Every finding on record at Palm Garden of Mattoon

Based on interview and record review the facility failed to protect resident's right to be free from resident-to-resident physical, verbal, and emotional abuse from another resident. This failure affected five (R1, R2, R3, R5, R6) of six residents reviewed for abuse on the sample list of six residents. These failures caused residents emotional distress and verbalizing not feeling safe in the facility. Findings Include: The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021 documents each resident has the right to be free from abuse including but not limited to verbal, mental, and physical abuse.R1's Medical Diagnoses list dated August 2026 documents R1 is diagnosed with Major Depressive Disorder and Generalized Anxiety Disorder.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact.R1's Care Plan initiated 9/19/25 documents R1 has a history of exhibiting inappropriate social behaviors including the use of racial slurs, racist comments, and offensive gestures and symbols which could be distressing to others and disruptive to the environment. R1 also has a potential to be verbally aggressive related to mental and emotional illness. R1 is at risk for abuse related to verbal and physical aggression towards others. R1 tells other residents to hit R1. Staff are to immediately attempt to separate residents.R2's Medical Diagnoses list dated August 2026 documents R2 is diagnosed with schizoaffective disorder.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact.The facility's State Agency Notification Form dated 8/13/26 documents an altercation occurred between R1 and R2 in the dining room at approximately 4:30 PM. R2 made physical contact with R1.On 8/20/26 at 10:40 AM, R2 stated that on 8/13/26 R1 became upset in the dining room about not being able to sit where R1 wanted to sit and started cursing and yelling at everyone. R2 stated that R2 listened to it for a minute but then told R1 to shut up. R1 then focused on R2 and began calling R2 a M*** F*** B*** (Expletives) repeatedly and told R2 to hit (R1). R2 stated R1 kept telling R2 to hit R1. R2 stated R2 turned to walk away and R1 called R2 a B*** (Expletive) again. R2 stated R2 turned around and punched R1 in the face. R2 stated R1 has caused problems ever since R1 moved to the back of the facility. R1 often picks on others and if R1 does not get R1's way, R1 starts yelling and cursing and calling people names. R2 stated R1 makes other residents feel uncomfortable.On 8/20/26 at 11:40 AM, V7 (Certified Nurse Assistant/CNA) stated V7 was in the drink room beside the dining room on 8/13/26 when R1 began yelling and cursing. V7 stated V7 and V5 (CNA) heard the commotion and went to the dining room. V7 CNA stated when V7 came into the dining room V7 saw R1 yelling and cursing and calling R2 all sorts of curse words and telling R2 to hit R1. V7 stated V7 and V5 tried to get R1 to calm down but R1 just kept yelling. R1 called R2 a B**** (Expletive) again and R2 turned around and punched R1 in the face. When R1 does not get R1's way, R1 argues with other residents and yells and curses at them. R1 tries to use R1's electric wheelchair as a weapon because R1 cannot walk. V7 stated R1 has upset a lot of people, and many residents have said they don't feel safe with R1 living in the facility.The facility's State Agency Notification form dated 8/16/26 documents an altercation occurred between R1 and R3 in the dining room at approximately 4:00 PM.On 8/20/26 at 10:08 AM, R3 stated that on 8/16/26 R1 threatened to kick R3's A** (Expletive). R1 was upset for some reason and began cursing and calling people names. R1 began telling R3 to come over to R1 and hit R1 repeatedly. R1 then began to quickly wheel R1's self over towards R3. R1 was about six feet from R3 when R1 was stopped by V8 (Licensed Practical Nurse/LPN). R1 then tried to hit V8 multiple times and R1was yelling all sorts of expletives as loud as R1 could. R3 stated R3 does not feel comfortable with R1 in the building. R1 is an instigator and R1 keeps pushing everyone's buttons to try to start fights.On 8/20/26 at 1:22 PM, V8 (LPN) stated that on 8/16/26 R1 began yelling a ton of curse words in the dining room. R1 was calling R3 a B*** (expletive), a M*** F*** (expletive), a C*** (expletive) and a drug addict. R3 did not respond at all. V8 stated R1 had been on edge for several days and was flying off the handle for no reason. R1 ended up wheeling towards R3 when V8 stepped in R1's path. R1 then swung multiple hard punches at V8 and called V8 a B**** (Expletive). R1 told V8 that R1 was going to hit V8 and R1 doesn't care if V8 is a woman. Many other residents have stated they are fearful of R1 and want R1 to be gone. R1 disrupts everyone. R6 came to me under great distress stating R6 did not feel safe with R1 in the building.On 8/20/26 at 10:03 AM, R5 stated R1 has told R5 to shut up and quit crying and cursed at R5 before and R5 does not feel safe living with R1.On 8/20/26 at 10:32 AM, R6 stated R6 was sitting on the couch in the common area and R1 was sitting on the opposite side in R1's wheelchair. R1 was talking and talking and R6 told R1 to be quiet. R1 got mad and told R6 to shut up. R1 started coming towards R6 while yelling and cursing and telling R6, R1 was going to run R6 over. R6 stated that R6 backed herself into the corner and put a walker in front of R6 to protect R6's self from R1. R6 stated R6 does not feel safe with R1 in the facility. R6 feels R1 would snap at any time and R6 would have to defend R6's self.On 8/20/26 at 1:38 PM, V1 (Administrator) confirmed R2 punched R1 during an altercation that occurred on 8/13/26 and has verbally attacked other residents. V1 confirmed R1 tries to intimidate residents with R1's electric wheelchair. V1 confirmed punching is considered physical abuse. V1 confirmed R1 intimidates, antagonizes, and is verbally aggressive/cursing with other residents which can be verbal/emotional abuse and cause emotional distress.

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from misappropriation of property for one resident (R1) of three residents reviewed for misappropriation of property/abuse in the sample list of four residents. Findings include: R1 was admitted to the facility on [DATE]. R1's diagnoses includes Displaced Fracture Seventh Cervical Vertebra, Generalized Anxiety Disorder, and Depression. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is mildly cognitively impaired. On 7/7/26 at 10:45AM R1 was seated in R1's room. When asked if R1 had ever had any of R1's personal property missing, R1 became tearful. R1 stated well back in May my son bought me a new white (name of phone) 17E. It was charging here in my room. My son was coming back to help me set it up. I went down to a meal and when I got back, the charger was there, and the phone was gone. We had agency CNAs (Certified Nursing Assistants) here and I really don't trust them. I told the nurse, and we searched and searched because we thought it was possible it slipped down in the recliner, but it was nowhere to be found. The Administrator and everyone else came in but it was gone. My son was really upset. As R1 talked R1 sniffed, and tears were visible on R1's face. R1 continued When we were looking for a place for me, we looked at several places. I chose this place because I thought I would be safe, and my things would be safe. I don't feel safe anymore. I have anxiety and now I feel like I have to watch everything like a hawk. Then a couple days later the charger for the (name of phone) disappeared. I guess someone needed it for the phone they took from me. R1 appeared upset and R1's hands were shaking as R1 spoke. The facility's report to the state agency dated 5/18/26 documents On 5/18/2026, the facility was notified that (R1) reported (R1's) (name of phone) 17E was missing from R1's room. (R1) stated (R1) was unable to locate the phone and staff initiated a search of the resident room and surrounding areas. The resident representative, physician, and local police department were notified. An investigation was initiated immediately. V9's (CNA) written statement (not dated) documents Did (R1's) inventory on 5/9/26. Seen (name of phone) box. Opened it. Seen the (name of phone) and charging block in the box. (R1) stated it was not activated. On Tuesday (5/12/26) I seen it on (R1's) table by the recliner. On Thursday (5/14/26) (R1) said 'can you look under my recliner? I think my phone slid under the chair.' I told R1 I would when I got (R1) out of the chair, but I didn't get a chance. On Saturday (5/16/26) I looked everywhere, and I couldn't find it (the phone). I asked the nurse to call the son to see if he had taken it home to activate it. On 7/7/26 at 1:30PM V9 (CNA) verified V9 had written the above statement, and it was to V9's knowledge accurate as written. V10's (Licensed Practical Nurse/LPN) written statement (not dated) documents I don't remember ever seeing a phone. I got a call from the facility to assist in locating the phone. I came in and helped look and couldn't locate it. I reported it after it couldn't be located. On 7/7/26 at 1:00PM V1 (Administrator) verified V1 was notified on 5/16/26 by V10 (LPN) (R1) was missing an (name of phone) 17E which had been observed by staff as being in (R1's) possession. R1's son provided the receipt for the device, and the facility had reimbursed him for the missing phone as of 5/29/26. R1's son was unreachable. Signed documents were provided by the facility verifying R1's son received a refund from the facility. The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021 states Policy Statement Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexualor physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:l. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:a. facility staff;b. other residents;c. consultants;d. volunteers;e. staff from other agencies;f. family members;g. legal representatives;h. friends;i. visitors; and/orj. any other individual.2. Develop and implement policies and protocols to prevent and identify:a. abuse or mistreatment of residents;b. neglect of residents; and/orc. theft, exploitation or misappropriation of resident property.3. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates.4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has:a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; orc. a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.

Based on interview and record review the facility failed to protect and promote the residents' rights and ensure dignity was maintained for six residents (R1, R3, R4, R9, R10, R11) out of six residents reviewed for dignity in a sample list of 25 residents. Findings include:1. R1's Minimum Data Set (MDS), dated [DATE], documents R1 as cognitively intact.On 6/5/26 at 10:05 AM, R1 stated there was an unknown resident (R22) banging on the wall behind his closet. R1 stated that because the head of his bed is positioned directly in front of his closet, it sounded like a hammer was banging on the wall at 5:00 AM. R1 stated he turned on his light and asked V32 (Agency Certified Nursing Assistant/CNA) to move R22 so she could not reach the wall to continue banging on it.R1 stated V32 (CNA) called me a racist and told me I wasn't going to get her fired. R1 stated he asked V32 to get the nurse (V31) so he could report the incident and was told by V32, Go tell the nurse yourself. I ain't dealing with you. You are a racist. R1 stated V32 (CNA) refused to get the nurse for him. R1 stated he got himself out of bed and went to find V31 (Licensed Practical Nurse/LPN). R1 stated that as he was telling V31 what had happened, V32 (CNA) walked around the corner near the nurses' station, where she had been eavesdropping, and showed a video on her phone while saying, You are not going to get me fired. I have it all on video. R1 stated V31 (LPN) also saw the video. R1 stated V32 (CNA) was not allowed to video record him without his permission and that he had not given permission. R1 stated, Why would I want to be on a video as a paraplegic? That would be embarrassing.On 6/5/26 at 11:00 AM, V32 (CNA) stated that other staff had pre-warned her about R1 being a racist and only allowing certain staff to care for him. V32 stated she was told by other staff that R1 didn't like (African Americans). V32 stated she is Black and sometimes has to deal with racial comments from residents. V32 stated she was assigned to R1 on the night of 5/30/26 into the morning of 5/31/26. V32 stated R1 put on his call light on 5/30/26 and, when she entered his room, he told her to get the f*** out (expletive). V32 stated that when she arrived on the evening of 5/31/26, she was upset about being assigned to R1 due to his comments from the previous evening. V32 stated R1 came out of his room and asked for V31 (LPN). V32 stated R1 was yelling at her and saying she was not doing her job because she would not move R22. V32 stated R22 had gotten up early on the morning of 6/1/26 because R22 was on the get up list. V32 stated R22 was sitting at a table by the nurses' station and was banging the table against the wall adjacent to R1's closet. V32 stated R1 told V31 (LPN) that V32 had been rude as f*** (expletive) to him. V32 stated she did tell R1 that she had audio and video of his behavior to prove she had not done anything wrong. However, V32 stated she only said this to make R1 think he could not get her fired and that she had not actually recorded him. V32 stated R1 said he would call the State Agency regarding her conduct. V32 stated she was afraid she would lose her CNA certification, which is why she said she had recorded R1.On 6/5/26 at 11:35 AM, V1 (Administrator) stated V32 (CNA) did not act appropriately toward R1. V1 stated R1 can be difficult, but staff are trained to respond appropriately and assist residents professionally. V1 stated V32 would not be returning to the facility.2. R3's Minimum Data Set (MDS), dated [DATE], documents R3 as cognitively intact. This same MDS documents that R3 requires supervision with toileting, personal hygiene, and transfers.On 5/29/26 at 9:40 AM, R3 stated she was embarrassed and shocked by how she was treated by staff on the morning of 5/11/26. R3 stated she has a normal morning routine of performing daily hygiene, using the bathroom, exercising for 10-15 minutes, and weighing herself before going to breakfast. R3 stated that due to her size, she has difficulty cleansing herself after using the bathroom. R3 stated she asked for assistance that morning and was told by V15 (CNA) that V15 was not supposed to help her. R3 stated, V15 told me I could do everything on my own and she did not have to help me. R3 stated she cleaned herself as best she could but could still smell feces after using the bathroom. R3 stated she then asked V15 to push her wheelchair to the scale because she was running behind after being required to complete her own perineal care.R3 stated V15 began pushing her into the hallway when V14 (LPN) stopped them and stated that R3 could push herself to the scale and needs the exercise. R3 stated she was so pi***d off by the way she had been treated by V15 and V14 that she asked to go outside to cool off. R3 stated, All they (staff) have to do is help me cleanse myself and give me a lift when I am in a hurry. I had to eat a cold breakfast that morning because they made me do everything myself. Why am I even here if I can do everything myself? I am here because I need the help.On 6/2/26 at 10:55 AM, V14 (LPN) stated she was passing medications in the hallway when she saw V15 (CNA) pushing R3 toward the scale to be weighed. V14 stated she stopped V15 and reminded R3 that she needed to push herself to the scale. V14 stated she was unaware of any previous conversations between V15 and R3. V14 stated R3 mentioned needing assistance, but V14 believed R3 was capable of pushing herself and should do so. V14 stated V15 then left R3 sitting in the hallway. V14 stated she could tell R3 was upset but did not realize the extent of her frustration until later.On 6/3/26 at 2:28 PM, V20 (LPN) stated R3 requires the assistance of one person with toileting because she is unable to adequately reach her perineal area to ensure cleanliness after toileting.On 6/5/26 at 9:50 AM, V15 (CNA) stated R3 was very upset on the morning of 5/11/26 because she wanted to be pushed to the scale to be weighed. V15 stated R3 is capable of pushing herself and staff encourage her to do so. V15 stated she tries to encourage residents to do as much for themselves as possible. V15 stated she was pushing R3 toward the scale when V14 stopped them and told R3 to push herself. V15 stated R3 then asked to sit outside. V15 stated she did not realize how upset R3 was at the time but now understands why. V15 stated R3 had also requested assistance with perineal care that same morning. V15 stated she had previously been instructed to have R3 complete her own perineal care to increase independence. V15 stated she told R3 to wash herself up after using the bathroom. V15 stated she did not intend to hurt R3's feelings and that, in the future, she would assist R3 with whatever she needed.On 6/5/26 at 11:40 AM, V2 (Director of Nursing/DON) stated staff had previously been educated on providing R3 assistance with perineal care and transportation assistance to and from wherever R3 wanted to go. V2 stated R3 is cognitively intact and should be provided assistance whenever she requests it.3.R4's Minimum Data Set (MDS), dated [DATE], documents R4 as cognitively intact.R9's MDS dated [DATE], documents R9 as cognitively intact.R10's MDS dated [DATE], documents R10 as cognitively intact.R11's MDS dated [DATE], documents R11 as cognitively intact.On 5/28/26 at 9:45 AM, V4 (CNA) stated that on 5/25/26 she was preparing to pass breakfast trays in the main dining room of the behavioral unit. V4 stated V5 (Assistant Dietary Manager/Cook) approached her while she was standing in the center hallway connected to the dining room, in front of the public restrooms. V4 stated V5 confronted her in an intimidating manner and told her to move the large coffee carafe from the resident dining room table. V4 stated she asked V5 to educate whoever had placed the coffee dispenser on the table not to do it again and that she would move it after using the restroom. V4 stated V5 then yelled, Aren't you a f****** (expletive) CNA?! and You are not that f****** (expletive) busy! V4 stated V5 appeared very angry while yelling profanities at her. V4 stated V5 continued berating her and using profanity for several minutes in front of residents. V4 stated the dining room was full of residents who would have heard the profanity.On 5/28/26 at 11:55 AM, R9 stated he witnessed V4 (CNA) and V5 (Assistant Dietary Manager/Cook) in a screaming match. R9 stated he and R4 were sitting at their usual dining room table after breakfast when V5 approached V4 and began yelling. R9 stated he did not know what they were arguing about but did not care for it and believed it upset R4. R9 stated he and R4 waited until both employees left the area before returning to their rooms because they would have had to walk through the area where the argument occurred.On 5/28/26 at 12:00 PM, R4 stated she heard two staff members (V4 CNA and V5 Assistant Dietary Manager/Cook) arguing after breakfast. R4 stated she and R9 were sitting at their usual table near the main entrance to the dining room on the behavioral unit. R4 stated she did not understand why people do not treat one another with respect. R4 stated it upsets her when there is arguing and bickering.On 5/28/26 at 12:30 PM, V7 (LPN) stated she clearly remembered the day (5/25/26) when V4 (CNA) and V5 (Assistant Dietary Manager/Cook) were arguing. V7 stated V4 was standing in front of the restroom and V5 was at the edge of the dining room hallway, while V7 (LPN) was standing at her medication cart between them. V7 stated V5 asked V4 to move the commercial-sized coffee pot sitting on a resident dining room table where R11 was seated. V4 responded that she would move it after using the restroom and asked V5 to educate whoever left the coffee pot on the table not to do so again because someone could get hurt. V7 stated V4's response angered V5, and they both began yelling. V7 (LPN) stated residents were present and would have heard the shouting match. V7 stated V5 worked in the kitchen and could have simply taken the coffee pot back to the kitchen. V7 stated the tone and volume used by both employees were disruptive to residents. V7 stated, It could have been avoided if (V5) would have just done his job, but he likes to tell others what to do.On 5/28/26 at 1:00 PM, V13 (Floor Care Technician) stated he was present when V4 (CNA) and V5 (Assistant Dietary Manager/Cook) were arguing. V13 stated he could hear both employees yelling from across the dining room while residents were present. V13 stated the argument occurred at approximately 7:15 AM on 5/25/26 as residents were finishing breakfast. V13 stated he had placed the commercial-sized coffee pot on the dining room table because it was in his way and that the pot was mostly empty. V13 stated if he had known it would lead to such a significant argument between V4 CNA and V5 Cook, he would have simply taken the coffee pot back to the kitchen.On 5/28/26 at 2:30 PM, R11 was observed sitting in her wheelchair in her room. R11 stated she heard two employees (V4 and V5) yelling at each other. R11 stated she does not like conflict and did not like having to hear the yelling.On 5/28/26 at 2:50 PM, R10 was observed sitting on the side of her bed. R10 stated she remembered two staff members (V4 and V5) yelling at each other. R10 stated the yelling was uncalled for and that she did not like it. R10 stated she prefers a quiet environment because excessive noise gives her headaches.On 6/2/26 at 9:00 AM, V5 (Assistant Dietary Manager/Cook) stated he was walking out of the kitchen on 5/25/26 carrying garbage through the dining room to take it to the dumpster outside the facility. V5 stated he saw one of the large industrial-sized coffee pots from the break room sitting on a table where R11 was seated. V5 stated he asked V4 to move the coffee pot so R11 would not get hurt. V5 stated V4 responded by yelling, You mother f****** a****** (expletives). V5 stated he did not say anything else other than asking her to move the coffee pot. V5 stated V4 told him that V13 (Floor Care Technician) had placed the coffee pot on the table and that he should ask V13 to move it. V5 stated R11 heard what V4 said. V5 stated R10 was in the dining room and asked whether V4 was trash talking him. V5 stated he did not move the coffee pot because he was taking out the garbage and did not understand why V4 could not move it herself. V5 stated he then reported the incident to V9 (Housekeeping Supervisor).On 6/3/26 at 3:15 PM, V1 (Administrator) stated she had been informed that V4 (CNA) yelled and used profanity toward V5 (Assistant Dietary Manager/Cook) in front of residents but was unaware that V5 had also yelled and used profanity toward V4. V1 stated employees should not engage in verbal altercations in front of residents. V1 stated residents should be able to eat their meals in peace without staff yelling at one another.The facility policy, dated 2021, documents that residents have the right to be treated with dignity, respect, and kindness.

Based on observation, interview and record review the facility failed to ensure a clean, homelike environment for five (R2, R16, R23, R24, R25) residents and failed to maintain clean resident community areas out of five residents reviewed for physical environment in a sample list of 25 residents. Findings include: 1. On 6/4/26 at 10:10 AM, observation of the 100 Hall shower room was conducted. The room was dry with no obvious odor. A toilet seat riser was stored on a rack against the back wall. The riser had visible long human hair and red/brown staining. The small shower chair had visible brown material spread on the back of the seat opening. The chair's PVC backrest was broken and cracked, with the mesh support torn. The trash can was approximately three-fourths full of soiled incontinence briefs, with additional trash on the floor next to the trash can. A dehumidifier was plugged into the wall near the sink. On 6/4/26 at 10:45 AM, V28 (Housekeeper) stated housekeeping performs a deep cleaning of the shower room every morning, which includes cleaning the shower room, sink, toilet, shower walls and floor, shower chairs, removing trash, sweeping, and mopping. V28 stated there is a housekeeper assigned to each hall seven days per week. On 6/4/26 at 12:05 PM, a second observation of the 100 Hall shower room was conducted. There was no change from the initial observation. Trash remained in the can and on the floor. The broken shower chair with visible brown material on the seat remained in use. On 6/4/26 at 12:10 PM, V26 (Certified Nursing Assistant/CNA) in the 100 Hall shower room, stated housekeeping cleans the shower room every morning and empties the dehumidifier. V26 stated CNAs clean bodily fluids. V26 stated, We use disinfectant to clean the chair in between each resident, then at the end of the day we do the walls and floor. When asked whether shower chairs are cleaned before a resident is placed in them, V26 stated, If I don't know if it's clean, I'll clean it before I use it. Like this one, while pointing to the soiled, broken shower chair, I'd clean before I put someone in it. Yeah, it's obviously dirty. V26 stated CNAs submit maintenance work orders for broken equipment. V26 stated, I'll put in an order for this. V26 further stated all residents on the hall use this shower room. On 6/4/26 at 1:15 PM, observation of the 100 Hall shower room was conducted. The room remained unchanged. Trash continued to be present in the can and on the floor. The broken, soiled shower chair remained in the shower room. The disinfectant bottle used in the shower room was empty. The manufacturer's directions for use state: Spray area from 6 to 8 inches away until visibly wet. Allow disinfectant to remain on the surface for two minutes, then wipe off with a clean paper towel or cloth. These directions apply to both hard and soft surfaces. On 6/4/26 at 1:15 PM, V26 (CNA) stated housekeeping maintains the disinfectant supply and staff request refills from housekeeping. When asked whether the disinfectant requires a contact time and to describe her cleaning process, V26 stated, I spray the disinfectant, wipe it down, and then rinse it off with the shower head. I don't wait any time before I wipe it down. On 6/5/26 at 9:40 AM, observation of the 100 Hall shower room was conducted. The broken shower chair remained in the shower room. The chair was clean with no visible debris or staining. On 6/5/26 at 1:10 PM, R23 stated, If I knew I was going to sit in a dirty chair, I'd be upset. On 6/5/26 at 1:15 PM, R24 stated, It would make me mad if I saw feces in there. R23's Minimum Data Set (MDS) documents a Brief Interview for Mental Status (BIMS) score of 15. R23 receives a shower twice weekly. R24's MDS documents a BIMS score of 15 and that R24 also receives showers twice weekly. The disinfectant directions state to spray the area from 6 to 8 inches away until visibly wet and allow the disinfectant to remain on the surface for two minutes before wiping with a clean paper towel or cloth. These directions apply to both hard and soft surfaces. Review of the facility's Housekeeper Duties document showed shower rooms are to be cleaned daily. The Illinois Long-Term Care Ombudsman Program booklet titled Residents' Rights for People in Long-Term Care Facilities, revised 11/02/18, documents, Your facility must be safe, clean, comfortable, and homelike. 2. On 6/4/26 at 10:10 AM, observation of R2's bathroom revealed the floor was missing any type of finished flooring surface, such as tile. The bathroom floor consisted of exposed concrete with multiple brown rings and stains present. The bathroom had a strong urine odor. The bottom corner of the bathroom door contained an approximately 4-inch-tall by 2-inch-wide hole. On 6/4/26 at 10:15 AM, R2 stated he would like to live in a room that isn't a danger zone. R2 stated his previous room was not in poor condition and that he expected his new room to be put together. R2 stated he should not have to live in a rat trap roach motel. 3. On 6/3/26 at 1:20 PM, observation of R16's room revealed the wall behind the head of the bed contained an approximately 3-foot-long by 2-foot-wide area with dozens of scrape marks approximately 1 foot in length, exposing the drywall underneath. The wall was painted dark brown, and the scrape marks exposed the white drywall beneath the paint. On 6/3/26 at 1:25 PM, R16 stated she likes to live in a room that looks presentable. R16 stated the damaged wall had been in that condition forever and that she had asked the facility to repaint it. R16 stated that instead of repairing the wall, staff moved her bed to help conceal the damaged area. R16 stated she would like to have the wall repaired. 4. On 6/3/26 at 2:45 PM, observation of R25's room revealed approximately one-third of the paint was missing from the walls. The room was painted dark brown, and the missing paint exposed the white drywall underneath. The condition was readily visible to staff, residents, and visitors. On 6/3/26 at 2:47 PM, R25 stated he would like the wall repainted the same color. 5. Observations made throughout the survey of resident common areas revealed the following: On 6/3/26 at 2:30 PM, the baseboard at the total-body mechanical lift station on the 100 Hall contained broken tile measuring approximately 4 inches by 4 inches. This area was located next to the nurses' station in a resident common area and was clearly visible to residents, staff, and visitors. On 6/3/26 at 2:35 PM, the baseboard in the behavioral unit dining room was curled outward for approximately 3 feet, creating a potential hazard and exposing the concrete underneath. The dining room walls contained dozens of liquid splatters and drips. The walls and floor showed visible buildup of grime and dirt. Three dining room tables were stained with a red substance. The floor beneath the tables was also stained with a red substance. Multiple deep scuff marks were present on the floor, exposing the underlying material of the floor tiles. On 6/3/26 at 2:40 PM, the floor in front of V12 (Psychiatric Rehabilitation Services Director/PRSD)'s office, which is also a resident common area, contained multiple deep scuff marks. The surface layer of the floor tiles had been worn away in several locations. Residents were observed walking through this area. On 6/4/26 at 10:20 AM, the resident common area located between the resident halls on the behavioral health unit contained dozens of dark brown scuff marks, several inches in diameter, that had worn through the surface of the tile flooring. On 6/4/26 at 3:00 PM, V34 (Maintenance Director) stated the facility is aware that portions of the resident areas require repairs, painting, replacement flooring, and overall deep cleaning. V34 stated the facility has developed a plan to address the issues but had not yet begun the work. On 6/5/26 at 1:20 PM, V1 (Administrator) stated the facility has plans to repair and/or replace many resident areas, particularly within the behavioral unit. V1 stated all residents should be provided with a clean and homelike environment.

