM, V8 LPN stated, R2 came to me around 11PM and he said his hand was hurting and he pulled up his shirt and his side was discolored. His hand was swollen. He was holding his hand down, but he was able to move his fingers. I asked him if he wanted anything for pain because I didn't know what was going on. He said this man did it to me, it was the doctor who did it. R2 said the man who worked behind the desk with the same color uniform as you did it. A lot of the residents call the male staff doctors here. R2 said the man grabbed him by his arm and took him in the room and told him not to come out again, then head butted him in his side. 6/23/21 at 2:18 PM, V9 stated, it was later at night when I heard R2 tell the nurse someone did something to him. I was in the hallway monitoring. He said the doctor that works in the morning did it. 6/23/21 at 2:59 PM, V6 (Assistant Administrator) stated, R2 stated someone hit him. The resident said it was a doctor. He said the doctor had on blue. We didn't have any doctors in the facility that day. We discussed it with the team and nursing staff initiated our investigation getting social services involved doing well being checks. We interviewed V8 LPN who was his nurse that night and she provided more details that R2 said it was a man. He was sitting behind the nursing station and wears blue. With the new information V8 LPN provided, the nurse in question was suspended pending the investigation. 6/24/21 at 12:06 PM, V14 (Physician) stated, The CT (computed tomography) scan and x-rays both showed R2 had wrist and rib fractures. The treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Abuse can cause this type of fracture. The rib fracture can also happen if someone hit him. The revised 01/2019 Abuse Prevention Program states: Policy: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. Procedure: Any alleged violations involving mistreatment, abuse, neglect, exploitation, misappropriation of resident property, any injuries of unknown origin, or reasonable suspicion of a crime against a resident MUST be reported to the Administrator or Director of Nursing. The Administrator is the Abuse Coordinator of the facility. I. Pre-employment screening of potential employees. II. Pre-Admission screening of potential residents. III. Orientation and Training of Employees- -Sensitivity of resident rights and resident needs. -Staff obligations to prevent and report abuse, neglect, exploitation, mistreatment, any crime against abuse prevention. -How to assess, prevent, and manage aggressive, violent, and/or catastrophic reactions of residents in a way that protects both residents and staff. -How to recognize and deal with burnout, frustration and stress that may lead to inappropriate responses or abusive reactions to residents. -What constitutes abuse (physical, mental, sexual, verbal), neglect, exploitation, mistreatment, and misappropriation of resident property. IV. Reporting- employees are required to immediately report any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or a crime against a resident they observe, hear about, or suspect to the Administrator if available or an immediate supervisor who must immediately report it to the Administrator. V. Identification of Allegations/Internal Reporting Requirements VI. Investigation- Any incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident will result in an abuse investigation. VII. Protection of Residents- The facility will take steps to prevent mistreatment while the investigation is underway. Prevention- The facility desires to prevent involving abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident by establishing a resident-sensitive and resident-secure environment. Based on interview and record review, the facility failed to protect resident's rights to be free from mental abuse as evidenced by staff witnessed speaking inappropriately to residents. This failure resulted in the residents expressing feelings of fear and sadness. This failure applied to four (R3, R4, R5 & R6) residents reviewed for abuse. Findings include: 6/24/21 at 9:47 AM, V5 (ADON) stated, I was notified the next day from the administration. V13 Assistant PRSC (Psychiatric Rehabilitation Services Coordinator) was called to the unit to find out why the residents were having so many behaviors on that day to see what was going on. She became verbally aggressive towards the residents. V13 was terminated for violating the abuse policy. 6/24/21 at 9:59 AM, V6 (Assistant Administrator) stated, I was notified by V11 (Central Supply Manager). V11 said she witnessed V13 being verbally inappropriate with the residents. V13 was screaming and shouting and making threats to the residents on the unit. V13 was sent home immediately and the managers interviewed the residents to find out if anyone had been affected by her behavior. We had a conversation with the residents and there were four residents that were affected. All four consistently stated they didn't understand why V13 was talking to them like that and that they did not like how she spoke to them. R5 stated he was worried he would not get his pass to see his family. V13 was terminated for verbal abuse. V13 admitted to the conversation but not how she spoke to the residents. 6/24/21 at 10:37 AM, R5 stated, she (V13) was hostile and volatile when she addressed everyone. I got scared because she said she would shut down everything on the unit. I was scared that I was going to lose my privileges of socializing on the unit and not be able to smoke or be able to use my pass to see my family. 6/24/21 at 10:26 AM, R3 stated, V13 said she would shut down the whole floor, that she did it once and would do it again. She would shut down the smoking for the whole floor based on the actions of one person. She was yelling. Everybody on the floor could hear what she was saying. The staff just fail to communicate and have a lack of understanding. R3 was asked how V13 yelling made him feel. R3 stated, I just ignored her because based on something I say the staff will stick me with needles and send me out to the hospital. 6/24/21 at 10:49 AM, R4 stated, V13 came up to the floor saying if the floor gets out of hand again, we would not be able to smoke. She was yelling and screaming. I think V13 would have retaliated. It made me feel sad when she was raising her voice at me. I thought she would punish us all because she said she would. Personally, I got scared that whole day. Some of us look up to the staff and I think we have the right to get treated with respect and dignity. We feel let down because this is a person who we go to when we need something. 6/24/21 at 10:54 AM, R6 stated, V13 came up to the floor to find out what was going on. She said she would shut the whole unit's smoking down. We wrote statements about her. Her voice got louder and louder when she was talking. I felt kind of bad because she was going to shut down the smoking. I think she should have done something about the people who were doing it. She was trying to punish everybody. I felt it was unfair. 6/24/21 at 11:21 AM, V11 stated, I heard the commotion on 7th floor and thought something was going on with the residents and that's when I caught V13's voice. She was just screaming at the top of her lungs! She called the residents out of their room. She kept hitting the top of the nurse's station with her hand and telling them to cut down the radio. She told them to shut up and act like they have some sense. I will shut the whole 7th floor smoking down and no one will smoke. I've done it before and will do it again. She said she would not come up to the 7th floor again. She was talking to the residents like they were her children. I went to my administrators V6 and V14 and told them what happened. I could tell that R3 was upset. Her yelling was making the situation worse, she was stirring up the residents instead of asking them what was going on. R6 was agitated. R4 and R5 were all agitated. 6/24/21 at 1:00 PM, reviewed V13's Assistant PRSC Abuse Prevention Program Policy & Procedure form signed and dated on 2/20/20. Review of the Employee Disciplinary Action form signed by V6 dated 6/15/21 indicates: V13 failed to follow facility category 1 number 1 policy of verbal abuse. As a result, the employee will be terminated without rehire privileges. The revised 01/2019 Abuse Prevention Program states: Policy: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. Procedure: Any alleged violations involving mistreatment, abuse, neglect, exploitation, misappropriation of resident property, any injuries of unknown origin, or reasonable suspicion of a crime against a resident MUST be reported to the Administrator or Director of Nursing. The Administrator is the Abuse Coordinator of the facility. I. Pre-employment screening of potential employees. II. Pre-Admission screening of potential residents. III. Orientation and Training of Employees- -Sensitivity of resident rights and resident needs. -Staff obligations to prevent and report abuse, neglect, exploitation, mistreatment, any crime against the resident, theft and how to distinguish theft from lost items and willful abuse from insensitive staff actions that should be corrected through counseling and additional training. Staff should report their knowledge of allegations without fear of reprisal. -Dementia management and resident abuse prevention. -How to assess, prevent, and manage aggressive, violent, and/or catastrophic reactions of residents in a way that protects both residents and staff. -How to recognize and deal with burnout, frustration and stress that may lead to inappropriate responses or abusive reactions to residents. -What constitutes abuse (physical, mental, sexual, verbal), neglect, exploitation, mistreatment, and misappropriation of resident property. IV. Reporting- employees are required to immediately report any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or a crime against a resident they observe, hear about, or suspect to the Administrator if available or an immediate supervisor who must immediately report it to the Administrator. V. Identification of Allegations/Internal Reporting Requirements VI. Investigation- Any incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident will result in an abuse investigation. VII. Protection of Residents- The facility will take steps to prevent mistreatment while the investigation is underway. Prevention- The facility desires to prevent involving abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident by establishing a resident-sensitive and resident-secure environment.

Based on interview and record review, the facility failed to adequately supervise and have interventions in place for a resident who was assessed to be at risk for falls and required staff assistance with all Activities of Daily Living (ADLs), including mobility. This failure affected one (R10) of three residents reviewed for falls and resulted in R10 being hospitalized with a pelvic and proximal humerus fracture as a result of a fall. Findings include: R10 is an [AGE] year old male who was admitted to the facility on [DATE] with past medical history including, but not limited to chronic kidney failure, cardiac arrhythmia, acute kidney failure unspecified, Type 2 diabetes, [CONDITION(S)], [CONDITION(S)], dementia in other diseases classified elsewhere, adult failure to thrive, essential primary hypertension, difficulty walking, weakness, other lack of coordination, etc. Nurse's progress note on 6/5/2021, R10 reported that he fell on his left side in the bathroom, was unable to raise his left arm and complained of severe pain to the left arm, Tylenol was given for pain, physician was contacted and ordered to send resident to the emergency room for further evaluation. R10 was sent to the hospital where an x-ray revealed a pelvic fracture and proximal humerus fracture. Review of admission record for R10 shows that he was admitted with weakness and unsteady gait and had a score of 7 in a facility fall risk assessment dated [DATE]. Facility Minimum Data Set (MDS) assessment dated [DATE] coded R10 as follows: Section C (Cognition), BIMS (Brief Interview for Mental Status) score of 01 Section G (Functional Status) coded as 3/2 - indicating extensive assistance needed with one-person physical assist for bed mobility, transfer, walk in room, walk in corridor toilet use and personal hygiene, and under mobility device Section H (Bladder and Bowel) documents that R10 is frequently incontinent of bowel and bladder. Facility functional abilities assessment for R10 dated 3/11/2021 also documented that R10 requires substantial/maximal assistance for toileting hygiene, oral hygiene, dressing, toilet transfer, walking 10 feet, etc. Review of R10's comprehensive care plans do not list any interventions related to falls, prior to the fall that occurred on 6/5/21. Care plan was updated on 6/5/21 to with a focus for risk for falls r/t cognitive impairment and includes intervention of a walker for ambulation. 6/29/2021 at 1:09 PM, V27 (C.N.A) stated that she works as a floater but familiar with resident, R10 is quiet and nice, does not ask for much, very co-operative, resident was dependent on staff for ADLS, wears an incontinence brief and is incontinent of bowel and bladder. R10 cannot walk by himself due to unsteadiness of his feet, requires staff assistance and supervision. V27 added that she was not present when R10 fell and does not know exactly what happened. 6/29/2021 at 2:30PM, V25 (MDS Coordinator) said that R10 needs help with ambulation, he is limited when he gets up and has to be monitored, R10 wears an incontinence brief due to incontinence of bowel and bladder and requires staff supervision for ambulation and physical assist for other ADLs. R10 is a fall risk but the only intervention he had was monitoring and restorative program, he does not have any assistive device like a walker bed alarm or wheelchair. PT was supposed to assess resident and give their recommendations. V25 added that all they can do is try to prevent falls, R10 had an unsteady gait, and was in a room with the bathroom located outside his room in the hallway. 6/30/2021 at 12:32PM, V30 (Doctor of physical therapy and evaluation) stated that R10 came in for evaluation, was able to walk on balance, did not need assistive device upon admission, though resident was high risk for falls, but he walks upon supervision and cueing. R10 was discharged with recommendation for stand by assist and occasional verbal cues for safety awareness while turning, for safe maneuvering in small spaces and for implementation of safety techniques in order to increase independence and safety in room and to prepare to walk to dine for meals. V30 added that R10 was on a dementia unit and was supposed to be supervised by staff. Facility document titled, Fall Prevention and Management Program (undated), states that the facility is committed to safety and maximizing each resident's physical, mental and psychosocial well-being. The purpose of the fall prevention program is to provide residents with an interdisciplinary approach to assess risk for falls and to provide appropriate interventions to prevent falls.

Based on interview and record review, the facility failed to prevent resident to resident physical assault for 2 of 4 residents (R15, and R16) reviewed for physical abuse. This failure resulted in R15 being hit in the face with a television resulting in hospitalization requiring sutures and R16 being hit in the face with a garbage can requiring hospitalization and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: R15's Progress Note dated 5-5-21 documents R15 came to the nursing station to report that he was hit in his room by another resident (R17), and sustained injury to his face. Hospital Record dated 5-5-21 documents laceration to left lateral eyebrow, hit with unknown object to face while sleeping at nursing home by another resident. R15's Progress Note dated 5-5-21 documents: Resident returned from hospital, alert and oriented x3 ambulating with steady gait. resident denies pain at this time, steri strips noted to left eyebrow area. On 6-9-21 at 12:30 PM, R15 said he does not remember who hit him, but he recalls being hit in the face with a television and that he went to the hospital for an x-ray and treatment. R16's Progress Note dated 5-5-21 documents around 5:20 AM the nurse noted R16 being hit with the garbage can by another resident (R17) while he was walking in front of the nursing station. R16 sustained injuries to his face. First aide provided, police notified; resident transferred by ambulance to the local hospital for evaluation, and treatment. Progress Note (5-5-21) documents R16 returned from hospital with reports of orbital and nasal fractures. Hospital Record dated 5-5-21 documents Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6-9-21 at 12:42 PM, R16 said he remembers R17 hitting him in the face with a garbage can, R16 said he went to the local hospital, and was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6-4-21 11:46 AM, V1 (Administrator/Abuse Coordinator) said R17 has history internal hallucinations. R17 threw television and struck R15. R15 required steri-strip to left eye. Thirty seconds later, R17 threw trash can at R16. R16 sustained a fractured nose. On 6-11-21 at 11:00 AM, V2 (Director of Nursing) said these incidents occurred without staff present and without staff able to intervene. Resident R17 does not require constant 1:1 monitoring but requires frequent monitoring to ensure safety of the residents. On 6-11-21 at 10:00 AM, V10 (Psychotropic Nurse/ ADON) said R17 requires monitoring to prevent agitation and aggression. On 6-11-21 at 10:00 AM, V9 (Psychiatric Nurse Practitioner) said R17 is a psych resident and they cycle without warning (very unpredictable). All residents should be supervised. On 6-8-21 at 9:52 AM, V11 (Supervisor/ LPN) said psych population is unpredictable and residents may be aggressive for no reason at all. Abuse Policy (revised on 1-2019) documents the facility desires to prevent abuse against a resident by establishing a resident-sensitive and resident-secure environment.

