Every finding on record at Little Village NRSG & RHB CTR

Based on interviews and reviews, the facility failed to ensure a resident (R1) remained free from sexual abuse by another resident in a sample of five reviewed. Findings include:R1's medical diagnosis in current face sheet includes but not limited to: Type 2 diabetes mellitus with other specified complication, other psychotic disorder not due to a substance or known physiological condition, bipolar disorder, current episode depressed, severe, with psychotic features. Minimum Data Set (MDS) Section C-Cognitive Patterns dated 05/24/2026 documents R1's Brief Interview for Mental Status (BIMS) as 12/15, indicating R1 has moderate cognitive impairment. On 06.04.2026 at 12:07PM, R1 was observed sitting outside her room in the hallway near the nursing station. R1 stated male resident (No name provided) was bothering her and touched her inappropriately. He was bothering me. I don't remember his name. It didn't make me feel good. R1 then stated she was hungry and wanted to go to eat and declined to speak anymore.R2's medical diagnosis in current face sheet includes but is not limited to: Major depressive disorder, recurrent, mild, schizoaffective disorder, unspecified, Type 2 diabetes mellitus with diabetic neuropathy, unspecified. Minimum Data Set (MDS) Section C-Cognitive Patterns Dated 05/18/2026 documents R2's Brief Interview for Mental Status (BIMS) as 10/15, indicating R1 has moderate cognitive impairment. R2 was not residing in the facility during this investigation. Facility Reported Incident Report (FRI) 5/19/2026 documents V7 (Housekeeping) reported to V6(Licensed Practical Nurse-LPN) that V7 saw R2's hand in R1's genital area. R1's nursing progress notes dated 05/26/2026, at 5:12 PM by V6(Licensed Practical Nurse-LPN) documents R1 reported that R2 touched her inappropriately.R1's Social Services progress notes dated 05/26/2026, at 8:19 PM by V5(Social Services Director-SSD) documents V5 did a wellbeing check with R1 after R1 reported that R2 touched her inappropriately. R1 was calm but visibly uncomfortable while recounting the incident. R1 stated that the contact was unwanted.R1's care plan dated 5/26/2026, Category: Psychosocial Well-Being, documents R1 reported inappropriate touching behavior by R2.Facility filed police report date 5/26/2026 # 2614610861.R2's progress notes SS (social service) dated 5/26/2026, at 7:35 PM documents R2 engaged in an inappropriate physical contact/touch with a R1 without her consent. R2 reported the incident to staff, and her statement was consistent with observed distress. R2 demonstrated impaired judgment and limited insight into the seriousness of the behavior.R2's care plan dated 5/26/2026 documents R2 has exhibited an episode of sexually inappropriate behavior, including physical gestures toward peers. This behavior places him at risk for peer conflict, and potential harm, and may violate others' rights.On 06/04/2026 at 12:27PM, V7 (Housekeeping) stated on 5/26/2026 during the beginning of the second shift between 2:25 PM and 2:50 PM as V7 was going to the D-wing of the unit, V7 observed R1 and R2 sitting on chairs in the hallway across the elevator beside each other. There were other residents sitting on the chairs by the elevators. V7 does not remember who the other residents were. V7 observed R1's hands in R2's private part (in between R2's legs). R2's hands were on top of R1's hands. V7 asked R1 and R2 what was going on and why R1's hands are touching R2's private parts with R2's hand on top of R1's hands. V7 stated R2, told V7 that R1 put her hand on his private parts. R1 stated she did not and that R2 grabbed her hand and put it on his private part. V7 stated he separated R1 from R2 and took R1 to the nursing station where there were three CNAs (Certified Nursing Assistants) and two nurses getting ready to start their shifts. V7 does not remember their names. V7 stated he explained to the nursing staff what he observed and left R1 at the nursing station. V7 stated residents are not supposed to touch each other inappropriately without consent. On 06/04/2026 at 1:06 PM, V5 (Social Services Director) said on 5/26/2026 during the PM shift, V6 (Licensed Practical Nurse-LPN) informed V5 R1 told V7 that R2 touched R1 inappropriately. V6 stated she was informed by a CNA (No name provided) about this issue. V5 stated he informed V1. V5 stated he went to meet R2 who at first denied anything happened between R2 and R1. V7 stated he told R2 to tell the truth. R2 then started he held R1's hand and kissed it at the back. V5 told R2 that R2 has crossed boundaries by touching R1 and kissing R1's hand without permission. V5 further stated For me, that was sexual abuse. Residents are not allowed to sexually abuse each other or touch each other inappropriately just because they are residents. V5 stated staff should monitor residents to make sure something like this does not happen. V5 stated R2 was petitioned out to a psychiatric hospital for further evaluation and has not returned to the facility.On 06/04/2026 at 2:00PM, V6 (Licensed Practical Nurse-LPN) via phone stated V8 (CNA) informed V6 that V7 came to the nursing station and informed staff that R2 had touched R1 inappropriately. V6 went to R1 who was sitting on chairs near the elevator. R1 stated R2 had touched her. R1 demonstrated by putting her hands on her private parts (Perineal Area). R2 was not near R1 at that time. R1 was assessed and monitored.V6 informed V1. V6 assessed R1 who denied pain, but R1's affect was flat without any emotions. V6 found R2 outside by the smoking area. R2 told V6 that he held R1's hand and kissed it and to R2 that was nothing. R2 was sent out to the hospital for evaluation. R2 was not willing to go to the hospital. Police were called and informed R2 he had to go to the hospital. V6 stated police interviewed R1 who demonstrated where R2 had touched her by touching her private part. V6 stated she heard R1 telling the police He touched my vagina. V6 stated residents can have consensual sex if both residents are alert and able to give consent. R1 cannot give consent. R1 is sometimes confused, not coherent and has not demonstrated sexual seeking behaviors. V6 stated nursing staff are supposed to monitor residents to prevent inappropriate touching. Touching someone in their private area is a form of sexual abuse. On 06/04/2026 at 2:33PM, V8 (Certified Nursing Assistant -CNA) via phone stated she was by the second nursing station near the elevators when she heard V7 telling other CNAs (No names provided) that he saw R2 grab R1's hand and put it on R2's crotch area. V9 (CNA) went and informed V6 (LPN), who was the nurse for that day, what they had heard V7 stating. V8 stated all nursing staff are supposed to be monitoring residents. If a resident is putting a hand on another resident's private part without consent of the other resident, that is inappropriate and can be considered sexual assault. On 06/05/2026 at 12:30PM V1(Administrator) stated on 5/26/2026 she was doing rounds on the unit when the second shift Nurse, V6 informed V1 that R1 was touched inappropriately by R2. When V7 saw what happened he removed R1 from the situation and took R1 to the nursing station. V1 went to R1 and asked R1 if she was touched inappropriately by a male resident. R1 stated yes and nodded towards her private area. When asked if she knew who the male resident was, R1 stated no. Police were notified. The police came and interviewed R1 and R2 and left the facility. Police were called back because R2 was refusing to go to the hospital. The ambulance was waiting for R2. R2 was petitioned out for further evaluation. R2 is still at the hospital. When R2 comes back, he will be on a behavior contract. The contract is to make sure that going forward, R2 will follow the facility policy, and his sexual behaviors will be monitored. Residents who are alert and oriented times four, meaning they have cognitive abilities to make informed decisions can consent to sex. R2 cannot make independent /informed decisions for herself. Her BIMS score shows R1 has moderate cognitive impairment. V1 stated all nursing staff are supposed to be monitoring residents. If a resident is putting a hand on another resident's private part without consent, that is inappropriate and can be considered sexual assault.Abuse Policy dated 5/19/2025 documents:- This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and residentsecure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents.- Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault

Based on interview and record review the facility failed to ensure the resident's care plan was revised to address ongoing medication refusal and escalating aggressive behaviors; and failed to implement effective, individualized interventions, resulting in the need for psychiatric transfer for one resident (R6). This failure affects 1 of 3 residents reviewed for care planning. Findings include: R6's face sheets shows that R6 has diagnosis which includes but not limited to: bipolar disorder, psychosis not due to a substance or known physiological condition, schizoaffective disorder, and insomnia. R6's Brief Interview for Mental Status (BIMS) dated 4/13/26 shows a score of 14 which indicated that R6 is cognitively intact. On 5/5/26 at 10:56 am, V7 (Licensed Practical Nurse, LPN ) stated on 3/22/26 during morning shift medication pass she offered R6 her morning medication and R6 refused. V7 then explain when a resident refuses medication the psychiatrist is informed after 3 days of missed medications and that this was the third day of R6 refusing her medication. V7 further explained that R6 usually sits in the hallway loud and disturbing other residents and on 03/22/26 R6 and another resident was having a verbal altercation with another resident. V7 then stated that both residents were yelling at each other and V7 then separated the residents by escorting the other resident out of the room and to the common area. V7 then explained that she informed V1 (Administrator) that they were not compatible as roommates and V1 then instructed V7 to call both physicians and let them know regarding both residents' behaviors. V7 then stated that upon V7 informing R6's physician regarding her behavior with the other resident V7 also informed R6's physician that R6 had been refusing her medications for the past 3 days and the psychiatrist informed V7 to petition R6 to the local hospital for an evaluation. V6 explained that she carried out the psychiatrist order, gave report to the local hospital, arranged transportation and informed R6 family that R6 would be transferring to the local hospital for a psychiatric evaluation. V7 then stated that V9 (R6's Family Member) was upset and stated that when she spoke with V9, he stated, Hold on I will be in the facility in 10 minutes. V7 stated that she then informed V9 that R6's transportation was already arranged and on the way to pick up R6 to transport R6 to the local hospital and V9 then replied that he was still coming into the facility. V7 further explained when V9 arrived at the facility R6 was no longer in the facility and was transported to the local hospital. V7 stated that V9 then demanded to speak with a supervisor on duty, questioned why R6 was being sent out to the local hospital and asked why the facility did not wait on V9 to arrive before sending R6 to the local hospital. V7 then explained that she informed V9 that R6 was sent out for noncompliance with medication and aggressive behaviors and V9 then responded by expressing that he did not want to speak with V7 and wanted to speak with the V1 (Administrator). V7 then explained she left the room with V9 to speak with V3 (Assistant Director of Nursing, ADON). V7 then explained that when R6 returned back to the facility after a few days she was still not complaint with medication and aggressive behaviors and was sent back to the local hospital for another psychiatric evaluation and has not returned to the facility. V7 stated that usually when a resident is having a behavior social service is contacted however when R6 had an aggressive behavior on 3/22/26 it was a weekend, and social services was not in the facility. V6 then explained that social service will talk to the resident who is has a behavior and encourage the resident to take their medication and also explained that the nurse will offer a prn (as needed medication) to help the resident to calm down. V6 further explained that the physician should be called every day after a refusal of medication, and the psychiatrist is informed on the third day of the residents refusal of medications, and the refusal is documented on the resident progress notes. V7 stated that R6's interventions in place were not effective requiring R6 to transfer to the local hospital frequently for behaviors and stated that R6 would have behaviors, staff would monitor her behavior, try to redirect R6 and educate R6 and then call her psychiatrist to be sent to the local hospital for behaviors. On 5/5/26 at 11:57 am, V8 (Social Service Aide) stated that she has worked at the facility for forty years in the social service department. V8 stated that she recalls R6 at the facility and that R6 was noncompliant with her medication, ADL's (Activities of Daily), smoking, conduct of behavior (verbally aggressive, socially inappropriate disrupting, yelling, screaming, hollering during the day and night), keeping her peers up, response to hallucinations, disorganized thinking, and wanting to establish her own routine. V8 stated, R6 is very difficult to say the least and is considered demanding. V8 then stated that when a resident refuses their medication they have so many days to refuse before the resident has to go to the hospital and the physician is notified. V8 also stated when R6 refuses medication V8 will counsel R6 consisting of asking R6 why she refused her medications, and that R6 would reply stating, I don't want to, and GOD told me that I don't need the medication. V8 also stated that sometimes R6 would respond by telling V8 to get out her face and to leave her alone. V8 stated that when a resident refuses medication they are encouraged to take the medication and are educated regarding the benefits of following medication regimen and health. V8 then explained when a resident has a behavior occurrence the resident's care plan is updated by social service department with an intervention implemented/updated in the resident's care plan. V8 also stated that there is a progress note that should be written regarding the behavior occurrence in the resident medical record and that the facility is currently short staff in the social service department. V8 stated that social service is not in the facility on the weekends and V8 is not aware of what happens to the residents who have a behavior occur over the weekend if social service is needed for a resident. On 5/5/26 at 12:27 pm, V2 (Director of Nursing, DON ) stated that R6 was non compliant with any of her care and that R6's behaviors has escalated over the past few years. V2 explained that the first day that R6 returns from the local hospital for behaviors she is complaint with her medication and then after R6 will stop taking her medications. V2 further explained that when a resident refuses medication after three days the psychiatrist is informed, and the physician is called for non-psychiatric medications daily however R6 was only taking a vitamin so R6's physician was not called for medications being missed. V2 stated that a residents behavior occurrence should be documented in the nurse's progress notes and social service is responsible for creating a behavior event for the occurrence. V2 then explained that when there is a behavior event the resident's behavior should be updated on the residents care plan quarterly. Then V2 stated that when the resident has a behavior leading to the resident involuntary discharge an intervention should be implemented, and the intervention should be documented in the resident's care plan. V2 then explained that the facility has exhaust interventions for R6 and that the social service department is responsible for the residents behavior care plan being updated at the facility.On 5/11/26 at 12:41 pm, V3 (Assistant Director of Nursing, ADON) stated the he is familiar with R6 regularly had behaviors where her baseline consisted of R6 yelling and arguing with other residents. V3 stated that interventions implemented for R6's behaviors were constantly redirecting her, placing R6 one on one, room changes, involving the family to assist with calming R6 down. V3 stated that on 03/22/26 V3 was the manager on duty at the facility, the floor nurse V7 (Licensed Practical Nurse, LPN) called V3 to the unit and informed V3 that R6 was arguing with her former roommate. V3 then explained that R6 had been arguing with her roommate earlier that day and V9 (R6's Family Member) helped to calm R6 down and that R6 was arguing with her roommate again. V3 then explained that V7 informed V3 that she had already called R6's psychiatrist and informed him that R6 was acting out and unable to be redirected and threatened violence to peers, and that R6 refused medication for the past 3 days and that R6's psychiatrist gave orders to send R6 to the local hospital. V3 then explained that R6 was placed on one to one with staff and the local ambulance arrived at the facility ten minutes later to transport R6 to the local hospital. V3 further explained that V9 (R6's Family Member) arrived at the facility twenty minutes after R6 was transported to the local hospital. V3 stated that V9 (R6's Family Member) was not aware that R6 had been being transported to the local hospital when he arrived. V3 stated that he spoke with V9 (R6's Family Member) he verbalized that he could have done more to calm R6 down before R6 was sent to the local hospital. V3 also stated that V9 also spoke with the V1 (Administrator) who informed V9 to come back the next day. V3 stated that the IDT (Interdisciplinary Team) is responsible for implementing interventions for a residents care plan, the social service department is responsible for updating the residents care plan after a resident has a behavior occurrence and is sent to the local hospital. Every time there is behavior occurrence, and the resident's interventions are not effective the residents intervention should be updated in the care plan. If the resident does not have effective interventions in place the resident can have safety issues. On 5/11/26 at 2:16 pm, V15 (Social Service Director ) stated that a resident's care plan is updated annually, quarterly and if there is a behavior with the resident. V15 then explained that the residents care plan should be revised when the resident has a behavior and the interventions in place are not effective. V3 explained that the resident's care plan shows what steps should be taken and followed for the residents plan of care if the resident has a behavior. V3 then explained if a resident's care plan is not updated the resident can have safety issues and the behavior can continue. R6's Resident Census shows the following census report for R6 being transferred to the local hospital for behaviors:hospital leave on 01/19/26 and returned to the facility on [DATE]hospital leave 01/31/26 and returned on 02/11/26hospital leave 03/22/26 and returned 04/03/26hospital leave 04/21/26 and discharged [DATE] R6's progress note from January 19, 2026, through March 22, 2026, shows repeated documentation of aggressive behaviors, refusal of medications and care as well as R6 being sent to the local hospital without any revisions to R6's care plan interventions. R6's Behavior care plan reviewed and shows no documented evidence of the care plan being updated following the residents change in condition after being transferred to the local hospital for behaviors on 1/19/26, 1/31/26, and 3/22/26.R6's care plan Problem start dated 1/14/26: Category: Behavioral Symptoms: R6 exhibits verbal aggressive behavior directed towards others i.e. (example) (cursing, yelling, to the point of disrupting others. History of physical aggressive behavioral symptoms directed towards others as evidenced by grabbing others, slapping others, and pushing others. Can be related to several factors, alteration in thought pattern (hallucinations). Diagnosis: Conduct Behavior (Aggression/Agitation). Schizoaffective Disorder, Psychosis. R6 was involved in a physical altercation with another resident on 3/25/23 . Problem Start Date 01/14/26: Category: Behavioral Symptoms: R6 has a history of non-compliance with following treatment plan (medicine). Refusing medicine, compliance with overall treatment plan. R/T (related to) poor judgment and insight. Thought pattern (delusions). Diagnosis: Conduct Disorder, non -compliance with medication regime. Schizoaffective Disorder, Bipolar Disorder. R6's Medication Administration Record (MAR) dated 03/01/26 - 03/31/26 shows that R6 refused 03/12/26, 03/13/26, 03/14/26, 03/15/26, 03/18/26, 03/19/26, 03/21/26, 03/22/26. The facility's policy dated 01/25/26 and titled Change in a Residents Condition or Status documents, in part: Objective: 1. Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status. Procedure: 6. If a significant change in a resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted by the assessment coordinator. The facility's policy dated 4/2017 and titled Comprehensive Care Plans documents, in part: to develop a comprehensive, person-centered plan of care, consistent with the resident's rights, that includes measurable objective and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Procedure: 3. The comprehensive care plan will include: b. Areas of potential risk to the resident with interventions to eliminate or reduce risk . d. Measurable objectives and timeframes . 5. Care plans are revised as changes in the resident's condition dictates, but no less than on a quarterly basis.