Based on interview and record review the facility failed to protect the residents' right to be free from verbal abuse by another resident (R2) for two residents (R1, R19) out of seven residents reviewed for abuse in a sample list of 25 residents. Findings include:1. R1's Electronic Medical Record (EMR) documents medical diagnoses of Paraplegia, Traumatic Brain Injury, Injury at the T7-T10 Level of the Thoracic Spinal Cord, Adjustment Disorder with Anxiety, Opioid Dependence, and Chronic Pain.R1's Minimum Data Set (MDS), dated [DATE], documents R1 as cognitively intact. This same MDS documents that R1 self-propels a wheelchair for mobility.R2's (EMR) documents medical diagnoses of Morbid Obesity, Tobacco Use, Generalized Anxiety Disorder, Acquired Bilateral Above-the-Knee Amputations, and Major Depressive Disorder in Partial Remission.R2's (MDS), dated [DATE], documents R2 as cognitively intact. This same MDS documents that R2 self-propels in a motorized wheelchair.R1 and R2's shared report to the State Agency, dated 5/24/26, documents that the investigation findings supported that R2 was verbally aggressive, disruptive, and displayed inappropriate behavior toward R1 on 5/23/26. This same report documents that multiple witness statements corroborated R2 yelling, using profanity, making racial slurs, and making threatening comments.On 5/30/26 at 11:10 AM, R1 stated R2 was at it again and that the facility had sent R2 to the hospital. R1 stated R2 yelled and cursed at him while they were sharing a smoking break. R1 stated R2 was now back on the behavioral unit. R1 stated that as long as R2 stayed on the behavioral unit, he was happy. R1 stated, I am tired of (R2's) s*** (expletive). I am glad he is back there. I got what I wanted. Now I won't have to deal with him.On 5/30/26 at 10:15 AM, R2 stated he was outside smoking on the evening of 5/23/26. R2 stated R13 and R15 were already outside when he arrived. R2 stated R1 then came outside to the smoking area and intentionally pushed the metal awning while walking by, causing it to make a loud twang noise, which R2 stated he does not like. R2 stated he could not prove it, but that R1 does things like that all the time to instigate him. R2 stated he called R1 names, causing R1 to go back inside. R2 stated R1 later returned and struck the metal awning again while smiling. R2 stated he was calling R1 bad names when V16 (LPN) came outside and told everyone to calm down. R2 stated that by then he was so angry that he continued calling R1 names such as little b**** (expletive), dirty b**** (expletive), and cry baby little p**** (expletive). R2 stated, Everything was yelling and verbal. Nobody hit each other.On 6/2/26 at 2:00 PM, V16 (Licensed Practical Nurse/LPN) stated she was R1 and R2's nurse on the evening of 5/23/26. V16 stated R2 had gone outside to smoke and then R1 also went outside to smoke. V16 stated R1 later came inside and reported that R2 was cursing at him. V16 stated that when she went to the smoking area, R1, R2, R13, and R15 were outside. V16 stated R2 was yelling at R1, calling him names, and also calling V16 offensive names. V16 stated R2 yelled at R1, you little b**** (expletive), you dirty b**** (expletive), and cry baby little p**** (expletive). V16 stated that when she attempted to calm R2, he began yelling racial slurs and profanities at her. V16 stated R2 called her a b**** and a c*** (expletives). V16 stated R1 did not help the situation because he was yelling, I will call the State (State Agency) on all of you! V16 stated R1 and R2 are both cognitively intact residents who do not like one another. V16 stated staff are expected to redirect R1 and/or R2 from smoking at the same time. V16 stated she had redirected them in the past but did not do so on 5/23/26 because she was unaware they were outside together.On 6/3/26 at 9:45 AM, R15 stated he was outside near the couches while R2 was under the awning. R15 stated R2 loudly said, (R1) is doing that s*** (expletive) just to piss me off. R15 stated he got tired of hearing it and went back inside.On 6/3/26 at 10:00 AM, R13 stated she was outside smoking when R2 came outside on 5/23/26. R13 stated R2 was not causing any problems until R1 also came outside. R13 stated R1 bumped the metal awning and R2 began yelling obscenities at him. R13 stated R2 called R1 a little b**** (expletive) and other foul names. R13 stated, I get so tired of these two (R1, R2). They are always yelling at each other. I just want to smoke and chill. I went back inside because I was tired of hearing them go at it again. It stressed me so much I called my family and asked them to come get me for a home visit.On 6/3/26 at 1:00 PM, V1 (Administrator) stated R1 and R2 were involved in a verbal altercation while smoking outside on 5/23/26. V1 stated R1 came inside to get V16 (LPN). V1 stated V16 went outside and asked all other residents to return inside the facility. V1 stated V16 then contacted V1, who instructed her to call the police regarding R2. V1 stated R1 instigates R2 but is smart enough to stay under the radar. V1 stated the facility is aware that R2 responds to R1's prodding, but staff have been unable to prove it. V1 stated R2 did yell and carry on toward R1 on 5/23/26 and that the facility must acknowledge R1's right to be free from verbal aggression, while also recognizing that R1 often starts it. V1 stated staff are expected to monitor both residents every 15 minutes. V1 stated staff are also expected to redirect R1 and/or R2 if one resident wishes to smoke while the other resident is already outside. V1 stated R1 and R2 are not supposed to have shared smoking times.2. R19's (MDS), dated [DATE], documents R19 as cognitively intact.R2's (EMR) documents medical diagnoses of Morbid Obesity, Tobacco Use, Generalized Anxiety Disorder, Acquired Bilateral Above-the-Knee Amputations, and Major Depressive Disorder in Partial Remission.R2's (MDS), dated [DATE], documents R2 as cognitively intact. This same MDS documents that R2 self-propels in a motorized wheelchair.R2's Nurse Progress Note, dated 6/3/26 at 3:30 PM, documents that R2 and other residents were on a smoke break when R2 began cursing and taunting other residents to fight with him. This same note documents that R2 stated, Come on. Bring it on. This chair isn't stopping me, and I will run you over with this chair.On 6/3/26 at 4:00 PM, V27 (Certified Nursing Assistant/CNA), V17 (Registered Nurse/RN), and V12 (Psychiatric Rehabilitation Services Director/PRSD) stated R2 was outside smoking when he became agitated because the facility door would not open properly. V27 stated she was outside with the residents during the 3:00 PM smoke break on 6/3/26 and that the door to the smoking area became stuck. V27 stated she handed R19 the lighter so he could attempt to open the door while she assisted. V17 (RN) stated she was pushing on the door from the inside while V27 (CNA) pulled from the outside. V27 stated the door eventually became unstuck. During that time, R19 lit his own cigarette and then lit another resident's cigarette. V27 stated R2 began yelling profanities at R19. V27 stated R2 yelled that R19 should not be lighting other residents' cigarettes and complained that R2 had been skipped. V17 (RN) stated she heard R2 yelling and cursing at R19. V17 stated R2 called R19 a little b**** (expletive) and a stupid b**** (expletive). V17 stated R19 responded by telling R2 he was going to kick his a** (expletive) and that R2 was going to get it. V27 stated R19 told R2 he needed to stay out of it, and R2 responded, Come over here and I'll beat your a** (expletive). V27 stated R19 then told R2 he was going to get him if R2 did not stop. V27 stated the two residents continued yelling at one another. V17 (RN) stated that if R2 comes at me, then R19 would swing back.On 6/4/26 at 1:10 PM, R19 stated he was outside for a smoke break on 6/3/26 when there was a problem with the door leading back into the building. R19 stated V17 (RN) and V27 (CNA) worked on the door and fixed it within a few minutes. R19 stated that while V27 (CNA) was working on the door, she handed him the lighter and instructed him to begin lighting residents' cigarettes. R19 stated R2 became upset because his cigarette was not lit first and began yelling at him. R19 stated R2 called him all kinds of names. R19 stated R2 yelled, you little b**** (expletive) and you are a stupid b**** (expletive). R19 stated he does not like being called names and responded by yelling that he would kick R2's a** (expletive). R19 stated V27 then instructed everyone to calm down and that was the end of it.On 6/4/26 at 3:10 PM, V1 (Administrator) stated R2 yelled profanities at R19 during a scheduled smoke break on the behavioral unit. V1 stated it is difficult to prevent verbal abuse because it is often impossible to predict when it will occur. V1 stated all residents have the right to be free from abuse and that the facility is responsible for maintaining resident safety.The facility policy titled Resident Rights and Abuse Prevention Policy and Procedure Manual, revised April 2021, documents that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy further documents that this right includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms.The policy defines verbal abuse as the use of verbal, written, or gestured communication, or sounds, directed toward residents within hearing distance, regardless of age, ability to comprehend, or disability.

Based on interview and record review the facility failed to immediately report verbal abuse to the Abuse Coordinator for one (R19) resident by another resident (R2) out of seven residents reviewed for abuse in a sample list of 25 residents.Findings include:R19's Minimum Data Set (MDS), dated [DATE], documents R19 as cognitively intact.R2's (MDS) dated [DATE], documents R2 as cognitively intact.R2 and R19's shared report to the State Agency, dated 6/4/26, documents that R2 yelled profanities at R19 during a shared smoke break at 3:00 PM on 6/3/26.On 6/3/26 at 4:00 PM, V27 (Certified Nursing Assistant/CNA), V17 (Registered Nurse/RN), and V12 (Psychiatric Rehabilitation Services Director/PRSD) stated that R2 yelled and used profanity toward R19 while they were on a smoke break.On 6/3/26 at 4:05 PM, V17 (RN) stated she heard R2 yelling and using profanity toward R19. V17 stated R2 called R19 a little b**** (expletive) and a stupid b**** (expletive). V17 stated there was no need to report the incident to V1 (Administrator/Abuse Coordinator) because neither R2 nor R19 became physically aggressive toward one another.On 6/3/26 at 4:30 PM, V1 stated she was unaware that a resident-to-resident incident had occurred on the behavioral unit. V1 stated staff should have reported the incident immediately.The facility policy titled Resident Rights and Abuse Prevention Policy and Procedure Manual, revised April 2021, documents that if resident abuse, neglect, exploitation, misappropriation of resident property, or an injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials in accordance with State law.The policy further documents that occurrences of such incidents are to be promptly reported to the nurse supervisor, Director of Nursing Services, and Administrator.

Based on interview and record review the facility failed to accurately document behaviors for three (R1, R2, R6) residents out of three residents reviewed for behavioral health in a sample list of 25 residents.Findings include: 1.R1's Electronic Medical Record (EMR) documents medical diagnoses as Paraplegia, Traumatic Brain Injury, Injury at T7-T10 level of Thoracic Spinal Cord, Adjustment Disorder with Anxiety, Opioid Dependence and Chronic Pain. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 self propels a wheelchair for mobility.R1 and R2's shared report to the State Agency dated 5/24/26 documents the investigation findings support R2 was verbally aggressive, disruptive and showing inappropriate behavior towards R1 outside at the smoking patio. This same report documents the incident occurred on 5/23/26 at 7:00 PM. R1's Behavioral Tracking Sheet dated May 1-31, 2026 does not document any yelling, verbal behaviors directed at others, accusing of others, cursing at others and/or screaming at others. This same behavioral tracking documents No behaviors observed. R1's Resident Monitoring form dated 5/23/26 documents R1 was in his room in bed from 4:00 PM through 12:00 AM 5/24/26.On 6/5/26 at 12:10 PM V1 (Administrator) stated she is aware of the issue with documentation and is educating staff again to ensure not only behaviors but all necessary documentation is completed by the end of each shift. 2.R2's Electronic Medical Record (EMR) documents medical diagnoses as Morbid Obesity, tobacco use, Generalized Anxiety Disorder, Acquired above the knee bilateral amputations and Major Depressive Disorder in partial remission. R2's (MDS) dated [DATE] documents R2 as cognitively intact. This same MDS documents R2 self propels in a motorized wheelchair. R2's Behavioral Tracking Sheet dated May 1-31, 2026 documents R2 was agitated on 5/2, 5/6, and 5/8. This same form does not document any yelling, verbal behaviors directed at others, accusing of others, cursing at others and/or screaming at others for the remainder of the month. This same behavioral tracking documents No behaviors observed for the remainder of the month. R2's Nurse Progress Notes document R2 yelling at staff on 5/12 and 5/24. R2's Nurse Progress Notes do not document any other behaviors for R2. On 6/5/26 at 12:05 PM V2 (Director of Nurses/DON) stated behavior tracking must be completed every shift to give an accurate depiction of the resident behavioral status. V2 stated V37 (Psychiatric Nurse Practitioner/NP) can better determine whether or not to make changes in the residents medication regime or implement new non-pharmacological interventions. 3.R6's Electronic Medical Record (EMR) documents medical diagnoses as Dementia, Altered Mental Status, Diabetes Mellitus Type II and Respiratory Conditions due to unspecified external agent. R6's (MDS) dated [DATE] documents R6 as cognitively intact. R6's Behavioral Tracking Sheet dated May 1-31, 2026 does not document any yelling, verbal behaviors directed at others, accusing of others, cursing at others and/or screaming at others. This same behavioral tracking documents No behaviors observed. R6's Nurse Progress Notes dated 5/16/26 at 9:20 PM document R6 was involved in a verbal altercation on 5/16/26 at 6:20 PM. On 5/28/26 at 12:10 PM R9 stated R9 and R4 both were sitting in the common area when R6 yelled at V12 (Psychiatric Rehabilitation Services Director/PRSD). R9 stated R6 was 'aggressive, mean and out of control' towards V12. R9 stated (R6) is the only other resident I am afraid of because he gets so violent so quick for no reason. I do everything I can to avoid him. But I was scared for (V12) that day because you never know what (R6) will do. R9 stated he clearly heard R6 yell 'Go f*** yourself' to V12. On 5/28/26 at 12:40 PM V12 (PRSD) stated on 5/25/26 R8 loaned R6 $5 so that R6 could get R8 some chips. V12 stated this is against the rules in the locked unit so she asked R6 to return the money to R8. V12 stated that is when R6 became verbally aggressive toward V12. V12 stated R6 was yelling profanities at her in front of other residents. V12 stated R4 and R9 were witnesses to R6's verbal outburst. V12 stated it is important to document all abnormal behaviors so that the provider can determine if there needs to be a change in medications or interventions to help the resident behave appropriately. V12 stated she is aware the documentation is lacking and is working on educating staff to complete the behavior tracking every day.

Based on interview and record review the facility failed to protect one (R6) resident's right to be free from verbal and physical abuse from another (R7) resident with R9-R13 witnessing this incident. The facility failed to protect one resident (R5) from verbal abuse by another resident (R8). These failures affect nine residents (R5, R6, R7, R8, R9, R10, R11, R12, R13) out of nine residents reviewed for abuse in a sample list of 33 residents.Findings include:1.R6's Electronic Medical Record (EMR) documents R6's medical diagnoses as Psychosis, Major Depressive Disorder, Mood Disorder, Paranoid Personality Disorder, Adjustment Disorder, Delusional Disorder and Mild Cognitive Impairment.R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. R7's Electronic Medical Record (EMR) documents R7's medial diagnoses as Paranoid Schizophrenia, Psychosis, Anxiety, Intellectual Disabilities, Morbid Obesity, Hallucinations, Delusions, Agitation, Aggression, Major Depressive Disorder (MDD), General Anxiety Disorder (GAD), Obsessive Compulsive Disorder (OCD) and Paranoia. R7's Minimum Data Set (MDS) dated [DATE] documents R7 as cognitively intact. R6's AIM for Wellness report dated 4/1/26 documents R6 was sitting at a dining room table involved in a group activity. There was an empty chair placed next to R6. This same report documents R7 approached and tried to move the chair. R6 did not want the chair moved so R6 held the chair so that R7 could not move the chair. This same report documents R7 hit R6 in the Left Shoulder because R6 would not let R7 move the chair.R6 and R7's combined investigation dated 4/1/26 documents written witness statements from R11, R12 and R13 all document R7 was moving chairs around as per R7's usual self when R7 got upset because R6 would not let R7 have an empty chair sitting at the dining room table where the activity was taking place. These same witness statements document V8 (Activity Director) instructed R7 to not touch the empty chair and R7 continued to try to move the chair. These same witness statements document R7 became mad, yelled at R6 and then hit R6. Witness statements from R9 and R10 document the same scenario but add that R7 called R6 a b**** (expletive) when R7 was yelling at R6 over the placement of the dining room chair. On 5/6/26 at 10:55 AM V4 (Psychiatric Rehabilitation Services Director/PRSD) stated on 4/1/26 R6 was sitting at a dining room table during an activity. V4 stated R6 had an empty chair sitting next to her. V4 stated R7 walked up to the activity table where R6 was sitting and started to take the empty chair. V4 stated V8 (Activity Director) instructed R7 the chair was not to be moved. V4 stated R7 continued to try to take the chair that R6 was holding in place. V4 stated R7 became upset and hit R6 in the Left upper Neck/Shoulder area. V4 (PRSD) stated V8 (Activity Director) should have allowed R7 to have the empty chair which would have resolved this incident without R6 being struck by R7. V4 stated R7 had no injuries and R6 had a red mark on her Left Neck/upper Shoulder area. On 5/6/26 at 11:05 AM V5 (Psychiatric Rehabilitation Services Assistant/PRSA) stated V5 was walking through the dining room at the same time R6 and R7 got into it. V5 stated V8 (Activity Director) told R7 that R7 could not have the empty chair. V5 stated R6 was holding onto the empty chair so that R7 could not use it. V5 stated this made R7 upset so R7 hit R6. V5 (PRSA) stated R9 who is R6's friend then stood up and told R7 to stop hitting R6. On 5/6/26 at 2:25 PM V8 (Activity Director) stated on 4/1/26 V8 was conducting an activity with numerous residents. V8 confirmed R6-R13 were present for the activity. V8 stated R6 was sitting next to an empty chair when R7 walked up and attempted to take the chair from R6. V8 stated V8 told R7 to not sit down and not take the chair. V8 stated R7 became more angry and yelled at R6 calling R6 a b**** (expletive) and hitting R6 on the Left Shoulder. V8 stated V8 could have stood up and walked over to R7 to redirect R7, or I should have just let (R7) sit down. V8 stated V8 told R7 to not move the chairs due to R7 moves the chairs all the time and it just scuffs the floors. On 5/7/26 at 8:55 AM R7 was laying in R7's bed in R7's room. R7 stated (R6) kept a hold of that chair. I wanted to move that chair. (R6) wouldn't let me. (V8) kept telling me to stop. (V8) told me to let go of the chair. I hit (R6) on the arm. I called (R6) a b**** (expletive) because (R6) is one. I haven't seen (R6) since then. I think (R6) moved. I am glad. I didn't like (R6). R7 stated R7 has not had any other concerns with other residents. R7 stated R6 was the only other resident R7 did not like. On 5/7/26 at 12:45 PM V1 (Administrator) stated the staff should have intervened between R6 and R7 prior to the incident escalating to the point of R7 hitting R6. V1 stated the staff have been trained on how to handle these kinds of situations and should have redirected R7. V1 stated we are aware that R7 moves dining room chairs frequently and should have redirected R7 as soon as R7 walked over to the table of residents. V1 stated R7 did hit R6 and it could possibly have been prevented if staff redirected R7. 2. R5's Electronic Medical Record (EMR) documents R5's medical diagnoses as Paraplegia, Opioid Dependence, Chronic Pain, Traumatic Brain Injury (TBI), Tobacco use, Unspecified injury at T7-T10 level of Thoracic Spinal Cord and Adjustment Disorder with Anxiety. R5's Minimum Data Set (MDS) dated [DATE] documents R5 is cognitively intact. R5's Care plan intervention dated 4/13/26 instructs staff to encourage R5 to avoid smoking when R8 whom R5 has previously had conflict is smoking.R8's EMR documents R8's medical diagnoses as Morbid Obesity, Depression, Congestive Heart Failure, Major Depressive Disorder (MDD), Tobacco use, Acquired absence of Right and Left Legs above the Knee.R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact. R8's Care Plan intervention dated 4/13/26 documents R8 was educated to smoke at separate times to avoid (R5) whom R8 has had previous conflict with.R5's Nurse Progress Note dated 5/10/26 at 3:16 PM documents R8 explained to V23 (Licensed Practical Nurse/LPN) that R8 was not listening to offensive music. This same note documents R8 stated the music R5 is complaining about is [NAME] in German. This same note documents R8 was counseled to be respectful of others' feelings. This same note documents R8 was sitting in the hallway in R8's wheelchair blocking R5's path to R5's room. This same note documents R5 stated R5 was upset due to R8 was blocking R5's path and staff let it happen. On 5/12/26 at 9:30 AM V1 (Administrator) stated on 5/10/26 R8 was playing R8's music which R5 did not care for. V1 stated R5 asked R8 to not play 'Nazi' music so that others have to listen to it also. V1 stated R8 then left the smoking area and went back to R8's hall. V1 stated R8 allegedly said to R5 you are a little b**** (expletive), you are a liar and you are a p****(expletive) because R5 told R8 to stop playing that kind of music. V1 stated when R8 was interviewed, R8 stated R8 can play any kind of music R8 likes and as loud as R8 likes. On 5/12/26 at 11:05 AM R5 stated R8 yelled you are a p**** (expletive), you are such a d*** crybaby (expletive) and you are a dirty rat liar at R5 on 5/10/26. R5 stated R8 and R5 were both outside smoking when R8 put R8's outstretched arm in the air like a (fascist salute) while blaring R8's music. R5 stated R5 did not engage R8 because R5 and R8 do not get along so R5 was trying to let staff solve the problem. R5 stated R8 then went down their shared hall and would not let R5 pass by R8 to get to R5's room. R5 stated R8 is a bully and the staff did not handle the problem. R5 stated the staff should have made R8 move out of R5's way so that R5 could go to R5's room but instead they (staff) are all scared of (R8) so they didn't make R8 move. R5 stated R5 turned around and went the other way and could hear R8 say you are a little b**** (expletive). On 5/12/26 at 11:35 AM V25 (Certified Nursing Assistant/CNA) stated V25 was at the nurses station on the hall where R5 and R8 both reside. V25 stated R32 and R5 both came down the hall to report that R8 was playing offensive music outside in the smoking area. V25 stated then both R5 and R32 both went back outside and shortly after R8 came down the hall to ask if R5 had reported R8 for playing R8's music too loud. V25 stated at that point, R5 had returned to the hall. V25 stated R8 yelled at R5 you are a cry baby and a rat! and you are a p**** (expletive). V25 stated R5 asked the staff (V22 CNA, V25 CNA and V23 LPN) to make R8 move so that R5 could pass by to get to R5's room. V25 stated staff asked R8 to move and R8 refused for several minutes so R5 turned around and left the hall. V25 stated R8 then finally moved to the side of the hall but R5 was already half way down the hall headed in the opposite direction by the time R8 moved. V25 stated V23 (LPN) asked R8 to be more respectful towards other residents. V25 stated R8 said some racial slurs to R5 to try to upset R5 due to R5 is married to an African-American. V25 staff should have redirected R8 to another side of the hall and should have redirected the two (R5, R8) from smoking at the same time. On 5/12/26 at 11:45 AM V22 (CNA) stated V22 was walking out of the activity room when R33 flagged me over like it was an emergency to inform me that R8 was out to get R5. V22 stated V22 saw R5 turning R5's wheelchair around to move the opposite direction as R8. V22 stated V23 (LPN) was telling R5 that R8 had moved for R5 to get through but R5 was half way down the hall by the time R8 decided to move his wheelchair. On 5/12/26 at 11:50 AM R8 stated R8 has the right to listen to R8's music anywhere R8 wishes and as loud as R8 wishes. R8 stated R5 is always lying about R8 and causing trouble. R8 stated R8 called R5 names and kept R5 from passing R8 in the hallway so that R8 could talk with R5 about R5's claim R8 was blaring offensive music. R8 stated I have rights too. I shouldn't have to turn my music down just because other people are around. I don't care how (R5) feels. I can listen to what I want. (R5) should have been a man and talked with me that day but (R5) just ran away because (R5) is scared.On 5/12/26 at 11:55 AM R33 stated R33 was at the soda machine in the main dining room and heard R8 yelling profanities at R5 from down their shared hallway. R33 stated R8 plays his German music so loud outside nobody can talk to each other or talk to anyone on their phones. R33 stated R8 taunts other residents especially R5. R33 stated R8 claims to be a white supremacist and picks on R5 due to R5 is married to an African-American.On 5/12/26 at 12:00 PM R32 stated R32 has heard R8 claim to be a white supremacist. R32 stated R8 tries to get other residents in trouble by doing things that R8 knows upsets them. R32 stated R8 raises R8's hand in the air to show the (fascist salute) while R8 plays R8's music too loud. R32 stated R8's music does not have offensive language but R8 blares it and that along with R8's salutes it just causes a lot of drama. On 5/12/26 at 12:25 PM V23 (LPN) stated V23 was the assigned nurse for R5 and R8 on 5/10/26. V23 stated R5 was on a smoke break when R5 came back to the hall to ask staff to tell R8 to turn down R8's music due to it was offensive to R5. V23 stated R5 claimed R8 was blaring (fascist slur) music and R8 was a racist by the things R8 said to R5. V23 stated R5 then went back outside to the smoking area. V23 stated V23 went out to R5 to warn (R5) that R8 was upset with R5 and to try to avoid R8. V23 stated V23 returned to the hall and R8 was already sitting in R8's wheelchair in the middle of the hallway in front of the nurse's station. V23 stated R8 asked V23 if R5 had reported R8 for playing R8's music too loud. V23 stated R8 played the same music for the staff and there were not any recognizable words due to the music was [NAME] in German. V23 stated the staff researched the band name and lyrics and found that there was not any foul language in the songs. On 5/12/26 at 2:10 PM V13 (LPN) stated V13 witnessed a portion of the incident on 5/10/26 involving R5 and R8. V13 stated R8 was being verbally aggressive towards R5. V13 stated R5 did not engage R8. V13 stated R5 was asking the staff to move R8 out of the way so R5 could get to R5's room. V13 stated R5 couldn't get through due to R8 ignored staff's instruction to move to the side of the hall. V13 stated R8 did eventually move to the side but by that time R5 had already turned around to leave the area. On 5/13/26 at 11:00 AM V1 (Administrator) stated R5 and R8 have an ongoing issue with one another. V1 stated the facility has tried to put interventions into place to help prevent R5 and R8's altercations. V1 stated the staff could have redirected R5 and/or R8. V1 stated both R5 and R8 are care planned for staff to encourage R5 and R8 to avoid smoking at the same times. V1 Administrator stated it is a difficult situation due to R5 and R8 are both cognitively intact and both refuse to change their routines. V1 confirmed R8 yelled profanities at R5 this time and the staff should follow the resident care plan. The facility policy titled Resident Rights and Abuse Prevention Policy and Procedure Manual Abuse Prevention Policies and Procedures revised September 2022 documents abuse of any kind against residents is strictly prohibited. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. Physical abuse includes but is not limited to hitting, slapping, biting, bunching and kicking. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication or sounds to residents within hearing distance, regardless of age, ability to comprehend or disability. Examples of mental and verbal abuse include harassing a resident, mocking, insulting, ridiculing, yelling or hovering over a resident with the intent to intimidate.

Based on observation, interview and record review the facility repeatedly failed to ensure medications and narcotics were locked and stored properly for 16 (R5, R8, R14, R19-R31) residents out of 16 residents reviewed for medication storage in a sample list of 33 residents.Findings include:The facility daily midnight census documents R5, R8, R14, R19-R31 all reside on the same hallway in the facility during the survey timeframe. On 5/6/26 at 11:20 AM and 1:50 PM the facility medication cart was sitting in the hallway next to the nurse's desk unlocked. There were several residents in the area with no staff present.On 5/6/26 at 2:15 PM the same facility medication cart was unlocked sitting in the hallway next to the nurse's desk with no staff present. Several residents were sitting in close vicinity of the medication cart. V15 (Licensed Practical Nurse/LPN) walked up to the medication cart. V15 stated the medication cart should always be locked. V15 opened the first large drawer of the medication cart without using keys and showed that the lid to the narcotic box did not close completely when the medication cart drawer was closed and then opened again. V15 showed that the lid to the narcotic box could be easily opened after the drawer had been opened. V15 stated all narcotics should be locked twice to make sure someone doesn't take them. On 5/6/26 at 2:20 PM V1 (Administrator)and V2 (Director on Nursing/DON) were informed of the medication cart and narcotic box being unlocked and unattended. On 5/6/27 at 2:45 PM V16 (LPN) and V2 (DON) visually confirmed the same medication cart narcotic box lid did not lock after the medication drawer was closed. V2 stated V2 was going to call pharmacy due to the narcotic box not locking properly. V2 stated the facility should always keep all narcotics under a double lock system to ensure the safety of the medication and to help reduce the risk of theft of narcotics. On 5/7/26 at 10:55 AM V15 (LPN) stated the staff were told to make sure the narcotic box lid was completely closed. The same medication cart narcotic box lid had a handwritten note taped to the top of the lid that documents Push down on narcotic box to ensure it locks. V15 visually confirmed the same medication cart narcotic box lid did not lock after the medication drawer was closed. V15 stated the narcotic box does not lock on its own. V15 stated staff must make sure the lid is completely closed. V15 stated, some of the nurses would close the lid but there are some that aren't that careful. On 5/8/26 at 12:00 PM the same medication cart was unlocked and positioned in the main dining room with no nurses present. Multiple residents were present in the dining room.On 5/12/26 at 9:00 AM V18 (LPN) and V22 (Assistant Director of Nurses) confirmed R5, R8, R14 and R19-R31 had schedule II, schedule IV and benzodiazepines that are stored in the same medication narcotic box. On 5/12/26 at 2:40 PM V1 (Administrator) stated the same medication cart was replaced on 5/11/26 due to a faulty lock.The facility policy titled Controlled Substances revised November 2022 documents controlled substances are separately locked in permanently affixed compartments.

Based on interview and record review the facility failed to treat a resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one resident (R8) out of three residents reviewed for dignity in a sample list of 33 residents.Findings include:R8's Electronic Medical Record (EMR) documents R8's medical diagnoses as Morbid Obesity, Depression, Congestive Heart Failure, Major Depressive Disorder (MDD), Tobacco Use, and acquired absence of the right and left legs above the knee.R8's Minimum Data Set (MDS), dated [DATE], documents R8 as cognitively intact.On 5/6/26 at 1:50 PM, R8 stated he was trying to find a visitor who normally sits in the facility conference room. R8 stated the conference room door was open, and although he cannot see very well, he could see someone inside the conference room. R8 stated he started to enter the conference room when V3 (Licensed Practical Nurse/LPN) came to the door and loudly told him to get out. R8 stated V3 shut the door on him and told him to go somewhere else to look. R8 stated he was trying to find the visitor and did not understand why V3 did not help him find the person he was looking for. R8 stated he was very upset by this incident. R8 stated V3 was snotty to him. R8 stated, I don't have cooties. (V3) was being a total B---- (spelled-out expletive) to me for no reason.On 5/7/26 at 12:30 PM, V1 (Administrator) stated the facility was having a party for the nursing staff, so the conference room was full of treats and goodies for staff. V1 stated R8 was looking for a visitor and tried to enter the conference room when V3 told him to look somewhere else. V1 stated she did not think V3 was being abusive toward R8, but V3 (LPN) could have offered to assist R8 in finding the visitor without conflict.On 5/8/26 at 10:25 AM, V3 (LPN) stated she went to the conference room to get a cup of hot chocolate when R8 started to enter the conference room. V3 stated she did not know whether residents were allowed in the conference room, but the conference room table was filled with food for staff, and she did not want R8 to put his dirty hands on the food. V3 stated R8 said he was looking for someone who was not in the conference room, and she did not know where the visitor was, so she told R8 to look elsewhere. V3 stated she did try to close the conference room door but did not slam it or close it aggressively. V3 stated she could have handled the situation differently by assisting R8 in finding the person he was looking for. V3 stated this was an unfortunate situation that should not have gone there. V3 stated R8 was upset over this incident, and V1 (Administrator) was informed at the time it occurred.The facility policy titled Dignity, revised February 2021, documents that all residents have the right to be treated with dignity and respect at all times.