Based on interview and record review, the facility failed to provide frequent monitoring of a resident that has a history of aggression this affects 1 of 3 residents (R17) reviewed for supervision/monitoring. This failure resulted in R17 physically attacking R15 by hitting R15 in the face with a television resulting in R15 receiving sutures, and R17 attacking R16 by hitting R16 in the head with a garbage can R16 was sent to the local hospital assessed to have suffered facial fractures. Findings include: R15's Progress Note dated 5-5-21 documents R15 came to the nursing station to report that he was hit in his room by another resident (R17), and sustained injury to his face. Hospital Record dated 5-5-21 documents laceration to left lateral eyebrow, hit with unknown object to face while sleeping at nursing home by another resident. R15's Progress Note dated 5-5-21 documents: Resident returned from hospital, alert and oriented x3 ambulating with steady gait, resident denies pain at this time, steri strips noted to left eyebrow area On 6-9-21 at 12:30 PM, R15 said he does not remember who hit him, but he recalls being hit in the face with a television and that he went to the hospital for an x-ray and treatment. R16's Progress Note dated 5-5-21 documents around 5:20 AM the nurse noted R16 being hit with the garbage can by another resident (R17) while he was walking in front of the nursing station. R16 sustained injuries to his face. First aide provided, police notified; resident transferred by ambulance to local hospital for evaluation, and treatment. Progress Note dated 5-5-21 documents R16 returned from hospital with reports of orbital and nasal fractures. Hospital Record dated 5-5-21 documents diagnoses: closed fracture of orbit (initial encounter) and closed fracture of nasal bone (initial encounter). On 6-9-21 at 12:42 PM, R16 said he remembers R17 hitting him with in the face with a garbage can, R16 said he went to the local hospital, and was treated for facial fracture. R17 was not present at the facility during this investigation. A review of R17's Aggression Care documents R17 history of aggression with interventions requiring frequent monitoring of R17. On 6-4-21 11:46 AM, V1 (Administrator/Abuse Coordinator) said R17 has history internal hallucinations. R17 threw television and struck R15. R15 required steri-strip to left eye. Thirty seconds later, R17 threw trash can at R16. R16 sustained a fractured nose. On 6-11-21 at 11:00 AM, V2 (Director of Nursing) said these incidents occurred without staff present and without staff able to intervene. Resident R17 does not require constant 1:1 monitoring but requires frequent monitoring to ensure safety of the residents. On 6-11-21 at 10:00 AM, V10 (Psychotropic Nurse/ ADON) said R17 requires monitoring to prevent agitation and aggression. On 6-11-21 at 10:00 AM, V9 (Psychiatric Nurse Practitioner) said R17 is a psych resident and they cycle without warning (very unpredictable). All residents should be supervised. On 6-8-21 at 9:52 AM, V11 (Supervisor/ LPN) said psych population is unpredictable and residents may be aggressive for no reason at all.

Based on interview, and record review, the facility failed to prohibit and prevent resident abuse in the facility, resulting in a resident sustaining a laceration to the head. The failure affects one of three residents (R5) reviewed for abuse in a total sample of eight residents. Findings include: R3 is a former resident of the facility. R3 has the following Diagnoses: [REDACTED]. Incident report dated 09/06/2019, notes that at 7:25AM, R3 hit R5 in the dining room. While reviewing the incident report, V21 (Psych Tech) made a statement on 09/06/2019. The statement documents that V21 was in the dining room and had her back turned. She heard someone get hit. When she turned around R5 was on the floor. Progress note dated, 09/06/2019, documents that V24 (Licensed Practical Nurse) was at the nurses' station and heard a noise in the dining room. When she went to the dining room, R5 stated he hit me and pointed to R3. Both residents were immediately separated. R5 had a laceration to the right side of her head. On 10/04/2019, at 1:31PM, V21 stated, I did not witness anything. I was just walking into work. On 10/04/2019, at 1:35PM, V5 (Psychiatric Rehabilitation Services Coordinator) stated, R3 does have aggressive behaviors. On 10/04/2019 at 2:45PM, V8 (Licensed Practical Nurse) stated, on 9/06/19 I was getting report and I did not witness anything. I just heard R5 scream and fell . R5 was lying on the floor holding the back of her head. R3 stated that he knocked the crap out of R5. I was told later by V2 (Former Director of Nursing) that R3 hit R5 in face. R5 fell backwards and hit her head. That is why R5 had a laceration to the back of her head. On 10/08/2019, at 2:22PM, V24 stated, on 9/06/19 I did not see anything. I just heard a noise. When I looked up, I saw R5 on the floor. I was helping R5 and I don't know if any staff was in the dining room. On 10/04/2019, at 11:56AM, V7 (Psychiatric Rehabilitation Services Coordinator) stated, R3 has a history of aggression. Safety precautions must be in place, we must be aware of our surroundings because you never know what can happen at any given moment. On 10/04/2019, at 1:00PM, V10 (Assistant Administrator) stated, staff is always supposed to be monitoring the residents. Care plan for R3 notes that R3 has aggression with verbal, physical behaviors and auditory hallucinations. Hospital records reviewed 10/08/2019 note that R5 was assaulted and sustained a laceration to the back of her head with bleeding. Facility policy titled Abuse Prevention Program, dated 2019, documents it is the policy of this facility to prohibit and prevent abuse against a resident in the facility. Abuse is the willful infliction of injury resulting in physical harm or mental anguish by an individual. Willful, means the individual must have acted deliberately, meaning the individual must have intended to inflict harm or injury. Physical abuse is hitting, slapping, pinching, and kicking.

Based on interview and record review, the facility is to ensure that a resident identified at risk for abuse was free from physical trauma from an injury of unknown origin for one of four residents (R9) reviewed for abuse in the sample of 14. This failure resulted in R9 sustaining bilateral peri-orbital hematomas (two black eyes), a laceration to the left side of face; a non-displaced, comminuted zygomatic fracture (fractured cheek bone) and a traumatic, subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain). Findings include: Review of R9's medical record (Progress Notes) documents: 6:06 PM: Writer is called by the CNA (Certified Nursing Assistant) to come and see; upon entering resident('s) room resident is observed in bed face up bleeding from laceration left side of the head. Noted multiple discolorations throughout the face. Resident is alert but disoriented; mouth twisted to the side. Resident is unable to follow simple commands. Hands grasp (hand grasps) are weak pupils reacted to light. VS (Vital Signs): 194/92, 82 (,) 16, 97.8. 911 called. 8:22 PM: Upon follow up call, resident is admitted for left side face fracture at (local hospital). Review of R9's medical record (Emergency Department Chart-Nursing Continuation Notes) documents: (Patient) was found to be victim of trauma of unknown cause. (Bilateral) periorbital hematomas with a 4cm lac (laceration) to the L (left) lateral eyebrow. (Pt) is not at baseline mental status, appears to almost be post ictal (altered state of consciousness after an epileptic [MEDICAL CONDITION])- (Family) denies hx (history) of sz ([MEDICAL CONDITION]). (First) attempt to contact NH (Nursing Home) staff at 1900 (7:00 PM)-(I) spoke c (with) a nurse who told me she does not know anything about the patient- (She) just knows he had a fall, I contacte(d) the PCP (Primary Care Physician) for further clarification- (He) states he was contacted because the patient had scratches to his face and maybe had a sz ([MEDICAL CONDITION])? this was followed by a phone call from a nurse at the NH facility per NH nurse the pt (patient) was found to be normal during vital check at 1500 (3:00 PM), next time he was checked on was at 1700 (5:00 PM) for dinner and was found in bed with trauma to his face so the NH called EMS (Emergency Medical Services). Additional review of R9's hospital record (CT scan facial bones) demonstrates a nondisplaced, comminuted [MEDICAL CONDITION] zygomatic bone. Discharge summary documents primary [DIAGNOSES REDACTED]. Review of ambulance run sheet (06.28.2018, at scene at 5:53 PM) documents (under narrative): Pt (patient) was bleeding with an approximate 5 mm laceration to left of his left eye. Pt presented with multiple bruises to his face and body, elder neglected (neglect) and abuse is suspected and reported. Review of R9's Abuse/Neglect care plan (initiated 12.14.2017, reviewed 04.21.2018) under Focus: The resident's comprehensive assessment reveals factors that may increase his susceptibility to abuse/neglect. The resident demonstrates periods of disorganized thoughts. Alteration in thought process, Hx (history) of aggression. Resident seeks to play fight with his peers putting him at risk for being a target of aggression. The care plan did not include any resident centered interventions. Review of the facility's initial incident report (06.29.2018, 12:59 AM) documents: A Brief Description of Incident: It was reported from (hospital) that resident (R9) was allegedly hit. Review of R15's interview included in incident report documents: Resident denies fighting peer or seeing anyone fighting peer. Resident states nothing happened. V12 (Certified Nursing Assistant, 07.05.2018 at 3:17 PM) said he made rounds of the unit when he started his shift; R9 was in bed sleeping at that time, I checked to make sure he was breathing. V12 said he made 2nd rounds around 4:30 PM; R9 was still in bed sleeping/breathing. V12 said he went from room to room around 5:30 PM to call residents for dinner, he was about to call R9 for dinner when he (V12) saw blood on R9's pillow. V12 said he saw a cut and bump to left side of R9's face; both eyes were black. He was responsive, but I couldn't understand what he was saying, he's Hispanic. V12 said he didn't see R9 fall, he was already in bed. V13 (LPN-Licensed Practical Nurse, 07.05.2018 at 4:04 PM, 07.12.2018 at 4:08 PM) said I don't know what happened to him (R9). V14 (LPN, 07.05.2018 at 4:12 PM, 07.12.2018 at 4:08 PM) said she saw R9 in bed around 4:55 PM. V14 said she was called to R9's room by V12. He was in bed. I saw bright, red blood on his pillow. There was blood coming from the left side of his face, there was bruising to his face (pointed to eyes). V13 came to the room. We were thinking, what happened? Did he fall? We didn't see blood anywhere else, the room looked okay. V14 said she has been instructed to report a suspected crime to V1 immediately ('the same way you would report a regular abuse). V14 said I don't know what happened to him. I thought he fell . I thought maybe he had a stroke because his mouth was twisted to the side. I didn't witness anything. I don't know how he got into bed. V1 (Administrator, 07.06.2018 at 3:38 PM) said she thought R9 fell . V1 did not respond as to how it was determined that R9 fell as he was found in bed, not on the floor. V2 (Director of Nursing, 07.06.2018 at 4:25 PM) said she contacted the hospital at approximately 8:30 AM on 06. 29.2018, the day following the incident to get information. She then reached out to R9's physician when she was unable to get any information from the hospital. R13 was not available for interview. R14 (07.13.2018 at 2:57 PM) said he was not in the room at the time of the incident. R15 refused to speak with this writer. V21 (Physician) and V22 (Registered Nurse) were not available for interview. Review of the facility's Abuse Prevention Program policy and procedure (revised 09.06.2017) states: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility.

