Every finding on record at Landmark of Hyde Park Rehabilitation and Nursing C

Based on observation, interview, and record review the facility failed to implement an effective pest control plan. This failure affects five residents (R3, R4, R6, R7, and R8) and has the potential to affect all 254 residents in the facility. Findings include:R3's Brief Interview of Mental Status (BIMS) dated 5/25/26 shows a score of 3 which indicates that R8 has cognitive impairments.R3's face sheet shows that R3 has diagnoses including epilepsy, memory deficit and major depressive disorder.R4's BIMS dated 6/15/26 shows a score of 15 which indicates that R4 is cognitively intact.R4's face sheet shows that R4 has diagnoses including major depressive disorder, asthma and malignant neoplasm of unspecified site of right female breast.R6's BIMS dated 6/15/26 shows a score of 15 which indicates that R4 is cognitively intact.R6 face sheet shows that R6 has diagnoses including dementia in other diseases, bipolar, anxiety, and encounter for attention not other artificial opening of urinary tract.R7's BIMS dated 7/27/26 and shows a score of 13 which indicates that R7 is cognitively intact.R7's face sheet shows that R7 has diagnoses including bipolar, ataxic gait, nicotine dependence, schizophrenia and psychosis.R8's BIMS dated 7/20/26 shows a score of 1 which indicates that R8 has cognitive impairments.R8's face sheet shows that R8 has diagnoses including dementia, schizoaffective disorder, bipolar and anxiety.On 7/31/26 at 11:14 am, R3 and R4's room was observed with insects consistent with gnats flying in R3 and R4's room. R4 stated that her granddaughter purchased her a fly trap that consisted of apple cider vinegar and dish soap that was observed on R4's bedside table contained in an apple shaped red container with multiple holes in the top of it, that held the liquid consistent with apple cider vinegar and dish soap. R4 stated that she sees less gnats since her granddaughter purchased her a fly trap.On 7/31/26 at 11:17 am, Surveyor observed V6 (Housekeeper) cleaning the third floor unit. V6 stated that R6, R7 and R8's room has multiple flies and gnats in the room. V6 then explained that he cleans R6, R7 and R8's room when he is assigned to the third floor unit and will spray their room with insect repellent that he receives from V8 (Housekeeping Supervisor) however, he still sees the gnats in the R6, R7 and R8's room when he cleans. There were numerous flying insects consistent with flies and gnats observed in R6, R7 and R8's room. R6 was in bed while multiple insects were observed present within R6 immediate environment, on R6's clothing and colostomy bag, all the bed linens and beds in the room, and all the privacy curtains in R6, R7 and R8's room. R6 stated There are flies because of my roommates. These people don't care. They just take my money. R7 and R8 were not available for questioning, the nurse stated that R7 and R8 were off the unit.On 7/31/26 at 11:35 am, these observations were immediately brought to the attention of V8 (Housekeeping Supervisor) and V1 (Administrator). V8 stated that if the staff do not report the sighting in the pest control book, V8 is not able to make the pest control aware to treat the sighting. V8 explained that the Pest Control company was at the facility the day before on 7/30/26 and did not treat R6, R7 or R8's room for gnats because staff did not report the sighting in the pest control sighting log. V8 then explained if a resident has multiple flies and gnats flying on them or around them it may bite the resident and can make the resident uncomfortable. Surveyor and V1 observed the insect infestation in R6, R7 and R8's room and V1 stated, Those are gnats. Gnats can bite. We can call the pest control company to come out and treat it. The facility's document titled Pest Control Sighting Log reviews without staff reporting any rooms on the third floor with flies or gnats.The facility's policy dated 2024 and titled Pest Control Policy documents, in part Purpose: This of this policy is to ensure a pest-free environment within our facilities by outlining procedures for the prevention, monitoring, and control of pest infestations. Scope: This policy applies to all employees, contractors, and visitors within the premises of the facility. Responsibilities: Management: ensure the implementation of this policy, provide necessary resources, and review pest control measures regularly. Employees: Adhere to this policy, report any past sightings immediately, and follow cleanliness protocols . Monitoring: 2. Reporting Please must report any past sightings to the designated pest control coordinator immediately. Maintain a pest sighting log for tracking and follow up purposes. Training: If staff see any pest activity, they should record it on the pest control log located at the nurses station. Keep employees informed about the importance of their role maintaining every environment.

Based on interview and record review the facility failed to ensure that an allegation of staff-to-resident abuse was reported in accordance with facility policy and regulatory requirements. This failure affects 1 of 3 residents (R2) reviewed for abuse.Findings include:R2's face sheet shows that R2's diagnoses including major depressive disorder, bipolar disorder, cannabis abuse, nicotine dependence, general anxiety disorder, insomnia, essential hypertension, gastro esophageal reflux disease without esophagitis.R2's Brief Interview for Mental Status (BIMS) dated 7/24/26 shows a score of 15 which indicates cognitively intact.On 7/31/26 at 11:52 am, R2 stated that on 7/14/26 around 8:40 pm, R2 left his sixth-floor unit and went to the third-floor unit at the facility to obtain a bottled beverage from the third-floor dining room vending machine. R2 then explained when he tried to get off the elevator on the third-floor unit V12 (Certified Nursing Assistant, CNA) lunged at R2 and told R2 No. You can't get off here and then started calling R2 out of R2's name with profanity (R2 does not recall the language he alleges V12 used). R2 stated he then told V12 that he does not need to speak to him in that manner and that he (R2) was not V12's kid. R2 then explained that V13 (CNA) allowed R2 to obtain the bottle beverage from the vending machine in the third-floor dining room and R2 got back onto the elevator went to the fifth-floor unit at the facility and reported the incident to V16 (Licensed Practical Nurse, LPN). R2 further explained that he did not mean to report that V16 witnessed the event and that he meant to explain that after he reported the event to V16, she (V16) then reported the incident to V14 (Registered Nurse, RN, Nurse Supervisor). R2 then stated that V14 came to R2's room and questioned R2 regarding the incident between R2 and V12 and that he reported to V14 that V12 lunged at him (R2) and was verbally inappropriate to him (R2), talking to him like a kid and using profanity. R2 then explained that he asked V14 for V12's name and that V14 refused to give him V12's name. R2 then explained that he called his mother and reported the incident to his mother who directed R2 to call the local police. R2 then explained that he called the 911 to report the incident to the local police however the local police did not come to the facility. R2 then stated the next day on 7/15/26, V4 (Social Service Director) came to R2's room and asked R2 what happened between R2 and V12 and R2 informed V4 that V12 lunged at him and was verbally inappropriate to R2, talking to him like a kid and using profanity. R2 then explained that V4 brought R2 down to V1's (Administrator) office and that V1 asked R2 regarding the incident between R2 and V12 and R2 reported to V1 that V12 lunged at him and was verbally inappropriate to R2, talking to him like a kid and using profanity the day before (on 7/14/26). R2 also explained that while he was in V1's office, he observed the video of R2 and V12 on V1's television paused with R2 at the elevator and V12 at the nursing station during the time of the incident. R2 stated that V1 informed R2 that V12 no longer works at the facility due to the incident between R2 and V12 however he still sees V12 when he is in the elevator. R2 then stated that he feels safe at the facility, that he is not afraid of V12 and explained when he is in the elevator with V12, V12 appears afraid of R2 and does not say anything to R2.On 7/31/26 at 12:47 pm, V4 (Social Service Director) stated she is familiar with R2 at the facility and that R2 reported having a verbal altercation with V12 (CNA) to V4 on 7/14/26. V4 explained that she read the incident in the overnight report on 7/14/26 around 8:30 pm - 9:00 pm, that is sent via text from V14 (Registered Nurse, RN, Nurse Supervisor) to the supervisors at the facility. V4 further explained that the report stated that R2 reported that V12 got in his face, started calling R2 names and verbally attacked R2 (V4 explained that R2 reported that he could not recall the words said by V12). V4 then explained on 7/15/26, the next morning, she went to speak with R2 and initially R2 refused to speak with V4 and requested that the police be called so that R2 could make a statement and that R2 continued to verbalize that he would only talk to the police and that he did not trust to speak with anyone else. V4 then explained a few hours later R2 began stating that he had already called the police, but the police never came to the facility. V4 then explained that R2 then came to V1's (Administrator) office two and half hours later and gave V1 a statement and reported that V12 (CNA) got in his face and verbally attacked him with profanity. V4 then stated that R2 explained that the incident between R2 and V12 started on 7/14/26 when R2 took the elevator from his room on the sixth floor to go to the second or third floor to get a bottled beverage. V4 stated that R2 reported that before he got off the elevator, he asked the V13 (CNA) if he could get off the elevator and V13 said told him yes and then R2 got off the elevator. V4 then explained that R2 stated once he got off the elevator V12 (CNA) got into his face and started calling him names and threatening R2 with verbal abuse. V4 further explained that R2 stated that he walked away and went back to his floor and reported the incident to V14 (Registered Nurse, RN, Nursing Supervisor) and that V14 did nothing regarding what R2 reported happened. V4 further stated that V4 and V1 reviewed the video from the reported incident on 7/14/26 and observed R2 going to the dining room, getting a bottled beverage, and then walking and speaking towards V12 attempting to get into V12's face, while V12 began to walk away from R2 and not saying anything to R2, while V13 (CNA) stopped R2 from walking towards V12. V4 explained that the video also showed there was no purpose for R2 to go towards V12 after getting his bottle beverage and that R2 could have gone directly to get on the elevator.07/31/26 at 1:18 pm, V1 (Administrator) stated that she was aware of R2's allegation of V12 being verbally abusive towards R2 and that V1 conducted an investigation by speaking with staff who witnessed the event and reviewed the facility cameras which shows that R2 was aggressive towards V12 and then determine that the R2's alleged report of verbal abuse did not occur and so she kept a Soft file regarding the event and did not feel that she needed to report R2's allegation of verbal abuse to the local state agency. V1 explained that on 7/15/25 R2 reported on 7/14/26 that he went to get a bottled beverage from the third-floor unit after 8pm and when he got off the elevator on the third floor, V12 (CNA) told R2 he was not supposed to be there, began cursing at R2 stating things like F ** you B**. V1 stated that she is the abuse coordinator for the facility and if a staff uses profanity such as F** you B** to the residents it is considered verbal abuse. V1 stated that any allegations of abuse must be reported to the local state agency within two hours due to the regulations. V1 then explained If a resident reports an allegation of abuse and the abuse is not investigated and reported to the local state agency the abuse can continue.On 8/1/26 at 9:10 am, V13 (Certified Nursing Assistant, CNA) stated she works on the 3:00 pm to 11:00 pm shift and on 7/14/26 she was on the third-floor unit standing at the nurses station around 8:00 pm, with V12 (CNA) assisting another resident when R2 got off the elevator on the third floor and walk into the dining room without stating why he was on the third floor (V13 explained that R2 lives on the sixth floor at the facility). V13 then explained that V12 tried to redirect R2 by telling him he was on the third floor and not the sixth floor and R2 then stated to V12 You can't tell me what to do and then lunged at V12 stating I'm a grown A*** man. V13 explained that she then told R2 to go and get the bottled beverage and the next time to let the staff know why he is trying to get off a floor that he is not assigned. R2 then started to approach V12 and V13 continued to redirect R2 to the elevator after R2 got his bottled beverage. V13 explained she stayed at the elevator until R2 got on the elevator and left the third floor and that V12 walked in the opposite direction of R2 while V13 stayed at the elevator with R2 until R2 got on the elevator. V13 denied that V12 hollered, lunged or was verbally abusive towards R2. V13 explained that V12 never spoke to R2 in a threatening manner. V13 stated when residents have behaviors the resident is redirected and if the resident not able to be redirected the psychiatric technician and supervisor is informed. V13 explained that R2 was able to be redirected without further incident on 7/14/26.On 08/01/26 at 9:39 am, V16 (Licensed Practica Nurse, LPN) stated she works on the 3:00 pm to 11:00 pm and that she is familiar with R2. V16 denied R2 ever reported an incident occurring with R2 and any staff at the facility. V16 explained on 7/14/26 she was at the fifth-floor nurses station standing at her medication cart when the elevator door opened and R2 stepped off the elevator with a bag in his hand stating, I'm tired of this. V16 then explained she asked R2 Tired of what? V16 then stated that she did not know what R2 meant and asked R2 again what he was tired of however R2 never answered V16 and got back onto the elevator. V16 explained once R2 got back onto the elevator she reported to V14 (Registered Nurse, RN, Nurse Supervisor) that R2 got off the elevator on the fifth floor stating, I am tired of this and that V14 should speak with R2 about repeating I'm tired of this. V16 denied that R2 has ever reported to V16 staff lunging at him, hollering at him or being verbally abusive to R2 at the facility. During this investigation surveyor requested for V14 (Registered Nurse, RN, Nurse Supervisor) contact information and V1 stated that V14 was out of the country, and no contact information was provided. Surveyor also requested to reviewed video recording for the third floor on 7/14/26 and V1 stated that she no longer has the recording that she reviewed on 7/14/26 regarding R2 and V12.The facility's policy dated 1/2019 and titled Abuse Prevention Program documents, in part: Policy: It is policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and crime against a resident in the facility. The following procedure 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 . V. Identification of Allegations of/Internal Reporting Requirements: Please 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 . Supervisor shall immediately inform the administrator or in the absence of the administrator, the director of nursing [NAME] of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, misappropriation of property, mistreatment, or a crime against a resident. Upon learning of the report, the administrator or in the absence of the administrator, the [NAME] shall initiate in incident investigation . Investigations: Incidents, allegations or suspicions 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 abuse investigation . Verbal Abuse: Of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, the ability to comprehend or disability.The facility's undated document titled Resident Behavior and Facility Practices documents, in part: Abuse: You have the right to be free from verbal, sexual physical or mental abuse, corporal punishment and involuntary seclusion. Staff Treatment: The must implement procedures that protect you from abuse, neglect or mistreatment, and misappropriation of your property. In the event of an alleged violation involving your treatment, the facility is required to report it to the appropriate officials. All alleged violations must be promptly and thoroughly investigated and the results reported to appropriate agencies. Correction must be taken.

Based on interview and record review, the facility failed to follow their Abuse Prevention Program policy by failing to notify the State Survey Agency immediately of abuse allegations. This failure affects two residents (R1, R4) of nine residents reviewed for abuse in a total sample of nine residents. Findings include: 1. R1's medical record documents, in part, the following medical diagnoses: left hip osteoarthritis, asthma, type 2 diabetes mellitus, hepatitis c, hypertension, hyperlipidemia, anemia, major depression, obesity, peripheral vascular disease, schizoaffective disorder and altered mental status. R1's Minimum Data Set (MDS) dated [DATE] documents that R1 is cognitively intact. On 7/13/26 at 2:50pm, R1 explained her abuse allegation and stated that she reported it because R1 felt that a nurse assistant was rude and rough. R1 indicated that the alleged abuse incident occurred on 7/12/26 at around 2:30pm. R1 could not recall the nurse assistant's name. On 7/15/26 at 2:50pm, V3 (DON-Director of Nursing) indicated that the employee was identified as V16 (CNA-Certified Nurse Assistant). R1's abuse allegation was reported to V1 (Administrator) on 7/13/26 at 3:45pm. According to an electronic mail (email) confirmation submitted by V1, R1's initial abuse allegation report was not sent to the State agency until 8:08pm on 7/13/26. 2. R4's medical record indicates an admission date of 7/21/25 and documents, in part, the following medical diagnoses: Major Depressive Disorder, Diabetes, Bipolar Disorder, Pain in hip/knee, Insomnia, Tobacco Use, Suicidal Ideations and Traumatic Brain Injury. R4's Minimum Data Set (MDS) documents a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. On 7/13/26 at 2:38PM, R4 was crying and reported an ongoing pattern of harassment by V7 (Psychiatric Technician). R4 states that an incident occurred today, 7/13/26, while V7 was distributing cigarettes. R4 states that V7 told her, Go stand over there, I'll make you stand there all day. R4 states that, when another resident attempted to offer R4 a cigarette, V7 intervened and prevented the exchange. V7 instructed the other residents to distance themselves from R4 and R4 sat alone and cried on the smoker's patio. R4 reports that V7 stated, Oh, now you're going to cry like a baby? R4 expressed that this ridicule in front of R4's peers caused R4 to become upset causing emotional distress. On 7/13/26 at 3:45PM, V1 (Administrator/Abuse Coordinator) was notified of the incident between V7 and R4 as well as an abuse allegation lodged by R1 regarding V16 (CNA). On 7/15/26 at 2:27PM, V1 provided an electronic mail (email) confirmation of R1 and R4's initial abuse report submissions to the State agency which documents a sent date of 7/13/26 and the time stamp is 20:08 (8:08pm). On 7/15/26 at 2:45pm, V1 confirmed that she was notified of R1 and R4's abuse allegations on 07/13/2026 at 3:45PM. V1 stated that the delay in reporting the abuse allegations to the State agency was, I need to have everything approved before I can send it out. Facility's Abuse Prevention Program Policy & Procedure with a revision date of 3/1/21) reads, in part: If you suspect abuse: Complete an incident report immediately. Fax report to (State agency) immediately.

Based on interview and record review, the facility failed to protect the resident's (R4) right to be free from verbal and mental abuse. This failure affects one resident (R4) of nine residents reviewed for abuse in a total sample of nine residents.Findings include:R4's medical record indicates an admission date of 7/21/25 and documents, in part, the following medical diagnoses: Major Depressive Disorder, Diabetes, Bipolar Disorder, Pain in hip/knee, Insomnia, Tobacco Use, Suicidal Ideations and Traumatic Brain Injury.R4's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.R4's Care Plan dated 4/26/26 has a focus of Abuse/Neglect/Exploitation/Trauma. Goal reads in part, Resident will remain safe, will be treated with respect, dignity and reside in the facility free of mistreatment (i.e., abuse/neglect). Interventions include in part, Provide me with emotional safety by developing a trusting therapeutic relationship with me.R7's medical record documents an admission date of 7/18/25 and R7's MDS dated [DATE] documents a BIMS score of 14 indicating intact cognition.R8's medical record documents an admission date of 10/22/24 and R8's MDS dated [DATE] documents a BIMS score of 15 indicating intact cognition.On 7/13/26 at 2:28PM, R7 stated that R7 witnessed V7 (Psychiatric Technician) exhibit hostile behavior towards R4 today. R7 states that during the distribution of cigarettes earlier (on 7/13/26) for smoke break, V7 aggressively instructed R4 to stand aside, stating, Go stand over there, I'll make you stand there all day, which caused R4 to become upset and start crying. R7 said that V7 then stated to R4, Oh, now you're going to cry like a baby? R7 reports V7 frequently treats R4 in this manner, resulting in R4 crying. R7 stated that she has witnessed V7's aggressively talk down to other residents too. On 7/13/26 at 2:38PM, R4 reported an ongoing pattern of harassment by V7. R4 indicated that she had been crying. R4 states that an incident occurred earlier today, 7/13/26, while V7 was distributing cigarettes prior to the smoke break. R4 states, V7 told her, Go stand over there, I'll make you stand there all day. R4 states that, when another resident attempted to offer R4 a cigarette, V7 intervened and prevented the exchange. V7 then instructed the other residents out to smoke to distance themselves from R4, and R4 sat alone on the smoker's patio and cried. R4 reports that V7 taunted her, stating, Oh, now you're going to cry like a baby? R4 expressed that this ridicule in front of R4's peers caused R4 to become upset causing emotional distress. On 7/13/26 at 3:45PM, surveyors notified V1 (Administrator) of the abuse allegation from V7 towards R4. On 7/14/26 at 2:45PM, R8 stated that he has witnessed V7 being verbally aggressive towards residents on the smoking patio during smoke break but had not reported these incidents to administration. On 7/15/26 at 10:47AM, V7 stated that during cigarette distribution in the game room on 7/13/26, R4 requested cigarettes belonging to another resident. V7 noted that residents frequently make these requests, but staff are prohibited from distributing resident's personal cigarettes to unauthorized individuals. When V7 was asked about abuse, V7 defined verbal abuse as utilizing aggressive language or profanity when speaking to residents. V7 defined mental abuse as making demeaning or derogatory remarks which can make people feel bad. V7 stated, I have a demanding voice, I mean what I say.On 7/15/26 at 11:11AM, V9 (Human Resources Director) stated all allegations of resident abuse or inappropriate behavior must be reported immediately.On 7/15/26 at 9:58AM, V1 stated that V7 has a loud speaking tone. Regarding abuse in-service, V1 stated that V7 has been educated on abuse prevention and reporting via in-services.Abuse Prevention & Reporting In-Service reviewed and dates include in part: 12/11/25, 3/6/26, 4/21/26. V7's signature is present on all three in-service dates.A facility Psychiatric Technician job description documents essential job functions include in part, provide patients with emotional support. Knowledge/skills and abilities, include in part, Be responsible, tactful and courteous.An undated facility policy titled, Resident Rights reads in part: The facility must care for you in a manner and environment that enhances or promotes your quality of life. The facility will treat you with dignity and respect. The facility must provide social services to attain or maintain your highest level of well-being. You have the right to be free from verbal, sexual, physical, or mental abuse. The facility must implement procedures that protect you from abuse neglect or mistreatment.Facility's Abuse Prevention Program Policy and Procedure (revised 3/1/21) reads in part, It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, and mistreatment.

Based on observation, interview and record review, facility failed to follow their policy to ensure residents are allowed to go out on pass individually for one (R8) out of three residents reviewed for community pass in a sample of 20. The facility also failed to replace a voters' registration card after being voiced to staff and documented in a grievance form for one resident (R6) in a total sample 20.Findings Include:1. On 05/27/2026 at 10:57 AM, R8 was in his room. R8 stated that he is not allowed to go out on pass. I am compliant with my medications. I have no physical or mental limitations. R8 stated that his pass was revoked on 04/28/2026 for some reason. They never gave me a reason. Just something that the doctor ordered me a red pass.On 05/27/2026 at 1:16 PM, V8 (Social Service Director) stated that social service does the community skills assessment. V8 stated based on that assessment, it is determined if the resident can go out on pass themselves. V8 stated that she is familiar with R8. V8 stated that R8 does have an independent pass. V8 stated that R8 came in twice late, outside the curfew. V8 stated that he did not notify the facility that R8 was coming in late. V8 stated that the doctor gave the order to suspend his passes for two weeks. Surveyor verified with V8 that there was no documentation about R8 coming back late from being out on pass. V8 stated that she doesn't document the reason but just the fact that R8 was notified that his pass was revoked.On 05/28/2026 at 10:30 AM, V32 (Medical Doctor) stated that he overlooks R8's care. V32 stated that R8 is stable to go out into the community by himself. V32 stated that no staff member have notified him about R8 coming late or his pass being revoked.MDS (minimum data set) with review date of May 6th,2026 documents a BIMS (brief interview of mental status) has a score of 13 indicating R6's cognition is moderate.On 05/26/2026 at 11:34 AM, this surveyor observed R6 wheeling himself in a wheelchair from the dining room to his room. R6 is alert and oriented to person, place and time. R6 appears calm and collected, free from pain. R6 stated he has been in the facility since March 2026, and since then he noticed that his voters registration card is missing. R6 stated he notified V8 (Social Services Director) about it but still does not have his card.On 05/28/2026 at 9:37 AM, V1 (Administrator) stated R6 did make her aware last week of his missing voters registration card. V1 stated there was a concern form that was filled out, in which V8 followed up on. V1 stated she showed V8 how to search if R6 is registered to vote on the website.2. On 05/28/2026 at 9:54 AM, V8 (Social Services Director) stated R6 had a concern with not having his voter's registration card. V8 stated R6 filled out a concern form, where R6 addressed this concern. V8 stated one evening R6 came into her office and shared these concerns with her, that day they both logged in to the voter's registration website. V8 stated she typed in R6's name and date of birth , she then notified R6 that he has never registered to vote, because to register to vote, he needs an identification card. V8 stated there is a form that needs to be filled out for applicants who have no source of income. V8 stated she and R6 are still working on getting his identification card and eventually on the voter's registration card as well. This surveyor asked V8 if she has any record or documentation of the date and time, she assisted R6 in getting him a replacement for his voter's registration card. V8 stated she printed the form as a receipt and has it in her office, she stated she will return and present it to this surveyor.On 05/28/2026 at 10:55 AM, V8 returned to the conference room, and presented to this surveyor a document titled Registration Look up Results with no date and time. After carefully reviewing the document, this surveyor noted the documents stated R6 is actively registered to vote in the state of Illinois. This surveyor asked V8 for clarification as to why she had not simply replaced R6's voters registration card, if he is already registered to vote. V8 appeared to be in denial regarding R6's status on being able to vote, as she originally had stated that R6 did not have a voters registration card when she looked him up on the Illinois Online Voter Application website. V8 had initially stated that R6 was never registered to vote and due to that reason, she was not able to replace R6's voters registration card. This surveyor provided the Registration Look up Results form. After V8 read the form, she confirmed that R6 is already registered to vote in the state of Illinois. V8 angrily approached this surveyor and stated she does not know how to get R6 a replacement voters registration form.Reviewed R8's progress notes. No documentation about notifying V32 (R8's physician), regarding revoking R8's right to go out on pass. Plus, no documentation on the reason for revoking R8's independent community pass.R8's progress note on 04/24/2026 documents in part: Resident out on pass with family. Scheduled to return 04/26/26 by 7:00 PM.R8's progress note on 04/26/2026 at 6:55 PM documents in part: R8 returned from pass in good condition.R8's community skills assessment on 04/27/2026 documents in part: R8 is approved for green pass and able to navigate the community independently.R8's care plan documents in part: The resident requires the support, care and services of a long-term care facility and has been determined by community access assessment to be able to access the community without supervision.Facility's Outside Community Pass Privilege Policy (06/2024) documents in part: The Interdisciplinary team (IDT) will meet on a daily basis to review resident incident reports, behavior forms, nursing notes social services notes, concern forms etc. and place residents on 72-hour restriction, red pass status, yellow pass status or green pass status.Policy and procedure titled, resident rights with no review date, documents in part as a resident of this facility, you have the right to a dignified existence and to communicate with individual and representatives of choice. The facility will protect and promote your rights as designated below. You may voice grievances concerning your care without fear of discrimination or reprisal. You may expect prompt efforts for the resolution of grievances.