Based on interview and record review the facility repeatedly failed to administer two medications to one (R2) resident causing significant medication errors out of eight residents reviewed for medication administration in a sample list of 33 residents.Findings include:R2's Electronic Medical Record (EMR) documents R2 admitted to the facility on [DATE] and discharged on 11/20/25. This same EMR documents R2's medical diagnoses as Total Left Hip Arthroplasty and revision, Anxiety Disorder, Pain due to internal Orthopedic Prosthetic Devices, Implants and Grafts, Pain in Left Hip, Infection and inflammatory reaction due to internal Left Hip Prosthesis, Joint Derangements of Left Hip and Cerebral Palsy. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. R2's Hospital Discharge Record dated 10/24/25 documents a physician order for Cefepime (antibiotic) 6 Grams continuously by intravenous infusion for six weeks.R2's Physician Order Sheet (POS) dated November 2025 documents a physician order starting 10/24/25 for Cefepime 6 Grams intravenously (IV) continuously every 24 hours for six weeks. This same POS documents a physician order starting 10/25/25 for Heparin Sodium Lock Flush 10 unites/milliliter (ml) 5 ml every day shift for infection after antibiotic and before starting next dose.R2's Medication Administration Record (MAR) dated November 2025 documents R2 was not administered R2's physician ordered IV Cefepime (antibiotic) on November 4, 13, 16, 18, 19 or the 20th. This same MAR documents R2 was not administered R2's Heparin Sodium 5 milliliter (ml) flush on November 4, 5, 7, 10, 13, 16, 19 or the 20th. R2's Nurse Progress Note dated 11/18/25 at 5:42 PM documents R2 came to the nurse's station to inform staff that R2 had cut the antibiotic line to (R2's) Continuous Ambulatory Delivery Device (CADD) pump last night because it was beeping. This same note documents Peripherally Inserted Central Catheter (PICC) line was still intact, flushes well and tubing noted to be in two pieces. This same note documents CADD pump could not be restarted due to no tubing/cartridge was found.R2's Nurse Progress Note dated 11/20/26 at 1:51 PM documents R2's Cefepime could not be administered due to the facility did not have the tubing for R2's CADD pump. On 5/13/26 at 12:30 PM V2 (Director of Nurses/DON) stated R2 was not administered R2's physician ordered Cefepime (antibiotic) on 11/4, 13, 16, 18, 19 and 11/20/25. V2 stated V2 could not find any documentation of why R2's antibiotic was not administered. V2 stated R2's Electronic Medical Record (EMR) documents R2 cut R2's CADD line on 11/18/25 so R2 had to have been administered the scheduled dose but that the antibiotic would not have been completed so R2 missed a partial dose. V2 stated R2 missed R2's complete doses on 11/19 and 11/20/25 due to the facility did not have the specific type of tubing required for a CADD pump. V2 stated facility nurses should administer resident medications per the physician order and if unable to do so then notify the physician and document why a resident's medication was held. V2 stated the facility should have reached out to the physician to see if another antibiotic could be administered orally or if the physician wanted to wait for the tubing to arrive from pharmacy. V2 confirmed R2's IV antibiotic was not administered per the physician order and there is no documentation to identify why it was not given. The facility policy titled Adverse Consequences and Medication Errors revised February 2023 documents a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. This same policy documents an example of a medication error is omission when a drug is ordered but not administered.

Based on observation, interview and record review the facility failed to prevent cross contamination during medication administration for three (R15, R16, R17) residents out of seven residents reviewed for Infection Control in a sample list of 33 residents.Findings include:The facility policy titled Handwashing/Hand Hygiene revised October 2023 documents staff are to perform hand hygiene immediately before touching a resident, after contact with contaminated surfaces, and after touching a resident and/or their environment. This same policy documents hand hygiene is indicated: immediately before and after touching a resident, after contact with contaminated surfaces and after touching the resident's environment. On 5/7/26 between 11:10 AM and 11:20 AM V13 (Licensed Practical Nurse/LPN) administered R15, R16 and R17's scheduled medications without washing V13's hands or using any hand hygiene before, during or after medication administration. V13 touched the medication cart, cards of resident medications, each resident (R15, R16, R17) and the dining room tables where each resident sat in between administering each resident their medications without performing hand hygiene between residents. On 5/7/26 at 11:45 AM V13 (LPN) confirmed V13 did not use any hand sanitizer or use any hand hygiene before, during or after administering medications to R15, R16 and R17. V13 stated V13 did not realize V13 needed to perform hand hygiene since V13 did not touch any of the medications. V13 stated V13 will make sure V13's medication cart has some hand sanitizer on it to help V13 to remember to use it. On 5/8/26 at 9:15 AM V2 (Director of Nurses) stated nurses should use good hand hygiene when administering medications. V2 stated nurses are expected to wash their hands if they are visibly soiled and/or use hand sanitizer between every resident to help reduce the risk of cross contamination.

Based on interview and record review the facility failed to protect resident's right to be free from resident-to-resident verbal abuse. This failure affected one of six residents (R1) reviewed for abuse on the sample list of six. Findings Include:The facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program Policy, dated April 2021, documents that each resident has the right to be free from abuse, including but not limited to verbal abuse.R2's Medical Diagnoses list, dated April 2026, documents that R2 is diagnosed with Major Depressive Disorder and Generalized Anxiety.R2's Minimum Data Set (MDS), dated [DATE], documents that R4 is cognitively intact, has bilateral lower extremity impairment, and uses an electric wheelchair for mobility.R2's Care Plan, dated 4/16/26, documents that R2 has the potential to be verbally aggressive related to mental and emotional illness. R2 exhibits inappropriate social behaviors, including the use of racial slurs, racist comments, and offensive gestures, which can be distressing to others.R2's Nurses Notes, dated 4/11/26, document that R2 was verbally attacking staff and residents and using racial slurs. R2 went into the smoking area and rammed his wheelchair into another resident's (R1's) chair.On 4/20/26 at 12:15 PM, R2 stated he did get into it with R1 because R1 put his two cents in where it didn't belong. R2 stated he was venting about staff to R1 when R1 laughed at him. R2 stated he then started going off on R1. R2 admitted to using the N word (racial slur) toward R1; however, he would not specify exactly what was said. R2 stated he is not racist but can get upset sometimes. R2 stated he does not want to get in any trouble. R2 stated he and R1 are not friends anymore and that is fine.R1's Medical Diagnoses List, dated April 2026, documents that R1 is diagnosed with paraplegia, chronic pain, and a personal history of traumatic brain injury.R1's Minimum Data Set (MDS), dated [DATE], documents that R1 is cognitively intact, has bilateral lower extremity impairment, and uses a manual wheelchair for mobility.On 4/20/26 at 11:45 AM, R1 stated that on 4/11/26, R2 was upset with the nursing staff and came outside to the smoking area where R1 and other residents were smoking and began venting to them. R1 stated R2 was complaining when R1 chuckled at something he was watching on his phone. R1 stated he believes R2 thought he was laughing at him because R2 then started to explode and went off on him. R2 was using profane language and racial slurs, calling R1 a N***** (expletive) lover because R1's wife is black, and his children are biracial. R1 stated he ignored R2 and tried to avoid any altercation. R1 stated R2 got in his face, moved his finger in front of him, and bumped him with his electric wheelchair. R1 stated he does not feel he should have to change his schedule to avoid R2. R1 stated that every time he goes out to smoke, he feels R2 tries to follow him. R1 wants to avoid R2 and does not want to speak to him again. R1 stated that R2 also yells at staff members and often uses racial slurs when upset. R1 stated R2 walks up and down the hallways yelling curse words and racial slurs, including saying [NAME] Hitler and making a Nazi salute. R1 stated he is not afraid of R2; however, R2's constant attempts to confront him are exhausting, and he does not want to feel uncomfortable where he lives.On 4/20/26 at 12:34 PM, R5 confirmed he was present on 4/11/26 when R2 became verbally abusive toward R1. R5 stated R2 is racist and often yells racial slurs in the hallways and toward staff. R5 stated R2 claims to be a Nazi, says [NAME] Hitler, and makes a Nazi salute. R5 stated he feels R2 tries to intimidate people and provoke reactions. R5 stated R2 had his finger in R1's face and was yelling and cursing, calling R1 a B**** (expletive) and a N***** (expletive) lover.On 4/20/26 at 12:52 PM, R4 confirmed she was present on 4/11/26 when R2 became verbally abusive toward R1. R4 stated R2 came outside to the smoking area and began venting about staff. R4 stated R2 was talking while R1 was watching videos on his phone. R4 stated R1 laughed at what he was watching, and R2 thought R1 was laughing at him. R2 then began verbally attacking R1, calling him a B**** (expletive) and a N***** (expletive) lover. R4 stated R2 rammed his wheelchair into R1's wheelchair, got in his face, and pointed his finger at him. R4 stated R1 ignored R2, but R2 continued the behavior. R4 stated she feels safe in the building but that it is concerning they must watch out for R2 because his behavior is unpredictable.On 4/20/26 at 3:30 PM, V1 (Administrator) confirmed R2 has a history of becoming verbally aggressive with other residents and is care planned for this behavior, including the use of racial slurs. V1 confirmed R2 and R1 were involved in a verbal altercation on 4/11/26. V1 stated both residents have been asked to avoid each other; however, both are cognitively intact and refuse to change their schedules to fully avoid one another. Therefore, both R1 and R2 are on 15-minute checks.

Based on observation, interview and record review, the facility failed to provide supervision and ensure a door alarm was audible to staff to prevent a cognitively impaired resident with exit seeking behaviors from eloping from the facility for one of four residents (R4) reviewed for elopement in the sample list of 40 residents. R4 was found eight blocks from the facility by a citizen who called emergency services when they saw R4 wandering in the road. These failures resulted in R4 falling and suffering abrasions to R4's palm and knee and R4 being exposed to significant danger including road hazards, uneven terrain and railroad tracks. Findings include: The immediate jeopardy began on 3/13/26 when R4 eloped unsupervised from the facility.V1 (Administrator) was notified of the Immediate Jeopardy on 3/27/26 at 3:53 PM. The facility presented an abatement plan to remove the immediacy on 3/27/26. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility three separate times on 3/31/26 for revisions. The facility presented a fourth revised abatement plan on 4/1/26 and the survey team accepted the fourth revision of the abatement plan on 4/1/26.The surveyor confirmed by observation, interview and record review that the immediacy was removed on 4/1/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training through ongoing Quality Assurance Performance Improvement (QAPI) review. R4's Electronic Medical Record (EMR) documents R4 admitted to the facility on [DATE] with medical diagnoses of Dementia with behavioral disturbance, Alzheimer's Disease, Anxiety, need for assistance with personal care and Major Depressive Disorder. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 requires supervision for bed mobility, transfers and walking up to 150 feet. R4's Elopement assessment dated [DATE] documents R4 as a high risk for elopement. R4's Social Service assessment dated [DATE] documents R4 has a behavior of wandering. R4's Care Plan focus area dated 12/11/25 documents R4 is at risk for wandering and/or elopement. This same care plan documents R4 may demonstrate a risk of leaving the facility unattended due to impaired safety awareness. This same care plan documents an intervention dated 12/11/25 that instructs staff to monitor R4's location and distract R4 from wandering by offering pleasant diversions, structured activities, food, conversation, television and/or a book. This same care plan documents an intervention dated 2/25/26 that instructs staff to visualize R4 every fifteen minutes. R4's Behavior Tracking dated 2/24/26, 2/25/26, 2/28/26 and 3/3/26 documents R4 was exit seeking and/or attempting to elope. R4's Nurse Progress Note dated 2/11/26 at 2:06 AM documents R4 was wandering into other resident rooms. This same note documents R4 was agitated with redirection and expresses that he is upset. R4's Nurse Progress Note dated 2/27/26 at 5:17 AM documents R4 was yelling out curse words to his roommate, yelling at the staff, following the staff around, and physically punching staff a couple of times. This same note documents staff continued to try to redirect R4 without success. R4's Community Survival Skills Screen dated 3/5/26 documents R4 is not able to safely navigate on community streets. This same screen documents R4 is not aware of potentially dangerous situations such as straying into an alley or taking rides from strangers and is not capable of unsupervised outside pass privileges. R4's Discharge Quarterly progress note dated 3/5/26 at 11:37 AM documents R4 is forgetful and has safety concerns. This same note documents R4 has special care needs identified of requiring 24-hour supervision and/or monitoring. R4's Nurse Progress Note dated 3/13/26 at 3:32 PM documents (V4) Licensed Practical Nurse (LPN) was notified that R4 had exited the facility. (V4) and facility staff returned (R4) to the facility. (R4) was able to walk into the facility. (R4) has a contusion to his Right Knee and two abrasions to his Right Palm of his hand. (R4) was able to move all of his extremities. (R4) was alert and oriented to self only which is baseline. R4's Nurse Practitioner Progress Note dated 3/13/26 at 2:49 PM documents staff notified V32 (Nurse Practitioner) of R4's incident. This same note documents R4 exited the building and sustained a fall outside. R4 was unable to give history of events due to R4's Dementia. R4 was noted to have blood on his pants at the area of his Right Knee. R4's Right Hand was wrapped with gauze and elastic bandage. Staff reports R4's fall was unwitnessed. R4 has limited ability of making his needs known. R4 is unable to follow commands without extreme focus which is his baseline. R4's Fall Risk Evaluation dated 3/13/26 documents R4 as a risk for falling. R4's AIM for Wellness Note dated 3/13/26 documents R4 eloped from the facility unsupervised obtaining two abrasions to his Right Palm and one contusion to his Right Knee. This same report documents a precursor to this event is that R4 wanders frequently. The environment was noisy and busy. R4's Skin Only Evaluation dated 3/13/26 documents R4 obtained a Right Palm abrasion measuring 4.0 centimeters (cm) long by 0.2 cm wide by 0.1 cm deep, a second Right Palm abrasion measuring 1.0 cm long by 0.5 cm wide by 0.1 cm deep and a Right Knee contusion measuring 1.0 cm long by 1.0 cm wide. R4's Nurse Progress Noted dated 3/18/26 at 11:51 PM documents (R4) awake, making his fist, asking to leave and attempted to use the bathroom here at the nurse's station. (R4) continues asking to leave. (R4) given snacks. (R4) asking for Certified Nurse Aides (CNA) to open the door so he can leave. Staff stated 'No', then (R4) makes a fist then grunts. (R4) then raises his hand pointing his Right Index finger at CNA. (R4) continues attempting to sit at nurse's desk. Multiple attempts to redirect (R4). On 3/19/25 at 1:05 PM R4 was sitting on the side of his bed mumbling incoherently to himself. R4 was not able to answer simple, direct questions such as What is your name?. On 3/19/26 at 2:50 PM V36 (Interim Maintenance Director) physically tested the alarms on the facility exit doors. V36 stated he has been doing exit door alarm checks daily since 3/13/26 by pushing on the alarm bar on the door but not pushing the door open. V36 stated he has been doing the exit door checks at 7:00 AM and did not want to wake up any residents that early by pushing the exit doors open to hear their alarm. V36 pushed onto the alarm bar of the exit door and an intermittent beep was heard seven times, then it changed to a continuous beep. There was no audible sound at the 200-hall nurse's desk. V36 pushed the 200-hall exit door open and no other alarm sounded. The facility 100-hall exit door was the same as the 200-hall door when V36 tested the door alarms. On 3/19/25 at 1:10 PM V27 (Licensed Practical Nurse/LPN) stated she did not know if the facility had folders or binders that showed which residents are at a high risk for eloping. V28 (Certified Nurse Aide/CNA) retrieved a binder that included a list of and face sheets for residents who are at a high risk for elopement. V27 (LPN) stated again she did not know there was such a thing. On 3/19/25 at 1:30 PM V28 (CNA) stated V14 (CNA) and V28 were working on R4's hall on 3/13/26. V28 stated there had been another CNA working with V14 and V28, but that employee had left prior to R4 eloping. V28 stated V14 and V28 were assisting another resident in a resident room with the door closed and did not hear any alarms sounding when R4 eloped from the facility. V28 stated V14 and V28 were the only staff on the hall at the time R4 eloped due to V4 (LPN) was in the dining room with the other residents who were still eating lunch. On 3/19/26 at 1:35 PM V4 (LPN) stated R4 was supposed to be on 15-minute visual checks but the staff were busy assisting other residents. V4 stated R4 was last seen around 12:15 PM when he was entering another resident's room. V4 stated V30 (CNA Supervisor) assisted R4 out of the other resident's room and guided R4 back to the nurse's station on his own hall. V4 stated she received a phone call from Emergency Medical Service (EMS) at 1:15 PM asking if R4 was a resident at the facility and if so, if he was accounted for. V4 stated she reported to EMS personnel that she was not aware of R4's whereabouts and would do a head check. V4 stated when the facility staff were unable to find R4, V4 and V29 (Social Service Director/SSD) used the facility van to drive to R4's location. V4 stated that would be eight or ten blocks away. V4 stated R4 would have to cross the railroad tracks to get to where he was found. On 3/19/26 at 1:40 PM V14 (CNA) stated V14 and V28 (CNA) were both in a resident room assisting another resident when R4 eloped from the facility. V14 stated she did not hear any alarms sounding. V14 stated she did not know how R4 eloped but that he was located by emergency medical services (EMS) in a neighborhood across the railroad tracks and across a busy street from the facility. V14 stated she knew R4 was in the dining room eating lunch but did not know how long R4 had been missing. V14 stated someone who lived in that neighborhood called 911 when they saw R4 wandering in their yard. V14 stated V4 (LPN) and V29 (SSD) drove the facility van over to the other neighborhood after EMS called the facility to inquire if R4 resided in the facility. V14 stated R4 was wearing a long sleeve shirt, pants and no skid socks with no shoes. V14 stated R4 told staff he was out looking for his lost dog. On 3/19/26 at 1:45 PM V31 (Human Resources Director) stated V31 and V21 (Business Office Manager) took turns monitoring the front door on 3/13/26 during lunch service. V31 stated she took her own lunch break leaving V21 to monitor the front door. V31 stated she did not hear any alarms sounding during the time she was by the front door. On 3/19/26 at 1:50 Pm V30 (CNA Supervisor) stated she saw R4 enter another resident room between 12:00 PM and 12:15 PM on 3/13/26. V30 stated she assisted R4 back to his nurse's station area and there were no staff present on the hall. V30 stated V14 (CNA) and V28 (CNA) were both busy in another resident's room and V4 (LPN) was still in the dining room monitoring other residents during lunch. V30 stated she was told R4 eloped unsupervised from the facility. V30 stated there are only two ways R4 could have gotten to where he was found. V30 stated R4 would have had to walk around the building to the back yard area or walk the sidewalk down the street, turn left on a very busy street and then turn left again on to the cul-de-sac street where he was found by a community member. V30 stated either way R4 went he would have to cross railroad tracks that are in use. V30 stated R4 could have fallen on the railroad tracks or on the sidewalk or on a road while crossing. V30 stated the facility does not know for sure which door R4 eloped from but believe R4 walked out the front door. V30 stated she did not hear any alarms sound during this time. V30 stated R4 was wearing a long sleeve shirt, pants, no skid socks with no shoes on and was not wearing a hat. V30 stated R4 was previously on 15-minute visual checks due to his high risk of elopement. V30 stated the staff did not complete the visual checks as were care planned. V30 stated R4 wanders 'all over the place' and is at high risk for eloping unsupervised due to his attempts to push on the exit doors and his poor cognition due to Dementia. On 3/19/26 at 2:00 PM V29 (SSD) stated she was not present during lunch on 3/13/26 because she was out doing some shopping for residents. V29 stated when she returned from the resident shopping trip, she was informed by V4 (LPN) that R4 had eloped. V29 stated V29 and V4 used the facility van to go pick up R4. V29 stated R4 probably walked out the front door and R4 would have had to walk around the back of the facility, or he would have followed the sidewalk down several blocks to a busy street to turn left again onto another street and then down a few more blocks to where he was located. V29 stated R4 would have had to cross railroad tracks and maneuver over several curbs, busy roads and steep decline/inclines on each side of the railroad tracks. On 3/20/26 at 9:40 AM V37 (R4's family member) stated the facility called her on 3/13/26 to inform her that R4 had escaped and was found by the staff. V37 stated she was told that R4 did not leave the facility property and was found by staff in the grassy area just beyond the resident smoking area. V37 stated R4 has attempted to elope twice before by pushing the exit doors open. V37 stated R4 attempted to exit the front door once, the alarm sounded, and the staff responded by redirecting R4 back into the facility. V37 stated R4 attempted to elope a second time on 3/18/26 after yelling and punching the staff. On 3/20/26 at 10:55 AM V22 (Regional Maintenance Director) stated all the facility exit doors have been tested and are functioning properly. V22 stated there was a 30 second delay on the front door that was changed to a ten second delay. V22 stated when the front door alarm bar was pushed its alarm sounded but the 'loud alarm' on the front door was set to 30 seconds which means the 'loud alarm' would not sound unless the door was opened for more than 30 seconds. V22 stated if no one were up by the front door to hear the alarm, a resident could pass through the front door within 30 seconds without anyone knowing. On 3/20/26 at 11:15 AM V32 (Nurse Practitioner/NP) stated she was in the facility on 3/13/26 when R4 eloped. V32 stated she was in a resident room when R4 followed V32 into the room. V32 stated V30 (CNA Supervisor) assisted R4 back to his nurse's station. V32 stated she was not certain of the time but stated it may have been around 12:30 PM. V32 stated R4 was especially [NAME] on 3/13/26. V32 stated EMS was called by a community member from a local neighborhood due to R4 wandering around their yard/driveway. V32 stated EMS assessed R4 at the location where he was found and made the decision to not take R4 to the emergency room. V32 stated R4 did have an abrasion on his right knee and right palm from an unwitnessed fall. V32 stated she had not been notified of any other of R4's elopement attempts. V32 stated she was aware of only one incident which happened on 3/13/26. V32 stated the facility should have completed the 15-minute visual checks and followed R4's Care Plan to ensure his safety. On 3/20/26 at 1:50 PM V24 (LPN) stated she was R4's nurse on the early morning of 2/27/26 when R4 did have multiple behaviors. V24 stated R4 was stalking the staff up and down the hall, trapped staff behind the nurse's station and was menacing to staff. V24 stated R4 was walking up and down the halls and repeatedly attempted to exit the facility but staff intervened before R4 was able to exit the facility. V24 stated R4 was overly aggressive, menacing and hollered at staff Let's go! Open the door!. On 3/20/26 at 3:15 PM V23 (LPN) stated 3/18/26 was her first night working at this facility and remembers R4 well. V23 stated R4 was very agitated. V23 stated R4 walked around the corner of the nurse's station where V23 was and yelled I need the door. I need the door. V23 stated R4 raised his fist at staff threatening to hit staff. V23 stated staff did try non-pharmacological interventions such as providing snacks. V23 stated R4 did not exit the facility but did need to be redirected away from the exit doors multiple times. The Immediate Jeopardy that began on 3/13/26 and the immediacy was removed on 4/1/26 when the facility took the following actions. 1. R4 was assessed on 3/13/26 by V4 (Licensed Practical Nurse /LPN) at the location R4 was found by the concerned citizen and again at the facility by V32 (Nurse Practitioner). 2. V41 (MDS/Care Plan LPN) stated she reviewed R4's care plan on 3/13/26. V1 (Administrator) stated V1, V2 (Director of Nursing/DON) and V17 (Assistant Director of Nursing/ADON) all in-serviced staff on R4's elopement interventions on 3/13/26. 3. On 3/20/26 at 10:55 AM V22 (Regional Maintenance Director) stated there was a 30-second delay with the front door that was changed to a ten second delay on 3/20/26. 4. On 3/31/26 the facility exit door alarms produced a ringing sound that were heard by V42 (CNA) and V43 (Social Service Assistant/SSA) when they were inside a resident room. Staff were observed rushing to the sounding door alarms. 5. On 3/17/26 upon entry for survey there was a notice posted on the doors. V1 (Administrator) stated she is monitoring the door notices during the audit period and will continue to visualize the door signs ongoing after the audit has concluded. 6. V2 (DON) stated R4 was on continual observation from 3/13/26-3/16/26 and then reinstated to the 15-minute visuals after the conclusion of the three days of continual observations. V2 stated staff were in-serviced on R4's individual elopement interventions on 3/13/26. General staff In-services on Safety and Elopement are dated 3/16/26 and 3/17/26. 7. V41 (MDS/Care Plan LPN) stated she started the review of care plans of residents who are at high risk for elopement on 3/13/16. V41 stated this review is ongoing and she has not been through the entire list yet. V41 stated she added R37, R39 and R40's elopement care plan on 3/30/26. V1 (Administrator) stated the facility reviewed all of the resident care plans who are at high risk for elopement on 3/13/26 and V41 then found that none of the residents listed as high risk had an elopement care plan. V1 stated a thorough review of all residents at any level of risk of elopement was completed on 4/1/26. V1 stated all residents at risk for elopement have elopement care plans in place as of 3/30/26 but the facility was not certain of this until 4/1/26. V1 stated a care plan for resident wandering is not the same as an elopement care plan. 8. V1 (Administrator) confirmed all residents at any level of risk for elopement have the potential to be affected. 9. In-services on Missing Resident Policy and Safety/Supervision Policy were conducted on 3/16/26 and 3/17/26 by V1 (Administrator) and V2 (DON) for all staff. V8 (Regional Director of Operations) stated the facility uses one agency for staffing needs. V8 stated the agency has been notified and provided two separate in-services for any agency staff to complete prior to picking up a shift. 10. V31 (Human Resources) stated she provides education on elopement/safety for all newly hired staff. V31 stated this is an ongoing process. 11. V1 (Administrator) stated V17 (ADON) reviewed the elopement binders on all halls. V1 Administrator stated the elopement binder on each hallway was updated on 4/1/26. 12. V1 Administrator stated the elopement drills were conducted on 3/16/26 and 3/17/26 which included 100% of their staff either on site or by phone. 13. V2 (DON) stated any residents on 15-minute visuals were monitored. V2 stated the staff were educated on monitoring residents on 15-minute visuals and documenting the visual observations every 15 minutes. Facility audit initiated on 3/16/26. 14. V36 (Maintenance Director) stated the door alarm checks began 3/13/26. V36 stated he has checked the door alarms every day by pressing on the cross bar of each exit door without pushing the door open. V36 stated he began checking the exit door alarms by pushing the cross bar and pushing the door open on 3/20/26. V1 (Administrator) stated the facility has a new QA nurse who starts next week (4/6/26) who will work every weekend and be responsible for checking the alarms and has already been instructed on how to check door alarms and documenting the door alarm checks are to be completed. 15. V1 (Administrator) stated the facility had an ad hoc Quality Assurance Performance Improvement (QAPI) meeting on 3/13/26. V1 stated the facility has not had another QAPI meeting but plans to discuss Missing Resident/Safety and Supervision and Elopement Policies, in-services and audits completed and/or in progress to ensure the safety of the residents. 16. V1 (Administrator) stated elopement drills are ongoing. V1 stated the last drill was completed on 3/16/26 and 3/17/26 and will be due again 'around' 4/16/26. 17. On 4/1/26 at 1:25 PM V1 (Administrator) stated IDT meets daily Monday through Friday. V1 and V2 (DON) stated the IDT discussed any new residents who were assessed to be an elopement risk and any changes in behaviors for established residents. V1 stated they were not aware that the initial list of residents at risk for elopement had not been reviewed until 4/1/26.