Based on observation, interview, and record review the facility failed to administer anti-[MEDICAL CONDITION] medications to 4 of 4 residents (R2, R4, R9, R10) reviewed for medication administration in the sample of 10. This failure resulted in R2 having a [MEDICAL CONDITION], sustaining a laceration and hematoma to the head, and transferred to the emergency room for evaluation. Findings include: On 5/27/15 at 11:45am in the 7th floor medication room, there are 3 large rectangular bins containing the medication blister packs of medications. Some blister packs are unused, some have pills remaining in them. The medications are for high blood pressure, anxiety, mood disorders, [MEDICAL CONDITION], depression, aggression, and [MEDICAL CONDITION]. The following was noted pertaining to medication for R2, R4 and R9: -The blister pack for R2's [MEDICAL CONDITION] medication [MEDICATION NAME] was found in these bins. There is 1 blister pack for [MEDICATION NAME] dated 4/24/15 with 12 pills remaining out of the 28 dispensed on the card. R2's dose is 250 milligrams (mg) twice a day. -Four blister packs dated 4/24/15 for R4's [MEDICATION NAME] were found in these bins. There were 28 pills dispensed in each pack; 23 pills, 21 pills, 14 pills, and 7 pills remained in each of the 4 blister packs. R4's dose for [MEDICATION NAME] is 250 mg twice a day. -Five blister packs dated 4/24/15 for R9's [MEDICAL CONDITION] medication [MEDICATION NAME] were found in these bins. R9's dose is 3-500 mg pills every 12 hours. The blister packs have a total of 93 pills left, equaling 31 out of 56 doses not administered for the 28 day cycle. According to the physician's orders [REDACTED]. Face Sheet documents R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician order [REDACTED]. [MEDICATION NAME] level 3/20/15 documents a result of none detected and the lab sheet notes faxed to MD (medical doctor). Progress Note 5/8/15 documents R2 was noted with a laceration and hematoma to the forehead. R2 could not remember how it happened and the nurse documents [MEDICAL CONDITION] activity. The physician and guardian were notified and R2 was sent to the hospital. Care Plan Update 3/30/15 documents R2 is non-compliant with taking his medications but the March - May 2015 progress Notes do not document R2 is refusing his medications. emergency room records 5/8/15 document R2's admitting [DIAGNOSES REDACTED]. On 5/26/15 at 1:50pm, R2 stated the nurses do not come and get him to give him his medications if he is sleeping and does not go to the medication room. On 5/27/15 at 1:10pm, Z3(Pharmacist) stated a 28 day supply is sent to the facility and the unused medications are returned to the pharmacy. The resident only gets a credit for the unused medications if the blister pack is unused. If even 1 pill is missing, there is no credit for the unused portion. There is no credit to Medicare or Medicaid. Z3 stated [MEDICAL CONDITION] medications should not be left over if the doses are given as ordered. On 5/27/15 at 1:45pm, R2 stated he hasn't had a [MEDICAL CONDITION] in a while. R2 stated sometimes he gets a lot of pills in the morning, other times he gets none or only one. On 5/27/15 at 3pm, E2(Director of Nursing) stated the pharmacy delivers on a continuous cycle, they send the blister packs at the end of the month and staff starts the new packs on the 26th of the month. All unused medications are returned to the pharmacy. On 5/28/15 at 1pm by phone, Z1(Physician) stated he is not aware of R2's [MEDICATION NAME] level or that the last result was none detected. Drawing a [MEDICATION NAME] level is to check if the resident is receiving the medication, not to adjust the dosage. Z1 stated none detected means that he was not ingesting it and the amount of medication in R2's blood was unable to be detected. Z1 stated R2 is not 100% compliant with taking his medications, but he has not known him to miss as much as was left over in the previous month. R2 is known to miss a few doses a month. Z1 stated the staff did not tell him that R2 was missing that high number of doses of [MEDICATION NAME]. This explains why R2 had a [MEDICAL CONDITION]. If R2 did not receive the medication, his level will be low, and he will have a [MEDICAL CONDITION]. Z1 stated he did not order a level upon return to the facility because he thought R2 had a level drawn in the hospital. Z1 stated the staff should notify him if that many doses were missed, not given, or refused. R2 had the [MEDICAL CONDITION] because he did not get the [MEDICATION NAME]. If Z1 would have known that R2 was missing that high number of doses, he would have checked the level sooner. Finally, Grievance Form 1/8/15 documents the area of concern as if the resident does not come to the nurse station, medications are not given since the nurse does not bring the medication to R10. Medication Administration policy - Medications must be administered in accordance with a physician's orders [REDACTED].>

Based on observation, interview and record review the facility failed to have an effective smoking program and monitoring system in place which prevent at risk smokers access to smoking materials in an unauthorized area and prevent residents from having facility's contraband items in their possession. As a result, staff members were unaware that an at risk smoker (R1) obtained non-permitted smoking materials. On 3/22/15 R1 used the smoking materials to cause a facility fire in a bed room, putting residents in the facility at potential danger from fire and smoke. This failure applies to 12 of 14 residents (R1, R2, R4, R5, R6, R8, R9, R10, R11, R12, R13, and R14) reviewed for supervision in a sample of 14. An immediate jeopardy was identified on March 26, 2015 and at 4:35 pm E1(administrator) was informed of the immediate jeopardy. The Immediate Jeopardy was determined to have begun on March 22, 2015 at 8:20 pm, when R1 had possession of smoking materials and set a mattress fire. On March 26, 2015 at 6:53 pm, while it was determined that the immediacy was removed, the facility remains out of compliance at a severity level 2. The facility needs to monitor and evaluate the effectiveness of the facility's staff education and revised policies and procedures. Findings Include: 1. The facility's incident report dated 03/22/15 indicated R1 admitted to smoking in her room and dropping the cigarette on her mattress which caught fire. The report indicated R1 refused to tell the facility staff where she got the cigarette and lighter. The facility report documented there was no injury to any residents during the fire. On 3/23/15 at 12:25 pm E4 (Certified Nursing Assistant /CNA) stated, on 3/22/15 the fire alarm sound and E3 screamed there was smoke in the hall on the women side. E4 stated herself along with E3 (Registered Nurse/RN) and E5 (CNA) began to move the residents to safety. E4 stated she did not recognize any usual behavior in R1 on 3/22/15. E4 stated she does recall R1 walking pass the nurses' station when the fire alarm sounded but did not think it was unusual. On 03/24/15 at 11:35 am E3 stated, On 03/22/2015 she noticed black smoke in the hall on the 8th floor on the women's wing. E3 stated she called security at the front desk to alert them of the fire. E3 stated, E4 and E5 began to place residents in the 8th floor dining room. E3 stated R1 had been her usual self and had not displayed any behaviors on 3/22/15. E3 stated R1 did not appear to be under the influence of any substances. On 03/24/15 at 11:45am E5 stated, On 03/22/2015 the fire alarm sounded and staff began to move residents to the 8th floor dining room. E5 stated she did not recognize anything out of the ordinary with R1. On 03/24/15 the surveyor observed R1 on the facility's security camera footage, causally leaving her room with a cloud of black smoke moving along the ceiling in the 8th floor hallway. The facility's smoking policy (previous to 03/2015 revision) stated: no resident is allowed to be in possession of cigarettes, cigars, matches, lighters or any other smoking materials at any time. No resident will be allowed to keep any smoking materials on his or her person or in their room. On 03/25/15 at 8:45am R1 was interviewed while in the hospital. R1 stated, she took the cigarette out of the smoking room. R1 stated it is easy to take cigarettes from the smoking room because the staff will give the residents two cigarettes at a time and they do not watch to see if both cigarettes are smoked before the residents leave the smoke room. R1 stated the female residents are not checked when leaving the smoking room. R1 stated she sent a resident with an outdoor pass to the store across the street from the facility on 03/22/15 to purchase a lighter for her so that she and a friend could smoke the cigarette. R1 stated she smoked the cigarette alone and when she was done smoking the cigarette she put it on her pillow and it caught fire. R1's hospital physician's assessment dated [DATE] indicated R1 was admitted to the hospital for a psychiatric evaluation. R1's labs results dated 03/23/15 indicated R1 had a blood alcohol level of 2 milligrams per deciliter (mg/dl). Lab's alcohol detection limit equal 5mg/dl. R1's medication list for March 2015 was reviewed and did not account for the alcohol blood level. On 03/26/15 at 11:10 am E11( Psychiatric Rehabilitation Services Counselor /PRSC) indicated R1 did not have a history of alcohol use and was not suspected of alcohol use. E11 stated R1 did not have a history of drug abuse. R1's smoking risk review assessment dated [DATE]: R1 may not be capable of handling/carrying any smoking materials and requires supervision when smoking. R1's care plan dated with the last revised date of 02/28/15 and initiated 08/16/14 had an identified smoking problem. The interventions were: Remind resident of facility smoking policies and encouraged compliance, remind resident staff will be observing and supervision smoking-related behavior and non-compliance is to be documented in the medical record. R1 had no community (outside) pass privilege. 2. On 03/23/15 at 1:45 pm R5 was in the 2nd floor's smoke room picking up the cigarette lighter, lighting his cigarette and handing the lighter. The smoke monitor staff in the room did not intervene. On 03/23/15 at 1:55 pm in the smoke room, R2 was positioned in a wheelchair in front of the smoking supply cart. R2 was observed picking up the cigarette lighter from the smoking supply cart while E7 and E8 (smoke monitors) moved around the room clearing ashtrays. E7 and E8 were observed not maintaining visual control of the unlocked smoking supply cart with cigarettes inside and a lighter on top of the cart. R2 was observed holding the lighter in her hand and resting it on her lap until E7 returned to the unlocked smoking supply cart to give her a cigarette. R2 was observed lighting her cigarette with the lighter and placing the lighter back on the cart. On 03/23/15 at 1:30 pm E7 (Smoke Monitor) stated that the maximum number of residents in the smoking room is 22 with one smoke monitor in the smoke room and one security officer outside of the security room. On 03/25/15 at 9:55 am 24 residents were observed in the smoking room. At 9:55am until 10:15 am R2, R4, R9, R10, R11, R12, R13 and R14 (all female residents) were observed exiting the smoke room without being stopped or checked by security for smoking materials At 10:15 am R4 was observed leaving the smoke room with a large purse. Among the residents not check was R11 who is on the facility's smokers on restriction list. The list indicates R11 is a new admission with a history of unsafe smoking in a previous facility and was placed on supervised smoking as a precaution. On 03/25/15 at 12:15 pm E9 (Security Director) stated the second floor security officer randomly checks residents (for smoking materials), however, male security officers cannot check female residents. E9 stated residents are randomly checked at the front door when re-entering the facility. E9 stated that there is one female security guard on the 2nd shift who will randomly check female residents The facility's list of smokers includes 131 residents out of 266 residents on the facility's roster. On 03/25/15 E1 (Administrator) in the presence of E13 (Director of Nursing /DON) stated that he had not performed a room to room check since the fire on 03/22/15. 3. On 03/25/15 at 12:15 pm E9 stated there is not a priority list for residents who need to be checked each time they re-enter the facility or exit the smoking room. E9 stated residents are randomly checked at the front door when re-entering the facility. E9 stated the facility has known residents who have pass privileges that will go to the local store for residents who do not have pass privileges. E9 stated residents are searched when re-entering the facility if they is a reason to suspect they have contraband. E9 stated a reason to suspect contraband include residents acting suspicious or having a history of trying to keep contraband in their possession. On 03/25/15 at 2:00 pm the surveyor accompanied staff while a random room check was conducted. E1 (Administrator), E9 (Director of Security) and E10 (Director of Social Services) were present at the time. In the room at this time, seven razors (with blades) were found at R8's bedside. R8's face sheet [DIAGNOSES REDACTED]. R8's progress note dated 01/29/15 indicated R8 was crying and saying he will get out of the facility either by the police or body bag. R8's behavioral follow-up notes dated 08/11/14 and 12/24/14 indicated R8 has a history of having smoking material in unauthorized areas of the facility. In the room at 2:15 pm, one pair of scissors, one pair of sharp long nose pliers, one metal can opener, one glass bottle of cologne, an electric shaver, one package of hair relaxer, one package of hair dye, a large bag of latex balloons and three packets of stop smoking aide chewing gum were observed at R6's bedside. R6's face sheet [DIAGNOSES REDACTED]. R6's risk management care plan revised 06/28/14 indicated R6 has a history of self harm ideations and behavior. R6's care plan 06/28/14 interventions included: warranted conduct/carry out daily monitoring and supervision of the resident and room safety checks. R6's aggression/criminal background care plan dated 6/28/14 indicates R6 has a history of criminal behavior and has served time in a correctional facility. The facility's contraband items list includes glass bottles, lighters and/or matches medication of any kind including over-the-counter, prescribed and alternative/natural remedies, sharp objects including metal items, hard plastic or items that cut or puncture. The facility took the following steps to remove the immediacy: -R1 no longer resides in the facility. On 03/22/15 R1 was presented a 30-day notice upon transfer out to the hospital due to unsafe smoking practices and endangering self and others. -The facility's Smoking policy was revised on March 24, 2015 to include random searches for reasonable suspicion of violation of smoking materials, maintaining smoking materials in a lock box in a secure area accessible only to security officers and smoke monitors and prohibiting residents from handling lighters. - On 03/24/2015 initiated staff members educated on the revised smoking policy and fire safety. A resident council meeting was held for all residents to make residents aware of the revisions to the smoking policy. - 3/26/2015 notices were posted at the front desk and elevators to alert residents and visitors to turn in all smoking material to security. Front desk security officers are logging smoking material in and out for the residents who have outdoor pass privileges. -Facility conducted room to room smoke materials and contraband searches. Initiated on 03/25/15 and completed on 03/26/15. -A special Quality Assurance meeting was held 03/25/15 to discuss event of 03/22/15 and facility interventions. The Medical Director was notified of the event and the need for an additional Quality Assurance/Quality Improvement meeting schedule for 03/27/15. - On 03/26/2015 the Social Service Director started a new log of residents smoking infractions in order to maintain compliance. -The Quality Assurance/Quality Improvement Team will meet monthly to discuss and re-evaluate the revised policy interventions. The facility's Administrator will be responsible for overall compliance to plan of correction in conjunction with the Security Director, Activity Director, Social Services Director, Human Resources Director and Maintenance Director.