Based on interview, and record review, the facility failed to ensure a resident (R4) was free from physical abuse and verbal abuse. These failures caused R4 to suffer humiliation and emotional distress due to derogatory language used by staff, and staff forcefully pulling multiple braided strands of hair from R4's scalp, resulting in removal of approximately six braids from the crown of R4's head causing pain and injury.R4 has a diagnosis which include but are not limited to: chronic obstructive pulmonary disease, bipolar disorder, suicidal ideations, hypertensive heart disease without heart failure, viral hepatitis c, schizoaffective disorder, alcohol abuse.R4's Brief Interview for Mental Status (BIMS) dated 2/3/26 shows a score of 15 which indicated that R4 is cognitively intact. The facility's initial reportable incident dated 2/13/26 documents in part: R4 reported to the charge nurse that a staff member was inappropriate towards her. Charge nurse asked R4 which staff member? R4 stated she does not know her name, but she is in the nursing department. Charge nurse asked R4 to describe the staff member. R4 describes the staff member in stated it happened over 2 weeks ago when she was going to the hospital. Charge nurse asked R4 to explain what happens. R4 stated that staff members used foul language. Charged nurse informed the medical doctor (MD) and psychiatrist and abuse officer of alleged incident. R4 will be wellness and behavior monitoring. S1 (who is now referred to as V6 (LPN for this investigation) is suspended pending investigation. The facility final reportable incident documents in part: R4 was discharged on 2/3/26 for aggressive behavior. Police officers were on site to escort her on the ambulance stretcher for her aggressive behavior with staff. Local hospital emergency room (ER) nurse called the facility for a report and stated that resident remains aggressive. A witness stated R4 was physically aggressive with V6 in front of police officers. Another witness stated that the police officers had to pull R4 off V6. Another witness stated they heard R4 and V6 arguing and using foul language. Witness states during the verbal confrontation R4 hit the nurse. Another witness stated that R4 was out of control, and the nurse was doing her job. R4 admitted that the nurse was trying to give her an intramuscular (IM) injection, and she resisted, and she hit the nurse and knocked her wig off her head. R4 states during the altercation the nurse grabbed her hair. V6 was interviewed and denied using foul language. V6 states R4 was very violent towards her and staff. Stated the police were called to the facility for assistance. V6 stated the police came and they were escorted to R4's room. V6 states R4 was very aggressive, and she does not remember R4 hit her. V6 denies grabbing R4 hair. V6 stated her and police officers had a hard time to get R4 back to baseline. V6 stated R4 was escorted by police officers on the stretcher to be discharged to the hospital. A police report was made out for this event. R4 will be on wellness and behavior monitoring. R4 care plan will be updated. R4 will receive a behavior event. V6 use of foul language was substantiated. V6 was terminated.On 3/5/26 at 9:33 a.m., V2 (Director of Nursing, DON) stated that V6 (Licensed Practical Nurse, LPN) was not R4's nurse on the 2/3/26 11:00 p.m. - 7:00 a.m. shift going into 2/4/26. V2 explained that on 2/3/26 at 5:03 a.m., V10 (LPN) informed her that R4 was acting physically and verbally aggressive and was attempting to elope several times and that V10 then had to call 911 to assist because staff could not get R4 to take a PRN (as needed) medication. V2 further explained that V10 stated that 911 came and transported R4 to the local hospital emergency room. V2 then stated that upon R4's return to the facility on 2/13/26, V5 (Licensed Practical Nurse) reported to V1 (Administrator) that R4 reported to V5 (LPN) that V6 (LPN) was aggressive the morning of 2/4/26 prior to R4 being transported to the local hospital. V2 stated she was not given details of the abuse report and that the abuse was reported to V1 who conducted the investigation. V2 then explained that she was instructed by V1 (Administrator) to suspend V6 (LPN) during V1's investigation and then a few days after V2 suspended V6, V1 instructed V2 to terminate V6 (LPN) due to being verbally aggressive with R4 on the 2/3/26 11:00 p.m. - 7:00 a.m. shift prior to R4 being transported to the local hospital. V2 explained that she was informed that two residents witnessed the inappropriate language but denied any knowledge of reports of V6 pulling R4's hair. On 3/5/26 at 11:10 a.m., R5 stated that he recalls the incident with R4 a few weeks ago. R5 explained that it was around 4:00 a.m. when he heard R4 asking the nurse for her medication and started running up and down the hallway. R5 then stated that he saw the nursing staff grab R4 and administer R4 an injection. R5 stated that he then saw the police enter the facility after R4 set the back door alarm off. R5 then explained he heard R4 call one of the nurses a B* and the nurse (who was identified as V6 (LPN) responded back to R4 and stated, Calm your a** down. Your momma's a B*. R5 denied witnessing R4's hair being pulled by V6 or any other staff member. On 3/5/26 at 11:16 a.m., R6 stated he recalls the incident on the 11:00 p.m. - 7:00 a.m. shift with R4 and stated that R4 was walking around talking to herself saying she needed her medication and trying to leave out the A-wing door. R6 stated that a nurse and R4 began tussling, R4 knocked the nurse who was tussling with R4's wig off, and then staff instructed R6 to go into his room. R6 stated he could still hear the commotion with the nurse and R4 as well as hear R4 state, Let my hair go, B*, to the nurse V6. R6 further explained he heard V6 reply and state, Your momma B* back to R4. R6 then stated that he did not witness R4's hair being pulled and that he just heard R4 telling the nurse to let go of her hair. On 3/5/26 at 11:28 a.m., R4 stated that the day R4 was sent to the local hospital, it was around 2:00 a.m. and she was playing music in her room when staff asked her to turn her music down. R4 stated that she told the staff that her music was not loud. She explained the staff called the police and when the police arrived R4 and V6 (LPN) began tussling. R4 further explained during the tussle she knocked V6's wig off her hair and V6 then began pulling R4's hair (which was braided) until R4's braided hair detached from the center of her scalp. During the interview, R4 showed the surveyor a bald area at the crown of her head and stated that the hair had been pulled out by V6 during the incident. R4 also showed the surveyor a plastic bag with six individual braided strands of hair with hair attached to the ends and stated that the braids had been pulled from her scalp by V6 during the incident. R4 also explained that there was an exchange of words from R4 and V6. R4 stated she called V6 a B* and V6 called R4 a B* back. R4 stated that she felt head pain, disrespected, humiliated, and embarrassed from the situation.On 3/5/26 at 11:50 a.m., V5 (Licensed Practical Nurse, LPN) stated that on 2/13/26 V5 informed V1 (Administrator) that R4 reported an allegation of abuse against V6 (LPN). V5 stated that when she was in R4's room R4 began to state that her head was hurting and she asked R4 how often she got headaches and R4 replied and stated, No I don't have a headache. My head hurts because I got into a fight with the nurse (whom she described to V5 as V6) before I went to the hospital. She pulled my hair out the top of my head, and my head is still sore. V5 then stated that R4 showed V5 a plastic bag with several strands of braids that R4 stated V6 pulled out of her head. V5 denied R4 informed her of any verbal abuse or derogatory exchange from V6. V5 stated that she immediately informed the abuse coordinator V1 of R4's allegation. On 3/9/26 at 12:00 p.m., V12 (R4's Physician) stated he is the medical director of the facility and recalls R4 having an unusual delusion with combativeness. V12 stated that staff informed him regarding the verbal and physical exchange between R4 and V6. V12 further stated that if derogatory language is used towards a resident it can result in the resident having emotional distress and humiliation. V12 also stated that he agreed 100% with V6's termination of employment when he was informed of R4's hair being pulled out. V12 also explained that he did not see R4's head and that if a resident has their hair pulled out it can cause momentary pain and injury. On 3/9/26 at 1:11 p.m., V10 (Licensed Practical Nurse, LPN) stated that on 2/3/26 R4 was having behaviors and called the local police and stated that there were people on the roof with guns. V10 stated that police verified no one was on the roof and left the facility. V10 further explained that R4 remained agitated and V10 administered her a PRN injection to calm R4 down. V10 further explained that R4 did not calm down and came out of her room speaking very loudly and agitated. V10 then stated that after several attempts to call R4's physicians (psychiatric physician and primary physician) and not reaching them, V10 called the police back to request the police transfer R4 to the local hospital for an evaluation. V10 stated that the police arrived and informed V10 that he would have to call the fire department to transport R4 to the local hospital. V10 then explained that she called the fire department and the police stayed with R4. V10 then explained when the fire department arrived the police brought R4 to the front door in a wheelchair wrapped in a blanket and the fire department transported R4 to the local hospital. V10 denied ever witnessing R4 and V6 or any other staff member in a verbal or physical altercation. V10 stated she learned about the altercation with V6 and R4 when V1 (Administrator) questioned her regarding the incident. On 3/10/26 at 9:56 am, V6 (Licensed Practical Nurse, LPN) stated that she recalls the incident with R4 on 2/3/26. V6 explained that R4 was erratic, pushing all the alarm doors and the Certified Nursing Assistants (CNA'S) out the exit doors at the facility. V6 then explained that R4 was not V6 assigned resident on 2/3/26 at the time of the event. V6 further explained that she was trying to calm R4 down due to R4's behaviors which also included R4 picking up a bottle of pop and throwing the bottle of pop in attempts to hit V6 in the face. V6 then explained that she (V6) pushed the bottle out of R4's hands to prevent R4 from hitting V6 in the face. V6 stated that R4's nurse V10 (LPN) was afraid to come to where R4 was at the A- wing unit and therefore V10 remained down the hall out of view of V6 and R4. V6 further stated that she instructed a CNA to tell V10 (LPN) to call the police while V6 remained trying to prevent R4 from pushing the door. V6 then explained that she grabbed R4's arms in attempts to remove her (R4's) arms off the exit door and R4 then knocked V6's wig off of her (V6's) head. Next, V6 explained that the police arrived and R4 tried to calm down after V6 stated to R4 This was not necessary. V6 then explained that the police then called for ambulance to transport R4 to the local hospital because R4 was still having a psychotic breakdown. V6 further explained once the ambulance arrived V6 walked away from R4 to open the door for the ambulance paramedics. V6 then stated that she took the paramedics to R4's room and R4 then attempted to spit on the ambulance paramedics therefore the police covered R4's face with a sheet to prevent her from spitting. V6 explained that R4 was placed on a stretcher and transported to the local hospital. V6 then stated that after R4 left the facility she informed V10 (LPN) regarding everything that occurred with R4, informed V10 that she was not charting the event with R4 because she was not R4's nurse and instructed V10 (LPN) to chart the occurrence. V6 denied the use of and derogatory language from R4 or V6 during the event. Surveyor then asked V6 if R4 called V6 a B* and V6 stated, Yes. However, V6 denied stating any derogatory language back to R4. V6 also denied grabbing R4's hair and stated that she only picked her (V6's) wig off the floor and placed it back on her (V6) head. V6 stated If staff uses derogatory language to a resident, it is verbal abuse and if staff pulls a resident's hair that is physical abuse. V6 then stated, I don't remember grabbing her hair. Abuse is reported immediately to V1 (Administrator).On 3/10/26 at 1:19 pm, V1 (Administrator) stated she is the facility's abuse coordinator and that abuse is reported immediately to V1 investigate. V1 stated that V5 (Licensed Practical Nurse, LPN) informed V1 that R4 complained of having a headache and that she had a fight with a staff member. V1 then stated that she began investigating R4's allegations and interviewed R4. V1 explained that R4 initially stated that R4 and the nurse got into an altercation and R4 hit the nurse and the nurses wig fell off her head onto the floor. V1 further explained that R4 stated that the nurse was walking behind her like a gangster while the police was present and was laughing at R4. V1 also stated that R4 stated the incident happened about two weeks ago and then further explained that she recalled a few weeks ago when she (V1) was informed by the nurse V10 (LPN) that R4 called the police and stated there was active shorter on the roof of the facility. V1 further explained that V10 sent R4 to the local hospital for hallucinations and delusions due to R4's hallucination episode. V1 then stated that she asked R4 who the staff member was and R4 stated that she did not know and directed V1 to ask R6. V1 then stated that she asked R6 and R6 stated that staff member was V6 (LPN) and that he heard R4 call V6 a B* and V6 replied back to R4 stating, Your momma is a B*. V1 further explained that R4 stated her hair was pulled by V6. V1 denied any other residents stated or reported hearing or seeing verbal or physical abuse transpire with V6 and R4. V1 then stated that if a resident's hair is being pulled by staff that is considered physical abuse. V1 further explained that R4 showed V1 the top of her head and informed V1 that V6 pulled her hair out. V1 stated that R4 showed V1 one braid that was removed from R4's head. R4's progress note dated 2/13/26 at 4:14 pm, authored by V5 (LPN) documents, in part: Resident informed the writer that a staff member was inappropriate to her. Writer notified abuse officer MD (Medical Doctor) and the psychiatric doctor of the allegations. Writer received no new orders. Resident will be on wellness and behavior monitoring. V6's Employee Report dated 2/12/26 authored by V2 (Director of Nursing, DON) documents in part: Staff member failed to report incident involving resident to immediate supervisor. Staff member was verbally aggressive to resident displaying inappropriate verbal interaction with resident. Staff member discharged due to discourteous verbal aggression towards resident.The facility's policy dated 10/2022 and titled Abuse documents in part: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive in residence secure environment. Purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents . Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment . Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual's age, ability to comprehend, or disability.

Based on interview and record review, the facility failed to ensure staff followed a resident's assessed transfer status, which required the use of a mechanical lift for transfers. This failure affected one out of three residents reviewed for falls and caused R3 to be sent to the local hospital due to R3 sustaining a fracture of the distal femoral shaft, which requires R3 to use a left leg brace.Findings include: R3's diagnosis include but are not limited to: fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with routine healing.R3's Brief Interview for Mental Status (BIMS) dated 2/24/26 shows a score of 5 which indicated that R3 has moderate cognitive deficits. R3's Minimum Data Set (MDS) dated [DATE] and 2/10/26 documents, in part: R3 requires maximum to dependent assistance with ADLs (Activities of Daily Living), transfer and bed mobility. The facility initial reportable incident dated 2/11/26 documents in part: R1 was being transferred to her wheelchair from the shower chair by staff and lost her footing. R1 was lowered to the floor by staff. R1 was immediately assessed by nurse on duty. R1 complained of discomfort to right lower extremity. R1 MD (Medical Doctor) made aware with orders to transfer to local hospital for evaluation. R1 family made aware via telephone. Local hospital called hospital in stated R1 sustained a right femur fracture. The facility final reportable incident 2/11/26 documents in part: Spoke with R1's primary MD who stated that R1 will be placed in an immobilizer and will not have surgical intervention she will be referred to therapy and monitored for pain and abnormal occurrences. R1's Hospital Record dated 2/10/26 .documents, in part: [AGE] year-old female presents from the nursing home for evaluation of right knee pain after a witnessed fall in the shower. Paiten said she fell down onto her right side . Imaging: x-ray femur RT (right) 2V (two view). Impressions: angulated foreshortened fracture of the distal femoral shaft, distal to the right femoral hardware. On 3/5/26 at 11:51 a.m., R3 stated she does not recall the full details of the fall but remembers losing her balance and breaking her leg during the incident on 2/10/26. R3 stated, I lost my balance, and she (referring to the CNA) could not catch me.On 3/5/26 at 11:57 a.m., V15 (Certified Nursing Assistant, CNA) stated that she was R3's CNA. V15 stated that prior to R3's fall on 2/10/26, R3 required assistance from two staff with a gait belt for transfers, and upon R3's return from the local hospital, staff now use a mechanical lift to transfer R3. V15 explained that R3 previously was able to assist with transfers; however, staff have now been instructed to use a mechanical lift when transferring R3.On 3/5/26 at 1:32 p.m., V4 (Licensed Practical Nurse, LPN) stated that approximately 2-3 weeks ago she was sitting at the nursing station when V9 (CNA) notified her that she had to lower R3 to the floor while transferring R3 from the shower chair to the wheelchair after R3's shower. V4 stated that she went into the shower room and observed R3 wet, in a gown, lying on the shower floor. V4 explained that R3's right leg was contracted and appeared pulled back further than normal. V4 stated that R3 uses a wheelchair for ambulation and that she did not know R3's transfer status at that time. V4 stated that she instructed the CNAs to transfer R3 to the wheelchair using a mechanical lift. V4 stated that she asked R3 if she was in pain, and R3 responded, Yes, and verbalized pain in the right leg. V4 further stated that she called R3's physician, who gave orders to send R3 to the local hospital, and R3 was sent for further evaluation.On 3/5/26 at 2:15 p.m., V9 (Certified Nursing Assistant, CNA) stated that in February 2026 she was assigned as R3's CNA on the evening shift. V9 explained that it was R3's shower day, and she wheeled R3 into the shower room in the wheelchair with a gown on and transferred R3 to the shower chair without the use of a gait belt, assistive device, or staff assistance. V9 stated that she had previously showered R3 by herself and did not think to ask for help. V9 stated that after finishing the shower, she dressed R3 in a gown and asked R3 to stand and hold the rail so she could transfer her back to the wheelchair. V9 stated that she placed a towel on the floor of the shower stall for R3 to stand on due to a bandage on one of R3's feet, which she could not recall, to prevent it from getting wet. V9 explained that when R3 stood up, her foot slipped, and she tripped on the footrest of the shower chair. V9 stated that she caught R3, and R3 began yelling, My leg, and V9 lowered R3 to the floor. V9 stated that during shift report, staff inform each other of the assistance each resident requires and how each resident transfers.On 3/9/26 at 11:45 a.m., V13 (R3's physician) stated that he recalls R3 at the facility. V13 explained that R3 suffered a right femur fracture after a recent fall in the shower room. V13 stated that when he received the call regarding the fall, the nurse reported that R3 was complaining of knee pain, and he directed the nurse to send R3 to the local emergency room to rule out fracture. V13 explained that staff should use a gait belt when transferring a resident for safety. V13 further explained that residents should be transferred according to their assessed ability documented in the medical record to prevent injury. V13 also stated that he initially thought R3 had a hip fracture and was glad R3 did not sustain a head injury.On 3/10/26 at 11:35 a.m., V2 (Director of Nursing, DON) stated that V4 called her on the evening of 2/10/26 and reported that R3 had a fall in the shower, then clarified that V9 (CNA) lowered R3 to the floor. V2 stated that V4 reported that R3 had no visible injuries and did not hit her head. V2 further stated that V4 called V13 (physician), who ordered that R3 be sent to the local hospital. V2 then stated that V4 had already called the ambulance and notified the family. V2 also stated that the following day she was informed that R3 sustained a fracture of the left femur related to the incident on 2/10/26. V2 explained that when she spoke with V9, V9 reported that she was transferring R3 from the shower chair to the wheelchair, both chairs were locked, and a bath blanket was placed on the floor to keep R3's dressings dry; however, she believed the blanket may have contributed to R3 sliding. V2 stated that when V9 noticed R3 sliding, she lowered her to the floor. V2 stated that R3's transfer status at the time required one-person assistance with pivot transfer. V2 explained that CNAs are instructed to review the resident care card to determine transfer status. V2 then stated that residents requiring one-person assistance should be transferred using a gait belt, and failure to use a gait belt can result in injury. V2 stated that residents requiring two-person assistance should also be transferred using a gait belt and mechanical lift. V2 also stated that on 2/19/26 she conducted an in-service with nursing staff regarding safe transfers, competency, return demonstration, and testing.R3's progress note dated 2/10/26 at 10:43 pm, authored by V4 (Licensed Practical Nurse, LPN) documents, in part: The writer made aware by CNA (Certified Nursing Assistant, CNA) that patient was lowered to the floor in shower room. CNA stated patient didn't hit her head. Writer assessed patient, patient c/o (complained of) pain to right knee/leg upon ROM (range of motion). Patient skin intact with no abnormalities noted. Writer administer pain medication as order pain 5/10. MD (Medical Doctor) notified gave orders to send resident to local hospital for post fall work up.R3's progress note dated 2/10/26 at 10:06 pm, authored by V4 (Licensed Practical Nurse, LPN) documents, in part: The writer made aware by CNA (Certified Nursing Assistant, CNA) that patient was lowered to the floor in shower room. CNA stated patient didn't hit her head. Writer assessed patient, patient c/o (complained of) pain to right knee/leg upon ROM (range of motion). Patient skin intact with no abnormalities noted. Writer administer pain medication as order pain 5/10. MD (Medical Doctor) notified gave orders to send resident to local hospital for post fall work up.R3's Care Plan documents in part that R3 has limited ability to transfer and requires mechanical lift and is dependent on staff assistance with transfers.R3's Minimum Data Set (MDS) dated [DATE] and 2/10/26 documents, in part: R3 requires maximum to dependent assistance with ADLs (Activities of Daily Living), transfer and bed mobility.The facility undated policy titled Safe Lifting and Movement of Residents documents, in part: Policy Statement: In order to protect the safety and wellbeing of staff and residents, and to promote quality care, this facility uses mechanical lifting devices for the lifting and movement of residents. Policy Interpretation and Implementation: 1. Mechanical lifting devices shall be used for any resident needing two-person assistance. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted.The facility's job description titled C.N.A. documents, in part: Duties/Responsibilities/Function: 10. Ensure that al transfers and lifts are performed with concern for safety of the resident according to the policies of the facility.

Based on interviews and record reviews, facility failed their policy and did not protect a resident from physical resident to resident abuse when a resident (R2) punched in the face another resident (R1) and that resulted in a brief red mark on R1's face. This failure affected one resident (R1) in the sample of three residents reviewed for abuse. Findings include:Facility's Final Reported Incident Report (12/23/2025), showed in part, that on 12/21/2025 at approximately 12:30 PM, R1 walked into R2's room and confronted R2 about another female resident. R2 said that R2 asked R1 to leave the room and R1 would not leave R2's room and so R2 then hit R1. R1 did not deny the allegation and did not have injuries.On 1/26/2026 at 11:26 AM, R2 stated that R2 had one incident of altercation with another resident, but it was a misunderstanding. R2 stated, that R1 came to R2's room and was yelling at R2 about R4, because R2 went to R4's room and partially removed covers from R4. R2 stated that R1 did not want to leave R2's room and so R2 lightly slapped R1 on the face and R1 went to complain to staff. R2 stated that R2 was later sent out to the hospital for behavioral evaluation.On 1/26/2025 at 12:14 PM, V10 (Licensed Practical Nurse/LPN) said that V10 heard about the incident between R1 and R2, but V10 was working and did not see the incident when it occurred. V10 stated, that R1 went to R2's room and R2 slapped R1 on the face and that V10 felt like the day of incident, R2 was not calm as usual. V10 stated that there were no injuries, R1 had a brief red mark on the face and that R2 was sent out to the hospital for behavioral evaluation.On 1/26/2026 at 12:20 PM, R4 stated that one day, (not sure of the exact day) R2 came to R4's room and flipped R4's bed covers to uncover R4 and that R4 did not like that. R4 said that R4 told R2 to leave the room and R2 left the room. R4 stated that R4 didn't report the incident to the staff but told R1, and that R1 is R4's good friend. R4 said that R4 is not sure what happened after, but R2 was sent to hospital. R4 said that R4 was just surprised by R2 uncovering R4. R4 said that R4 did not witness R2 and R1's altercation, but heard that R2 hit R1, but said that R1 was not hurt.On 1/26/2026 at 12:23 PM, V11 (Social Service Aide), stated, that after R1 and R2's incident, V11 spoke to R1 and was performing a well-being check. V11 stated that the altercation between R1 and R2 started because of R4. R4 told R1 that R2 was playing with R4 and pulled out R4's covers from the bed while R4 was laying in the bed and R1 thought that R1 should go to R2's room and talk with R2. R1 went to R2's room and wouldn't leave, and that is when R2 hit R1. V11 stated that R1 most likely cussed R2 out. V11 stated that V11 is not sure about the police report.On 1/26/2026 at 12:49 PM, V12 (Social Services Director), stated that V12 was part of the investigation of R1 and R2's incident. V12 said that R4 is in a friendship relationship with R1 and R2. V12 said that R2 was joking with R4 and pulled covers off R4's bed, while R4 was laying in the bed and R1 went to confront R2 about it and that is when R2 hit R1. R2 was sent out to the hospital for behavioral evaluation and R1 was not injured.On 1/26/2026 at 1:51PM, V2 (Director of Nursing/DON), stated, that incident between R1 and R2 was reported and that R1 came to R2's room and confronted R2 about another female resident. R2 told R1 to leave the room, but R1 did not leave and so R2 hit R1 in the face. V2 stated that R2 was sent to the hospital for behavioral evaluation.On 1/26/2026 at 3:03 PM V14 (Registered Nurse/RN) stated, that V14 remembers the incident with R1 and R2 and was notified by other residents, (does not remember who) that R1 and R2 were having a brief altercation and that R2 hit R1. V14 stated, that R1 went to R2's room and confronted R2 about R4, because R2 went to R4 's room earlier and pulled the covers off R4's bed while R4 was lying in the bed. V14 stated that R2 said that R2 was just joking and was playing with R4 and that the whole incident was a misunderstanding and was apologetic about hitting R1. V14 stated that when police came, the paperwork incident was not filled out because R1 did not want to press charges.On 1/26/2026 at 3:25 PM, V2(DON) stated, that police report was not filed because R1 did not want to press charges. On 1/27/2025 at 9:29 AM, R1 stated that, R4 told R1 about R2 coming to R4's room and flipped the covers on R4's bed and that R4 did not like that. R1 said that R1 came up to R2's room, between the doors, and told R2 to leave R4 alone. R1 said that R2 should not do that and R2 got mad and started yelling and punched R1 on the right side of face. R1 said that R1 and R2 were separated by the staff and then later R1 observed R2 being taken to the hospital. R1 said that R2 did not hit him hard, and R1 did not have any injury, just slight redness for few minutes. R1 said that the police came and talked with R1, but R1 did not want to press charges because R1 already saw R2 being sent out to the hospital.1/27/2026 at 1:12 PM V1 (Administrator) stated, that V14 (Registered Nurse/RN) notified V1 about R1 and R2's incident and that there was physical and verbal confrontation, with no injuries. V1 said that R1 went to R2's room to confront R2 about a friend (R4), because R2 went to R4's room before and flipped the bed covers off R4 and R1 went to tell R2 that it is not appropriate. V1 said that R2 got mad and agitated and hit R1. V1 said that R1 had no injury, R2 was sent out to hospital for behavioral monitoring and that police was called in, but the report was not filed due to R1 not wanting to press charges and R2 going to hospital.R1's Face Sheet showed in part R1 was admitted to facility on 7/26/2022 and R1's Diagnosis include but are not limited to Hypertensive heart disease, Bipolar disorder, Atherosclerotic heart disease, Iron deficiency, Hepatic failure, Substance abuse, Unsteadiness on feet, Muscle wasting and Atrophy, Abnormal posture, Cognitive communication deficit, Depression, Mental Disorder, Hyperlipidemia, Unspecified psychosis, Xerosis cutis, schizoaffective disorder, History of Syphilis, and Diverticulosis.R1's MDS (12/5/2025) Section C for Cognitive Patterns showed Brief Interview for Mental Status (BIMS) score of 13, which showed mild cognitive impairment.R1's Care Plan (12/5/2025) showed in part that R1 is at risk for abuse related to nursing home living and diagnoses of Schizoaffective Disorder and unspecified Psychosis and the short-term goal was for R1 to remain free of abuse/neglect.R1's Care Plan (12/21/2025) showed in part that R1 went to another resident's room and had verbal and physical altercation when refused to leave other resident's room.R1's Progress notes (12/21/2025 at 2:35PM) documented by V12 (Social Services Director) showed in part that R1 had a counseling session related to impulse control, Boundaries and Self - Awareness due to R1's going to other male resident's room and that male resident hit R1.R1's Progress notes (12/21/2025 2:49 PM) documented by V13 (RN) showed in part that R1 had altercation with another male resident and police was called.R1's Abuse Risk Review (12/4/2025) showed in part that R1 has serious mental illness and verbally threatening behavior and to continue current plan of care where R1 will be monitored for verbal and physical abuse.R1's Abuse Risk Review (12/21/2025) documented by V12 (Social Services Director) showed in part that R1 has serious mental illness, communication barriers, Impulse Control Issues, verbally threatening behavior, Minimization of circumstances, Low self-esteem/self-worth, Aggression/Combativeness and Exposure to Trauma.R2's Face Sheet showed in part R2's admission date on 4/30/2019 with a hospital stay from 12/21/2025 - 12/30/2025.R2's Diagnosis include but not limited to Major Depressive disorder; Type 2 Diabetes Mellitus; Unsteadiness on feet; Schizophrenia; Bipolar Disorder; Hyperlipidemia; Auditory hallucinations; Gastro-esophageal reflux disease and Muscle wasting and atrophy.R2's Minimum Data Sheets (MDS) (1/6/2026), Section C for Cognitive Patterns showed Brief Interview for Mental Status (BIMS) score of 15, which showed intact cognition.R2's Physician Order Report (12/1/2025 -1/27/2026), showed in part and active new order for Divalproex 250mg oral tablets twice a day and Haloperidol decanoate 50mg/ml intramuscular injection on the 1st of the Month and discontinued order for Sertraline 50mg oral tablet.R2's Care plan (1/7/2026) showed in part that R2 has a history of Physical and verbal aggression related to Hallucinations, Schizophrenia and Major Depressive Disorder and that R2 should not have any incidents of physical and verbal aggression.R2's Progress Notes (12/21/2025 at 2:30 PM), documented by V12 (Social Services Director) showed in part that R2 had an altercation with R1 because R2 was playing with R4 and R1 got upset; R2 said that R2 was not serious but R1 did not think so and got upset.R2's Progress Notes (12/21/2025 at 2:31 PM), documented by V14 (Registered Nurse/RN), showed in part that R2 was accepted to hospital for admission and ambulance would come pick R2 up from the facility.R2's Progress Notes (12/21/2025 at 2:42 PM), documented by V14 (RN) showed in part that R2 had an altercation with another male resident, no injuries noted, police was called and V14 obtained an order to admit R2 to hospital for psych admission.R2's Abuse Risk Review (12/21/2025), showed in part R2 has serious mental illness, communication barriers, Impulse control issues, Verbally threatening behavior, Minimization of circumstances, low self-esteem, aggression/combativeness, and exposure to trauma.R2's Hospital records showed in part, that R2 was admitted (12/21/2025 at 10:45 PM) to acute care hospital for behavioral evaluation due to punching a resident in the face. Internal medicine history and physical document (Date of service on 12/22/2025) showed in part that R2's chief complaint was punching a resident in the face. Assessment and plan showed in part that R2 will be in-patient to psych to manage psychosis/aggression. Patient Visit Information sheet (received 12/30/2025 at 11:54 AM) showed in part, that R2 will be returning to facility on 12/30/2025 with orders for Divalproex 250mg oral tablets, twice a day (9AM and 9PM), and Haloperidol decanoate 50mg intramuscular injection monthly and that the Sertraline 25mg oral tablets to be discontinuedR4's Face Sheet showed in part that R4 was admitted to facility on 2/12/2024 and diagnosis include but not limited to Chronic Obstructive Pulmonary disease; Major depressive disorder with psychotic features; Cocaine abuse; Emphysema; Tobacco use and Personal history of other infectious and parasitic disease - Syphilis.R4's MDS (11/18/2025) Section C for Cognitive Patterns showed Brief Interview for Mental Status (BIMS) score of 15, which showed intact cognition.