Based on interview and record review the facility failed to initiate an elopement care plan for three (R37, R39, R40) residents out of four residents reviewed for elopement in a sample list of 40 residents. Findings include:1.R40's Electronic Medical Record (EMR) documents medical diagnoses as Dementia, Disorganized Schizophrenia, Anxiety, Major Depressive Disorder, Psychotic disorder with Delusions, Mild Intellectual Disabilities and unsteady on Feet. R40's Minimum Data Set (MDS) dated [DATE] documents R40 as severely cognitively impaired. R40's Elopement Risk assessment dated [DATE] documents R40 as being a high risk for elopement. R40's Elopement care plan was initiated 3/30/26. This same care plan did not include a focus area, goal nor interventions prior to 3/30/26 for R40's high risk for elopement. 2.R37's Minimum Data Set (MDS) dated [DATE] documents R37 as cognitively intact. R37's Elopement Risk Evaluation 2/12/26 documents R37 as a high risk for elopement. R37's Elopement care plan was initiated 3/30/26. This same care plan did not include a focus area, goal nor interventions prior to 3/30/26 for R37's high risk for elopement. 3. R39's Minimum Data Set (MDS) dated [DATE] documents R39 as cognitively intact. R39's Elopement Risk Evaluation 12/23/25 documents R39 as a high risk for elopement. R39's Elopement care plan was initiated 3/30/26. This same care plan did not include a focus area, goal nor interventions prior to 3/30/26 for R39's high risk for elopement. On 4/1/26 at 11:35 AM V41 (MDS/Care Plan Licensed Practical Nurse) stated she started reviewing resident charts who were at high risk for elopement on 3/13/26. V41 stated she is still in the process of the initial review and has not looked at any resident care plan that was considered low or moderate risk for elopement yet (4/1/26). V41 stated she added elopement care plans for R37, R39 and R40 on 3/30/26. V41 stated she was unsure if any of the residents assessed as low or moderate risk for elopement have had their care plans reviewed yet. On 4/1/26 at 1:25 PM V1 (Administrator) stated all residents who are at any level of risk for elopement should have had their care plan initiated, reviewed and/or updated by 3/16/26. V1 stated after the initial review and updating on 3/16/26 the Interdisciplinary Team (IDT) should have reviewed all care plans for those residents at risk for elopement weekly. V1 stated the care plans should have been updated on 3/16, then reviewed on 3/23 and again on 3/30. V1 stated the elopement care plans should have been initiated when each resident (R37, R39, R40) was first assessed as being at risk for elopement. V1 stated V41 should have initiated R37, R39 and R40's care plans on 3/16/26 when updating all resident care plans who are at risk for elopement. V1 confirmed R37, R39 and R40's Elopement care plans were initiated on 3/30/26. The facility policy titled The Safety and Supervision of Residents dated 2001 documents the facility Quality Assurance Performance Improvement (QAPI) committed and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary. The QAPI committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks and hazards shall include communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training, as necessary, ensuring that interventions are implemented, and documenting interventions. The facility will monitor the effectiveness of interventions by ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed and evaluate the effectiveness of new or revised interventions.

Based on interview and record review the facility failed to protect a resident's right to be free from staff to resident physical and emotional abuse which caused skin tears to the resident's arm and severe emotional distress. This failure affected one of three residents (R93) reviewed for abuse on the sample list of 39. Findings Include: The facility's Abuse Prevention Program dated February 2021 documents that the facility affirms residents' rights to be free from abuse. This includes freedom from physical restraint, mistreatment, or abuse of any resident. Abuse is defined as the willful infliction of injury, intimidation, or punishment resulting in harm, pain, or mental anguish. Willful means the individual acted deliberately; it does not require intent to inflict injury or harm.R93's Medical Diagnoses list dated January 2026 documents diagnoses of Congestive Heart Failure, right and left above-the-knee amputations, neuromuscular bladder dysfunction, generalized anxiety, depression, and a pressure ulcer of the buttocks.R93's Minimum Data Set (MDS) dated [DATE] documents R93 is cognitively intact, has no documented behaviors, requires substantial to maximum assistance with rolling side to side, and is dependent on staff for toileting hygiene. R93 has a urinary catheter and is always incontinent of bowel.R93's Abuse Final Report dated 1/13/26 documents R93 reported that two night-shift Certified Nursing Assistants (CNAs), V34 and V35, were rough with him during care. Both CNAs were agency staff and were not permitted to return to work at the facility.On 1/20/26 at 11:30 AM, R93 was observed sitting in his wheelchair in his room. R93 had a dressing on his right forearm. R93 stated that approximately one week prior, during the early morning hours, two CNAs entered his room to provide incontinent care. R93 stated he requires staff assistance with incontinence care due to bilateral lower-extremity amputations. R93 stated he did not know the identities of the two CNAs, had never seen them prior to that night, and had not seen them since. R93 stated the CNAs called him derogatory names and pinned him down in bed by holding his arms. R93 stated he was incontinent with a large amount of diarrhea and that both CNAs were upset with him for requiring cleanup. R93 stated one CNA had very long fingernails, which caused skin tears on his arms. R93 stated he became very upset and yelled at the CNAs, calling them names. R93 stated he then took a drink of his pop, and the same CNA who had held his arms down struck his hand so hard that the drink flew out of his hand. R93 stated V1 (Administrator) informed him the two CNAs had been suspended and would not work at the facility again.On 1/28/26 at 1:29 PM, V25 (CNA) stated she arrived at work at 6:00 AM on 1/13/26 and heard R93 yelling from his room. V25 stated she went directly to R93's room and observed him crying uncontrollably. V25 stated she had never previously seen R93 cry and described him as extremely distraught. R93 told V25 he intended to report the night-shift CNAs for abuse and mistreatment. V25 stated it took some time for R93 to calm down. V25 stated R93 told her one CNA held his arms down and tore the skin on his arm. V25 stated she examined R93's arms and observed two fresh skin tears on his left arm, both shaped in a manner consistent with fingernail injuries. V25 stated R93 reported the CNAs removed the pillow from under his head while changing him and that after the incident, he told them to leave his room. V25 stated R93's bedding and pillow were covered in feces and feces were present on the floor. V25 stated R93 told her when he attempted to take a drink of his pop, the CNA who held his arms down struck the bottle, causing it to fly across the room. V25 stated the pop was dried and sticky on the floor, and the bottle was located across the room. V25 stated R93 admitted he yelled profanities at the CNAs because he was upset about how he was treated. V25 stated she had never known R93 to act in that manner, does not believe R93 makes false allegations, and stated R93 typically allows staff to provide care and does not refuse assistance. V25 stated R93 only wants to be treated respectfully and does not want to be left lying in his own feces.On 1/28/26 at 1:53 PM, V36 (Registered Nurse/RN) stated she was asked to complete a skin assessment on R93 following an allegation of abuse occurring on 1/13/26. V36 stated R93 reported night-shift CNAs grabbed his arms, held him down, and that a CNA's fingernails tore his skin. V36 stated she observed dried blood on R93's left arm. V36 observed a skin tear on the left forearm and, adjacent to it, a crescent-shaped indentation that broke the skin and had blood present. V36 stated the injury appeared consistent with a fingernail.On 1/28/26 at 2:00 PM, V34 (Agency CNA) stated she worked with R93 on the night shift between 1/12/26 and 1/13/26. V34 stated she and another CNA (V35) entered R93's room to provide care and that R93 became upset. V34 stated R93 became combative and admitted she held his wrists down on the bed. V34 stated R93 was so upset that they were unable to complete care and left him soiled until the next shift.On 1/29/26 at 10:11 AM, V2 (Director of Nursing) stated staff should never antagonize a resident or restrain a resident by holding their arms. V2 stated R93 is typically very cooperative with staff and does not become upset when treated respectfully. V2 confirmed R93 is not known to make false allegations. V2 confirmed R93 alleged emotional and physical abuse and stated staff should never treat a resident in that manner.

Based on interview and record review the facility failed to implement pressure relieving measures timely, failed to complete a thorough skin assessment weekly and failed to prevent one (R107) resident's right heel pressure ulcer from worsening to a stage IV out of three residents reviewed for pressure ulcers in a sample list of 39 residents. R107 obtained a Stage IV pressure ulcer to her right heel at the facility. Findings include:R107's undated Face Sheet documents R107 was admitted to the facility on [DATE].R107's Electronic Medical Record (EMR) documents medical diagnoses of chronic respiratory failure with hypoxia, cognitive communication deficit, vitamin D deficiency, asthma with acute exacerbation, atelectasis, iron deficiency, delusional disorder, pulmonary embolism without acute cor pulmonale, morbid obesity, cellulitis of the right lower limb, fatty liver, hepatic encephalopathy, and a right heel Stage IV pressure ulcer.R107's Minimum Data Set (MDS) dated [DATE] documents R107 is moderately cognitively impaired. The MDS further documents R107 is dependent on staff for assistance with oral hygiene, bathing, dressing, toileting, personal hygiene, bed mobility, and transfers.R107's Pressure Risk assessment dated [DATE] documents R107 was at risk for developing a pressure ulcer.R107's Nurse Progress Note dated 2/4/25 at 10:01 PM documents new open areas to R107's right heel. The note documents the right heel tissue was black with bloody drainage, red wound edges, and edema.R107's Skin-Only Evaluation dated 2/4/25 documents the plantar surface of R107's right heel had an open area measuring 0.9 cm long x 1.0 cm wide x 0.1 cm deep with bloody drainage and necrotic tissue. The evaluation further documents the posterior aspect of the right heel had an open area measuring 2.0 cm long x 2.0 cm wide, with no depth documented, and necrotic tissue with bloody drainage. The evaluation also documents R107's left heel was red, with no measurements or further assessment documented.R107's Nurse Progress Note dated 2/13/25 at 2:41 PM documents V41, Wound Physician, was notified of a wound care referral. The note documents a new physician order for R107 to wear a heel guard and that wound supplements were ordered for R107's right heel Stage III pressure ulcer.R107's EMR does not document a full wound assessment of R107's right heel pressure ulcer upon R107's return from the hospital on 2/13/25.R107's Wound Evaluation and Management Summary dated 2/20/25 documents an initial visit for R107's right heel Stage IV pressure ulcer measuring 4.0 cm long x 3.0 cm wide x 0.2 cm deep.On 1/27/26 at 3:05 PM, V10 (Licensed Practical Nurse/LPN), stated V41 (Wound Physician) saw R107 on 2/20/25 for her right heel. V10 stated she observed R107's right heel during wound rounds on 2/20/25 and that the wound appeared worse than when R107 returned from the hospital. V10 stated V41 categorized the wound as a Stage IV pressure ulcer on 2/20/25.On 1/28/26 at 11:10 AM, V7 (LPN) stated R107 had a significant pressure ulcer on her right heel. V7 stated the facility identified the wound on 2/4/25 as facility-acquired; however, R107 was hospitalized from [DATE] to 2/13/25. V7 stated R107 did not want to do anything and preferred to lie on her back in bed. V7 stated R107's heels rested directly on the bed for the majority of each day. V7 stated the facility should have obtained heel protectors upon R107's admission.On 1/28/26 at 2:10 PM, V18 (Regional Registered Nurse/RN), stated the facility was unable to provide documentation of a right heel wound assessment upon R107's readmission from the hospital. V18 stated the facility should document skin assessments, especially when a resident returns from the hospital. V18 stated the facility would provide education to nursing staff regarding timely assessments, interventions, and pressure ulcer prevention.The facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018, documents the nurse shall describe and document a full assessment of a pressure ulcer, including location, stage, length, width, depth, and the presence of exudate or necrotic tissue. The policy further documents staff and practitioners will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions.

Based on interview and record review, the facility failed to implement fall prevention interventions and failed to maintain a safe environment for two residents (R7 and R107) out of six residents reviewed for falls in a sample of 39 residents. R107 experienced pain and fear as a result of falling, as well as a closed head injury and multiple contusions following a fall on 1/1/25. R107 required further evaluation of her injuries in an emergency room following falls on 1/1/25 and 1/8/25 due to having a physician order for Xarelto (anticoagulant therapy). Findings include: 1.R107's Electronic Medical Record (EMR) documents medical diagnoses as Chronic Respiratory Failure with Hypoxia, Systolic Heart Failure, Schizophrenia, Cognitive Communication Deficit, Vitamin D Deficiency, Atelectasis, Iron Deficiency, Delusional Disorder, Pulmonary Embolism without acute Cor Pulmonale, Morbid Obesity, Cellulitis of Right Lower Limb, and Hepatic Encephalopathy. R107's Minimum Data Set (MDS) dated [DATE] documents R107 as moderately cognitively impaired. This same MDS documents R107 as being dependent on staff for assistance with oral hygiene, bathing, dressing, toileting, personal hygiene, bed mobility and transfers. R107's Fall Care Plan initiated 12/19/24 documents the root cause of R107's falls as dizziness upon standing. R107's Care Plan intervention dated 1/4/25 documents R107 is to utilize a wheelchair. This same Care Plan documents an intervention dated 1/8/25 for staff to assist R107 to the dining room and assist R107 to a chair. This same Care Plan documents an intervention dated 2/28/25 to keep a bedside table for personal items within reach. R107's Fall Risk Evaluation dated 12/18/2024 documents R107 as being a high fall risk. R107's Physician Order Sheet (POS) dated January and February 2025 document a physician order starting 11/27/24 for Rivaroxaban (anticoagulant) 15 milligrams (mg) twice daily for Pulmonary Embolism. R107's Nurse Progress Note dated 1/1/2025 at 1:02 PM documents R107 had an unwitnessed fall in the resident common area. This same note documents R107 stated she attempted to stand, felt dizzy, fell and hit her head. This same note documents R107 was noted to have a large purple bruise on her Coccyx/Sacral area. This same note documents R107 was sent to the hospital for evaluation. R107's fall investigation dated 1/1/25 documents R107 had an unwitnessed fall in the resident common area. This same fall investigation documents R107 tried to stand up, felt dizzy and fell back and hit her head on the floor. This same investigation documents R107 was sent to the emergency room for further evaluation due to R107 takes an anticoagulant. R107's Hospital Record dated 1/1/25 documents R107 fell at the facility obtaining a closed head injury, cervical strain and contusions of her Left Knee, Right Knee, Left Forearm and Left Shoulder. R107's Nurse Progress Note dated 1/1/25 at 9:00 PM documents R107 returned to the facility. This same note documents R107 obtained a status post fall closed head injury, cervical strain, contusion of Left Knee, Right Knee, Left Forearm and Left Shoulder. This same note documents physician orders to rest, apply ice, elevate affected extremities and wear ace wrap to Left Forearm and bilateral knees. R107's Nurse Progress Note dated 1/5/25 at 1:07 PM documents R107 stayed in her room all shift. This same note documents R107 stated 'I'm scared to come out because I don't want to fall. I'm not coming out.' R107's Nurse Progress Note dated 1/7/25 at 6:16 PM documents R107 refused to get out of bed unless up in a wheelchair. This same note documents R107 stated she is not coming out (of her room) due to she is scared of falling. This same note documents R107 refused to take herself to the bathroom and is choosing to soil herself. R107's Nurse Progress Note dated 1/8/25 at 12:43 PM documents R107 was walked to the dining room with staff assistance. This same note documents R107 walked over to a different chair and fell to the floor. This same note documents this fall was witnessed by V43 (Certified Nursing Assistant/CNA) who stated she 'watched (R107's) head bounce off of the floor'. R107's fall investigation dated 1/8/25 documents R107 had a witnessed fall in the facility dining room. This same fall investigation documents R107 was walking independently to move to another chair and R107 missed the chair falling to the floor and hit her head. R107's Hospital Record dated 1/8/25 documents R107 obtained a Hematoma to the posterior aspect of R107's scalp due to her falling on 1/8/25 at the facility. R107's Fall Investigation dated 2/28/25 documents R107 had an unwitnessed fall out of her bed because she was reaching for candy due to R107 did not have a bedside table. R107's fall investigation dated 2/28/25 documents R107 had an unwitnessed fall in her room. This same investigation documents R107 was found on the floor with feet towards the window and head propped up on the side of the bed. Investigation documents R107 stated 'she was reaching for a piece of candy and slid out of bed'. This same investigation documents R107 did not have any injuries. R107's Nurse Progress Note dated 3/1/25 at 5:56 PM documents the root cause of R107's unwitnessed fall on 2/28/25 as R107 was reaching for her personal items at her bedside and slid out of bed. This same note documents the intervention for R107's fall was to keep a bedside table at R107's bedside. On 1/27/26 at 3:00 PM V10 (Licensed Practical Nurse/LPN) stated R107 fell out of her bed on 2/28/25 due to R107 was trying to reach over to her bedside dresser to get some candy. V10 stated R107 did not have a bedside table in her room. V10 stated if R107 had a bedside table she would not have had to reach so far and most likely not fallen out of her bed. V10 stated it is standard for all residents to have a bedside table and there was no reason R107 did not have a table to put her personal belongings on. R107's fall on 2/28/25 could have been prevented if R107 had a bedside table. V10 stated since R107 was on a low air loss mattress R107 should have had a bedside table to prevent her from falling out of bed. On 1/28/26 at 11:05 AM V7 (LPN) stated she was R107's nurse regularly. V7 stated the staff knew R107 had been dizzy every time she stood up and 'really nothing had been done about it'. V7 stated the staff should have been monitoring R107 closer since 'we knew she was sitting on the bench, and she would be going to the dining room for lunch'. V7 stated R107 hit her head on the hard floor then complained of a headache so she was sent to the emergency room. V7 stated R107 had a 'large' bruise on her Sacral area. R107's fall on 1/1/25 could have been prevented with closer supervision due to the staff knew for 'a few days' that R107 was not feeling good and complained of dizziness with standing. V7 stated R107 fell again on 1/8/25 after therapy walked R107 to the dining room but did not leave a wheelchair for her to use. V7 stated R107 was supposed to use a wheelchair at that point and she did not have one to use. V7 stated R107 wanted the wheelchair and would have used it instead of trying to walk. V7 stated R107 was scared to walk alone and would have used the wheelchair. V7 stated R107's fall on 1/8/25 could have been prevented if R107 had a wheelchair accessible. V7 stated R107 wanted to use the wheelchair due to her fear of falling again. On 1/29/26 at 9:50 AM V18 (Regional Registered Nurse/RN) stated the facility does not have any documentation to show that fall interventions were in place at the time of R107's falls. V18 stated all residents should have a bedside table. V18 stated that it is a standard piece of equipment and does not know why R107 did not have a bedside table in her room. V18 stated staff should have been supervising R107 if they had known she was complaining of being dizzy when standing. V18 stated a wheelchair should have been left with R107 in the dining room so she wouldn't have walked over to another chair. V18 stated the staff should follow the interventions put into place to help reduce a resident's falls. The facility policy titled Falls-Clinical Protocol revised March 2018 documents After a first fall, the staff (and physician, if possible) should watch the individual rise from a chair without using his or her arms, walk several paces, and return to sitting. If the individual has no difficulty or unsteadiness, additional evaluation may not be needed. If the individual has difficulty or is unsteady in performing this test, additional evaluation should occur. 2. R7's Medical Diagnoses list dated January 2026 documents R7 is diagnosed with Chronic Obstructive Pulmonary Disease, Fractured Left Tibia, Disorder of Muscles, Lack of Coordination, Gait Abnormalities, Muscle Wasting, Phantom Limb Syndrome, and Right Above the Knee Amputation. R7's Physician Order Sheet dated January 2026 documents a physician order for a left half side rail in the up position while in bed to enhance bed mobility. Staff should check positioning and functioning of device. R7's Health Status Note dated 12/17/25 documents R7 was heard yelling from her room. Staff went in to check on R7 and found her sitting on the floor by her bed. The left side rail was on the floor beside her. R7 stated she attempted to sit up on the side of the bed, using the side rail, when it fell off the bed frame, causing R7 to fall with it onto the ground. On 01/22/2026 10:45 AM V15 (Maintenance Director) stated nursing staff often remove or replace side rails on resident's beds and do not secure them to the bed frames properly. V15 stated this is what he believes happened when R7's bed rail came off the frame and caused her to fall. V15 confirmed the bed rail was not properly secured. On 1/22/26 at 3:00 PM V2 (Director of Nurses) confirmed only maintenance staff are to remove and install bedrails. V2 confirmed the bedrails need to be installed correctly to be safe and not pose a hazard for residents. V2 confirmed when R7 fell from her bed on 12/17/25, her bed rail came off the bed when she attempted to use it. V2 confirmed the bed rail must not have been secured and therefore posed a hazard which resulted in R7 falling onto the floor.

Based on interview and record review the facility failed to provide a sufficient number of Licensed Nurses and Certified Nursing Assistants staff to meet the residents' needs for safety and quality of care. This failure has the potential to affect all 94 residents residing in the facility. Findings Include: The Facility assessment dated [DATE] documents an average daily census of 80-85 residents. The facility's goal is to maintain sufficient staffing to ensure an adequate number of qualified staff are available to meet each resident's needs.The Daily Nursing Schedule for 1/24/26 and 1/25/26 documents that on the night shift of 1/24/26 there was one nurse and one Certified Nursing Assistant (CNA) assigned to the front half of the building. On the day shift of 1/25/26, there was only one nurse in the building until 11:00 AM, when a second nurse arrived.On 1/29/26 at 8:45 AM, V37 (Licensed Practical Nurse/LPN) stated she was the front hall nurse on the night shift of 1/24/26. V37 stated she was alone in the front of the building for approximately one and a half hours, from 10:00 PM to 11:30 PM, before any other staff arrived. V37 confirmed she did not feel this staffing level was safe or in the best interest of the residents. V37 stated that at the end of her shift, she needed to leave and there was no one available to replace her. V37 stated V2 (Director of Nursing/DON) agreed to come in to work; however, V2 lived nearly an hour away and had to be plowed out of her driveway due to winter weather. V37 stated she left at 8:00 AM and handed her keys to the back hall nurse, who then became the only nurse on duty in the entire building.V37 further stated she is always the only nurse assigned to the front halls at night. She typically has one CNA and one unit aide. The unit aide works from 10:00 PM to 4:00 AM. V37 stated that from 4:00 AM to 6:00 AM, the front halls require two CNAs to assist residents with toileting and morning care. During this time, she begins her early morning medication pass and is unable to consistently assist the sole CNA.On 1/29/26 at 10:11 AM, V2 (DON) confirmed staffing levels from 1/24/26 to 1/25/26 were very low due to winter weather conditions. V2 stated she came to the facility Sunday morning to cover the shift and arrived close to 11:00 AM. V2 confirmed V40 was the only nurse in the building from 8:00 AM until nearly 11:00 AM. V2 stated staffing shortages are an ongoing issue. V2 confirmed the facility utilizes multiple agency staff members who frequently call off, resulting in the facility being short-staffed.On 1/29/26 at 11:24 AM, V40 (LPN) stated she worked the day shift on 1/25/26. V40 stated she was the only nurse in the building from 8:00 AM until 11:00 AM, when V2 (DON) arrived. V40 stated she was assigned to the back halls of the building. V40 confirmed that the morning was particularly stressful, as a resident in the front hall experienced a seizure and fell to the floor. V40 stated the facility is often short-staffed, especially on weekends. V40 stated she feels resident care suffers when staffing is inadequate and resident safety is compromised. V40 stated nurses are unable to perform their duties effectively and must rush through tasks when staffing levels are insufficient.

Based on observation, interview and record review the facility failed to employ a full time Certified Dietary Manager (CDM). This failure has the potential to affect all 94 residents residing in the facility. Findings include: The facility daily midnight roster dated 1/20/26 documents 94 residents resided in the facility.From 1/21/26 through 1/23/26, at various times of the day, V3 (Certified Food Protection Manager/CFPM), was observed educating kitchen staff, providing direction to dietary staff, and assisting with meal preparation and service to residents.From 1/27/26 through 1/29/26, the facility did not have a Certified Dietary Manager (CDM) employed or onsite.On 1/21/26 at 2:10 PM, V3 (CFPM) stated she is not a Certified Dietary Manager. V3 stated she has not started any classes and is not enrolled in a CDM program.On 1/23/26 at 2:00 PM, V27 (Regional Registered Nurse), stated the facility does not have a CDM. V27 stated V3 (CFPM) was serving as the acting dietary manager. V27 stated she was unsure whether there was a policy requiring the facility to have a CDM. V27 stated the facility is supposed to have a CDM and is working on hiring a CDM to replace V3 (CFPM).

Based on observation, interview, and record review the facility failed to develop and implement interventions to address behaviors to prevent a reoccurring injury following a fall that resulted in a partial finger amputation (R1). The facility also failed to supervise, implement fall interventions, and thoroughly investigate a fall (R3) for two of four residents (R1, R3) reviewed for falls in the sample list of four. This failure resulted in R3 experiencing an unwitnessed fall and coccyx fracture. Findings include:1.) R3's 6/13/25 Minimum Data Set (MDS) documents R3 has moderate cognitive impairment and requires staff supervision/touch assistance for chair/bed transfers and walking at least 10 feet. R3's 9/9/25 MDS documents R3 has moderate cognitive impairment, had one fall with injury and one fall with major injury since the last review, and R3 requires supervision/touch assistance for transfers and partial/moderate assistance for walking.R3's active Care Plan documents the following: R3 has impaired cognition, short term memory loss, intellectual disability, dementia, disorganized schizophrenia, and psychotic disorder with delusions resulting in repetitive verbalizations/questions and memory loss related issues. R3 requires supervision or touching assistance for transfers. R3 has risk factors including impaired mobility/balance, impaired gait, mental illness, impulsive behaviors, extrapyramidal and movement disorder, a history of falls, and R3 requires monitoring and intervention to reduce the potential for self-injury. Interventions for 15-minute checks for safety and positioning was initiated on 9/10/24, a sign to call before getting up was placed in R3's bathroom initiated on 5/22/24, and a note was placed in resident's room that states to call for help before getting up initiated on 3/7/24. R3's unwitnessed fall report dated 7/18/25 at 11:00 AM, recorded by V4 (Licensed Practical Nurse/LPN), documents V4 was in the dining room passing medications during lunch, as V4 walked to the nurse's station R4 (R3's roommate) told V4 that R3 was saying help. V4 immediately went into R3's room and found R3 sitting on her bottom on the floor with her knees pulled up towards her. R3's shirt was inside out over R3's head, covering R3's face. This report documents injuries post incident as a coccyx fracture. The facility's investigative file for R3's fall, did not include documentation of when R3 was last checked on by staff, who last observed R3 or what R3 was doing when last observed prior to the fall. There is no documentation in this file that R3's 15-minute checks were implemented or if there were reminder signs posted in R3's room when R3 fell. The facility's initial report to the state surveying agency dated 7/18/25 documents R3 sustained a fall on 7/18/25 at 11:00AM that resulted in a hairline fracture of the pelvis and an investigation was initiated. The facility's final report of R3's injury, dated 7/22/25, documents R3's fall as noted above and R3 was sent to the hospital where a computed tomography (CT) found R3 had a subtle nondisplaced fracture involving the right upper coccyx segment. The root cause of the fall was R3 standing up in her room putting her shirt on when R3 lost balance and fell. The post fall intervention was to provide R3 with clothes that are easier to put on such as button up or with zippers. This report documents R3 will remain on 15-minute visuals and staff are to provide assistance when R3 is observed changing clothes. R3's CT of pelvis dated 7/18/25 documents reason for exam as fall with pelvic pain, findings indicate probably mild osteopenia and concern for hairline nondisplaced fracture involving the right aspect of the upper coccyx level. R3's Progress Note dated 9/22/25, recorded by V14 (Physician) documents Coccyx fracture secondary to fall 7/18/25.On 10/14/25 at 12:46 PM R3 was sitting in a wheelchair in the hallway outside of R3's room. R3 was unable to give any details regarding her falls and stated, I don't remember. R3 stated R3 does not need staff assistance for activities of daily living and R3 walks by herself. On 10/15/25 at 9:33 AM there were no signs posted in R3's room or bathroom to remind R3 to call for assistance before getting up. On 10/15/25 at 9:42 AM V4 (LPN) confirmed R3's unwitnessed fall on 7/18/25 and V4 found R3 sitting on the floor on her bottom in front of her closet. V4 stated R3 requires standby assistance from staff for transfers/walking. V4 entered R3's room/bathroom and confirmed there were no signs posted to remind R3 to call for assistance and there should be signs posted. V4 stated the signs must not have moved with R3 when R3 changed rooms. V4 stated R3 is noncompliant with calling for assistance and R3 will get up and walk around and needs reminders to sit down and to ask for assistance. V4 stated R3 uses the call light often. At 12:00 PM V4 stated R3 had not had a room change in a very long time. V4 stated V4 was unsure when R3 was last checked on by staff or who had last seen R3 prior to her fall on 7/18/25. V4 confirmed R3 has an intervention for 15-minute checks which was an intervention prior to this fall. V4 stated 15-minute checks are documented on a paper form and that is not something the nurses document as part of the fall investigations. V4 stated V4 did not recall seeing the call reminder signs posted in R3's room the day R3 fell, and this is not something that V4 would have documented. On 10/15/25 at 10:51 AM V8 (LPN) stated V8 put reminder signs in R3's room on the bathroom door, the wall near the television and the wall near R3's dresser and R3 must have removed the signs. At 11:15 AM V8 stated V8 does the fall investigations and for R3's fall investigation V8 interviewed V4 (LPN), V15 and V16 (Certified Nursing Assistants/CNAs), who didn't see R3's fall. V8 confirmed prior interventions for 15-minute checks and signs should have been in place when R3 fell on 7/18/25. At 12:00 PM V8 verified all documentation regarding R3's 7/18/25 fall investigation was provided. V8 confirmed V8 did not know when R3 was last observed, who last observed R3 and R3's activity prior to R3's fall. V8 confirmed there was no documentation of this information in R3's fall investigation. V8 stated 15-minute checks are documented on paper form and V8 will look for the form for 7/18/25. At 12:50 PM V8 stated medical records staff were looking for R3's 7/18/25 15-minute check form. On 10/15/25 at 1:57 PM V14 (R3's Physician) stated V14 started seeing R3 as of 7/28/25 and R3 had a fall on 7/18/25 that resulted in a coccyx fracture, based on R3's progress notes. V14 stated R3's osteopenia puts R3 at risk for breaking any bones, and if R3 fell and landed on R3's buttocks it would be more likely to fracture R3's coccyx due to osteopenia. V14 confirmed R3 has poor recall ability. V14 stated fall prevention interventions for R3 should include reminder signs to call for assistance and a room close to the nurse's station to keep a close eye on her (R3). V14 confirmed R3 needs close supervision with frequent visual checks due to R3's impulsiveness and poor memory. V14 stated it is hard to say if the signs and visual checks would have 100% prevented R3's fall, but with the checks staff might have been able to lower R3 to the floor. On 10/15/25 at 3:26 PM V2 (Director of Nursing) stated V2 is still searching for R3's 15-minute check forms and had not found any documentation for 7/18/25. At 3:43 PM V2 stated V2 had not located R3's 15-minute check form for 7/18/25. 2.) On 10/14/25 at 12:15 PM R1 was sitting on the bed in his room. R1's left middle finger was red/swollen with a dark scab on the fingertip and missing the distal joint (end joint/tip). R1 was asked what caused R1's finger injury. R1 stated R1 fell at home and was unable to provide any additional details. R1 then put one of his fingers into his nose. The facility's final report dated 10/6/25, completed by V8 (LPN), documents R1's diagnoses include schizophrenia, anxiety disorder, extrapyramidal and movement disorder in diseases classified elsewhere, and unsteadiness on feet; and R1 has severe cognitive impairment. This report documents on 9/29/25 R1 had a witnessed fall in the [NAME] unit director's (V3) office. R1 had his finger in his mouth at the time of the fall which caused severe damage to the left third fingertip that required an almost complete surgical amputation of the fingertip on 9/30/25. R1's Operative Note dated 10/1/25 documents R1 sustained an almost complete traumatic amputation of the left fingertip of the middle finger, apparently due to biting his finger when he fell. X-rays showed a severely comminuted and markedly displaced fracture of the left distal phalanx of the left finger. The amputation was almost complete with a small bridge of tissue remaining that did not contain any vessel that could sustain reconstruction. R1 also had cognitive challenges and level of unawareness and a known history of removing dressings, therefore trying to do an open reduction internal fixation and leaving pins in place would be detrimental to the function of R1's hand. The decision was made to proceed with amputation of R1's finger at the level of the distal interphalangeal joint. The facility's investigative file for R1's 9/29/25 fall and injury did not include documentation that interventions were developed and implemented to address R1's behaviors of having R1's fingers in R1's mouth. R1's active care plan includes R1's fall on 9/19/25 and R1's fingertip injury, but does not include a problem, goals, and interventions to address R1's behaviors of having R1's fingers in R1's nose or mouth and to prevent further injuries to R1's fingers. On 10/14/25 at 10:25 AM V3 (LPN/MDS Coordinator) stated on 9/29/25 around 4-4:30 PM R1 was sitting on a folding chair in V3's office, R1 stood from the chair, lost his balance, then fell backwards into the chair and down the wall sliding to the floor onto his bottom. V3 stated R1 held up his left hand after the fall, R1's left middle fingertip was just hanging, and R1 must have bit it off when R1 fell. V3 stated V3 believed R1's unsteadiness caused the fall. V3 stated R1 having R1's finger in R1's mouth made the fall a lot worse and the next day R1 had to have the rest of his fingertip amputated by an orthopedic surgeon. V3 stated R1 had no prior history of finger injuries. At 1:45 PM V3 confirmed R1 has a long history of putting R1's fingers in his mouth. V3 was asked about interventions and care planning for this behavior. V3 stated staff just tell R1 to keep his fingers out of his mouth. V3 confirmed this should be care planned. V3 stated V3 will update R1's care plan to include this behavior and interventions. On 10/14/25 at 1:55 PM V4 (LPN) stated R1 always has his fingers in his mouth, nose, or pants. V4 was asked what interventions are used to address these behaviors. V4 stated we just try to tell (R1) to stop. V4 was unsure what new interventions were implemented following R1's fall and injury on 9/29/25. On 10/14/25 at 2:52 PM V6 (LPN) stated on 9/29/25 V6 was called to V3's office following R1's fall. V6 stated V6 found R1 sitting on the floor with a straight line cut across R1's finger and fingernail. V6 stated R1 must have had his finger in his mouth when R1 fell causing the injury. V6 stated it is common for R1 to have R1's fingers in his mouth, nose, or pants. V6 was asked about interventions to address this behavior. V6 stated staff frequently tell R1 to stop putting his fingers in his mouth and R1 will comply. V6 was unsure what new interventions were added after R1's fall injury. V6 stated V3 provided some fidget toys to keep R1's hands busy, but this was just initiated today. On 10/15/25 at 11:39 AM V8 (LPN) confirmed V8 completed the investigation of R1's 9/29/25 fall and injury. V8 stated R1 has a long history of putting R1's hands in his mouth despite staff reminding him not to do that. V8 stated I don't know what we could have put in place to prevent (R1) from injuring his finger like that or to prevent it from happening again. V8 confirmed interventions were not developed/implemented to address R1's history of putting his fingers in his mouth and to prevent any additional injuries. The facility's Accident and Incidents - Investigating and Reporting policy dated July 2017, documents the nurse supervisor or charge nurse will initiate and document an investigation of the accident or incident. This policy documents that the report of incident/accident form should include the circumstances surrounding the incident, corrective actions taken, follow-up information, and any other pertinent information as necessary or required.