Based on interview and record review, facility failed to ensure residents are free from physical abuse for one (R10) out three residents reviewed for abuse in a sample of 21.Findings include:On 05/26/2026 at 12:30 PM, R16 stated that he heard R12 going into R10's room and beating her up. R16 stated that he even heard that R10 was bleeding a little bit but he never saw it. R16 stated that whole floor knows R12 beat up R10. R16 stated that the incident happened around midnight. R16 stated that R12 is known to have behavior problems.On 05/26/2026 at 2:44 PM, V7 (Registered Nurse) stated that he is familiar with R12. V7 stated that he was R12's nurse when R12 had an incident with R10. V7 stated that the incident happened around midnight. V7 stated that he was off the unit. V7 stated that he received report from the CNA of what happened. V7 stated that the CNA mentioned to him that R12 hit R10. V7 stated that R12 was placed on 1:1 and was given Haldol (antipsychotic medication). V7 stated that the police were called, and they came. V7 stated that he doesn't remember who that CNA was. V7 stated that he notified his supervisor.On 05/27/2026 at 10:39 AM, V20 (Assistant Administrator) stated that he is familiar with R12 and R10. V20 stated that he was the person who did the investigation. V20 stated that he interviewed the pysch tech and R16. I think V7 (Licensed Practical Nurse) was the first staff to intervene between R12 and R10's fight. V20 stated that fight happened on 02/21/2026. V20 stated that he is not sure what time it happened. Surveyor verified with V20 that there is no time on the initial report submitted to IDPH. V20 said R10 told him that R12 came to her room and grabbed her arm. V20 stated that R12 came to R10's room. V20 stated that R12 grabbed R10 and fought her. R12 has been doing that for a long time and R10 didn't do anything. V20 stated that he submitted the reportable around 2:00 PM that same day. V20 stated that initial reportables are to be submitted within 2 hours of being notified. V20 stated that he was notified in during day that this incident happened.On 05/26/2026 at 2:00 PM, V18 (Licensed Practical Nurse) stated that she heard from the previous night shift that R12 fought R11. V18 stated that she is not sure of the full details but just the fact that they were separated when the CNA came in.On 05/26/2026 at 1:08 PM, V6 (Social Worker) stated that she has been working in the facility for two years. V6 stated that she is familiar with R12. V6 stated R12 has behavior issues on and off. V6 stated that R12 has become verbally aggressive with residents and staff. V6 stated that R12 had an incident where she was angry and she was slapping staff and throwing water at social services. V6 stated that R12 had a verbal disagreement with R10. V6 stated that she doesn't know if R12 physically hit R10.R16's minimum data sheet (MDS) Section C documents in part: R16 have a Brief Interview of Mental Status (BIMS) score of 15. R16 are cognitively intact.R16's written statement on 02/21/2026 documents in part: R12 went into R10's room and started fighting her.Facility's abuse policy (01/2019) documents in part: Any alleged violations involving mistreatment, abuse, neglect, exploration, misappropriation of resident property, any injuries of an unknown origin, or reasonable suspicion of a crime against a resident must be reported to the Administrator or Director of Nursing (DON). The Administrator is the Abuse Coordinator of the facility. Additionally, the person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to the Charge Nurse who will immediately report the allegation to the Administrator, regardless of the time lapse since the incident occurred. The charge nurse will immediately report the incident to the Administrator or to the DON during the Administrator's absence. This report shall be made immediately, but no later than two hours after the allegation is made. Crimes include but may not be limited to murder, manslaughter, rape, assault and battery, sexual abuse, theft robbery, drug diversion for personal use or gain, identity theft, and fraud and forgery. 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. if you suspect abuse; separate the alleged perpetrator and assure all residents safety. Notify the Administrator and Director of Nursing immediately. If the Administrator or DON are not present in the facility, notify the nursing supervisor who will notify the Administrator/DON immediately. Complete an Incident Report immediately. Do not leave the building until above is completed. Fax report to IDPH immediately. Any incident involving abuse, neglect, exploitation, misappropriation of property, or a crime against a resident will result in an abuse investigation. Any incident that involves crimes or a significant injury to a resident will be reported within 2 hours of the incident. For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: Physical Abuse: Hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to properly report allegation of misappropriation of property for one (R9) out of three residents reviewed for misappropriation of property in a sample of 20. Facility also failed to report abuse within 2 hours of notification of abuse allegation for two (R10, R12) out of three residents reviewed for reporting of abuse allegation in a sample of 20. Findings include:1. R9's minimum data sheet (MDS) Section C documents in part: R9 has a Brief Interview of Mental Status (BIMS) score of 15. R9 is cognitively intact.On 05/26/2026 at 11:00 AM, surveyor observed R9 in her room on her bed. R9 stated that people have been coming into her room and taking her stuff. R9 stated that she has mentioned to CNAs, and nurses. R9 stated that she doesn't remember the names of who she has told. R9 stated that this one black woman would come in and take my money.On 05/26/2026 at 1:08 PM, V6 (Social Worker) stated that she has been working in the facility for two years. V6 stated that she is familiar with R10. V6 stated that she heard from her office about R10 taking people's things. V6 stated that she never reported it because it was never actually reported to her. V6 stated that she is expected to report all allegations of abuse and theft to the administrator. V6 stated that she heard about R10 taking other residents' things from people talking in the halls.On 05/28/2026 at 12:15 PM, V1 (Administrator) stated that all staff are expected to report any theft to her immediately. V1 stated that it doesn't matter if it was reported to them or not. Any time they hear of any allegation of abuse or theft, it to be reported to me immediately. V1 stated that no staff member have reported to her about any allegation of theft. V1 stated that abuse is to be reported to the State Survey Agency within two hours.2. On 05/26/2026 at 12:30 PM, R16 stated that he heard R12 going into R10's room and beating her up. R16 stated that he even heard that R10 was bleeding a little bit but he never saw it. R16 stated that whole floor knows R12 beat up R10. R16 stated that the incident happened around midnight. R16 stated that R12 is known to have behavior problems.On 05/26/2026 at 2:44 PM, V7 (Registered Nurse) stated that he is familiar with R12. V7 stated that he was R12's nurse when R12 had an abuse incident with R10. V7 stated that the incident happened around midnight. V7 stated that he was off the unit. V7 stated that he received report from the CNA of what happened. V7 stated that the CNA mentioned to him that R12 hit R10. V7 stated that R12 was placed on 1:1 and was given Haldol. V7 stated that the police were called, and they came. V7 stated that he doesn't remember who that CNA was. V7 stated that he notified his supervisor.On 05/27/2026 at 10:39 AM, V20 (Assistant Administrator) stated that he is familiar with R12 and R10. V20 stated that he was the person who did the investigation. V20 stated that he interviewed the pysch tech and R16. I think V7 (Licensed Practical Nurse) was the first staff to intervene between R12 and R10's fight. V20 stated that fight happened on 02/21/2026. V20 stated that he is not sure what time it happened. Surveyor verified with V20 that there is no time of the incident on the initial report submitted to IDPH. V20 said R10 told him that R12 came to her room and grabbed her arm. V20 stated that R12 came to R10's room. V20 stated that R12 grabbed R10 and fought her. R12 has been doing that for a long time and R10 didn't do anything. V20 stated that he submitted the reportable around 2:00 PM that same day. V20 stated that initial reportables are to be submitted within 2 hours of being notified. V20 stated that he was notified in during day that this incident happened.R12 and R10 abuse initial reportable submitted to the State Survey Agency on 02/21/2026 at 2:59 PM.Facility's abuse prevention program policy (01/2019) documents in part: Any alleged violation involving mistreatment, abuse, exploration, misappropriation of resident property must be reported to the Administrator or Director of Nursing. The administrator is the abuse coordinator of the facility. The person observing an incident must immediately report such incidents to the charge nurse who will report the allegation to the administrator, regardless of the time lapse since the incident occurred. For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful temporary, or permanent, use of a resident's belongings or money without the resident's consent. When an alleged or suspected case of abuse, neglect, exploitation, or crime against a resident is reported to the facility Administrator, the Administrator, or Director of Nursing (DON) in the Administrator's absence, will notify the following persons or agencies of such incident immediately. Any incident that involves crimes or a significant injury to a resident will be reported within 2 hours of the incident. Any incident that involves a resident death will be called to the Illinois Department of Public Health immediately.

Based on interviews and record reviews, facility failed to ensure necessary post fall interventions, to rule out injury, were completed for one (R11) out of three residents reviewed for falls in a sample of 21.Findings include:R11 is a [AGE] year old male with multiple medical diagnosis such as cerebral infarction, muscle wasting and atrophy, weakness, end stage renal disease, anemia, vitamin D deficiency, hypothyroidism, non-st elevation nstemi) myocardial infarction, atherosclerotic heart disease, systolic (congestive) and diastolic (congestive) heart failure, osteoarthritis of knee, thromboembolism.R11's progress note by physician on 03/28/2026 documents in part: Presents for evaluation post fall. R11 fell at approx. 22:15. Fall was not witnessed. R11 was lying on the bed. The CNA was completing rounds and found R11 on the floor. Per RN, the right leg was caught in the bed rails. The rest of his body was on the floor. Per RN the bed was in a low position. Patient reports hitting his head. R11 is not ambulatory at baseline.R11's progress note on 3/27/2026 documents in part: Patient was observed on the floor by the CNA. R11 was seen to have fell off from the bed with right leg hanging on bed and the upper body on the floor. R11 stated R11 hit his head. Nursing manager on duty was notified. Other staff on floor was called for help to put the patient back to bed using a full mechanical lift. Patient is alerted and oriented at baseline, PERRLA, denies pain, Upper extremities and lower extremities range of motion at baseline. Medical doctor was informed. She recommends following the facility fall precautions and Neuro check per facility guidelines. Family member was informed via phone. Will endorse to night on coming nurse.R11's physician order sheet documents in part: R11 has an order for anticoagulant.On 05/27/2026 at 12:29 PM, V2 (Director of Nursing) stated that she is in charge of investigating all the falls in the facility. V2 stated that she starts the investigation, has statements from staff and put in interventions. V2 stated that restorative help put in interventions. V2 stated that unwitnessed falls, hit the head, injury are reasons to send the resident out to the hospital after a fall. V2 stated that she is somewhat familiar with R11. V2 stated that R11 fell sometime in April. V2 stated that R11 had an unwitnessed fall. V2 stated that the CNA came in and found R11 on the floor. V2 stated that R11 was not sent out to the hospital after the fall. V2 stated that no x-rays or CT scans were ordered. V2 stated that R11 fell on a Friday 3/27/2026 and she only found out on Monday. V2 stated that R11 was placed on neuro checks and 72-hour monitoring. V21 stated that she doesn't think R11 had any injury after his fall.On 05/28/2026 at 10:30 AM, V32 (Medical Doctor) stated that after a fall, it is important to take the residents vitals and do an assessment. V32 stated that it can be an emergency situation if the resident who has fallen, is on anticoagulants and blood thinners. V32 stated that it is very important to send the resident out immediately for a CT scan to rule out bleeding as well monitor for any embolism or clots that may develop. V32 stated that Eliquis is an anticoagulant.Reviewed R11's physician order sheet. No order to be sent out to the hospital and no order for stat x-ray.Facility's Accidents/Fall policy (undated) documents in part: 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.

Based on interview and record review, facility failed to follow their policy to provide COVID-19 vaccination upon readmission to the facility for one (R6) resident in a sample of 20 residents reviewed.Findings include:R6's MDS (minimum data set) with review date of May 6th, 2026, documents a BIMS (brief interview of mental status) has a score of 13 indicating R6's cognition is moderate.On 05/26/2026 at 11:34 AM, this surveyor observed R6 in a wheelchair. R6 was alert and oriented to person, place and time. R6 appears calm and collected, free from pain. R6 stated he has been in the facility since March 2026. R6 stated when he first arrived in the facility 6 months ago, the facility did not offer the COVID-19 vaccination. R6 stated he requested the vaccine, and V2 (Director of Nursing) told him the vaccine had to be requested from the lab. R6 stated he has not received the vaccine but is still interested in receiving the vaccine.On 05/27/2026 at 10:37 AM, V25 (Infectious Disease Nurse) stated she has been working as an infectious disease nurse since December 1st, 2025. V25 stated her job is to prevent and maintain the spread of infection. V25 stated she is responsible for offering vaccinations and providing education to the residents. V25 stated when she initially took the role she arranged a COVID-19 clinic. V25 stated she attempt to get the number of staff and residents who were interested in the vaccine. V25 stated if there are no vaccines available in the facility, she will order the vaccines from the pharmacy and wait for them to arrive. V25 stated all resident are offered the vaccinations upon admission, readmission, every 6 months after receiving the initial COVID-19 vaccination, or per request. V25 stated R6 was re admitted in early March of this year, but prior to discharging she had offered R6 the COVID-19 vaccination and R6 refused. V25 stated the refusal form was signed and uploaded in the electronic medical record. V25 stated she did not offer the vaccination upon readmission, because since he had refused it on February, she will not ask again if it's within the same season. V25 stated R6 did request the COVID-19 vaccination, but there were no vaccines available at that time. V25 stated she ordered the vaccine for R6. This surveyor asked V25 for a document verifying she had ordered the vaccine for R6.On 05/27/2026, reviewed R6's provider order sheet, a new order for the COVID-19 vaccination was entered on this day.On 05/27/2026 at 11:15 AM, V25 stated R6 confirmed he is interested in receiving the COVID- 19 vaccination, and she has just placed an order for the vaccine through the pharmacy. V25 stated R6 has signed his consent form and will wait for the vaccine to arrive. V25 stated prior to this there were no order or documentation on the electronic medical records because she had not offered the vaccine upon re admission.On 05/28/2026 at 11:21 AM, V2 (Director of Nursing) stated residents are to be offered during admission, readmission and if the resident inquires in receiving the COVID-19 vaccine. V2 stated they are educated on its benefits, it prevents the spread of COVID-19 and keeps the individual as healthy as possible. V2 stated there is a consent form that the resident must sign whether they want to receive or refuse the vaccine. V2 stated if the resident refuses the vaccine the risks and benefits are explained, the provider, family or power of attorney are notified and documented on the electronic medical records. Policy and procedure titled fact sheet for recipients and caregiver about moderna COVID-19 vaccine (2024-2025 formula) which has emergency use authorization (EUA)to prevent coronavirus disease 2019 (COVID-19) in individuals 6 months through [AGE] years of age with no review date.