Based on interview and record reviews, the facility failed to follow their policy and provide an adequate number of staff to meet resident needs based on their facility assessment. This has the potential to affect all 99 residents residing in the facility. Findings include: CMS (Centers for Medicare & Medicaid Services) PBJ (Payroll Based Journal) Report for facility's Fiscal Quarter 4 2025 (July 1 - September 30) documents in part that the facility triggered for excessively low weekend staffing. Facility Assessment 2025 (last reviewed by the facility on 11/19/2025) documents in part a staffing of two nurses per shift, five CNAs (Certified Nurse Aides) for morning shift, four CNAs during evening shift, and four CNAs during night shift. On 12/17/2025 at 9:42 AM, V3 (Assistant Director of Nursing) stated that V2 (Director of Nursing) oversees nursing schedules. When V2 is off, V3 oversees the schedules such as during the time of the survey. V3 stated the facility should have two nurses per shift. When it comes to CNA (Certified Nurse Aide) staffing, the facility should have six CNAs during the day shift, four to five during the evening shift, and a minimum of four CNAs during the night shift. Facility provided a handful of 2025 assignment sheets. There were multiple assignment sheets that did not meet CNA staffing levels. These included 7/1, 7/4-7/8, 7/10-7/12, 7/16, 7/18, 7/21, 7/26, 7/27, and 7/30 for fiscal quarter 4. For the current fiscal quarter (1), the facility did not meet CNA staffing levels on 10/1, 10/4-10/6, 10/9, 10/11, 10/12, 10/14, 10/16-10/19, 10/21, 10/25, 10/26, 10/28, 10/29, 11/1, 11/2, 11/4, 11/5, 11/7-11/10, 11/12, 11/15-11/17, 11/19, 11/22, 11/23, 11/29, 11/30, 12/6, 12/13, and 12/14. During the same interview, V3 stated the circled staff names were the staff that did not report to work for whatever reason. V3 stated what's provided and written on the assignment sheets were for the most part the staff that worked the units during the given days. V3 stated facility usually asks previous shift staff to volunteer to work overtime or later shifts to come early to cover missing spots, but it's not always the case. Asked facility to provide staff timecards to prove adequate staffing. None provided at the completion of the survey. Facility's (1/8/2021) Staffing Policy documents in part: It is the policy of this facility to provide an adequate number of staff to successfully implement resident functions to meet resident needs.

Based on interview and record reviews, the facility failed to ensure there was a RN (Registered Nurse) that worked eight consecutive hours daily. This has the potential to affect all 99 residents that reside in the facility. Findings include: CMS (Centers for Medicare & Medicaid Services) PBJ (Payroll Based Journal) Report for facility's Fiscal Quarter 4 2025 (July 1 - September 30) documents in part that the facility triggered for four or more days within the quarter with no RN (Registered Nurse) hours. The infraction dates were for 7/04/2025, 7/12/2025, 7/13/2025, and 7/26/2025. 7/04/2025 assignment sheet did not list a RN working. 7/12/2025, 7/13/2025, and 7/26/2025 assignment sheets listed V3 (Assistant Director of Nursing) as the manager on duty. Requested V3's timecards for proof of RN hours worked. On 12/15/2025 at 3:01 PM, V1 (Administrator) stated the facility should have a RN for 8 consecutive hours a day. V1 stated they did not have a RN during the discussed days in July because people called off. Facility's 1/08/2021 Staffing Policy documents in part: A Registered Nurse will be scheduled seven days a week at least one continuous (8) eight hour shift.

Based on observation, interview, and record review the facility failed to follow proper sanitation and food storage practices as evidenced by a.) Food not properly labeled, and b.) staff personal items in the food preparation area. These deficient practices have the potential to affect all 99 residents receiving food prepared for the nursing skilled facility.Findings include:On 12/15/25 at 9:20 AM, During initial kitchen tour V15 [Dietary Manager] observed two large cans of string beans with no open dates, no discard dates, no expiration dates on the cans. V15 stated, Once the box was open and the cans were placed on the shelf it should have been labeled. If dietary staff prepare food, not knowing how long the food has been on the shelf it could potentially cause a foodborne illness.On 12/15/25 at 9:30 AM, V15 and surveyor observed car keys in the food preparation area. Noted raw uncooked, uncovered cookies on the food preparation table. V15 stated, Those car keys belong to V25 [ Dietary Aide]. Employee personal items should not be stored in the dietary kitchen to prevent cross contamination.On 12/15/25 at 9:35 AM, V25 [Dietary Aide] stated, The car keys belong to me. I should have placed them in my locker, I forgot. My car keys should not be stored on the food preparation area; it could potentially cause cross contamination.Reviewed the facility's In-Service Record dated 12/15/25: Personal itemsAll personal items must be in your lockers no in the kitchen such as car keys and coats.Policy documented in part:Labeling and Dating Foods {No date}Cans and items will be labeled with the date received when unpacked from cases.Personal Property:You will be assigned a locker for your personal possessions.

Based on observation, interview and record review the facility failed to a.) ensure medications had the proper label, b.) ensure medications were labeled and dated after opening, c.) ensure medications requiring refrigeration were refrigerated, d.) ensure insulin pens were stored in a bag to prevent cross contamination and e.) discard discontinued medications in 2 of 2 medication carts reviewed for medication labeling and storage.Findings Include: On [DATE] at 11:01 AM medication cart B was reviewed with V14 (Licensed Practical Nurse). R40's Albuterol Sulfate 90 mcg aerosol inhaler was observed in the medication cart with no open date. Surveyor asked V14 if the inhaler should be labeled with an open date. V14 responded, for these I am not sure. An Albuterol inhaler was observed in a bag with no name or label. R22's Albuterol 90 mcg aerosol inhaler was observed in the medication cart with no open date. R25's Albuterol 90 mcg aerosol inhaler and Humulin R25's sliding scale insulin vial was observed in the medication cart with no open date. V14 stated the insulin should be labeled with an opened date. I think the insulin is good for 30 - 60 days. days. R102's Lispro insulin pen 8 units three times a day was observed in a cup, not in an individual bag stored with R14's and R27's insulin pens in the medication cart. The insulin pens were not stored in a bag and had no open date or label. R102's name was written on the insulin pen with a marker. R27's Glargine insulin pen was observed in the cup, not in an individual bag stored with R14's and R102's insulin pens in the medication cart. There was no order found for the insulin pen. R14's Basaglar insulin pen 8 units daily was observed in the cup, not in an individual bag stored with R27's and R102's insulin pens. V14 stated, the insulin pens should be in individual bags because of infection. On [DATE] at 01:18 PM medication cart A was reviewed with V12 (Licensed Practical Nurse). R47's Latanoprost Ophthalmic solution dispensed on [DATE] was observed in the medication cart unopened with a label indicating refrigerate. R28's Lantus insulin pen was observed in the medication cart unlabeled with no open date or bag. V12 stated the insulin pen should be labeled and dated with the expiration date and date it was opened. The insulin pen should be in a bag to prevent cross contamination.On [DATE] at 09:13 AM V3 (Assistant Director of Nursing) stated Labeling and storage, the resident name and date opened should be on the medication. The Albuterol inhalers are good for 30 days after being opened. The insulin vials once opened should have the resident name, date opened and expires 28 days from the open date. If the insulin and albuterol is given after the expiration date it is inappropriate and there is a potential the expired medication may be inactive if expired. Insulin pens are kept in the medication cart, labeled and dated. I thought all of the insulin pens were stored together once opened. If the insulin pens are not stored in separate bags there is a contamination risk. If the eye drops are stored in the medication cart and should be refrigerated, they should be tossed and reordered. Once the eye drops were received, they should have been refrigerated. There is a potential eye drops can be inactive so it was inappropriate, and the resident needed the right medicine. The residents name should not be written on the medication with a marker. If the medication is not properly labeled the nurse should get rid of it and order a new one. The inhaler with no name or label should have been discarded and another should have been ordered. The discontinued insulin pen should have been discarded.Policy:Titled Storage of Medications reviewed 01/25 document in part: Medications and biologicals are store safely, securely and properly, following manufacturer's recommendations or those of the supplier. 5. Medications requiring refrigeration or temperature between 2 degrees Centigrade (36 degrees Fahrenheit) or 8 degrees Centigrade (46 degrees Fahrenheit) are kept in a refrigerator with a thermometer to allow temperature monitoring.

Based on observations, interviews, and record reviews the facility failed to follow their policy to a.) ensure medications was handled in a sanitary manner for 1 (R11) resident, b.) ensure reusable medical equipment was cleaned and disinfected between resident use for 4 (R11, R58, R94, R98) residents, c.) perform hand hygiene between 2 (R2, R58) residents contact, d.) store insulin pens to prevent cross contamination for 4 (R14, R27, R28, R102) residents and e.) ensure infection control protocols related to linen handling were followed for 1 (R5) out of 4 residents reviewed for linen handling out of a sample of 21.Findings include: On [DATE] at 10:45 AM, surveyor observed R5 in his room. Surveyor observed dirty towel and gown on the floor behind the door. R5 stated that he threw those there last night. On [DATE] at 10:50 AM, surveyor asked V8 (Certified Nursing Assistant) to come into R5's room. V8 noticed R5's dirty towel and gown on the floor. V8 picked up the dirty gown and towel and placed it in the dirty linen bin. V8 stated that dirty linen should not be on the floor. On [DATE] at 11:30 AM, V6 (Infection Preventionist) stated that dirty linen should not be on the floor due to contamination and spread of infection. On [DATE] at 11:00 AM, V3 (Assistant Director of Nursing) stated that no linen should be on the floor. V3 stated that dirty linen should not be on the floor due to spread of infection. Facility's laundry services policy (01/2019) documents in part: The laundry staff shall store, process and transport all linen and resident personal laundry in accordance with procedures which ensure safety and sanitary conditions to prevent the spread of infections. On [DATE] at 09:07 AM V12 (Licensed Practical Nurse) said to R11 first I am going to take your blood pressure. V12 entered R11 room and placed the blood pressure cuff on R11's right arm to check R11's blood pressure and oxygen saturation with the pulse oximeter. V12 exited R11's room, returned to the medication cart placed the blood pressure cuff and pulse oximeter on top of the medication cart without performing hand hygiene or cleaning and disinfecting the blood pressure cuff and pulse oximeter. V12 removed R11's medication from the medication cart and began preparing R11 medications in a medication cup. Surveyor asked the number of pills in the medication cup. V12 began counting and transferring R11 pills to another medication cup using her finger to push the pills from one medication cup to the other. V12 then said there are 11 pills. On [DATE] at 09:19 AM R58 approached the medication cart. V12 (Licensed Practical Nurse) placed the wrist blood pressure cuff on R58's right wrist while standing at medication cart. V12 stated, R58's blood pressure is 132/95. V12 placed the wrist blood pressure cuff on top of the medication cart without cleaning and disinfecting it. On [DATE] at 09:27 AM V13 (Licensed Practical Nurse Orientee) retrieved the wrist blood pressure cuff from the top of the medication cart then rechecked R58 blood pressure placing the wrist blood pressure cuff on R58's left wrist. V13 stated I am an orientee and this is my first day. R58's blood pressure is 127/67 pulse 83. V13 then placed the wrist blood pressure cuff on top of the medication cart without performing hand hygiene or cleaning and disinfecting the wrist blood pressure cuff. On [DATE] at 09:29 AM R94 approached the medication cart. V12 (Licensed Practical Nurse) place the wrist blood pressure cuff on R94's left wrist. V12 stated R94's blood pressure is 147/93 pulse100. V12 removed and placed the wrist blood pressure cuff on top of the medication cart without cleaning and disinfecting it. On [DATE] at 09:34 PM V13 (Licensed Practical Nurse Orientee) Donned a gown, face shield and gloves then entered R2's room with V13 without performing hand hygiene between the R2 and R58. On [DATE] at 09:44 AM R98 approached the medication cart with the use of a walker. V12 (Licensed Practical Nurse) said to R98, I am going to take your blood pressure. V12 placed the wrist blood pressure cuff on R98's left wrist while standing at the medication cart. V12 said R98's blood pressure is 119/86 then placed the wrist blood pressure cuff on top of the medication cart without cleaning and disinfecting it. On [DATE] at 09:48 AM surveyor asked V12 (Licensed Practical Nurse) what she should have done when taking the resident vital signs. V12 responded, I should have sanitized the blood pressure cuff and pulse oximeter between each resident to prevent cross contamination. V13 (Licensed Practical Nurse) said and in house infections. On [DATE] at 09:50 AM surveyor asked V13 (Licensed Practical Nurse) what she should have done between resident contact. V13 responded, I should have use hand sanitizer or hand hygiene to prevent cross contamination. On [DATE] at 11:01 AM medication cart B was reviewed with V14 (Licensed Practical Nurse). R102's Lispro insulin pen 8 units three times a day was observed in a cup, not in an individual bag stored with R14's and R27's insulin pens in the medication cart. The insulin pens were not stored in a bag and had no open date or label. R27's Glargine insulin pen was observed in the cup, not in an individual bag stored with R14's and R102's insulin pens in the medication cart. R14's Basaglar insulin pen 8 units daily was observed in the cup, not in an individual bag stored with R27's and R102's insulin pens. V14 stated, the insulin pens should be in individual bags because of infection. On [DATE] at 01:18 PM the medication cart A was reviewed with V12 (Licensed Practical Nurse). R28's Lantus insulin pen was observed in the medication cart unlabeled with no open date or bag to prevent cross contamination. V12 stated the insulin pen should be in a bag to prevent cross contamination. On [DATE] at 09:13 AM V3 (Assistant Director of Nursing) stated The blood pressure monitor and pulse oximeter should be cleaned with disinfectant wipes after each use. If they are not cleaned there is a potential for infection control, and it prevents the spread of infectious material. Hand hygiene is done between all interactions with residents, anytime you are touching a client or going in and out of the resident rooms. When counting the resident pills, it should be accounted for by signing for one pill at a time. You are not supposed to touch the pills at all. The pills should not be touched because of infection and contamination. We reordering medication when it gets to the last row on the medication card. When medication is missing, they are reordered stat. The medications should be reordered before they run out. If the medications are missed there is a potential it will affect the blood levels. The residents need their medications because bad things can happen to the resident if they will miss a medication dose. if the medication is not there and we should order it stat. The pharmacy can send the medications the same day or we can check the convenience box to see if it is available in there. If the resident miss their Metformin there is a potential for hyperglycemia, it can affect the residents blood sugar or the resident having to go out to the hospital. When there is a missed medication, you circle the initials on the MAR (Medication Administration Report). If a medication is missed it should be ordered immediately, inform the doctor as well and they should document. If it is not documented, it is not done. Labeling and storage, the resident name and date opened should be on the medication. The Albuterol inhalers are good for 30 days after open. Insulin vials once opened should have the resident name, date opened and expires 28 days from the open date. If the insulin and albuterol is given after the expiration date it is inappropriate there is a potential the expired medication may be inactive expired. Insulin pens are kept in the medication cart, labeled and dated. I thought all of the insulin pens were store together once opened. If the insulin pens are not stored in separate bags there is a contamination risk. If the eye drops are stored in the medication cart and should be refrigerated, they should be tossed and reordered. Once received the eye drops should have been refrigerated. There is a potential eye drop can be inactive, so it was inappropriate, and the resident needed the right medicine. The residents name should not be written on the medication. If the medication is not properly labeled the nurse should get rid of it and order a new one. The inhaler with no name or label should have been discarded and another should have been ordered. The discontinued insulin pen should have been discarded. The Controlled Substance Check Form should be done and signed shift to shift, nurse to nurse every day. The nurse should check to see if any new narcotics have come, and the sheet should still be signed. The admitting nurse does the initial base line care plan, and it is up to the care plan coordinator to take it from there. During admission the baseline care plan is for the initial care and connect dots with initial care. Policy: Titled Handwashing/Hand Hygiene Policy effective date: 03/20 document in part: It is the policy of the facility to assure staff practice recognized handwashing/hand hygiene procedures a primary means to prevent the spread of infections among residents, personnel, and visitors. Alcohol based hand rubs (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or body fluids. 1. All personnel shall be educated on recognized handwashing/hand hygiene procedures and shall follow such procedures. 4. When hands are not visibly soiled, employees may use an alcohol-bases hand rub containing at least 60% alcohol in all of the following situations: a. before direct contact with residents. b. after direct contact with a resident but prior to direct contact with another resident. c. before donning gloves. e. before preparing and handling medications. i. after contact with a resident's intact skin. k. after contact with objects such as medical devices or equipment in the immediate vicinity of a resident that may be potentially contaminated. m. after removing gloves. Titled Cleaning and Disinfection of Reusable Equipment reviewed 01/25 document in part: Reusable medical equipment can transfer germs between residents if it is not cleaned and disinfected correctly. This policy establishes clear expectations for cleaning and disinfecting reusable equipment to reduce the risk of infection and protect resident, staff and visitors. All reusable equipment used in resident care areas must be cleaned and disinfected between residents using facility-approved products. Reusable equipment is cleaned and disinfected after each resident use and before it is used on another resident. Staff follow manufacturer instructions for disinfectant use, including required contact time so the disinfectant works effectively. Examples of reusable equipment include blood Titled Infection Control Policy reviewed 01/25 document in part: The facility's written program is for the implementation of systems that provide a safe, sanitary and comfortable environment and helps prevent the development and transmission of communicable diseases and infections. 6. Hand hygiene is utilized to reduce the spread of germs to residents and the risk of the Health Care provider's colonization of infection by germs acquired from a resident. The facility utilizes hand hygiene via hand washing and alcohol-based hand sanitizers. 17. The facility maintains policies and procedures that address storage and handling of linen.

Based on observation, interview, and record review, the facility failed to follow their policy to ensure call light is within reach for 1 (R73) out of 3 residents reviewed for call lights in a sample of 24. Findings Include:On 12/15/2025 at 10:12 AM, surveyor observed R73 in his bed in his room. R73's call light is not within reach. R73 stated that he doesn't get out of bed on his own. R73 stated that he doesn't know where his call light is. On 12/15/2025 at 10:14 AM, surveyor asked V9 (Certified Nursing Assistant) to come into the room. When V9 came into R73's room, surveyor asked V9 where is R73's call light. V9 stated that R73's call light is by the wall. V9 stated that R73's call light should be clipped to his bed. Surveyor observed V9 clip R73's call light to his bed. V9 stated that R73 cannot get out of bed by himself. V9 stated that R73's call light should be within reach so R73 can call for help and make his needs known to avoid falls. On 12/16/2025 at 11:48 AM, surveyor observed R73's call light not within reach of the resident. On 12/17/2025 at 11:00 AM, V3 (Assistant Director of Nursing) stated that all resident call lights are to be within reach. V3 stated that call lights are to be within reach for residents to make their needs known and avoid falls. R73's fall care plan documents in part: Keep call light within reach. Round every two hours. Facility's call light policy (08/2008) documents in part: When residents are in bed, be sure the call light is within reach of the resident.

Based on interview and record review the facility failed to obtain a Physician's order with the code status for three (R8, R71, R111) residents reviewed for Advance Directives in a total sample of 21 residents reviewed. Findings Include: R8's Facesheet documents that R8 was admitted to the facility on [DATE]. R8's Facesheet documents that there are no advanced directives selected for this resident. R8's Physician Orders Sheet/POS does not document a physician order for an advanced directive. R71's Facesheet documents that R71 was admitted to the facility on [DATE]. R71's Facesheet documents that there are no advanced directives selected for this resident. R71's Physician Orders Sheet/POS does not document a physician order for an advanced directive. R111's Facesheet documents that R111 was admitted to the facility on [DATE]. R111's Facesheet documents that there are no advanced directives selected for this resident. R111's Physician Orders Sheet/POS does not document a physician order for an advanced directive. On [DATE] at 10:08 AM, V16 (Social Services Aide) states upon admission, residents are informed about advanced directives and asked what their decision is regarding their medical care. V16 states the resident then signs a POLST/Physician/Practitioner Orders for Life-Sustaining Treatment form documenting their code status and it is provided to the physician to sign for it to be valid. V16 states it is important for the advance directives to be documented so the nurses and the rest of the team know the code status of the resident in case of an emergency. V16 states during an emergency, the POLST form lets the staff know whether to do CPR/Cardiopulmonary Resuscitation for a Full Code or DNR/Do Not Resuscitate. V16 states there is a book that contains the resident's POLST forms and is kept at the nurse's station. V16 states the POLST forms for every resident in the facility should be located in this book. V16 states whenever there is an emergency and residents are sent to the hospital, a copy of the resident's POLST form is obtained from the book by the nurses to send with the resident. On [DATE] at 10:45AM, V16 provides surveyor with a book titled Resident DNR/do not resuscitate & Full Code List. V16 states all resident code statuses should be inside of the book. Record review of facility's Resident DNR/do not resuscitate & Full Code List book shows there are no POLST forms found for R8, R71, and R111.Facility policy dated 01/2020 titled, Advance Directives documents in part, 6. Copies of written advance directive documents will be filed/uploaded in the resident's clinical record. 8. Will initiate the necessary processed to modify the status changes in the resident's record, including contact of the resident's attending physician so that appropriate orders to reflect these status changes are secured. 12. The POLST form is the physician order.