Based on observation, interview, and record review the facility failed to protect one (R4) resident's right to be free from verbal and mental abuse and being physically threatened by another resident (R5) which was witnessed by a resident (R6) out of nine residents reviewed for abuse in a sample list of 12 residents. R4 was made to cry, feel sad and scared causing her to be fearful of being physically abused. Findings include: R4's undated Face Sheet documents medical diagnoses as Bipolar Disorder, Anxiety, Non-Rheumatic Mitral and Pulmonary Valve Insufficiency, Chronic Diastolic Congestive Heart Failure, Syncope and Collapse. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. This same MDS documents R5 requires supervision with dressing, bathing, personal hygiene, bed mobility and transfers. R5's Nurse Progress Note dated 4/22/25 at 9:49 AM document (R5) sat next to (R4) and began to talk to (R4). (R4) said she did not want to talk to (R5) at that time. (R5) got upset and called (R4) a b**** (expletive). Then (R5) started yelling and screaming at (R4). R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. R4's Initial Report to the State Agency documents R5 allegedly verbally abused R4 on 4/22/25. R4's initial Abuse Investigation dated 4/23/25 documents R5 told R4 to 'stay away from my man you b**** (expletive) and then R5 swung at R4. This same investigation documents R4 was sitting with R6 when R5 said R5 wanted to go to bed with R6. This same file documents R4 was walking down the hall after supper and R5 said 'stay away from me b**** (expletive)'. R4's Nurse Progress Notes do not document any altercation with R5 on 4/21/25 nor 4/22/25. R4's Care plan initiated 6/13/24 does not include a focus area, goal nor interventions of R4's risk of being abused. On 4/23/25 at 9:45 AM R4 stated on 4/21/25 R4 went out to the commons area after breakfast. R4 stated R5 came up to her and wanted to talk. R4 stated she didn't feel like talking right then so R4 told R5 to go away. R4 stated R5 was not happy with R4 for not talking to R5 but R5 did leave the area. R4 stated the next day (4/22/25) R5 walked up to R4 and R6 after breakfast when R5 began screaming and yelling profanities at R4 with R6 present. R4 stated She (R5) was saying awful things. (R5) called me a b**** (expletive) and told me to 'go f*** (expletive) myself. R4 stated she began crying as R5 continued to yell and scream at R4 in front of R6. R4 stated finally R5 walked away. R4 stated she was very embarrassed because R5 was saying 'awful' things to her in front of R6. R4 stated R5 told R6 that R5 wanted to have sex with R6. R4 stated R6 refused R5's sexual advances. R4 stated her and R6 are good friends and do not need any other close friends coming between her and R6. R4 stated R5 made her feel scared. R4 was crying during the interview. R4 stated Please don't let (R5) come near me again. I am so scared (R5) will hurt me. (R5) told me she would hurt me bad. I believe (R5). (R5) is a lot bigger than me. (R5) could knock me over and hurt me. I am supposed to walk up and down the halls to exercise my hip. I don't walk down (R5's) hall because I am afraid (R5) will see me and beat me up. (R5) is unpredictable and crazy. I don't want (R5) anywhere near me. R4 stated After lunch that day (4/22) (R5) walked up and started yelling at me. Calling me a b**** (expletive) and telling me how bad I am at sex things. Then (R5) swung her whole arm at me. (R5) didn't actually hit me but I was so scared. I just kept yelling 'Get her off of me! Help me! (R5) is trying to kill me!' On 4/23/25 at 10:25 AM V18 (Psychosocial Rehabilitation Assistant/PRSA) stated R4 was crying hysterically after being screamed at by R5. V18 stated he verbally consoled R4 and then later when R4 was still upset about the matter, the staff allowed R4 to call her sister to help console her also. On 4/23/25 at 11:10 AM V21 (PRSA) stated R5 was 'out of control' on 4/22/25 due to the way R5 was treating R4. V21 stated she heard R5 tell R4 to 'Shut the F*** (expletive) up!' and 'I'll beat you're a** (expletive)!'. V21 stated R5 should have been put on a one-to-one observation but was not. V21 stated R5 kept returning to R4 throughout the day to yell at R4. On 4/23/25 at 12:00 PM R4 left the main dining room for the unit and walked towards the resident hallways. R4 walked down to the end of her hallway, turned around and walked back to the center resident commons area. R4 did not walk down the opposite hallway where R5 resides. On 4/23/25 at 12:40 PM R5 stated R5 yelled, screamed, and cursed at R4 because R4 would not talk to her the day before (4/21/25). R5 stated R4 was in a bad mood so R5 called R4 a b**** (expletive). R5 stated she wished R5 would have hit her when R5 swung at R4. R5 stated I would have hit (R4) right to the ground. R5 stated she tried to 'get with' R6 to make R4 mad but R6 didn't want to be with R5 and that made R5 even more mad. R5 stated she 'went after' R4 several times that day and told R4 what a b**** (expletive) R4 is. On 4/23/25 at 1:40 PM V9 (Psychosocial Rehabilitation Director/PRSD) stated on 4/22/25 after breakfast she heard R5 yelling and screaming in the resident commons area. V9 stated she was in her office right next to the resident common area. V9 stated she went out to see what was going on and saw R5 yelling at R4 and R6 as R5 was walking away from R4. V9 stated she heard R5 call R4 a b**** (expletive). V9 stated R5 was so loud it was hurting her ears. V9 stated R5 told V9 that she had to tell off R4 because R4 is racist. V9 stated V9 told R4 that R5 did not mean anything R5 said. V9 stated R4 was crying, tearful and stating she was very scared of R5. V9 stated R6 stated he heard R5 call R4 a b**** (expletive) and to 'get the f*** (expletive) out of R5's way'. V9 stated R4 calmed down after about an hour. V9 stated R5 went back to her room and V9 went back to her office. V9 stated she is the director of the psychiatric locked down unit and was never told that she had to report verbal and/or mental abuse to V1 (Abuse Coordinator/Administrator). V9 stated after lunch R5 walked up to R6 and stated R5 could do R6 'sexual favors' better than R4. V9 stated this made R5 mad so she started yelling at R4 and R6 again. V9 stated R5 called R4 a b**** (expletive). V9 stated V8 (Psychosocial Rehabilitation Counselor/PRSC) then came out to help de-escalate R5. V9 stated R4 was terrified and tearful after being yelled at by R5. On 4/25/25 at 1:00 PM V24 (Nurse Practitioner/NP) stated R5 yelling, screaming derogatory words, and attempting to hit R4 could have a negative effect on R4. V24 stated R4 could experience Post Traumatic Stress Disorder (PTSD), Anxiety and Insomnia caused by R5 verbally and mentally abusing R4. V24 stated R5 humiliated R4 in front of her close friend R6 which could cause R4 to have regressive behaviors. V24 stated mentally ill residents such as R5 do have behaviors but this instance of R5 verbally and mentally abusing R4 would be considered abuse. On 4/25/25 at 2:35 PM V20 (Regional Director of Operations) stated the facility should have communicated better in order to monitor R5 for behaviors. V20 stated the staff were aware R5 was upset with R4 on the day before (4/21/25) R5 abused R4. V20 stated these incidents could possibly have been avoided if the staff were paying closer attention. V20 stated the locked unit houses mentally ill individuals who need extra support and monitoring to prevent these types of things from happening. V20 stated the facility is re-training their staff on the facility Abuse policy and behavior management to reduce abuse. The facility policy titled Abuse Prevention Program revised 11/28/2016 documents the facility affirms the right of our resident to be free from abuse, neglect, misappropriate of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Abuse is the willful injection of injury, unreasonable confinement, intimidate, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual including a caretaker, of good or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse is the oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend or disability. Examples of verbal abuse include, but are not lied to, threats of harm, or saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Mental abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident, harassment, humiliation and threats of punishment or deprivation.

Based on observation, interview, and record review the facility failed to protect one (R4) resident from being repeatedly verbally and mentally abused by another resident (R5) throughout an entire day while the staff were aware of R4 being abused. Two residents (R4, R5) were affected by this failure out of nine residents reviewed for abuse in a sample list of 12 residents. R4 felt scared causing her to change her activity routine in fear of being further abused by R5. Findings include: R4's undated Face Sheet documents medical diagnoses as Bipolar Disorder, Anxiety, Non-Rheumatic Mitral and Pulmonary Valve Insufficiency, Chronic Diastolic Congestive Heart Failure, Syncope and Collapse. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. This same MDS documents R5 requires supervision with dressing, bathing, personal hygiene, bed mobility and transfers. R4's Initial Report to the State Agency documents R5 allegedly verbally abused R4 on 4/22/25. R4's initial Abuse Investigation dated 4/23/25 documents R5 told R4 to 'stay away from my man you b**** (expletive)' and then R5 swung at R4. This same investigation documents R4 was sitting with R6 when R5 said R5 wanted to go to bed with R6. This same file documents R4 was walking down the hall after supper and R5 said 'stay away from me b**** (expletive)'. On 4/23/25 at 12:00 PM R4 left the main dining room for the unit and walked towards the resident hallways. R4 walked down to the end of her hallway, turned around and walked back to the center resident commons area. R4 did not walk down the opposite hallway where R5 resides. R5 left the dining room a few minutes later, stopped in the same commons area, looked towards R4, and then proceeded to her own room. No staff were present in the dining room nor in the commons area. On 4/24/25 at 12:10 PM R4 and R5 were sitting in the dining room at the same time during lunch service. R5 stood and walked by R4. There were no staff in the dining room at that time. On 4/23/25 at 9:45 AM R4 stated R5 yelled and screamed 'foul' language at her multiple times on 4/22/25. R4 stated R5 swung at her at one point. R4 stated the staff, including V9 (Psychosocial Rehabilitation Director/PRSD) was aware that R5 kept walking up to R4 to yell obscenities at R4. R4 stated R5 made her feel scared. R4 was crying during the interview. R4 stated Please don't let (R5) come near me again. I am so scared (R5) will hurt me. (R5) told me she would hurt me bad. I believe (R5). (R5) is a lot bigger than me. (R5) could knock me over and hurt me. I don't walk down (R5's) hall because I am afraid (R5) will see me and beat me up. I don't want (R5) anywhere near me. R4 stated R5 walked up to R4 'multiple' times on 4/22/25, yelling profanities and threatening to hurt R4. R4 stated After lunch that day (4/22) (R5) walked up and started yelling at me. Calling me a b**** (expletive) and telling me how bad I am at sex things. Then (R5) swung her whole arm at me. (R5) didn't actually hit me but I was so scared!' R4 stated V8 (Psychosocial Rehabilitation Counselor/PRSC) and V9 (PRSD) were aware of R5's behaviors on 4/22/25. R4 stated the facility did not do anything to help R4 so she told V19 (Registered Nurse/RN) the next morning (4/23/25). R4 stated she did not sleep the night of 4/22/25 for fear R5 would come into her room and attack her. R4 stated R5 lived right across the hall from her at that time so R5 could easily walk over into R4's room to hurt her. R4 stated I know (V19) Registered Nurse (RN) would help me, so I waited for her to come into work the next morning (4/23/25) and told her what happened. On 4/23/25 at 11:10 AM V21 (Psychosocial Rehabilitation Assistant/PRSA) stated R5 was 'out of control' on 4/22/25 due to the way R5 was treating R4. V21 stated she heard R5 tell R4 to 'Shut the F*** (expletive) up!' and 'I'll beat you're a** (expletive)!'. V21 stated R5 should have been put on a one-to-one observation but was not. V21 stated R5 kept returning to R4 throughout the day to yell at R4. On 4/23/25 at 12:40 PM R5 stated she wished R5 would have hit her when R5 swung at R4. R5 stated I would have hit (R4) right to the ground. R5 stated she 'went after' R4 several times that day and told R4 what a b**** (expletive) R4 is. On 4/23/25 at 1:40 PM V9 (PRSD) stated V9 was aware that R5 walked up to R4 multiple times throughout the day (4/22/25) to yell and scream profanities at R4 due to R4 did not talk to R5 the day before (4/21/25). V9 stated she should have separated R5 from everyone until they (staff) could figure out what had happened and to ensure the safety of R4. V9 stated R4 could have been hurt. V9 stated R5 did threaten to hurt R4 and 'you never know if a threat is real or not until something happens'. V9 stated R5 was placed on 15-minute checks on 4/23/25 at 11:00 AM. V9 stated R5 should have been placed on a one-to-one continuous observations due to her repeatedly abusing R4. On 4/25/25 at 1:10 PM V24 (Nurse Practitioner/NP) stated R5 should have been sent to the emergency room for a psychiatric evaluation by a physician. V24 stated R5 isn't known to have those kinds of behaviors. V24 stated R5 could have had some clinical issue happening or R5 could have been going through some type of new mental health issue that she had not experienced before. V24 stated R4 was not protected by this facility due to R5 was not monitored closely enough if R5 was allowed to repeatedly abuse R4 verbally and mentally. On 4/25/25 at 2:30 PM V20 (Regional Director of Operations) stated the staff should have monitored R5 more closely after they were aware that R5 had yelled at R4 after breakfast on 4/22/25. V20 stated R4 was not protected from R5's repeated abuse and should have been. The facility policy titled Abuse Prevention Program revised 11/28/2016 documents residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety, as well as the safety of other residents and employees of the facility.

Based on observation, interview, and record review the facility failed to timely report decreased urination and abdominal distention (R1). The facility also failed to perform hand hygiene after toileting assistance (R5) for two (R1, R5) of four residents reviewed for urinary tract infections (UTIs) in the sample list of six. This failure resulted in R1 being hospitalized for a UTI, urinary retention, and acute kidney injury. Findings include: 1.) R1's Minimum Data Set, dated dated dated [DATE] documents R1 has moderate cognitive impairment, is dependent on staff assistance for toileting, and is always incontinent of bowel and bladder. R1's Fluid Intake report dated March 2025 documents the following total daily fluid intake: 960 milliliters (ml) on 3/3/25 480 ml on 3/4/25 1100 ml on 3/5/25 360 ml on 3/6/25 1440 ml on 3/7/25 R1's Bowel and Bladder Elimination log dated March 2025 does not document R1 urinated on all shifts on 3/3/25, second shifts on 3/2/25, 3/6/25, 3/7/25 and third shifts on 3/1-3/5/25 and 3/7/25. This log documents R1 had a medium, loose bowel movement on 3/1/25, formed medium bowel movement on 3/4/25, loose medium bowel movements on 3/5/25-3/7/25 and one large loose bowel movement on 3/6/25. R1's Nursing Notes document the following: On 3/7/25 at 11:09 AM R1's abdomen was distended, and a new order was received to obtain a urinalysis. R1 had a loose medium bowel movement. On 3/7/25 at 7:46 PM R1's urine sample was collected and placed in the fridge for pick up. R1's urine was dark and odorous. On 3/7/25 at 9:11 PM R1's abdomen remained distended and firm. On 3/8/25 at 4:44 AM R1 fell during staff assist. R1 was lying on the floor complaining of back and neck pain and wanted to go to the emergency room . Emergency services was called. The healthcare messaging software documents on 3/6/25 at 2:30 PM R1 had abdominal distention, only one wet brief during the night and once during dayshift, took in 240 ml and had a loose bowel movement. This was reported to V33 (Advanced Practice Registered Nurse/APRN) who ordered a urine sample for urinalysis and culture with sensitivity. There is no documentation in R1's medical record that this order was transcribed until 3/7/25 at 4:33 AM, per R1's physician orders, or that R1 had abdominal distention prior to 3/7/25. There is no documentation that R1's abdominal distention and decreased urinary output was reported to V33 prior to 3/6/25 at 2:30 PM. R1's emergency room Note dated 3/8/25 at 6:17 AM documents a urinary catheter was inserted and with a return of over 2500 ml of urine. R1 was admitted with diagnoses of urinary retention, UTI, and acute kidney injury. R1's laboratory results dated [DATE] at 8:01 AM documents R1's Blood Urea Nitrogen (BUN) was 42 (high) and Creatinine (Cr) 1.57 (high). R1's Hospital Discharge Summary dated 3/12/25 documents a urinary catheter was inserted on admission with three liters of urine returned with initial gross hematuria (bloody urine) that resolved. R1's urine culture grew Enterococcus and R1 received antibiotic therapy. R1 was given intravenous fluids and R1's Creatinine levels normalized. Urology was consulted and ordered an abdominal Computed Tomography that showed a large amount of stool in the rectum with surrounding inflammatory changes consisted with stercoral proctitis (rare and serious inflammatory condition). R1 also had bladder wall thickening related to inflammatory changes, mild hydronephrosis, and gaseous bowel distention. Laxatives were ordered and R1 had several bowel movements during his hospitalization . The facility's Daily Assignment dated 3/5/25 documents V25 (Licensed Practical Nurse/LPN) was assigned to R1's unit for day shift and evening shift, V32 (Certified Nursing Assistant/CNA) was assigned R1's unit on day shift, and V24 (CNA) was assigned to R1's unit on evening shift. The Daily Assignments dated 3/6/25 and 3/7/25 document V24 was assigned to R1's unit on evening shift. On 4/7/25 at 1:29 PM V34 (APRN) stated V34 recently started working for the facility on 3/10/25. V34 stated R1 was hospitalized for urinary retention and UTI but had no prior history of UTIs or urinary retention. On 4/7/25 at 2:16 PM V13 (LPN) confirmed R1's abdomen was distended on 3/7/25. V13 stated there was already an order to collect R1's urine sample that was entered on the prior shift, and it was passed onto V13 that day that R1 had abdominal distention. V13 stated that day V13 had R1 urinate in a urinal, R1 put out almost a full urinal full of urine, and V13 collected R1's urine sample which was dark in color and cloudy. V13 stated unidentified staff had reported that R1 had difficulty urinating days prior. On 4/7/25 at 3:10 PM V24 (CNA) stated V24 went to get R1 up for supper one night, R1 was really sweaty and not acting himself, and R1 was sent to the hospital. V24 stated a week later R1 was sent to the hospital again (3/8/25) and returned to the facility with a urinary catheter. V24 stated during the week prior, R1 had been drinking well but R1's brief was dry most of the time which was unusual for R1 since R1 would usually pull his pants down and urinate a large amount all over. V24 stated V24 reported this to V25 (LPN). V24 stated R1's stomach looked more swollen on 3/7/25. On 4/8/25 at 9:46 AM V25 (LPN) stated R1 had no reported problems on 3/4/25. V25 confirmed on 3/5/25 V24 (CNA) reported R1 had not urinated that day. V25 stated R1's abdomen was also distended that day. V25 stated V25 just passed this information onto night shift and to monitor R1's urination. V25 confirmed V25 did not report R1's abdominal distention and decreased urine output to a physician or APRN. On 4/8/25 at 10:02 AM V32 (CNA) stated a few days prior to R1's hospitalization R1 wasn't himself, was urinating very little and did not have good bowel movements, which was new for R1. V32 stated R1 was still drinking well at that time, R1's abdomen started getting harder and bigger and V32 reported this to V25 (LPN). On 4/8/25 at 12:22 PM V35 (Registered Nurse/RN) stated V35 works through an agency, night shift on 3/7/25 was the only day that V35 had worked at the facility, and V35 was not very familiar with R1. V35 stated V35 sent R1 to the hospital early that morning following a staff assisted fall and complaints of back and neck pain. V35 stated nothing had been reported about R1 having decreased urination or abdominal distention. On 4/8/25 at 3:40 PM V2 (RN) stated V2 entered R1's urinalysis order on 3/7/25 which V2 obtained off the healthcare messaging software. V2 stated staff on the prior shift, second shift, had notified V33 (APRN) through the messaging software. On 4/8/25 at 1:15 PM V12 (Quality Assurance Nurse/Infection Preventionist) stated the CNAs should document continence/incontinence for urine output every shift. V12 verified the lack of this documentation from 3/1/25-3/7/25 on R1's bladder elimination log. V12 stated the CNAs should report decreased urine output to the nurse, the nurse should monitor for symptoms and notify the physician. V12 stated provider notification would be documented in a nursing note. At 2:15 PM V12 stated V36 (R1's Family) contacted V12 after R1's hospitalization to ask how the staff didn't notice R1's abdominal distention and decreased urine output. V12 confirmed R1's nursing notes do not document R1's decreased urine output and abdominal distention or that this was reported to a physician or APRN prior to 3/7/25. On 4/8/25 at 2:35 PM V33 (APRN) stated R1's abdominal distention and decreased urinary output should have been reported immediately. V33 stated a UTI can cause an obstruction in urinary flow and a UTI. V33 stated a delay in treatment of UTI and/or urinary retention can affect laboratory values, including elevated BUN and Cr, and cause an acute kidney injury. V33 stated V33 was assigned to receive calls for the facility between 9:00 AM and 5:00 PM Monday through Friday. V33 stated the on-call provider took call after 5:00 PM until 9:00 PM and outside of those hours the facility would have to contact the physician or medical director. The facility's Notification for Change in Resident Condition or Status policy dated 12/7/17 documents the charge nurse will notify the resident's attending physician or on-call physician when there are any signs or symptoms or apparent discomfort of sudden onset, a marked change, and unrelieved by previously prescribed measures; when there is a significant change in the resident's physical/emotional/mental condition; and when there is a need to significantly alter treatment. This policy documents that the nurse will document information related to the changes in a resident's condition in the resident's medical record. 2.) On 4/9/25 at 11:37 AM V8 and V26 (CNAs) assisted R5 with toileting. V26 removed R5's soiled brief, applied a clean brief, and cleansed R5's perineal area. V26 removed her gloves and did not perform hand hygiene prior to leaving the room and transporting R5 in a wheelchair to the common area. On 4/9/25 at 11:48 AM V26 stated hand hygiene should be performed after providing toileting or incontinence cares. V26 confirmed V26 did not perform hand hygiene after providing R5's with toileting care. The facility's undated General Procedure for Toileting policy documents to wash your hands after providing toileting assistance and perineal care.