Based on observation, interview and record review the facility failed to protect one resident (R9) from being physically abused by another resident (R13) out of 5 residents reviewed for abuse and neglect in the sample of 16. This failure resulted in R13 physically assaulting R9 in three (3) different incidents. R9 sustained scratches to the face, an injury to the eye and a broken nose. After the first and second incidents, R13 remained in the facility on the same floor as R9. This resulted in an Immediate Jeopardy. On 3/27/13 at 4:02pm, an Immediate Jeopardy was identified to have begun on 3/5/13 when facility staff failed to protect R9 from a physical assault by R13. The facility was aware of R13's aggressive and violent behaviors after the first incident on 3/5/13 and R9's previous history of aggressive, violent behavior and current wandering behaviors. The facility failed to implement interventions to protect R9 and 18 other 4th floor residents with Dementia and wandering behaviors. E16 (Acting Administrator), E2 (Assistant Administrator) and E3 (Director of Nursing) were notified of the Immediate Jeopardy on 3/27/13 at 4:02pm. The Immediate Jeopardy was removed on 3/27/13 at 5:33pm When R13 was removed from the facility. The facility remains out of compliance at a severity level two as the facility is still reassessing dementia residents for behaviors and conducting staff in-servicing. Findings include: Admission Record documents R9 is a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nutritional Risk Review dated 3/8/13 documents R9 is 63 inches tall and weighs 126 pounds. Minimum Data Set (MDS) Section C, dated 3/5/13, Brief Interview for Mental Status scores R9 a 3 out of 15, R9 was unable to complete the interview for mental status, and has disorganized thinking. Section E does not document any behaviors or wandering. History and Physical dated 2/6/13 at the hospital prior to admission to the facility documents "acute [MEDICAL CONDITION], agitation, and aggressive behavior." Admission Record documents R13 is a [AGE] year old male resident admitted on [DATE]. Nutritional Risk Review dated 12/24/12 documents R13 is 68 inches tall and weighs 195 pounds. Minimum Data Set (MDS), dated [DATE], Section I lists [DIAGNOSES REDACTED]. Section C Brief Interview for Mental Status scores R13 as 11 out of 15 and does not have any behavior symptoms. MDS Section E dated 3/10/13 documents "Physical behavior symptom directed toward others scored as 1-behavior of this type has occurred 1 to 3 days." Maladaptive Behavior Check List dated 9/17/12 prior to admission to facility documents "20. noncompliance with medications and limited cognitive ability lead to poor judgement." R9 and R13 were involved in three incidents as follows: R13's Incident Report 3/5/13 at 4pm describes the incident as "Resident (R13) observed with another resident (R9) in his room and holding him down his hands on his back. Also observed him with a right sclera redness and a scratch on his left upper lip." Resident (R13) description is documented as "Resident alert x3 and aware wrongdoing." Immediate action taken by the facility is documented as "Redirected and separated. Smoking privileges removed. Meds given and taken well." No injuries were observed to R13. Other Information from the incident report documents "Resident (R13) alert and oriented times 3 and claim hitting this resident (R9) as he cannot take him out of the room." R13 does not have a care plan for aggressive, abusive or impulsive behaviors prior to this incident on 3/5/13. There is no evidence of a care plan being updated for these behaviors after the incident. R13 remained in the facility. R9's Incident Report 3/5/13 at 4pm describes the incident as "Resident (R9) observed by nurse aides in another resident's room (R13) being held down by him. Also observed with redness to his right sclera and a scratch on his left upper lip about 2 centimeters." Resident (R9) description is documented as "Resident confused." Injury Location is "right eye". Incident Report documents physician and family notification. Behavior Incident 3/5/13 documents R13 wandering in and out of rooms, has poor impulse control (argumentative, easily frustrated, defiant), is responding to others who are hostile, and has a limited attention span. Cause/Factor Conclusion statement documents "(R9) has a [DIAGNOSES REDACTED]. He wanders into other residents rooms and goes through their belongings." R9 has a care plan with the focus "The resident is an elopement risk/wanderer resident wanders aimlessly, disoriented to place, significantly intrudes on the privacy or activity". R9 has a care plan initiated on 3/1/13 for verbally abusive and physical behaviors. There is no evidence that this care plan was updated after the incident. On 3/26/13 at 1:15pm E17 (Nurse) stated "On March 5th about 3:30-4pm, two aides brought the residents (R9 and R13) to the nurses station and I asked what happened. (R13) said he was the one who hit him; that he knew what he was doing. (R9) wanders all the time; it's not possible to constantly watch him." On 3/29/13 at 6:55am, by phone interview, E18 LPN (Licensed Practical Nurse) stated "I was working Friday night 3/8/13 into Saturday morning 3/9/13. (R13) hit (R9), this was the second incident between the two residents. I brought (R9) out to the nurses station for the rest of the night to monitor him. I notified the family and doctors. I called (E4) the Assistant Director of Nursing. (R9) is very confused and wanders all the time. (R9)'s eye was swollen and there was a scratch on his nose. After I cleaned it, there wasn't anything there that needed further treatment. " E18 stated that a third incident happened on 3/10/13 when (E17) (Nurse) was working. E18 was coming into work and (R9) and (R13) were both being sent out to the hospital. E18 stated " There were 3 incidents in that week." Review of the 24 Hour Nursing Reports for the 4th floor document "3/9/13 11pm-7am shift (R13) hit (R9)". Nurse Note 3/9/13 4:10am by E18 documents "I/C (incident charting) 1 of 3 resident sat at nurses station for observation most of the evening right eye slightly swollen only feels pain to touch neuro checks in progress at this time will continue to monitor safety maintained." E18 stated that as long as R9 sat at the nursing station, she was able to watch him. Otherwise, it is not possible to watch R9 all the time. The facility was unable to provide evidence of an incident report or an investigation. R13's Incident Report 3/10/13 at 11:20pm describes the incident as "Resident (R13) struck another resident (R9) in the face. Resident (R13) refuses to answer what happened." R13's mental status is assessed as oriented to person, place, time, and situation. Both the attending physician and psychiatrist were notified. R13 did not have a care plan for aggressive, abusive, or impulsive behaviors at the time of this incident on 3/10/13. R9's Incident Report 3/10/13 at 11:19pm describes the incident as "Resident (R9) observed in another resident's room. Resident noted with vertical laceration to bridge of nose. Resident (R9) states someone hit him. Unable to further describe due to cognitive status." Physician and family were notified." R9 was transferred out to the hospital on [DATE] for a medical evaluation. Hospital CT (Computer Tomography) Scan Maxillofacial without contrast 3/10/13 "There is minimally displaced [MEDICAL CONDITION] nasal bone with adjacent soft tissue swelling. There is a nondisplaced [MEDICAL CONDITION] aspect of the left nasal bone." On 3/25/13 at 1:30pm at the hospital, R9 was asleep in bed. R9 is thin, with sunken cheeks. R9 has a healing scar to the nose. R9 opened his eyes when name was called but did not participate in the conversation. At 1:35pm, Z6 (Hospital Nurse Aide) stated that R9 wanders constantly, needs to be fed, and is difficult to understand when talking. " We have to sit with him 24 hours a day because (R9) wanders all the time. If (R9) walks around, we go with him. " Z6 stated R9 wanders into other patient rooms at the hospital. On 3/26/13 at 1pm, R13 stated "He (R9) kept coming into my room. I had enough and hit him. I knew what I was doing." On 3/26/13 at 2:40pm, R17 stated "(R9) would come into our room all the time. He would go into everyone's room all the time. When (R9) came into the room, staff was never with him. They would come and get him sometimes. But other times, he was alone and he wouldn't leave." On 3/26/12 at 1:10pm, E20 (Dementia Unit Director) stated that wandering was part of R9's behaviors, "(R9) wandered all the time." R9 had severe dementia and was difficult to redirect. E20 stated R9 should have been supervised by all the staff on the 4th floor by "knowing his whereabouts". Staff should have visually seen him, do hall checks, and should have known where he was. E20 stated interventions would be one to one activities, keep R9 in eye sight, engage him in an activity, and offer food. E20 stated "There is no place to chart supervision." E20 explained that staff do not chart a wandering residents locations. On 3/26/13 at 4:20pm by phone interview, Z11 (Physician) stated R9 is very demented, the incident on 3/10/13 was very aggressive, and R9 does not know what he is doing. " The staff needs to watch (R9) constantly. " On 3/26/13 at 4pm by phone interview, Z9 (Psychiatrist) stated R13 didn ' t like that R9 kept coming into his room. " I don ' t know why (R13) wasn ' t sent out after the first time " on 3/5/13, " (R13) should have been sent out. " Z9 stated that he only knew of the 2 incidents on 3/5/13 and 3/10/13. On 3/26/13 at 4:45pm by phone interview, Z14 (Psychiatrist) stated R9 does not know what he is doing due to dementia. Z14 was notified of the 2 incidents on 3/5/13 and 3/10/13. " Staff should have been watching him closely especially after the first incident knowing that (R13) has the aggressive and violent behavior. " Z14 explained that close monitoring would be occupying him with activities, watching where he is, keeping him out of other resident rooms. Nurses Notes for R9 from 2/27/13 through 3/10/13 document confusion, wandering behaviors, very hard to redirect, very confused. There is no evidence that the staff is supervising R9 with regard to wandering behaviors. The notes do not contain information of what the staff is doing to supervise and monitor R9. Nurse Note 3/2/13 documents " (R9) very confused-refuses to stay sitting in his wheelchair-gets up and walks ad-lib then he just stops and sits anywhere-gets into others beds-hard to redirect-physically abusive to staff-will continue to monitor. " There are no nursing notes for 3/3/13 or 3/4/13 monitoring R9 ' s wandering behaviors. Nurse Note 3/5/13 documents R9 was found by CNAs in R13 ' s room, being held on his back by R13. Abuse Prevention Program Policy documents " Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Staff will identify residents with increased vulnerability for abuse. Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect or misappropriation of property they observe, hear about, or suspect to the administrator or the person in charge of the facility acting on behalf of the administrator, or an immediate supervisor who must then immediately report it to the administrator. Residents who allegedly mistreat another resident will be removed from contact with other residents during the course of the investigation. The accused resident ' s condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility." The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy. R9 was transferred to the hospital on [DATE] per transfer/discharge sheet and nursing notes dated 3/10/13. R9 has not returned to the facility. R13 was transferred to the hospital on [DATE] per transfer/discharge sheet and nursing notes dated 3/27/13. Interview with E16, Assistant Administrator on 3/27/13 at 4:30 pm stated that R13 would be sent to a local hospital for psychiatric care and from there would be transferred to the state psychiatric hospital that he was initially released from. On 3/27/13 at 5:33 pm R13 was observed leaving the facility via medical transport. Reviewed in-services and in-service sign in sheets on 4/1/13. The in-services documented that staff were trained on proper investigation procedures for incidents, reporting to the state agency and abuse. The surveyor confirmed through random direct care staff interviews on 4/1/13 am that the staff was knowledgeable and had understanding of the material that was presented by the administrative staff. There were no concerns with the information presented or the interviews conducted.

Based on observation, interview and record review the facility failed to follow their abuse policy by not reporting 2 incidents of resident to resident abuse, by not investigating one incident of resident to resident abuse, and by not protecting one resident (R9) from being physically abused by another resident (R13) out of 5 residents reviewed for abuse and neglect in the sample of 16. R13 physically assaulted R9 in three (3) different incidents. R9 sustained scratches to the face, an injury to the eye and a broken nose. After the first and second incidents, R13 remained in the facility on the same floor as R9. This resulted in an Immediate Jeopardy. On 3/27/13 at 4:02pm, an Immediate Jeopardy was identified to have begun on 3/5/13 when facility staff failed to protect R9 from a physical assault by R13. The facility was aware of R13's agressive and violent behaviors after the first incident on 3/5/13 and R9's previous history of aggressive, violent behavior and current wandering behaviors. The facility failed to report 2 incidents of physical assault of R9 by R13 on 3/5/13 and 3/9/13, and failed to investigate the incident on 3/9/13. The facility failed to implement interventions to protect R9 and 18 other 4th floor residents with Dementia and wandering behaviors. E16 (Acting Administrator), E2 (Assistant Administrator) and E3 (Director of Nursing) were notified of the Immediate Jeopardy on 3/27/13 at 4:02pm. The Immediate Jeopardy was removed on 3/27/13 at 5:33pm when R13 was removed from the facility. The facility remains out of compliance at a severity level two as the facility is still reassessing dementia residents for behaviors and conducting staff inservices. Findings include: Admission Record documents R9 is a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 3/5/13 Minimum Data Set (MDS) Section C Brief Interview for Mental Status scores R9 a 3 out of 15, R9 was unable to complete the interview for mental status, and has disorganized thinking. Section E does not document any behaviors or wandering. History and Physical 2/6/13 at the hospital prior to admission to the facility documents "acute [MEDICAL CONDITION], agitation, and aggressive behavior." Admission Record documents R13 is a [AGE] year old male resident admitted on [DATE]. 9/27/12 Minimum Data Set (MDS) Section I lists [DIAGNOSES REDACTED]. Section C Brief Interview for Mental Status scores R13 as 11 out of 15 and does not have any behavior symptoms. MDS 3/10/13 Section E documents "Physical behavior symptom directed toward others scored as 1-behavior of this type has occurred 1 to 3 days." Maladaptive Behavior Check List 9/17/12 prior to admission to facility documents "20. noncompliance with medications and limited cognitive ability lead to poor judgement." R9 and R13 were involved in three incidents as follows: R13's Incident Report 3/5/13 at 4pm describes the incident as "Resident (R13) observed with another resident (R9) in his room and holding him down his hands on his back. Also observed him with a right sclera redness and a scratch on his left upper lip." Resident (R13) description is documented as "Resident alert x3 and aware wrongdoing." Immediate action taken by the facility is documented as "Redirected and separated. Smoking privileged removed. Meds given and taken well." No injuries were observed to R13. Other Information from the incident report documents "Resident (R13) alert and oriented times 3 and claim hitting this resident (R9) as he cannot take him out of the room." R13 does not have a care plan for aggressive, abusive or impulsive behaviors prior to this incident on 3/5/13. There is no evidence of a care plan being updated for these behaviors after the incident. R13 remained in the facility. R9's Incident Report 3/5/13 at 4pm describes the incident as "Resident (R9) observed by nurse aides in another resident's room (R13) being held down by him. Also observed with redness to his right sclera and a scratch on his left upper lip about 2 centimeters." Resident (R9) description is documented as "Resident confused." Injury Location is "right eye". Incident Report documents physician and family notification. Behavior Incident 3/5/13 documents R13 wandering in and out of rooms, has poor impulse control (argumentative, easily frustrated, defiant), is responding to others who are hostile, and has a limited attention span. Cause/Factor Conclusion statement documents "(R9) has a [DIAGNOSES REDACTED]. He wanders into other residents room and go through their belongings." R9 has a care plan with the focus "The resident is an elopement risk/wanderer resident wanders aimlessly, disoriented to place, significantly intrudes on the privacy or activity." R9 has a care plan initiated on 3/1/13 for verbally abusive and physical behaviors. There is no evidence that this care plan was updated after the incident. On 3/26/13 at 1:15pm E17(Nurse) stated "On March 5th about 3:30-4pm, two aides brought the residents (R9 and R13) to the nurses station and I asked what happened. (R13) said he was the one who hit him, that he knew what he was doing. (R9) wanders all the time, it's not possible to constantly watch him." Review of the investigation does not show evidence that the initial allegation or final conclusion were faxed to the Department of Public Health. The facility is unable to present evidence of reporting this incident to the Department of Public Health. Fax cover sheet 3/28/13 sent by E19 documents "unable to find proof of faxing on 3/5/13." On 3/29/13 at 6:55am, by phone interview, E18 stated "I was working Friday night 3/8/13 into Saturday morning 3/9/13. (R13) hit (R9), this was the second incident between the two residents. I brought (R9) out to the nurses station for the rest of the night to monitor him. I notified the family and doctors. I called (E4) the Assistant Director of Nursing. (R9) is very confused and wanders all the time. (R9)'s eye was swollen and there was a scratch on his nose. After I cleaned it, there wasn't anything there that needed further treatment. A third incident happened on 3/10/13 for (E17). I was coming into work and (R9) and (R13) were both being sent out to the hospital. There were 3 incidents in that week." Review of 24 Hour Nursing Reports for the 4th floor document "3/9/13 11pm-7am shift (R13) hit (R9)". Nurse Note 3/9/13 4:10am by E18 documents "I/C (incident charting) 1 of 3 resident sat at nurses station for observation most of the evening right eye slightly swollen only feels pain to touch neuro checks in progress at this time will continue to monitor safety maintained." On 3/28/13 at 12:10pm, E3 (Director of Nursing) stated "There were 3 incidents between (R9) and (R13). E3 did not answer any more questions that were directed toward her. E3 got up and left the conference room without answering any more questions. E2 (Assistant Administrator), E16 (Administrator), and E19 (Director of Clinical Services) did not answer any of the questions related to the investigation, resident protection, or reporting of the incident between R9 and R13 in the early morning of 3/9/13. The facility did not provide an incident report or any documentation for the incident on 3/9/13 R13's Incident Report 3/10/13 at 11:20pm describes the incident as "Resident (R13) struck another resident (R9) in the face. Resident (R13) refuses to answer what happened." R13's mental status is assessed as oriented to person, place, time, and situation. Both the attending physician and psychiatrist were notified.R13 was transferred out of the facility for a psychiatric evaluation. R9's Incident Report 3/10/13 at 11:19pm describes the incident as "Resident (R9) observed in another resident's room. Resident noted with vertical laceration to bridge of nose. Resident (R9) states someone hit him. Unable to further describe due to cognitive status." Physician and family were notified." R9 was transferred out to the hospital for a medical evaluation. Hospital CT Scan Maxillofacial without contrast 3/10/13 "There is minimally displaced [MEDICAL CONDITION] nasal bone with adjacent soft tissue swelling. There is a nondisplaced [MEDICAL CONDITION] aspect of the left nasal bone." Abuse Prevention Program Policy documents "Residents who allegedly mistreat another resident will be removed from contact with other residents during the course of the investigation. The accused resident ' s condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. Initial Reporting of Allegations: If mistreatment has occurred, the resident ' s representative and the Department of Public Health shall be informed as soon as possible within 24 hours. Five-Day Final Abuse Investigation Report: Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. " The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy. R9 was transferred to the hospital on [DATE] per transfer/discharge sheet and nursing notes dated 3/10/13. R9 has not returned to the facility. R13 was transferred to the hospital on [DATE] per transfer/discharge sheet and nursing notes dated 3/27/13. Interview with E16, Assistant Administrator on 3/27/13 at 4:30 pm stated that R13 would be sent to a local hospital for psychiatric care and from there would be transferred to the state psychiatric hospital that he was initially released from. On 3/27/13 at 5:33 pm R13 was observed leaving the facility via medical transport. Reviewed in-services and in-service sign in sheets on 4/1/13. The in-services documented that staff were trained on proper investigation procedures for incidents, reporting to the state agency and abuse. The surveyor confirmed through random direct care staff interviews on 4/1/13 am that the staff was knowledgeable and had understanding of the material that was presented by the administrative staff. There were no concerns with the information presented or the interviews conducted.