Based on observation, interview, and record review, the facility failed to provide a home like environment for one (R17) in a total sample of 21 residents residing in the facility.The Findings include:On 12/15/2025 at 11:19 AM, Surveyor observed R17 eating a sandwich while watching television. R17 is alert and oriented to person, place and time. R17 seemed comfortable and free of pain. Surveyor smelled a foul odor coming from R17's bedroom. Surveyor observed the bathroom toilet; it was filthy with dried out feces' residue. Surveyor observed urine stains and spills around the toilet seat. The sink and floor both looked dirty, the entire bathroom looked unsanitary.On 12/15/2025 at 11:20 AM, R17 stated he is concerned with housekeeping not cleaning his room. R17 stated he cleans his own room and bathroom because the housekeeping team won't do it. R17 stated he has not seen housekeeping coming in his room for a few days. Surveyor asked R17 when the last time was the bathroom was cleaned. R17 stated he has not cleaned the bathroom for a few days because he ran out of gloves. R17 stated he does not even bother asking for assistance because no one ever comes to clean.On 12/16/2025 at 11:30 AM, Surveyor observed R17's bathroom's, there was dried out feces' residue inside the toilet. Surveyor observed urine stains and spills around the toilet seat. Surveyor asked R17 if housekeeping has come in to clean his room. R17 stated no one has cleaned his bathroom or mopped the floors. Surveyor asked R17 if he is comfortable being under these circumstances. R17 stated he does not like his room being dirty and will usually clean his room and make his own bed.On 12/16/2025 at 11:32 AM, V17 (Housekeeping Aide) stated she assists in changing the resident beds twice a week. V17 stated if the resident refused at the time of me coming in to change the linens, V17 will come back later. Surveyor asked V17 what can potentially happen if the linen is not cleaned. V17 stated they will sleep in dirty sheets and not be comfortable.On 12/16/2025 at 11:45 AM, V18 (Housekeeper) stated he is assigned a hallway, and is responsible to cleaning the resident rooms. V18 stated he ensures the resident room is mopped and swept. V18 stated he cleans the bathroom toilet and sink every day. V18 stated the last time he cleaned R17's room was Friday. V18 stated he was off over the weekend, and on Monday. V18 stated today is his first day back on the job, and he is working his way throughout the hallway.On 12/17/2025 at 8:57 AM, V22 (Housekeeping) stated he is responsible for making sure that the resident's room is clean every day. V22 stated the bathrooms, toilets, sink, cabinets, windows, floors should be cleaned daily. Surveyor asked V22 if residents are responsible for cleaning their own bathrooms. V22 stated housekeeping should make sure that the residents' bathrooms are cleaned daily. Surveyor asked V22 what can potentially happen if the resident's bathroom is not cleaned daily. V22 stated if bathroom is not cleaned daily, the residents are at risk for infection.On 12/17/2025 at 9:03 AM, V21 (Housekeeping Director) stated there is only one floor in this facility, however they are split into hallways. V21 stated there are three housekeepers, one in each hallway. V21 stated the housekeeping team is responsible for making sure that all resident rooms are cleaned every day. V21 stated the housekeeper is responsible for cleaning the bathrooms, toilets, sinks, sweeping, mopping, taking out the trash, cleaning the walls, windows, etc. V21 stated on the weekends he will staff one housekeeper in the morning shift and one housekeeper in the afternoon shift. Surveyor asked V21 if the resident is responsible for cleaning their own bathroom and room. V21 stated the housekeeping team should be cleaning the bathrooms and rooms. Surveyor asked what can potentially happen if the resident room and bathroom is not clean. V21 stated it will make the resident question if this is a place where he wants to be, because he won't feel comfortable living under these conditions, it is not a homelike environment. Policy titled Housekeeping Policy Services with review date of 01/2025 documents in part It is the policy of this facility to maintain a clean, order free, comfortable and orderly environments in all healthcare and public areas, which meet the sanitation needs of the facility and resident's rights for a safe, clean, comfortable home-like environment. The department shall routinely clean the environment of care, using accepted practices, to keep the facility free from offensive odors, the accumulation of dust, rubbish, dirt, and hazards.

Based on interview, and record review, the facility failed to protect the resident's right to be free from abuse for two (R51, R92) in a sample of 21 residents. Findings include: Facilities incident report form (11/11/2025 at 5:45 PM) documents in part: R51 and R92 had an altercation in their room. R51 stated R92 hit him in the stomach. R92 stated R51 took his belongings, placed his profile picture on his television, and was blowing kisses at him. R51 has a medical history of schizoaffective disorder, bipolar disorder, and a brief interview for mental status (BIMS) score of 14, which means R51 is cognitively intact. R92 has a medical history of bipolar disorder, and schizophrenia and a BIMS score of 12, which means R92 is moderately impaired. On 12/15/2025 at 11:12 AM, Surveyor observed R92 laying on his bed while watching television. R92 seems comfortable and free of pain. R92 stated he had an altercation with his roommate R51. R92 stated the altercation started because he caught his roommate stealing his clothes. R92 stated he got into a physical and verbal altercation due to that reason. Surveyor asked R92 if he can describe the physical altercation in detail. R92 stated he cannot remember all the details of the altercation, but he does remember it became into a physical and verbal altercation. On 12/16/2025 at 9:25 AM, R51 stated he had an altercation with R92 a few weeks ago. R51 stated when R92 was not in the room he went through his personal belongings. R51 stated he took some Kool-Aid from R92's bedside drawer. R51 stated he made a cup of Kool-Aid and went back to his bed. R51 stated when R92 came back to the room, he noticed that R51 had gone through R92' s personal belongings. R51 stated R92 became very angry and started yelling. R51 stated R92 walked up to him while he was laying down on the bed and punched him in the stomach. R51 stated he was sent to the hospital for further evaluation. R51 stated a police report was made on that day due to the incident. R51 stated he returned from the hospital 1-2 days later, he was free of any injuries. R51 stated he was moved to another room across the facility and has not had any contact with R92 ever since the altercation. On 12/16/2025 12:15 PM, V1 (Administrator) stated she is part of the abuse prevention program in the facility. V1 was called to come to the first floor, the D hallway on the day of the incident. V1 stated the second shift nurse on duty informed her of an altercation that was taking place between R51 and R92. V1 stated R92 admitted to hitting R51 in the stomach because he was upset that R51 was going through his belongings. V1 stated R92 was also upset that R51 was blowing kisses at him, hung a profile picture of himself on R92 television, and took some of his Kool-Aid. V1 stated R51 admitted to taking R92's Kool-Aid, denied hanging up his profile picture of himself on R92's television and denied blowing kisses to R92. V1 stated the ambulance was called, and R51 was sent to the emergency department for further evaluation, he had no injuries. V1 stated we had a room ready for him as soon as he came back. V1 stated the new room is located across the other side of the facility in the H hallway. V1 stated it took a while to calm R92 down, he was very upset and wanted to leave the facility against medical advice (AMA). V1 stated the psychiatrist ordered a one-time order of Haldol 5 mg intramuscular, and a Haldol 5 mg every 6 hours by mouth or intramuscular as needed for 14 days. V1 stated R51 is intrusive, he likes to socialize with everyone, he likes to walk throughout the facility. V1 states R92 is always in his room, he hardly ever comes out. V1 stated the staff is aware to monitor both R51 and R92, if they encounter each other, especially in the activity room. V1 stated both residents smoke on different patios, and there has been no other issues after the incident. Progress notes by V5 (Social Services Director) for R92 documents in part: on 11/13/2025, the social worker met with resident about altercation with another resident. Resident stated that his roommate has been going through his belongings and blowing kisses at him. Resident also stated that his roommate put his profile picture on his television. R92 is receiving coping mechanisms for managing anger. R92 on monitoring. Progress notes by V5 for R51 documents in part: on 11/17/2025, the social worker met with resident due to him displaying inappropriate behavior with another resident. During the session, the social worker check- in on how the coping skills is going for the resident. According to the resident, he feels like they are making him more self- aware of impulses as relates to his sexuality, and he has a better understanding of accepting boundaries. R51 is receiving counseling for emotional support. R51 is on monitoring. Reviewed care plan from 10/09/2025 for R51 documents in part: R51 is at risk for abuse due to living in a nursing home with other residents. R51 has a history of displaying behavioral symptoms inappropriate sexual behaviors towards peers and staff i.e entering female resident's room without their permission. Making inappropriate sexual advances/ remarks on 11/11/2025 blowing kisses at his roommate. Policy titled Abuse Policy with review date of 05/19/2025 documents in part This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Physical abuse includes hitting, pinching, kicking, and controlling behavior through corporal punishment. Residents who allegedly abused another resident shall be immediately evaluated to be determined the most suitable therapy, care approaches, and placement, considering his or her safety of other residents and employees of the facility.

Based on interview and record review the facility failed to ensure a baseline care plan was developed within 48 hours of admission for one (R109) resident reviewed for baseline care plans in a sample of 21.Findings Include:R109 was admitted to the facility on [DATE] with diagnosis not limited to Fracture of Unspecified Part of Neck of Left Femur, Asthma, Low Back Pain, Chronic Pain, Schizoaffective Disorder, Presence of other Bone and Tendon Implants.Progress note dated 12/10/25 12:57 PM document in part: Progress Note R109 arrived at 12:03 pm. R109 was admitted to the hospital for a fall where he (R109) sustained a left hip fracture and has 3 sutures intact and open to air. R109 is alert to name, place and time. R109 has a hx (history) of Asthma, Chronic lower back pain and Schizophrenia. R109 is continent with use of urinal and bed pan, uses a wheelchair for locomotion and is weight bearing as tolerated. R109 has an abrasion to his left knee and bruising to left thigh post fall. R109 is an active smoker. On 12/15/25 02:36 PM an email was sent to V1 (Administrator) by the surveyor requesting R109's care plan.On 12/15/25 the surveyor was presented with an undated document that documents in part: R109's ARD (Assessment Reference Date) is 12/16/25. It has not been completed yet. On 12/15/25 the surveyor was presented with a document titled Observation Detail List Report: Initial/Baseline Care Plan with an observation date: 12/15/25 02:53 PM, date recorded: 12/15/25 02:53 PM, date completed 12/15/25 02:53 PM Description: Admission. On 12/16/25 at 10:59 AM V12 (Licensed Practical Nurse) stated I admitted R109 on the 12/10/25. As a new nurse they never told us that we had to start the baseline care plan. I started R109's baseline care plan yesterday 12/15/25. If I had known I would have started the baseline care plan on admission.On 12/17/25 at 09:13 AM V3 (Assistant Director of Nursing) stated The admitting nurse does the initial base line care plan, and it is up to the care plan coordinator to take it from there. During admission the baseline care plan is for the initial care and connect dots with initial care.Policy:Titled Care Plan Standard Guidelines reviewed 11/14/25 document in part: All resident/client will be evaluated for individual risk factors which may increase the chance of hospitalization. All potential conditions that could increase the chance of hospitalization should be identified for care planning needs. The resident care plan will incorporate risk factors identified in preadmission, assessment, hospital records and admission evaluations. 1. The interdisciplinary team will collect and record data within 24 hours for the admission baseline Care Plan. 7. The care plan will be reviewed throughout the resident's stay upon admission, quarterly and with changes in condition. Baseline Care Plan: It is the practice of this facility to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality care. The baseline care plan will: 1. Be developed within 48 hours of a resident's admission: 2. Include the minimum healthcare information necessary to properly care for a resident including, not limited to: a. Initial goals based on admission orders. b. Physician orders. c. Dietary orders. d. Therapy services. e, Social services. f. PASARR (Preadmission Screening and Resident Review), if applicable.

Based on observation, interview, and record review the facility failed to provide scheduled showers for a resident that requires partial/moderate assistance with Activities of Daily Living/ADL care. This failure affects one (R71) resident in a total sample of 21 residents reviewed for ADL care. Findings include:On 12/15/2025 at 12:53PM, R71 observed sitting on his bed with a red walking stick lying next to him. R71 states he is blind and is unable to see. R71 states he has concerns with getting his scheduled showers in the facility. R71 states he is scheduled to receive a shower in the facility twice a week on Mondays and Thursdays. R71 states on his shower days, the staff does not always come to get him and take him for his shower. R71 states when he asks staff about his shower, they tell him they will return, but no one returns to give him his scheduled shower. R71 states he did not receive a shower this past Thursday on 12/11/2025. R71's Facesheet documents that R71 has diagnoses not limited to: Legal blindness.R71's MDS/Minimum Data Set, dated [DATE] documents that R71 requires partial/moderate assistance with bathing/showers in the facility and uses a cane to ambulate.R71'S shower schedule documents that R71 is scheduled to receive a shower in the facility twice a week on Mondays and Thursdays. On 12/15/2025 at 1:22PM, V10 (CNA Supervisor) states the resident's shower schedule and shower sheets are kept in a binder located at the nurses' station. V10 states the CNAs/Certified Nursing Assistants are responsible for providing residents their showers on their scheduled days. V10 states after a resident receives their shower, the nurse on duty performs a skin check and sign the shower sheet acknowledging that the resident received their scheduled shower. V10 states all residents in the facility should be receiving a scheduled shower at least twice a week and as needed. V10 states if a resident refuses a shower, it is also documented on the resident's shower sheet. V10 states if a resident's shower is not documented, then the resident's shower was not provided. V10 located at the nurses' station and provides surveyor with R71's shower sheets dated 11/2025 and 12/2025. R71's shower sheets dated 11/2025 documents that R71 did not receive his schedule shower on the following dates: 11/03/2025, 11/27/2025.R71's shower sheets dated 12/2025 documents that R71 did not receive his schedule shower on the following dates: 12/04/2025, 12/11/2025.R71's care plan documents in part R71 requires training and skill practice in dressing/grooming 6-7 days a week to prevent decline related to impaired vision. R71 is at risk for falling related to diagnosis of legal blindness. Facility policy dated 08/2002 titled Shower/Tub Bath documents in part, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. 7. Transport the resident to the bath area. 14. Assist the resident into the tub or shower. The following information should be recorded on the resident's ADL record and/or in the resident's medical record, if indicated: 1. The date and time the shower/tub bath was performed.

Based on observation, interview and record review the facility failed to follow their policy to ensure the narcotic count was completed at the beginning and end of each shift and failed to sign the controlled drug count record at the beginning and end of each shift for 1 of 2 medication cart narcotic logs reviewed.Findings Include:On 12/15/25 at 11:01 AM medication cart B was reviewed with V14 (Licensed Practical Nurse). During review of the Controlled Substances, November 2025 and December 2025 Controlled Substance Check Form there were observed with multiple blank boxes. V14 stated, there were no narcotics before 2 days ago and we did not have any narcotics before that because the doctor does not prescribe narcotics. On 12/15/25 at 01:18 PM the medication cart A was reviewed with V12 (Licensed Practical Nurse). On 12/17/25 at 09:13 AM V3 (Assistant Director of Nursing) stated The Controlled Substance Check Form should be done and signed shift to shift, nurse to nurse every day. The nurse should check to see if any new narcotics have come, and the sheet should still be signed.Policy:Titled Controlled Drug policy and Procedure reviewed 01/25 document in part: 2. The inventory of the controlled drugs must be recorded on the narcotic records and signed for accuracy of count. 3. The controlled drug checklist must be signed by the nurse coming on duty and going off duty to verify that the count of all controlled drugs is correct.

Based on observation, interview and record review the facility failed to ensure a medication error rate of less than 5%, by making 2 errors out of 31 attempts with an error rate of 6.45%. This deficient practice was identified for 2 (R11, R58) of 4 residents observed for medication administration.Findings Include:R11 was admitted to the facility with diagnosis not limited to Hypertensive Heart Disease with Heart Failure, Biventricular Heart Failure, Congestive Heart Failure, Dementia, Unspecified Severity, with Moo Disturbance, Bradycardia and Presence of Cardiac Pacemaker.R11's Care Plan document in part: Problem: Category: Cognitive Loss/Dementia. R11 has memory/recall problems, forgetting vital information towards her plan of care. BIMS (Brief Interview of Mental Status) score 3, indicating cognitively impaired.On 12/15/25 at 09:07 AM V12 (Licensed Practical Nurse) stated said to first I am going to take your blood pressure. V12 entered R11's room and placed the blood pressure cuff on R11's right arm and checked R11's oxygen saturation with the pulse oximeter. V12 exited R11's room, returned to the medication cart. V12 removed R11's medication from the medication cart and began preparing R11 medications in a medication cup. Surveyor asked the number of pills in the medication cup. V12 began counting and transferring R11's pills to another medication cup then said there are 11 pills. V12 reentered R11's room and administered her medications.1. 1. Allopurinol 100 mg daily2. 2. Amlodipine 10 mg daily3. 3. Losartan 25 mg daily4. 4. Metoprolol 25 mg daily 5. Divalproex 500mg Twice a day6. 6. Risperidone 1 mg every 12 hours7. 7. Eliquis 5 mg every 12 hours8. 8. Memantine 10 mg Twice a day9. 9. Metformin 500 mg daily 10. Ferosul 325 mg daily 11. Amiodarone 200 mg daily 12. Aricept 10 mg daily (V12 circled the entry as not given on the Medication flow sheet. There is no documentation of doctor notification).R58 has diagnosis not limited to Schizoaffective Disorders Diabetes Mellitus, Other Conduct Disorders and Schizophrenia.R58's Care Plan document in part: Problem: R58 has dietary restrictions and need for metformin related to type 2 diabetes mellitus.On 12/15/25 at 09:19 AM R58 approached the medication cart. V12 began preparing R58's medications. V12 stated, I have to check the closet to see if R58's Metformin is in there, otherwise I have to reorder it. V12 proceeded down the hallway, returned to the medication cart and said, I have to reorder the Metformin.On 12/15/25 at 09:27 AM V12 (Licensed Practical Nurse) prepared then administered R58's medications stating there are 9 pills in the medication cup.1 13. Cetirizine HCL 10 mg daily 14. Aspirin 81 mg daily1 15. Clozapine 100 mg + 25 mg daily 16. Divalproex 500 mg twice a day 17. Docusate Sodium 100 mg twice a day 18. Metoprolol 50 mg every 12 hours 19. Ferosul 325 mg twice a day 20. Famotidine 20 mg daily 21. Metformin 850 mg twice a day (V12 circled the entry as not given on the Medication flow sheet. There is no documentation of doctor notification). 22. Fluphenazine Decanoate solution 25 mg/ml 1 ml injection once a day on the 15th of the month. On 12/16/25 at 10:59 AM surveyor asked V12 (Licensed Practical Nurse) at any time yesterday (12/15/25) did she back track and administer any medications to the residents that were observed by the surveyor during the medication administration. V12 stated I did not backtrack and give any additional medications after the observation. R58's metformin came on the night shift and I gave it this morning. I notified the doctor but did not make a note. Medications are reordered when they get to the last roll on the medication card.Review of R11 and R58 progress note has no documentation of physician notification for the missed medications.Review of the Convenience Box List of medications had no Metformin listed.On 12/17/25 at 09:13 AM V3 (Assistant Director of Nursing) stated We reordering medication when it gets to the last row on the medication card. When medication is missing, they are reordered stat. The medications should be reordered before they run out. If the medications are missed there is a potential it will affect the blood levels. The residents need their medications because bad things can happen to the resident if they miss a medication dose. If the medication is not there and we should order it stat. The pharmacy can send the medications the same day or we can check the convenience box to see if the medication is available in there. If the resident miss their Metformin there is a potential for hyperglycemia, it can affect the residents blood sugar or the resident having to go out to the hospital. When there is a missed medication, you circle the initials on the MAR (Medication Administration Report). If a medication is missed it should be ordered immediately, inform the doctor as well and they should document. If it is not documented, it is not done.Policy:Titled Administration of Medication revised 05/17 document in part: 1. Residents shall receive their medications on a timely basis and in accordance with our established policies. 3. Medications may not be prepared in advance and must be administered within one (1) hour of scheduled administration time.Titled Medication and Treatment Orders revised 11/17 document in part: 11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than 3 days prior to the last dosage being administered to ensure that refills are readily available.

Based on observations, interviews, and record reviews, the facility failed to protect the rights of the resident and allow one (R2) resident to go out on a community pass after a ninety-day restriction without performing a reassessment. R2's Minimum Data Set (MDS) dated [DATE] shows R2 is cognitively intact.R2's was admitted to the facility on [DATE] with diagnoses including but not limited to other bipolar, major depressive disorder recurrent, severe with psychotic symptoms, generalized anxiety disorder, and other psychoactive substance abuse. On 8/19/25 at 10:58 AM, R2 received in room, stated he has been in the facility since October 2023. He went out to the community on independent pass on 2/28/25, he came back to the facility intoxicated with drug-marijuana, and he was given a ninety-day community pass restriction on 3/3/25. His ninety-day community restriction officially ended in June 2025, but he is still not being allowed to leave the facility despite multiple requests voiced to the facility V7 (Social Service Director), and the facility is violating his rights.On 8/19/25 at 3:10 PM, V7 (Social Service Director) stated that he has been in the facility for one year, the residents have the right to go out on pass based on safety community assessment. The resident could go out for two hours, four hours, or eight hours, when the resident violates the contract, the resident will be restricted as ordered and complete a new community access observation assessment to determine if the resident is qualified to go out to the community independently or with supervision. R2 had repeated violations of constant alcohol/drug overdose whenever he goes out independently, on 2/28/25 he overdosed with some drug, and the physician placed him on ninety-day community restriction until 6/1/25. V7 stated that, R2 should have been reassessed since 6/1/25 to determine if he is qualified to go out to the community independently or with supervision, but he was not reassessed until surveyor walked into the facility on 8/19/25.On 8/21/25 at 12:20 PM, V1 (Administrator) stated that she has been in the facility for twenty years, the residents have the right to go out to the community. R2 should have been reassessed after the end of the ninety-day community pass restriction on 6/1/25 because that is his right. She will ensure V5 takes care of this situation right away.R2's physician order dated 3/3/25 documents in part; Restricted community pass for 90 days until 6/1/25.R2's community access observation assessment dated [DATE]. Residents Rights dated 10/2027 documents in part: residents are entitled to exercise their rights and privileges to the fullest extent possible.

Based on interview and record review, the facility failed to report an allegation of mental abuse (bullying) to the state survey agency. This failure affects 1 resident (R1) sampled for abuse reporting. Findings include: On 5/20/2025 at 11:00 AM, V1 (Administrator) explained that when R1 was admitted to the hospital, V1 was notified by V9 (Licensed Practical Nurse) that the hospital told V9 that R1 was being bullied by R1's roommate (R4). V1 could not recall the actual date of the allegation. V1 stated that V1 investigated the allegation by interviewing other staff and R4. V1 said that the facility could not substantiate the bullying allegation but kept R1 and R4 separated after the allegation was made. V1 denied that the allegation was reported to the state survey agency. V1 affirmed that bullying can be mental abuse and that the allegation should have been reported. On 5/21/2025 at 12:11 PM, V9 (Licensed Practical Nurse) could not recall the exact date, but could recall that during R1's last hospitalization , a social worker from the hospital had called and asked to speak with a nurse. V9 stated that the social worker was inquiring about the relations between R1/R4 (R1's Roommate) and said that R1 reported being bullied by R4 to hospital staff. V9 stated that V1 is the abuse prevention coordinator, and immediately notified V1 of the allegation. Record review of facility witness statement collected from R4 dated 4/24/25 documents in part that R4 was accused of bullying R1. Facility policy titled, Abuse (Reviewed 1/18/2024) documents in part .When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has been made, the administrator, or designee, shall notify the Department of Public Health's regional office immidiately by phone or fax. Public health shall be informed that an occurance of potential abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has been reported to the administrator and is being investigated.