Failures at this level require more than one Deficient Practice Statement. A. Based on observation, interview, and record review the facility failed to supervise a resident after providing the resident with a hot pureed food. This failure affects one (R31) of six residents reviewed for accidents in the sample of 33. This failure resulted in R31 spilling hot liquid on R31's lap sustaining redness and 3 blistered areas to R31's bilateral lower extremities requiring subsequent treatment which is ongoing. B. Based on observation, interview, and record review the facility failed to remove a tripping hazard to prevent a fall and failed to implement fall interventions and complete a root cause analysis for two residents (R133, R20) of six residents reviewed for accidents in the sample of 33. This failure resulted in R133 sustaining an unwitnessed fall leading to hospitalization for a Subdural Hematoma. C. Based on observation, interview, and record review the facility failed to prevent siderail entrapment for one of six residents (R54) reviewed for accidents in a sample list of 33 residents. Findings Include: a.1.) R31's Care Plan dated 12/17/24 includes the following diagnoses: Psychotic Disorder, Cerebral Infarction with Dominant Right sided Hemiparesis/Hemiplegia, Anxiety, Major Depression. Dysphagia, Muscle Weakness, and Reduced Mobility. R31's Minimum Data Set (MDS) dated [DATE] documents R31 is Severely Cognitively Impaired, has Bilateral Decreased Range of Motion to Lower and Upper Extremities, is Wheelchair Bound, and Totally Dependent on staff for eating. R31's Progress Note dated 1/19/2025 at 2:53 PM documents (R31) spilled beets on lap Administrator, Power of Attorney, Nurse Practitioner on call, and Hospice notified. Administered Morphine for pain and cool compress. Hospice nurse will see (R31) tomorrow. (Physician) ordered Antibiotic Ointment to be applied. On 1/22/25 at 11:00 AM V1 (Administrator) stated We did not initiate an incident investigation for (R31's) burn. I didn't feel like we needed to. There wasn't a serious injury. On 1/23/25 at 12:00PM V7 (Certified Nursing Assistant/CNA) stated I was working on 1/19/25 in the dining room. I was feeding another resident when they brought (R31's) lunch tray out and set it in front of (R31). (R31) is anxious and she will grab at things. The next thing I knew (R31) hit the hot beets in (R31's) lap. I went ahead and fed (R31). (R31) was wearing slacks and a top and I covered the spill. I didn't have any idea those beets were so hot. Then when I got (R31) back to bed 25 minutes or so later and removed (R31's) pants I discovered (R31) had been burned. I got the nurse right away. On 1/23/25 at 12:10 PM V5 (Licensed Practical Nurse/LPN) stated I knew (R31) had spilled the beets in her lap on 12/19/25, but I wasn't aware until (V7) took (R31) to bed and took off (R31's) pants, (R31) had been burned. (R31's) thighs were red and tender and later blisters came up and burst. I notified (V1), the Nurse Practitioner on Call, Hospice, and resident's representative. We got an order for Antibiotic Ointment, and I applied that and cool compresses. On 1/21/25 at 12:00 PM and on 1/22/25 at 11:45 AM R31 was observed sitting at the dining room table with uneaten hot foods in front of (R31). There were no staff visible directly assisting R31. R31 was muttering and moving hands back and forth. On 1/23/25 at 2:00 PM R31 was lying in bed. V5 (LPN) pointed out an open area on R31's left outer thigh appearing as a sloughing blister approximately 1/2 in diameter, another sloughing blister on R31's Left inner thigh approximately 1 in diameter, and another sloughing blister on R31's Right inner thigh approximately 1/2 in diameter with a separate area on R31's right thigh measuring approximately 1/2 in diameter. On 1/23/25 at 12:30 PM V13 (Dietary Manager) stated The beets went out on 1/19/25 at a temperature of 180 degrees Fahrenheit. I had no idea those little insulated bowls keep the temperature so hot. I was wrong and I will not let that happen again. On 1/24/25 at 11:00 AM V1 (Administrator) denied the facility has a policy for incident reporting or investigation. V1 stated now we are making sure (R31) does not have the food in front of (R31) before (R31) is fed. When notified R31 had hot food in front of R31 unsupervised on 1/21/25 and 1/22/25, V1 stated I'll look into that and verified (R31) should not have been unsupervised with hot food in front of (R31). 20892 b. 1.) The facility's investigation report for R133 dated 1/12/25 no time given documents (R133) had an unwitnessed fall in his room. Roommate was not in the room at the time of the fall. (R133) was transferred to emergency room at the local hospital who transferred (R133) to another hospital for care. R133's Physician's Order Sheet (POS) dated January 2025 documents the following diagnoses: Parkinson Disease, Schizophrenia, Depression, Diabetes and Epileptic Seizures. R133 is able to be interviewed and walks with his walker. On 1/21/25 at 11:00 AM R133 stated Yes, I fell in my room, I got up from bed to go to the bathroom and I tripped on the fall mat that was next to my bed. I had to go to the hospital, and they transferred me to another hospital. I came back home on 1/10/25. R133 continue to say My fall mat next to my bed was torn, I had that fall mat for a long time. I have a new fall mat now. On 1/23/25 at 11:30 AM the fall mat which was removed from R133's room was torn on the bottom. The netting on the bottom of the fall mat was ripped from the bottom of the mat and was hanging down off the mat. The hospital emergency department Radiology Results records dated 1/5/25 document R133 arrived at the Emergency Department on 1/5/25 at 2:05 PM and a CT (computed tomography) Scan without Contrast was completed which documented Left frontoparietal Subdural Hematoma is slightly higher attenuation than previously suggesting interval rebleeding. The emergency documentation dated 1/5/25 documents RN called to NH (nursing home) to notify facility (R133) will need to be transferred to higher level of care facility due to CT results. Hospital records document (R133) transferred to another hospital for care on 1/5/25. The records document the receiving hospital decision was R133 need to have an embolization procedure, which was performed on 1/8/25. Hospital records document Impression after the procedure. Successful intracranial portion of the left middle meningeal artery embolization without immediate procedure complications. The records document R133 was discharged back to the facility on [DATE]. V10 (CNA) stated per phone interview on 1/23/25 at 10:22 AM I was sitting at the nurses desk charting when I heard yelling and I went to check and found (R133) face down on his stomach, hands under his chin and (R133) stated 'I tripped on my mat going to the bathroom.' V10 stated the nurse was notified and came to the room and assessed R133 and stated she was going to call EMS (Emergency Medical Services) for R133 and R133 was taken to the hospital. On 1/23/25 at 1:08 PM V11 (Nurse Practitioner) stated According to my information from the hospital records I have in front of me (R133) received a Subdural Hematoma from the fall. I understand he did not lose consciousness but still needed the embolization procedure to be done. R133's investigation report dated 1/5/25 no time available, documented the root cause analysis for R133's fall was due to frayed safety mat by R133's bed. 2.) R20's Care Plan revised 1/13/25 includes the following diagnoses: Closed Fracture Left Radius, Moyamoya Disease, Age Related Physical Disability, Generalized Anxiety Disorder. R20's Minimum Data Set (MDS) dated [DATE] documents R20 has a history of falls. R20's Care Plan includes a problem first initiated 12/29/23 and continued since then documenting (R20) is unsafe with transfers and often attempts to transfer self. (R20) has had numerous falls related to self-transferring. This Care Plan also states 1/7/2025: Actual Fall: 15-minute checks for safety and positioning. Date Initiated: 01/07/2025. Although 15 Minute checks were check marked as complete in the electronic medical record, there was no documentation of resident's location or activity at the time of the check or interventions initiated to prevent falls. The facility's final report to the state agency dated 1/20/25 documents (R20) had an unwitnessed fall in room. (R20) stated to staff (R20) slid off the bed and complained of pain in the left wrist. (R20) was sent to (local hospital) emergency room . X-rays to Left wrist were completed and revealed fracture to Left Distal Radius. There is no root cause analysis documented as to the cause of (R20's) fall. On 1/24/25 at 3:00PM V3 (Registered Nurse/RN) stated I did the investigation. I don't recall what the root cause was. V3 verified a root cause must be determined to decide appropriate interventions to initiate to prevent more falls. The facility's policy Fall Prevention revised 11/10/18 states Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor resident's wishes/desires for maximum independence and mobility. Procedure: Conduct fall assessments on day of admission, quarterly, and with a change in condition. Identify, on admission, the resident's risk for falls. Assessment of fall risk will be completed by the admission nurse at the time of admission. Appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours. The admitting nurse will assign a temporary category. 41970 c.1.) R54's undated Face Sheet documents medical diagnoses as Dementia, Psychosis, Sensorineural Hearing Loss, Dependence on wheelchair, unsteady on feet and Dysphagia. R54's Minimum Data Set (MDS) dated [DATE] documents R54 as severely cognitively impaired. This same MDS documents R54 is dependent on staff for toileting, transfers, and maximum assistance for bathing, dressing and personal hygiene. R54's Physician Order Sheet (POS) dated January 2025 documents a physician order starting 6/24/24 with no end date for R54 to use Left siderail when R54 is in bed to enhance bed mobility. R54's Bed Rail/Transfer Bar consent dated 7/7/23 documents R54 has been assessed to benefit from a Left half siderail to be used at all times when resident is in bed. R54's Nurse Progress Note dated 12/13/24 at 4:01 AM documents R54 was calling out. R54 was in her bed, laying across the bed. R54's head was closer to the right side of the bed. R54's Lower extremities on the left side of the bed. R54's Left Lower Extremity (LLE) was caught in between the first and second bar on her half siderails. R54 stated she was trying to get up. No new injuries to LLE noted. On 1/21/25 at 10:00 AM R54 was laying in her bed with two half siderails in the up position. On 1/23/25 at 1:15 PM R54 was laying in her bed with two half siderails in the up position. On 1/22/25 at 2:45 PM V1 Administrator stated she was unaware that R54 had gotten her LLE stuck in the siderail. V1 Administrator further stated R54 is not supposed to use two siderails. V1 (Administrator) stated R54 could have easily been injured.

Based on interview and record review the facility failed to adequately supervise a resident with a history of falls and complete a thorough fall investigation for one of three residents (R3) reviewed for falls on the sample list of 14. Failing to supervise R3 resulted in R3 falling and suffering fractures. Findings include: R3's Current Diagnoses Sheet documents the following: Unspecified Dementia, Severe With Other Behavior Disturbance, Generalized Anxiety, Primary Insomnia, Unsteady On Feet, and History of Falling. R3's Minimum Data Set date 12/03/24 documents R3 has severe cognitive impairment. R3's Care Plan History (hx) dated as revised 07/26/2024, documents the following: Falls: Resident does not understand mobility limits due to cognitive limitations. She has a hx (history) of falls with major to min (minor) injury. She is unsafe to use a wheelchair or walker d/t (due/to) severe cognition impairment. She tolerates ambulating holding the hand of a staff for directional purposes. Her impaired cognition and weakness put her at high risk for falls. On 12/27/24 at 1:30 pm V5 (Certified Nursing Assistant/CNA) stated I got here about 6:00 am (11/22/24). I was told in report that morning that (R3) had not slept all night. She (R3) was still up. I could tell she was really, tired. I took her to the dining room for breakfast. I laid her in the recliner, by the nurses' station first thing, after she (R3) ate (breakfast). She fell right to sleep. (R3) was sleeping, good. I was going to leave her in the recliner at lunch and feed her when she woke up on her own. (V1 Administrator) had said even if residents are sleeping, we have to bring them to the dining room to make sure they eat. We were told everybody needs to be up and in the dining room every meal. I got (R3) up and in her wheelchair. (R3) was really antsy and fidgeting in her chair. She was trying to stand up. I reminded her it was time to eat thinking that would help settle her a little bit. I took her to the dining room. I think I locked her wheelchair. She was still real tired when I got her up for lunch. (R3) was really anxious again and fidgeting in her chair. She was shaking the arms of her wheelchair the last time I saw her in there (dining room). There were other residents in the dining room then, but no staff. I had to go back down the hall to get the other resident up and out to eat. The other staff were also getting people up. I saw activity people bringing some residents to the dining room too. I think (V7 Activity Assistant) is one of their names. I left to get another resident. I was about halfway down the hall. The residents at (R3's) table are not alert and oriented. (R7) and (R8) are (alert and oriented). They were seated across from (R3) a couple tables away. (R7) is the one that screamed '(R3) fell .' I think it was (V6 CNA) and (V14 Licensed Practical Nurse) that got to (R3) first, and maybe (V7 Activities). (R3) was on the floor and bleeding. (V2 Registered Nurse) came and put a dressing on her (R3) head. I could see she (R3) was real hurt. I felt bad. I wish I would have stayed with her in the dining room when I saw her shaking the arms of her wheelchair. I could have talked to her and calmed her down. I was focused on getting everybody down my hall up for lunch. (Witness R7's) Minimum Data Set, dated dated dated [DATE] documents R7's Brief Interview of Mental Status score of 15 out of a possible 15, indicating no cognitive impairment. On 12/27/24 at 2:07 pm R7 stated I (R7) am the one (resident) that yelled that (R3) was on the floor. There were no staff in the dining room at the time. Staff would come in and out and did not seem to notice (R3) was agitated. I had been watching her as she became more restless over the course of time that we sat in the dining room. I can't tell you how long we were waiting for our meal. Some days it is 15 or 20 minutes and other times it can be closer to an hour. That day I can't specifically say. Even if it was only 15 minutes, (R3) was restless the whole time. She was in the dining room when I came in, so I can't be sure how long she had been there. I saw her stand up from her wheelchair, take one step, and went down immediately. I had to scream, very loud for somebody to come. An activity person (unidentified) and a nurse (unidentified) were in the dining room within probably 15 seconds. It all happened so quick. You could tell (R3) was in pain and bleeding. A bunch of other staff came in to help with her too. An ambulance was here within a few minutes. (R3) was sent to the hospital for treatment. On 12/31/24 at 3:30 pm V7 (Activity Assistant) stated Yes, I responded to (R7's) yell that (R3) had fallen (fell ). I was the first person into the dining room when (R3) fell . There wasn't any staff around. (R3) was laying on the floor face down, with her feet up against the wheelchair. Her feet were freely moving it (the wheelchair) because the wheelchair was not locked. It looked like she went over the side of the wheelchair. I moved the wheelchair, so her feet wouldn't get caught. I then went and got a nurse (unidentified). (R3) is a known fall risk. There is supposed to be staff in the dining room always watching the residents. There wasn't that day. Had there been somebody, maybe her fall could have been prevented. If her wheelchair was locked, she might have had a better chance of not falling too. No one asked me to make a statement, or they would have known these things. R3's Final Investigation Report dated 12/02/24 to state surveying agency regarding R3's fall 11/22/24 was provided with witness statements. There is no documentation of V7 (Activity Assistant) being interviewed and no documentation of R3's wheelchair being unlocked. R3's same Final Fall Investigation Report dated 12/02/24 documents the following: Root cause: IDT (Interdisciplinary Team) has determined the cause of the fall is due to (R3) is not aware of safety limitations due to cognition status and self-transferred due to incontinence. Intervention- Resident (R3) will be toileted prior to meals and frequently to ensure resident is dry. Staff with be in-serviced (educated) on leaving (R3) in the dining room unattended. PT/OT (Physical Therapy/Occupational Therapy) will eval (evaluate) and treat upon returning to the facility. (R3) had an [NAME] (open reduction-surgical procedure) to Right femur on 11/24/24. (R3) has a splint to her R (right) arm for a proximal humerus fracture. On 12/31/24 at 11:55 am V2 (Registered Nurse/RN) stated she responded to R3's fall in the dining room, after hearing some kind of noise. She was third staff in the dining room at time. (R3's) head was bleeding from a laceration on her head. I (V2) applied a pressure dressing and cleaned the area, while two CNAs (unidentified) were getting vital signs. The two CNA said the floor nurse (unidentified) was calling 911. The ambulance came and (R3) was transferred to the gurney for transport to the hospital. V2 also stated I come in early in the morning to make sure the residents are all up and out for breakfast. That came from me (direction for all resident to be in the dining room for meals). We are addressing residents left in bed. The CNAs have been told all residents come to the dining room, unless there are issues that require them to remain in their beds. I was told after the fall, (R3) had not slept the night before. That would be a circumstance CNAs would relay to the nurse, so (R3) could continue to sleep. There is to be a CNA, always in the dining room, while the other staff are getting the other residents out for meals. We discussed, during morning meeting the next day (after R3's 11/22/24 fall), that there was no one in the dining room, supervising the residents. That should never have happened. Her (R3's) fall could have been prevented. On 12/31/24 at 4:00 pm V14 (Licensed Practical Nurse/LPN) stated I did not witness (R3's) fall. I came out of my office when I heard (R7) yell for help. (R3) was lying flat on her stomach, with the right side of her face on the floor. She was very tense and never talked. The wheelchair was already moved away from (R3's) feet, so I don't know if it was locked or not. I heard she (R3) was really groggy when they got her out of the recliner to bring her to the dining room that day. I think it was (V19 Social Service Director) that called 911. R3's AIM (Assessment/Evaluation Intercommunication Management/Intervention) For Wellness- Event Record dated 11/22/2024 at 10:55 am documents the following: Late Entry: Note Text: Event Details: (R3) appears to have experienced an alleged Intentional Change in Plane; Witnessed w (with)/head involvement. Event was first noted on 11/22/2024 10:55 am Evaluation of the resident and event occurred on or about 11/22/2024 11:00 AM. Just prior to/at the time of the event (R3) appears to have been sitting in w/c (wheelchair) at the dining room table. (R3's) account of the event is unable to explain what happened. Witness to the event includes: (R7) stated she (R3) stood up from her w/c and started to walk and immediately fell to the ground hitting her head. Location of the event is: Dining room. Description of the environment at the time of the event includes quiet. Staff's immediate response is noted as Assessed resident, VS (vital signs) taken, EMS (Emergency Medical Service) called. Unable to determine if this type of event is known to have occurred previously. R3's Hospital Emergency Documentation signed by V29 (emergency room /ER Physician) dated 11/22/24 at 12:54 pm documents the following: Chief Complaint: Patient to the ED (Emergency Department) via EMS (Emergency Medical Service) from (Facility) for (an) unwitnessed fall. Patient (R3) was in dining room, stood from her wheelchair, and fell . Laceration to right forehead skin tear to right upper arm. History of Present Illness: This is a [AGE] year-old female brought to the emergency room by ambulance from (facility name) nursing home for a complaint of a fall with right hip pain. The patient herself is quite demented so I am unable to get any history from her. According to the chart the patient was in the dining room and stood up from her wheelchair and fell . I am unable to get any details from the patient due to her dementia, no other description of the fall was given. Review of Systems: Review of systems is unobtainable other than what is stated in the HPI (history of present illness). Physical Exam: Vital signs reviewed. In general, the patient is awake, pleasantly demented, appears in no acute distress. Pupils are equal, sclera clear, TMs (Tympanic Membrane's/eardrum) normal, nares are pink, oropharynx is clear. The patient's right upper forehead has a 2 cm (two centimeter) vertical superficial abrasion without any surrounding soft tissue swelling or hematoma. Neck has no midline tenderness or step deformities. Heart is regular rate and rhythm without murmurs. Lungs are clear. Abdomen is soft, nondistended, with active bowel sounds. Extremities shows shortening and external rotation to the right lower extremity. The patient has significant tenderness palpation of the right hip. There is no tenderness to the knee or ankle on that side. Her right upper extremity at the mid bicep triceps area shows a 1-1/2 cm superficial skin tear without any bruising or hematoma formation. The patient has marked tenderness to palpation of the proximal and mid right humerus and there is crepitance, shoulders, elbows, and wrists are nontender and have no deformity. Palpation of her chest wall and ribs shows no tenderness or deformity. The same report documents: ED Course: An x-ray was performed of the patient's right hip that I reviewed. The patient has a displaced intertrochanteric right hip fracture. I did order baseline labs. X-ray of the right humerus shows a comminuted and mildly angulated and displaced fracture to the proximal humerus below the humeral head. A CT (Computed Tomography) of the brain without contrast was performed and I reviewed the images myself. There is atrophy and periventricular lucencies but I do not see any evidence of bleed or midline shift. Still awaiting radiology report. I did contact (V30 Physician) from orthopedics, and he will consult. He feels that the humerus fracture will be nonoperative and the hip will be operative repair. I spoke with (V31 Nurse Practitioner) from the hospital service and the above was discussed with her. She does agree to admit the patient for her right humerus and right hip fractures with orthopedics consulting. I did have nursing staff placed the right upper extremity in a long-arm sugar-tong splint. Baseline labs were drawn. The facility Fall Prevention policy dated 11/18/17 documents the following: Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. The same policy documents direct all staff 'must observe residents for safety.' If residents with are observed up or getting up, help must be summoned, or assistance must be provided.

Based on observation, interview, and record review, the facility failed to prevent resident to resident physical abuse. This failure affects two residents (R1, R2) of three reviewed for abuse in the sample of three. R2's hands were on the right side of R1's neck and R1 received a skin tear on the right side of R1's neck that was treated with wound closure strips. Findings include: The facility Abuse Prevention Program policy (2/2021) documents: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. The same record documents Physical Abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The facility Residents' Rights policy (November 2018) documents: You must not be abused, neglected, or exploited by anyone-financially, physically, verbally, mentally or sexually. R1's diagnosis list (8/30/2023) documents diagnoses including Dementia, Major Depressive Disorder, Epilepsy, Psychosis, Schizophrenia, and Cerebral Infarction (stroke). R1's Resident Assessment (8/9/2023) documents R1 has severely impaired cognition, requires extensive staff assistance to perform activities of daily living, uses a wheelchair, and has left and right-side upper extremity impairment. R2's Resident Assessment (7/3/2023) documents R2 is cognitively intact, uses a wheelchair, and does not have any upper extremity impairment. R2's Care Plan (8/31/2023) documents R2 has a history of displaying physical aggression and/or threats of aggression towards others and has a history of striking others when upset. On 8/30/2023 at 3:05PM, V3 (Registered Nurse) reported being present at the nurse's station on 8/10/2023 on the hallway where R1 and R2 reside and hearing a commotion outside of R1's room located nearby the station. V3 reported observing R1 seated in R1's wheelchair at the doorway to R1's room and moving R1's wheelchair back and forth on the floor towards R1's room. V3 reported R2 was in R2's wheelchair trying to pass R1 in the hallway when R1 rolled backwards and bumped into R2's wheelchair and then R2 rammed R1's wheelchair two or three times with R2's wheelchair and then began swinging R2's arms towards R1. V3 reported leaving the nurse's station to separate R1 and R2 and finding R2's hands were on the right side of R1's neck as R1 was covering R1's head with R1's hands. V3 reported R1 had a small skin tear on the right side of R1's neck which V3 treated with wound closure strips. V3 reported R1 is cognitively impaired and R2 is cognitively intact and R2 has a short temper. On 8/30/2023 at 3:04PM, a mostly healed skin tear (approximately one centimeter in length) was located on the right side of R1's neck. R1 stated yes (R2 had hit R1 on 8/10/2023). The facility Witness Statement (8/11/2023) documents an interview between V1 (Administrator) and R2 where R2 reported knowing R2 should not have gotten into a fight with R1, but R1 was blocking the hallway (on 8/10/2023) when R2 was trying to get to R2's room after supper. R2 reported telling R1 to move and R1 did not move R1's wheelchair, so R2 bumped into R1's wheelchair to get R1 to move out of the way. R2 reported R1 then began swinging R1's arms at R2 so R2 responded by swinging R2's arms back toward R1. On 8/30/2023 at 1:05PM, R2 reported R1 bumped R2's wheelchair on 8/10/2023 and then R2 hit R1 with a fist a few times while R1 covered R1's head with R1's hands. R2 raised R2's closed fist into the air to demonstrate how R2 hit R1. On 8/31/2023 at 1:50PM, R2 reported hitting R1 in the head area three to four times on 8/10/23.

Based on observation, interview and record review the facility failed to implement resident centered fall prevention interventions following a fall for one resident (R4) of three residents reviewed for falls in a sample list of five residents. This failure resulted in R4 falling and sustaining an ankle fracture. Findings Include: R4's diagnoses list printed 8/14/23 at 2:05PM includes the following diagnoses: Neuroleptic Induced Parkinsonism, Seizures, Essential Hypertension, and Paranoid Schizophrenia. R4's Minimum Data Set (MDS) dated [DATE] documents R4 scored a 15/15 on the Brief Interview of Mental Status (BIMS) indicating R4 is cognitively intact. R4's Care Plan includes a risk for fall initiated and continued since 4/2/20. A note was added 5/15/23 documenting (R4) stated (R4) fell in room and was having difficulty seeing. (R4) received new glasses recently. Remind (R4) to change position slowly. This is the only updated to R4's fall Care Plan since 4/2/20. R4's Physical Therapy Plan of Care initiated 5/16/23 documents R4 required therapy due to a fall on 5/12/23 as a result of patient losing her balance during walking resulting in right knee abrasion. Patient has complaints of right knee pain with resulting impairments in strength, balance, safety awareness, and decreased functional mobility. Therapy is necessary to regain lost function and reduce falls. Without therapy, patient is at risk for falls and further decline in function. This Physical Therapy Plan of Care also documents Discharge Plans: Remain in Skilled Nursing Facility with restorative nursing program. The end of care date for Physical therapy is documented as 7/3/23. There is no documentation to support a restorative program or any other fall prevention interventions were added to R4's Care Plan following discontinuation of therapy. R4's Progress Note dated 7/20/23 at 12:30AM documents (R4) experienced an unwitnessed fall in (R4's) room while ambulating from bathroom back to bed. The note documents (R4's) account of the event is (R4) stated (R4) fell returning from bathroom while ambulating; unable to recall how (R4) landed when (R4) fell . R4's Progress Note dated 7/20/23 at 4:25AM documents (R4) returned from (Local Hospital) emergency room with Diagnosis: Fracture of right lateral malleolus. (ankle) On 8/14/23 at 1:46PM R4 was seated in her room alone in a recliner with her feet elevated. A fiberglass cast was visible above her pants on her right ankle/foot. R4 stated I fell on [DATE]th. I got up to go to the bathroom with my walker and as I was trying to get through the bathroom door and my walker got tangled up and I fell and broke my ankle. I told the staff I was falling more. They gave me therapy for a while. It helped. Now I'm weaker again and I have this cast. On 8/15/23 at 12:00PM V10 (Physical Therapy Assistant/PTA) stated We did teaching with (R4) and the floor staff related to (R4's) home exercise plan which should have been initiated after (R4) met her goals to maintain (R4's) safety and balance. On 8/15/23 at 2:25PM V11 (Nurse Practitioner) stated (R4's) fall caused the fracture of her ankle. It would have been my expectation that after therapy was discontinued the facility would put interventions in place to help (R4) maintain her safety. On 8/15/23 at 2:00PM V12 (Certified Nurse's Aide/CNA) stated I know (R4) pretty well. I am assigned to her unit for this shift. (R4) doesn't have any restorative programs. The facility's policy Fall Prevention revised 11/10/18 states Policy: To provide for resident safety and to minimize injuries related to falls, decrease falls, and still honor each resident's wishes/desires for maximum independence and mobility. Immediately following any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will place documentation of the circumstances of the fall in the nurse's notes or on the AIMS (Assessment, Intervention, Monitor) for Wellness form along with any new intervention deemed to be appropriate at the time. The unit nurse will also place any new interventions on the CNA assignment worksheet. Report all falls during the morning quality assurance meeting Monday through Friday. All falls will be discussed in morning quality assurance meeting and any new interventions will be written on the care plan.

Based on observation, interview and record review the facility failed to protect a resident's right to be free from physical abuse by another resident for one (R3) of three residents reviewed for physical abuse from a total sample list of three. This failure resulted in R3 being bitten on the breast, requiring a tetanus shot and antibiotics. Findings include: The facility Abuse Policy dated 11/28/2016 documents that the facility affirms the right of their residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility prohibits mistreatment, exploitation, neglect or abuse of its residents. The facility abuse policy defines abuse as, The willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the depravation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled thorough the use of technology. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. R2's Minimum Data Set, dated dated dated [DATE] documents R2 as cognitively intact and ambulatory. R2's nursing summary dated 2/21/23 documents that R2 gets agitated with her roommate and yells at her. R2's nursing summary dated 5/24/23 documents that R2 has delusions that her roommate stole her husband and yells and screams at her sometimes. R3's Minimum Data Set, dated dated dated [DATE] documents R3 as severely cognitively impaired. R3's progress notes dated 6/27/23 document, (R2) came to nurse's station and reported to this (registered nurse) that she had just thrown water onto (R3) after (R3) would not leave her alone and would not stop talking after she had asked her to. (R3) was immediately assessed and found with a wet shirt and a five-centimeter by four-centimeter bite mark to left breast. (R3) stated that (R2) had thrown water on her and bit her breast. R3's physician orders dated 6/27/23 document to apply Neosporin to left breast topically two times a day for bite wound for ten days. Give Augmentin 500/125 milligrams, one tablet by mouth two times a day for prophylaxis for wound to left breast for 10 days. Give Tetanus-Diphtheria Toxoids (Td) intramuscular Suspension 2-2 LF/0.5 milliliter (Tetanus-Diphtheria Toxoids (Td). Inject 0.5 milliliter intramuscularly one time only for prophylaxis for wound. On 7/17/23 at 10:45AM, R2 stated, I bit her, and I threw water on her cause she just wouldn't let it go. I am glad to not be in the same room with her anymore. On 7/17/23 at 10:30AM, R3 stated, She (pointing to R2) bit me. R3 then pulled up her shirt and on the left breast, near the nipple there was a healing bite mark approximately the size of a half dollar with teeth marks indented into the skin. R3 stated, She threw water on me and bit me twice. I don 't want to room with her anymore. She don't like me. On 7/17/23 at 8:40AM, V2 (Psychiatric Rehabilitation Services Counselor) stated, R2 and R3 were roommates and they had verbal disagreements before but never anything physical. R2 was having more hallucinations around that time. On 7/17/23 at 10:40AM, V5 (Certified Nursing Assistant) stated, (R2 and R3) had been verbal, but not physical. They both are acting normal now and seem happier that they are apart.

Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by a staff member and physical abuse by another resident for three of three residents (R1, R2 and R3) reviewed for abuse in the sample of six. Based on V5's statement that R1 seemed very upset, disturbed, silent, and looked heartbroken, it can be determined that the reasonable person in the resident's position would have experienced psychosocial harm (e.g., embarrassment, humiliation, anxiety) as a result of the verbal abuse. Findings include: The facility Abuse Prevention Program policy (2/2021) documents: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. The same record documents Physical Abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment and Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, or saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. The facility Residents' Rights policy (November 2018) documents: You must not be abused, neglected, or exploited by anyone-financially, physically, verbally, mentally or sexually. 1. R1's Psychiatry Note (2/1/2023) documents R1's diagnoses including Major Depressive Disorder, Anxiety, Insomnia, and Dementia. On 2/17/2023 at 11:40AM, V7 (Registered Nurse) reported R1 also has a medical history of Traumatic Brain Injury. R1's Minimum Data Set (1/6/2023) documents R1 is dependent on staff assistance for completing all activities of daily living. The facility Final Report (2/15/2023) documents on 2/8/2023 V5 (Certified Nurse Assistant/CNA) was helping V3 (CNA) perform nursing cares for R1 in R1's bathroom when V3 began to yell inappropriately at R1. The Report documents V6 (CNA) overheard the yelling, entered R1's bathroom, and told V3 to leave. V6's Witness Statement (2/8/2023) documents V6 was returning to the nursing floor from a break and heard V3 yelling at R1 Get the (expletive) off the floor then stating you are (expletive) disgusting. V5's witness statement (2/8/2023) documents V5 was assisting V3 with R1 when V3 began yelling at R1 (get) the (expletive) off of the floor and stating to R1 (you're) (expletive) disgusting and ridiculous. The statement documents R1 seemed very upset and disturbed by V3's statements. On 2/17/2023 at 9:57AM, V5 recalled the incident on 2/8/2023 and reported R1 had fallen onto the bathroom floor beside R1's toilet and V3 and V5 went into R1's bathroom to help R1 get up off the floor. V5 said V3 began yelling at R1 telling R1 (you are) (expletive) disgusting and need to get off the (expletive) floor. V5 reported being shocked and stated R1 seemed extremely upset and silent and looked heartbroken. (V3) was raising her voice pretty loud and right in his face yelling at him. The facility Notice of Termination (2/10/2023) documents the facility terminated V3's employment for cussing at a resident (R1) on 2/8/2023 while providing direct care. V3 personally signed an Employee Residents' Rights Acknowledgement form on 10/26/2022 affirming understanding of the facility Residents' Rights policy. 2. R2's Physician Orders (February 2023) document diagnoses including: Psychosis, Schizoaffective Disorder, Depression, and Anxiety. R3's Progress Note (2/9/2023) documents R3 has a diagnosis of Violent Behavior. The facility Final Report (2/14/2023) documents on 2/8/2023, R2 was in R2's bathroom cleaning when R3 entered the bathroom agitated and began hitting R2. The report documents R3 reported being mad and felt like hitting someone. The facility Witness Statement (2/8/2023) documents R2 reported R3 hit R2 in the left arm, left side of chest, and left side of ribs. The same record documents R2 reported R3 hit R2 as hard as R3 could hit. On 2/17/2023 at 2:05PM, R2 reported R3 walked into the bathroom where R2 was and began cussing and hitting R2 with a closed fist. R2 reported R3 punched R2 in the left chest, ribs, arm, and shoulder areas four-five times.

Based on interview and record review, the facility failed to ensure safe footwear and effective supervision of R4 while dressing. This failure resulted in R4 slipping and falling to the ground sustaining a forehead laceration, brain bleed, brain bruising, nasal fractures, and eye socket fractures requiring emergency medical treatment at two hospitals. R4 is one of three residents reviewed for falls in the sample of six. Findings include: R4's Physician Orders (January 2023) document R4's diagnoses include Dementia, Osteoarthritis (degenerative joint disease), Osteopenia (reduced bone density), Hypotension (low blood pressure), and Near Syncope (near-fainting). R4's Minimum Data Set documents R4 is dependent upon staff for cares, requiring complete dependence on staff for bathing and weight-bearing support from staff while dressing. The facility Incident report (2/3/2023) documents R4 sustained a witnessed fall on 1/30/2023 after showering. The report documents V11 (Certified Nurse Assistant) had showered and partially dressed R4 and assisted R4 to a standing position when R4 slipped and fell to the ground sustaining multiple injuries requiring emergency medical treatment at the hospital. The report documents R4's non-slip socks at the time of the fall were missing portions of the non-slip surface on the bottom of the socks and the facility concluded the socks were the root cause of R4's fall. R4's hospital reports (1/30/2023) document R4 was initially sent to a local hospital for emergency medical evaluation and treatment. The local hospital's assessment of R4 documented R4 sustained injuries during a witnessed fall including a forehead laceration, periorbital (eye socket) bruising, left and right-side brain contusions (bruising), brain hematoma (bleed), left and right-side nasal bone fractures, and right-side orbit (eye socket) fracture. The report documents R4 required neurosurgical medical evaluation, trauma services, and otorhinolaryngology services and was transferred to a regional hospital capable of the additional evaluation and treatment. The reports document the regional hospital sutured R4's forehead laceration and R4 was admitted there for continued neurological assessment following R4's brain injuries. R4's Physician Orders (February 2023) document R4 required ongoing neurological assessment and wound treatment at the nursing home following R4's discharge from the hospital after R4's 1/30/2023 fall. On 2/21/2023 at 2:50PM, V12 (Registered Nurse) reported V12 was present in the shower room after R4 fell to the ground on 1/30/2023. V12 recalled V11 reported showering then dressing R4, turning around, then R4 fell to the ground. On 2/22/2023 at 10:00AM, V13 and V14 (both R1's family) reported the facility contacted them after R4's fall on 1/30/2023 and their understanding was V11 was dressing R4 after a shower, then V11 turned away from R4 when R4 fell to the ground. On 2/22/2023 at 10:31AM, V11 (CNA) reported R4 does not have good balance sometimes and R4 gets R4's legs tangled often. V11 reported two staff are usually present when dressing and undressing R4 during perineal cares. V11 reported R4 is not combative unless changing clothes, and R4 was combative the day of R4's fall on 1/30/2023. V11 stated (R4) had grippers (non-slip socks) on (at the time of the fall), but the socks didn't have the good grip (the rubber patterns found on the bottom of non-slip socks) on and that probably made it worse, and it seemed like (R4) slipped and (R4's) leg got twisted. V11 reported I may have had a towel beneath (R4's) feet (at the time of the fall). V11 stated I saw (R4's) legs cross and (R4) went to pull a foot out and it (R4's foot) didn't (pull free) and (R4) went hard (falling to the floor). V11 reported R4 does not have good balance when staff change R4's clothes, and when staff touch R4, R4 seems irritated. V11 could not recall if R4 leans on V11 for weight-bearing support while staff dress R4. On 2/22/2023 at 3:18PM, V2 (Quality Assurance Registered Nurse) reported the root cause of R4's fall was due to the non-slip surface of R4's socks being worn down.

Based on observation, interview, and record review the facility failed to provide a safe environment by failing to accurately determine the need for padded side rails, failing to provide safe transfers, and failing to apply a seatbelt utilized for safety for one of three residents (R1) reviewed for injury of unknown origin on the sample list of nine. These failures resulted in R1 sustaining a right elbow fracture. Findings include: R1's Radiology report dated 8/9/20 documents R1 has a complete oblique fracture involving the olecranon to the right elbow. R1's emergency room report dated 8/9/20 documents: R1 was sent to the emergency room for a broken elbow. R1's right elbow was bruised and swollen. R1 is bedridden or wheelchair bound at all times. The fracture is an olecranon fracture. R1's emergency room paperwork contained an informational document that documents an Olecranon fracture commonly occurs after falling on a hard surface with a bent elbow and other causes include a forceful hit (blow) to the elbow, falling onto an outstretched arm, or a forceful twist to the elbow. On 8/18/20 at 4:15 PM, V5 Registered Nurse stated R1 is immobile and requires staff assistance to get out of bed. V5 stated R1 can not turn self in bed and has side rails on both sides of the bed. V5 stated R1 is dependant on staff to move from the bed to chair. V5 stated R1 is transferred with a mechanical lift. V5 stated R1 can not move self in wheelchair and has to be pushed. The facility's final report dated 8/9/20, written by V2 Unit Director/Registered Nurse documents that R1 relies on staff for transfers using a mechanical lift and uses a wheelchair for locomotion per staff. This report document R1 was sent to the emergency roiagnom on [DATE] for swelling to the right elbow and that R1 was diagnosed with [REDACTED]. This report documents a conclusion that the facility was unable to determine the cause of the fracture. This report documents R1 as having a history of [MEDICAL CONDITION] which may have caused the injury. On 8/17/20 at 11:27 AM, V2 Registered Nurse/Unit Director stated V2 investigated R1's fracture. V2 stated R1 has bilateral half rails that are put up when R1 is in bed. V2 stated during the investigation of R1's injury of unknown injury V2 noted that the rails were not padded. V2 stated V2 discovered V3 CNA (Certified Nursing Assistant) had transferred R1 on 8/8/20 on the second shift. V3 stated V3 transferred R1 by cradle lifting by V3's self instead of using the mechanical lift. R1 is a mechanical lift. V2 stated V3 received a written discipline for transferring R1 incorrectly. V2 stated R1 can not bear weight or turn self in the bed. V2 stated R1 wears a seatbelt when up in the wheelchair due to sliding in wheel chair. On 8/17/20 at 11:41 AM, half side rails were elevated on both side of R1's bed. R1's physician's orders [REDACTED]. On 8/19/20 at 7:12 AM, V17 Licensed Practical Nurse stated R1 is extensive assist with bed mobility. V17 stated R1 has a [MEDICAL CONDITION] disorder and has had [MEDICAL CONDITION] in the past. V17 stated R1 had a [MEDICAL CONDITION] around the beginning of July. R1's side rail assessment dated [DATE], 5/5/20, and 8/11/20 does not document that R1 has a [MEDICAL CONDITION] disorder under the assessment of considerations for entrapment. This assessment documents if a [MEDICAL CONDITION] disorder is present the facility needs to consider padding side rails. On 8/19/20 at 10:34 AM, V7 Care Plan Coordinator stated V7 stated that she should have marked yes on the side rail assessment. V7 stated R1 side rails should have been padded due to R1 having a [MEDICAL CONDITION] disorder. On 8/19/20 at 7:22 AM, V16 CNA stated R1 can not move in bed at all. R1 would not be able to try to stand up, R1 doesn't even try to move in R1's wheelchair, the most R1 can do is move R1's arms a little bit. R1's rail was not padded before R1's elbow fracture. V16 stated V16 thinks R1 was injured when they rolled R1 in bed or laid R1 down it may have hit the bed rail. V16 stated R1 is a mechanical lift but they (the staff) had been cradle lifting R1 before R1 got the fracture. V16 stated R1 was supposed to be a mechanical lift. R1's care plan dated 5/18/16 documents an intervention to use two assist with the mechanical lift for all transfers. On 8/18/20 at 3:34 PM, V3 CNA stated she took care of R1 on 8/8/20 on the second shift. V3 stated R1's side rails were not padded at the time. V3 stated she cradle lifted R1. V3 stated everyone lifts R1 like that. V3 stated V3 knew R1 was a mechanical lift. R1's Physician order [REDACTED]. R1's care plan dated 5/18/16 documents R1 requires the use of a self releasing seat belt while up in the wheelchair due to sliding down in chair. On 8/17/20 at 11:41 AM, R1 was sitting up in a high back wheel chair and was covered with a blanket. R1's safety belt was not in place. V9 (certified nursing assistant) CNA in training and V16 CNA were present in the room. V16 stated they did not fasten R1's safety belt. On 8/26/20 at 9:06 AM, V2 Registered Nurse/Unit Director there isn't a way that R1 could have injured R1's self. V2 stated R1's side rails were not padded prior to R1 having a fractured elbow. V2 stated the facility did discipline V3 for not using the mechanical lift.

Based on interview and record review the facility failed to provide a [MEDICAL CONDITION] medication per physician's order for one of three residents (R6) reviewed for [MEDICAL CONDITION] medications on the sample list of nine. This failure resulted in R6 having a psychotic episode which required hospitalization and electroconvulsive treatment. Findings include: R6's Behavioral Health Discharge note written by V26 Psychiatrist dated 4/21/20 documents, (R6) was discharged to (the facility) on 3/9/20. After discharge, (R6's) [MEDICATION NAME] injection due date was apparently overlooked by nursing staff. By the time the due date was discovered and the medication was ordered by the pharmacy, the pharmacy informed the facility that the medication was not covered by the (R6's) insurance. According to (V25, Registered Nurse) at (the facility), (R6) began spitting out (R6's) psychiatric medications and posturing on 4/6/20. On 4/8/20, (R6) refused to leave (R6's) clothing on and became physically aggressive with the nursing home staff. (R6) was transported to (the hospital) for further evaluation and treatment. (R6) required restraints as (R6) was combative with paramedics. In the emergency department, (R6) refused to answer questions. (R6's) medical work-up was reassuring. (R6) was subsequently transferred to psychiatry for further evaluation and treatment. R6's Medication Administration Record [REDACTED]. This Medication Administration Record [REDACTED]. On 8/20/20 at 8:24 AM, V23 Licensed Practical Nurse stated R6 was readmitted to the facility on [DATE], R6 was admitted with an order for [REDACTED]. R6 went to the hospital 4/8/20 due to refusing R6's medications and psychiatric issues. R6's Behavioral Health Discharge note written by V26 Psychiatrist dated 4/21/20 documents R6 had a total of three electroconvulsive therapy treatments while R6 was here in the hospital. On 8/24/20 at 8:34 AM, V26 Psychiatrist stated R6 was a harm to himself and others when admitted to the hospital on [DATE]. V26 stated R6's psychotic episode was due to not receiving the prescribed [MEDICATION NAME]. V26 stated R6 required electroconvulsive therapy while in the hospital.

Based on interview and record review the facility failed to ensure R100 was not subjected to resident to resident physical abuse and R101 was not subjected to employee to resident mental abuse by intimidation. This failure affects two residents (R100 and R101) out of four reviewed for abuse on the sample list of 33. This failure resulted in R100 being struck multiple times, experiencing a fractured finger and lacerated right ear. This failure resulted in R101 being intimidated, denied personal choices, and feeling treated like an animal. Findings include: 1. R100's Minimum Data Set ((MDS) dated [DATE] documents R100 received a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15, rating R100 as being severely cognitively impaired. On 1/14/20 at 10:30 am, R100 was not interviewable, making no verbal responses to simple greetings. R36's MDS dated [DATE] documents R36 received a BIMS score of 15 out of a possible 15, rating R36 as being cognitively intact. On 1/14/20 at 10:23 am, R36 stated, I used to be in a different room with someone else. I had a fight with the guy because he was touching my stuff. I hit him about 8 or 9 times. He got hurt. The nurses took a cold washrag and wiped the blood off. I'm not sure if he went to the hospital. His name was (R100). The facility's Interdisciplinary Team Review dated 12/30/19 documents, Resident (R36) had a resident to resident altercation hitting another resident. R36's Nurses Note dated 12/28/19 documents, Resident (R36) had a resident to resident altercation perpetrated by (R36) hitting another resident (R100) at 5:55 pm, following a response to resident's roommate (R100) ambulating towards the nurse, noted to be bleeding from the right ear and blood noted to the right hand. Staff checked the other resident (R36) and room finding blood on the floor on residents (R36's) side of the room where (R36) was presently sitting in the wheelchair watching television. Staff had spoken with the resident (R36) who stated (R36) had hit the other resident (R100). While being evaluated over a video conference with a Medical Doctor (V15), (R36) told the doctor (R36) thought the shoes (R100) was wearing belonged to (R36) so (R36) had yelled at (R100) to not take the shoes and (R100) didn't pay no mind so (R36) grabbed (R100) and hit (R100) several times. The facility's Final Report (dated 1/6/20) on (R36) and (R100) Incident on 12/28/19 at 5:55 pm, documents, (R36) struck (R100) several times. (R100) assessed and sent to (hospital) for treatment. X-ray of right hand complete with fourth distal phalanx (finger bone) fracture. The (hospital) Emergency Documentation dated 12/28/19 documents (R100) was experiencing bleeding from the right ear and right hand. The (hospital) Diagnostic Radiology dated 12/28/19 documents Acute fracture of 4th distal phalanx, intra-articular (in the joint of the finger). The (hospital) Progress Note dated 12/28/19 documents hospital staff spoke with nurse at (facility) to make a follow up appointment with orthopedist and to keep the hand splinted until the appointment. On 1/17/20 at 9:54 am, V14, Primary Care Physician for R36 and R100, and facility Medical Director, stated, This was an unfortunate incident. I think there was an over-reaction of (R36) towards (R100). I think there was some level of harm with the broken finger, but I don't think (R36) intended to break (R100's) finger. I agree (that (R100) would experience some amount of pain with a broken finger and since (R36) had a history of [REDACTED]. R36's Care Plan dated (started) 1/10/18 documents, Resident is known and has a history of displaying physical aggression towards staff and other residents. Resident may strike other residents when upset. Resident has hit other residents over the head when irritated with them. 2. R101's Minimum Data Set ((MDS) dated [DATE] documents R101 received a score of 15 out of a possible 15, rating R101 as cognitively intact. R101's Physician order [REDACTED]. R101's Face Sheet documents R101 has no other legal Power of Attorney besides R101's self. On 1/14/20 at 11:50 am, R101 stated, One male nurse (V18, Registered Nurse) made me go to the dining room when I didn't want to and made me sit at a table that wasn't mine. R101 further stated, I am trying to lose weight. On 1/17/20 at 1:18 pm, R101 stated, When (V18) made me go to the dining room, it made me feel upset, I didn't think I was in danger, but (V18's) hands were out like (V18) was herding sheep, like corralling me and taking away my choices. I wanted to go back to my room. On 1/16/20 at 12:46 am, V16, Certified Nursing Assistant, stated, (R101) does refuse a lot of cares like showers and meals. I have to approach and re-approach (R101) several times to get her to go to the shower or meals. Sometimes if (R101) refuses after a couple of tries, I will have Social Services (V17, Psychiatric Rehabilitation Services Coordinator) talk to (R101) and eventually (R101) will go. On 1/16/20 at 12:50 pm, V12, Registered Nurse, confirmed, (R101) is her own person. V12 further stated, (R101) will refuse to go to showers or meals a lot. We can never force residents to do things they don't want to do. We do have the Social Services (V17) educate and counsel (R101). On 1/16/20 at 1:16 pm, V4, Psychiatric Rehabilitation Services Director, stated, With (R101), if we ask her to do something and (R101) doesn't want to do it right then, (R101) may start to throw a tantrum with yelling and screaming and tears, then we have to try to re-approach (R101) again about 15 minutes later, and if that doesn't work, one of us will talk to (R101) or have the Social Services (V17) talk to (R101) to explain that (R101) really should go to the shower or go down to eat or to the doctor appointment, whatever it is. Eventually, on some days, (R101) will go ahead and go to the shower or meal, and some days (R101) won't, so if (R101) doesn't go, then we have to accept a refusal. On 1/16/20 at 1:30 pm, V1, Administrator, stated, The incident between (V18, Registered Nurse) and (R101) happened this past weekend. It does appear that (V18) made (R101) go to the dining room when (R101) didn't want to. I understand (V18) wasn't forcefully dragging (R101) but (V18) was holding (V18's) hands out to the side and was more or less blocking (R101's) path and not letting (R101) turn back to go back to (R101's) room. Then when (V18) did get (R101) to the dining room, (V18) placed (V18's) chair right next to (R101) and was basically keeping (R101) from leaving the dining room table. We did terminate (V18) because we thought he made a bad choice about making (R101) go to the dining room. It was just time for (V18) to move on. On 1/16/20 at 1:43 pm, V18, Registered Nurse, stated, I can't say anything to you, I can give you the number of my lawyer and you can talk to him. R101's Care Plan dated (initiated) 5/31/16 documents, resident is morbidly obese, has some interest in reducing overall weight, willing to vary from usual habits in small ways to reduce overall intake, resident will lose 1 - 3 pounds per month. This same Care Plan was documented as reviewed on 12/17/19 and 1/2/20. The facility's Final Report of R101 incident with V18, Registered Nurse, documents, The facility concluded that (V18) should not have made R101 go to the dining room to eat. (V18) was suspended and then terminated due to handling the situation poorly. The facility's Residents' Rights (from Illinois Department on Aging) dated 6/09, documents, You have the right to safety and good care, your facility must provide you with services to keep your physical and mental health, and sense of satisfaction. You must not be abused by anyone - physically, mentally, financially, or sexually. You have the right to participate in your own care, your facility must develop a written care plan that states all the services it provides for you, you facility must make reasonable arrangements to meet your needs and choices.

Based on interview and record review the facility failed to administer the correct dose of insulin as ordered and failed to administer insulin immediately before or during a meal. This failure affects one of three resident (R1) reviewed for medication errors in the sample of five. This failure resulted in R1 losing consciousness, missing a scheduled [MEDICAL TREATMENT] appointment and becoming extremely weak throughout the next day. Findings include: The facility's Medication Administration policy dated 7/13/13 documents, Medications must be identified by using the six (6) rights of administration: right resident, right drug, right dose, right time, right route, right documentation. The facility's Adverse Drug Reactions and Medications Discrepancy policy dated 11/6/18 documents, Assess the resident for adverse reaction side effects including vital signs, blood glucose levels, oximetry and relevant effects of neurological, metabolic, respiratory, circulatory nature as suggestive of current medications as applicable. This policy goes on to document, Document a detailed account of the discrepancy or adverse reaction in resident's medical record. Documentation must include but is not limited to: date and time of incident, description of discrepancy or adverse reaction, name, strength, dose of associated medication, resident's reaction to the medication including assessment results, interventions to treat adverse effects, response to treatment, notifications made and response. The facility's Subcutaneous Injections (insulin/[MEDICATION NAME]) policy dated 11/6/18 documents, Verify the medication order. This policy goes on to document, Serve diet in the prescribed length of time. R1's Minimum (MDS) data set [DATE] documents that R1 is cognitively intact and that R1 received insulin injections seven days a week. R1's Medication Error Report dated 9/27/19 documents the date and time of the error as 9/27/19 at 6:45 AM. This report documents R1 was given 60 units of Humalog and the physician's orders [REDACTED]. This report documents the cause of the error was misreading the writing on the MAR (Medication Administration Record). This report documents that this error endangered the life or welfare of the resident by making the blood sugar drop and this was discovered at 8:30 AM on 9/27/19 by V3 Registered Nurse (RN) and V3 was also the nurse that made the error. R1's AIM (Assess, Intercommunicate, Manage) form dated 9/27/19 documents R1 was being observed for a medication error. R1's Vital signs documented on this report are as follows; blood pressure 140/50, pulse 60, respiration rate 20, temperature 97.6 and blood sugar 55. This set of vitals are the only vital signs documented on this report. This report documents Physician notification at 10:00 AM and Resident Representative notification at 11:00 AM. This report documents to monitor R1's blood sugars every hour and hold the noon insulin until evening (dinner). R1's Physician order [REDACTED]. This POS documents an order with a start date of 7/6/19 for Humalog 100 units/ml (milliliter), Inject 6 units sub-q (subcutaneous) three times daily before meals. R1's Medication Administration Record (MAR) dated 9/2019 documents an order for [REDACTED]. The lower case u that was originally written next to the number 6 is scribbled out on the MAR and units is written above the scribbled out u. R1's MAR dated 9/26/19 through 9/30/19 documents an order dated 9/26/19 for NPO (nothing by mouth) after midnight for CT (computed tomography) of abd (abdomen) on 9/27/19 at 8:00 AM. This same MAR documents an order dated 9/27/19 for [MEDICATION NAME] ([DIAGNOSES REDACTED] Antidote) 1 mg (milligram) SQ (subcutaneous) one time. This MAR documents an order dated 9/27/19 to recheck blood glucose hourly and has blood glucose results documented started at 12:00 PM. The first result documented was 356 at 12:00 PM, 403 at 1:00 PM, 342 at 2:00 PM, 338 at 3:00 PM, 327 at 4:00 PM, and 319 at 5:00 PM. On 10/21/19 at 1:40 PM, V3 RN stated on 9/27/19 at approximately 6:45 AM, V3 checked R1's blood glucose then gave R1 R1's morning Humalog and other oral medications. V3 stated R1's MAR looked as if it said 60 units of Humalog. V3 stated the u abbreviation for units looked like a 0. V3 stated V3 administered 60 units of Humalog to R1. V3 stated that was the first time V3 had taken care of R1. V3 stated V5 Certified Nursing Assistant came to V3 and told him that R1 was sweating and shaking. V3 stated V3 went to check on R1, V3 checked R1's blood glucose. V3 stated the lowest R1's blood glucose level got was in the 30s. V3 stated V3 started giving R1 cinnamon rolls and orange juice. V3 stated that V4 LPN/MDS (Licensed Practical Nurse/Minimum Data Set) nurse intervened. V3 stated the nurse practitioners were already in the building that morning. V3 stated the nurse practitioners did not feel that R1 needed to be sent to the emergency room since they were able to be monitoring R1 at the facility. V3 stated they did not take R1 to R1's room. They kept R1 at the dining table the entire time. V3 stated that R1 did seem to lose consciousness a little. V3 stated that R1 told V3 that R1 was hurting pretty bad afterwards. On 10/22/19 at 2:32 PM, V3 stated that R1 got the ultrasound of R1's abdomen before breakfast. V3 stated R1 got R1's insulin at 6:45 AM then R1 had the scan completed in the facility and then R1 ate breakfast. On 10/21/19 at 2:19 PM, V4 (Licensed Practical Nurse/Minimum Data set nurse) stated the management team was in their morning meeting at 9:00 AM and V4 was leaving the meeting and saw all the people around R1 in the dining room. V4 stated V4 stopped to see what was happening. V4 stated staff told V4 that R1's blood sugar was low, and they couldn't get it to stay up. V4 stated they were giving liquids to try to bring R1's blood sugar up. V4 stated they checked R1's blood sugars 2-3 times and it was still going down. V4 stated V10, R1's Nurse Practitioner (NP), was in the building. V4 stated that V4 went to the NP and got an order for [REDACTED]. V4 stated R1 was not cognitively intact enough to swallow at that time so V4 got the order for [MEDICATION NAME] injection and administered it immediately. On 10/21/19 at 3:58 PM, V6, R1's family stated V6 was notified of the incident of insulin overdose. V6 stated R1 called V6 and left messages and R1's speech was slurred on the messages. V6 stated around 4:00 PM on 9/27/19 that R1's speech was still slurred. On 10/22/19 at 9:03 AM, V5 Certified Nursing Assistant stated that V5 brought R1's breakfast tray to R1 at the dining table and noticed R1 looked like R1 did not feel good. V5 stated V5 tapped R1 on the shoulder and asked R1 if R1 was ok. V5 stated that R1 did not respond. V5 stated R1 was starting to sweat and shake. V5 stated that V5 went to get V3 the nurse and the V3 came and checked on R1. V5 stated they started to give R1 several glasses of orange juice then V4 came to help and took over. V5 stated that R1 was eating breakfast at approximately 8:30-8:45 AM on 9/27/19. V5 stated that R1 was not acting like R1's self, R1 was very sleepy. V5 stated R1 seemed to come in and out of consciousness. On 10/22/19 at 10:38 AM, R1 stated R1 remembers V3 giving R1 insulin that morning of 9/27/19. R1 stated R1 remembers feeling R1's blood sugar dropping. R1 stated R1 then lost consciousness and when R1 came to R1 stated there were 5 to 6 people surrounding R1. R1 stated R1 remembers staff slapping R1's chest to try to wake R1 up. R1 confirmed the facility did not send R1 to the hospital. R1 stated that R1 felt, very, very fatigued after the incident and the next day. R1 confirmed R1 missed R1's scheduled [MEDICAL TREATMENT] on 9/27/19. R1 stated R1 went to [MEDICAL TREATMENT] the next day. On 10/23/19 at 9:23 AM, V8, R1's Physician stated R1 should have eaten within an hour of receiving insulin. V8 stated that receiving 10 times the scheduled dose of Humalog could have been fatal. V8 stated the nurse should have clarified the insulin order since R1 was NPO for a procedure. V8 stated the facility should have waited to give R1 the insulin until after the procedure was completed especially since it delayed a meal. On 10/23/19 at 9:56 AM, V9 Pharmacist stated that a person should eat with in 20 to 30 minutes of receiving Humalog. V9 stated, that is quite a transcription error. V9 stated that V9 was just recently in the facility for the pharmacy review and V9 does not remember seeing anything in R1's medical record indicating an overdose. V9 stated V9 would have reviewed the medication error had V9 been aware. V9 confirmed that V9 reviews the resident's Nurse's Notes for documentation of irregularities. V10's, R1's Nurse Practitioner, documents a progress note dated 9/27/19 at 4:13 PM. V10 documented the chief problem for the visit as low blood glucose. V10 documented R1 was found to have a blood glucose level in the 30s. R1 was given an erroneous dose of Humalog, 60 units instead of the ordered 6 units. V10 documents R1 experienced low blood glucose related to NPO status and medication error. The Humalog package insert from www.Humalog.com documents Humalog starts working faster than other insulins that contain regular human insulin. Humalog should be taken within fifteen minutes before eating or right after eating a meal.