Based on interview and record review, the facility failed to ensure four [R1, R4, R5, R13] of eight residents remained free from abuse. This failure resulted in: R2 sustained a closed fractured tooth, human bite, swollen lip and pain. R4 sustained displaced fracture of distal phalanx of right ring finger and displaced fracture of proximal phalanx of right little finger, and pain. R5 sustained forehead altered skin integrity, that required 911 transport for emergency treatment. Findings include: 1. R1's clinical record indicates the following in part: R1 is a fifty-four-year-old with medical diagnosis of: Displaced fracture of lateral Right Fibula, asthma, chronic heart failure, anemia, overactive bladder, schizophrenia, and major depression. R1's minimum data set [MDS] Brief Interview Mental Status Score [15] indicates R1 is cognitively intact. R1's progress notes in part: On 2/9/26 at 12:34 AM, V21 [Registered Nurse] Note: R1 was attacked by her roommate [R2] while sleeping. R1 said the roommate called her a b****, bit her middle finger, scratched her face, and R1's lips were slightly swollen. R1 was sent out for medical evaluation. R1's Emergency Department document in part: Dated 2/9/26-Reason for visit, Victim of assault, closed fracture of tooth- initial encounter, and human bite-initial encounter. Medications given: Amoxicillin-potassium clavulanate, and tetanus diphtheria injection. R2's clinical record indicates in part: R2 is a twenty-eight-year-old with medical diagnosis of schizophrenia, restlessness, agitation, cardiac arrest, respiratory failure, and hemiplegia. R2's minimum data set [MDS] Brief Interview Mental Status Score [15] indicates R2 is cognitively intact. R2's Care plan in part: R2 displays conflictual difficult behaviors manifest by conflict, anger towards friends and roommates. R2's Progress noted in part: On 9/2026, at 12:12AM V21 Note [Registered Nurse] Note Text: R2 attacked her roommate [R1] while sleeping and bit her [R1] on her right middle finger. There is a finger scratch on her face, and her lips are slightly swollen. The physician was called and ordered R2 to be sent to hospital for Psych -evaluation. On 3/31/26 at 1:10 PM, R1 stated, R2 and I were roommates. I was sleeping in bed late at night with a fractured ankle. The nurse helped me in the bed and must have left my wheelchair in the pathway. I was asleep when R2 started calling me b****ches, yelling and screaming at me about my wheelchair blocking the pathway. R2 came over to my bed and started hitting me in the face, head and bit my finger. I could not get up a get away from her due to my fractured ankle. Finally, the nurse came in a pulled R2 off me. My finger was hurting swollen, my mouth was bleeding, and my face had scratches. I was sent to the hospital, and they moved R2 out the room. On 3/31/26 at 1:20 PM, R2 stated, I was R1's roommate. R1 used an extra-large wide wheelchair and always blocked the pathway so I could not get to my side of the room. I yelled at R1 and told her I was tired of her leaving the wheelchair in my way. R1 told me to shut the f*** up. R1 and I started arguing then we both started hitting each other. I'm not going to allow anyone to disrespect me. Yes, I hit R2 first, because R1 told me to shut the f*** up. Yes, I bit R1's finger, because she was trying to swing on me. I got R1's finger in my mouth and I bit R1's finger. The nurse came and pulled me off R1. I'm tired of these people disrespecting me. On 4/1/26 at 2:00 PM, V22 [Certified Nurse Assistant] stated, I worked on 2/9/26, and was R1 and R2 certified nurse assistant. I was assisting another resident and saw the call light on for R1 and R2's room. I entered the room and saw R2 on top of R1 in R1's bed. I called out for help for another staff member assisted me to get R2 off of R1. I saw R1 bleeding; I was not sure where the blood was coming from. R1 had scratches on her face, her lips were swollen and R1 told me R2 bit her finger, and it was hurting. The nurse came to assess the residents. On 4/1/26 at 3:50 PM, V21 [Registered Nurse] stated, I was R1 and R2's nurse the day of the incident. The certified nurse assistant came and got me. R1 said she was attacked while sleeping by R2. R1 was noted with a swollen lip, her finger was bitten, and R1 had some scratches on her face. The two residents were separated and R1 was sent to the emergency room for evaluation. R2 was known to have aggressive behaviors in the past. R1 has not had any aggressive encounters. They are no longer roommates. On 4/1/26, V5 [Social Service Director] stated, I started working here 11/24/2025. I assist with investigation abuse related to behaviors. R1 and R2 shared a room together. On 2/9/26 around 12:30 AM, R1's wheelchair was in the pathway. R2 started arguing with R1, when R1 was sleeping in bed. R1 said R2 was hitting her, bit her finger, hit her in the mouth, and scratched her face. R2 was moved to another floor and being monitored closely. On 4/2/26 at 2:55PM, V1 [Administrator] stated, I did not substantiate abuse. There was no witness when the residents contacted each other. Their rooms were separated. 2. R3's clinical record indicates in part: R3 is a forty-three-year-old with medical diagnosis of anxiety disorder, major depression, cannabis abuse, left hand contracture, essential hypertension, embolism and thrombosis of artery. R3's minimum data set [MDS] Brief Interview Mental Status Score [14] indicates R3 is cognitively intact. R3's Progress note in part: V8 [Registered Nurse/Nurse Supervisor]- 1/23/26 at 9:45 PM R3 allegedly made contact with another resident [R4]. R3 immediately separated other peer. Body assessment performed no apparent injury noted. 1/24/26, at 4:59 AM Nurse Note: R3 admitted in hospital diagnosis with major depression. R4's clinical record indicates in part: R4 is a thirty-four-year-old with medical diagnosis of schizophrenia, psychophysiologic insomnia, displaced fracture of distal phalanx of right ring finger dated 1/28/26, and displaced fracture of proximal phalanx of right little finger dated 1/28/26. R4's Progress Note in part: V8 [Registered Nurse/Nurse Supervisor] Note-1/23/26 at 9:54PM. Another peer [R3] allegedly made contact with R4. R4 immediately separated from peer. Noted slight swelling and redness to the right hand. MD order Xray to the right hand. V29 [Licensed Practical Nurse] Noted: 1/28/26 at 5:22 AM, R4 returned back to the facility with diagnosis of right fourth and fifth metacarpal fractures. R4's emergency room document: 1/28/26: R4 diagnosis with displaced fracture of distal phalanx of right ring finger and displaced fracture of proximal phalanx of right little finger. On 3/31/26 at 2:15 PM, R3 stated, R4 and I were roommates. I don't remember why we started to argue. R4 is not his right mind. R4 talks to himself and hears voices. There is nothing wrong with my mind. We were arguing and R4 came over to me. It looked like he had a fork, so I started hitting him with my cane. Yes, I hit R4 first, because I saw something in his hand, I'm not sure what was in his hand. They sent me to the hospital for a psych eval and moved R4 out the room to another floor. On 3/31/26 at 2:35 PM, R4 stated, R3 and I were roommates. R3 kept coming over to my side of the room bothering my television. I kept telling him to stop. We got into an argument and R3 drove his electric wheelchair over to my side of the room. Out of nowhere, R3 started hitting me hard with his cane. I was trying to block the hits, but he kept hitting my hand and broke it. Staff came and took the cane from R3 and sent him to the hospital. I wanted a room change, and they moved my room that day. I did not want to go to the hospital; the people came here and took a picture of my hand. My hand still hurts, this my right hand it hurt every time I move it, but it's getting better. On 4/3/26 at 1:05 PM, V17 [Certified Nurse Assistant] stated, I was their aide on the day of the incident. Earlier, I did not notice anything different with R3 and R4. All I know is R3 hit R4 with his cane. I did not witness the fight, but I saw R4's hand was swollen. On 4/1/26, V5 [Social Service Director] stated, R3 and R4 had an incident on 1/23/26. I learned that R4 was listening to loud rap music on his television and R3 went and turned it down. They both started to argue and R3 hit R4 with the cane on R4's hand as R4 was trying to block the cane. R3's cane was removed, because he used it as a weapon to injury R4's hand. R4 agreed for a room change, he was moved to a different floor. On 4/2/26 at 2:55PM, V1 [Administrator] stated, The allegation of abuse was not substantiated, R3 unintentionally made contact with R4's hand. 3. R5's clinical record indicates the following in part: R5 is a twenty-three-year-old with medical diagnosis of anxiety disorder, homicidal ideations, stimulant use, and anemia. R5's minimum data set [MDS] Brief Interview Mental Status Score [15] indicates R5 is cognitively intact. R5's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents dated. 1/23/26, document in part: Reason for discharge: The safety of individuals in this facility is endangered. R5's Care plan in part: R5 demonstrates behavior distress. R5 will refrain from verbally or physically abusive behavior following staff intervention. R5's Progress notes in part: V27 [Licensed Practical Nurse] Note: 1/23/26 at 3:40 PM: It was reported that R5 made contact with co-peer [R6] in dining area. Both residents separated immediately. Body assessment completed with noted altered skin integrity. R5 sent out 911. [Per Administrator [V1] V27 was currently hospitalized , not available for interview]. V5 [Social Service Director] Note: 1/23/26 6:27PM: R5 was given a Notice of Involuntary Discharge and Opportunity for Hearing for Nursing Home Residents (IVD) form. The form was given by the Administrator and the Social Services Director. R6's clinical record indicates the following in part: R6 is a fifty-year-old with medical diagnosis of schizoaffective disorder, glaucoma, essential hypertension, weakness, heart failure, type II diabetes, and chronic obstructive pulmonary disease. V27 [Licensed Practical Nurse] Note dated 1/23/26 at 3:33PM in part: It was reported R6 made contact with co-peer R5 in dining area. Residents were separated immediately with body assessment completed with no altered skin integrity observed. V5 [Social Service Director] Note dated 1/23/2026, at 6:29PM in part: R6 was given a Notice of Involuntary Discharge and Opportunity for Hearing for Nursing Home Residents (IVD) form. The form was given by the Administrator and the Social Services Director. V27 [Licensed Practical Nurse 1/23/2026, 10:00PM R6 admitted to hospital with admitting diagnosis of Schizophrenia. On 4/2/26 at 2:38PM, V5 [Social Service Director] stated, Per my investigation, R5 and R6 was in the dining room during day shift. R5 threw her cell phone through the dining room door, and R6 told staff what R5 did. Then R5 started hitting R6, then R6 started hitting R5 back. R5 had an injury to her forehead form R6. Both residents exhibit very aggressive behavior and were not easily re-directed. Both received an involuntary discharge. On 4/2/26 at 2:55PM, V1 [Administrator] stated, The allegation was not substantiated, because there was no witness. All new hires receive abuse training during orientation, annually and as needed. The last abuse training was in December 2025. Policy Documented in part: Abuse Policy dated 3/1/2021 in part: This facility prohibits and prevents resident abuse, neglect, exploitation, 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 members, other residents, or family members. Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain, or mental anguish. Physical abuse: Hitting, slapping, pinching, kicking etc. 3. R13 is a [AGE] year-old resident with diagnoses that include but are not limited to fracture of right and left foot; cellulitis of left lower limb; fracture of upper and lower end of right fibula; old myocardial infarction; psychoactive substance abuse; schizoaffective disorder. R13 progress note dated 3/6/2026, reads in part: Co-resident (R14) alleged made physical contact with the resident (R13). Staff immediately separated residents, complete body check done, resident (R13) noted with skin alteration to upper right lip. R13 MDS (Minimum Data Set), 2/16/2026, BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognition. R13 Abuse/Neglect/Exploitation/Trauma care plan, initiated 3/8/2026, documents in part: 3/6 – Incident with peer. On 3/31/26 at 1:58 PM, R13 said R14 hit me in the head. R14 stabbed me in the face. I don't know with what. R14 came at me out of the blue. I don't know R14. I was in my wheelchair waiting for the elevator. I fell backwards in the chair and fell to the floor. I had blood coming from my face. I did not go to the hospital. R14 is a [AGE] year-old resident with diagnoses that include but are not limited to polyneuropathy; major depressive disorder; anxiety disorder; schizoaffective disorder, bipolar type; psychosis not due to a substance or known physiological condition; delusional disorder; auditory hallucinations; restlessness and agitation; violent behavior homicidal and suicidal ideations. R14 MDS (Minimum Data Set), 2/16/2026, BIMS (Brief Interview for Mental Status) score is 8 indicating moderately impaired cognition. R14 progress note, 3/6/2026 16:03, documents in part: Resident (R14) presents with bizarre aggressive behaviors with physical behavior involved towards peer (R13). Resident refuses prn (as needed) medications with resident currently on 1:1 with staff until discharged from facility. R14 progress note, 3/6/2026 16:43, documents in part: Writer informed by staff that resident (R14) was involved in an altercation with co peer (R13) with them immediately separated with resident observed with no injuries. Resident refuses prn (as needed) medication with 1:1 initiated until discharge from facility. Writer informed psych doctor of behaviors with orders received to send resident out with petition. R14 Ineffective Coping care plan, initiated 8/9/2024, documents in part: R14 has a problem with ineffective coping and has displayed difficulty with managing/responding to stressful situations including lack of acceptance about the realities of current health/psychiatric illnesses and need for services in a structured care setting environment. Additionally, the resident has been noted to present with cognitive deficits, confusion, and behaviors that include forgetting that they have eaten meals/snacks and complaining that they were not provided meals/snacks. Misuse of 911 emergency services to report meal/snack issues, repeated misuse of call light, becoming upset and aggressive with personnel, having repetitive verbalizations and requests despite having all needs regularly and satisfactorily addressed by personnel. On 10/29/2024 resident attempted physical aggression towards staff and was redirected. R14 is care planned for demonstrating behavioral distress related to feeling powerless, out of control. Problems are manifested by verbally abusive behavior when agitated, initiated 11/14/2024. 4/1/26 at 2:20 PM, V33 (Psych Tech) stated they were at the desk at the elevators. They were helping a resident in a wheelchair onto the elevator. The residents were coming in from smoke break. The line was pretty long, at least 15 residents. R13 was against the wall in the line to get onto the elevator. R13 was close in vicinity to the elevator. R14 came from outside smoking. R14 just came from out of nowhere and ran upfront and hit R13. I saw R14 swinging at R13s face. R14 did not have anything in their hands. We grabbed R14 and another Psych Tech escorted R14 to their floor. I don't recall who the other Psych Tech was. I did not notice any scratches, or blood. To keep them separated R13 was sent to the dining area. 4/1/26 at 3:00 PM, V4 (Assistant Administrator) stated, I was walking past when the residents were coming from smoke break from the patio. They were lined up for the elevator. I assisted a wheelchair into the elevator. R13 never said a word to R14. R14 came from the end of the line. R13 was in their wheelchair at the elevator area. R14 attacked R13 at the elevator area. R14 punched R13 in the face. Maybe it was R14s nails that scratched R13 near the mouth. I grabbed R14 and had a Psych Tech take them upstairs. I took R13 to the dining room. R13's nurse came to do their assessment. R14 was put on 1:1. Afterwards when EMS (Emergency Medical Service) was taking R14 out, R14 said I don't like here. I don't like anybody here. I want to leave now. I don't want to be here. I don't want to come back. R13 told me they (R13 and R14) don't even talk. On 4/1/26 at 3:50 PM, V20 (Registered Nurse) stated they was R13's nurse when the incident happened. They came downstairs to assess R13. R13 was in their wheelchair with no distress, no complaint of pain. V20 stated they saw a little skin tear near R13's mouth/lips. There was no blood. R13's vital signs were stable. R13 was taken upstairs to their room, and a complete body check was done. There were no other marks or injury on the rest of R13's body. V20 notified the physician. R13 took their regular scheduled medication. R13 was in bed when V20 left at the end of the 3pm-11pm shift. On 4/1/26 at 4:16 PM, V1 (Administrator) stated I am the Abuse Coordinator. I do trainings for all staff on abuse quarterly and as needed. Types of abuse include physical, mental, sexual, emotional, financial, neglect. I was in my office and heard the code called. R13 was in the dining room yelling to me You owe me money. I received the information from my team. R13 said they didn't know R14. The team told me R14 came out of nowhere from the back of the line. The residents were coming in from outside. I saw R13 had a scratch on their face/mouth area. On 4/2/26 at 11:23 AM, V4 (Assistant Administrator) stated R14 was IVD (Involuntarily discharged ) because of aggressive behavior when they attacked R13. R14s baseline was aggressive behavior. There have been other instances of R14 being physically aggressive to other residents, verbally aggressive toward staff. Previously, in 12/24, R14 was petitioned, IVD. R14 has a diagnosis of violent behavior. We (the facility) couldn't guarantee R14s safety and the safety of the other residents with R14 here due to their aggressive behavior. That's why we did the IVD. R14 has a State appointed guardian. We notified the guardian and R14s mom of the IVD. We sent a copy with the petition with R14 to the hospital. We emailed a copy to the Ombudsman and to IDPH (Illinois Department of Public Health). R14 Petition for Involuntary/Judicial Admission, 3/6/2026, documents in part: V14 presents with bizarre aggressive behavior, physical aggression towards peer (R13). R14 is in need of immediate hospitalization for psychiatric evaluation to prevent them from harming self and others. R14 Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents, 3/6/2026, indicates R14's immediate discharge due to the safety of individuals in the facility is endangered. R13 Incident Report, Physical Aggression Received, 3/6/2026, documents in part: Co-resident (R14) allegedly made physical contact with the resident (R13). Staff immediately separate residents, complete body check done, resident noted with skin alteration to upper right lip. R14 Incident Report, Physical Aggression Initiated, 3/6/2026, documents in part: Writer informed by staff that resident (R14) was involved in an alleged altercation with co peer (R13) with them immediately separated with resident observed with no injuries. Resident immediately separated with no injuries observed on resident with them offered prn (as needed) medications with them refusing with resident placed on 1:1 with staff with psych doctor aware of behavior. Writer received orders to send resident out to hospital related to behaviors Facility Report of Incident, follow-up report, incident date 3/6/2026, involving R13 and R14 documents in part: It is alleged that R1 (R14) allegedly made contact with R2 (R13). Residents separated. Body assessment completed on both residents by nursing. R2 (R13) noted with scratch to right side of the mouth. Police was notified. Medical doctor contacted with order to send R1 (R14) to the hospital for psychiatric evaluation, family and guardian notified appropriately. R1 (R14) was on 1:1 monitoring until discharge to hospital. Facility Abuse Prevention Program Policy, 3/1/21, documents 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. 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, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on interview and record review, the facility failed to follow a resident's fall care plan for 1 (R10) of 3 residents reviewed in a total sample of 18.Findings include:R10's clinical records show an initial admission date of 01/13/2026 with listed diagnoses not limited to heart failure, anemia, gastro-esophageal reflux disease, history of falling, dementia, anxiety, bipolar disorder, schizoaffective disorder, major depressive disorder.R10's MDS (minimum data set) with review date of January 30, 2026, documents in part the BIMS (brief interview for mental status) of 10 indicating that R10 has moderate cognitive impairment.Care plan with review date of 03/02/2026 documents in part neuro-checks, Bilateral floor mats, reclining chair, special mattress, Reorder comfort pack, Apply bilateral bed bolters, educate family and care givers about safety reminders and what to do if a fall occurs.R10's progress notes dated on 2/28/2026, documents in part, Nurse was informed by CNA that resident was observed on the floor by the bedside. Nurse assessed resident. Resident was observed with skin alteration to forehead. First aid provided. Nurse and CNA place resident back in bed. ROM WNL. Nurse called 911. Residents do not appear to be in acute distress. Nurse called son in law and Lumina Care. Ambulance arrived via 2 attendees. Resident was taken to University of Chicago. R10's progress notes dated on 3/15/2026, documents in part, Resident was noted on the floor to the right of her bed, safety mattress in place. Resident assessed by writer, and returned to bed via hoyer Lyft, no injuries noted at this time. ADON made me aware. Family member aware, no concerns voiced. Phone numbers listed for MD aren't open for calls at this time. Voice message left on system for MD will endorse to am nurse to f/u/ make MD aware of fall. Neurochecks initiated. BP 132/88 P 81 T 98.3 R 18 O2- 96%ra.R10's progress notes dated on on 03/17/2026, documents in part, Resident attempted to get off bed and rolled to the right side of bed on the floor mat. Resident vitals were taken Bp:126/74 Pulse:72 Temp:97.6 O2:97% on room air. Writer completed A head to toe assessment. Resident is A & O X 2-3 in stable condition no injuries or bruising noted. Md notified , Emergency contact notified no answer, DON notified, Hospice and palliative care made aware. Patient care is ongoing writer will continue to monitor resident.R10's fall risk assessment dated [DATE] R10 is high risk for fall. This fall risk assessment also shows R10 has had 3 or more falls in the past 3 months. R10 has had a fall on 2/28/26, 3/15/26, 3/17/26, 3/27/26.On 03/31/2026 at 12:16 PM, surveyor observed R10 laying down on her bed sleeping. There were bilateral floor mats, one on the left side, the other mat was on the right side. There were 2 wedges in place, one on the left side and the other on the right side. The air mattress was functioning well. Resident was sleeping, however when this surveyor introduced self, R10 opened her eyes, and responded to her name.On 04/01/2026 at 12:10 PM, V2 (Director of Nursing/ DON) stated the resident was sent to the hospital on [DATE]. V2 stated the cause of the fall was due to R10 experiencing anxiety. V2 stated R10 has been experiencing a lot of anxiety and restlessness lately and has had frequent falls. V2 stated the hospice team has been notified for further evaluation. V2 stated some interventions that are taking place are to ensure R10 is up in the dayroom, and she was also moved closer to the nurse's station. Surveyor asked when the last time R10 had a room had changed. V2 stated she was not sure and looked at R10's electronic medical record (EMR). After reviewing R10's EMR, V2 stated there has been no room change yet. V2 stated that it has not been discussed, however it is not a bad idea and considering a room change now. Surveyor asked V2 what can potentially happen if R10 is not being closely monitored, and if she considers R10 a priority to be monitored at all times to prevent frequent falls. V2 stated it is a priority and she will have R10's room change near the nurses station.On 04/02/2026, surveyor reviewed R10's care plan, R10 does not have a room change in her care plan. R10 is currently in room which is not near the nurse's station. On 04/02/2026 at 9:48 AM, V7 (Restorative Nurse) stated the hospice team will evaluate R10 due to her increase level of impulsiveness. Surveyor stated what can potentially happen if a resident who has been more agitative and impulsive causing frequent falls is not being monitored by staff. V7 stated this morning that R10 was moved from room [ROOM NUMBER] to room [ROOM NUMBER], which is now closer to the nurse's station.On 04/03/2026 at 9:15 AM, a phone interview conducted with V26 (License Practical Nurse/ LPN) stated R10 in on hospice, she has been more agitated at times, she moves a lot, and she is at risk for falls. V26 stated R10 requires a lot of supervision. V26 stated R10's room is 208, which is in the middle of the hallway. Surveyor asked V26 if she considered that room to be near the nurse's station. V26 stated the room is in the middle of the hallway and not near the nurse's station. Surveyor asked V26 what can potentially happen to R10 if she is not supervised frequently. V26 stated anything can happen if R10 is not being supervised.On 04/03/2026 at 9:07 AM, a phone interview conducted with V30 (Agency Registered Nurse) stated on the day of the fall, housekeeping walked by R10's room and noted R10 was on the floor. Surveyor asked V30 if R10's room was near the nurse's station. V30 states R10's room was mid hallway; her room was not near the nurse's station. Surveyor asked V30 if she would consider it beneficial if R10's room was near the nurse's station. V30 stated it would be beneficial for R10 to be near the nurse's station because R10 is not able to utilize a call light.On 04/03/2026 at 9:40 AM, V31(License Practical Nurse/ LPN) stated on the day of the fall I was informed by the certified nurse's assistant that R10 had a fall. V31 stated R10 is not alert enough to use a call light, and due to that reason, she would make sure to have R10 up in the dining room or stationed by the nurse's station. V31 stated she did not feel comfortable leaving R10 unsupervised in her room, which is in the middle of the hallway. V31 stated R10 does always require frequent supervision, and with the room being so far down the hallway it made it difficult to keep an eye on R10.Policy title Fall Prevention and Management Program with no review date, documents in part, the facility is committed to safety and maximizing each resident's physical, mental and psychosocial well- being. Through an interdisciplinary approach, this facility will provide fall prevention assessment, implement interventions to prevent falls as much as possible, and manage post fall treatment. Interventions that are implemented based upon the identified risk factors. Reassessment of risk after a fall with modification and/ or additional interventions as appropriate.

Based on interviews and record reviews, the facility failed to follow their 'Abuse Prevention Policy' and report any alleged violations involving mistreatment, or suspecting resident abuse, to the Administrator for one [R1] of five [R2, R3, R4 R5] residents reviewed for abuse. Findings include: R1 is the subject of the complaint. R2 is the alleged perpetrator [R1's Spouse]. R1's clinical record indicates the following in part: R1 is a forty-eight-year-old admitted on [DATE]. R1's medical diagnosis of major depressive disorder, depression, and schizophrenia. R1's face-sheet, medical diagnosis, physician order sheets, minimum data set [MDS] Brief Interview Mental Status Score indicates R1 is cognitively intact. R1's progress notes in part: 3/19/26 at 6:02 PM V10 [Licensed Practical Nurse] note:R1 returned from out on community pass and was transferred to another room on the second floor. 3/19/2026 6:02 PM, Nursing Progress Note [V10]: Note Text: R1 Returned from OOP (out on pass). R1 was escorted by psych tech to remove her belongings from her room. Transferred to 2nd floor. Resident escorted to 2nd floor by psych tech. Supervisor aware. R1's Trauma Screening dated 1/19/26 indicates in part:R1 said she does not have a history of any abuse; physical, sexual, verbal, emotional, financial, domestic violence or unexplained injuries prior to admission. R1's Care plan notes, in part:Abuse, neglect, exploitation trauma. Interventions: Encourage R1 to verbalize any instances of abuse. Provide a safe environment, free from judgement, especially during the investigation. Provide emotional support. Evaluate R1 response to psychological interventions and support to determine the effectiveness of the treatments provided and expected outcomes. Assure R1 that she is in a safe and secure environment with caring professionals. Offer reassurance. R2's [R1's Spouse] Clinical Record indicated the following in part: R2 is a forty-two-year-old admitted on [DATE]. R2 medical diagnosis of schizoaffective bipolar type disorder, alcohol abuse, alcohol induced acute pancreatitis. R2's face-sheet, medical diagnosis, physician order sheets, minimum data set [MDS] Brief Interview Mental Status Score Indicates R2 is cognitively intact. R2's Progress Note in part: 3/19/2026 10:29 Nursing Progress Note Note Text: R2 left facility on community pass in stable condition, due to return by 2:25 PM. 3/19/2026 9:46PM V10 [Licensed Practical Nurse]Note Text: R2 returned to the facility from community pass. Writer asked R2 if he wanted to take his medication. R2 noted by writer pocketing his medication. Writer informed R2 that if he did not want to take his meds, that is his right but, he had to give writer the meds back. R2 laughed and stated, Shut the f**k up talking to me b-tch! R2 started walking to his room. While walking to his room, R2 continued hollering out profanities. As he opened the door to his room he started hollering Where is my f**king wife at b-tch? I bet you I'll f-ck you up if you don't tell me where my wife is. He continued threatening writer and started walking towards the nurse's station. R2 continued to verbally threaten writer. Psych tech desk called for assistance. Supervisor called. Per supervisor send resident out 911. R2 being monitored off the unit by psych tech until police arrive and medics arrive. Psych on page. 3/19/2026 9:54PM V10 Nursing Progress Note Note Text: discharged out to hospital. Transported via stretcher by [4] 911 medics and 2 police officers. 3/19/2026 22:06 Social Service Note Note Text: R2 was given a Notice of Involuntary Discharge and Opportunity for Hearing for Nursing Home Residents (IVD) form. The form was given by the Administrator and the Social Services Director. The form was completed under the federal proceedings; for the safety of individuals in this facility is endangered. The resident, the resident's representative, the Ombudsman, IDPH and facility attorney were sent a copy of the completed Involuntary Discharge form. The administrator and Social Services Director reviewed the Involuntary Discharge form with the resident, explained the 10-day appeal process, gave the R2 a self-addressed stamped envelope. The physician gave an order to present the R2 with an Involuntary Discharge due to the safety of the individuals in the facility being endangered. Interviews: On 3/21/26 at 10:00 AM, R1 stated, R2 is my legal husband. R2 was admitted to the facility first then I came to the facility. The facility allows R2 and I to share a room because we are married. Before we were admitted to the facility we had several physical altercations in the past. R2 stopped drinking alcohol and smoking marijuana, and we got married in January 2025. Recently R2 started drinking alcohol and smoking marijuana again. R2's behavior was starting to become more aggressive, telling me he was hearing voices. R2 would ask me if he I heard the voices, I told R2 no. I did not report to nursing that R2 was hearing voices. One day, I do not remember the day, R2 got angry and grabbed my wallet and dumped all my cards in the toilet and urinated on everything. R2 made me go in the toilet and take my cards out, then he tore up my social security card. R2 then started calling me b .h- -. On Monday [3/16/26], I went to V4 [Social Worker] office. I told V4 R2 was scaring me and making me feel nervous. I also told V4 R2 dumped out my wallet in the toilet and V4 told me R2 was my spouse, and we need to work it out as a married couple. I did not tell V4 that R2 was physically abusive to me in the past. I think it was the next day, I don't remember the day, R2 was mad at me and told me not to talk about him to anyone, then he punched me on my cheek[face]. This happened in our room with the door closed. I did not yell for help; I just got quiet. I did not report the incident to anyone. My face did not bruise or swell. R2 asked me to go out on community pass with him afterwards, I told him I would lay down. Once R2 left the facility I left out on pass alone and called V3 [External Agency Help Desk] and told V3 that R2 hit me. I called V5 [R1's Friend] and told her about R2 behavior, but I did not tell V3 that R2 hit me. I did not tell anyone at the nursing facility that R2 hit me, I could not remember when R2 hit me. I did not tell V3 that R2 spit on me, I said he looked like he wanted to spit on me. All I needed was a room change. On 3/21/26 at 1:15 PM, V4 [Social Worker] stated, R1 is very quiet and stays to herself. R1 and R2 shared a room as a married couple. R1 came to my office earlier this week, maybe it was on Monday. R1 reported R2 sometimes drinks alcohol. While speaking with me, R1 kept looking out the door and would stop talking if someone walked past. I asked R1 if she was okay, R1 said she was fine. R1 said, R2 don't want me to say nothing to you. R1 said she felt afraid and nervous with him. Soon after, she ended the conversation and left my office. The same day R1 and R2 came to my office and asked for a community past to leave the facility together. R1 did not report that R2 hit her, cursed her, nor made R1 pick her cards out of the toilet. They appeared calm and peaceful; I grated them the pass. Later they both returned calm and peaceful. At that point I was confused, I really did not know what to think. I was going to report this to the administrator, but I wanted to gather my facts first. The information she gave me was so confusing. I received abuse training in December 2025. The abuse coordinator is the administrator. On 3/21/26 at 2:24 PM, V10 [Licensed Practical Nurse] stated, I have been R1 and R2's nurse often. I have not heard or witnessed any abuse between them. R1 has never reported any abuse to me. I have never seen any bruises or marks on R1. R1 has never told me she was afraid or nervous being around R2. If she did, I would have notified the administrator immediately. On 3/19/26, I was notified by V7 [Nurse Supervisor] that R1 would be moving to another floor. Later R2 returned from out on pass and became upset that R1 was not in the room. R2 started yelling at me swearing and walking towards making threats. I called the psych techs, administration, and R2's physician. I received orders to send R2 to the hospital. On 3/22/26 at 6:45 PM, V5 [ R1's Friend] stated, R1 came to see me at my job on 3/19/26. R1 told me she was thinking about leaving the nursing facility and not returning because she was tired of R2 and wanted a new start. I told R1 she needs to allow the facility to help her with housing program, and medical support. R1 told me R2's behavior has gotten worse over time due to him drinking and smoking and needed to get away from R2. R1 did not tell me that R2 hit her. I called V1 [Administrator], and I explained to V1 that R1 needs her own space and room and needs time away from R2. V1 ensured that she will move R1 out of the room. The same day, when I got off work, I went to the facility and R1 was in a new room on a different floor from R2. On 3/24/26 at 1:40 PM, V1 [Administrator] stated, I was not made aware that R1 was being abused by R2. I was not made aware that R1 felt afraid or nervous being in the room with R2. The moment V5 called me on 3/19/26, I moved R1 out of the room immediately. While speaking with R1, she never told me R2 hit her or anything If so, I would have immediately called the police. Later the same day, R2 returned from community pass and was upset, yelling, swearing and making threats to the nursing staff, 911 was phoned and R2 was petitioned to the hospital. R2 received an involuntary discharge from the facility. R2 is not allowed back on the facility's premises. My expectation is, if any resident tells any staff member, they are afraid or nervous being around another resident or staff member, they should have notified me immediately. I am the facility's abuse coordinator. All new hires receive abuse training in orientation. All staff receive abuse training annually and as needed. The last abuse training was 12/11/25. Policies documented in part:Abuse Prevention Program 1/2019Any alleged violations involving mistreatment, abuse, neglect, exploration, misappropriation of resident property, any injuries of an unknown origin, or reasonable suspicion of a crime against a resident must be reported to the Administrator.Additionally, the persons observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to the Administrator.This facility will not tolerate residents abuse by anyone including staff members and other residents. All personnel must promptly report any incident or suspect incident of resident abuse.