Based on interview and record review the facility failed to ensure that 4 of 4 residents (R1, R2, R5, and R6) were free from physical abuse. This failure affected R1, R2, R5, and R6 who had verbal altercation that resulted in R1 injury and bleeding to mouth and R6 injuries resulting in stitches to eyebrow and injury to forehead. This has the potential to affect all 103 residents residing in the facility. Findings include: On 02/27/25 at 12:44pm, R1 observed in the room sitting on the bed. The surveyor asked R1 about the incident of 01/25/25. R1 stated that I (R1) can't remember what happened, but (R2) and I (R1) had a misunderstanding. I (R1) did not steal anything from (R2). (R2) hit me and punched me in my face and my mouth. I (R1) was bleeding from my mouth. On 2/27/25 at 12:55pm, R2 was observed in the room. when the surveyor asked about the incident of 01/25/25, R2 stated R1 was drunk and was taking my pop drinking them. R2 stated that I (R2) came to the nurse's station and told them (staff) about it, and they did nothing. R2 stated that when I (R2) went back to the room (R1) was still drinking my Pop. R2 stated that I (R2) pushed (R1) down on the bed and held (R1) because (R1) was stealing from me. R1 medical record showed V17's documentation in the progress note date 01/25/25 timed 10pm that indicated that R1 noted fighting with roommate (referring to R2). Roommate (R2) hit (R1) in the face and the mouth with moderate bleeding noted from R1's mouth. On 03/04/25 at 12:25pm, R5 stated that R6 and I shared the same bathroom. R6 is always urinating on the floor and everywhere. R5 stated that on the day of the incident I tried to let R6 know that (R6) must clean it up because R6 always leaves the place dirty, and I end up clean it. When asked whether the housekeeper/staff know about these concerns. R5 stated Yes, because they clean it all the time and R6 will dirty it again and again. And nobody (referring to staff) does nothing about it. I (R5) have reported it but (R6) kept (urinating) on the floor, I feel like (R6) is saying whatever I (R6) do you are going to clean it up. R5 stated that I am a grown man, and no one is going to be treating me like hat. R6 punch me in my face so I hit (R6) hard. A fight broke out and R6 started bleeding in the face. At 1:20pm, R6 observed with three wound closure strips on the right eyebrow and approximately 2 inches of healing wound to the fore head. When the surveyor asked about what happened to R6's face. R6 stated that I fought with (R5). (R5) is not my boss, (R5) thinks he can fight, and I (R6) showed him. (R5) keeps putting everything that is wrong on me, and (R5) hit me, and I (R6) hit him back. R1 medical record Face Sheet showed that R1 was admitted to the facility on [DATE] with diagnosis list that includes but not limited to chronic obstructive pulmonary disease unspecified, schizoaffective disorder, bipolar type, alcohol abuse uncomplicated Type 2 diabetesmellitus with hyperglycemia. R2 medical record Face Sheet showed that R1 was admitted to the facility on [DATE] with diagnosis list that includes but not limited to Type 2 diabetes mellitus with hyperglycemia, non-pressure chronic ulcer of other part of left foot with unspecified severity -left foot. R5 medical record Face Sheet showed that R1 was admitted originally to the facility on [DATE] with latest admitted [DATE]. Diagnosis list includes but not limited to Major depressive disorder, drug induced subacute dyskinesia, schizoaffective disorder, acquired absence of eye-right eye, and blindness one eye unspecified eye-right eye. R6 medical record Face Sheet showed that R1 was admitted to the facility on [DATE] with diagnosis list that includes but not limited to chronic obstructive pulmonary disease unspecified, schizoaffective disorder, bipolar type, alcohol abuse uncomplicated Type 2 diabetes mellitus with hyperglycemia. On 03/04/25 at 2:15pm, V2 stated that she expected the licensed nurses to separate the resident immediately when there is a suspicion of any abuse. In the case of R1 and R2 the nurse (V17) should have separated the residents before the altercation escalated into actual physical abuse. V2 stated hitting, holding down of resident by another resident is a form of physical abuse and should not happen. V2 stated that both R1 and R2 should have been separated and placed on 1:1 supervision. On 03/12/25 at 1:49pm, V1 (Administrator) stated that she (V1) expected the nurse to first separate the residents, assess them, and depending on the type of altercation put the resident on 1:1 supervision, call the medical doctor (physician) and both residents must be sent out. The nurse should call me the abuse coordinator. V1 stated that when (V18) informed the nurse (referring to V17 LPN), she did what she was supposed to do it is not her (V18) responsibility to separate the resident. R1 just had tooth extraction may be the alcohol caused R1 to bleed because R2 said I did not hit R2 from my interview. When asked whether pushing and holding down another resident a physical contact holding another resident down in a physical altercation, is that appropriate behavior. V1 stated no, it is not allowed that is like restraining a person. The surveyor then asks are residents allowed to restrain another resident. V1 stated No. The facility policy on Abuse with reviewed date 1/18/2024 documented that the facility affirms the right of our (facility) residents to be free from abuse. the policy under definitions documented in part that abuse is the willful infliction of injury and the term willful means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse listed includes but not limited to hitting, slapping, and controlling behavior through corporal punishment.

Based on interview and record review the facility failed to develop and implement appropriate measures to ensure adequate supervision is afforded to two residents R1 and R2 reviewed for physical abuse. This failure affected R1 and R2 who had an altercation that resulted into physical abuse and R1 injury to mouth and has the potential to affect all 103 residents residing in the facility. Finding include: R1 medical record Face Sheet showed that R1 was admitted to the facility on [DATE] with diagnosis list that includes but not limited to chronic obstructive pulmonary disease unspecified, schizoaffective disorder, bipolar type, alcohol abuse uncomplicated Type2 diabetes mellitus with hyperglycemia. R1 was sent to the local hospital on 1/15/25 and the discharge record showed that R1 was treated for alcohol intoxication. R2 medical record Face Sheet showed that R1 was admitted to the facility on [DATE] with diagnosis list that includes but not limited to Type 2 diabetes mellitus with hyperglycemia, non-pressure chronic ulcer of other part of left foot with unspecified severity left foot. According to facility investigation witness statement presented dated 1/31/25, V18 stated that on 1/25/25 R2 came to the front desk and reported that R1 was stealing R2's food and this was reported to V17 (Nurse). V17 went to the resident's room and came out and said R1 and R2 were fine. V18 made V17 aware that R1 was drunk and V17 went back into the office (referring to medication room used as the nurse's office). V18 (Receptionist) stated R2 came back to the nurse's station and said someone needs to come and get R1. V18 stated that while sitting at the nurse's station she heard them fighting (referring to R1 and R2). V18 witness statement documentation showed that V17 was first notified at 7:30pm. According to the V17's witness statement V17 documented in part that at 7:00pm she was notified that the two residents R1 and R2 that something is going on with these 2 (referring to R1 and R2). V17 did not separate the resident R1 and R2 from each other. At 9:30am V18 documented that R1 had unsteady gait and suspected alcohol intoxication. V17 documented that R1 had bleeding from the mouth. R1 medical record showed V17's documentation in the progress note date 01/25/25 timed 10pm indicated that R1 noted fighting with roommate (referring to R2). Roommate (R2) hit (R1) in the face and the mouth with moderate bleeding noted from R1's mouth. On 03/04/25 at 2:15pm, V2 stated that she expected the licensed nurses to separate the resident immediately when there is a suspicion of any abuse. in case of R1 and R2 the nurse (V17) should have separated the residents before the altercation escalated into actual physical abuse. V2 stated hitting, holding down of resident by another resident is a form of physical abuse and should not happen. V2 stated that both R1 and R2 should have been separated and placed on 1:1 supervision. On 03/12/25 at 1:49pm, V1 (Administrator) stated that she (V1) expected the nurse to first separate the residents, assess them, and depending on the type of altercation put the resident on 1:1 supervision, call the medical doctor (physician) and both residents must be sent out. The nurse of cause should call me the abuse coordinator. V1 stated that when (V18) inform the nurse (referring to V17 LPN), she did what she was supposed to do it is not her (V18) responsibility to separate the resident. R1 just had tooth extraction may be the alcohol caused R1 to bleed because R2 said I did not hit R2 from my interview. When asked whether pushing and holding down another resident a physical contact holding another resident down in a physical altercation, is that appropriate behavior. V1 stated no, it is not allowed that is like restraining a person. The surveyor then asks are residents allowed to restrain another resident. V1 stated No. During this investigation both V17 and V18 cannot be reached by the surveyor. Both V1 (Administrator) and (V2 DON (Director of Nurse's) tried to reach the staff without success. The facility did not provide any supervision policy. The facility policy on Abuse with reviewed date 1/18/2024 documented that the facility affirms the right of our (facility) residents to be free from abuse. the policy under definitions documented in part that abuse is the willful infliction of injury and the term willful means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse listed includes but not limited to hitting, slapping, and controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to ensure that residents were free from physical abuse. These failures affected R2, R3, R5, R7 and R9 as a result of R2 who was physically hit in the head with a chair by R1, causing R2 harm of pain and a facial laceration by the right eye; R7 who was physically hit in the face by R8, causing R7 psychosocial harm by feeling unsafe as a legally blind and wheelchair dependent resident in the facility; R5 who was physically pushed by R6, causing a right hand scratch; R9 who was physically hit in the face by R2; and R3 who was physically hit by R4 in the sample of 14 residents reviewed. Findings include: 1) On 5/15/24 at 9:33 am, when asked about an altercation with R1 on 3/26/24 on the smoking patio, R2 stated, (R1) grabbed my chair, and (R1) hit me with it (chair). R2 stated, I (R2) had a cut on this eye, and it hurt me, really hurt me, pointing to R2's right eyebrow. R2's Face Sheet documents, in part, diagnoses of paranoid schizophrenia, type 2 diabetes mellitus, chronic obstructive pulmonary disease, emphysema, cardiac pacemaker, cardiomegaly, atherosclerotic heart disease, idiopathic epilepsy, and auditory hallucinations. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 12 which indicates that R2 has moderate cognitive impairment. On 5/14/24 at 10:38 am, when asked about an altercation that occurred with R2 on 3/26/24 on the smoking patio, R1 stated that the altercation was with R2 on the smoking patio at the first smoke break (7:00 am). R1 stated that R1 was holding R1's cup of hot coffee and walked down the corridor out onto the smoking patio where residents can sit or stand to smoke on the left side or the right side of the smoking patio. R1 stated that R1 walked to the open wicker chair in front of the grid iron fence, so with R1's left hand, R1 grabbed the arm of the wicker chair to try to sit down when R2 grabbed the other arm of the chair. R1 stated that R1 used R1's right elbow on the iron fence to balance self which then R1's coffee poured out of the cup. R1 stated that R2 let go of the arm of the chair, and I (R1) took the chair and swinged it around and hit (R2). I whacked (R2) in the back of the head and back. R1 stated, I (R1) called over (V11, Smoke Monitor) because (V11) was not visible. R1 said that when V11 responded, V11 said, 'What's going on?' because (V11) didn't see nothing. When asked about other residents that may have been witnesses to R1 and R2's altercation, R1 stated that R12 was there. This surveyor asked R1 to show surveyor the smoking patio, so R1 and surveyor walked out to the smoking patio during smoke break to observe the area where R1 and R2's altercation took place on 3/26/24. The black iron fence is observed as an internal gate, and the outer gate (enclosure) of the smoking patio is a chain link fence which is visible through with the left side of the smoking patio being closest to the street corner of the intersecting streets. R1's Face Sheet documents, in part, diagnoses of hereditary and idiopathic neuropathies; major depressive disorder, recurrent, severe with psychotic symptoms; hypothyroidism; bipolar disorder; anxiety disorder; schizophrenia; hypo-osmolality and hyponatremia. R1's MDS, dated [DATE], documents, in part, a BIMS score of 15 which indicates that R1 is cognitively intact. On 5/15/24 at 10:49 am, V10 (Social Services Assistant, SSA) stated on 3/26/24 a little after 7:00 am, V10 was on my way to work. I (V10) was in my car driving west when V10 stopped at the street intersection adjacent to the facility. V10 stated, I (V10) stopped at the stop sign. I glanced over and seen something going on between (R1) and (R2). V10 stated that V10 looked at R1 and R2 on the smoking patio and had a good view due to V10 facing in that direction. V10 stated that V10 drove through the intersection and pulled up in V10's car and observed R1 and R2 struggling at the gate. V10 stated that V10 could not enter through the external chain link fence (enclosure of the smoking patio), but I (V10) see (R1) with chair and hitting (R2). V10 stated that R1 was lifting up chair and striking (R2), and R2 was cowering down towards the ground while being struck with the chair as V10 visually demonstrated to this surveyor with bending motion down to try to cover head with arms. On 5/14/24 at 1:16 pm, R12 stated that R12 has witnessed resident to resident fighting in the facility. When asked about the altercation between R1 and R2 on 3/26/24 on the smoking patio, R12 stated that it was on 3/26/24 at 7:00 am to 7:15 am at beginning of smoke break. R12 stated that R12 witnessed (R2) get attached by (R1) and was fighting with the chair. R12 stated, (R1) hit (R2) first. R12's MDS, dated [DATE], documents, in part, that R12's BIMS score of 15 which indicates that R12 is cognitively intact. On 5/14/24 at 11:52 am, V11 (Smoke Monitor) stated that on 3/26/24 around 7:00 am, V11 opened the smoking patio door for residents who could walk to go for seating, and I (V11) gave them their cigarettes. V11 stated that V11 then went back down the corridor to the door because other residents were calling me (V11) to help bring the wheelchair residents through the smoking patio door. V11 stated that V11 then heard chaos, and walked from the door, down the corridor, and sees where R1 and R2 were standing on the left side of the patio by the gate V11 stated that V11 did not witness R1 and R2's altercation, and R1 told V11 that R1 pulled the chair from R2 when R2 was trying to take the chair. V11 stated that R2 said that R2 fell and that R1 hit R2 with the chair. On 5/15/24 at 9:42 am, V3 (Assistant Director of Nursing, ADON) stated that V3 responded to R1 and R2's altercation on 3/26/24 to the code white that was called during the transition of shifts (night and day shifts). V3 stated that V3 assessed R2 right after the incident, and (R2) did have on scratch on (R2's) right side of the face by (R2's) right eye. Facility document for the final abuse investigation for R1 and R2, titled Facility Incident Report Form and dated 4/1/24, authored by V1 (Administrator), documents, in part, that this reportable event occurred on 3/26/24 at 7:30 am with description of occurrence: Staff member reported that R1 and R2 had a physical altercation . R2 have laceration to (R2's) right eye. R2 was evaluated for pain on the scale 1 - 10. R2 pain scale is a 5. R2 received pain medication as prescribed. V1 documents, in part, the occurrence resolution as: Investigation has been completed . R2 stated (R2) and R1 approach a chair on the patio, and they both was struggling to sit down in the chair. R2 stated R1 took the chair from (R2) and hit (R2) with the chair . R1 stated that (R1) went to patio to sit down and R2 try to take (R1's) chair. R1 stated (R1) got the chair from R2 and hit (R2) with the chair. (V10) witnesses the incident and states (V10) saw a struggle at the gate. (V10) stated then (V10) saw R1 hit R2 with the chair . Police was notified of incident. Police report, titled Victim Information Notice/(City) Police Department with date/time of occurrence of 3/26/24 at 7:15 am, documents, in part, the incident of Battery with the name of the victim as R2 with the perpetrator listed at R1. On 5/15/24 at 1:09 pm, V1 (Administrator) stated that V1 is the abuse coordinator for the facility and is responsible for reporting and performing abuse investigations in the facility. V1 stated that V1 reviewed all of the resident, witness and staff statements to come to a conclusion if physical abuse did occur. When asked if physical abuse did occur between R1 and R2 on 3/26/24, V1 stated, Yes. It was substantiated. On 5/16/24 at 12:05 pm, this surveyor and V1 reviewed together the Facility Incident Report Form dated 4/1/24 for R1 and R2's final abuse report. When V1 was asked where did V1 receive the information of R2's facial laceration near right eye and R2's pain score with pain medication administered on 3/26/24 after being hit with a chair by R1, V1 stated, I (V1) received it from (V3, ADON), and I looked myself. (R2) had a small laceration over (R2's) eyebrow. It was open to air. (V3) stated (R2's) pain level that morning when it happened. I assessed (R2) myself. That's why I charted it in the abuse report. V1 stated that V1 is a Registered Nurse, RN. This surveyor informed V1 that with this surveyor's record review performed of R2's electronic medical record (EMR) documentation of progress notes (March 2024) and paper medication administration record (MAR, March 2024), no documentation is noted of R2's facial laceration near right eye and R2's pain score of 5 with whenever needed pain medication administered on 3/26/24 after being hit with a chair by R1. On 5/16/24 at 11:50 am, V2 (Director of Nursing, DON) stated that nurses are to document the pain assessment of the resident using the 0-10 pain scale, document pain medication administration and then document how effective the pain medication is. When this surveyor showed V2 the March 2024 MAR for R2, V2 was asked if V2 can explain why there is no documentation of R2's pain scale score of 5 and pain medication administered, V2 stated, I (V2) cannot. When this surveyor showed V2 the progress notes dated 3/26/24 for R2 with no documentation for R2's facial laceration by right eye, V2 was asked if V2 can explain why there is no documentation in R2's electronic medical record, and V2 stated, I cannot. V2 stated that it's the expectation that a nurse document a resident to resident physical altercation incident, including skin impairment, injuries or pain, and nurses should have documented it in events. This surveyor showed V2 the events portion in R2's EMR, and no event is documented for R2 in 2024. 2) On 5/13/24 at 12:11 pm, R7 observed in R7's wheelchair in 1st floor dining room with head looking down. V7 (Certified Nursing Assistant, CNA) moved R7 (with R7's verbal permission) via wheelchair by wheeling R7 out of the dining room to speak with surveyor. When asked about an altercation with R8, 3 days ago on 5/10/24, R7 stated, I (R7) got hit. I got hit in the face by (R8). R7 stated that R7 was in R7's wheelchair in R7's room doorway waiting for V7 (CNA) to wheel R7 out for a smoke break, and R8 hit R7. R7 stated, I (R7) am blind, and I can't see. R7 stated that R7 felt the hitting from R8 standing over R7 who was in a seated position in R7's wheelchair. When asked if R7 feels safe in the facility, R7 stated, No. I (R7) don't feel safe. I can't walk. I can't get away when someone is standing over me hitting me. I can't go nowhere. R7's Face Sheet documents, in part, diagnoses of blindness one eye with low vision other eye, kyphosis, dependence on wheelchair, bipolar disorder, schizophrenia, hypertensive heart disease, atrial fibrillation, hyperlipidemia, dementia (unspecified severity) with agitation, osteoarthritis, and benign prostatic hyperplasia. R7's MDS, dated [DATE], documents, in part, that R7's vision is scored as 4 which is severely impaired - no vision or sees only light, colors, or shapes; eyes do not appear to follow objects. R7's BIMS score is documented as a 5 which indicates that R7 has severe cognitive impairment. On 5/16/24, V1 (Administrator) provided this surveyor with R7's MDS, dated [DATE], section GG, due to no section GG being present on R7's MDS, dated [DATE], per V1. R7's MDS (5/2/24) documents, in part, that R7's mobility device is a wheelchair. On 5/14/24 at 10:29 am, R10 stated that R10 did witness a resident-to-resident physical assault on 5/10/24. R10 stated, I (R10) was around the corner walking in the hallway by the elevator. It was right at their (R7 and R8's room) door. I saw (R8) hit (R7) in the head a couple of times with (R8's) hands. It was last Friday (5/10/24). R10 stated that R7 was in R7's wheelchair and that R8 was in a standing position. R10 stated that R10 hollered out for help, and housekeeping staff responded. R10's MDS, dated [DATE], documents, in part, that R10's BIMS score of 15 which indicates that R1 is cognitively intact. On 5/14/24 at 11:08 am, V9 (Housekeeping, Floor Tech) stated that V9 was in the hallway mopping on 5/10/24 around 9:00 am when V9 heard R7 hollering, (R8) hit me (R7). (R8) hit me. V9 stated that V9 immediately went to R7 and R8's room where V9 observed R7 in R7's wheelchair and R8 standing near R7. V9 stated that only R7 and R8 were in their room. V9 stated that V9 stood in between R7 and R8, and that R7 was again saying, (R8) hit me (R7). V9 stated that R8 then said, I (R8) hit (R7). I want out of here. I will call the police myself. V9 stated that R8 proceeded to pull out R8's cellular phone and called the police R8's self saying, I (R8) hit (R7). I want out of here. I am at (facility's name), and gave the address of the facility. On 5/13/24 at 2:29 pm, V7 (CNA) stated that V7 is R7's regularly assigned CNA on the day shift and sometimes the evening shift. V7 stated that R7 is blind, is in a wheelchair, and calls out V7's name when R7 needs assistance or wants to be wheeled to another location, like the smoking patio. V7 stated that after breakfast meal on 5/10/24 when V9 alerted V7 that R7 was hit by R8, so V7 wheeled R7 out of the room away from R8 and wheeled R7 to the dining room to stay with V7. V7 stated that R7 said, (R8) hit me (R7) across the face a couple of times. This surveyor asked V7, as V7 is with R7 in the dining room after being hit by R8, how was R7 feeling, and V7 stated, (R7) was afraid. I kept (R7) in the dining room. R8's Face Sheet documents, in part, diagnoses of bipolar disorder, disorganized schizophrenia, attention deficit hyperactivity disorder, insomnia, asthma, and suicidal ideations. R8's admitted to the facility is documented as 5/6/24, and R8's discharge date is documented as 5/10/24 to the hospital. R8 was not available to be interviewed. On 5/15/24 at 10:49 am, V10 (Social Service Aide) stated that V10 interviewed R8 on 5/10/24 after altercation with R7 (before going to the hospital). V10 stated that R8 said, I (R8) hit (R7). I want to go to jail. On 5/15/24 at 11:32 am, V13 (Licensed Practical Nurse, LPN) stated that on 5/10/24, during the morning medication pass, V13 was told by V12 (Housekeeper) that R8 had hit R7, and V13 responded to R7 and R8's room where R8 said that R8 hit R7. When asked about R7's status, (R7) is visually impaired, in a wheelchair. (R7) needs assistance to get around building escorted by CNA or nurse. Staff have to move (R7) in wheelchair. (R7) cannot see (R7's) surroundings. (R7) will ask who is there to know who is with (R7). In R8's Progress Note, dated 5/10/24 at 8:57 am, V13 (Licensed Practical Nurse, LPN) documents, in part, (R8) seen physically abusing (R7), when asked if (R8) hit (R7), (R8) aggressively stated that (R8) did and actively called the police. Facility document for the initial abuse investigation, titled Facility Incident Report Form and dated 5/10/24, authored by V1 (Administrator), documents, in part, that this reportable event occurred on 5/10/24 at 9:00 am between R7, who is blind in both eyes, and R8 with description of occurrence: Staff member reported that (R7) and (R8) had a physical altercation. On 5/15/24 at 1:09 pm, V1 stated that on the morning of 5/10/24, V1 received phone calls from several staff members about R7 and R8's physical altercation, and since V1 was not in the facility on 5/10/24, V1 endorsed to social services and nursing staff to collect witness statements from residents and staff about the altercation. V1 stated that V1 has reviewed the witness statements for the abuse investigation, and After investigation, I (V1) came to a conclusion. I substantiated physical abuse. (R8) did not deny the allegation. (R10) saw it. (R8) committed battery. (R8) wanted to get out here to jail. V1 stated that V1 will submit the final abuse investigation report to the state agency at the end of 5 business days. When asked if R7, who is legally blind and wheelchair bound, considered vulnerable for abuse, V1 stated, Of course, (R7) is in that group. (R7) is vulnerable for abuse. 3) On 5/14/24 at 11:46 am, R5 stated that on 4/28/24, R5 was in R5's room and was waiting to use the bathroom which is shared with R6 from the room on other side of the bathroom (a jack and [NAME] bathroom). R5 stated, (R6) is using the bathroom constantly and that R6 plays around with the water in the sink. R5 stated that R5 had to use the bathroom, knocked, and opened the shared bathroom door, and that R6 threw water at R5 and pushed R5's body back. R5 stated that in the process of R6 pushing R5, R6 cut R5's hand in between 2 fingers on R5's right hand which was bleeding. R5's Face Sheet documents, in part, diagnoses of chronic obstructive pulmonary disease, hypertensive heart disease, simple chronic bronchitis, asthma, dyspnea, atherosclerotic heart disease, hyperlipidemia, and anemia. R5's MDS, dated [DATE], documents, in part, a BIMS score of 15 which indicates that R5 is cognitively intact. On 5/14/24 at 1:12 pm, R13 who is R5's roommate stated that R13 was in their room on 4/28/24 but did not see the altercation between R5 and R6. However, R13 stated, I (R13) heard them both (R5, R6) at the bathroom. I heard (R5) say, 'Don't throw that water.' I didn't see it. My (R13) curtain was closed. R13's MDS, dated [DATE], documents, in part, a BIMS score of 15 which indicates that R13 is cognitively intact. On 5/13/24 at 1:29 pm, V5 (LPN) stated that R5 is alert, oriented x 4 (person, place, time, and situation), and walks independently in the facility. V5 stated that in the morning on 4/28/24, V5 responded to the scene (R5's room) where V5 visibly sees R5 with water on R5's face. V5 stated that R5 said, He threw water on me (R5), and that V5 sees R13 (R5's roommate). V5 stated that V5 asked R5 who threw water on R5, and R5 stated that it was R6 who threw the water and was in the shared bathroom. V5 stated that V5 observed a scratch on R5's hand by a finger and asked how it happened. V5 stated that R5 said, (R6) pushed (R5). V5 stated that R5 said that R6 had been in the bathroom repeatedly flushing the toilet, like 20 times, and that R5 asked R6 what R6 was doing because R5 had to use the bathroom. R5 said that R6 pushed R5 and that R5 threw (R5's) hand up. V5 stated that V5 provided first aid to R5's hand scratch by cleansing it with normal saline and applying a dry dressing. V5 stated that R6 was no longer in the shared bathroom and was in the dining room where V5 asked about what occurred between R5 and R6, and R6 said, I (R6) don't know. I don't know. I don't know. On 5/14/24 at 1:08 pm, when asked about an altercation with R5 on 4/28/24, R6 stated that R6 don't bother nobody. When asked if R6 was in the bathroom and R6 pushed R5, R6 stated, I (R6) don't do nothing. When asked if R6 threw water on R5, R6 stated, I (R6) don't bother nobody. R6's Face Sheet documents, in part, diagnoses of polyneuropathies, hypertensive heart disease, atherosclerotic heart disease, cognitive social or emotional deficit following unspecified cerebrovascular disease, hyperlipidemia, schizophrenia, delusional disorders, and cerebral ischemia. R6's MDS, dated [DATE], documents, in part, that R6's BIMS score is 5 which indicates that R6 has severe cognitive impairment. In R5's Progress Note, dated 4/28/24 at 11:36 am, V5 (LPN) documents, in part, (R5) was pushed by another resident and scratched on (R5's) right hand. (V5) cleaned the right hand with (normal saline solution), pat dry, and applied a dry dressing. In R5's Progress Note, dated 4/28/24 at 2:59 pm, V4 (SSD) documents, in part, (V4) was made aware that (R5) was involved in a physical altercation where (R5) received aggression . (R5) stated that (R6) through (threw) water on (R5) right before pushing (R5). On 5/15/24 at 1:09 pm, V1 stated that V5 informed V1 on 4/28/24 that R5 and R6 had an altercation by the bathroom where R6 pushed R5 who sustained a scratch on the hand. V1 stated that V4 (SSD) obtained R5's statement, and V1 interviewed R6 after R6 returned from the psychiatric hospitalization who said that R6 don't remember pushing R5. When asked about V1's conclusion of the altercation between R5 and R6 on 4/28/24, V1 stated, (R5) had a scratch when (R6) touched or pushed (R5) or something. Physical abuse is substantiated, I (V1) would say that. Facility document for R5 and R6's final abuse investigation, titled Facility Incident Report Form and dated 5/2/24, authored by V1 (Administrator), documents, in part, that this reportable event occurred on 4/28/24 at 9:00 am with occurrence resolution as: Investigation has been completed. (R5) stated (R5) wanted to use the bathroom. (R1) stated (R5) inform (R6) that (R5) had to use the washroom. (R5) stated when (R6) came out of the bathroom, (R6) push (R5) . (R5) stated (R5's) right hand was bleeding. (R5) stated (R6) scratch (R5) when (R6) pushes (R5) . (R6) did not denied pushing (R5). 4) On 5/14/24 at 10:49 am, R9 stated that on 5/3/24, R9 was in another room and that it was in the morning time. R9 stated that R9 walked out of R9's room into the hallway, and (R2) hit me (R9) in my left eye pointing to R9's left side of face near eye. R9 stated that R2 hit R9 in the hallway and that R9 didn't do nothing to (R2). R9 stated that R9 did not strike R2 back. When asked if there were other residents or staff around when R2 hit R9 on 5/3/24, R9 stated, No. R9's Face Sheet documents, in part, diagnoses of schizoaffective disorder, bipolar type, chronic obstructive pulmonary disease, type 2 diabetes mellitus, abnormalities of gait and mobility, muscle wasting and atrophy, heart failure, and hyperlipidemia. R9's MDS, dated [DATE], documents, in part, a BIMS score of 7 which indicates that R9 has severe cognitive impairment. On 5/15/24 at 9:33 am, when asked about an altercation on 5/3/24 with R9, R2 stated, I (R2) didn't want no one to hold me back. I pushed (R9) and hit (R9) in the eye. I wanted to get by to go smoke. On 5/14/24 at 2:15 pm, V12 (Housekeeper) stated that V12 was in the hallway near the smoking patio door and the north nursing station desk on 5/3/24 around 7:00 am and was having a general conversation with R9. V12 stated that V12 then walked down the hallway, and when I came back into that vicinity, it was over. V12 stated that V12 did not witness the altercation between R2 and R9, but R9 was saying, (R2) hit me (R9). (R2) hit me. On 5/14/24 at 5:21 pm, V18 (LPN) stated that V18 was completing the night shift medication pass on 5/3/24 around 7:00 am, when V18 responded to an altercation that had occurred between R2 and R9 in the hallway. V18 stated that V18 did not witness it but did interview and assess both R2 and R9 afterwards. V18 stated that R9 said that R9 was hit in the face by R2, and that R2 said that R9 would not get out of R2's way. In R9's Progress Note, dated 5/3/24 at 7:17 am, V18 (LPN) documents, in part, that (R9) was hit by (R2) in the face, because (R9) wouldn't move from in front of (R2). On 5/15/24 at 1:09 pm, V1 stated that V1 was notified by several nursing staff members on the morning of 5/3/24 that R9 was hit by R2. V1 stated that V1 interviewed R2, R9, and staff that were working on 5/3/24 at 7:00 am for the abuse investigation. When asked about V1's conclusion of this incident between R2 and R9, V1 stated, It's physical abuse. It was substantiated. Facility document for R2 and R9's final abuse investigation, titled Facility Incident Report Form and dated 5/9/24, authored by V1 (Administrator), documents, in part, that this reportable event occurred on 5/3/24 at 7:20 am with occurrence resolution as: Investigation has been completed. Upon interviews (R2) hit (R9) because (R9) did not move out of (R2's) way in the hallway. Facility policy, titled Abuse Policy and revised (10/2022) with reviewed date of 1/18/24, documents, in part: This facility affirms the right of our residents to be free from abuse . This facility therefore prohibits abuse . In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment . This facility is committed to protecting our residents from abuse . by anyone including . other residents . Definitions: . Abuse means any physical or mental injury . inflicted upon a resident other than by accidental means . Physical abuse include hitting. Facility policy, titled Attachment J: Statement of Resident Rights and undated, documents, in part: No resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the Constitution of the Stare (State) of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of the (facility), nor shall a resident forfeit any of the following rights: (a) Resident rights: The resident has a right to a dignified existence . (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. 50728 5. On 5/13/24 at 12:24 PM, R3 stated that R3 remembered R4 coming up to R3 in the hallway on 4/30/24 in the morning. R3 stated, (R4) began hitting me (R3) out of nowhere on my head. (R4) was grabbing my wrists too. I thought maybe (R4) was making a sexual advance towards me. I was trying to defend myself when the staff came. On 5/13/24 at 12:28 PM, R3 stated, I no longer feel safe in the facility. All of the people (residents) make me feel unsafe. R3's Resident Face Sheet documents in part the following diagnosis: Paranoid Schizophrenia, Hypertensive heart disease without failure, and Unspecified psychosis not due to a substance or known physiological condition. R3's Minimum Data Set, dated dated dated [DATE] documents in part that Brief Interview for Mental Status (BIMS) Score is 13 indicating R3 is cognitively intact. Facility document for the final abuse investigation for R3 and R4, titled Facility Incident Report Form and dated 5/6/2024, prepared by V1 (Administrator), documents in part, Investigation has been completed. (R3) stated (R3) was ambulating in the hallway and (R4) was talking to (R3) about things (R3) did not understand. (R3) stated that (R4) continue talking to (R3), and (R4) hit (R3) unprovoked. On 5/13/24 at 2:30 PM, V9 (Housekeeper, Floor Tech) stated that V9 was working on 4/30/24 and confirmed that V9 was the staff member who witnessed the altercation between R3 and R4. V9 stated that V9 witnessed R3 and R4 fighting in the hallway. V9 stated, I (V9) immediately intervened to break up the two residents (R3, R4) and yelled for help. The residents could not tell me (V9) what they were fighting about. They both looked upset. On 5/13/24 at 1:35 PM, V5 (Licensed Practical Nurse, LPN) confirmed V5 was working on 4/30/24 and remembered the altercation. V5 stated that V5 responded to the incident due to the code white being called overhead. V5 stated that upon arrival to the hallway, (R3) was shaking, and both R3 and R4 were visibly upset. On 5/15/24 at 11:28 AM, V4 (Social Services Director, SSD) stated that V4 responded to the code white for R3 and R4's altercation, but V4 did not witness the incident. V4 stated that V4 did speak with R3 afterwards who informed V4 that R3 walked by the nurses station in the hallway, and R4 hit R3. In R3's Progress Note, dated 4/30/24 at 3:43 PM, V4 (SSD) documents in part, (V4) was made aware by staff that (R3) was involved in a physical altercation where (R3) received aggression. (R3) presents to be aox3 (alert, oriented to person, place and time) and can verbalize (R3's) wants and needs with no issues. (R3) stated 'I was just minding my business and (R4) came up and started hitting me. I started to block (R4's) hits. On 5/14/24 at 2:10 PM, R4 was observed sitting on the edge of the edge of the bed, rocking back and forth. R4 was observed responding to internal stimuli and talking to R4's self. When R4 was asked about the incident that occurred on 4/30/24 with R3, R4 stated I (R4) am not going back to that damn hospital! You would be mad if blacks jumped you too! R4 was unable to answer any further questions regarding the altercation. R4's Resident Face Sheet documents in part the following diagnosis: Chronic Obstructive Pulmonary Disease, Unspecified psychosis not due to a substance or known physiological condition, Chronic Respiratory Failure with Hypoxia, Combined Systolic and Diastolic Heart Failure, Iron deficiency Anemia, Dietary Calcium Deficiency, Hypertensive Heart Disease with Heart Failure, and Chronic Viral Hepatitis C. R4's MDS dated [DATE] documents in part that BIMS Score is 12 indicating R4 has moderate cognitive impairment. On 5/15/24 at 12:38 PM, V1 (Administrator) confirmed V1 is the facility staff member who conducted the abuse investigation on 4/30/24. V1 stated that V1 was notified of the incident by V5. V1 stated, I (V1) don't exactly know what happened. I was told by staff that (R4) had hit (R3) and initiated an investigation. On 5/15/24 at 12:50 PM, V1 stated that based on the facility's abuse investigation that V1 conducted for R3 and R4's altercation, I (V1) was able to substantiate resident to resident physical abuse occurred during this incident. When asked about what are the effects on a resident when a resident experiences physical abuse in the facility, V1 stated, It's an impact on their wellbeing and safety. Residents have the right to be free of abuse and neglect. Facility undated policy titled Code [NAME] - Resident with Aggressive Behavior Policy, documents in part, Purpose: To provide a safe environment for all residents and staff . Procedure: 1. Announce overhead code white by any staff if you see resident with aggressive behavior/physical or verbal altercation between residents.