Based on observation, interview and record review the facility failed to supervise and implement interventions to prevent one resident (R9) from being physically abused by another resident (R13) out of 5 residents reviewed for incidents and accidents in the sample of 16. R13 physically assaulted R9 in three (3) different incidents. This failure resulted in R9 sustaining scratches to the face, an injury to the eye and a broken nose. After the first and second incidents, R13 remained in the facility on the same floor as R9. This resulted in an Immediate Jeopardy. On 3/27/13 at 4:02pm, an Immediate Jeopardy was identified to have begun on 3/5/13 when facility staff failed to protect R9 from a physical assault by R13. The facility was aware of R13's aggressive and violent behaviors after the first incident on 3/5/13 and R9's previous history of aggressive, violent behavior and current wandering behaviors. The facility failed to supervise and implement interventions to protect R9 and 18 other 4th floor residents with Dementia and wandering behaviors from being abused by R13. E16 (Acting Administrator), E2 (Assistant Administrator) and E3 (Director of Nursing) were notified of the Immediate Jeopardy on 3/27/13 at 4:02pm. The Immediate Jeopardy was removed on 3/27/13 at 5:33pm when R13 was removed from the facility. The facility remains out of compliance at a severity level two as the facility is still reassessing dementia residents for behaviors and conducting staff in-servicing. Findings include: Admission Record documents R9 is a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nutritional Risk Review dated 3/8/13 documents R9 is 63 inches tall and weighs 126 pounds. Minimum Data Set (MDS) Section C Brief Interview for Mental Status dated 3/5/13 scores R9 a 3 out of 15. R9 was unable to complete the interview for mental status, and has disorganized thinking. Section E does not document any behaviors or wandering. Section I lists a [DIAGNOSES REDACTED]. History and Physical 2/6/13 at the hospital prior to admission to the facility documents "acute delirium, agitation, and aggressive behavior." Admission Record documents R13 is a [AGE] year old male resident admitted on [DATE]. Nutritional Risk Review dated 12/24/12 documents R13 is 68 inches tall and weighs 195 pounds. Minimum Data Set (MDS) Section I dated 9/27/12 lists [DIAGNOSES REDACTED]. Section C Brief Interview for Mental Status scores R13 as 11 out of 15 and does not have any behavior symptoms. MDS dated [DATE] Section E documents "Physical behavior symptom directed toward others scored as 1-behavior of this type has occurred 1 to 3 days." . Maladaptive Behavior Check List 9/17/12 prior to admission to facility documents "20. noncompliance with medications and limited cognitive ability lead to poor judgement." R9 and R13 were involved in three incidents as follows: R13's Incident Report 3/5/13 at 4pm describes the incident as "Resident (R13) observed with another resident (R9) in his room and holding him down his hands on his back. Also observed him with a right sclera redness and a scratch on his left upper lip." Resident (R13) description is documented as "Resident alert x3 and aware wrongdoing." Immediate action taken by the facility is documented as "Redirected and separated. Smoking privileged removed. Meds given and taken well." No injuries were observed to R13. Other Information from the incident report documents "Resident (R13) alert and oriented times 3 and claim hitting this resident (R9) as he cannot take him out of the room." R13 does not have a care plan for aggressive, abusive or impulsive behaviors prior to this incident on 3/5/13. There is no evidence of a care plan being updated for these behaviors after the incident. R13 remained in the facility. R9's Incident Report 3/5/13 at 4pm describes the incident as "Resident (R9) observed by nurse aides in another resident's room (R13) being held down by him. Also observed with redness to his right sclera and a scratch on his left upper lip about 2 centimeters." Resident (R9) description is documented as "Resident confused." Injury Location is "right eye". Incident Report documents physician and family notification. Behavior Incident 3/5/13 documents R13 wandering in and out of rooms, has poor impulse control (argumentative, easily frustrated, defiant), is responding to others who are hostile, and has a limited attention span. Cause/Factor Conclusion statement documents "(R9) has a [DIAGNOSES REDACTED]. He wanders into other residents rooms and goes through their belongings." R9 has a care plan with the focus "The resident is an elopement risk/wanderer resident wanders aimlessly, disoriented to place, significantly intrudes on the privacy or activity." R9 has a care plan initiated on 3/1/13 for verbally abusive and physical behaviors. There is no evidence that this care plan was updated after the incident. R9 did not have a room change after this incident. On 3/26/13 at 1:15pm E17 (Nurse) stated "On March 5th about 3:30-4pm, two aides brought the residents (R9 and R13) to the nurses station and I asked what happened. (R13) said he was the one who hit him; that he knew what he was doing. (R9) wanders all the time; it's not possible to constantly watch him." On 3/29/13 at 6:55am, by phone interview, E18 stated "I was working Friday night 3/8/13 into Saturday morning 3/9/13. (R13) hit (R9), this was the second incident between the two residents. I brought (R9) out to the nurses station for the rest of the night to monitor him. I notified the family and doctors. I called (E4) the Assistant Director of Nursing. (R9) is very confused and wanders all the time. (R9)'s eye was swollen and there was a scratch on his nose. After I cleaned it, there wasn't anything there that needed further treatment. " E18 stated that a third incident happened on 3/10/13 when (E17) (Nurse) was working. E18 was coming into work and (R9) and (R13) were both being sent out to the hospital. E18 stated " There were 3 incidents in that week." Review of the 24 Hour Nursing Reports for the 4th floor document "3/9/13 11pm-7am shift (R13) hit (R9)". Nurse Note 3/9/13 4:10am by E18 documents "I/C (incident charting) 1 of 3 resident sat at nurses station for observation most of the evening right eye slightly swollen only feels pain to touch neuro checks in progress at this time will continue to monitor safety maintained." E18 stated that as long as R9 sat at the nursing station, she was able to watch him. Otherwise, it is not possible to watch R9 all the time. R13's Incident Report 3/10/13 at 11:20pm describes the incident as "Resident (R13) struck another resident (R9) in the face. Resident (R13) refuses to answer what happened." R13's mental status is assessed as oriented to person, place, time, and situation. Both the attending physician and psychiatrist were notified. R13 did not have a care plan for aggressive, abusive, or impulsive behaviors at the time of this incident on 3/10/13. R13 was transferred out of the facility for a psychiatric evaluation on 3/10/12, after the third incident. A care plan for the focus of "The resident is/has potential to demonstrate physical behaviors, physical aggression r/t Dementia, poor impulse control" is initiated on 3/20/13, upon readmission to the facility. R13 ' s care plan does not document any of the behavioral incidents on 3/5/13, 3/9/13, or 3/10/13. R9's Incident Report 3/10/13 at 11:19pm describes the incident as "Resident (R9) observed in another resident's room. Resident noted with vertical laceration to bridge of nose. Resident (R9) states someone hit him. Unable to further describe due to cognitive status." Physician and family were notified." R9 was transferred out to the hospital on [DATE] for a medical evaluation. On 3/28/13 at 12:10pm, E3 (Director of Nursing) stated "There were 3 incidents between (R9) and (R13). " E3 did not answer any more questions that were directed toward her about the incident between R9 and R13 on 3/9/13. E3 got up and left the conference room without answering any more questions. E2 (Assistant Administrator), E16 (Acting Administrator), and E19 (Director of Clinical Services) did not answer any of the questions related to an investigation, resident protection, or reporting of the incident between R9 and R13 in the early morning of 3/9/13. The facility did not present an incident report or any documentation for this incident that occurred on 3/9/13. Hospital CT (Computer Tomography) Scan Maxillofacial without contrast 3/10/13 "There is minimally displaced fracture of the right nasal bone with adjacent soft tissue swelling. There is a nondisplaced fracture of the anterior aspect of the left nasal bone." On 3/25/13 at 1:30pm at the hospital, R9 was asleep in bed. R9 is thin, with sunken cheeks. R9 has a healing scar to the nose. R9 opened his eyes when name was called but did not participate in the conversation. At 1:35pm, Z6 (Hospital Nurse Aide) stated that R9 wanders constantly, needs to be fed, and is difficult to understand when talking. " We have to sit with him 24 hours a day because (R9) wanders all the time. If (R9) walks around, we go with him. " Z6 stated R9 wanders into other patient rooms at the hospital. On 3/26/13 at 1pm, R13 stated "He (R9) kept coming into my room. I had enough and hit him. I knew what I was doing." On 3/26/13 at 2:40pm, R17 stated "(R9) would come into our room all the time. He would go into everyone's room all the time. When (R9) came into the room, staff was never with him. They would come and get him sometimes. But other times, he was alone and he wouldn't leave." On 3/26/12 at 1:10pm, E20 (Dementia Unit Director) stated that wandering was part of R9's behaviors, "(R9) wandered all the time." R9 had severe dementia and was difficult to redirect. E20 stated R9 should have been supervised by all the staff on the 4th floor by "knowing his whereabouts". Staff should have visually seen him, do hall checks, and should have known where he was. E20 stated interventions would be one to one activities, keep R9 in eye sight, engage him in an activity, and offer food. E20 stated "There is no place to chart supervision." E20 explained that staff do not chart a wandering residents locations. E20 stated R13 was readmitted to the facility on [DATE]. E20 stated that the residents on the 4th floor are care planned for the [DIAGNOSES REDACTED]. Care plans for R9 and R13 were reviewed and verified with E20 that neither care plan was updated after the incidents on 3/5/13, 3/9/13, and 3/10/13. E20 also verified that R13 did not have a care plan regarding his abusive, aggressive physical behaviors until 3/20/13, when he was readmitted to the facility. On 3/26/13 at 4:20pm by phone interview, Z11 (Physician) stated R9 is very demented, the incident on 3/10/13 was very aggressive, and R9 does not know what he is doing. " The staff needs to watch (R9) constantly. " On 3/26/13 at 4pm by phone interview, Z9 (Psychiatrist) stated R13 didn ' t like that R9 kept coming into his room. " I don ' t know why (R13) wasn ' t sent out after the first time " on 3/5/13, " (R13) should have been sent out. " Z9 stated that he only knew of the 2 incidents on 3/5/13 and 3/10/13. On 3/26/13 at 4:45pm by phone interview, Z14 (Psychiatrist) stated R9 does not know what he is doing due to dementia. Z14 was notified of the 2 incidents on 3/5/13 and 3/10/13. " Staff should have been watching him closely especially after the first incident knowing that (R13) has the aggressive and violent behavior. " Z14 explained that close monitoring would be occupying him with activities, watching where he is, keeping him out of other resident rooms. Nurses Notes for R9 from 2/27/13 through 3/10/13 document confusion, wandering behaviors, very hard to redirect, very confused. There is no evidence that the staff is supervising R9 with regard to wandering behaviors. The notes do not contain information of what the staff is doing to supervise and monitor R9. Nurse Note 3/2/13 documents " (R9) very confused-refuses to stay sitting in his wheelchair-gets up and walks ad-lib then he just stops and sits anywhere-gets into others beds-hard to redirect-physically abusive to staff-will continue to monitor. " There are no nursing notes for 3/3/13 or 3/4/13 monitoring R9 ' s wandering behaviors. Nurse Note 3/5/13 documents R9 was found by CNAs in R13 ' s room, being held on his back by R13. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy. R9 was transferred to the hospital on [DATE] per transfer/discharge sheet and nursing notes dated 3/10/13. R9 has not returned to the facility. R13 was transferred to the hospital on [DATE] per transfer/discharge sheet and nursing notes dated 3/27/13. Interview with E16, Assistant Administrator on 3/27/13 at 4:30 pm stated that R13 would be sent to a local hospital for psychiatric care and from there would be transferred to the state psychiatric hospital that he was initially released from. On 3/27/13 at 5:33 pm R13 was observed leaving the facility via medical transport. On 4/1/13; randomly reviewed residents with dementia that reassessed using the Alzheimer ' s Special Care Unit/Dementia assessment tool and the aggressive or dangerous behavior assessment tool for appropriate placement. No concerns were noted. Oberservation noted of the new dementia unit hall monitor on 4/1/13 during the am hours. Reviewed in-services and in-service sign in sheets on 4/1/13. The in-services documented that staff were trained on proper investigation procedures for incidents, reporting to the state agency and abuse. The surveyor confirmed through random direct care staff interviews on 4/1/13 am that the staff was knowledgeable and had understanding of the material that was presented by the administrative staff. There were no concerns with the information presented or the interviews conducted.