Based on observation, interview and record review, the facility failed to ensure a homelike environment for one resident (R30) in the sample of 80 residents. Findings include:On 02/23/2026 at 12:05pm observation made of R30's room. In R30's room bathroom upon entering the door observed a hole in the left lower wall, baseboard hanging off the lower left wall, a black substance between the floor and the lower left wall, and the lower left wall was covered with white plaster and not painted the color of the other walls in the bathroom. On 02/25/2026 at 1:00pm R30 observed sitting in a wheelchair in the third-floor dining room. R30 alert and oriented. R30 stated my room was not clean. Reviewed R30's BIMS (Brief Interview for Mental Status) score dated 01/14/2026, which documents R30's cognition is intact. On 02/25/2026 at 9:50am surveyor requested V19 (Maintenance Director) to come into R30's room bathroom. V19 arrived in R30's bathroom and observed a hole in the left lower wall, baseboard hanging off the lower left wall,a black substance between the floor and the lower left wall, and the lower left wall covered with white plaster and not painted the color of the other walls in the bathroom. On 02/25/2026 at 9:55am V19(Maintenance Director) stated I just saw this yesterday (02/24/2026). I don't know why this happened, it may be because of water behind the wall dripping down. I will need to replace the drywall in this area of the bathroom. V19 stated the maintenance staff is responsible for making repairs to holes in the wall and making sure the baseboards are properly attached to the walls. V19 stated this does not represent a homelike environment for the residents, I would not want the bathroom in my home to be like this. On 02/25/2026 reviewed the facility's Resident Rights policy which documents in part, underneath Environment-The facility must provide a safe, clean, comfortable, home-like environment. On 02/26/2026 reviewed the Maintenance Staff's job description dated 01/24/24, which documents, in part, The Maintenance Assistant helps maintain buildings and grounds in a safe and comfortable environment. Must ensure that quality maintenance services are provided on a daily basis and safeguard the health, safety, and welfare of all residents. On 02/26/2026 the Maintenance Director's job description was reviewed, dated 01/01/24, which documents, in part, assist with all aspects of cleaning and maintaining the facility interior and grounds; ensure residents' rooms are clean, safe, comfortable, and maintained in an attractive manner.

Based on interview and record review, the facility failed to implement their policy to inventory the belongings of one (R4) resident of eight reviewed for personal property.Findings include:2/11/26 at 2:00 PM, V2 (Director of Nursing) stated there is no inventory list for R4s belongings.2/13/26 at 11:26 AM, V10 (Certified Nursing Assistant) stated for new admissions, a staff member, usually a CNA (Certified Nursing Assistant), is supposed to record their belongings. There's a form we use to log what the resident has. So, we know what the resident has/come in with. The CNA gives the form to the nurse after filling it out. I believe the resident is supposed to sign the form. We don't log new items that are brought in after admission. We insure there is no contraband. When discharged the belongings should be bagged up by the CNA and taken to a storage area by housekeeping.2/13/26 at 12:42 PM, V1 (Administrator) stated they are supposed to be doing inventory sheets. Everything the resident comes in with is supposed to be noted on the inventory sheet. The sheet is supposed to be uploaded to the system. The purpose is to keep track of what the resident comes in with. To ensure what they have is what they should have in the facility. We do not have an inventory sheet for R4. I am not aware if anyone has come to retrieve R4s belongings. Belongings are packed up when residents go out and put into a storage area then given back when they come back. If they don't come back, the belongings are held for 30 days as we reach out to the family for instruction on what to do with the belongings.2/13/26 at 1:37 PM, V1 (Administrator) located/verified a bag of R4s personal belongings, including a Bible, on the third floor with no name, still in the facility and had not been returned to R4.Facility policy Resident Personal Clothes and Belongings Handling, no date, documents in part: Purpose: To ensure that all clothing/personal belongings are identified/labeled/stored/laundered appropriately. Procedure: (Upon admission and annually the following will be done) Personal belongings are to be listed as well, such as TV/recliner/bookcase etc. The CNA (Certified Nursing Assistant) submits the list of the resident's clothing/belongings to the charge nurse. This list becomes part of the chart.

Based on interview and record review, the facility failed to assert the rights of the residents and prevent and protect residents from resident-to-resident abuse. This failure affects two of three residents (R1, R2) reviewed for abuse. Findings include: R1 is no longer in the facility and was reviewed as a closed record. R1's Facesheet documents that R1 has diagnoses not limited to: Schizoaffective disorder, bipolar disorder, current episode manic without psychotic features, cocaine abuse, anxiety disorder, other asthma, depression, schizophrenia, other psychoactive substance abuse, insomnia, adult failure to thrive.R1's progress notes document:10/31/2025 at 10:55AM Resident was physically aggressive towards peer unprovoked. Resident immediately separated and placed on 1:1. Refused PRN (as needed). Order received from psych (psychiatric) team to petition for further psych evaluation. all notifications made.10/31/2025 at 11:07AM Resident is exhibiting aggressive behaviors with increased agitation and is unable to be redirected. NP (Nurse Practitioner) notified, and an order was received to send resident to hospital for psych evaluation.10/31/2025 at 12:28PM Resident left facility in stable condition with ambulance via stretcher on a petition to hospital for psych evaluation. All belongings secured, family and staff notified. Will follow up as needed.R1's aggression assessment dated [DATE] documents that R1 is at moderate risk for aggression, Resident has demonstrated the need for re-evaluating services due to recent behavior.R1's care plan documents in part, R1 presents with signs & symptoms of persistent anger towards self & others related to: Feeling abandoned by support system (which may include family members, friends, physician, God & religion, etc.)., Psychotic symptoms (i.e., delusions, hallucinations, paranoia).R2's progress notes:10/31/2025 at 10:58AM, Resident received physical contact from peer. Residents were immediately separated. Head to toe assessment completed. No visible bruises or injuries noted. Denies pain and discomfort. MD and family made aware. Vital signs stable. All notifications made.On 02/10/2026 at 12:20PM, R2 observed lying in bed in a supine position with an electric wheelchair next to his bed. R2 states this incident occurred so long ago that he does not recall what happened. R2 states R1 was his girlfriend, and she is no longer in the facility.R2's care plan documents in part, R2 will remain safe, will be treated with respect, dignity and reside in the facility free of mistreatment (i.e., abuse/neglect) through next review. Provide a safe environment, free from judgment, especially during the investigation. Provide emotional support to the resident.On 02/10/2026 at 1:22PM, V3 (Nursing Supervisor/RN) states, he is not sure exactly what happened, but he was made aware that R1 hit R2. V3 states R2 is someone that he built a rapport with and talks to frequently. V3 states R2 told him that R1 hit him but R2 did not hit R1 back. V3 states R2 did not complain of pain and stated that he was fine. V3 states he did not speak with R1 regarding the incident, but he has seen R1 upset and aggressive on previous occasions. V3 states he would often calm R1 down by offering her to take a cigarette smoke break because this is the only thing that seemed to calm R1 down when she was not redirectable. V3 states he has even seen R1 become aggressive and verbally abusive towards her own mother. V3 states he would hear R1 curse, get loud, and tell R1's mother I don't want to speak to you, you put me here. On 02/10/2026 at 1:36PM, V1 (Administrator) states she has been the abuse coordinator at the facility since 09/29/2025. V1 states on 10/31/2025, she and other staff members were in a morning meeting, and everyone heard a noise and came running out of the room to see what was happening. V1 states she observed that R1 was having a behavioral episode. V1 states she was trying to tell R1 to calm down and then R1 slapped R2 across the back of his head right in front of V1. V1 states she then told R1 now I have to send you out to the hospital and R1 said I don't care send me out. V1 states R1 and R2 were separated until 911 came and took R1 out to the hospital. V1 states a body assessment was performed for R2 and R2 did not have any bruising or complain of pain. V1 states she observed that R1 did not hit R2 willfully and R1 was just having an episode. V1 states it was not a willful intent to hurt or harm R2. V1 states she also informed R1 that R1 could not return back to the facility.Facility Reported Incident dated 10/31/2025 documents that the facility reported that R1 made physical contact with R2.Facility policy dated 01/2019 titled Abuse Prevention Program documents 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. 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,.Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse: Hitting, slapping, pinching, kicking, etc.

Based on interview, and record review, the facility failed to provide adequate supervision and implement fall prevention interventions for one of six residents (R1) reviewed for high risk for falls. These failures caused R1 to sustain a fall and was sent out to the local hospital with a laceration to the right eyebrow, a large subdural hematoma with mass effect, effacement of the right lateral ventricle, and a right zygomatic facial fracture.Findings include:R1 has a diagnosis of history of falling, weakness, cellulites of right lower limb, unspecified dementia, severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety.R1 has a Brief Interview for mental status dated 10/15 25 with a score of 3 which indicates that R1 has some cognitive impairments.The facility's initial reportable incident to the local state agency dated 10/03/25 at 11:32 pm, documents in part: Upon rounds nurse noted of resident alert and confused period lying on his lateral side on the floor in his room with a skin alteration to his right eyebrow.The facility's final reportable incident to the local state agency dated 10/11/25 at 12:13 am, documents in part: Conclusion the facility completed its investigation through medical review and statements. Based on interviews, the resident sustained an injury to his head due to him jumping up impulsively attempting to ambulate without staff assistance and stumbled through the floor Staff saw resident approximately 3 to 5 minutes prior to the resident was seated on his bed with his helmet on . The resident was observed next to his bed on the floor with his helmet close by. The resident was sent to the hospital and returned on 10/8/25 on hospice care.The facility's document dated 10/03/25 and titled Falls documents in part: Upon rounds nurse noted of resident alert and confused period lying on his lateral side on the floor in his room with a skin alteration to his right eyebrow. V10 (Registered Nurse, RN) statement documents in part: Resident was observed lying on his right side on the floor in his room. He was immediately assessed and observed with bleeding to his right eye. The helmet was next to his body on the floor.R1's progress note dated 10/03/25 at 10:05 am authored by V10 (Registered Nurse, RN) documents in part: The resident left via ambulance to be transferred to the local hospital related to fall in his room.R1's hospital record dated admission dated 10/03/25 documents, R1 is a [AGE] year-old man with a history of hypertension (HTN), dementia, anemia, heart failure, atrioventricular block (AV), bipolar disorder, who transferred from and outside hospital as a L2 (level 2) trauma activation status post unwitnessed fall from bed at his nursing home. Scan at (local hospital) revealed a large right subdural hematoma with mass effect and effacement of right lateral ventricle. Repeated scan showed right subdural hematoma and . right zygomatic facial fracture.R1's care plan dated initiated 12/07/23. Goal: I will have interventions and place that will help reduce my risk for falls and injury through the next review. Interventions: R1 with low bed . Dysem under floor mat . Apply floor mats to the side of my bed closest to the door; . R1 helmet on at all times as tolerated. R1's care plan dated initiated 12/07/23 documents in part: Focus: I have a Self-Care Deficit and I require assistance with ADL's to maintain the highest possible level of functioning AEB (as evidence by) the following limitation and potential contributing factors: Impaired Cognitive Status with DX (diagnosis) Dementia or Alzheimer's Disease, - (+) (plus) ROM (range of motion) Deficits, -Depressive episodes, - General weakness, HTN (hypertension), Heart Failure and Anemia. Interventions/Task: . Bed Mobility: I usually requires dependent assist with bed mobility.On 11/19/25 at 2:45 pm, V2 (Director of Nursing, DON, Falls Nurse ) stated that V2 is the facility's falls coordinator. V2 then explained that R1 was alert, oriented to name only, high risk for falls due to multiple falls at the facility, used a wheelchair due to his unsteady gait and that R1 was impulsive, easily jumping up from a sitting position due to R1's confusion. V2 further explained that R1 sustained multiple falls at the facility and wore a helmet to prevent R1 from sustaining a fall with injury. V2 explained that R1 required close monitoring by staff due to R1's impulsive manner to jump up from a sitting position.On 11/20/25 at 9:44 am, V10 (Registered Nurse, RN ) stated that he worked at the facility since 2012. V10 explained that he was R1's night shift nurse at the facility. V10 then stated that R1 was a resident who was alert to name but not able to follow directions at all times, was high risk for falls due to having multiple falls in the past and required close supervision especially when awake due to R1 attempts to stand and ambulate when awake. V10 then explained that R1 was a one person assist and required a wheelchair for ambulation. V10 also explained that R1 would stay with staff when awake to prevent R1 from falling. V10 also stated that when R1 fell at the facility on 10/03/25 it was around the last hour of the night shift between 5:30 am and 7:00 am. V10 further explained that he was in the hallway at the room next door to R1's room checking his narcotics count when he heard what sounding like a heavy book bag dropping noise coming from R1's room. V10 explained that he went into R1's room and observed R1 laying on the bare floor, on his right side between the dresser and bed, with R1's helmet lying beside R1's head tilted, to the side of R1. V10 stated that R1 was laying on the bare floor and that V10 does not recall where R1's floor mat or R1's floor mat dysem was in the R1's room. V10 explained that R1 had floor mats to each side of R1's bed that should have been in place however, V10 did not observe R1 laying on a floor mat during the time of the fall. V10 stated that R1 was laying on the bare floor, fully dressed, with a laceration above R1's right eyebrow about 2 inches long and about 1-inch-wide, bleeding. V10 then explained R1's bed was not in the lowest position and that R1's bed was slightly raised up to where R1 could sit on the side of the bed with his feet dangling. V10 further stated that R1 was not able to state what happen and was just saying Hey, hey. V10 then stated that when he observed R1 lying on the bare floor in R1's room, he yelled out for V11 (Certified Nursing Assistant, CNA) for help and that V11 came along with two other CNA's came into R1's room to assist with R1 fall. V10 stated that he was able to apply a cold compress and pressure to stop R1's right eyebrow laceration from bleeding. V10 then explained that he has observed R1 remove his helmet in the pass and that he does not think that R1 was wearing his helmet during time of the fall. V10 further explained that the last time he observed R1 prior to his fall on 10/03/25 was between 3:00 am and 4:00 am when R1 was sitting on the edge of the bed nodding off with his eyes closed and R1's head titled wearing his helmet. V10 explained that it is all the staff's responsibility to make sure fall precautions such as the floor mat is next to the residents bed and bed in lowest position to prevent a resident from falling and sustaining a injury. V10 also stated that V10 is given in report who is high risk for falls and V10 then will verbally tell the CNA's who is high risk for falls and what interventions should be in place. V10 explained that he believes that there are documents in place to inform the staff of what residents who are high risk for falls however he is not aware of where the staff can refer to get the information and that he does not use it. V10 stated if a resident who is high risk for falls is not properly supervised and fall interventions are not in place the resident can sustain a fall. On 11/20/25 at 11:07 am, V11 (Certified Nursing Assistant, CNA) stated he has worked at the facility for 2 years. V11then stated that he recalls R1 at the facility and that R1 was not alert, oriented, required 1 person assist, utilized a wheelchair for ambulation, was high risk for falls and had multiple falls at the facility. V11 explained on 10/03/25 around 5:30 am V11 went into R1's room and observed R1 sitting on the edge of the bed. V11 stated that he dressed R1 and placed R1's helmet on R1's head around 5:30 am. V11 then explained that he went to get R1's some socks from R1's dresser that was along the wall, across from R1's bed in R1's room when he sustained a fall. V11 explained that R1's bed was not at the lowest position when he left R1 sitting on the edge of R1's bed's bed to get R1 some socks because V11 had just finished dressing R1. V11 then explained that R1 fell on a floor mat next to R1's bed facing the door with R1's helmet next to R1 on the floor and that he believes that R1 removed his helmet. V11 then explained that he called out for V10 (RN) (R1's nurse) to come into the room. V11 stated that R1's bed is always at floor level to prevent R1 from falling however V11 raised R1's bed from the floor to dress R1. On 11/20/25 at 11:51 am, V2 (DON, Falls Coordinator) explained that after a fall occurs V2 conducts an investigation, review the risk management form, and collect statements from staff pertaining to the fall. V2 further explained that a fall risk assessment recommendation meeting with the falls team which consist of V2, wound care nurse, social services, therapy department, V1 (Administrator) , Minimum Data Set (MDS) nurse, restorative nurse and activity department is held to discuss the fall plan of care with the interventions. V2 then explained that the restorative nurse is in charge of putting the interventions in place and updating the residents care plan. V2 stated that the nursing staff is responsible for ensuring that the interventions remain in place at all times. V2 explained that there is a binder on each unit that informs the nursing staff of who is high risk for falls and the residents interventions. V2 then explained that R1's fall interventions included R1 being closely supervised, helmet in place, bedside mats in place, bed in the lowest position, ensuring his belongings are near, and R1's call light was to be placed in reach. V2 further explained that if a residents fall intervention are not in place the resident can get injured.On 11/20/25 at 12:30 pm, V12 (R1's Physician) stated that R1 had an extremely advanced dementia, extreme confusion, disoriented, with malnutrition. V12 then stated, R1 was a very high-risk for falls resident, not steady on his feet, who required constantly watching him or R1 would get up and fall because he could not walk properly. V12 explained that every time he saw R1, he was wearing a helmet. V12 also explained that he would observe R1 pulling on his clothing and helmet but never saw R1 remove his helmet. V12 stated that R1's fall interventions included R1 being closely monitored at all times especially when awake, a low bed, floor mats, and R1's room close to nursing station. V12 then stated if R1's falls interventions/preventions are not in place, R1 could sustain an injury. V12 stated that he was called many times regarding R1 falling at the facility . V12 further stated that V12 recalls giving orders to send R1 to the local hospital for a fall where R1 suffered a subdural hematoma (SDH) and that R1 returned to the facility on hospice care. R1's progress note dated 10/03/25 at 5:45 am, authored by V2 (Director of Nursing, DON, Falls Nurse) documents, in part; Upon rounds the nurse noted the resident was alert and confused, lying on his lateral right side on the floor in his room with a skin alteration to his right eye. Head to toe assessment completed, no other injuries noted. First aid rendered. Clean dry dressing applied. Resident assessed for pain, none noted. Range of motion (ROM) to all extremities within normal limits. Medical doctor (MD) notified. Order for hospital evaluation. The facility's document dated 9/18/25 and titled Fall Risk Review shows that R1 has a score of 14 indicating that R1 was high risk for falls. The facility's document dated 10/03/25 and titled Fall Risk Review shows that R1 has a score of 20 indicating that R1 was high risk for falls. The facility's document dated 10/08/25 and titled Fall Risk Review shows that R1 has a score of 13 indicating that R1 was high risk for falls. The facility's document dated 10/15/25 and titled Fall Risk Review shows that R1 has a score of 17 indicating that R1 was high risk for falls. The facility's document dated 05/01/25 through 11/19/25 shows that R1 sustained a fall at the facility on 06/07/25, 10/03/25 and 10/15/25 at the facility. The facility's undated document titled Incident/Accident/Falls documents, in part: It is the policy of the facility to ensure that an incident accident to include falls is Reported immediately to the nurse or appropriate person designated to be in charge . the facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated, and resolved . This information will be used to implement corrective action to include any needed training to prevent reoccurrences the impossible.

Based on interview and record review, the facility failed to ensure resident's care needs were being met by permitting one employee (V15) to sleep on duty. This failure has the potential to affect 16 residents on the unit V15 was assigned.Findings include:On 9.17.2025 2:57 PM, V2 (DON-Director of Nursing) said V15 (Former CNA-Certified Nursing Assistant) was terminated after she was caught sleeping while on duty for the second time. She was caught sleeping around 5:59 AM in the laundry room by laundry staff. That is an unauthorized area. V15 told a staff member you need to give (V15) 10-15 minutes. At 5:59 AM, (V15) should have been doing final rounds. Staff (laundry) found her in unauthorized area.On 9.18.2025 at 10:00 AM V2 (DON) said, V15 (Former CNA-Certified Nursing Assistant) should not have been sleeping while on duty, she should have been attending to her job duties, attending to the residents. It's very important we stay awake while working, something may happen to the residents. It's against the facility policy as well as union rules.On 9.18.205 at 10:33 AM V4 (Director of Housekeeping) said, when my staff came in that morning, she found a CNA sleeping at the folding table, with a blanket over her. (V15) told my staff they needed to give her 10 more minutes and then she'll be up. V17, Laundry Aide found V15 and reported it to me. V17 took a picture of V15, CNA and sent it to me. I reported the incident to V2.On 9.18.2025 at 1:36 PM via telephone, V17 (Laundry Aide) said, I want to say it was two weeks ago, around 5:42 AM. I came into the laundry room and saw a CNA sleeping. V15 had a blanket wrapped around her, her head down on the folding table. She scared me, I was expecting to see washers and dryers, not someone sleeping. V15 said to me, just give me five or ten minutes more, then put head back down. I went upstairs to clock in, when I came back down, she was gone. I took a picture of V15. I informed my supervisor (V4- Director of Housekeeping).The facility's CNA Assignment Sheet, dated 9.3.2025, documents V15 was working 11:00 PM-7:00 AM and assigned to the 2nd floor. Midnight census report dated 9.3.2025 documents a total of 16 residents in rooms V15 was assigned to.V15's Employee Disciplinary Action Form signed 9.9.2025 documents: On 9.3.2025 (V15) was reportedly sleeping while on duty in the basement laundry room. Sleeping while on duty is a violation of Category One offense #4 per union working agreement. Due to violation of the listed offense, (V15) is terminated from her position as CNA of (Facility).