Based on interview and record review, the facility failed to supervise residents on the smoking patio. This failure affected R1 and R2 resulting in R1 physically hitting R2 in the head with a chair, causing R2 harm of pain and a facial laceration by the right eye, in the sample of 14 residents reviewed. Findings include: On 5/15/24 at 9:33 am, when asked about an altercation with R1 on 3/26/24 on the smoking patio, R2 stated, (R1) grabbed my chair, and (R1) hit me with it (chair). R2 stated, I (R2) had a cut on this eye, and it hurt me, really hurt me, pointing to R2's right eyebrow. R2's Face Sheet documents, in part, diagnoses of paranoid schizophrenia, type 2 diabetes mellitus, chronic obstructive pulmonary disease, emphysema, cardiac pacemaker, cardiomegaly, atherosclerotic heart disease, idiopathic epilepsy, and auditory hallucinations. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 12 which indicates that R2 has moderate cognitive impairment. On 5/14/24 at 10:38 am, when asked about an altercation that occurred with R2 on 3/26/24 on the smoking patio, R1 stated that the altercation was with R2 on the smoking patio at the first smoke break (7:00 am). R1 stated that R1 was holding R1's cup of hot coffee standing in the hallway in front of the smoking patio door to be let out by staff to the smoking patio. R1 stated that when the door was opened, R1 walked down the corridor out onto the smoking patio where residents can sit or stand to smoke on the left side or the right side of the smoking patio. R1 stated that 2 chairs were open on the left side of the smoking patio near the black grid iron fence, and there were two chairs available, a wicker chair and an iron chair. R1 stated that there was no traffic of residents to the wicker chair, so with R1's left hand, R1 grabbed the arm of the wicker chair to try to sit down when R2 grabbed the other arm of the chair. R1 stated that R1 used R1's right elbow on the iron fence to balance self which then R1's coffee poured out of the cup. R1 stated that R2 let go of the arm of the chair, and I (R1) took the chair and swinged it around and hit (R2). I whacked (R2) in the back of the head and back. R1 stated, I (R1) called over (V11, Smoke Monitor) because (V11) was not visible. R1 said that when V11 responded, V11 said, 'What's going on?' because (V11) didn't see nothing. When asked about other residents that may have been witnesses to R1 and R2's altercation, R1 stated that R12 was there. When asked to describe the smoke break process, R1 stated that smoke monitors feed us (hand out) the cigarettes and it goes fast. This surveyor asked R1 to show surveyor the smoking patio, so R1 and surveyor walked out to the smoking patio during smoke break to observe the area where R1 and R2's altercation took place on 3/26/24. The black iron fence is observed as an internal gate, and the outer gate (enclosure) of the smoking patio is a chain link fence which is visible through with the left side of the smoking patio being closest to the street corner of the intersecting streets. R1 and this surveyor are standing in front of the black iron fence where R1 and R2's altercation took place, and R1 states, (V11) was around that corner (pointing back to the corridor from the door to the smoking patio) and (V11) can't see in that hallway. R1's Face Sheet documents, in part, diagnoses of hereditary and idiopathic neuropathies; major depressive disorder, recurrent, severe with psychotic symptoms; hypothyroidism; bipolar disorder; anxiety disorder; schizophrenia; hypo-osmolality and hyponatremia. R1's MDS, dated [DATE], documents, in part, a BIMS score of 15 which indicates that R1 is cognitively intact. On 5/15/24 at 10:49 am, V10 (Social Services Assistant, SSA) stated on 3/26/24 a little after 7:00 am, V10 was on my way to work. I (V10) was in my car driving west when V10 stopped at the street intersection adjacent to the facility. V10 stated, I (V10) stopped at the stop sign. I glanced over and seen something going on between (R1) and (R2). V10 stated that V10 looked at R1 and R2 on the smoking patio and had a good view due to V10 facing in that direction. V10 stated that V10 drove through the intersection and pulled up in V10's car and observed R1 and R2 struggling at the gate. V10 stated that V10 could not enter through the external chain link fence (enclosure of the smoking patio), but I (V10) see (R1) with chair and hitting (R2). V10 stated that R1 was lifting up chair and striking (R2), and R2 was cowering down towards the ground while being struck with the chair as V10 visually demonstrated to this surveyor with bending motion down to try to cover head with arms. V10 stated, I (V10) did see (V11, Smoke Monitor) after they (R1, R2) were struggling, and there was only one staff member (V11) on the smoking patio at that time on 3/26/24. On 5/14/24 at 1:16 pm, R12 stated that R12 has witnessed resident to resident fighting in the facility. When asked about the altercation between R1 and R2 on 3/26/24 on the smoking patio, R12 stated that it was on 3/26/24 at 7:00 am to 7:15 am at beginning of smoke break. R12 stated that R12 witnessed (R2) get attached by (R1) and was fighting with the chair. R12 stated, (R1) hit (R2) first. R12's MDS, dated [DATE], documents, in part, that R12's BIMS score of 15 which indicates that R12 is cognitively intact. On 5/14/24 at 11:52 am, V11 (Smoke Monitor) stated that on 3/26/24 around 7:00 am, V11 opened the smoking patio door for residents who could walk to go for seating, and I (V11) gave them their cigarettes. V11 stated that V11 then went back down the corridor to the door because other residents were calling me (V11) to help bring the wheelchair residents through the smoking patio door. V11 stated that V11 then heard chaos, and walked from the door, down the corridor, and sees where R1 and R2 were standing on the left side of the patio by the gate. V11 stated that V11 did not witness R1 and R2's altercation, and R1 told V11 that R1 pulled the chair from R2 when R2 was trying to take the chair. V11 stated that R2 said that R2 fell and that R1 hit R2 with the chair. When asked if there were any other staff supervising the residents for the smoke break at 7:00 am on 3/26/24 when R1 and R2's physical altercation occurred, V11 stated, No. No one else. V11 stated, It's like everyone wants to come out at once. Like a stampede to want to smoke. On 5/15/24 at 9:42 am, V3 (Assistant Director of Nursing, ADON) stated that V3 responded to R1 and R2's altercation on 3/26/24 to the code white that was called during the transition of shifts (night and day shifts). V3 stated that V3 assessed R2 right after the incident, and (R2) did have a scratch on (R2's) right side of the face by (R2's) right eye. On 5/15/24 at 2:29 pm, V14 (Activity Director) stated that the first smoke break daily is at 7:30 am, and all residents are allowed out via the one patio door. V14 stated that there are 2 smoke monitors who are supervising residents on the patio. V14 stated that the process for the smoke breaks is that the smoke monitors will bring out the residents in wheelchairs and assist residents with walkers first out to the patio, then the remaining ambulatory residents are allowed out. V14 stated that the 2 smoke monitors will then distribute smoking materials. V14 stated that one smoke monitor will be supervising one side (left side), and the other smoke monitor will be supervising the other side (right side). V14 stated that the 2 smoke monitors are stationed in the center of the left and right patios to move smoke monitors where they can view everyone in the center of the patio. When asked the purpose of having 2 smoke monitors on the patio during smoke breaks, V14 stated, To stop anything before it happened. Facility document for the final abuse investigation for R1 and R2, titled Facility Incident Report Form and dated 4/1/24, authored by V1 (Administrator), documents, in part, that this reportable event occurred on 3/26/24 at 7:30 am with description of occurrence: Staff member reported that R1 and R2 had a physical altercation . R2 have laceration to (R2's) right eye. R2 was evaluated for pain on the scale 1 - 10. R2 pain scale is a 5. R2 received pain medication as prescribed. V1 documents, in part, the occurrence resolution as: Investigation has been completed . R2 stated (R2) and R1 approach a chair on the patio, and they both was struggling to sit down in the chair. R2 stated R1 took the chair from (R2) and hit (R2) with the chair . R1 stated that (R1) went to patio to sit down and R2 try to take (R1's) chair. R1 stated (R1) got the chair from R2 and hit (R2) with the chair. (V10) witnesses the incident and states (V10) saw a struggle at the gate. (V10) stated then (V10) saw R1 hit R2 with the chair . Police was notified of incident. Police report, titled Victim Information Notice/(City) Police Department with date/time of occurrence of 3/26/24 at 7:15 am, documents, in part, the incident of Battery with the name of the victim as R2 with the perpetrator listed at R1. On 5/15/24 at 1:09 pm, V1 (Administrator) stated that V1 is the abuse coordinator for the facility and is responsible for reporting and performing abuse investigations in the facility. V1 stated that V1 reviewed all of the resident, witness and staff statements to come to a conclusion if physical abuse did occur. When asked if physical abuse did occur between R1 and R2 on 3/26/24, V1 stated, Yes. It was substantiated. On 5/16/24 at 12:05 pm, this surveyor and V1 reviewed together the Facility Incident Report Form dated 4/1/24 for R1 and R2's final abuse report. When V1 was asked where did V1 receive the information of R2's facial laceration near right eye and R2's pain score with pain medication administered on 3/26/24 after being hit with a chair by R1, V1 stated, I (V1) received it from (V3, ADON), and I looked myself. (R2) had a small laceration over (R2's) eyebrow. It was open to air. (V3) stated (R2's) pain level that morning when it happened. I assessed (R2) myself. That's why I charted it in the abuse report. V1 stated that V1 is a Registered Nurse, RN. This surveyor informed V1 that with this surveyor's record review performed of R2's electronic medical record (EMR) documentation of progress notes (March 2024) and paper medication administration record (MAR, March 2024), no documentation is noted of R2's facial laceration near right eye and R2's pain score of 5 with whenever needed pain medication administered on 3/26/24 after being hit with a chair by R1. On 5/16/24 at 11:50 am, V2 (Director of Nursing, DON) stated that nurses are to document the pain assessment of the resident using the 0-10 pain scale, document pain medication administration and then document how effective the pain medication is. When this surveyor showed V2 the March 2024 MAR for R2, V2 was asked if V2 can explain why there is no documentation of R2's pain scale score of 5 and pain medication administered, V2 stated, I (V2) cannot. When this surveyor showed V2 the progress notes dated 3/26/24 for R2 with no documentation for R2's facial laceration by right eye, V2 was asked if V2 can explain why there is no documentation in R2's electronic medical record, and V2 stated, I cannot. V2 stated that it's the expectation that a nurse document a resident to resident physical altercation incident, including skin impairment, injuries or pain, and nurses should have documented it in events. This surveyor showed V2 the events portion in R2's EMR, and no event is documented for R2 in 2024. Facility policy, titled Abuse Policy and revised (10/2022) with reviewed date of 1/18/24, documents, in part: This facility affirms the right of our residents to be free from abuse . This facility therefore prohibits abuse . In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment . This facility is committed to protecting our residents from abuse . by anyone including . other residents . Definitions: . Abuse means any physical or mental injury . inflicted upon a resident other than by accidental means . Physical abuse include hitting. Facility policy, titled Attachment J: Statement of Resident Rights and undated, documents, in part: No resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the Constitution of the Stare (State) of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of the (facility), nor shall a resident forfeit any of the following rights: (a) Resident rights: The resident has a right to a dignified existence . (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. Facility job description (undated) titled Smoke Monitor documents, in part, Position Summary: The primary purpose of the Smoking Monitor is to provide each resident a safe smoking environment and is designated to meet the interests and wellbeing of each resident. Responsibilities: 1. Monitor resident smoking to assure safety and security . 8. Follow (facility's) policies and procedures. 9. Create and uphold an atmosphere of warmth, patience, enthusiasm, and a calm cheerful environment.