Based on record review and interview facility failed to follow their abuse policy regarding identifying patterns and occurrences for potential abuse for two of four residents (R5, R6) reviewed for possible abuse, out of a sample of 7. This failure resulted in one resident (R6) with left eye trauma and R5 with a stab wound to the neck. Findings Include: Facility's abuse prevention program policy included the following: - identifying occurrences and patterns of potential mistreatment - implementing systems to investigate all report and allegations of mistreatment promptly and aggressively, - filing accurate and timely investigative reports. R5's social service progress notes dated 10-19-11 denotes R5 in possession of a dangerous object (bent fork) when searched by security. R5 felt intimated by roommate and explained to R5 to inform staff of any issues and not to take matters into his own hands by using violence. Interview with E1 (Administrator) on 3-2-12 at 9:00 AM states that incident on 10-19-11 was not generated for the bent fork because it was just a random check of personal items by security. R5's clinical records denotes petition for involuntary/judicial admission to the hospital on 10-24-11, (R5) was accused by peer of repeatedly striking him. (R5) has had history of altercations with peers before. Interview with E13 (Director of Nursing) on 3-15-12 at 10:50 AM, states unable to locate the incident report for the incident on 10-24-11 and can not find the nurses notes in regards to that incident of 10-24-11 involving R5. R5's licensed progress notes dated 11-5-11 R5 threatened another resident on the bathroom. R5's licensed progress notes dated 11-12-11 R5 and his room mate got into real serious verbal confrontation. R5's licensed progress notes dated 11-13-11 R5 noted to physical aggressive towards others. Interview with E10 (Psychiatric Rehabilitation Service coordinator) on 3-13-12 states there was no anger management program set up for the residents, not until the December. E10 states if anger management program was available R5 would have been placed. Interview with E2 (Psychiatric Rehabilitation Service Director) on 3-13-12 at 1:15 PM states was not hired until after October and was not aware of R5's history of physical altercations with other resident in the past. R5's licensed progress notes dated 8-20-11 denotes R5 upset with roommate and threw padlock at him. R5's licensed progress notes dated 9-18-11 R5 in washroom attempting to whip another resident with belt. E2 states there was huge problem with insurance carrier of the state, which stopped paying for the services that were provided to the residents during November. E2 states that Anger Management was canceled during the month of November and did not resume until the end of December. E2 states staff was instructed to do 1:1 counseling. Interview with E8 (Psychiatric Rehabilitation Service coordinator) on 3-13-12 states R5 was one of the residents that he would counsel during September 2011. E8 states if he was aware of R5's history of aggression towards another resident in august would of had him placed in anger management program. E8 states the Consultant at that time during august thru October was not giving us any guidance. R5's history of aggressive, inappropriate behavior care plan dated 11-7-11 approach/intervention provide supportive intervention five times per week, Psychiatric Rehabilitation Service Coordinator will visit resident five times a week to evaluate mood and address concerns. R5's social service progress notes only one Psychiatric Rehabilitation Service Coordinator note during the month of December (12-15-11). R5's unusual occurrence report date 12-20-11 at 5:00 PM R5 stated another resident (R6) struck him in the neck on the left side with a sharp object, causing small laceration. The investigation assessment dated [DATE] at 5:00 PM denotes observable injuries: R5 had injury to left side of neck [MEDICAL CONDITION] cm (centimeters) scratch and R6 injury to left eye, left eye red with laceration to face. Record review of description of the incident denotes R6 alleged that he was on his way to the dining room for dinner when R5 hit him in the face with a belt. R5 stated R6 owed me money and R6 scratched on left side of neck. R5's preliminary 24-hour incident report denotes on 12-20-11 at 5 PM, hallway on the 5th floor R5 alleged that R6 scratched him on the neck when he asked for his money. Resident (R5) has area [MEDICAL CONDITION] centimeter on left side if neck. Small amount of bleeding noted. Resident (R5) transferred to hospital for medical evaluation and treatment. R6' preliminary 24-hour incident report denotes 12-20-11 5 PM, hallway on the 5th floor resident (R6) was involved in a physical altercation with peer (R5). Unable to find out the circumstance that lead to incident. Injury to left eye. Resident transported to hospital for medical evaluating and treatment. Record review of final investigation and comprehensive analysis of unusual occurrence dated 12-20-11 R5 and R6 had physical altercation that caused injury to both. R5 stated R6 approached him and scratched him on the neck when he asked for his money. R5 then hit R6 with belt buckle on the left side of face. Incident happened fast, no witness. Staff working that hour were busy taking care of other residents. Interview E1 (Administrator) on 3-14-12 at 11:00 AM, states " I saw the incident report for R5 and R6 and signed off on it. We had the hospital records but I don't think we concluded that R5 got stabbed, we believed it was a scratch". E1 states that police were notified but R5 and R6 refused to press charges against each other. R5's hospital records dated 12-21-11 denotes discharge Diagnosis: [REDACTED]. Record review of R5's licensed nurses progress notes dated 12-21-11 11:10 AM denotes resident (R5) returned to the facility and transported to another hospital for psychiatric evaluation. Record review of R6's hospital records dated 12-20-11 at 1817 (6:17 PM), Patient (R6) brought in by emergency medical service after getting hit in his left eye by another resident. Police called and are talking with patient (R6) on the phone. Computerized tomography scan: globe rupture, no lens seen. Patient (R6) needed urgent evaluation and specialty consultation. Was taken to operating room for emergency surgery. R6 on 3-2-12 at 3:45 PM, states " I came out of my room he (R5) said something and I said something back. He (R5) swung at me with a belt missed then I stabbed him in the neck with a pair of scissors to get him off me. Then he (R5) swung again and hit my eye. E15 (Licensed Practical Nurse) on 3-13-12 at 4:25 PM, states "R5 could not get along with people. R5 approached me with a small laceration on the neck, but did not tell me what happened. Then R6 came to me did say his eye was messed up and said R5 hit in eye with belt buckle. I assessed him and called 911 ambulance. R6 had issues but was mild manner. R5 didn't get along with people and was moved from another floor and not long after always started arguments with the other residents but was re-directable".

Based on observations, interview and record review, the facility failed to provide supervision for cognitively impaired individuals assessed as high risk for falls and failed to provide effective interventions to prevent the numerous falls, some falls resulting in fractures for R2 and sutures for R19 and R44, failed to provide supervision for cognitively impaired residents who have been in physical altercation with other cognitively impaired residents and resulted in injuries and failed to investigate and assess individuals for the root cause for falls in 6 of 13 residents (R2, R13, R15,R18, R19, R23) reviewed for falls in the sample of 30 residents and 8 residents (R34, R44, R38, R36, R33, R32, R39, R45) in the supplemental sample. The findings include: 1) R2 is a wheel-chair bound, [AGE] year old male who has a [DIAGNOSES REDACTED]. R2 is disoriented by all 3 spheres (person, place and time) per the 5/9/11 and 9/14/11 care plan for memory and decision- making. On 9/27/11 at 10 A.M. in the 4th floor dining room, R2 was seated in wheel-chair. E16 (nurse aide) was standing along side him, re-applying his semi-cast and wrap to his right hand/wrist. E16 stated he has a tendency to remove the cast so she is re-applying it. R2 stood up and activated his chair alarm and was re-directed to sit. On 9/28/11 at 9:30 A.M., sitting in wheel-chair in the hall near the nurses ' station. R2 ' s semi-cast and ace bandage were off and his sling around his neck was not in use. R2 ' s right hand is swollen. E13 (nurse) stated not to know why the cast is off but stated he often removes it and it needs to be replaced. E13 returned and stated the physician's order [REDACTED]. E13 stated the nurse aide stated she could not find the semi-cast in his room. E13 stated she will contact the restorative department. At 10 A.M., R2 removed from the 4th floor dining room to be fitted for a semi-cast. E13 stated since the cast can not be found, R2 will be refitted. At 10:55 A.M., R2 is back in the dining room. The semi-splint is off and on the floor. E17 (activity aide) and E15, the P.R.S.C. (Psychiatric Rehabilitation Service Counselor) were circulating the room. Throughout the week, R2 was in his wheel-chair in the dining room and/or in the hall near nurses ' station. R2 was seen to remove his splint and throw it on the floor. Numerous times resident needed reminders not to get out of his wheel-chair. R2 is care planned for removing his splint but it is to be re-applied when removed. The cast was not always put back on. Review of the facility ' s incident reports (April ' 11 to September ' 11) show numerous falls that were not witnessed, many resulting with injuries and no investigation as to how and why the falls occurred. Review of the incident reports for R2 document a fall on 6/8/11 at 6:15 A.M. in the 4th floor dining room, where R2 is found on the floor with an over-bed table broken next to him. It is not witnessed nor is it investigated. R2 was unable to say what happened. Review of the nurses ' notes dated 6/8/11 document R2 found on dining room floor. R2 is confused however he interacts with staff. If R2 becomes more confused, he will be sent out to hospital. The next fall is 6/11/11 at 12:15 P.M. when R2 is on the floor in the hall. The report documents that staff saw him walking down the hall prior to fall. The report does not indicate which staff person saw him walking and whether or not be should have been walking independently due to his unsteady gait. The report does not document if there were any injuries. It documents 911 was called. Review of the nurses ' notes dated 6/11/11 document R2 was walking down hall to lunch and went to floor. R2 found on his right side with his right arm and hand under him. R2 complained of pain to head and arm. R2 complained of dizziness while standing and while on the floor. R2 ' s right side of face was red. 911 was called. R2 was admitted to the hospital with [REDACTED]. The next documented fall is dated 6/14/11 at 6:30 p.m. where R2 was found on his floor. The report documents he was removed from floor and placed in wheel-chair. The report documents no injury but there is no investigation into the fall to determine how and why it happened. Nor is there any follow-up to ensure there is no injury. The next documented fall is dated 6/21/11 at 11:40 A.M. where R2 is found on the dining room floor. R2 can not say what happened. R2, who is disoriented to all 3 spheres and confused, was reminded to stay in his chair. The interventions are to continue to monitor resident and to evaluate resident for laptop cushion. There was no investigation into the fall. The laptop cushion was not effective due to R2 removing it so the facility implemented the chair alarm but the time frames are unclear as to when the laptop was discontinued and the chair alarm implemented. The report dated 8/31/11 at 2:40 p.m. document R2 stated another resident hit him and there was a new cut on the right cheek. R2 received first aid to cut. There was no investigation nor was the other resident identified. The report dated 9/14/11 at 10:30 P.M. documents R2 on floor next to bed. When R2 was asked what happened, he stated he rolled onto the floor because it feels better. R2 ' s right arm cast is with in normal limits with some edema. It documented the cast is not related to this fall and R2 has soft cast to arm. None of the incident reports document fracture resulting from a fall. Review of nurses ' note dated 8/10/11 at 6 A.M. document R2 on the floor sitting Indian-style. R2 claimed to not fall. There is no incident report seen or any investigation into it. The nurses ' note dated 8/11/11 documents R2 ' s right wrist swollen and R2 complaining of pain. X-rays were ordered. There was no investigation into this incident. Review of the portable x-ray done on 8/11/11 documents no fracture. Review of the nurses ' notes dated 9/4/11 documents R2 to be very lethargic and weak. R2 was pale in color and had swelling in the right eye orbital area and sent out to hospital. Nurses ' note dated 9/4/11 at 8 P.M. documents R2 was admitted under altered mental status. R2 returns back to the facility on [DATE] and an x-ray was done on 9/6/11 at the hospital. The hospital x-ray documents there is a fracture through the neck of the 5th metacarpal of the indeterminate age with close opposition of fracture fragments. There was no investigation into the fracture to determine when and how he fractured his 5th metacarpal. On 9/29/11 at 11:15 A.M., in R2 ' s room, there is a portable x-ray machine and Z6 (a technician) and R2. Z6 stated he was called to do an x-ray on R2 ' s right wrist and hand. On 9/30/11 at 9:38 A.M., E3 (acting director of nursing) stated the x-ray was done because he keeps removing the semi-cast. The results are the fracture is still healing. Review of R2 ' s current care plan for falls dated 9/19/11 and 9/22/11 document a fall on 9/14/11 with injury. The incident of 9/14/11 does not document an injury to the fall. R2 already had the injury prior to 9/14/11. On 9/30/11 at 9:55 A.M. during daily meeting with administration, E3 and E2 (director of operations) stated they are unable to answer why no investigations were done into the falls, the physical altercations between residents and incidents of unknown origins. E2 stated she was hired one month ago and E3 stated she thought Z7 (ex-director of nursing) was handling the investigations. E3 stated Z7 was employed from 10/25/10 to 7/29/11 when she resigned. The personnel file reflected the same dates. 2) R19 is a [AGE] year old, ambulatory male who wanders the unit without purpose. R19 is tall and extremely thin. At 72 inches tall, he weighs 109# per the 8/24/11 MDS. R19 is disoriented to all 3 spheres, person, place and time per the current care plan for orientation. R19 was seen throughout the week to wander in and out of dining room, resident rooms and in the hall. R19 wears a cervical collar at all times. The current care plan documents the cervical collar is to be worn at all times. On 9/27/11 between 9:50 A.M. to 10:35 A.M. during the initial tour of 4th floor with E13, E13 stated R19 wears the cervical collar due to his numerous falls. Review of the incident reports for R19 document falls on 7/26/11, 8/14/11, 8/19/11 which were not witnessed and 2 of the incidents resulted in injuries. The incident report dated 8/14/11 at 2:50 P.M. documents R19 sitting on floor of another resident ' s room. R19 sustained a 2 inch cuts to forehead, above the right eye, the lip, left eye lid, left and right knees. R19 was sent out to hospital. There was no investigation. The incident dated 8/19/11 at 2:45 P.M. document R19 face down underneath a dresser in another resident ' s room. R19 sustained a cut to the shoulder and the left elbow. No investigation. The incident of 7/26/11 at 10:40 A.M. documents R19 sitting on the floor in the hallway next to a chair. No injuries were documented and no investigation done. The incidents dated 7/18/11 at 4:20 A.M. document R19 fell from bed and " hit his upper left orbital area " sustaining a small 1 inch wound. R19 required 4 sutures to the forehead. The reports documents E32, a nurse aide, witnessed the incident but there is no statement from her nor was there an investigation. An incident dated 5/29/11 at 1:15 P.M. documents a housekeeper and a nurse aide see R19 ambulating in the dining room, stood still, lost balance and fell . R19 landed on his left side. R19 ' s left elbow is swollen. An order is obtained for an x-ray to entire left arm. The staff were not identified by name nor are there any statements. There were no x-ray results provided or seen. This incident was not investigated. There is an incident for R19 dated 8/4/11 at 2 P.M. documents while making rounds R19 and another resident were swinging at each other in the hallway. R19 sustained a skin tear to the right wrist area. No injuries to other resident. The other resident was identified by room number but no name. Both separated and monitored. No investigation as to why it happened and why R19 and other resident were not in a structured activity. 