Based on interview, and record review the facility failed to consistently administer bilevel positive airway pressure (BIPAP) therapy as ordered by a physician for one resident (R2) out of three residents reviewed for respiratory care in a total sample of seven residents. Findings include:R2's current face sheet documents R2 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to: obstructive sleep apnea (adult) (pediatric), chronic obstructive pulmonary disease, unspecified, morbid (severe) obesity due to excess calories, sleep related hypoventilation in conditions classified elsewhere.R2's MDS/Minimum Data Set, dated [DATE] documents that R2 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R2 has intact cognitive function. R2's active physician order set documents in part Bipap (bilevel positive airway pressure) at 15 cm (centimeters) H2O (water) On at Night and off while awake. No additional details were documented in the scheduled portion of the order. R2's physician note dated 8/26/2025 10:01 PM documents bipap trial at night, on nasal canula oxygen at the rate of 2 liters / min, keep head end of the patient elevated. Patient and staff educated on overall plan of care and warning signs and symptoms reviewed with patient. R2's physician note dated 9/3/2025 7:31PM documents in part obstructive sleep apnea, bipap trial at night.R2's physician note dated 9/8/2025 7:51PM documents in part bipap trial at night.R2's care plan documents R2 is at risk for acute cardiac distress, SOB (shortness of breath), and risk R/T (related to) COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure), OSA (Obstructive Sleep Apnea). Respiratory risks will be minimized with nursing and medical interventions thru next review. There is no documentation of BIPAP therapy documented in R2's care plan interventions.R2's medication administration records and treatment administration records dated August 2025 and September 2025 did not document R2's Bilevel Positive Airway Pressure (BIPAP) is scheduled nor administered. R2's progress notes since admission reviewed and no consistent documentation that R2's BIPAP was administered as ordered by the physician.On 09/17/2025 at 10:55 AM, R2 was lying on her bed with R2's head of the bed elevated. R2 noted with oxygen via nasal cannula at 2 liters/minute. R2 stated that she has been in the facility for about three weeks to four weeks. This surveyor observed R2's (BIPAP), a non-invasive ventilation therapy used to assist patients with breathing difficulties, on R2's bedside table. R2 stated that she is not able to put on the BIPAP by herself and needs assistance. R2 stated that no one was putting it on R2 since R2 had been here until recently. R2 said that when she inquired about her BIPAP the nurse's response was I can't bother with this, it is too hard. R2 said that she cannot recall the nurse's name who said this to R2. On 09/17/2025 at 11:35 AM, V2 (Director of Nursing) said I saw R2 maybe a couple of weeks ago pertaining to R2's BIPAP. V2 stated that R2 reported that she was not getting the BIPAP therapy. On 09/18/2025 at 10:45 AM, V2 (Director of Nursing) stated that the administration of BIPAP should be documented in the electronic medication administration record (EMAR) or in the resident's progress notes. V2 stated that R2's BIPAP order does document when it should be administered which is at night and off in the morning time. V2 stated that she did see some notes that it was administered, V2 stated but she did not see the notes consistently. V2 stated that the order is not in the EMAR with scheduled details and where the nurses can sign off when administered. V2 stated that the importance of a BIPAP machine is to ensure that the resident is getting adequate oxygenation and to prevent them from going into pulmonary distress or respiratory distress, to keep the lungs open. On 09/18/2025 at 10:14 AM V14 (Registered Nurse) stated that she regularly works with R2. V14 stated that the importance of a BIPAP machine is for their breathing and is commonly ordered for conditions such as COPD (chronic obstructive pulmonary disease) and sleep apnea. V14 stated that the nurses would know to administer the BIPAP if the order is in the MAR (medication administration record) or the TAR (treatment administration record), or sometimes by reviewing R2's physician order set. V14 stated that the administration of the BIPAP would need to be documented in the MAR, TAR, or the resident's progress notes. V14 stated that if it is a standard order, it would be documented in the MAR. V14 stated that if it is not documented then it is not done. Facility document not dated documents in part physician orders (following physician orders). It is the policy of the facility to follow the orders of the physician. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission. Facility provided document not dated documents in part resident rights. You have the right to safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction.

Based on observation, interview, and record review, the facility failed to ensure residents remained free from abuse. This failure affects two residents (R1, R2) reviewed for abuse. This failure lead to physical assault by R2, which resulted in R1 sustaining a laceration to the head. Findings include: R1 is a [AGE] year old with diagnosis including but not limited to: Transient Ischemic Attack (TIA), Cerebral Infarction without Residual Deficits, Osteoarthritis, Weakness, Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease, Schizophrenia, and bipolar disorder. R1's BIMS (Brief Interview of Mental Status) dated 4/18/2025 documents a score of 12, which indicates moderately impaired. R1's Abuse Care Plan documents, R1 will remain safe, will be treated with respect, dignity and reside in the facility free of mistreatment. R2 is a [AGE] year-old with a diagnosis including but not limited to: Type 2 Diabetes Mellitus without Complications, Unspecified Convulsions, Other Hypertrophic Cardiomyopathy, Essential Hypertension, Acquired Absence of Other Left Toe(S), Acquired Absence of Other Right Toe (S), Anemia Unspecified, Personal History of Other (Healed) Physical Injury and Trauma. R2's BIMS (Brief Interview of Mental Status) dated 6/16/2025 documents a score of 15, which indicates cognitively intact. During investigation on 6/25/2025 at 2:46 pm, R1 stated It was all on camera, he (R2) slammed me on the floor and made me hit my forehead. It really hurt, look at my head. I have stitches. R1 pulled his hair back from his forehead and stitches were noted to R1's right forehead. On 6/25/2025 at 11:57 am, V7 (NP/ Nurse Practitioner) stated the following, the expectation of resident safety during an altercation is de-escalation and separating the residents involved so that neither resident is able to physically harm the other. If a resident falls and hits their head during a physical altercation, the resident can sustain a skull fracture or intracranial hemorrhage. A head injury can lead to a resident's demise or a decline in the resident's health. On 6/25/2025 at 1:53 pm, V4 (DON/ Director of Nursing) stated the following, If there is a physical altercation between two residents, the expectation is that the residents are immediately separated to ensure the residents are safe in the environment. The aggressive resident is removed from the area and the residents are sent out to the hospital for an evaluation if needed. If a resident hits their head or if a resident sustains an injury, they are sent to the hospital for a further evaluation to make sure the resident didn't sustain a skull fracture or brain bleed. A head injury can lead to a resident's decline in resident's health. On 6/25/2025 at 3:19 pm, R2 stated the following, R1 was yelling and walking towards me, making threats and using profanity. R1 got close to me, so I grabbed his walker and shoved him. He fell and hit his head and begin to bleed. I didn't mean to shove him (R1) that hard. Initial Facility Report of Incident dated 6/17/2025 documents the following: it is alleged that R2 made contact with R1; R1 and R2 were immediately separated; MD (Medical Doctor) and Family notified; Police Report (#JJ298430); R2 placed on 1:1 supervision and sent out for psych evaluation; and R1 was sent to the Hospital. R1's Progress note dated 6/17/2025 at 22:11 documents in part, allegedly co-peer made contact with the resident(R1), residents (R1 and R2) were immediately separated, first aid rendered to open area noted to the right side of R1's head, and R1 was sent to the hospital for an evaluation. Chicago Police Report dated 6/17/2025 at 1900, RD Number JJ98430 documents, Simple Battery; Name of Victim/Complainant; R1 . Facility document titled, Statement, dated 6/17/2025 documents: R1's statement of the incident; I was trying to pass him (R2), and he bumped me, and my head hit the desk. V8 LPN's (Licensed Practical Nurse) statement of incident dated 6/17/2025 documents: the resident (R1) was walking out his room going toward the nursing station. R2 said something to R1 and R1 walked toward R2. V9 (CNA/Certified Nursing Assistant) got in the middle and pulled R1 to the side. After V9 (CNA) turned around, R2 got out of his wheelchair and pushed R1. V9's (CNA) statement of incident dated 6/17/2025 documents, V8 (LPN) stated that R1 and R2 were in a verbal interaction, and I (V9) tried to separate them but suddenly R2 pushed R1 away from him. R1's Hospital admission Record dated 6/17/2025 at 8:42 pm, documents: forehead laceration; needs wound check in 2 days and suture removal in 7 days. Facilities Policy titled, Abuse Prevention Program 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.

Based on interview and record review, the facility staff failed to report an allegation of abuse to the administrator for one of three residents (R1) in a total sample of four. Findings include: On 6.3.2025, at 1:17 PM, V1 (Administrator) said, the incident happened on 5.10.2025. Two residents R1 and R2 got into it. It wasn't initially a reportable incident because no resident was injured and there was no mental distress of either resident. He (V3) stated CNA-Certified Nursing Assistant) came in and hit him in the face. R1 did not reference R2. On 6.3.2025, at 1:32 PM, V3 (CNA-Certified Nursing Assistant) said, I did not hit R1. V3's written statement of 5.12.2025, documents in part, V3 observed R1 and R2 involved in an altercation, intervened by separating the residents; V3 reported the incident to the nurse. On 6.4.2025, at 12:17 PM, V10 (PRSC- Psychiatric Rehabilitation Services Coordinator), said it was towards the end of my shift (5.10.2025). They called me down to the 3rd floor, because there was an incident that was going on. By the time I got down there it was over. R1 couldn't tell me what happened. At first, he didn't want to talk to me. All he would tell me was that there was an altercation between him and R2. When I came back on Monday (5.12.2025), an investigation was in progress. I reported it to V12 (Social Service Director). We reported it to V1 on Monday. On 6.4.2025, at 12:38 PM, V11 (Psych Tech) said, I didn't report it (the altercation between R1 and R2) because it was over when I got up there. On 6.4.2025, at 1:24 PM, V12 (Social Service Director) said, I was told about the altercation between R1 and R2 on Monday (5.12.2025). I found out from V1 In the morning meeting (Administrator) that it was a reportable (incident) for behavior. It should be reported to the abuse coordinator. On 6.4.2025, at 2:19 PM, via telephone, V9 (CNA-Certified Nursing Assistant) said, I would let the charge nurse know about any abuse. V8 (RN-Registered Nurse) was the charge nurse that shift. She knew, she reported it (the incident) to V2 (DON-Director of Nursing). On 6.4.2025, at 3:05 PM, V2 (DON-Director of Nursing) said, R1 and R2 had a verbal altercation and V3 intervened. It wasn't reported to me that either of the residents hit each other. None of my staff reported anything to me about the alleged incident of 5.10.2025. I didn't find out about the incident until Monday or Tuesday. I was never told it was physical contact. Abuse is reported to the administrator immediately. He's the abuse coordinator. They don't have to report it (abuse) to me, they should report it to V1. On 6.4.2025, at 3:27 PM, V13 (Nurse Supervisor) said, honestly, I did not hear anything until V1 questioned me on 5.12.2025. V1 asked me if I heard about an incident involving V3 and R1. R1 stated that V3 allegedly punched R1 in the face. If a resident hits another I need to know immediately. If residents have a verbal altercation, staff should let me know immediately. I would immediately let V1 know. Facility incident report (initial of 5.10.2025) documents in part, V3 made contact with resident (R1). Addendum: It is alleged that residents (R1) and (R2) made contact with each other. Conclusion: V3 did not make contact with R1. V3 responded to a disagreement between R1 and R2. The allegation was not substantiated. Facility incident report (initial of 5.12.2025) documents part, V3 made contact with resident R1. Facsimile cover sheet documents both initial reports were faxed to the Illinois Department of Public Health on 5.12.2025 Abuse Prevention Program Policy and Procedure (Revised 3.26.12) documents in part: -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 if available or an immediate supervisor who must immediately report it to the Administrator. In the absence of the Administrator, reporting can be made to the DON. Supervisors shall immediately inform the Administrator or in the absence of the Administrator, the DON of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, misappropriation of property, mistreatment, or crime against a resident. Procedure: Any alleged violations involving mistreatment, abuse, neglect, exploration (exploitation), misappropriation of resident property, any injuries of an 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. Additionally, the person(s) observing an incident of resident abuse or suspecting resident abuse must IMMEDIATELY report such incidents to the Charge Nurse who will immediately report the allegation to the Administrator, regardless of the time lapse since the incident occurred. The Charge Nurse will immediately report the incident to the Administrator or to the DON during the Administrator's absence. This report shall be made immediately, but no later than two hours after the allegation is made. If the events that (cause) the allegation involve abuse or resulted in serious bodily injury, or not less than 24 hours if the events that cause the allegation do not involve abuse and did not result in serious bodily injury.

Based on interview and record review the facility failed to ensure a resident was free of physical abuse for one (R3) resident in a sample of three. This failure resulted in physical injury to R3's face requiring transfer to a hospital and R3 receiving three sutures to R3's face. Findings include: R3 is a [AGE] year old female with a diagnoses including Bipolar disorder, Schizoaffective disorder, Obesity, Auditory hallucinations and Depression. R3 has a BIMS (Brief Interview for Mental Status) score 15/15. R3 was first admitted to the facility on [DATE]. R3's care plan includes Abuse & or Neglect. Comprehensive assessment reveals a history of suspected abuse, neglect, exploitation, past trauma and/or other factors that may increase my susceptibility to abuse/neglect. The resident demonstrates: Diagnosis of Mental Illness. Date initiated 2/2/24. R4 is a [AGE] year old male with a diagnosis including Schizophrenia, Suicidal ideation's, Bipolar disorder, Anxiety disorder and Auditory hallucinations. R4 was first admitted to the facility on [DATE]. R4 has a BIMS (Brief Interview for Mental Status) score of 15/15. R4's care plan includes behavioral symptoms related to severe mental illness. R4 displays inappropriate behaviors towards staff. Date initiated 7/4/24. Red Pass. R4 present with inappropriate behaviors not able to be redirected by staff. R4 will continue with a Red pass for 30 days. 2nd offense. Date initiated 7/2/24. The following progress note review shows the following behaviors for R4. 7/3/24 social service note: It was reported to this writer that R4 displayed verbal aggression to staff. Writer educated resident on non-tolerance for behaviors and to respect staff at all times. Resident showed understanding and was receptive to education. Behavior tool form could be found in (electronic charting system). S.S (social services) will continue to document as needed. 7/4/24 progress note: It was brought to writer attention by CNA (certified nursing assistant) doing rounds that resident was in a female residents room while they were sleeping and refused to leave when asked by the CNA. Resident became agitated and began screaming. Writer asked resident to remain calm and attempted to redirect but resident began screaming at writer stating that he does not have to listen to anyone. Psychiatric tech was called and resident went to room where he remained for the rest of shift. Staff will continue to monitor. The facility final incident report dated 7/11/24 shows the following: After a thorough investigation, which included interviewing all possible witnesses, the following was concluded: Resident R4 and resident R3 were sitting together in the smoking patio along with other residents and the supervising Psychiactric Technician (V30). They were having a conversation. Both residents are alert and oriented. The conversation led to R4 becoming displeased and he made contact with the side of R3's face. Staff immediately separated them and placed them both on 1:1 monitoring. Both R4 and R3 were sent to the hospital for further evaluation. R3 returned to the facility after receiving treatment for right upper cheek laceration which included three sutures. R5 remains out of the facility and will not be returning to the facility. Police took no further actions. R3 received emotional support and well being checks from social services. She does not have any concerns and stated she feels safe and comfortable in the facility. R3 had no mental anguish or emotional distress. Care plan reviewed and updated. MD and family made aware of the outcome of the investigation. This serves as the final report. On 7/23/24 at 3:15PM V30 (Psychiatric technician) stated R3 and R4 were having an argument on the patio about R4 being with another female. I went up to them and told them to stop. I turned around and walked away. Shortly after I heard a commotion and looked in their direction. R4 hit R3 in the face with a closed fist. He then started choking her. I went over and stopped the fight. I alerted other staff immediately. On 7/23/24 at 2:30 PM V29 (Physician) stated the force that caused R3 to receive the injury to her face was caused by a forceful blow by a closed fist. This resulted in R3 receiving three sutures to her face. The following progress notes shows the description of incident. 7/11/24 progress note: Writer was made aware that resident got into an altercation with peer. Staff immediately intervened and separated the two. Resident was assessed with injury being present. Resident stated that she feels safe in the facility with 911 being called. MD, DON and sister was notified. Resident is alert and oriented. Resident able to voice all concerns with no complaints of pain at this time. Resident verbally agreed to understanding the bedhold policy. 7/12/24 progress note: Resident (R3) returned from hospital ambulating with steady gait alert and she denies any pain or discomfort at this time. Resident immediately assessed with 3 sutures to upper right cheek with minimal swelling to area with no redness or drainage seen. Resident has 2 small superficial scratches to the front of her neck with no bleeding or swelling to neck area. Writer received verbal report from ER doctor stating that all test with no fractures or dislocations seen. Writer observed in discharge documents that resident was + for trichomonas with her informing writer that she did have a light discharge with no itching involved. Writer informed np of return to facility with current finding's with new order's received and noted with resident aware of current medication order's. Writer spoke with resident sister informing her of return to facility and that resident is safe here in the facility. Resident is stable having lunch with no voiced concern's at this time. Hospital report dated 7/11/24 shows R3 sustained a 2 centimeter laceration to right upper cheek. Wound closed with three sutures. Facility policy titled Abuse Prevention Program revised 01/2019 states including: 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 the interview and record review, the facility failed to ensure that provider orders were followed for three residents (R2, R3, R4) out of three residents reviewed for Hepatitis C treatment. This failure resulted in R2 not receiving treatment for Hepatitis C resulting in liver damage, hepatocellular carcinoma, and progression of R2's liver tumor giving strong evidence of carcinomatosis (cancer is spreading). Findings include: 1) On 6/11/24 at 12:27 PM, V9 (Physician) stated that R2 was admitted to the hospital on 5/30/24 and that V9 was supervising R2's care during R2's hospitalization . During R2's hospital admission, V9 stated that V9 had concerns that R2 was diagnosed with Hepatitis C that was not treated by the facility. V9 affirmed that R2 was diagnosed with hepatocellular carcinoma, which can be a complication of untreated Hepatitis C, and that the cancer had spread to other areas of R2's body. V9 stated that if the facility had treated (R2's) diagnosis of Hepatitis C, (R2's) cancer could have been prevented. Review of R2's hospital records from R2's 5/30 admission document in part that progression of the liver tumor gave strong evidence of carcinomatosis (spreading). Oncology was consulted and given R2's malnutrition and advanced disease state, oncology confirmed R2 was outside of the treatment window for cancer. A goal of care meeting was held for R2 on 6/5/24 at the hospital, and hospice care was elected. Facility's R2's records document in part the following diagnoses: Chronic obstructive pulmonary disease, human immunodeficiency virus, asthma, hepatic cell carcinoma, schizoaffective disorder, unspecified liver cirrhosis, type 2 diabetes mellitus, epilepsy, chronic kidney disease, unspecified psychosis, schizoaffective disorder. No diagnosis of hepatitis C was noted. Record review of R2's laboratory values indicate a positive Hepatitis C antigen on 10/13/23 and 2/28/24. No records of Hepatitis C viral load or Hepatitis C genealogy testing results were noted in R2's medical record. Record review of R2's progress notes indicate that V10 (Physician) ordered Hepatitis C genealogy and Hepatitis C viral load on 2/28/24, 4/9/24, and 5/10/24 and ordered for an infectious disease consult on 1/29/23. Record review of R2's physician orders indicate V11 (Nurse Practitioner) ordered referrals for an infectious disease consult on 10/16/23, 3/1/24, and 3/6/24 for R2's diagnosis of Hepatitis C. On 6/12/23 at 11:14 AM, V11 (Nurse Practitioner) stated that V11 was a provider for R2 during R2's stay at the facility. V11 confirmed that R2 had a diagnosis of Hepatitis C, gave orders for lab work and an infectious disease consult. V11 stated that V11 gave the order for infectious disease consultation multiple times and was not made aware by the facility that R2 did not get treatment by an infectious disease specialist. V11 affirmed that it is V11's expectation that orders given from a provider are followed. When surveyor asked V11 regarding what the potential outcomes of not treating Hepatitis C are, V11 replied that patients may get cancer or liver failure that could require a transplant. On 6/12/24 at 11:40 AM, V10 (Physician) stated that V10 was R2's primary care physician during R2's stay at the facility. V10 confirmed that R2 was diagnosed with Hepatitis C, as well as liver cancer, while at the facility and that orders were given for further laboratory testing as a standard of care for when R2 saw a specialist. V10 stated that Hepatitis C is a disease that V10 did not feel comfortable treating and R2 needed to see a specialist to treat it. V10 could not recall if R2 ever was seen by a specialist. When surveyor asked what harm can come from not treating Hepatitis C, V10 stated that a patient's liver can be damaged, resulting in cancers, cirrhosis, or liver failure. On 6/13/24 at 12:55 PM, V3 (Director of Nursing) confirmed that the facility had no documentation that R2 was seen by an infectious disease provider or that the Hepatitis C genealogy/viral load laboratory testing was completed. V3 stated that the nursing department monitors to ensure orders and treatments are carried out. V3 affirmed that the facility expectation is that orders by the provider are followed and carried out by the nursing department. 2. Record review of R3's admission record documents in part a diagnosis of chronic viral Hepatitis C. Record review of R3's MDS (Minimum Data Set) dated 6/5/24, documents in part a BIMS (Brief Interview of Mental Status) of 11, indicating moderate cognitive impairment and an active diagnosis of viral Hepatitis. Record review of R3's care plan dated 9/11/22 affirms that R3 has a diagnosis of Hepatitis C and is at risk for complications. Record review of progress notes dated 6/5/24 from R3's physician (V10) indicates a diagnosis of chronic viral Hepatitis C and orders given for laboratory testing for Hepatitis C genotype, Hepatitis C viral load. On 6/11/24 at 1:19 PM, R3 confirmed that R3 was aware of R3's Hepatitis C diagnosis. R3 affirmed that R3 had received treatment for Hepatitis C years ago but did not receive treatment recently. R3 stated that R3 was still positive for Hepatitis C and that R3's physician stated that R3's liver was getting very bad. R3 confirmed that would R3 like treatment for Hepatitis C diagnosis if R3 was eligible. On 6/12/24 at 11:30 AM, V10 (Physician) confirmed that V10 was R3's primary care physician. V10 confirmed that R3 has an active diagnosis of Hepatitis C. V10 affirmed that the facility was given orders for laboratory testing on 6/5/24 related to R3's diagnosis of Hepatitis C. V10 denied any knowledge of the laboratory testing not being completed by the facility. V10 stated that V10 expects any orders given to the facility to be carried out. V10 stated that if Hepatitis C is left untreated, it can lead to liver failure, cirrhosis, and cancer. On 6/13/24 at 12:55 PM, V3 (Director of Nursing) confirmed that the facility had no documentation that the Hepatitis C genealogy/viral load laboratory testing was completed for R3. V3 stated that the nursing department monitors to ensure orders and treatments are carried out. V3 affirmed that the facility expectation is that orders by the provider are followed and carried out by the nursing department. 3) Record review of R4's admission record documents in part a diagnosis of chronic viral Hepatitis C. Record review of R4's care plan dated 12/26/23 affirms that R4 has a diagnosis of Hepatitis C and R4's goal is to not develop any complications related to R4's Hepatitis C diagnosis. Record review of R4's MDS dated [DATE], documents in part a BIMS of 3, indicating severe cognitive impairment and an active diagnosis of viral Hepatitis. Record review of progress notes dated 5/17/24 and 5/25/24 from R4's physician (V10) indicates a diagnosis of chronic viral Hepatitis C. The following orders were given in response to the diagnosis: Hepatitis C genotype, Hepatitis C viral load On 6/11/24 at 1:19 PM, R4 denied any knowledge of R4 being diagnosed with Hepatitis C and denied any knowledge of being treated for Hepatitis C. On 6/12/24 at 11:30 AM, V10 (Physician) confirmed that V10 was R4's primary care physician. V10 confirmed that R4 has an active diagnosis of Hepatitis C. V10 affirmed that the facility was given orders for laboratory work on 5/25/24 and 5/17/24. V10 was not notified if the facility carried out V10's orders for R4. V10 stated that V10 expects any orders given to the facility to be carried out. V10 stated that if Hepatitis C is left untreated, it can lead to liver failure, cirrhosis, and cancer. On 6/13/24 at 12:55 PM, V3 (Director of Nursing) confirmed that the facility had no documentation that Hepatitis C genealogy/viral load laboratory testing was completed for R4. V3 stated that the nursing department monitors to ensure orders and treatments are carried out. V3 affirmed that the facility expectation is that orders by the provider are followed and carried out by the nursing department. Facility's undated document titled, Physician Orders- (Following physician orders) documents in part: It is the policy of the facility to follow the orders of the physician. Facility's undated document titled Job Description, Registered Nurse documents in part: E. Role Responsibilities- Nursing Care: 5. Request and arranges for diagnostic and therapeutic services, as ordered by the physician and in accordance with our established procedures. 17. Obtains sputum, urine and other specimens for lab test as ordered.