Based on interview and record review, the facility failed to follow their abuse policy to protect resident's right to be free from resident-to-resident abuse for two of five residents (R2, R4) these failures resulted in 1) R2 sustaining facial fractures after R2 was struck by a peer and 2) R4 experiencing back stiffness after R4 was struck by a peer. Findings include: 1) R2's medical record (Face Sheet, Minimum Data Set) documents R2 is a cognitively intact [AGE] year old readmitted to the facility on 12.21.2023 with diagnoses including but not limited to: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Major depressive disorder, Maxillary fracture, left side, subsequent encounter for fracture with routine healing, Fracture of orbit, unspecified, subsequent encounter for fracture with routine healing. Final Incident Report of 12.20.2023 documents in part, staff reported that (R3) hit (R2) in the hallway. (R3) did not deny accusations against him. (R2) had injuries to his face. 12.14.2023 After Visit Summary documents in part: You were seen today for fractures to the face. -Reason for visit: Assault victim -Diagnoses: Closed fracture of left side of maxilla, Closed fracture of orbital wall 1.17.2024 at 10:38 AM, V5 (LPN-Licensed Practical Nurse) via telephone. V5 said she remembered the incident involving R2 and R3. V5 said, I was inside the Nursing Office (at the time of the incident) when one of the CNAs (V8) alerted me that two residents were fighting. V8 said hey, there are two guys fighting. I came out of the office and saw R2 on the floor shielding himself, R3 was doing most of the hitting. According to V8, R2 was the aggressor, he pushed R3. I assessed both residents; R2 had facial bruising and edema, R3 had no visible injury. Both residents were sent to the ED for evaluation and treatment. Yes, this is resident to resident abuse, I notified the Administrator. 1.17.2024 at 11:45 AM, V8 (CNA-Certified Nursing Assistant) said via telephone. I was coming into work. I didn't see the beginning of it, I came in on it. I saw R3 hit R2 in the face. I don't know who started it. 12/14/2023 11:06 PM Resident was in physical altercation with another Resident. Both residents seems to be intoxicated. Both residents sent to ER for evaluation. Police report made. Administrator, DON made aware. 12/15/2023 02:30 PM Resident returned from (local hospital). Resident was treated for Orbital and Maxillofacial fractures. Left eye swollen and red. R2 and R3 were not in the facility during the investigation. 2) R4's medical record (Face Sheet, MDS-Minimum Data Set) documents R4 is a severely cognitively impaired [AGE] year-old readmitted to the facility on 11.28.2023 with diagnoses including but not limited to: Parkinsonism, Other schizophrenia, Type 2 diabetes mellitus with diabetic nephropathy, Morbid (severe) obesity due to excess calories, Body mass index [BMI] 40.0-44.9, adult. Final Incident Report of 12.20.2023 documents in part, staff reported (R5) hit (R4) in the hallway unprovoked. (R4) stated (R5) hit him in the back because he was moving slow in the hallway. (R5) stated he (was) frustrated and when (R4) would not move he bump(ed) him with the clothing cart on the back of his wheelchair. 1.16.2024 at 2:31 PM, R4 said, when I was going out the door, he (R5) thought I was in his way, he couldn't get around me, he fell in my lap then he hit me in the back. Yes, I got hurt, I have back pain (points to right side). They sent me to the hospital to get checked out. 1.17.2024 at 11:20 AM, V6 (LPN-Licensed Practical Nurse) said, it was reported to me by another resident (R6) that he (R5) hit R4; R4 confirmed that R5 hit him. I spoke with R5; he denied the allegation. He (R5) was irate, his behavior was escalating; I notified Social Service to do a 1:1. Yes, that's abuse because he (R5) put his hands on R4. 1.17.2024 at 11:26 AM, V7 (LPN-Licensed Practical Nurse) said via telephone, they (residents) came to tell us that R4 was pushed and hit in the back (of R4's wheelchair) by R5. R4 confirmed that the other resident (R5) hit him at the back (of wheelchair). I assessed R4, there was no visible injury, R4 was not complaining of pain. I reported the incident to the Administrator. Yes, that's physical abuse because he's (R5) is trying to make the other person uncomfortable, it was deliberate. 1.18.2024 at 12:38 PM, R6 said (regarding incident involving R4 and R5), R4 was in his wheelchair waiting to go outside to smoke. I guess R4 wasn't moving fast enough for R5, R5 forcefully pushed a cart into the back of R4's wheelchair then punched R4 in the right shoulder. 12/13/2023 07:45 PM, It was reported by staff that resident was hit at the back by another resident. Upon interview, (R4) confirmed that the other resident hit him at the back while at the padio (patio) while in his wheelchair. No physical injuries seen on (R4). No change in condition noted. Administrator notified. Nursing will continue to monitor resident. 12/14/2023 03:12 PM, Well Being Check: Staff met with this resident concerning his feelings about the physical altercation with another resident on 12/13/2023. 1:1 counseling with this resident. This writer asked this resident is he feels safe in this facility. Resident responded with yes also reporting being a little stiff. Staff will continue to assist and monitor for any changes in his condition. R5 was not in the facility during the investigation. Abuse Prevention Policy revised 10.2022 -This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment - Abuse means any physical or mental injury or sexual assault infliction upon a resident -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish to a resident.

Based on interviews and record reviews, the facility failed to follow their policy to protect the resident's right to be free from [A] verbal abuse by staff members for two (R83 and R242) residents, this failure resulted in R83 and R242 feeling scared when they come across the accused staff members, [B] mental abuse by staff to two residents (R83, R88) in sample of 18 reviewed for abuse. This failure resulted in R88 feeling humiliated and fearful of retaliation, and R83 feeling depressed, crying, and increase in anxiety. Findings Include: 1. On 11/07/2023 at 1:17 PM, R242 stated that staff members are very rude to residents. R242 stated that there were these receptionists who cursed at residents and did not treat them with respect. This made us feel like we couldn't say anything. It felt like we were in prison. R242's written witness statement (10/20/2023) documents in part: V18 is verbally abusive to him and other residents. V18 would yell at them and is mean. 2. On 11/07/23 at 09:19 AM, reviewed document titled Reportable Event which documents in part on 10/19/23 @ 5:33 PM reportable event occurred involving resident and employee and it was brought to the administrator's attention that some of the staff members have not been acting in a professional manner. Reviewed signed document by R88 on 10/20/23 which documents in part that smoking monitors are rude and talk to them like a kid. Document stated R88 could not give names of smoking monitors. On 11/07/23 at 10:25 AM, R88 stated that he is a smoker and that all of the smoking monitors are rude. R88 stated the smoking monitors talk to the residents in a disrespectful and mean manner. R88 stated I don't like the way they talk to me and I get spoken to like I'm a child and this makes me feel humiliated. R88 stated he is fearful to speak up for himself because he's worried the staff will take R88's cigarettes away. R88 stated he does not know the names of the smoking monitors and that it is not one specific staff member. On 11/07/23 at 10:04 AM, V1 (Administrator) stated many of the residents living at the facility have mental health issues and that staff should speak to the residents in a respectful and professional manner. V1 stated residents should not feel intimidated by staff or fearful of speaking up to the staff. V1 stated this facility is the resident's home and that the residents should feel safe here. R88's diagnosis included but not limited to Bipolar Disorder, Major Depressive Disorder with Recurrent Severe Psychotic Symptoms, and Generalized Anxiety Disorder. R88's MDS (Minimum Data Set) dated 10/09/23 BIMS (Brief Interview for Mental Status) score is 15/15 indicating intact cognition. R88's psychosocial well-being care plan goal dated 10/13/23 documents in part R88 will be free of abuse/neglect. 3. On 11/05/2023 at 10:30 AM, R83 stated that V18 (Former Receptionist) was very rude to her and that she would curse at other residents. V18 stated that she would yell at me all the time. V18 stated this would bring me anxiety and I would be scared to go out of my room. I just didn't want to cross paths with her. R83's written witness statement (10/20/2023) documents in part: V18 (Former Receptionist) is mean to her and other residents. She refused to get up and give her or other residents ice. V18 was rude to her and yelled at her. Reviewed R83's clinical record documents in part R83 was admitted to the facility on [DATE], with the medical diagnosis of hypertensive heart disease, depressive disorder, gastritis, anxiety disorders and insomnia. R83's face sheets, medical diagnosis, physician order sheets, minimum data set [MDS] Brief Interview Mental Status score of [15] indicates R83 is cognitively intact, alert/oriented x3, care plans, medication administration record, treatment administration record, community pass assessments and progress notes. There were no progress notes from 10/1/23 thru 10/18/23, no documentation during the time frame. On 11/5/23 at 10:38 AM, R83 stated, In order for me to leave the facility on my community pass, the nurse and the social worker must sign the pass, and the pass is given to the receptionist before I'm able to leave the facility. On 10/19/23, I went to my nurse, and she signed my pass, then I went to V14 [Social Worker] and he signed my pass. Then I took my signed pass to the receptionist to sign out and leave. V18 [Former Receptionist] told me that I could not leave the facility, because my pass privileges were restricted. I spoke with V1 [Administrator] she informed me that V13 [Social Service Director] placed my independent community pass on restriction for 30 days because I went out on pass on 10/13/23 and returned to the facility and staff smelled marijuana on me a week ago. On 10/13/23, I went out on pass, and when I came back into the facility and signed back in and went to my room. No one said anything to me that I smelled like marijuana. Later, that same day [10/19/23], V14 came to me with a The Behavior Intervention Program Counseling Form dated 10/19/23 read [ Resident [R83] was suspected to be under the influence of a substance while in the facility.] I signed that form, because V14 told me I had to sign it. I asked V14 why a week later that I was notified staff accused me of smelling like marijuana, V14 told me that V13 [Social Service Director] told him to place me on a 30-day pass restriction. On 10/13/23 no one, no nurse, no social worker said one word to me or asked me to give a urine sample for a toxicology drug screen. The first time anyone talked to me was on 10/19/23. Right before 10/19/23, V1 [Administrator] found a type of letter in the bathroom that named me as the writer, making accusations against the facility staff committing abuse. The letter V1 showed me was typed on a form. I told V1 to get out my room with that mess, how could I type and print off a letter on a form. I believe V1 got angry with me because she felt I typed the letter, but I did not. I feel V1 placed me on pass restriction because of the letter that someone placed under her bathroom door. I've been up every night, not able to sleep, crying because I feel like I'm in prison on false charges. I feel so depressed, and my anxiety has increased. R83 provided surveyor copy of The Behavior Intervention Program Counseling Form dated 10/19/23 read: [ Resident [R83] was suspected to be under the influence of a substance while in the facility [Attachment-A] On 11/5/23 at 12:15 PM, V14 [Social Worker] stated, I've been working here since January 2023. I was told by a few certified nurse assistants (CNA) that R83 smelled like marijuana when she came back from pass on 10/13/23. On 10/13/23, I asked V19 [Social Service Aide] to assist me with obtaining a urine toxicology screening from R83 because R83 and V19 were both females. I stood outside R83's room when V19 asked R83 for a urine sample and explained the reason. R83 refused to give urine. Then I presented R83 with the Behavior Intervention Program Counseling Form, and R83 and I signed the form. The form read: [Resident [R83] was suspected to be under the influence of a substance while in the facility.] and noted restriction will be from 10/13/23 thru 11/13/23. R83 and I signed the form. On the form it was dated for 10/19/23, but it was for the incident on 10/13/23. I presented the form on 10/19/23, because that was when V13 [Social Service Director] came up with R83's interventions. R83 should have been medically assessed, and it was all based on hearsay, I did not agree that R83 should be on pass restriction. On 11/5/23 at 1:36 PM, V13 [Social Service Director] stated, I was informed by a case manager that R83 came back from community pass smelling like marijuana. V18 [Former Receptionist] told V19 [Social Service Aide] then told me. This was R83's first offense, and she does not have a history of drug use. R83 was placed on a 30-day community pass restriction. The Behavior Intervention Program Counseling Form dated 10/19/23 reads in part- [ Resident [R83] was suspected to be under the influence of a substance while in the facility. Resident [R83] refused a urine toxicology screening and admitted to social service staff related to using marijuana. Intervention: Resident [R83] educated and counseled on the negative effects of using illegal substances and taking prescription medications. Staff reinforced the facility substance abuse policy and placed on a behavior intervention program.] [Surveyor asked V13, why the The Behavior Intervention Program Counseling Form dated 10/19/23 with R83 and V14's signatures have added information and surveyor showed V13 the copy of the original form. (Attachment B)] On 11/5/23 at 1:45 PM, V13 stated, I added to the original The Behavior Intervention Program Counseling Form dated 10/19/23, that V14 presented to R83. I wrote: Resident [R83] refused a urine toxicology screening and admitted to social service staff related to using marijuana. Intervention: Resident [R83] educated and counseled on the negative effects of using illegal substances and taking prescription medications. Staff reinforced the facility substance abuse policy and placed on a behavior intervention program. I did not know R83 got a copy of the form, wow. I updated the form after R83 signed the form, and no R83 was not aware. I did not know that I could not update R83's signed medical form without her knowing or agreeing to the change of the additional information. R83 is currently on pass restriction from 10/13/23 until 11/13/23, the only person that could override the policy is the administrator [V1]. The Behavior Intervention Program Counseling Form is a part of R83 medical record. R83 should have been presented with the Behavior Intervention Program Counseling Form on 10/13/23, the day of the occurrence. I do not remember why R83 was given the form on 10/19/23. On 11/6/23 at 9:51 AM, V1 [Administrator] stated, V2 [Director of Nursing] was sitting at the receptionist desk when R83 returned from community pass on 10/13/23. V14 was made aware and R83 was offered a urinary toxicology drug screen test, R83 declined. At that time R83 was made aware that her community pass was restricted for 30 days. V2 [Director of Nursing], V14 [Social Worker], V13 [Social Service Director], nor V19[Social Service Aide did not document that R38 smelled like marijuana. The appropriate protocol for a resident who is suspected of being under the influence of drugs or alcohol would be to notify their physician, ask the physician if there is any medication should be held, ask the resident to take a toxicology urine test, inform social services, monitor vital signs, frequent monitoring, and start wellbeing checks for 72-hours. V13 should have completed a new Behavior Intervention Program Counseling Form and asked R83 to sign the updated form. V13 was not to add information to the form that was signed by R83 and V14, without R83 and V14 consents, doing so is falsifying the document. Someone found a typed letter under the bathroom door, naming R83 and other residents referencing allegations against some staff and the state was going to be notified. Regarding the letter, R83 said, she did not have anything to do with the letter. On 11/6/23 at 2:00 PM, V1 stated, V13 was suspended for falsifying R83's document. The facility failed to document and handle things timely with R83, I will have social service re-evaluate R83 for a community pass now and end her restriction. On 11/7/23 at 11:10 AM, V2 [Director of Nursing] stated, I was sitting at the reception desk working on the nursing staff schedule, when R83 came back in the facility from community pass. R83 smelled like a strong odor of marijuana. I don't remember doing much of anything. It was an assumption that the marijuana came in with her, but I was not sure. I did not call the physician, take R83's vital signs or make any frequent rounds on R83. I did not notify R83's nurse. My focus was completing the nursing staff schedule. On 11/7/23 at 11:45 AM, R83 came to the conference room crying and stated, V14 just came to my room and tried to get me to sign another Behavior Intervention Program Counseling Form, that said I admitted to using marijuana on 10/13/23, and I refused a urine toxicology test. I told V14 I would not sign that form, because it is not true. I was not smoking marijuana, and I was not offered to take a urinary toxicology drug test. V14 is stressing me out, they are picking on me, causing me to feel bad and my anxiety is through the roof. They keep picking on me because I called the state and filed a complaint. V13, V14, and V1 think I'm stupid. I knew not to sign the paper, that I know it is not true. I cannot take any more harassment from any of them V13, V14, and V1. I was feeling better, I have one more week of restriction. Now, they are messing with my mental, I feel so bad, full of anxiety. I am scared that V1, V13 and V14 will retaliate against me for filing a complaint with IDPH and telling you the truth. I'm not sure why they will not leave me alone. V14 told me that V13 told him to have me sign the new form. On 11/7/23 at 12:00 PM, V1 stated, V28 [Nurse Consultant] asked V14 to have R83 sign the new updated form. Because the old form was not written correctly, they want to make sure R83 had a copy with her signature. If R83 would have signed the new form, with the exact wording from V13, then V13 wouldn't have falsified R83's document, but that was not our intent. On 11/7/23 at 12:10 PM, V14 stated, I re-wrote the Behavior Intervention Program Counseling Form, and asked R83 to sign the new form with the updated interventions. No one told me to ask R83 to sign information over all on a new form, using V13's exact words, so R83 would understand her interventions. I was trying to clear everything up. R83 refused to sign the new form, because R83 said the information on the new form was false. [Copy of The Behavior Intervention Program Counseling Form presented to R83 on 11/7/23 noted as [Attachment C] On 11/7/23 at 12:40 PM, V28 [Nurse Consultant] stated, I asked V14 to go and talk with R83 and give her the corrected document with the interventions. To assist with correction process. My intent was to cause R83 any emotional distress. Facility's Final Incident Report Form (10/25/2023) documents in part: Investigation has been completed. In the conclusion of the investigation staff member V18 was accused by several residents of verbal abuse. Based on the negative verbal interviews, V18 will not be continuing her employment at this facility. Policy: Documents in part: Abuse Prevention Policy dated 2/2017 -This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment - Abuse means any physical or mental injury or sexual assault infliction upon a resident -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish to a resident. Policy: Documented in part Resident Rights: -Resident has the right to be informed of their rights and all the rules and regulations governing resident conduct and responsibilities -A facility must not prohibit or in any way discourage a resident from communicating with federal, state surveyors -Resident has the right to be informed, participate in their treatment -Resident has the right to be informed in advance of changes in their plan of care 45002 46342

Based on interviews and record reviews the facility social service staff failed to assist one resident[R83] in maintaining their mental and psychosocial health in a sample of 18. This failure resulted in R83 crying, feeling depressed, increase of anxiety and fear of retaliation Findings include: Reviewed R83's clinical record documents in part R83 was admitted to the facility on [DATE], with the medical diagnosis of hypertensive heart disease, depressive disorder, gastritis, anxiety disorders and insomnia. R83's face sheets, medical diagnosis, physician order sheets, minimum data set [MDS] Brief Interview Mental Status score of [15] indicates R83 is cognitively intact, alert/oriented x3, care plans, medication administration record, treatment administration record, community pass assessments and progress notes. There were no progress notes from 10/1/23 thru 10/18/23, no documentation during the time frame. On 11/5/23 at 10:38 AM, R83 stated, In order for me to leave the facility on my community pass, the nurse and the social worker must sign the pass, and the pass is given to the receptionist before I'm able to leave the facility. On 10/19/23, I went to my nurse, and she signed my pass, then I went to V14 [Social Worker] and he signed my pass. Then I took my signed pass to the receptionist to sign out and leave. V18 [Former Receptionist] told me that I could not leave the facility, because my pass privileges were restricted. I spoke with V1 [Administrator] she informed me that V13 [Social Service Director] placed my independent community pass on restriction for 30 days because I went out on pass on 10/13/23 and returned to the facility and staff smelled marijuana on me a week ago. On 10/13/23, I went out on pass, and when I came back into the facility and signed back in and went to my room. No one said anything to me that I smelled like marijuana. Later, that same day [10/19/23], V14 came to me with a The Behavior Intervention Program Counseling Form dated 10/19/23 read [ Resident [R83] was suspected to be under the influence of a substance while in the facility.] I signed that form, because V14 told me I had to sign it. I asked V14 why a week later that I was notified staff accused me of smelling like marijuana, V14 told me that V13 [Social Service Director] told him to place me on a 30-day pass restriction. On 10/13/23 no one, no nurse, no social worker said one word to me or asked me to give a urine sample for a toxicology drug screen. The first time anyone talked to me was on 10/19/23. Right before 10/19/23, V1 [Administrator] found a type of letter in the bathroom that named me as the writer, making accusations against the facility staff committing abuse. The letter V1 showed me was typed on a form. I told V1 to get out my room with that mess, how could I type and print off a letter on a form. I believe V1 got angry with me because she felt I typed the letter, but I did not. I feel V1 placed me on pass restriction because of the letter that someone placed under her bathroom door. I've been up every night, not able to sleep, crying because I feel like I'm in prison on false charges. I feel so depressed, and my anxiety has increased. R83 provided surveyor copy of The Behavior Intervention Program Counseling Form dated 10/19/23 read: [ Resident [R83] was suspected to be under the influence of a substance while in the facility [Attachment-A] On 11/5/23 at 12:15 PM, V14 [Social Worker] stated, I've been working here since January 2023. I was told by a few certified nurse assistances that R83 smelled like marijuana when she came back from pass on 10/13/23. On 10/13/23, I asked V19 [Social Service Aide] to assist me with obtaining a urine toxicology screening from R83 because R83 and V19 were both females. I stood outside R83's room when V19 asked R83 for a urine sample and explained the reason. R83 refused to give urine. Then I presented R83 with the Behavior Intervention Program Counseling Form, and R83 and I signed the form. The form read: [Resident [R83] was suspected to be under the influence of a substance while in the facility.] and noted restriction will be from 10/13/23 thru 11/13/23. R83 and I signed the form. On the form it was dated for 10/19/23, but it was for the incident on 10/13/23. I presented the form on 10/19/23, because that was when V13 [Social Service Director] came up with R83's interventions. R83 should have been medically assessed, and it was all based on hearsay, I did not agree that R83 should be on pass restriction. On 11/5/23 at 1:36 PM, V13 [Social Service Director] stated, I was informed by a case manager that R83 came back from community pass smelling like marijuana. V18 [Former Receptionist] told V19 [Social Service Aide] then told me. This was R83's first offense, and she does not have a history of drug use. R83 was place on a 30-day community pass restriction. The Behavior Intervention Program Counseling Form dated 10/19/23 reads in part- [ Resident [R83] was suspected to be under the influence of a substance while in the facility. Resident [R83] refused a urine toxicology screening and admitted to social service staff related to using marijuana. Intervention: Resident [R83] educated and counseled on the negative effects of using illegal substances and taking prescription medications. Staff reinforced the facility substance abuse policy and placed on a behavior intervention program.] [Surveyor asked V13, why the The Behavior Intervention Program Counseling Form dated 10/19/23 with R83 and V14's signatures have added information and surveyor showed V13 the copy of the original form. (Attachment B)] On 11/5/23 at 1:45 PM, V13 stated, I added to the original The Behavior Intervention Program Counseling Form dated 10/19/23, that V14 presented to R83. I wrote: Resident [R83] refused a urine toxicology screening and admitted to social service staff related to using marijuana. Intervention: Resident [R83] educated and counseled on the negative effects of using illegal substances and taking prescription medications. Staff reinforced the facility substance abuse policy and placed on a behavior intervention program. I did not know R83 got a copy of the form, wow. I updated the form after R83 signed the form, and no R83 was not aware. I did not know that I could not update R83's signed medical form without her knowing or agreeing to the change of the additional information. R83 is currently on pass restriction from 10/13/23 until 11/13/23, the only person that could override the policy is the administrator [V1]. The Behavior Intervention Program Counseling Form is a part of R83 medical record. R83 should have been presented with the Behavior Intervention Program Counseling Form on 10/13/23, the day of the occurrence. I do not remember why R83 was given the form on 10/19/23. On 11/6/23 at 9:51 AM, V1 [Administrator] stated, V2 [Director of Nursing] was sitting at the receptionist desk when R83 returned from community pass on 10/13/23. V14 was made aware and R83 was offered a urinary toxicology drug screen test, R83 declined. At that time R83 was made aware that her community pass was restricted for 30 days. V2 [Director of Nursing], V14 [Social Worker], V13 [Social Service Director], nor V19 [Social Service Aide] did not document that R83 smelled like marijuana. The appropriate protocol for a resident who is suspected of being under the influence of drugs or alcohol would be to notify their physician, ask the physician if there is any medication should be held, ask the resident to take a toxicology urine test, inform social services, monitor vital signs, frequent monitoring, and start wellbeing checks for 72-hours. V13 should have completed a new Behavior Intervention Program Counseling Form and asked R83 to sign the updated form. V13 was not to add information to the form that was signed by R83 and V14, without R38 and V14 consent, doing so is falsifying the document. Someone found a typed letter under the bathroom door, naming R83 and other residents referencing allegations against some staff and the state was going to be notified. Regarding the letter, R83 said, she did not have anything to do with the letter. 11/6/23 at 2:00 PM, V1 stated, V13 was suspended for falsifying R83's document. The facility failed to document and handle things timely with R83, I will have social service re-evaluate R83 for a community pass now and end her restriction. On 11/7/23 at 11:10 AM, V2 [Director of Nursing] stated, I was sitting at the reception desk working on the nursing staff schedule, when R83 came back in the facility from community pass. R83 smelled like a strong odor of marijuana. I don't remember doing much of anything. It was an assumption that the marijuana came in with her, but I was not sure. I did not call the physician, take R83's vital signs or make any frequent rounds on R83. I did not notify R83's nurse. My focus was completing the nursing staff schedule. On 11/7/23 at 11:45 AM, R83 came to the conference room crying and stated, V14 just came to my room and tried to get me to sign another Behavior Intervention Program Counseling Form, that said I admitted to using marijuana on 10/13/23, and I refused a urine toxicology test. I told V14 I would not sign that form, because it is not true. I was not smoking marijuana, and I was not offered to take a urinary toxicology drug test. V14 is stressing me out, they are picking on me, causing me to feel bad and my anxiety is through the roof. They keep picking on me because I called the state and filed a complaint. V13, V14, and V1 think I'm stupid. I knew not to sign the paper, that I know it is not true. I cannot take any more harassment from any of them V13, V14, and V1. I was feeling better, I have one more week of restriction. Now, they are messing with my mental, I feel so bad, full of anxiety. I am scared that V1, V13 and V14 will retaliate against me for filling a complaint with IDPH and telling you the truth. I'm not sure why they will not leave me alone. V14 told me that V13 told him to have me sign the new form. On 11/7/23 at 12:00PM, V1 stated, V28 [Nurse Consultant] asked V14 to have R83 sign the new updated form. Because the old form was not written correctly, they want to make sure R83 had a copy with her signature. If R83 would have signed the new form, with the exact wording from V13, then V13 wouldn't have falsified R83's document, but that was not our intent. On 11/7/23 at 12:10 PM, V14 stated, I re-wrote the Behavior Intervention Program Counseling Form, and asked R83 to sign the new form with the updated interventions. No one told me to ask R83 to sign information over all on a new form, using V13's exact words, so R83 would understand her interventions. I was trying to clear everything up. R83 refused to sign the new form, because R83 said the information on the new form was false. [Copy of The Behavior Intervention Program Counseling Form presented to R83 on 11/7/23 noted as [Attachment C] On 11/7/23 at 12:40 PM, V28 [Nurse Consultant] stated, I asked V14 to go and talk with R83 and give her the corrected document with the interventions. To assist with correction process. My intent was to cause R83 any emotional distress. Policy: Documented in part Resident Rights: -Resident has the right to be informed of their rights and all the rules and regulations governing resident conduct and responsibilities -A facility must not prohibit or in any way discourage a resident from communicating with federal, state surveyors -Resident has the right to be informed, participate in their treatment -Resident has the right to be informed in advance of changes in their plan of care