3) R38 is a [AGE] year old, wheel-chair bound male who is confused and disoriented. R38 ' s [DIAGNOSES REDACTED]. On 9/27/11 between 9:50 A.M. to 10:30 A.M. during the initial tour with E13, R38 was seated in a wheel-chair in the 4th floor dining room. R38 was wearing a winter coat over street clothes and had long (1 inch) finger nails. Throughout the week, R38 was seen propelling himself throughout the unit, in and out of rooms and dining rooms. On 9/29/11 at 11:35 A.M. during the environmental tour with E20 (director of environmental tour), R38 was in the female common bathroom, which is located on the opposite side of the unit. R38 was in his wheel-chair in a toilet stall, facing toilet. When spoken to, R38 did not respond. E13, nurse, was summoned. In the meantime, R38 stood up from the wheel-chair using the grab bars in the toilet stall, failing to lock his wheel-chair, the chair rolled backwards. R38 removed his pants and incontinent brief and dropped them to the floor. It was then E13 entered the room and asked R38 what he was doing in the female bathroom. No response from R38. Review of the current quarterly (7/11/11) MDS documents R38 requires one person limited assistance for toilet use. R38 is continent of bowel and bladder. Review of the incident report dated 5/24/11 at 2:10 P.M. document R38 lost his balance and fell in the 4th floor dining room, landing on his left side of his body and hitting his head on the floor. R38 could not say what happened. A nurse aide witnessed it but there is no name or statement from the person. An x-ray was done on left hand and it was negative. There was no investigation to determine the cause for R38 to loose his balance and fall. Review of the incident dated 6/11/11 at 6 P.M. documents R38 is orient times two. R38 fell in the 4th floor dining room landing on his left side. The incident does not document if it was witnessed. There is second page to the Unusual Occurrence Report (incident report). The second page is labeled Management Follow-up to Incidents. There is a section labeled " interview with staff " it documents the staff found R38 on the floor. R38 was unable to say what happened. R38 was stood up after the fall and he walked to the smoke room (the outside patio adjacent to dining room). There was no investigation to determine what happened to cause his fall. Nor does the report identify the staff person. The incident report date 6/14/11 at 6 P.M. documents R38 is orient times one, loss stability and fell to the floor onto his right side. R38 was picked up and placed into wheel-chair. This was witnessed by a nurse on the floor. There is no name of this nurse and there is no investigation into the fall. R38 was unable to say what happened. It is unclear if R38 was ambulating or stood up from wheel-chair prior to the fall. The incident report dated 7/5/11 at 8:35 A.M. documents R38 laying on the dining room floor and it was not witnessed. R38 could not say how he fell . No injuries noted and R38 placed in wheel-chair. No investigation was done. The incident report dated 6/28/11 at 12:30 P.M. documents R38 was striking a female resident in the face with his fist. This was witnessed by E33, a staff person. No title was given in the report. There was no investigation into the altercation nor was the female resident identified. The incident report dated 8/29/11 at 1:35 P.M. document R38 was struck in the right side of the forehead by another peer because R38 had ran over the peer ' s feet with his wheel-chair. The peer is identified by room number but there is no other identifier for this resident. The aggressor ' s identity is unclear. The incident was witnessed by a nurse aide. This aide is not identified nor is there a statement from the aide. Both residents were re-directed. On 9/30/11 at 9:55 A.M. during the daily meeting with administration staff, E2 and E3 stated they are unable to identify the residents involved in the physical altercations or any staff member who witnessed the falls. E2 stated to be employed for one month and E3 stated she thought the former Director of Nursing was doing the investigations. 4) On 9/27/11 between the 9:50 A.M. to 10:30 A.M during the initial tour with E13 (MDS Coordinator/nurse), R44 was ambulating the unit and asking for money from E13. R44 was very confused. R44 ' s [DIAGNOSES REDACTED]. On 9/29/11 at 11:23 A.M during the environmental tour with E20 (Director of Maintenance), R44 was standing inside his room at the doorway. In the hall outside of his room, on the floor, was a yellow-pooled liquid that looked like urine. E20 stated R44 has a habit of urinating on the floor and in the air conditioner units. The air conditioner unit in the room next to R44 ' s room, which is not occupied, smelled of urine. R44 had a fixed glare on his face and would not answer any questions. E20 summoned the housekeeper to mop up the spill. Review of the current quarterly 8/11/11 MDS documents R44 requires one person limited assistance in toilet use and occasionally incontinent of bowel and bladder. Review of R44 ' s incident reports dated 6/5/11 at 5:30 A.M., 7/12/11 at 12:30 A.M. and 7/18/11 at 2:30 P.M. documents all falls with the incident of 7/18/11 resulting in sutures to the left eye brow. The 6/5/11 incident was not witnessed and R44 was found sitting on the floor next to bed with a small amount of blood on the right cheek. R44 was unable to say what happened. There was no investigation to determine what caused the fall. The witnessed fall of 7/18/11 documents R44 as disoriented and he got up from his wheel-chair without locking the brakes and the wheel-chair rolled backwards. R44 lost his balance and fell forward hitting his head causing a cut above the left eye brow. It required 3 sutures. The intervention is to keep him out of any wheel-chair because he is ambulatory. R44 was unable to say what happened. There was an order for [REDACTED]. The neurologist ' s report dated 8/12/11 documents R44 is a [AGE] year old male with history of Epilepsy. The chief complaint listed " Initial neurological exam. The patient has seizures disorder and dementia. " The report does not document any test done. Recommends levels (Valproic acid and Dilantin) and RTL (routine labs) in 2 months. There was no investigation and the witness is not identified. The incident dated 7/12/11 documents the fall was witnessed by E34, a nurse aide. R44 had stumbled over his feet. The report does not document the factors such as condition of floor and R44 ' s foot wear. There is no statement from the unidentified nurse who assisted R44 off the floor. 5) R36 is a [AGE] year old, wheel-chair bound male. R36 was confused and not oriented to all 3 spheres. Staff would push R36 in and out of the dining room. At times, R36 would use his feet to propel the wheel-chair. R36 ' s [DIAGNOSES REDACTED]. Review of R36 ' s annual 9/19/11 MDS documents R36 requires one person assistance with walking and uses a wheel-chair on the unit. The MDS documents he has impairment with his lower extremities and requires a wheel-chair for mobility. Review of R36 ' s incident reports dated 4/9/11 at 10:30 A.M., 4/29/11 at 2:40 p.m., 5/26/11 at 2:45 A.M. and 6/20/11 at 8:25 A.M. document witnessed falls. The incident dated 4/9/11 documents during a group meeting on the second floor, R36 stood up, was unsteady and fell hitting his right side of the face. R36 stated he remembers falling but denied headache or visual disturbances. The intervention is for activity staff to check with nurses prior to removing R36 from the floor. R36 has an unsteady gait and requires a wheel-chair when leaving floor. There was no investigation or statements to determine why R6 was not asked to remain seated when he got up from chair with unsteady gait. The 4/29/11 incident documents R36 is sitting in a dining room chair, stood up, walked with unsteady gait across the room and fell . When R36 was asked if he was okay, he responded " no. " following the " no " response, the report documents R36 always responds " no " . E35, the nurse is the one who witnessed the fall and documents R36 ' s gait to be unsteady. The intervention was to counsel him on safety. The incident of 5/26/11 documents E37, nurse aide saw R36 come out of his room, stumble down the hallway and fall. E37 informed the nurse, who is not identified, and she finds R36 on his backside on the hallway floor. No injuries. R36 stated he was going home, stumbled forward and used his hands to brace his fall. No investigation to determine why he is so unsteady. The incident dated 6/20/11 documents R36 was carry his own breakfast tray, tripped over his own feet, falling to the floor and injuring both knees. The intervention were to check vitals and notify Physical therapy department. R36 stated he fell to the floor. There is no investigation as to why he continues to fall and why there are no interventions in place. The incident dated 4/14/11 at 7:25 A.M, 8/28/11 at 11:45 A.M. and 9/16/11 at 6:15 A.M. are un-witnessed incidents, The 4/14/11 incident documents R36 face down on the floor in his room. R36 was unable to say what happened. The intervention is one on one monitoring. There was no investigation into the fall. The incident 8/28/11 documents a nurse aide, not identified, finds R36 on the floor of his room. R36 stated he was walking and lost balance. The nurse aide stated during her rounds she found him on floor and informed the nurse. The nurse is not identified. The intervention is for R36 to use the hall rails if necessary and to ask for assistance if needed. There was no investigation to determine what caused him to fall. The incident dated 9/16/11 documents a noise was heard and R36 found on floor in his room. No injuries. R36 responded he was trying to go home. The nurse aide, not identified, found R36 on the floor. The intervention is to place R36 in a wheel-chair but because he continued to get up from the chair he was placed at the nurses ' station. No investigation as to why he continues to fall. 6) On 9/28/11 at 11:58 A.M. in the 4th floor dining room, R32 was holding up his pants while he walked because the pants were too big in the waist and the length of the pants were several inches too long. R32 ' s [DIAGNOSES REDACTED]. Review of the annual 9/13/11 MDS documents him to be independent for walking but requires supervision and set-up for dressing. The incident dated 6/1/11 at 2:30 P.M. documents R32 on his buttocks on the dining room floor. It was not witnessed. R32 was unable to say what happened. There was no investigation as why he fell . The incident dated 8/27/1 at 9:50 A.M. documents R32 is pushed by a female peer and R32 turns around and hit her in the face. Both residents are separated and re-directed to their rooms. E30 (nurse aide) stated she saw another resident, who is not identified, grab R32 ' s collar and push him against the elevator doors. R32 then struck the other resident. There is no investigation into the physical altercation and why was there no immediate intervention/supervision. The intervention was to separate the residents, medication given to decrease the agitation but does not indicate if both residents were medicated or just one resident and re-direct them to their rooms, not a supervised area. 7) Throughout the week, R34 would ambulate in and out of her room to the nurses ' station and in/out of the dining room, carrying a bible and saying incoherent gibberish and return to her room where she would mostly stay, sitting on her bed. R34 would wear a house dress and non-skid socks. R34 is an [AGE] year old, ambulatory female who is very disoriented. R34 ' s [DIAGNOSES REDACTED]. On 9/29/11 at 11:30 A.M. during the environmental tour with E20 (director of maintenance), R34 is seated on her bed with her bible as seen all week. R34 was talking to herself. She left room and began to follow us talking incoherently and swearing. As we left her side of the unit and proceeded back to the nurses ' station. There is a 12 foot electrical cord for the floor buffer that extends the width of the hallway. R34 is following us and needs to step over the cord. The incident reports dated 4/29/11 at 2:30 A.M. documents a loud noise was heard by nurse and nurse aide, both not identified by name, who find R34 on the floor on her backside. R34 complained about soreness on her right shoulder but refused the Tylenol. X-ray was negative for a fracture and dislocation. R34 stated she had a dream that there were snakes in the bed so she ran to the window. There were no interventions put in place. The incident dated 6/14/11 at 8:45 A.M. documents R34 is found on the floor of her room and has a cut on her forehead. Other resident re-directed and residents kept separate. There is no investigation into how the injury occurred and it does not identify the other resident. R34 sent out to hospital for evaluation and treatment but no follow-up to this information. The incident dated 7/22/11 at 2 A.M. documents a nurse aide, not identified by name, found R34 on the floor. The nurse aide helped R34 off the floor and onto the bed. R34 was unable to say what happened. There is no account from the nurse aide as to what she witnessed nor is there an investigation into why R34 fell . R34, who is cognitively impaired, was instructed to ask for assistance. The incident dated 6/23/11 at 10:40 P.M. document R34 was punched in the right side of her head by another resident. The report documents a witness but no one is identified nor is there any statement. There was no investigation. The incident dated 8/23/11 at 4:10 P.M. documents R34 being very upset and stated she was struck in the face by another female resident in the female Common Bathroom. No injuries seen. The other resident was not identified and there was no investigation into the incident. R34 was relocated to the dining room at this time. The incidents dated 4/15/11 at 11 A.M and 6/24/11 at 4:30 P.M. document R34 physically assaulting ( 2.5 inch scratch on neck) the a hospice nurse for no reason except she walked by her when R34 was escalating at the nurses ' station. No investigation into what caused R34 to escalate. The incident dated 6/24/11 documents R34 scratched E38 (staff) when R34 was re-directed by E38. R34 was aggressive and uncooperative. R34 was sent out to hospital for psychiatric evaluation. No follow up to the incident nor was there an investigation into the cause of R34 ' s erratic behavior. 8) R33 is a [AGE] year old, ambulatory female who has a [DIAGNOSES REDACTED]. On 9/27/11 between 9:50 A.M. to 10:30 A.M. during initial tour with E13 (nurse), E13 stated R33 was receiving radiation treatment that morning and was out of facility. The incident dated 5/27/11 at 10:35 P.M. documents R33 as oriented and the incident report dated 6/10/11 at 2:30 P.M. document her as disoriented. These two incidents and incidents dated 6/28/11 at 12:30 P.M are all physical altercations between R33 and other residents. The 5/27/11 incident documents R33 complaining about her roommate hitting her in the back when she was taking a shower. Redness noted on her backside. The report documents that staff spoke to the aggressor and both are separated. No investigation documented. The incident dated 6/10/11 documents R33 and another resident were entangled in a physical altercation and pulled apart by staff. R33 stated the other resident scratched her hand so she threw a cup at her and will do it again. The intervention is to " see if R33 could have medication work-up on a psychiatric ward " per Z3, the psychiatrist. There was no documented follow through on this intervention. The incident dated 6/28/11 documents R33 being struck in the face by R38 and it was witnessed by staff. There are no staff identified and no investigation into what caused the altercation. The incident dated 7/7/11 at 8 P.M. R33 is found on the floor. R33 is delusional and could not say what happened. The intervention was for R33 to " watch where she is going. " There was no investigation as to what caused the fall. 9) Throughout the week, R39 was in the 4th floor dining room ambulating in and out and Back and forth from his room. Review of the incident report dated 9/13/11 at 9:30 A.M. documents R39 to be [AGE] years old with [DIAGNOSES REDACTED]. The 9/13/11 at 9:30 A.M incident documents R105 reporting to staff that R39 and R146 were fighting in the dayroom. R105 stated he saw R146 throw water on R38. R39 stated after R146 threw water on him, he hit R146. Staff did not witness the incident. There was no investigation or explanation why residents were not supervised in the dayroom. The incident dated 8/1/11 at 10:10 P.M. document R39 was walking out of his room and fell straight backwards hitting his head on the floor. No injury. It is unclear if it was witnessed. There is no investigation into the incident. 10) The incident report dated 7/4/11 at 1:30 P.M. document R45 was found on the floor of the dayroom. R45 is a [AGE] years old and has [DIAGNOSES REDACTED]. R45 stated she fell out of her wheel-chair but not sure how. There was no investigation to determine what happened and why the dayroom was not supervised. The incident was not witnessed. 11) The facility ' s policy labeled " Falls - Clinical Protocol " document that falls often have a medical causes; they are not just a " nursing issue. " Under Cause Identification, item 1. " Staff will attempt to define the possible causes within 24 hours of the fall. Item 2. If the cause of the fall is unclear, and it may be significant medical causes such as stroke or an adverse drug reaction or if the resident continues to fall despite attempted interventions, a physician will review the situation and help identify contributing causes. Under item 3. The staff and physician will continue to collect and evaluate information until either the cause of falling is identified or it is determined that cause cannot be found or that finding the cause would not change the outcome or the management of the falls. Under Treatment/Management, under item 2., if the underlying cause cannot be identified or corrected, staff will try various relevant interventions based on assessment of the fall until the falls reduces or stop or until a reason is identified for its continuation. Under Monitoring and Follow-up, under item 4., if the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident ' s falling and will re-evaluate the continued relevance of current interventions. 12) R13 has [DIAGNOSES REDACTED]. R13 was initially admitted to the facility on [DATE]. R13 ' s Criminal History Analysis Security Recommendation Report ( CHASRR) dated 8/30/11, indicated that R13 is an identified offender, and was assessed as Moderate Risk for convictions from forgery, criminal trespass vehicle, several drug related offenses, to prostitution. Her security recommendation per this analysis is, R13 requires closer supervision and more frequent observation than standard or routine for most resident in the open facility. Regular monitoring should be attentive to behavioral changes that may signal a need for closer observation or sustained visual monitoring on a limited time basis. This assessment also indicated, that R13 admitted to currently drinking alcohol and had recently snorted cocaine. R13 ' s nurses notes dated 9/21/11 at 12 AM, indicated that R13 was staying with R13 ' s next of kin, Z1, and that Z1 said that R13 will be back in AM. Per nurses notes dated 9/21/11 written at 11:30 ( no indication if AM or PM ), R13 returned to the facility stating that she got into a physical altercation, and that, a man hit her. R13 ' s right eye is shut, swollen, very dark and red, and was having spasms. R13 ' s left eye is also slightly swollen and red. R13 was sent to the hospital and came back on 9/22/11 at 4 AM. Review of facility ' s abuse investigations shows no evidence that an abuse investigation was done, nor was the state department made aware of an initial and final result of the investigation. During 9/28/11 interview at 1:50 PM, E1 ( Administrator ) said that he is not aware of any allegation of abuse involving a resident and a family or another non-resident from the outside. Per E8 ( case worker ) during 9/28/11 interview at 11:27 AM, R13 returned late after a community pass on 9/21/11, and was sent to the hospital because she had a black eye. E8 said that the police initially came to the facility, but R13 was upset and did not talk to them. E8 continued that after the police left, R13 told E8 that she knows the man who hit her. E8 said that she spoke to R13 again on 9/27/11 and that this time, R13 said that she had a physical altercation with this guy she knows, and when the fight was broken off, the man unexpectedly hit her with a pole after the fight ended. E8 said that R13 just said it was a friend and did not say what the person ' s name was. E8 said she did not ask R13 further on 9/21/11. Per R13 ' s Physician order [REDACTED].