Based on interview and record review, the facility failed to prevent R2 from being physically abused by R3, who has a documented history of aggressive behaviors. This failure resulted in R2 sustaining facial and body scratches during a physical assault by R3. Findings include: On 12/27/22 at 11:18 AM, R2 stated, A few weeks ago, I was sitting on the side of my bed when R3 walked over to me and opened her jacket with no clothes on. R3 and I started fighting. While we were fighting R3 started scratching up my face, neck, arms, and hands. R3 hit me and we started fighting until V6 (Social Worker) came into the room and broke us up from fighting. Next thing I knew R3 was moved out the room and never came back into the room. My scratches were burning and bleeding a little bit, and no one came to clean up my scratches or put any cream on them. I used paper towels out the bathroom to stop the bleeding. When R3 scratched my face, neck, arms and hands it made me feel sad and embarrassed. I didn't do anything to provoke R3. I was so happy once the scratches healed and went away. V6 saw the scratches and my roommate (R4) did too. I feel safe here in the facility, and R3 moved to another place to live. I have not had any more problems. The next day the lady from {Behavior Transition Facility} came and took me to the DMV (Department of Motor Vehicles) for an identification card. V5 (Behavior Transition Facility Coordinator) saw my scratches and asked me what happened. I told her that R3 and I got into a fight, and she (R3) scratched me up. I told her (V6/Social Worker) everything. R2's Face sheet, medical diagnosis, and physician order sheets (no treatment order for scratches noted) were reviewed. Minimum Data Set (MDS) Brief Interview Mental Status score of 15 indicates R2 is cognitively intact. R2's care plans, medication administration record, treatment administration record, and progress notes dated 11/14/22-11/30/22 were reviewed. Also reviewed the facilities Illinois Department of Public Health (IDPH) reportable incident the initial and final. On 12/27/22 at 11:53 AM, V5 (Behavior Transition Facility Coordinator] stated, I came and picked up R2 the next day after the incident (11/15/22) to take her (R2) to the Department of Motor Vehicles for an identification card. I notice scratches on her face. R2 reported that her roommate (R3) came over to her (R2) bed where she (R2) was sitting and R3 had undressed while standing in front of her (R2). R3 would not move per R2's requested. Once R2 got up, then they started fighting. R2 showed me the scratches on her neck, which was covered up with a turtleneck shirt. R2 reported to me that R3 had scratched up her face, neck, arms, and hands. R2 also stated V6 (Social Worker) knew about the incident, because V6 was the one who broke the fight up. On 12/27/22 at 11:29 AM, R4 stated, I remember when R2 and R3 was fighting here in the room, I was in here. R3 came over to R2, they started arguing, then they started fighting. I went out into the hallway to find someone to stop the fight. The social worker (V6) came in and broke up the fight. R3 was terrible scratching up R2's face, like she (R3) did. I'm happy they move her out of the room immediately. I have not been abused by any resident or staff member here at the facility. I feel safe being here in this facility. On 12/28/22 at 5:19 PM, V9 (Licensed Practical Nurse/LPN) stated, I've been working here at the facility for 3 months, and I received abuse training during orientation. Some types of abuse are physical, mental, verbal, theft, and involuntary seclusion. I worked on 11/14/22 with R2 and R3 during day shift. I was notified by V3 (Director of Nursing) that while I was on break, R2 and R3 had an altercation in their room. I assessed R2 and did not see any injuries or scratches on the resident at all. V3 took care of the documentation, because I was out to lunch at the time of the incident. On 12/28/22 at 2:55 PM, V8 (LPN) stated, I have been working here at this facility for a year. However, I have been a nurse for over [AGE] years. I worked on 11/14/22 second shift on 3pm- 11PM. There was no altercation on my shift. I received in report that the altercation occurred on the first shift, and everything was taking care of. I really do not remember what happened. I passed medication to R2 that evening and she (R2) told me that altercation happened between her and R3. R2 reported that R3 was fighting her (R2). I usually document change of conditions, hospitalization s, admissions, wounds, and scratches. The scratches would be considered abuse. I worked with R2 the next day as well 12/15/22, but I did not see any scratches on R2's face, neck, arms, or hands. R2 always keep her mask and hood on. I had abuse training less than a month ago. Some types abuse physical, verbal, misappropriation of funds, sexual, emotional, and involuntary seclusion. On 12/29/22 at 10:15 AM, V2 (Director of Nursing/DON) stated, On 11/14/22, I was notified by staff that incident occurred and R2 wanted to see me. R2 reported to me that her roommate (R3) was making a lot of noise and she (R2) was trying to rest. So R2 got up to leave the room to get help from staff, when R3 stood in the doorway. R3 would not move and R2 then moved her out the way gently. R2 was calm during the conversation. I did not see any scratches or any signs of distress with her. R2 did not tell me her face was scratched, and R2's mask was on her face. Then I went into the room to see R3, and she seem to be agitated. R3 reported that R2 was trying to make her be quiet, and said that this was her room as well, and she wanted to leave the facility and did not like being here. I placed R3 on 1:1 due to her being agitated. Due to R2 made contact by moving R3 out the way, I notified V1 (Administrator) and social services. R3 was moved out the room per her request. At a later date, per R3 request, R3 was moved to another facility. R2 and R3 has never had any previous physical altercations in the past. On 12/29/22 at 1:03 PM, V1 stated, I have been here for two years. On 11/14/22 I was made aware of the incident between R2 and R3. I conducted the investigation, interviewed staff and residents that might have knowledge of the incident and determined that no abuse occurred. It was determined that R3 was acting out in the doorway to her bedroom. R2 and peer wanted to exit the room to seek staff in the hallway to help redirect R3. R2 gently moved R3 out of the way while walking out of the room. Staff immediately intervened and separated both residents. R2 voiced feeling safe within the facility. R3 expressed desire to discharge to another facility and no longer resides in the facility. Point of contacts and physicians of both residents made aware and expressed satisfaction. This incident abuse was not substantiated, because there was no physical harm intentionally made and no injuries was observed. To the best of my knowledge R2 and R3 have not had any physical altercations in the past. The new hire staff are provided abuse training during orientation. All staff receive abuse training annually and as needed. R3's medical record document in part: Face sheet indicates R3 was admitted on [DATE]. Admitting diagnosis: Absence Epileptic Syndrome, Type I Diabetes, hypercholesterolemia, hypotension, schizophrenia, extrapyramidal, bipolar disorder, major depressive disorder, schizoaffective disorder, insomnia, dysphagia, acute respiratory failure, muscle wasting, and abnormal gait. MDS Brief Interview Mental Status score is 9, indicating R3 is cognitively mildly impaired. Medication administration record, treatment administration record, and progress notes were reviewed. R3's Abuse Screening Indicator read in part: R3 has a psychiatric history and/or present mental health diagnosis, including, psychotic symptoms and possible misinterpretation of events and the intentions of others. Present signs and symptoms of depression mood distress include low self-esteem, isolation and withdrawn behavior. Complaints of chronic pain, illness, fatigue and persistent anger, fear and anxiety. History of dysfunctional behavior such as provoking, aggressive, manipulative, derogatory, disrespectful, abhorrent, insensitive, attention-seeking and otherwise abrasive inappropriate behavior, including roaming, wandering into peer's rooms and personal space. R3's Care plan dated 7/15/22 documents R3 is an adult living with chronic health conditions, psychiatric illness, behaviors, challenges, and co-morbidities that includes bipolar disorder, schizophrenia, and major depressive disorder. 11/21/22 care plan documents R3 has non-complaint behavior. 10/4/22 care plan documents R3 has medication refusal behavior. 11/17/22 care plan documents R3 will demonstrate an improvement or reduction in distressing behavioral symptoms in response to behavior management; R3 encouraged to attend conflict resolutions, symptom management, and anger management. R3 has the tendency not to report potential disagreements. R3's behavioral symptoms possibly related to a diagnosis of chronic mental illness. IDPH initial reportable dated 11/14/22 documents R3's statement documents She (R3) was not disturbing anyone and was dancing to music in the room. R3 stated, Don't believe what they tell you pumpkin, I know better than that. Progress note dated 11/4/22 staff nurse documented in part: R3 cut the cord on the desk phone with R3 informing staff that she (R3) will continue to act up. Nurse practitioner gave new orders for monthly injection. Staff to continue to monitor and support R3. Progress noted dated 11/4/22 nurse practitioner document in part: R3 is non-compliant with meds, agitation and aggression noted with delusional thinking. On 12/29/22 at 11:29 AM V6 stated, I am familiar with R2 and R3. I was both of their social worker during 11/14/22. I heard R4 in the hallway saying she needed staff help. I came out my office, one of the nurses was in the room. R3 was already out of the room and R2 was sitting on her bed. I told R2 to come with me. R2 reported she (R2) was tired of R3 being on her side of the room and R3 was stealing and taking items from her. R2 confronted R3 about going through her personal items. Then they started fighting, staff pulled them apart prior to me getting to the room. R3 got moved out the room to the fifth floor. I did not notice any scratches on R2's face, neck, arms, or hands. Once R2 was calm and R3 was moved out the room, then R2 was able to return back to her room. R2 and R3 have not had any past physical altercation. R3 does have a history of aggressive, and non-compliant behaviors. I received abuse training around a month ago, some types of abuse are physical, verbal, mental and financial. I reported the situation to the administrator immediately. R1 and R4 both reported no concerns with abuse. Both stated they feel safe in the facility. R1 and R4's face sheet, medical diagnosis, physician order sheets were reviewed. MDS Brief Interview Mental Status score, care plans, medication administration record, treatment administration record, and progress notes were reviewed. Facility's Abuse Prevention Program dated 1/2019 documents in part: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property

Based on interviews and record review, the facility failed to ensure two residents (R1 and R2) were free from abuse by failing to prevent physical aggressive behavior between R1 and R2 as a result R1 sustained a closed fracture of left orbital (eye socket) floor. The failure affects 2 (R1 and R2) out of 3 residents reviewed for abuse. The findings include: On 10/18/22 at 11:26 am R5 states they (R1 and R2) were fighting with each other. R1 brought R2 to the room by R2's neck and cornered her. Then R2 started punching R1 in the face about 5 times. R1 got up from the wheelchair to get R2 and fell . They were fighting about a lighter. I did not see R1 hitting (R1) her head on the dresser. That is what R1 said, but what really happened was that R2 punched R1's face about 5 times. R5 says she and another roommate assisted R1 back to the wheelchair. R5 said there was no staff there and it happened early in the morning. On 10/18/22 at 11:53 AM, R2 states R1 grabbed my neck and dragged me to her room, then I started hitting R1 in the face, I hit her on the cheek. R1 was in her wheelchair but she was able to grab my neck. I don't remember the reason we were fighting. After I hit her, she fell . I don't know if she hit the dresser. I went back to my room. She had a fight with another girl (R3) the day before and R1 grabbed her neck too. On 10/19/22 at 10:12 AM, R1 denies being punched in the face and states she fell on her own, but states she had an altercation with R3 and R3 kicked her on R1's legs. R1 states that staff members were aware about the incident between her (R1) and R3 and aware about R3 kicking her (R1) legs. A right leg quarter size discoloration lesion is noted on R1's right shin. On 10/19/22 at 12:03 PM, V11 (Licensed Practical Nurse/LPN) states I learned about the incident when I came to work that morning. R1 came to me before 7:30 am. When I saw R1 she had this little knot on her forehead. I asked what had happened and R1 said we got into it. Progress notes (draft) on R2's chart dated 9/21/22 reads: 11:11 am R2 believes a resident stole an item she just purchased from peer and then taken by same peer. R2 went in peer room and tried to take item back which led to a verbal and physical altercation. R2 was counseled and educated on buying and selling item from peers. R2 was receptive to counseling and education. R1's Progress Note dated 9/21/22 reads: Note Text: Writer received the patient back at 8:05PM on the floor from Hospital ER via wheelchair accompanied by 1 ambulance attendant. The patient remains AOX3 but verbally aggressive, uncooperative with staff. VS 97.3 (blood pressure)145/98 (pulse)100 (respirations) 20, 96% room air. Result for CT scan (computerized tomography, or imaging) per report from the hospital nurse reveals closed fracture of left orbital floor. Facility statements from R2, R5, R1 and R1's roommate (not identified). R1's statement does not provide any information about the incident. Facility's investigation does not include any other source of information about the incident besides R1, R2 and R1's roommates' statements and these statements are not consistent with the statements taken by the surveyor during the investigation. There are no staff members' statements even though the facility report in its conclusion reads: staff and residents with knowledge of the incident were interviewed and no one could corroborate the allegation of abuse. There is no evidence that facility did a physical assessment on R1's body to identify possible injuries caused by R3's kick. There is no investigation of the incident between R1 and R3. There are no statements taken from staff or R3 related to R1's allegation of being kicked by R3. In the interview V1 states that he reported the two incidents to the Illinois Department of Public Health, however there is no evidence in the facility investigation that this allegation has been investigated other than a note saying that R1 had reported to them about the physical aggression perpetrated by R3. Facility's policy and procedure title Abuse Prevention Program revised on 01/2019 reads: For the purpose of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: Physical abuse: hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment.

Based on interview and record review, facility failed to follow their policy to provide necessary care and services to keep residents free from physical abuse. This failure resulted in a male resident (R3) physically assaulting another male resident (R4) for two out of three residents reviewed for physical abuse. R4 sustained a comminuted (characterized by the breaking of a bone into several small pieces) displaced fracture of the right nasal bone, left frontotemporal scalp hematoma (A collection of blood outside the blood vessels) R4 required surgical intervention. Findings Include: On 07/19/2022 at 12:25 PM, R4 stated that R3 came into his (R4) room and started punching him in the head. R4 stated, I had to get stiches in my ear because of how hard he (R3) punched me. On 07/20/2022 at 9:55 AM, V1 (Administrator) stated, that he (V1) received a telephone call that there was a physical altercation. V1 stated that he (V1) followed the abuse protocol. The nurses separated the residents, contacted the doctor, assessed the residents, called Chicago police to report the incident and notified point of contact. This incident was reported to IDPH. V1 stated that R3 was not known to have any aggressive behavior. During the investigation, the roommate of R4 stated that R4 used the N word at R3. V1 stated the nurse stated that R3 was calm and saw R3 go into R4's room. V1 stated that wasn't the first time they interacted. After the verbal communication, R3 hit R4 in the head. V1 stated, After assessment, the facility sent both residents out for evaluation. We sent R3 for a psych evaluation and R4 for medical evaluation. At the hospital, they confirmed R4 had facial fractures from the physical altercation from R3. R3's progress note by facility nurse on 6/22/2022 documents in part: Resident was escorted out on petition to the Hospital from the facility via ambulance on stretcher. This follows up on physical altercation reported by 5th floor staff pointing out that resident being the aggressor. R4's progress note by facility nurse on 6/22/2022 documents in part: R4 was involved in altercation with co-peer. R4 and co-peer were immediately separated and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's progress note by facility nurse on 6/22/2022 documents in part: hospital Summary discharge reports CT scan with comminuted displaced fractures of the right nasal bones and facial [CONDITION(S)] for R4. R4 has referral appointment for plastic surgery on 6/29/2022. Was prescribed [MEDICATION(S)] (antibiotic) 500mg tabs every 12 hours for 7 days. R4's progress note by facility nurse on 6/23/2022 documents in part: Resident noted with nose fracture, discoloration and small scratches to face. R4 had Auricular block (to reduce pain) performed at hospital related to left ear skin tear. Dressing is sutured in place. R4's hospital record (6/22/2022) documents in part: Comminuted displaced fracture of the right nasal bone. Left frontotemporal scalp hematoma and scalp swelling with pockets of gas in the left retroauricular (the retroauricular region separates the auricular region -the ear- from the neck), soft tissue without evidence of underlying calvarial (calvaria is the top part of the skull) fracture. Facility Investigation Report between R3 and R4 (6/26/2022) documents in part: In conclusion, it was determined that R3 noted having a conversation with staff on the unit before stopping by co-peer, R4's room where R3 made contact with R4. Facility's Abuse Policy (01/2019) documents 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. Abuse, defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual. Willful, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse is defined as hitting, slapping, pinching, kicking etc. This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, or other residents.

Based on interview and record review, the facility failed to educate residents on how to resolve disputes among each other without causing harm to another resident. This affected 1 (R2) of 10 residents reviewed for freedom from abuse. On 06/08/22 R3 hit his roommate, R2 in the face during a verbal altercation which resulted in R2 sustaining a left cheek laceration, scalp hematoma and left periorbital (around the left eye area) soft tissue swelling on 06/08/22. Findings include: The 06/08/22 Facility Reported Incident states R2 and R3 were involved in a physical altercation. 1. R2's 04/14/22 BIMS (Brief Interview for Mental Status) determined a score of 12 (moderately impaired). R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/27/22 at 11:25 am, surveyor asked R2 about the 06/08/22 incident. R2 stated, R3 calls himself a preacher. R3 is impersonating a minister. I asked him, Are you ordained? R3 got mad, so R3 hit me with his fist in the left eye. I got six stitches. R2's nursing progress note dated 06/08/22, documents, in part, (R2) reported receiving physical aggression during verbal altercation with roommate evident by facial swelling and laceration upon assessment of the face. Site cleaned with gauze and normal saline, (R2) kept safe. R2's 06/08/22 ED (Emergency Department) history and physical documented, will washout and apply (topical skin adhesive) and (skin closure strips) to R2's left cheek laceration. R2's 06/09/22 CT (Computerized Tomography) scan includes a small right frontal scalp hematoma and left periorbital soft tissue swelling. 2. R3's 04/22/22 BIMS determined a score of 13 (cognitively intact). R3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/28/22 at 12:49 pm, the surveyor asked R3 about the 06/08/22 incident. R3 stated, I was speaking with R8 who also shared the room. I was saying something to R8 about biblical issues. I'm not sure why R2 grabbed me. It appeared maybe he (R2) didn't want to hear what I was saying. I did hit R2. I'm so very sorry. My Lord, last thing I want to do is strike an individual. 3. R8's 04/01/22 BIMS determined a score of 13. On 06/28/22 at 1:02 pm, R8 (roommate) affirmed that he witnessed the 06/08/22 incident involving R2 and R3. R8 stated, R3 had clothes in a bag on the floor that R2 kept running over with a wheelchair. R3 asked R2 nicely to stop running over the clothes and R2 was just cursing at R3. R2 lunged out of the wheelchair and grabbed (R3) by the hands. R3 reacted by punching R2. R8 believes R2 provoked R3. R8 added, there's only so much a person can take. R8 described R2 as 'real foul'' and stated that R2 curses out staff as well. On 6/27/22 at 10:39 AM V1 (administrator) was interviewed. V1 confirmed he was the abuse coordinator at the time of incident involving R2 & R3. They (R2 & R3) were roommates. R2 was talking, responding to internal stimuli. R3 was talking to him (R2). They had a verbal disagreement which led to a physical altercation before staff could intervene. When R3 made the first contact, immediately they were separated. We followed protocol, I was notified, notified the physician, point of contact, notified the police. Per Doctor's order, R3 was sent to hospital. No injury but I believe R2 had a skin alteration on his nose. Both were sent to hospital. R3 was sent for psych evaluation. They have not had this type of altercation in the past. On 06/29/22 at 3:20 pm, surveyor interviewed V23 (Physician) about potential harm after being punched in the face. V23 stated There's a potential for fracture of the nose or laceration. V23 added that with any physical altercation, there's a potential for injury.