Based on interview and review of documents the facility failed to ensure residents have the right to be free of abuse in 2 of 4 (R1, R2, R3 and R4) residents in a sample of 10 by not preventing a physical altercation leading to injuries to both R1 and R2. Findings include: R1 is a [AGE] year-old male resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 has a BIMs score of 11. R2 is a [AGE] year-old male with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 has a BIMs score of 13. Facility incident report stated on 4/16/22 5:20PM, R1 and R2 were involved in a physical altercation. Nurses assessed R1 with swelling to right hand. R2 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . First aid was provided to R1 and R2. R1 was sent to hospital for psych evaluation per physician orders. R2 was sent to the hospital per physician orders. R1 stated he entered his own room. R1's roommate and R2 were inside the room talking. R1 stated he told R2 to get out of the room and R2 wanted to fight me. R1 stated he hit R2 in the face. R2 stated he was in R1's room talking to R1's roommate. R2 stated when R1 entered the room, he told R1 you owe me 3.50 for the pop. R2 states R1 got angry and hit him in the face. R2 progress note dated 4/16/22 5:20PM states resident involved in physical altercation w/another resident in peer's room; both residents were separated, and safety provided at all times. Staff responded to room after hearing commotion. Patient sustained multiple facial fractures; right eye superficial laceration w/moderate to severe soft tissue swelling to bilateral orbits. Moderate bleeding to facial injuries noted but easily controlled; no prescribed blood thinners and no loc (loss of consciousness). Basic first aid administered ice pack applied to facial injuries. 1:1 provided at all times until EMTs arrived. Physician notified. Patient escorted out via 911. R1 hospital record dated 4/16/22 states, Displaced fracture of neck of 5th metacarpal bone of right hand. R2 hospital record dated 4/16/22 shows R2 sustained multiple facial bone fractures requiring surgical repair and 9 sutures. R2 had [CONDITION(S)] to the face, right eye partially closed and left eye closed. R2 returned to the facility on [DATE]. On 05/19/22 at 11:15AM, R1 stated R2 was in my room. R2 wanted to fight me. We both started hitting each other. I punched him in the face. We ended up on the ground. The nurse came in and broke it up. I went to the hospital. My finger got broke from hitting him. On 05/19/22 at 10:40AM, R2 stated I was talking to R1's roommate (R5) when R1 came into the room and started punching me in the face. I had to go to the hospital. I am sore now from the fight. I feel safe here now I haven't had any other altercations with R1. On 05/23/22 at 11:20AM, R5 stated I was in my room with R2 who was talking to me. R1 came into the room and told R2 to get out. They both started hitting each other. They ended up on the floor. The nurse came in and broke it up. They both went to the hospital. R1 is still my roommate. I don't see R1 and R2 around each other. That is all I know. V1 (Administrator) stated R1 and R2 got into a fight in R1s room on a Saturday 4/16/22. The Director of Nursing was not at the facility. The two nurses that broke up the fight were agency nurses. I have no way of contacting those nurses for you to interview. We are monitoring R1 and R2. Care plans were revised. There were no earlier indications of R1 and R2 having any issues before the incident. I am the abuse prevention coordinator. I followed the policy. IDPH was notified. The police were notified. R1 went for a psych eval. He also was diagnosed with fracture to finger. R2 was sent to hospital for cut under his eye. At hospital fractures were found to face. The hospital had to do extensive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to prevent abuse because we had no prior indication that R1 and R2 were going to have an altercation. Facility Abuse Prevention Policy Dated February 2017 states including: This affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interviews, and record reviewed, the facility failed to prevent V12 (staff member) from hitting a resident (R3) in the back. This failure affected 1 of 3 residents (R3) reviewed for abuse. As a result R3 experienced right lateral back pain, and bruising. Findings include: On 6/30/20 at 9:43AM R3 said on the day V12, Certified Nursing Assistant (CNA) hit him. He had an altercation earlier with V12 in the hallway. R3 said V12 would not let him go into his room so he put his hands on V12 to push him out of the way. R3 said he then entered his room and laid down in his bed. Later around 3:30 or 4:00PM, while in his room, R3 said he heard V12 tell his room mate R4 to go into the bathroom. V12 then approached R3 at his bed and hit him in the belly, chest, and gestured along the right side of his rib cage / torso region. R3 said V12 hit him multiple times. V12 said the only witness was his roommate R4. According to R3's face sheet R3 is [AGE] years old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Comprehensive Assessment R3's Cognitive Assessment from 4/13/20 indicates he is cognitive intact. On 6/30/20 at 9:49AM R4 said he was laying in bed when V12 entered his room and asked him to step into the bathroom. R4 said from the bathroom he heard the sound of hitting and R3 was yelling, then I heard V12 leave the room. I went back to my bed. R4 said about 20 minutes passed and V12 came back into the room and he saw V12 hit R3, I didn't see where. I left the room and didn't tell anyone what happened. On 6/30/20 at 10:10AM V10, CNA, said R4 answers questions appropriately, and understands what is going on around him. At 2:17PM V10 said R3 only needs cues and reminders, but can dress and takes self to the bathroom. R4 only needs monitoring. V10 said she has not known R3 or R4 to be incontinent. R3 and R4 only require a few seconds of interaction for reminding or monitoring. On 6/30/20 at 10:15AM V1, Administrator, said she was notified of R3's allegation by phone, and initiated an investigation, and suspended V12. V1 said she was told that R3 had a behavior episode on 4/25/20 with V12 so she watched the surveillance video that showed R3 charging and swinging at V12. The episode deescalated and R3 went into his room and V12 went down the hall. I watched the video from between 3:30 and 4:00PM for 4/25/20 the time R3 indicated V12 entered his room. The time frame V12 gave me was accurate compared to what I saw on the video. I saw V12 enter the room and leave once via the room door. R4, roommate, told me that about 20 minutes later V12 had return to the room and I was able to see this on the video. The rooms are set up to share bathrooms with the neighboring room. It is possible V12 entered the neighboring room and entered V12's room from the bathroom. I would not be able to see that on the video. R4 told me the first time V12 was in the room he told him to go into the bathroom and he did and then he heard commotion. V12 denied being aggressive while in V12's room. V1 said R3 and R4 are independent with cares and the call light was not on in the video. V12 may have been getting vital signs, but V1 said she did not see him carrying a blood pressure cuff or stethoscope on the video. V1 said R4 reported he heard noises like the CNA beating V12. V1 said she asked V12 why he entered R3's room alone following the altercation that had been reported earlier that shift and he said just to check on them. V1 said no other reason to explain the bruising could be found during the investigation and V12 was terminated. V1 said R3 is alert and orientated and R4 is alert and not known to fabricate stories. On 6/30/20 at 10:50AM V8, Psychiatric Rehabilitation Service Director, said he followed up with R3 after he returned from the hospital and he complained of pain to him. V8 said R3 is alert and oriented. V8 said with so much consistency its hard to say R3 and R4 made up the allegation. On 6/30/20 at 2:40PM V9, Doctor, said R3 talks to me a lot, he remembers me for taking care of him with his urinary problems. If he told you something and the story is consistent its likely he is telling the truth. He is not demented or confused that he would misconstrue situations. On 7/1/20 at 9:33AM V9 said the pneumothorax would not cause bruising to occur because it was a minimal pneumothorax. V9 said being physically assaulted would not have caused the pneumothorax to occur but could cause bruising. On 7/1/20 at 10:30AM V13, Nurse, said on 4/25/20 V12 told me R3 was yelling at him. When I found R3 he was outside smoking and gave no complaints. He was his normal self. The next shift I worked, I was told by V2, Director of Nursing (DON), that R3 had a bruise on him. I put a [MEDICATION(S)] patch on him and gave him extra strength Acetaminophen for the pain around 6AM. The [MEDICATION(S)] patch was for pain on the right side of his back. He never told me what caused the bruise, he said nothing happened. The bruise was purple and reddish in color, a couple of funny looking spots. The bruising was located on his back close to his rib cage off to the right side. The area did not resemble an open hand. A contusion is a bruise from an object. On 7/1/20 at 11:17AM V2, DON, said R3 was sent to the hospital because he was having pain and shortness of breath on the night of 4/26/20. Around 12:30 at night the hospital doctor called me and told me that R3 said staff had hit him a couple of days ago. I was told he had bruising to his ribs. R3 returned to the facility on [DATE]. Later on, 4/27/20 the hospital called back to request R3 return due to chest x-ray results showed pneumothorax. He was sent back to the hospital but returned to the facility a few hours later. R3 is alert and oriented to person, place, time, and know staff names and faces. I was told an x-ray was being done due to the contusion and allegation of being hit. When he returned, I saw the bruising it was red and blue on the right side of R3's lower ribs it was a large area about the size of a closed hand. R3 had not fallen or had an altercation with another resident. V2 said R3 stated to her the bruising was caused by V12 hitting him in that area. A [MEDICATION(S)] patch was being used for pain in his right side, he was in pain. It was hard for him to lay down. V2 said the only documentation of the bruise being present is in the progress notes. The bruising resolved around 5/6/20, 9 days after allegation. R3 had never accused anyone of doing anything to him. Review of R3's hospital History and Physical record dated 4/26/20 reads: per the patient he complains of right lateral upper back pain at the site of a bruise. He states 2-3 days ago he was hit by an employee at the nursing home. No pains outside of the location of the bruise. Alert and oriented to person, place, and time. Skin appearance ecchymosis. Presenting for right sided posterior [MEDICATION(S)] pain at the side of a bruise. Patient states this was caused by an altercation at the nursing home. R3's hospital History and Physical record for 4/27/20 notes he (R3) reports someone hit him at the nursing home. Medical Problems list includes Contusion and Contusion of rib on right side. R3's facility Progress Notes dated 4/27/20 read resident assessed post arrival, bruising and redness noted to right lower ribs. Note written by V14, Nurse, who was unable to be reached by phone and no longer works at the facility. Final Incident Report dated 5/1/20 for R3 reads resident was interviewed by V1 on 4/27/20 and R3 was able to provide the name of the staff member that was allegedly physically aggressive with him. Nurse assessed R3 upon return from hospital with bruising and redness noted to the right lower ribs. R3's Plan of Care dated 4/27/20 from hospital note Problem: contusion of rib on right side. Patient Visit Information sheet dated 4/27/20 reads you were seen today for contusion of rib on right side. R3's facility Care Plan reads R3 is at risk for any type of abuse or aggression secondary to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/25/20 R3 was involved in episode of verbal / physical abuse / aggression. In service record dated 3/11/20 lists topic: Free from Abuse and Neglect. V12's signature is listed. Inservice states in part the resident's right to be free from verbal, sexual, physical, and mental abuse. Review of the types of abuse, reporting to the Stage agency, investigating the occurrence and protecting the residents. The staff was also in serviced in deescalating verbally aggressive behaviors to prevent physical abuse from occurring. In service record signed by V1 as in service provider. The facility Abuse Prevention Policy dated 02/20 states, in part, the facility affirms the right of our residents to be free from abuse or mistreatment. The facility prohibits abuse and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free of abuse for one of four residents (R2) reviewed for abuse in the sample of 5. This failure affected R2 who had an altercation with peer that escalated into physical abuse resulting in R2 sustaining skin tear to left elbow and inner arm and has the potential to affect all 69 listed residents that smokes in the facility. Findings include: R1's medical record documented that R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's medical record showed that R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the facility incident report on 2/3/2020 at approximately 10:15am, R2 was noted in the room preparing to go out to the store with V3 (Case Worker). At 2:05pm R2 stated (R1) was his roommate but he was just walking around in the room on his side of the bed, while he (R2) was watching a program he likes on the television. R2 explained that R1 will go out of the room slamming the door. R2 stated during the smoking time both him and R1 got into a verbal altercation and R1 threatened him that he was going to beat him up and before he knew it, R1 started kicking and punching him and his arm started bleeding. Review of facility investigation report documented that R2 stated I was in bed trying to watch TV (referring to television) and (R1) kept slamming the door, I asked him to stop but he kept doing it. Then we went outside for our smoke break and he charged at me and hit me. V12 (Activity Aide) smoke monitor who was present at the time of incident statement dated 1/6/20 pointed out that he heard an exchange of words between R1, R2, and R1 was the first to throw and connect with a punch. On 2/3/2020 at approximately 10:25am, during the smoking time observation in the patio designated for smoking time. Residents were noted with two activity aides V5 and V6 (Activity Aides). V5 was noted passing the cigarettes to the resident's while V6 was monitoring and helping residents who need help in getting back into the facility. V5 and V6 stated two activity aides are usually assigned to the patio during smoking time. R2's progress note dated 1/6/2020 timed 9:16am, documented in part that R2 sustain a minor skin tear to left elbow and outer arm and basic wound care provided. The facility Abuse Prevention Policy dated February 2017 presented indicated that the facility affirms the right of our residents to be free from abuse and prohibits abuse. The facility policy defines abuse that includes but not limited to any physical or mental injury inflicted upon a resident other than by accidental means. The policy further defines physical abuse as the infliction of injury on a resident that occurs other than by accidental means that requires medical attention that includes but not limited to hitting, slapping, and kicking.

Based on observation, interview, and record review, the facility failed to implement appropriate measures to ensure adequate supervision was provided during smoking period for R1 and R2 who had a verbal altercation that escalated into physical abuse. This failure resulted in R2 having a skin tear to left elbow and inner arm and was treated in the facility, failed to develop and implement individualized plan of care according to medical diagnoses, and failed to analyze the circumstances of fall and develop individualized interventions to minimize the risk of recurring falls for one resident R5 reviewed for falls. This failure affected R5 who was found on the floor face down and was sent to the hospital. Findings include: On 2/3/2020, review of incident report and investigation report showed that R1 and R2 had a verbal altercation that escalated into physical aggression and abuse resulting in R2 sustaining an injury to R2's left arm. Review of both resident's plan of care did not show that plan of care was reviewed and revised. R1's care plan showed it was revised on 2/3/2020 28 days after the incident. When this was brought to V15's PRSD (Psychiatrist Rehabilitation Service Director) attention, V15 stated it should have been revised, I guess we forgot to do it. V15 then stated to the surveyor let me check if some of the other staff in the department did it. After checking V15 stated yeah it was not done and I did it on 2/3/2020 when you got here (referring to the facility). V15 acknowledged that the plan of care should have be reviewed and revised immediately within 24 hours. V15 stated physical aggression is treated like an abuse, the facility protocol on abuse and physical altercation is the same. During this investigation V5 V6, V12 (Activity Aides) and V13 (Activity Director) were interviewed concerning supervision during smoking time. They all stated during smoking time, two activity aides are assigned to monitor the residents. V13 (Activity Director) explained that the two activity aides are needed for safety and elopement issues. On 2/3/20 at approximately 4:45pm, V12 stated on the day of the incident 1/6/2020 he was the only activity aide/ smoking monitor present distributing the cigarettes and monitoring the residents so, it was hard for him to get to R1 and R2 before the physical fight but he heard them when they first started arguing. On 2/3/2020, R5's medical record showed that R5 was admitted on [DATE] with [DIAGNOSES REDACTED]. R5 was sent to the hospital on [DATE] with [DIAGNOSES REDACTED]. R5 return to the facility same day. Review of R5's care plan did not show that plan of care was revised. On 2/3/ 20 at approximately 2:26pm, V9 LPN (Licensed Practical Nurse) assigned to R5 on 12/19/19, stated that V10 was the one that found R5 on the floor and alerted her around 10:00am. When the surveyor asked V9 how often she make her rounds and saw R5, V9 replied I'm always on the floor. V10 stated I make rounds 3 to 4 times and I cannot go in the rooms when I'm passing medication. V9 explained that R5 cannot get out of her bed by herself but can reach for things. V9 stated I don't know how she got on the floor. On 2/3/20 at approximately 2:35pm, V10 CNA (Certified Nurse's aide) stated that she was the aide on duty assisting with R5's care on the day of the fall. V10 explained that she did not know when R5 fell and was busy with getting the breakfast trays out from the rooms and when she got to R5's room she found R5 laying on the floor face down. V10 stated she knew R5 is high risk for fall. V10 stated R5 did not have any alarm to the wheelchair but belief R5 has a safety mat. V10 could not be sure whether R5 had a floor mat. R5's admission note dated 11/28/2019 timed 2:57am, V19 LPN (Licensed Practical Nurse) documented that R5 has history of [MEDICAL CONDITION], no baseline care plan initiated to address the issue of [MEDICAL CONDITION]. After the facility tool use in assessing the residents coded R5 [DIAGNOSES REDACTED]. R5's fall assessment risk observation dated 11/27/19 scored R5 as 18.0 and rated level scored as high risk. Under the contributing factor it showed that R5 was checked for Cardiovascular- cardiac [MEDICAL CONDITION] and Neuromuscular/ function that includes but not limited to [MEDICAL CONDITION]/ [MEDICAL CONDITIONS] disorder and unsteady gait. R5 had recorded fall on 12/19/19 was sent to the hospital. R5 returned the same day, R5's care plan was not reviewed and revised. R5's medical record did not show any cause analysis to show how and why the fall happened, what approaches needed to prevent the fall from happening again. R5 was found unresponsive in bed on 12/22/19, emergency call made and was transferred to local hospital for emergency treatment. R5's [DIAGNOSES REDACTED]. On 2/5/20 at approximately 3:33pm, V18 (Care Plan Coordinator) stated in part that when she is developing the care plan some [DIAGNOSES REDACTED]. V18 explained that for each fall incident, the fall care plan must be reviewed. As at 2/6/20 4:30pm, the facility was unable to present any documentation that showed that the fall incident was investigated to show how and what was the cause of R5's fall. The facility policy on Care Plan presented with effective, updated date of April 2015 pointed out that an individual Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing and or psychological needs is developed for each resident. Policy specification includes but not limited to developing the Comprehensive Care Plan within 7 days of the completion of the resident's comprehensive assessment MDS (Minimum Data Set). Revising the care plan as changes in the resident's condition dictates.

Based on interview, and record review, the facility failed to develop and implement appropriate measures to ensure adequate supervision for one resident (R145) in the sample of 21 reviewed for supervision and death. This failure affected R145 who expired in the facility with cause of death identified as Combined Drug (Heroin, [MEDICATION NAME], Acetyl [MEDICATION NAME], and Lorezepam) Toxicity. Findings include: On [DATE], review of R145's medical record Face Sheet showed that R145 was last admitted [DATE] with [DIAGNOSES REDACTED]. R145 expired on [DATE] at the facility. Review of R145's State Certificate of Death listed Cause of Death as Combined Drug (Heroin, [MEDICATION NAME], Acetyl [MEDICATION NAME], Lorezepam) Toxicity. On [DATE] at approximately 9:22am, V4 PRSD (Psychiatrist Rehabilitation Services Director) stated R145 was on supervised pass to the community at the time of death. V4 explained that if a resident has an independent community pass they sign in and out at the front desk and if it is a supervised pass the family, or the staff accompanying resident out will sign in and out. V4 was unable to present any record where R145 was signed out on [DATE]. V4 presented R145's independent Pass sign out that showed that R145 was signed out with supervision on ,[DATE], ,[DATE], ,[DATE] and on ,[DATE] R145 signed (R145) out independently to the park. V4 identified the signed sheet as [DATE], [DATE], [DATE] and [DATE] stating those are for this year. V4 explained that she is new to the facility but to her knowledge R145 should not be signing (R145) out by himself because R145 is on supervised community pass. On [DATE] at approximately 10:47am, V6 LPN (Licensed Practical Nurse) was stated on [DATE] while making the rounds V12 CNA (Certified Nurse's Aide) called that R145 was not responsive and CPR (Cardiac [MEDICAL CONDITION] Resuscitation) was initiated and emergency line called. V6 stated R145 was pronounced dead by the paramedics.V4 stated in part that (V4) could not remember on [DATE] during the day shift 7am to 3pm whether R145 went out. On [DATE] at approximately 11:18am, V12 stated that on [DATE] while making round in the morning shift R145 was noted in bed face down. V12 stated on [DATE] R145 seems quite and stayed to self. V12 stated (R145) did not go out that day on community pass. V12 further explained that (R145) is on restriction pass which means R145 can only go out with family and supervision. On [DATE], V23 LPN acknowledged she worked on [DATE] on ,[DATE] shift and there was no unusual occurrences happenings on the shift. V23 stated were interviewed and they all stated they were. Review of R145 medical record MAR (Medication Administration Record) for [DATE] to [DATE] did not show that 9:00pm scheduled medications that includes but not limited to Atorvastatin 40mg (Milligram) tablet and [MEDICATION NAME] 15mg tablet were not administered. No documentation presented to show why R145 did not take the medicine. On [DATE] and [DATE] the facility was unable to provide any documentation that showed why R145 did receive 9:00pm Atorvastatin and [MEDICATION NAME] medications. V3 ADON (Assistance Director of Nurses) identified V24 RN (Registered Nurse) has the nurse who was schedule and worked with R145 on [DATE] 11pm to [DATE] 7am. V3 then stated but V24 is no longer working with the facility. V3 explained that V24 has been terminated. Review of V24 personal file showed that on [DATE] night shift, V22 was terminated for failures to monitor CNA rounds, rounds not done, round shift form not accurate, and not responding when told that a resident suffered injury. On [DATE], V4 PRSD (Psychiatrist Rehabilitation Services Director) stated the PRSC (Psychiatrist couseling done for R145. V21 (PRSC) assigned to R145 last day of work was [DATE]. V4 (PRSD) was unable to show any documentation that R145 went out of the facility from [DATE] to [DATE]. And no documentation of R145 being noted to be missing in the facility on [DATE] before expiration. On [DATE], V4 presented a note with no facility letter heading dated [DATE] that pointed out that No (MONTH) 1st -[DATE]th supervised community pass was used for following days. On [DATE] at V12 (CAN) V6 and V23 (LPN)'s stated the rounds are made every two hours. The facility was unable to present any rounds documentation for [DATE]. The facility policy titled Resident Community Access with revised date ,[DATE] pointed out in part that the facility would like all residents who wish to go out to the community to be as safe as possible. Under policy interpretation and implementation the policy further documented in part that residents who have been approved for pass privileges must sign in and out of the facility. The facility Medication/ Treatment Administration policy with no effective date stated pointed out that it is the facility policy that each medication/treatment administered will be promptly documented in the medication record after administration. The facility Nurse Staff Rounding policy with no date pointed out that it is the policy of this facility for nursing staff to monitor the well-being of residents on at two hour intervals and as needed. The policy listed procedure to be followed that includes but not limited to if resident is not found the building must be searched, surrounding are searched, management, families and authorities notified. The facility Job description on (LPN) and RN with no date pointed out to closely monitor and supervise all facility residents per facility policies and as warranted by good nursing judgment. To ensure that appropriate documentation/ charting is completed as required and in accordance with established policies and procedure.