F323 Based on observation, interview and record review the facility failed to provide supervison and monitor 1 sampled resident R2 Identified with a history of smoking in inappropriate places. This failure resulted in R2 causing a fire in her room, as a result of the fire R2, and R9 was transported to the hospial for evaluation of smoke inhalation. The facility also failed to assure residents floors and residents access areas including stairwells and bathrooms were monitored for smoking by staff. The facility also failed to ensure that R9 identified with unsafe smoking behaviors were reassessed for safe smoking behaviors. These failures resulted in an Immediate Jeopardy. These failures, has the potenital to effect 311 residents curently at the facility. E1(Administrator) was notified of the Immediate Jeopardy on February 15, 2011 at 1:45pm via telephone confernce. The Immediate Jeopardy was determined to have begun February 10, 2011 when R2 started a fire in her bedroom. Findings include: On 2/10/11 at 12:00pm E1(administrator), said that at 3:20am he was notified at home by security that there was fire on the 6th floor at the facility. According to the facilities unusual occurrence report dated 2/10/11 R2 was observed running out of her room yelling fire, fire everybody needs to get up and go home. R2 was assessed as confused, vital signs were assessed blood pressure 128/76, pulse rate 84, respirations 18, temperature 98.3. The management follow-up to incident the follow up indicated that R2 was in her room and a fire just started by her bed. She also stated that she was mad at another resident. R2 was placed on 1:1 intervention to prevent injury to self, and others. The follow up denotes that R2 was sent to the hospital for evaluation and smoke inhalation. On 2/10/11 at 12:45pm with E3 (Assistant administrator), Room 623 was observed to have water on the floor, and a mattress which appeared to have been burned, black in color and cover of mattress appeared to be melted. E3 said the mattress belongs to R2, the mattress was moved to the other side of the room. On R2's side of the room there was pile of burned damaged clothing black and destroyed, the privacy curtain was burned and melted up to the ceiling On 2/10/11 at 2:00pm E1 said that R2 had been sent to the hospital for psychiatric evaluation, and was unavailable for observation or interview on 2/10/11. E1 said that no other residents were sent out to the hospital related to fire. E1 said that R2 had (2) room mates both still in the facility. On 2/10/11 at 3:45pm in the 8th floor break room R3 said that she was R2's room mate, and was assessed to be alert and oriented to person/time. R3 said that around 3:00am on 2/10/11 she heard her room mate R2 yelling fire, fire. R3 said that she observed flames coming from under R2 ' s bed along with a lot of smoke. R3 said she was told to get out the room. R3 said that she have been the room mate of R2 for about 10 months. R3 said that R2 has a history of smoking in the room at night after the smoke room closes. R3 said that she didn't report it to anyone but said that staff has come in the room saying that they smell smoke. R3 said that the experience was scary. R3 said that she feels okay and can breathe fine. On 2/10/11 at 4:05pm in the 8th floor break room R4 said that she is the room mate of R2, and has been the room mate for about 3 to 4 months. R4 said that at around 3:00am on 2/10/11 she was awakened by R2 yelling there was a fire in the room. R4 said that she grabbed some things and got out of the room. R4 said that she didn't see R2 smoking in the room that morning, but did say that R2 smokes in the room every night after the smoke room closes on the first floor. R4 said that she has not reported it to staff, but said that staff will come in the room checking because they smelled smoke. According to R2's clinical record R2 was last assessed for smoking safety on 6/21/2009. R2 was assessed potential for causing injury to self, or others in unauthorized area or careless use of smoking materials. R2 was also assessed to be a potential risk for safely following the facility's safe smoking policy. The assessment indicates that R2 has no history of hazardous and inappropriate behaviors. The comments indicate that R2 has been redirected for inappropriate smoking. A review of R2's plan of care indicated that R2 was assessed to have impaired judgment related to mental illiness, a nicotine dependency, and compulsive smoking. R2's plan failed to indicate any interventions to monitor, or supervise and keep R2, and other safe related to R2 being identified with a history of inappropriate smoking. A review of R2's plan of care indicated that R2 was assessed to have a nicotine dependency, and compulsive smoking. According to social service notes dated 2/10/11 indicates that R2 was smoking in her room in the early morning hours, and her bed caught on fire. According to social service notes dated 12/31/10, and 1/31/11 both notes indicate that R2 has a history of smoking inappropriately. The notes were written by E11. On 2/11/11 at 5:40pm E11 (social service), said that R2 has a history of smoking in inappropriate places, but can't recall R2 being observed smoking in inappropriate places recently. E11 said that staff is required to make rounds every 2 hours, to check for inappropriate smoking. E11 said that residents assessed for inappropriate smoking are listed on the facility's smoking program. E11 said that R2 is not on the smoking program list. E11 said residents are not allowed to have smoking material on their person to include cigarettes, matches, and lighters. E11 said that residents are assessed for smoking appropriateness, at admission, annually, and quarterly. E11 said that he has only been assigned to R2 since January, 2011. E11 said that he has not assessed R2 for smoking since he has taken over R2's case. E11 said that R2 goes out into the community on pass, at times. E11 said that security is expected to search residents upon returning to the facility. E11 explained that the facility smoking program is for residents that are assessed or observed to have unsafe smoking behaviors or smoke in inappropriate places. On 2/16/11 via telephone E7 (licensed nurse), said that at around on 3:00am he was told by E8 (certified nurse aide), that she smelled smoke. E7 said then he heard the fire alarm ring. E7 said that he received a call from security stating that room 623 smoke detector was alarming. E7 said that as went to the east hall way R2 was running out of room 623 yelling fire, fire. E7 said that R2 was delusional as she was running out of the room. E7 said that he looked into Room 623 and yelled for R3/R4 to come out of the room. E7 said that all residents were initially evacuated to the first floor except for R9 in room 625. E7 said that he observed R2 ' s mattress in-gulfed with flames and a box of clothing also on fire under R2 ' s bed. E7 said that he inhaled a lot of smoke and notified the fire department to get R9 out of room 625. E7 said that after accounting for all residents he put R2 on 1:1 monitoring, and E7 said that R2 didn ' t say how the fire started. E7 said that he has caught R2 with smoking materials, before and said that he confiscated the materials from R2. E7 said that when a resident is found with smoking materials they are referred to social service for counseling and assessed for inappropriate smoking. E7 said he recalls confiscating cigarettes and a lighter from R2 sometime this year (2011). E7 said he didn ' t recall if he referred R2 to the social service department. E7 said that residents are not allow to smoke after 11:00pm and can restart smoking at 8:30am daily. E7 said that at times he works with 1 or 2 certified nurses aides, but on 2/10/11 there was only on certified nurses aide working with him on the 6th floor unit. E7 said that he was aware that certified nurses aides are required to make rounds every 2 hours to check to see if the appropriate resident is the correct rooms, smoking and any loud noises. E7 said that he was aware that some point R2 was assessed for inappropriate smoking, but lately R2 was not observed smoking in inappropriate areas. E7 said there were no safety measure in place for R2 on 2/10/11 other than rounding. E7 said that he recalls speaking with R4 (R2 ' s room mate), and was told by R4 that she smelled cigarettes scent coming from R2 ' s area of the room. On 2/23/11 at 11:00am via telephone E8 (Certified Nurses aide), said she did rounds on at 11:00pm on 2/9/11, ensure that all resident were in the appropriate rooms. E8 said as she made rounds she could smell smoke in the female washroom. E8 said that when she entered the bathroom R2 was observed in the washroom with a scent of cigarette smoke. E8 said that R2 was observed with no smoking materials. E8 said she made rounds again at 2:00pm and R2 was in ther bed with the cover over her head. E8 said she returned to the nurses desk to complete paper work. E8 said about 3:00am the alarm sounded, it was identifed as being in room 623, E8 said that as she and the nurse went to see what was going on black smoke was noted coming from R2's room. E8 said that R2 and roomates were running out of the room. E8 said that R9 was in room 625 and said that the heavy smoke made it impossible to get to R9 in room 625, but said that the fire department was directed to the room. E8 said that R2 has a history of unsafe smoking. E8 said that she has observed R2 smoking in other residents room. E8 said that R2 is also known to have smoking materials on her person, contray to the facility policy. E8 said that she makes rounds on the unit every 2 hours. On 2/18/11 at 12:55pm E12 (security director), said that in general security asks, residents when returning to the facility if they have smoking materials on them. E12 said if a resident is identified as unsafe smoker, they will pat their bodies down. E12 said that there is one female security officer on staff, and when she is working she checks female residents. E12 said that R2 has a history of bringing smoking materials into the facility, E12 said that R2 hides material in her vaginal area. During a tour of the facility on 2/10/11 of the 7th and 8th floor, cigarette ashes, and cigarette butts were obsereved on the floor of the both the east and west bathroom. While touring the facility cigarettes butts were observed in the stairwells of both the 7th/8th floors. E3 and E5 was were present during the tour. During the tour at 1:30pm E3 said that this is psyche facility and we do our best. According to the hospital records dated 2/10/11 E9 was admitted to the hospital with [REDACTED]. On 2/10/11 at 5:30pm E3 (social service director), said that staff are required to do rounds on the nursing units every two hours and complete the facility's smoking rounds log. On 2/10/11 the facility was unable to provide survey team with current smoking rounds for the 6th floor. A review of the smoking rounds log sheets, for the 6th floor was last noted to be complete was 2/4/2011. On 2/18/2011 at 10:00am E3 said that the facility was unable to locate the missing smoking round sheets. However the E3 did provide surveyor with a new revised smoking assessment, and safesmoking round sheet. According to the facility's smoking policy denotes the purpose of the polciy is to promote and protect the safety and welfare of the facility's resident. The policy also indicates that facility staff will identify residents observed or assessed as exhibitin unsafe/inappropriate smoking behaviors and assign them to the smoking program. Once assigned to the smoking program, residents identified as exhibiting inappropriate and/or unsafe smoking behaviors will be placed on smoking rounds. The policy also denotes that no resident will be allowed to keep smoking materials on his/her person, or in their rooms. The policy also denotes the facility will provide a designated smoking area, and all residents smoking will be monitored. According to the facility's protocol social service are required to perform an smoking safety risk assessment at time of admission, and annually. On 2/17/10 the facility provided survey team with a revised protocol indicating that residents will be have a smoking safety risk assessment completed at time of admission, annually, quaterly and observation/incdent. The immediate Jeopardy was removed on February 18, 2010 at 4:30pm. E2 (Director of Nursing), was present. However the facility still remains out of compliance at a scope and severity level 2 because of the need to allow for the facility to complete Nursing in-service, and to evaluate the effectiveness of the revised protocol to search residents upon entering the facility, revised smoking policy, hourly rounds/ monitoring and assessment for inappropriate smoking behaviors and care plan updates. The facility provide the following plan: 1. All residents were re-assessed. All care plans will be updated with interventions campleted by 2/21/2011. I dentified residents with known violations will be re-assessed and care plan updated quarterly, and as needed, (of any and all observed infractions). 2. Staff (Nurses, Social service, and Security) will conduct a search of all residents upon entering the facility and leaving the smoke room. 3. A through search of all identified residents room will be conducted every two hours daily or as needed by Nursing, and Social service personnel. until 2/28/2011. Thereafter every shift daily indefinitely. 4. All searches will be conducted appropriate and according to residents rights. 5. A smoking log will be kept on each floor with residents who violate facility's smoking policy. The Social service designee will audit smoking logs daily to ensure that residents who violate the facilitiy's smoking policy will be placed on the non-compliance smoking rules processes. (Offense 1,2, and 3). 6. Social worker will attend a special residents council meeting to expalin revised facility smoking policy. 7. Quality Assurance meeting will be held 2/22/11 at 10:00am with Medical Director. 8. 75% of staff in-services are projected to be completed by 2/22/2011. The remaining 25% will be completed by 2/28/2011. The titled in-services to be completed a. Revised smoking policy b. Search/Rounds protocol The Facility Administrator will monitor for overall compliance.