Based on interview and record review, the facility failed to immediately report a resident's fall and initiate assessment as defined in the facility's policy; failed to adequately investigate the root cause of the fall and provide appropriate documentation for the resident's fall. This failure affected one resident, R1, of two residents, reviewed for quality of care. R1 fell by the elevator/nursing station on the fourth floor around the time of shift change (approximately 3pm) on [DATE], and no proper documentation of R1's fall, although the fall was witnessed by nursing staff. No record of a timely physician notification until [DATE] at 8:35pm and no record of a head-to-toe assessment after the fall. On [DATE] at 8pm, R1 was noted lethargic and barely responding to touch nor the calling of his name. R1 was sent to the hospital on [DATE] at 8:20 pm and expired on [DATE]. Findings include: On [DATE] at 11:58 AM, the surveyor asked V14 (CNA/Certified Nurse Assistant) if V14 was present at the time R1 fell in front of the nursing station. V14 stated, I do remember when R1 fell straight back. V14 stated, in part, that R1 walked up to the nurse's station and was trying to get onto the elevator. The elevator was full at the time and V16 (Psych tech) who was riding the elevator attempted to tell R1 that R1 needed to wait for the next elevator because there were too many people on it at the time. According to V14, R1 kept trying to get on the elevator at which point V16 grabbed R1 by the arms and attempted to move R1 back. V14 stated that R1 lost his balance and fell backwards onto the floor near a cart that was sitting in front of the nurse's station. V14 stated that it didn't look like R1 hit R1's head on the floor; that R1's back took the [NAME] of the fall and R1 stopped his head from hitting the floor. V14 stated that 3 staff members (V14, V16, and V17-LPN/Licensed Practical Nurse) assisted R1 back up off the floor and that R1 proceeded to get on the elevator after the fall. V14 stated that this happened right before 3pm because V14 was getting ready to punch out at the end of the shift. On [DATE] at 12:09 PM, the surveyor interviewed R14 who was sitting in a chair in the doorway of R14's room directly across from the nurse's station in view of the elevator. When the surveyor asked R14 if R14 witnessed the incident involving R1, R14 stated, Yes. R14 stated, in part, that R1 was trying to get on the elevator, but it was too full. R14 stated that, One of the guys that works here grabbed (R1) by the chest and pushed (R1) out of the way. That's when R1 fell back. R14 was unable to state who the staff member was that pushed R1. R14 stated that R1 lied down on the floor for a few minutes then got up and went to R1's room. When the surveyor asked R14 if R1 hit R1's head, R14 stated that with the way R1 fell backward then R1 probably did hit R1's head. When the surveyor asked if the staff had done an assessment or any vital signs on R1 at the time of the fall, R14 stated, Nobody checked to see if (R1) was injured. On [DATE] at 12:14 pm, R15 stated that R1 was R15's roommate. When the surveyor asked if R15 had witnessed the incident involving R1, R15 stated, No. R15 stated that R15 was in R15's room when R1 entered the room and lied down on the bed after the incident occurred. R15 stated that R1 told R15 that one of the psych techs had punched R1 in the chest and R1 fell and hit R1's head. R15 stated that R1 told staff right away that R1 was injured and that R1 was in a lot of pain, but they (the staff) just kept giving R1 pain pills. R15 stated that staff didn't come to do vital signs on R15 until later that night. R15 stated that the incident took place around 1:,d+[DATE]:00 pm. R15 stated, I had to help R1 put R1's covers on. R1 couldn't move. R15 stated that R15 can't recall if it was the same day of the incident or if it was the next day that R1 was sent to the hospital, but by that time, R1 was unconscious. On [DATE] at 3:47 PM, the surveyor asked V1 (DON/Director of Nursing) if V1 was notified that R1 had a fall. V1 stated, Yes, the nurse called me, but R1 didn't report it that day. V1 stated that it was the next day or day later that R1 was complaining of R1's leg hurting. V1 stated that the doctor ordered an x-ray. When the surveyor asked where the fall took place, V1 stated, R1 was getting off the elevator. The surveyor asked V1 what the protocol is for reporting a fall. V1 replied, They (staff) have to call me or the ADON (Assistant Director of Nursing), do an incident report, contact the doctor, call the family, and update the fall assessment because it's a new fall. V1 stated, At the time the nurse called me, R1 was self-reporting the fall. V1 stated that, R1 was very alert R1 would talk to V1 about everything. The surveyor asked V1 if a staff member had witnessed the fall at the nurse's station what would be the expectation of the staff member. V1 stated, It depends on the situation. They (staff) would be expected to immediately report the fall, maybe get labs, move the resident closer to nurse's station, do head-to-toe assessment, do vital signs, interview the resident to make sure the resident is alert. V1 stated that R1 was provided education after reporting the fall. When the surveyor asked if R1 was a risk of falls, V1 stated, No, R1 was not a risk at all for falls. I believe it was an isolated incident. The surveyor asked if V1 was aware that there was an altercation with another staff member at the time of the fall, V1 stated, No. The surveyor asked V1 if V1 knows why V16 (psych tech) resigned. V1 stated that V16 didn't give a reason why. V1 stated, Sometimes people take it personal when we have to look into certain things. On [DATE] at 4:16 PM, the surveyor asked V18 (MD/Medical Doctor/R1's Attending Physician) when V18 was notified that R1 had a fall. V18 stated, I'm not in the system so I can't look at the note. I don't know if it was same day or next day. The surveyor asked if a resident fell backwards what is the expectation of the staff. V18 stated, They're supposed to notify the doctor with any fall. It doesn't matter if fell backward or forward. On [DATE] at 9:36 AM, the surveyor asked V1(Director of Nursing) to review footage from the camera located at the nurse's station on the fourth floor. V1 stated that V1 spoke with the Administrator (who was on vacation at the time of the investigation) regarding accessing the camera system. V1 stated that the Administrator told V1 that, The camera system is not an advanced system and does not have the capability of rewinding back no more than seven days. On [DATE] at 11:30 AM, the surveyor asked V19(LPN) to recount the day V19 worked with R1. V19 stated, I was giving out medication when R1 called me from his room that R1's leg hurt. R1's room is close to the nurse's station. R1 was requesting pain medication. R1 tried getting up and R1 was limping. R1 said R1 fell yesterday. When I asked R1 if R1 reported the fall to anyone, R1 said that he didn't tell anybody and that he'll be ok. I told him next time tell the nurse. I educated him to report the fall in a timely manner. V19 stated that V19 called the DON that R1 was complaining of pain and unsteady gait. V19 stated, I called the doctor to get a stat x-ray. V19 stated that the x-ray was done during V19's shift and that V19 also gave R1 a pain medication. V19 stated, I didn't know anything after that. When the surveyor asked what R1's mental status was at the time, V19 stated, R1 was very alert and oriented x 4. I had worked with him before. V19 stated that R1 had no other complaints at that time other than the leg. The surveyor asked V19 where R1 had told V19 that he fell . V19 stated, He told me that he fell in the elevator. The surveyor pointed out that in V19's progress note on [DATE] at 12:36 pm, it says R1 fell in the elevator and then again that R1 fell in the restroom and failed to report it. V19 stated, No. I think R1 told me he fell in the elevator. The surveyor inquired about a change of condition progress note that V19 wrote with a created date documented as [DATE], and the effective date was February 26, 2022. V19 stated, I got a call from the supervisor that I should lock my notes. I think it was last week. They stated that I shouldn't leave my note on the draft. [DATE] was the date they told me to lock my notes. On [DATE] at 10:14 am, the surveyor did a phone interview with V20 LPN. The surveyor asked V20 if V20 had gotten any report from the day shift nurse that R1 had reported a fall. V20 stated, No, I was not aware V1 had fallen. V20 stated that R1 was not on 72-hour observation or neuro (neurological) checks. V20 added, If I had known that he had fallen, I would have relayed that message to the doctor when R1 went to the hospital. The nurse had not charted anything. On [DATE] at 3:38 PM, V18 MD was interviewed regarding falls in general and was asked if a resident fell backward and hit his head, could that cause a subdural hematoma. V18 responded, Yeah, that can happen. When asked what other potential harm can be caused by falling backward, V18 stated that sometimes nothing happens, but other times a resident can have bleeding in the brain, can break the neck or the skull depends on what the resident hit on the floor. Review of the 72 Hours Neurological Flow Sheet shows that neuro checks were started on R1 on [DATE] at 12:30 PM and were continued by V20 LPN starting at 4:15 PM until 7:15 PM. Review of the facility daily staffing sheets showed that V16 (psych tech) was scheduled on [DATE] for the ,d+[DATE] pm shift on the 5th floor. V14(CNA) and V17(LPN) were scheduled on the 7 am-3 pm shift on the 4th floor. Review of V16's personnel file documents V16's last day worked was [DATE] and contained a handwritten note from V16 on [DATE] documenting V16's resignation. The Facility Reported Incident dated [DATE] documents the brief description of the incident as: It was reported to writer that R1 alleged that staff member was inappropriate with him. No fall was mentioned in the report. Review of R1's progress notes show no documentation of R1 sustaining a fall on [DATE]. The first mention of a fall was documented by V19 LPN (Licensed Practical Nurse) on [DATE] at 12:36 PM. R1's Nursing Progress Note documented, in part, R1 summoned writer to (R1's) room, upon arrival R1 reported pain to left hip, stated (R1) had a fall yesterday in the elevator. Resident stated (R1) had a fall in the restroom, R1 thought (R1) was okay that's why (R1) failed to report. The created date of this progress note was [DATE](6 days later). R1's Nursing Progress Note written by V20(LPN) on [DATE] at 8:00 pm documents, in part, Resident noted lethargic, and barely responding to touch nor calling of his name. R1's hospital EM (Emergency Medicine) Resident Assessment Note dated [DATE] at 9:26 PM documented by V21 (MD/Medical Doctor) indicates that R1 presented with Altered Mental Status. In the history of present illness, V21 documented, Pt (patient) obtunded with only a gag reflex and intubated on arrival. R1's hospital hand-written progress note dated [DATE] at 4:48 PM from an unknown hospital employee documented, Sent V22 (Resident physician) an email to call the medical examiner for assistance with the death certificate. V22 stated that (V22) is unsure if patient cause of death was traumatic or non-traumatic. During this investigation, several attempts were made to speak with V22 or an attending physician at the hospital but were unsuccessful. R1's Brief Interview for Mental Status (BIMS) dated [DATE] documented a score of 14 out of 15, indicating that R1 was cognitively intact. R14's Brief Interview for Mental Status (BIMS) dated [DATE] documented a score of 15 out of 15, indicating R14 is cognitively intact. R15's Brief Interview for Mental Status (BIMS) dated [DATE] documented a score of 15 out of 15, indicating R15 is cognitively intact. The undated facility policy titled Incidents/Accidents/Falls documents, in part, 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. The facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated and resolved. Procedure includes but is not limited to: 2. In the case of a fall, the resident will have a head-to-toe assessment to include a pain assessment and assessment as to any change in their ROM (Range of Motion) ability/function. Further, residents who have an unwitnessed fall must have neuro checks (neurological checks) started and continued per policy. Neuro checks will be initiated even if the resident states they did not hit their head in an unwitnessed fall. 3 .When possible, a descriptive statement(s) will be obtained from the resident and/or any witnesses .11. All falls will have a site investigation by appropriate staff 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.

Based on interview and record review, the facility failed to immediately report a resident's fall and initiate assessment as defined in the facility's fall policy; failed to adequately investigate the root cause of the fall and provide appropriate documentation for the resident's fall. This failure affected one resident, R1, of two residents, reviewed for quality of care. R1 fell by the elevator/nursing station on the fourth floor around the time of shift change (approximately 3pm) on [DATE], and no proper documentation of R1's fall, although the fall was witnessed by nursing staff. No record of a timely physician notification until [DATE] at 8:35pm and no record of a head-to-toe assessment after the fall. On [DATE] at 8pm, R1 was noted lethargic and barely responding to touch nor the calling of his name. R1 was sent to the hospital on [DATE] at 8:20 pm and expired on [DATE]. Findings include: On [DATE] at 11:58 AM, the surveyor asked V14 (CNA/Certified Nurse Assistant) if V14 was present at the time R1 fell in front of the nursing station. V14 stated, I do remember when R1 fell straight back. V14 stated, in part, that R1 walked up to the nurse's station and was trying to get onto the elevator. The elevator was full at the time and V16 (Psych tech) who was riding the elevator attempted to tell R1 that R1 needed to wait for the next elevator because there were too many people on it at the time. According to V14, R1 kept trying to get on the elevator at which point V16 grabbed R1 by the arms and attempted to move R1 back. V14 stated that R1 lost his balance and fell backwards onto the floor near a cart that was sitting in front of the nurse's station. V14 stated that it didn't look like R1 hit R1's head on the floor; that R1's back took the [NAME] of the fall and R1 stopped his head from hitting the floor. V14 stated that 3 staff members (V14, V16, and V17-LPN/Licensed Practical Nurse) assisted R1 back up off the floor and that R1 proceeded to get on the elevator after the fall. V14 stated that this happened right before 3pm because V14 was getting ready to punch out at the end of the shift. On [DATE] at 12:09 PM, the surveyor interviewed R14 who was sitting in a chair in the doorway of R14's room directly across from the nurse's station in view of the elevator. When the surveyor asked R14 if R14 witnessed the incident involving R1, R14 stated, Yes. R14 stated, in part, that R1 was trying to get on the elevator, but it was too full. R14 stated that, One of the guys that works here grabbed (R1) by the chest and pushed (R1) out of the way. That's when R1 fell back. R14 was unable to state who the staff member was that pushed R1. R14 stated that R1 lied down on the floor for a few minutes then got up and went to R1's room. When the surveyor asked R14 if R1 hit R1's head, R14 stated that with the way R1 fell backward then R1 probably did hit R1's head. When the surveyor asked if the staff had done an assessment or any vital signs on R1 at the time of the fall, R14 stated, Nobody checked to see if (R1) was injured. On [DATE] at 12:14 pm, R15 stated that R1 was R15's roommate. When the surveyor asked if R15 had witnessed the incident involving R1, R15 stated, No. R15 stated that R15 was in R15's room when R1 entered the room and lied down on the bed after the incident occurred. R15 stated that R1 told R15 that one of the psych techs had punched R1 in the chest and R1 fell and hit R1's head. R15 stated that R1 told staff right away that R1 was injured and that R1 was in a lot of pain, but they (the staff) just kept giving R1 pain pills. R15 stated that staff didn't come to do vital signs on R15 until later that night. R15 stated that the incident took place around 1:,d+[DATE]:00 pm. R15 stated, I had to help R1 put R1's covers on. R1 couldn't move. R15 stated that R15 can't recall if it was the same day of the incident or if it was the next day that R1 was sent to the hospital, but by that time, R1 was unconscious. On [DATE] at 3:47 PM, the surveyor asked V1 (DON/Director of Nursing) if V1 was notified that R1 had a fall. V1 stated, Yes, the nurse called me, but R1 didn't report it that day. V1 stated that it was the next day or day later that R1 was complaining of R1's leg hurting. V1 stated that the doctor ordered an x-ray. When the surveyor asked where the fall took place, V1 stated, R1 was getting off the elevator. The surveyor asked V1 what the protocol is for reporting a fall. V1 replied, They (staff) have to call me or the ADON (Assistant Director of Nursing), do an incident report, contact the doctor, call the family, and update the fall assessment because it's a new fall. V1 stated, At the time the nurse called me, R1 was self-reporting the fall. V1 stated that, R1 was very alert R1 would talk to V1 about everything. The surveyor asked V1 if a staff member had witnessed the fall at the nurse's station what would be the expectation of the staff member. V1 stated, It depends on the situation. They (staff) would be expected to immediately report the fall, maybe get labs, move the resident closer to nurse's station, do head-to-toe assessment, do vital signs, interview the resident to make sure the resident is alert. V1 stated that R1 was provided education after reporting the fall. When the surveyor asked if R1 was a risk of falls, V1 stated, No, R1 was not a risk at all for falls. I believe it was an isolated incident. The surveyor asked if V1 was aware that there was an altercation with another staff member at the time of the fall, V1 stated, No. The surveyor asked V1 if V1 knows why V16 (psych tech) resigned. V1 stated that V16 didn't give a reason why. V1 stated, Sometimes people take it personal when we have to look into certain things. On [DATE] at 4:16 PM, the surveyor asked V18 (MD/Medical Doctor/R1's Attending Physician) when V18 was notified that R1 had a fall. V18 stated, I'm not in the system so I can't look at the note. I don't know if it was same day or next day. The surveyor asked if a resident fell backwards what is the expectation of the staff. V18 stated, They're supposed to notify the doctor with any fall. It doesn't matter if fell backward or forward. On [DATE] at 9:36 AM, the surveyor asked V1(Director of Nursing) to review footage from the camera located at the nurse's station on the fourth floor. V1 stated that V1 spoke with the Administrator (who was on vacation at the time of the investigation) regarding accessing the camera system. V1 stated that the Administrator told V1 that, The camera system is not an advanced system and does not have the capability of rewinding back no more than seven days. On [DATE] at 11:30 AM, the surveyor asked V19(LPN) to recount the day V19 worked with R1. V19 stated, I was giving out medication when R1 called me from his room that R1's leg hurt. R1's room is close to the nurse's station. R1 was requesting for pain medication. R1 tried getting up and R1 was limping. R1 said R1 fell yesterday. When I asked R1 if R1 reported the fall to anyone, R1 said that he didn't tell anybody and that he'll be ok. I told him next time tell the nurse. I educated him to report the fall in a timely manner. V19 stated that V19 called the DON that R1 was complaining of pain and unsteady gait. V19 stated, I called the doctor to get a stat x-ray. V19 stated that the x-ray was done during V19's shift and that V19 also gave R1 a pain medication. V19 stated, I didn't know anything after that. When the surveyor asked what R1's mental status was at the time, V19 stated, R1 was very alert and oriented x 4. I had worked with him before. V19 stated that R1 had no other complaints at that time other than the leg. The surveyor asked V19 where R1 had told V19 that he fell . V19 stated, He told me that he fell in the elevator. The surveyor pointed out that in V19's progress note on [DATE] at 12:36 pm, it says R1 fell in the elevator and then again that R1 fell in the restroom and failed to report it. V19 stated, No. I think R1 told me he fell in the elevator. The surveyor inquired about a change of condition progress note that V19 wrote with a created date documented as [DATE], and the effective date was February 26, 2022. V19 stated, I got a call from the supervisor that I should lock my notes. I think it was last week. They stated that I shouldn't leave my note on the draft. [DATE] was the date they told me to lock my notes. On [DATE] at 10:14 am, the surveyor did a phone interview with V20 LPN. The surveyor asked V20 if V20 had gotten any report from the day shift nurse that R1 had reported a fall. V20 stated, No, I was not aware V1 had fallen. V20 stated that R1 was not on 72-hour observation or neuro (neurological) checks. V20 added, If I had known that he had fallen, I would have relayed that message to the doctor when R1 went to the hospital. The nurse had not charted anything. On [DATE] at 3:38 PM, V18 MD was interviewed regarding falls in general and was asked if a resident fell backward and hit his head, could that cause a subdural hematoma. V18 responded, Yeah, that can happen. When asked what other potential harm can be caused by falling backward, V18 stated that sometimes nothing happens, but other times a resident can have bleeding in the brain, can break the neck or the skull depends on what the resident hit on the floor. Review of the 72 Hours Neurological Flow Sheet shows that neuro checks were started on R1 on [DATE] at 12:30 PM and were continued by V20 LPN starting at 4:15 PM until 7:15 PM. Review of the facility daily staffing sheets showed that V16 (psych tech) was scheduled on [DATE] for the ,d+[DATE] pm shift on the 5th floor. V14(CNA) and V17(LPN) were scheduled on the 7 am-3 pm shift on the 4th floor. Review of V16's personnel file documents V16's last day worked was [DATE] and contained a handwritten note from V16 on [DATE] documenting V16's resignation. The Facility Reported Incident dated [DATE] documents the brief description of the incident as: It was reported to writer that R1 alleged that staff member was inappropriate with him. No fall was mentioned in the report. Review of R1's progress notes show no documentation of R1 sustaining a fall on [DATE]. The first mention of a fall was documented by V19 LPN (Licensed Practical Nurse) on [DATE] at 12:36 PM. R1's Nursing Progress Note documented, in part, R1 summoned writer to (R1's) room, upon arrival R1 reported pain to left hip, stated (R1) had a fall yesterday in the elevator. Resident stated (R1) had a fall in the restroom, R1 thought (R1) was okay that's why (R1) failed to report. The created date of this progress note was [DATE](6 days later). R1's Nursing Progress Note written by V20(LPN) on [DATE] at 8:00 pm documents, in part, Resident noted lethargic, and barely responding to touch nor calling of his name. R1's hospital EM (Emergency Medicine) Resident Assessment Note dated [DATE] at 9:26 PM documented by V21 (MD/Medical Doctor) indicates that R1 presented with Altered Mental Status. In the history of present illness, V21 documented, Pt (patient) obtunded with only a gag reflex and intubated on arrival. R1's hospital hand-written progress note dated [DATE] at 4:48 PM from an unknown hospital employee documented, Sent V22 (Resident physician) an email to call the medical examiner for assistance with the death certificate. V22 stated that (V22) is unsure if patient cause of death was traumatic or non-traumatic. During this investigation, several attempts were made to speak with V22 or an attending physician at the hospital but were unsuccessful. R1's Brief Interview for Mental Status (BIMS) dated [DATE] documented a score of 14 out of 15, indicating that R1 was cognitively intact. R14's Brief Interview for Mental Status (BIMS) dated [DATE] documented a score of 15 out of 15, indicating R14 is cognitively intact. R15's Brief Interview for Mental Status (BIMS) dated [DATE] documented a score of 15 out of 15, indicating R15 is cognitively intact. The undated facility policy titled Incidents/Accidents/Falls documents, in part, 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. The facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated and resolved. Procedure includes but is not limited to: 2. In the case of a fall, the resident will have a head-to-toe assessment to include a pain assessment and assessment as to any change in their ROM (Range of Motion) ability/function. Further, residents who have an unwitnessed fall must have neuro checks (neurological checks) started and continued per policy. Neuro checks will be initiated even if the resident states they did not hit their head in an unwitnessed fall. 3 .When possible, a descriptive statement(s) will be obtained from the resident and/or any witnesses .11. All falls will have a site investigation by appropriate staff 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.

Based on observation, interview and record review the facility failed to provide and maintain proper wound assessments and treatments and failed to ensure appropriate bedding to prevent skin breakdown for 3 (R3, R5, R6) of residents reviewed for pressure ulcers. These failures resulted in a new wound on R3's right heel and worsening of left heel and coccyx pressure ulcers. Findings include: 1. R3's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Braden Score dated 7/30/21 was 10 and categorized as High Risk. Weekly Wound Assessments read that R3 had 3 pressure wounds on the following sites: Right Heel, Left Heel and Coccyx. Right heel pressure ulcer had only a single assessment dated [DATE] categorizing the wound as unstageable. Right heel pressure wound measured 6.5 cm X 5.0 cm X Unable to Determine (UTD). Review of all Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Right heel pressure ulcer did not have any record that it was being treated. V17's (Licensed Practical Nurse/LPN) admission notes dated 7/23/21 categorized right heel as deep tissue injury (DTI), but no treatment was ordered until R3 was discharged on [DATE]. Left heel pressure ulcer wound initial assessment dated [DATE] read that wound measured as follows: 3.5 cm X 2.0 cm X 0.1 cm. Wound assessment dated [DATE] (3 days after initial assessment) showed the wound drastically increased in size. Left heel wound measured 7.5 cm X 7.0 cm X 0.1 cm. Left heel pressure ulcer had a treatment order for gauze with [MEDICATION(S)] and wrap dated 7/25/21. The treatment was discontinued upon R3's discharge date d 8/10/21. Treatment Administration Records (TAR) for July and August showed that treatment was not recorded as being performed on July 27th, 28th and August 4. Coccyx pressure ulcer wound assessment dated [DATE] read wound measured as follows: 2 cm X 1 cm X 0.1 cm. Wound assessment dated [DATE] (10 days later) showed the wound drastically increased in size. Coccyx wound measured 6.5 cm X 5.0 cm X Unable to Determine (UTD). Coccyx pressure ulcer had a treatment order for gauze soaked with [MEDICATION(S)] and cover with border gauze from 7/25/21 to 7/30/21. Treatment Administration Records (TAR) for July showed that treatment was not recorded as being performed on July 27, 28 and 30. Three out of six days physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/29/21 at 1:57 PM. V10 (Wound Coordinator/Licensed Practical Nurse/LPN) stated, I am not sure the reason why R3's right heel does not have any order for treatment. But I agree, there must be a treatment order in place because that is an open wound and needs to be treated. We might have missed it. On 9/30/21 at 3:15 PM. V10 stated, I do not know why R3's wounds on the coccyx and left heel drastically increased. I also do not know why that many days were not signed as being done in the treatment administration record (TAR), as treatment was performed. But I agree; if it was not documented, it was not done. On 9/30/21 at 9:57 AM. V11 (Wound Doctor) stated, Facility nursing staff will inform me, then primary care doctor will give referral, then she will assess the resident. But the bottom line is that treatment should be done as ordered and an open wound must have physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 2. On 9/29/21 at 12:18 PM. R5 was on bed being assisted with eating lunch. R5 was able to answer questions but did not elaborate when asked. R5 was observed on a low air loss mattress with thick draw sheet and flat sheet underneath her on the bed. V9 (LPN) stated that she was not familiar with residents on the floor who had wounds or pressure ulcers. V9 checked the sheets and linens underneath R5. V9 observed R5 was lying on a draw sheet at the bottom, flat sheet at the middle then another draw sheet. There were 3 linens placed underneath the R5. V9 stated, This is not right, there must be only 1 sheet when using a low air loss mattress. The mattress is not effective when there are too many sheets. V9 then went to ask a Certified Nursing Assistant to take off the sheets. During bedside care, R5's sacrum was observed with cream only and no other dressing. On 9/29/21 at 1:57 PM. V10 (Wound Coordinator/LPN) stated, We used flat sheet; a thin one, not the one with rubber ends. We should only a flat sheet. At night a pad with no {incontinence brief}. A low air loss air mattress is not going to be effective when there are too many pads. R5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Second order was to cleanse sacrum with normal saline and place foam adhesive dressing after patting dry. R5's Braden Score dated 9/25/20 was 12 and categorized as High Risk. R5's TAR for August showed multiple days that fell on the weekend as not recorded as being performed. 3. On 9/29/21 at 12:56 PM. R6 was observed in the dining room. R6 was alert and able to verbally express her thoughts. R6's sacral wound was seen with a dressing in place. R6 had a treatment order for collagen dated 8/31/21. R6's TAR for September read on 9/11, 9/12, 9/18, 9/19, 9/25 and 9/26 (Saturday and Sunday dates successively) indicate treatments were not done. Facility Wound Management Program and Policy not dated reads: The purpose of our Wound Management Program is: To ensure our residents have access to the appropriate assessment and management in prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to monitor and supervise a resident who has a history of two elopement attempts. This failure affected one resident (R1) and has the potential to affect 6 other residents (R2, R3, R4, R5, R6 and R7) on elopement precautions. R1 jumped down through the window opening of the sixth-floor dining room and landed on the ground outside the building, without any staff witnessing the incident. R1 was later pronounced dead at the hospital. This failure resulted in an Immediate Jeopardy. According to the Administrator, the immediacy was removed on [DATE] when all the dining room windows were completely closed with deadbolt locks after the incident with R1. Surveyor findings show the immediacy was removed on [DATE], however remains out of compliance at a Severity Level 2 while the facility continues to educate staff about closer monitoring and supervision of all residents, especially those at risk for elopement and suicide. Findings include: R1's Face Sheet shows that R1 was originally admitted to the facility on [DATE]. R1's admitting diagnoses include but are not limited to: [CONDITION(S)], [CONDITION(S)] Disorder (Depressive type), [CONDITION(S)], Dementia, Major Depressive Disorder, [CONDITION(S)], Generalized Anxiety Disorder, and Borderline Personality Disorder. R1's Social Service progress notes written by V7 (Psychiatric Rehabilitation Services Coordinator/PRSC) dated [DATE] at 12:19pm and [DATE] at 4:32pm both show that R1 attempted to elope from the facility. On [DATE] at 11:58am, V7 stated that R1 did not verbalize any suicidal or homicidal ideations. V7 explained that the two times R1 had attempted to elope, R1 went to other residents' floor and she did not get outside the facility and that R1 likes her daughter, and the elopement attempt was probably to see her daughter. R1's Screening Assessment for Evaluating Self-Harm/Suicide Risk dated [DATE] shows a score of 4 (minimal or low risk for suicide). On [DATE] at 10am, V1 (Administrator) stated that he completed the final investigation on the incident where R1 jumped out the window of the sixth floor dining room, and he didn't know how someone could squeeze her body through the small window opening and no staff member witnessed the incident. V1 explained that all the windows have metal window stoppers that only allow a small opening. V1 added that he took a picture of the window after the incident and that the police officer who came to assess the situation expressed surprise that anyone could go through the opening. V1 stated that he believed the resident climbed the chair, opened the window, and squeezed her body through the window because R1 weighed only 109 pounds. At this time, V1 presented the facility's initial and final investigation reports dated [DATE] and [DATE] respectively that were sent to the State's Agency. V1 later presented the picture of the window to the surveyor. On [DATE] at 9:50am, V2 (Director of Nursing/DON) stated, I was the nurse in charge at the time for the resident on the sixth floor, because the nurse (V3/Registered Nurse) would come late for the shift. I was on the floor with two CNAs (Certified Nursing Assistants/V5 and V8). I saw the resident pacing back and forth. I was called to another floor and I left the sixth floor to attend to some other issues as the DON. While I was away from the floor, I heard the code blue called asking all nurses to come down. When I got there, the crash cart was already there and the nurse (V9 Licensed Practical Nurse/LPN) had already started CPR (Cardio-Pulmonary Resuscitation). The paramedics arrived and took over and took the resident to the hospital. The incident happened while I was away to the other floor. After the paramedics took the resident to the hospital, I came inside the building to the sixth floor to see how the whole incident happened. I saw the last window closer to the wall slightly pulled opened, and there was a chair by the window. It didn't open much because of the metal window stopper. I don't know how she managed to squeeze herself into such a small opening. No one brought the resident back into the building. 911 was called immediately. Survey asked V2 why R1 was not placed on a one-to-one monitoring, considering the fact that R1 had attempted to elope earlier on that shift. V2 stated that one-to-one monitoring will make R1 more agitated, but V2 agreed that R1 should have been monitored more closely. V2 explained that R1 and six other residents (R2, R3, R4, R5, R6 and R7) are on elopement risk. V2 later presented the list of the six other residents at risk for elopement. On [DATE] at 1:40pm, V5 (CNA) stated, I and the other CNA (V8) were working on the sixth floor. The last time I saw her (R1) was when she was moving around pacing. I went to pass dinner trays. Both of us were watching her and passing trays at the same time. When we didn't find her, we were looking everywhere and then they paged code blue. On [DATE] at 3:20pm, V8 (CNA) stated, I was working on the sixth floor with V5 (CNA). Earlier in the shift, (R1) was pressing the elevator buttons. The last time I saw her was when she was in her room about 30 minutes before dinner trays came up. No one was assigned to watch her on a one to one. I was at the nursing station and (V5) was passing the dinner trays. The nurse for the floor was (V2) the DON but he got called to another floor. On [DATE] at 1:45pm, V4 (R1's Psychiatric Doctor) was interviewed regarding R1. V4 stated in part, R1 has diagnoses of [CONDITION(S)] and Major Depression. There could be poor impulse control, agitation, feeling helpless and hopeless. If psychotic, she might be hearing voices. Sometimes, the patient will not show any sign and will be psychotic. The patient could have psychomotor excitement with [CONDITION(S)] and that is when they can do something like what she (R1) did. That is the reason such patients should be in a skilled facility. Depression is treatable but can kill if the patient is not compliant with medications. On [DATE] at 3:49pm, V10 (R1's Primary Physician) was interviewed. V10 stated, No one told me she (R1) attempted to elope. I am not the Psychiatrist; I'm the Medical Doctor. If a resident attempted to elope, we have to find out why. Either they don't like the food or they don't just like to be in the facility. If so, then the patient can be discharged to a place they like. If the interdisciplinary team cannot make a decision yet about whether or not to discharge the patient, you can monitor the patient and put them on a locked unit to prevent elopement while trying to make the decision. R1's Self-Harm Ideation care plan dated [DATE] states that R1 has a history of self-harm ideation due to severe mental illness and poor impulse control. Intervention includes in part As warranted, conduct/carry out daily monitoring and supervision of the resident. Facility's Policy and Procedure Regarding Missing Residents and Elopement dated ,d+[DATE] with latest revision on [DATE] documents, It is the policy of this facility that all residents are provided adequate supervision to meet each resident's nursing and personal care needs. All residents will be assessed for behaviors or conditions that put them at risk of elopement. All residents assessed to be at risk of elopement will have this issue addressed in their care plan. On [DATE] at 2:10pm, the V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy. On [DATE], the surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Maintenance Staff checked all windows in the entire facility for ability to only open 1 to 2 inches 2. The Elopement assessment was completed on any resident who was at risk for elopement and was placed on the Elopement list which includes the Resident Face Sheet, and their current pictures placed in a Bright Yellow Binder located at every nursing station in a Wall Holder attached to the wall on right side of the nursing station which is attached with a chain on the front desk on wall located to left of chair attached with chain. 3. The social service team completed Screening for residents at risk for Self-Harm. According to the Social Services Director, residents who attempt to elope from the facility or are exhibiting Exit Seeking Behaviors, the following process will be immediately put into effect: A. If a resident elopes from the facility, the resident will be immediately placed on visual monitoring. B. Nurse will notify Psychiatrist/Psychologist/Psychological Nurse Practitioner for further instructions. C. Nurse will notify the Administrator and DON who will then notify the ADON (Assistant Director of Nursing), NP (Nurse Practitioner), PCP (Primary Care Physician) and Social Service Team of elopement attempt. The facility revised the following Policies and Procedures. 1. Visually Monitored 2. Elopement Missing Person Education of Staff: On [DATE] between 10am and 2:30pm, random interviews were conducted for three staff members on every floor of the building, totaling about 15 staff members regarding the above stated education to verify that staff were educated on [DATE] and after. V1 (Administrator) stated that Staff on vacation and on leave of absence will be educated via emails, verbally over the telephone, and in the facility by Administrator and/or Director of Nursing before resuming to work. Audit dates were from [DATE] through [DATE]. Based on observation, interview, and record reviews conducted on [DATE], the facility completed all measures on the abatement plan.

Based upon record reviews and interviews the facility failed to ensure that 1 (R3) of 5 residents in sample received the supervision service. R3 sustained a Fracture to Right Hip. Findings Include: R3 was admitted to the facility per review of the face sheet record on August 12, 2008 with [DIAGNOSES REDACTED]. The nurses notes and fall incident report dated July 1, 2011 in part denotes the following: "ambulating independently in hallway when fell to floor, upon observation pain to Right hip sent to the hospital per MD." E4(CNA/certified nurse aide) was interviewed on 9/21/11. E4 stated," I responded to the noise that I heard; R3 was lying on the hallway floor by her bedroom. R3 ambulates and R3 is a wanderer...I called nurse to assess. R3 had been walking in hall." E4 was queried regarding if another staff was with R3, and responded, "No." Review of R3 most recent MDS (minimum data set) Section G- depicts in part the following functional status coding for R3: Walks in corridor as 2 under self-performance and a 2 under support which are defined as follows: Self-performance -2-resident highly involved in activity staff provided guided maneuvring. 2-ADL (activity of daily living) Support provided- One person physical assist. The nurse notes dated 7/1/11 at 10:30pm depict a follow-up to a local hospital denoted R3 was admitted with a [DIAGNOSES REDACTED].". E2 (DON/Director of Nursing) was interviewed on 9/22/2011 via phone requesting the Xray record for R3 and stated,"I could not get the report from the hospital. The nurse just gave the report over the phone to my nurse." R3 was ambulating without staff assist, and subsequently fell resulting in a right hip fracture

Based on observation, record review and interview the facility failed to ensure that residents in the facility are free from any type of abuse by: -failing to recognize when an abusive occurrence happens during an incident on 12/6//2010 between R26 and E24 (psych tech). -not investigating this resident's emotional impact/psychosocial harm of a physical and verbal confrontation, R26 had with E24 on 12/06/2010. -not recognizing and interviewing any and all possible witnesses to the incident of 12/06/2010. As a result of this failure, an incident occurred on 12/06/2010. R26 had incident involving E24 (psych tech) who physically restrained R26. During this incident R26 alleged E24 displayed verbally abusive behavior, after physically coming in contact with the resident. As a result, R26 expressed a fear of E24 and does not feel comfortable around this staff member. E24 was observed on duty at the facility during the survey that started on 12-27-2010. E24's duty as a psych tech involves him being in direct contact with any resident in the facility, at any given time. During resident interviews, R26 expressed that she views E24's presence as some type of threat to her well-being physically and mentally. The facility's allegations of abuse over the past year, included the incident of 12/06/2010 involving R26 and E24. The facility's conclusion and summary documented no abuse occurred. These actions lead to an Immediate Jeopardy which began on 12-06-2010, the day of the between R26 and E24. The Immediate Jeopardy for R26, due to the physical and psychosocial harm to R26. On 01/04/2011 at 2:15pm, E1(Administrator) was made aware of the Immediate Jeopardy. Although the Immediate Jeopardy was removed on January 04, 2011 at 5pm, the facility remains out of complaince at a Severity level 2 , in order to allow for the implementation of the facility's plan of correction and the facility's re-investigations and actions resulting in the re-investigation. This failure occurred for 2 out of 30 residents in the sample(R22,R26) and has the potential to affect the 200 residents in the facility. Findings include: R26 is a [AGE] year old resident with [DIAGNOSES REDACTED]. R26 is totally dependent on staff for all activities of daily living. On 12/29/2011 at 1:20pm, the surveyor observed R26 moving a wheelchair with the use of the left foot only. R26 had a left upper arm amputation and the right hand and arm were contracted and very little range of motion. During the interview with R26 the surveyor asked R26 to move the right leg. R26 did not attempt to move the right leg, stating she could not move it. R26 told the surveyor she wanted to take to her about something that happened to her. R26 stated she was not right, after an employee put his hands on her and called her a bad name. R26 stated he put his hand around my throat. He is still walking around here. The surveyor asked R26 how did that make her feel? R26 stated scared. The surveyor asked R26 to describe what the employee did to her. R26 stated, he handle me roughly while I was in the wheelchair. I ran over another resident's feet. He did not have to handle me like that. Yeah, I curse at him but, he did not have to put his hands on me. I came out my wheel chair, down to the floor to get attention. I wanted to see the supervisor. He called me a b..ch. -On 12/29/2010 between at 4:45pm and 5:05pm, the surveyor interviewed E24 regarding the incident involving R26, in the presence of another surveyor. According to E24 on that day in questioned, he was assigned to monitor another resident (R52). R52 has a behavior of stretching out his legs. R26 came to the area, rolling the wheel chair backward. E24 put his hands on R26 to stop her from rolling on R52's feet. E24 stated, R26 immediately went off. E24 grabbed R26's wheelchair an swung it around to remove R26 from R52's path. R26 continued to be out of control and he came in front of R26 and placed her arm down and placed his hands on her shoulder. E24 stated he was preventing her from falling. R26 was cursing at him and she was swing her amputated arm at him. According E24, R26 threw herself out of the wheelchair. E24 stated he remember some residents being in the area and a nurse but, exactly where they were located he could not remember. At the time of the incident E24 stated, he placed R26 at a room entrance near the nursing station. The surveyor noted E24 is a tall person. E24 said his height is six foot three inches and he weighs two hundred and forty-five pound. -On review of the facility's reported incident and abuse allegations, the surveyor noted a report involving R26 and E24 (psych tech). This investigation had multiple pages including statements from R26, E24 and 7 other staff members with a police report verification form. Only 2 of 7 staff members wrote a statement concerning what happen before, R26 put herself on the floor. No interview or statements from any resident was included in the investigation. The initial 24 hour incident investigation report sent to the state agency had the following information: On 12/06/2010 at 7:30pm, resident reported that staff inappropriately redirected R26 by pushing on there back, pulling on her hair and swearing in her presence. No injury noted. In addition, the facility generated two additional form for the incident. An quality management program's Concern identification form and Concern resolution form. Both forms indicated E24 physically touch R26 either by grabbing the resident's clothing, pushing on her from the back and pulling on her hair. The concern identification form stated: "She slid out of her chair on purpose to get out of the tech's hold." There was no resolution written in regards to any of the two concerns. E7 (nurse aide), a witness to the incident provided the facility with two documented statements and the following was noted from E7's signed statements : 12/06/2010 "I, E7 was assisting another resident down the hall when I heard screaming, I turned around and saw the psych tech E24 choking R26, as she was trying to get free from his grasp. She jumped out the chair and ended up on the floor. That's when I called for another tech to come because he was handling her too rough...R26 became non-complaint because she was upset she didn't want to get off the floor until she spoke to the supervisor. As E24 had his hands on her, he stated b..ch what are you trying to do. R26 was cursing back telling him to get his hands off of her." 12/07/2010 3pm, "I E7 would like to clarify on what I saw I saw E24 grabbing not choking R26 around her shoulders as a means to prevent her from falling onto the floor, to not cause further harm. I heard E24 say B..ch, What are you trying to do!" E10 (floor nurse) written statement on one page had a date of 12/6/2010 7:15pm stated, " I heard the psych tech asked the resident to back up so that she will (would) not run into another resident. I heard them verbally going back and forth. I did not see the psych tech physically handle the resident......" 12/7/2010, " I did not hear the psych tech use any profane words towards the resident, but the resident did use several profane words towards the staff." E24's written in part, on 12/6/2010, stated the following..." R26 another 4th floor resident was baggin (backing) her chair up, not paying attention to where she was going. Coming straight for me and R52 so, to stop from breaking his legs and running into me I simply placed my hand on her back to let her know we were behind her and she just completely went off swinging on me in her chair screaming don't f..king touch me! B..ch you ain't my momma! ........She kept trying to swing her partial arm at me and try to force her chair into me and hurt me and possible break R52's legs so I turned her chair towards the pantry so she couldn't push it back on me, then she dropped out her chair so I couldn't take her either her room or the day room. Then began trying to trip me with her and bite me so I grabbed the arms to her jacket to limit her movement but she persist until other staff came to secure on the ground, to put her back in her wheelchair that she purposely got out of because she was upset, for whatever reason that had nothing to do with me because, I hadn't had any contact." The surveyor interviewed the following staff members regarding the facility's abuse policy and the incident of 12/06/2010 involving R26 and E24 and the following details and information were obtained: 12/28/2010 at 4:45pm, E24 described to the surveyor what took place between himself and R26 on 12/6/2010. According to E24 he explained why he was on the 4th floor. While supervising R52, he had to stop R26 from backing up on R26's legs, which were stretched out at the time. E24 stated, I put my hand on her back to stop her from running over his (R52) feet. I grabbed the wheelchair and swung it around. 12/29/2010 at 4:20pm, E13 (abuse coordinator/social service director) reported the investigation included the written statements from the staff members and the summary of information gather. The surveyor asked, if E13 asked any additional questions outside the written statement and E13 indicated there was none. 1/04/2011 at 1:30pm, E13 told the surveyor E7 revised her statement about seeing R26 choked by E24; after it was demonstrated to her how E24 was holding R26. 1/04/2011 at 1:45pm, E8 (case manager/ previous abuse coordinator) informed the surveyor: verbal abuse consist of yell or calling someone a bad name. The surveyor asked while spelling the bad name out (b..ch), would that be verbal abuse. E8 answered Yes. 1/04/2011 at 2:58pm, E7 confirmed she wrote the two statements within the facility's abuse investigation. E7 reported, she met with E1 (administrator) and E13 after the first statement was written. They (E1 and E13) acted out how E24 was holding R26 and the statement was change. The surveyor asked did E24 call R26 out a bad name. E7 stated, there was cursing back and forward between both of them (R26 and E24). 1/04/2011 at 3:30pm, E10 (nurse) reported she did not witnessed E24 having any type contact with R26. Nor did she hear E24 cursing at R26. However, she heard R26 cursing at E24. E10 did report R26 was crying and she wipe the tears from her eyes. E10 indicated there were resident looking near the day room door entrance at the time of the incident. 01/04/2011 at 4:54pm, E33 (evening nurse supervisor) report the local police was call due to R26's fall. It is the facility's policy to contact the police. That is what the police report was about. When I heard R26 was attacking a staff member, I thought that was unusually behavior for her. It was my understanding that until E24 came in front of her, in the wheelchair, that the (uncontrollable) behavior began. She was very upset and crying. Later during the shift R26 told me that E24 tried to choke her. That's when I wrote out the concern form. 1/04/2011 E13 (abuse coordinator) told the surveyor the allegation of E24 was not found to be true. It's in the summary. The surveyor asked about E24 calling R26 a bad name. E13 stated, She cursing at him first. E13 stated R26 said he didn't call her that. The surveyor refer to the type statement of R26, which states R26 heard E24 call her a bad name. E13 acknowledge she typed this statement for R26. The surveyor asked E13 what is the procedures for investigating multiple complaints about the same staff member, as it relate to abuse prevention? E13 did not respond to the question. The facility's abuse policy does not address how or when the facility will monitor for possible abusive staff member. Based on interview of 2 staff members (E10 and E33) they knew about the emotional state of R26, yet there was no investigation of why this resident was upset. There is no resolution documented for the two concerns generated from the incident. The surveyor reviewed E24's employee's file and there was no discipline actions or counseling regarding handling a resident with negative behavior. The facility took the following steps to remove the Immediate Jeopardy for F223. BASED ON THE REPORT GIVEN TO THE ADMINISTRATOR BY THE SURVEYORS, ANOTHER ABUSE INVESTIGATION BEGAN IMMEDIATELY. R26 WILL BE MADE AWARE THAT THE EMPLOYEE HAS BEEN REMOVED FROM THE WORKING SCHEDULE PENDING FURTHER INVESTIGATION. R1 AND R2 WILL AGAIN BE INTERVIEWED IN A NON-THREATENING MANNER IN AN AREA THAT IS COMFORTABLE TO THE RESIDENTS. STEP II ANY RESIDENT THAT EXPRESSES FEAR OF ANY EMPLOYEE AFTER REPORTING AN ALLEGATION OF ABUSE HAS THE SAME POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE. STEP III RE-INSERVICE EMPLOYEES ON REPORTING ABUSE POLICY. ALL MANAGERS AND ADMINISTRATION WILL BE IN-SERVICED ON CONDUCTING / DOCUMENTING AN ABUSE INVESTIGATIONS THROUGHLY. POST ABUSE ALLEGATION INVESTIGATION, THE INVOLVED RESIDENT AND EMPLOYEE WILL RECEIVE COUNSELING ON THE OUTCOME OF THE INVESTIGATION AND GIVEN AN OPPORTUNITY TO ADDRESS ANY FEARS AND/OR CONCERNS. THE INVOLVED RESIDENT AND EMPLOYEE COUNSELLING WILL BE HELD TOGETHER IN AN EFFORT TO MAKE THE RESIDENT LESS FEARFUL. PRESENTER: RETIRED NURSING HOME ADM.& REGISTERED NURSE) AND/OR DESIGNEE TOPIC: DOCUMENTING AN ABUSE INVESTIGATION DATE OF IN-SERVICE: JANUARY 5, 2011 AND ON-GOING STEP IV THE FOLLOWING QUALITY A. TOOL WILL BE IMPLEMENTED: TOPIC OF Q.A. TOOL: ARE RESIDENTS FEARFUL MONITOR: ABUSE COORDINATOR AND/OR DESIGNEE FREQUENCY: AFTER ANY ALLEGATION OF ABUSE Completion date for the above: January 5, 2011 and ongoing.

Based on record reviews and interviews the facility failed to supervise and monitor 1 resident (R28) who has a history of Aspirin overdose, attempt to harm self and suicidal ideation. The facility also failed to follow their policy regarding checking of contrabands that could potentially be harmful to the residents. This failure resulted in R28 ingesting a large amount of over the counter medication (Aspirin) on 10/24/10 requiring hospitalization . This has the potential to affect 5 residents in the facility who are identified with suicidal ideation and history of self harm. Findings include: R28 was a closed record review. R28 has multiple [DIAGNOSES REDACTED]. Review of R28's nurses' notes dated 12/15/09 shows, "Nurse stated during medicine pass, resident told nurse that she ingested several pills, she stated that they were ASA (aspirin). She didn't know how many pills. She stated that she had 1/3 small bottle and she took all." 911 was called and the resident was sent to the hospital. R28 was admitted to the hospital with [REDACTED]. R28 was readmitted to the facility on [DATE], post hospitalization . Review of R28's nurses' notes dated 3/12/10 (1400 PM), "Upon making rounds pt. (patient) noted attempting to throw self on floor & wrapping nasal cannula around neck. Writer able to prevent pt. from throwing self on floor. Pt. placed on 1:1." R28's physician was sent to the hospital. R28 was readmitted to the facility on [DATE]. Review of R28's universal progress notes dated 5/15/10 indicates, that the resident was sent out to the hospital for psychiatric evaluation. Review of R28's nurses' notes dated 5/14/10 (7:15 PM) shows, "Resident notified staff of feeling depressed & stated she felt like she would harm herself or others. More specifically she stated that she felt like she would commit suicide." R28's physician was notified of the behavior, the resident was sent out to the hospital and was diagnosed with [REDACTED]. Review of R28's entire care plan from readmission on 12/17/09 through 5/15/10 shows no evidence that R28's history of drug overdose, attempt to harm self and suicidal ideation was addressed by the facility. During an interview held on 12/28/10 at 2:00 PM, E5 (Assistant Director of Nursing) and E27 (care plan coordinator) both confirmed that R28 does not have any care plan in place to address the resident's history of drug overdose, attempt to harm self by wrapping a nasal cannula around the neck and suicidal ideation from 12/17/09 through 5/15/10. E5 and E27 confirmed that a care plan for self harm was only initiated on 10/24/10, after R28 again ingested a large amount of over the counter medication (Aspiration) on 10/24/10. Review of R28's nurses' notes dated 10/24/10 (8:43 PM) documents, " Informed by charge nurse that resident called nursing supervisor on her cellular phone and stated she had just taken 30 of Aspirin." "resident present a bottle of family dollar 81 mg tablet Aspirin with a third of the bottle remaining." R28's physician was notified and the resident was sent to the hospital. R28 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's undated policy regarding contrabands states, "Policy: To assure the safety of all residents and staff, bags and belongings will be checked at staff's discretion. This will include but will not be limited to when residents return from pass. All residents must turn in any contraband that is in their possession. The following is a list of what will be considered contraband on the unit: List." Further review of the contraband policy reflects that an over the counter medication like Aspirin was one of the contraband medication. During an interview held on 1/4/11 at 3:30 PM, Z3 (Psychiatrist) stated that due to R28's history of suicidal attempts and history of drug overdose, the goal for the resident is to be free from self harm. Per Z3 she expects the facility to provide a stable environment for the resident. the facility is expected to constantly monitor R28's safety due to the resident's attention seeking behavior and the facility is also expected to provide structured support. Z3 also stated that due to R28's history of drug overdose specifically Aspirin overdose, the facility was expected to check R28 for possession of Aspirin, any unprescribed and/or over the counter medications and or any contrabands. Based on record reviews, R28 had multiple attempts to harm herself. The facility did not have a plan in place to address R28's history of Aspirin overdose (12/16/09), attempt to harm self (3/12/10) and history of suicidal ideation (5/14/10). The facility did not monitor and supervise R28 for self harm and use of contrabands. R28 subsequently ingested 30 Aspirins on 10/24/10, while in the facility, that caused the resident to be hospitalized and was diagnosed with [REDACTED].