Based on record review and interview the facility failed to administer the correct medications to the correct resident for one of three residents (R1) reviewed for medication errors in the sample of 41. This failure resulted in R1 being hospitalized in the critical care unit with [MEDICAL CONDITION]. Findings include: The facility's Medication Administration policy with a revised date of 10/2007 documents, The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders [REDACTED]. This policy also documents, Medications must be identified by using the seven (7) rights of administration: Right resident, Right drug, Right dose, Right consistency, Right time, Right route, Right documentation. This policy also documents, Identify each resident prior to medication administration. Two methods of verification must be utilized prior to administration of a medication: Check photograph, Ask resident his/her name, Verify resident's identity with another employee familiar with the resident, Call the resident by name and ask for confirmation. The facility's Adverse Drug Reactions and Medication Discrepancy policy with a revised date of 10/2006 documents, A medication discrepancy/error has been made when one of the following occurs: Wrong medication administered, Wrong dose administered, Medication administered by wrong route, Medication administered to wrong resident, Medication administered at wrong time, Medication not administered. R1's Face Sheet documents an original admission date of [DATE]. R1's Physician order [REDACTED]. This POS documents R1 had MEDICATION ORDERS FOR [REDACTED]. R1's Medication Administration Record [REDACTED]. R1's PRN (as needed) Medication information sheet documents R1 did not received any of R1's prn [MEDICATION NAME] on 2/9/19. R1's Minimum Data Set ((MDS) dated [DATE] documents R1's BIMS (Brief Interview for Mental Status) score was 8/15 which indicates moderately impaired cognition. R1's Medication Error Report dated 2/9/19 completed by V15 Registered Nurse (RN) documents the date of the error as 2/9/19 and the time of the error as 8:00 PM and a description of the error stating V15 gave the wrong resident another resident's medication. This report documents V15 gave R1 Prevastatin (cholesterol lowering medication) 20mg, [MEDICATION NAME] (antipsychotic) 400mg, [MEDICATION NAME] (anticonvulsant) 200mg and [MEDICATION NAME] (antipsychotic) 2mg. This report documents R1's Physician ordered medications to be administered at 8:00 PM was [MEDICATION NAME] 10mg. This report documents the time the error was discovered as 8:15 PM on 2/9/19. R1's A.I.M. (Assess, Intercommunicate, Manage) for Wellness form documents V15 notified V27 Physician on call, of the medication error and V27 gave orders to monitor resident's blood pressure, respirations and oxygen saturation percentage every hour for four hours and if the systolic blood pressure drops below 100 or the oxygen saturation percentage drops below 88% (percent) to send R1 to the emergency room for evaluation. R1's Nurses Notes dated 2/9/19 at 8:00 PM documents R1's first set of vitals after identifying the error were a blood pressure of 116/58, pulse of 80 beats per minute (bpm), respirations were 18 per minute and oxygen saturation was 96% on room air. R1's Nurses Notes documents on 2/9/19 at 9:15 PM, V15 returned to R1's room to recheck R1's vital signs. R1's vital signs at that time were a blood pressure of 70/40, respirations of 18, pulse of 83 bpm, oxygen saturation was 90% on room air. This Nurses Notes documents V15 called 911 (emergency help) and returned to R1. V15 documents R1 would arouse with the calling of R1's name but then R1's eyes would flutter shut. V15 placed a non-rebreather mask on R1 with oxygen at 15 liters per minute. V15's Witness Statement completed on 2/10/19 documents after V15 rechecked R1's vital signs at 9:15 PM, V15 asked the CNA (Certified Nursing Assistant) to get V26 Licensed Practical Nurse (LPN) to help and to go get the crash cart. V15 goes on to document on this statement that V15 was not able to get R1 to respond again and R1's oxygen saturation was no longer registering on the pulseoximeter. V15 documents that V15 rechecked R1's blood pressure and R1's blood pressure at that time was 50/30 and the ambulance personal arrived at that time. V15 documents that the ambulance personal immediately transferred R1 to a gurney obtained R1's important paperwork and left the facility. R1's hospital encounter information documents R1 arrived at the hospital on [DATE] at 9:48 PM. R1's hospital record documents R1's admitting [DIAGNOSES REDACTED]. This hospital record documents R1's procedures as Respiratory Ventilation and Insertion of Endotracheal Airway into Trachea. R1's hospital Progress Notes document R1 was admitted to the CCU (Critical Care Unit) on 2/10/19 at 12:15 AM from the emergency department. This notes also documents, (R1) currently on ventilator and sedated with propofol (anesthetic). R1's hospital Discharge Summary documents admitting [DIAGNOSES REDACTED]. This Discharge Summary documents R1 was discharged from the hospital on [DATE] to a different facility. On 1/21/19 at 1:22 PM, V15 stated V15 does not normally work at this facility V15 was just trying to help out. V15 stated 2/9/19 was total chaos. V15 stated there were six falls and they were trying to get fall vitals on them and then multiple alarms were going off. V15 stated there was a Dementia resident that kept removing their lap buddy. V15 stated V15 identified R1 and then got interrupted by the distractions. V15 stated when V15 returned V15 grabbed R4's medications and gave them to R1. V15 stated V15 did not realize the error had happened until a short time later when V15 reached R4's room. V15 stated at that moment V15 realized what V15 had done. V15 stated V15 immediately went to check on R1 and obtained a set of vital signs then paged the Physician on call. V27 Physician on call returned V15's call and gave orders to monitor R1's vital signs every hour for the next four hours and if the systolic blood pressure drops below 100 or the oxygen saturation drops below 88 percent to send R1 to the emergency room for evaluation. At this same time V15 stated V15 made the necessary notifications of the error then finished the medication pass. V15 stated it was not quite a whole hour since the last set of vital signs had been taken on R1 but V15 went ahead and checked on R1. V15 stated R1's blood pressure was 70 something over 40 something and R1 did not arouse easily. V15 stated V15 called 911 (emergency personal). V15 stated V15 returned to R1's room and checked the oxygen saturation which was 90-91 percent. V15 stated V15 requested V16 Certified Nursing Assistant (CNA) go get V26 Licensed Practical Nurse (LPN) to assist V15 and requested V16 retrieve the crash cart. V15 stated V15 placed a non rebreather mask on R1 and started to reassess R1. V15 stated R1's blood pressure was even lower and then the ambulance personal arrived. V15 stated V15 gave the ambulance personal the information they needed and they left quickly with R1. On 2/25/19 at 10:04 AM, V15 added that V15 prefilled the medication before V15 went to pass the medication. V15 confirmed V15 prefilled R1 and R4's medication. V15 stated V15 identified R1 then got interrupted. V15 stated when V15 returned to the medication cart V15 grabbed R4's cup of medications instead of R1's cup of medications. V15 stated V15 gave R1 medications that were meant for R4. On 2/21/19 at 12:30 PM, V16 Certified Nursing Assistant (CNA) confirmed V16 worked on 2/9/19 and stated V15 asked V16 to obtain vital signs on R1 every hour for four hours. V16 stated V16 did not know why but V16 agreed to get the vital signs. V16 stated it had not quite been a full hour from the last set of vital signs and V16 saw V15 go into R1's room. V16 stated a few minutes later V15 asked V16 to go get V26 Licensed Practical Nurse to help. V16 stated V16 got V26 right away and then V16 and V26 attempted to wake R1 up. V16 stated V16 was rubbing R1's legs and V26 was rubbing R1's chest with no response from R1. V16 stated V16 heard someone ask for the crash cart so V16 stated V16 ran to get the crash cart. V16 stated when V16 got back to R1's room the ambulance personal were arriving and they took R1 to the hospital. On 2/21/19 at 2:19 PM, V17 R1's Physician stated R1's [MEDICAL CONDITION] was probably due to an accumulation of all of the medications R1 was given. V17 stated the combination of [MEDICATION NAME] and [MEDICATION NAME] can cause respiratory depression. V17 stated the nurses should double check the resident's names before giving medications. V17 stated V17 thinks they just tried to go to fast, they need to slow down.

Based on record review, observation and interview, the facility failed to safely transfer R122 . This failure resulted in R122 suffering pain and a laceration, requiring emergency medical treatment including eleven sutures. This failure affected one of five residents (R122) reviewed for falls in the sample of 27. Findings include: R122's, Physician order [REDACTED]. R122's Minimum (MDS) data set [DATE] documents R122 has moderate cognitive impairment, does not ambulate and requires extensive assistance of a staff member for resident transfers. R122's Care Plan dated 2/7/18 documents the following fall intervention: Use one assist and a gait belt for all transfers. R122's SBAR (Situation Background Assessment Recommendation) and Progress Note for Registered Nurse's (RN) / Licensed Practical Nurse (LPN) dated 2/18/18 at 7:40 pm, documents the following: (V4) CNA (Certified Nursing Assistant) reported resident (R122) was injured (left leg /ankle, inner aspect) during transfer. Nurse (V6, LPN) measured (the) wound at (length) 10.0 centimeters (cm) by (width) 2.5 cm, area cleaned. (V21) Medical Director on call (for V16, Physician) notified via video (conference). New orders to send to emergency room for eval (evaluation) and treatment. 02/21/18 04:10 PM V4 stated the following: I (V4) was assisting (R122) from the bed to the wheelchair, without a gait belt I pivoted (R122) while holding (R122) up in a bear hug, to take R122 to the bathroom. (R122) stated that R122's leg hurt. I did not realize how bad R122's leg was injured until I saw the blood running down to (R122's) sock. There was a broken bed alarm attached to the bed frame that caused the injury. I thought at first it was just a skin tear. On 02/22/18 01:18 PM V6 stated the following: I (V6) was at the nurses station charting when (V4 ) reported (R122) had a skin tear that (R122) got when (V4) transferred (R122) without a gait belt. I (V6) assessed the injury to (R122) leg, right away, it was much more than a skin tear. I talked to (V19, RN) because he is an RN. He (V19) agreed that (R122's) left leg injury was more than a skin tear. We (V6 and V19) called with a (electronic communication device) (video conference) the doctor (V21, MD) covering for (V16). (V21) said (R122) needed to go to ER (emergency room ) for stitches. R122's Emergency Documentation hospital report documents the following: Chief Complaint Patient (R122) sent from (facility), patient was being transferred from bed to wheelchair and cut (R122's) left inner leg on something, laceration noted, bleeding controlled, patient also complained of right knee pain. The same report documents R122 also complained of left leg / ankle pain, required X-rays to the left ankle, right knee, and received [MEDICATION NAME] (narcotic pain medication) and 11 sutures to close the laceration. The facility Incident Investigation Form dated 2/18/18 (unknown time), signed by V9, RN documents the following: (V1, Administrator) and (V2, Director of Nursing) were notified of resident (R122) injury on 2/18/18 at 7:40 pm. (V2) sent (V4) home pending further investigation. Resident (R122) sent to ER for eval and treatment. The same Incident Investigation Form document Environment checked for safety issues. Recreated (R122) transfer. At this point, injury believed to have occurred from a piece of equipment on bed, which has been removed. On 02/20/18 at 11:10 am, V9 stated she is investigating the transfer of R122 on 2/18/18. (V4 CNA) was originally sent home, until we discovered (the) injury was likely caused by a broken alarm box on (the) bed had a sharp edge, that probably caused the injury. V4's Supervisor Report of Council form dated 2/21/18 documents the following: Unintentional compromise of skin during transfer resulting in need for (R122) ER visit for eval and treat. The same form documents V4 was counseled for the following: Review of safe resident transfer and handling. On 02/21/18 at 04:05 pm, V2, DON (Director of Nursing) stated on 2/18/18 at 19:40 pm, V4, CNA improperly transferred R122, catching R122's leg on a bed alarm piece that was attached by (hook and loop fastener) to the frame of the bed, which caused the laceration. On 02/22/18 at 09:15 am, V10, LPN, completed R122's wound treatment as ordered. V10 cleansed R122's inner left lower leg / ankle laceration. R122 had a jagged wound laceration closed with 11 sutures. The bottom five sutures were surrounded by deep purple bruising. On 02/22/18 at 01:40 pm, V16, Physician stated the facility notified me of (R122's) injury during transfer which resulted in the need for sutures. The facility policy Transfer Belts / Gait Belts dated April 10, 2016 documents the following: All certified nursing assistants and licensed nursing personnel engaged in the lifting and transferring of residents will use gait belts.

Based on record review and interview, the facility failed to reassess pain levels and ensure that an ordered diagnostic test was completed in a timely manner for one of five residents (R2) reviewed for injury and pain in the sample of five. This failure resulted in R2 experiencing unrelieved pain from a fractured right femur for 10 days. Findings include: The Physician order [REDACTED]. The POS documents an order for [REDACTED]. A mobile x-ray report dated 4/1/15 for R2 documents the following under Findings: Right Femur. 2 views, with documented Impressions of : "There is a lucent line in the subtrochanteric area of the femur seen on the lateral view only and an incomplete subtrochanteric fracture versus a positional artifact cannot be excluded. Recommend a follow up and should include a localized study of the hip and should include two views. Clinical correlation is recommended." The same report is noted with hand written documentation by E9, Registered Nurse that R2's Primary Care Physician, Z1 was notified and orders were received for a Computed Tomography (CT) scan of R2's right leg. The medical record contains a Telephone Order dated 4/1/15 documenting that E9 received an order from Z1 for R2 to have a CT scan without contrast of the subtrochanteric area of the right femur. A facility form titled "Information Needed to Make Resident Appointment" dated 4/1/15 and completed by E9, documents that R2 is to go out to the Radiology Department at a local hospital for a "CT scan without contrast on subtrochanteric area of the femur. The form documents that the appointment is requested by Z1 and there is an order from Z1. The same form requires a selection of the priority level that the appointment needs to be made. E9 documents that the appointment needs to be made "now". The form documents that the appointment is arranged on 4/8/15, scheduled for 4/10/15 at 3:45 pm and that nursing is notified of the appointment on 4/8/15 by E3, Social Services Director. R2's Minimum Data Set (MDS dated [DATE] documents R2 as cognitively intact and is independent in transfers. The MDS inaccurately documents that R2 has not received any pain medication in the previous five days from the assessment reference date of 3/31/15. Nursing Notes document on admit of 3/25/15, that R2 complained of right hip pain and pain medication was given. On 3/26/15 pain medication is documented as given at 4:05 pm and again at 9:15 pm for complaints of right leg pain. At 2:00 am Nursing Notes document "(R2) was needy at the first part of the shift." On 3/27/15 at 1:00 am Nursing Notes again document R2 to be "needy and on the call light." On 3/28/15 pain medication is documented as given at 4:25 pm for leg pain. On 3/29/15 and again on 3/30/15 Nursing Notes document R2 as "still very needy on the night shift." On 3/30/15 at 7:45 am Nursing Notes document that R2 fell while standing in the restroom and complains of right leg pain and is given pain medication of Tylenol. On 4/1/15 at 1:00 pm Nursing Notes document that R2 has complaints of pain to the right leg. Z1 is notified, an x-ray is ordered. On the same date of 4/1/15 at 3:00 pm documentation in the Nursing Notes state that x-ray results are received and Z1 is notified. New orders for CT Scan of right femur received. On 4/2/15 at 1:00 am Nursing Notes document R2 sliding out of bed onto the floor at 11:50 pm. On 4/3/15 Tylenol is documented as given for complaints of right leg pain. There is no further documentation in the Nursing Notes after 4/3/15 until 4/9/15, when a late entry for 4/8/15 is made on 4/9/15 concerning pain management review by the IDT (Interdisciplinary Team). On 4/10/15, Nursing Notes document R2 being transported from the facility for a CT Scan and is returned. Tylenol is given for leg pain at 6:20 pm. At 6:55 pm, Z1 notifies the facility that R2 has a fractured right hip and is to be sent to the emergency room . R2 is transferred to the hospital and is admitted with the [DIAGNOSES REDACTED]. On 4/14/15 Nursing Notes document R2's return to the facility Post Surgical repair of the right femur/hip on 4/12/15. The Medication Administration Record [REDACTED]. R2's facility report titled "Pain Assessment" dated 3/25/15 and 3/30/15 document moderate pain. The Pain assessment dated [DATE] documents mild pain. There is no further documentation in the Medical Record of any further Pain Assessments after 4/1/15. The Care Plan dated 3/25 through 4/5/15 documents that R2 is a "Newly admitted resident with pain or risk factors for pain, needs monitored and or treated for [REDACTED]. A report titled "Physical Therapy Plan of Care" dated 4/2/15 documents that on evaluation and assessment, R2 reports a pain scale rating of 9 out of 10 for right leg pain and is unable to ambulate due to pain. The goal for R2's pain level per the evaluation is that R2 will be able to report a decrease in pain from 9 to 7 on a scale of 1 to 10, 10 being the worse pain. Physical Therapy Daily Treatment Notes document the following: On 4/3/15 notes document that R2 complains of right knee/inner thigh area pain, rating it at 10 out of 10, which increased with activity. On 4/6/15 Physical Therapy (PT) documents that R2 is unable to take a step and was limited secondary to fear of falling and right leg pain is rated an 8 to 9 on a scale of 10. R2 is shuffling and has a decrease step length and height. On 4/8/15, R2 reports during physical therapy, when instructed to put more weight through right leg, that it hurts too bad. On 4/9/15 during physical therapy, R2 rated his pain at 10 out of 10 in the right leg. On 4/10/15 therapy notes document that R2 is only able to stand 2 to 3 minutes at a time. R2 complains of pain in left leg/hip during weight bearing and rates the pain at 8 to 9 out of 10. On 4/13/15, Physical Therapy Discharge Summary documents that R2's decrease in pain goal had not been met as of 4/10/15. On 4/14/15 at 1:30 pm E2, Director of Nursing stated that R2's x-ray report had not been reviewed previously by E2. On 4/14/15 at 1:35 pm E2 reviewed the x-ray and stated "Yes a CT Scan should have been done right away." E2 acknowledged there had been a delay in treatment for [REDACTED]. On 4/14/15 at 2:30 pm, E3 stated that a Care Conference had been held on 4/8/15 with R2 in attendance and Z3, Charleston Transitional Facility Assistant via telephone. E3 stated during the conference, Z3 had concerns of R2's pain and R2 verbalized that pain was an issue. E3 stated she reported the pain issue to E8, Registered Nurse that same day. On 4/14/15 at 3:30 pm, E8 stated she had been notified of R2's pain issues but had no knowledge of R2's falls or R2's x-ray results. No new orders were requested. On 4/14/15 at 3:45 pm Z1, Primary Care Physician stated that he had been notified by the facility of R2's x-rays and continued unrelieved pain so an order was given for a CT Scan of R2's hip area. Z1 stated that the expectation was that it would be done right away. On 4/15/15 at 9:20 am, R2 stated he told several nurses that his pain was bad and getting worse. R2 stated "It made it hard for me to sleep at night." R2 stated when he complained about pain the nurses would tell him that he would have to let the medicine that he was given take affect. R2 stated "I felt like they were ignoring me so I told (Z3) about it." R2 also stated that he had asked for a shot of something so the pain would go away, but was told no. On 4/15/15 at 9:40 am E9, Registered Nurse stated that R2's x-ray results from 4/1/15 had been given to Z1 on 4/1/15 and an order for [REDACTED]. The form documents a rating scale based on a one to five for resident need; One meaning the CT Scan is needed right away. On 4/15/15 at 9:50 am E3, Social Service Assistant stated the facility has a system for making appointments. The nurses fill out an "Information Needed to Make Resident Appointment" form and it is given to E3 and the appointment is made according to the need documented. E3 stated sometimes she does not get these requests right away. E3 stated "I don't know what happens to them. I was not aware that (R2) had an x-ray showing a possible fracture." E4 stated she did not have an explanation of why R2's CT Scan did not get made when it should have. On 4/15/15 at 1:30 pm E6 and E7, both Physical Therapy Assistants stated that R2 had complained multiple times of right hip.

Based on observation, record review and interview, the facility failed to complete a physical restraint assessment, obtain informed consent and physician's orders [REDACTED]. This failure resulted in R7 being distraught and fearful. R7 is one of three residents reviewed for physical restraints in the sample of eighty nine. Findings include : R7's Physician order [REDACTED]. R7's Minimum Data Set (MDS) dated 8/15/14 documents a Brief Interview for Mental Status (BIMS) as 10/15 (mild cognitive impairment). On 9/25/14 at 9:22 am, Z2, Psychiatrist stated that " (R7)'s cognition is indeed intact, she is very reliable. Staff have told me that (R7) can get loud, I believe that is necessary for (R7) to speak more clear with [MEDICAL CONDITION]'s affecting her speech delivery." On 9/25/14 at 10:30 am E13, Certified Nursing Assistant (CNA) stated " (R7) does get up by herself and walks from her wheelchair when she gets to her room." On 9/30/14 at 10:25 am R7 stated " I will show you how I can get up and transfer to my wheelchair." R7 scooted to the front of her recliner chair, checked to make sure the brakes were locked on her wheel chair, stood without assistance facing the chair, turned around and sat down. On 9/25/14 at 10:35 am R7 stated " I can walk a little but need help with long distances. I get up in my room and use the furniture to keep me from falling." On 9/24/14 at 1:00 pm E18, CNA stated " (R7) was up at the nurses station hollering and yelling that she wanted to go to bed but she wouldn't stay in bed. She (R7) is a fall risk that's why second shift got her (R7) up and brought her to the nurses station because she kept trying to get out of bed. (R7) was yelling she wanted to go to bed. We (E17, Registered Nurse and E18) told her (R7)when she calmed down we'd put her in bed..... Then (E17) tied the sheet on one side of the wheel chair arm and I (E18) tied the other to the bar in front of the wheel chair arm." On 9/23/14 at 4:38 pm, E17 stated " (R7) was put to bed and got on her call light constantly. (R7) wanted a (disposable incontinence brief) on so she could go (urinate) in her bed if she wanted to...... (R7) continued restless, trying to climb out of bed and on the call light. We got her up in the wheel chair, she (R7) had on a hospital gown on when we brought her to the nurses station. The oncoming nurse is male so I tied the bed sheet to the arms of the wheel chair to cover the resident who was bucking and thrusting her pelvis forward......I wanted her (R7) covered for her own dignity while I gave (E14, Licensed Practical Nurse (LPN) report. I told (E18) to come over and help me with the sheet...... I'm talking to (R7) telling her she needed to calm down. We would take her to the bathroom anytime she needed to go and put her in bed, once she was calm. I finished report and did some paper work, left a little late and (R7) was still in the chair and had not calmed down." On 9/25/14 at 5:30 am E19, Certified Nursing Assistant (CNA) stated that "(E18, CNA) told (E19,CNA), (R7) was gotten up out of bed and taken to the nurses station so she wouldn't fall." E19 then stated that "the nurse (E17, Registered Nurse, RN) stooped down beside the wheelchair while (R7) was trying to stand up and heard (E17) tell (R7) to behave. " E19 stated " I saw that (R7) had a bed sheet tied tight enough around her, to keep her in her wheelchair so she wouldn't fall. (R7) was very irritated and kept trying to tell (E17) that she wanted to go to bed." "(R7) was louder that she usually was when I worked." "I heard (E17) tell (R7) that (R7) was already in bed and wouldn't in stay there." On 9/25/14 at 8:05 am E14 stated that on 9/5/14 he received in report from E17 that E17 got R7 up and put R7 at the nurses station to watch her so she doesn't fall. On 9/24/14 at 8:25 am, R7 stated " I was really scared then (9/5/14) and again last night, that's the same nurse (E17) who was working that night. (E17) kept telling me I was bad because I wanted to go to the bathroom.... I wear underpants and had those and a nightgown on when the nurse (E17)got mad because I would not wear that diaper..... (E17) and (E18) tied the bed sheet behind the back of my wheelchair. They (E17 and E18) don't like me that's why they did it." " (E17) wouldn't take it (bed sheet) off my wheel chair so I finally got the sheet untied myself, then (E18) took me to the bathroom and let me go to bed." R7's Chart review was devoid of a physical restraint assessment, documentation of informed consent, a physicians order for application of a physical restraint and identification of a medical symptom being treated by the physical restraint. On 9/25/14 at 9:55 am, E2, Director of Nursing stated "I looked in her (R7) chart too, there is no restraint assessment, consent or order from her physician for a restraint. ... we viewed this as a dignity issue." The Facility Restraint Policy dated 01/02 documents that "a physical restraint will not be used for the purpose of discipline or convenience and must treat a physical symptom." Procedures include: "A complete restraint assessment, a consent and a physicians order."

Based on interview and record review, the facility failed to prevent a witnessed physical assault on R8 by R9 which resulted in a right humerus and right femoral neck fracture. R8 and R9 are two of eight residents reviewed for abuse in the sample of eighty nine. Findings include: R9's Admission Face Sheet is dated 11/06/13. R8's Admission Face Sheet is dated 11/07/13. R9's Physician order [REDACTED]. R8's POS documents [DIAGNOSES REDACTED]. R9's admission assessment for violence dated 11/6/13 documents that R9 has had a history of [REDACTED]. There was no documented evidence of R9's physical aggression toward others on file. R9's Minimum Data Set ((MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 11/15 ( mild cognitive impairment). R8's MDS dated [DATE] documents a BIMS score of 14/15 (no cognitive impairment). On 9/25/14 at 9:22 am, Z2, Psychiatrist stated " (R9) is cognitively intact. He (R9) is very aware of what he is doing. (R8) is cognitively intact and I am not aware of any indication of aggression towards other residents." R9's Nursing Notes, signed by E12, Registered Nurse (RN) and dated 9/19/14 at 5:00 pm document "resident was in the dining room and drinking coffee. He (R9) flung his coffee across the room......Resident was helped back to his room after this incident as other residents were complaining about being made wet." On 9/25/14 at 9:05 am, R10 stated " I was out in the dining room when (R9) threw his coffee. The cup hit me and the coffee landed on them (R14 and R15). Then (R9) said 'I threw the coffee, so sue me.'" On 9/25/14 at 9:40 am, R15 stated " I was leaving my table when (R9) threw the cup of coffee and hit (R10 and R14). I was in a direct line to be hit if I hadn't been leaving the table." On 9/25/14 at 4:15 pm, R14 stated " I started yelling help, help, help to the staff as (R9) raised his hot cup of coffee, aimed at me and threw it directly at me. Hot coffee got all down my left arm. Three CNA Staff (unknown names) came running. Then another CNA (E15) took (R9) to his room." On 9/24/14 at 2:10 pm, E15 Certified Nursing Assistant (CNA) stated "(R9) spilt his coffee and I took him to his room to helped him wash his hands. He (R9) said he was going to take a nap." R9 remained in his room while others continued in the dining room. R9's Facility Nursing Notes, signed by E12, Registered Nurse (RN) and dated 9/19/14 at 6:00 pm documents " (R9) was seen by (E10, CNA) to push another resident (R8)." On 9/23/14 at 2:38 pm, E10 stated "I saw (R9) push (R8). (R8) flew across the room and landed on his right side." On 9/24/14 at 2:30 pm, E12 stated "I was called to the floor Stat (immediately), (R8) was on the floor. I knew right away that his (R8) leg was broken, it was rotated outward and he complained of pain in his leg and shoulder. (E10) told me that (R8) needed to use the bathroom (which is connected to R9's room) they were yelling about it when (E10) saw (R9) push (R8). (E10) told me (R8) flew across the room landing on his right side." On 9/24/14 at 1:20 pm, E25 CNA stated " I worked the night (R9) pushed (R8) down. I can usually calm (R9) down but not that night. He (R9) kept saying I want to fight him (R8).....R8 was on the floor in his (R8) room and (R9) just kept yelling. I couldn't calm him ( R9) down so another (E15)CNA came to help me." On 9/24/14 at 5:45 pm, R8 stated " about every night since I've been in this room (connected by the bathroom to R9's room) every couple of nights (R9) wakes me up slamming doors and yelling.....Now I know what he's (R9) is capable of, it's not just (R9) threatening me now he (R9)can physically hurt me again. I can't continue to fear him because of this assault." The emergency room Note dated 9/19/14 at 8:17 pm documents R8 suffered a right femur fracture and a right humerus fracture and was admitted the hospital for surgical repair. The emergency room Note dated 9/19/14 at 7:33 pm documents that R9 was treated for [REDACTED]. E12 stated on 9-24-14 at 2:30 p.m. that R9 was returned to the facility and placed on a behavioral care unit under one to one supervision. The Facility Policy titled "Abuse Prevention Program" dated 11/11/11, documents ......Residents who allegedly mistreat another resident will be removed from contact with other residents during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of other residents and employees of the facility...."

Based on record review and interview, the facility failed to ensure that staff safely transferred R5 by using a gait belt per the plan of care, while toileting. R5 lost her balance, struck her arm on the door, and sustained a fractured left wrist. R5 is one of six residents reviewed for falls in a sample of 24. Findings include: The Physician order [REDACTED]. R5's Minimum (MDS) data set [DATE] documents that R5 requires extensive assistance in transfers and that R5 is unable to steady herself without staff assistance during transitions and walking. The Plan of Care updated 5/2/13 for R5 directs staff to use two assist and a gait belt for all transfers and two assist and a gait belt for ambulation. A Fall Risk assessment dated [DATE] documents R5 as being at high risk for falls. The facility policy titled "Transfer Belts/Gait Belts" and dated 12/17/12, states that "gait belts are mandatory and that all Certified Nursing Assistants and Licensed Nursing personnel engaged in the lifting and transferring of residents will use gait belts. The use of gait belts and mechanical lifts is essential to reduce the risk of accident and injury to both residents and employees..... A gait belt is used if indicated on the care plan." A facility report dated 7/10/2013 as "Final Report" documents that on 7/4/2013 E17, Certified Nursing Assistant (CNA) was toileting R5 when "(R5) lost her balance and leaned far to her left. (Has Huntington's) CNA tried to grab (R5) by (R5's) right arm, but (R5) bumped into bathroom door and hit her left wrist area. Original x-ray was negative on 7/5/2013. On 7/7/2013 swelling was noted to left hand, wrist area. Another x-ray was obtained which showed fracture to epiphysis of radius." Attached to this report is a fax cover letter documenting (Illinois Department of Public Health) being notified of R5's incident and injury. A X-Ray report dated 7/7/2013 documents the following on R5's left wrist: "Findings: There is a non-displaced fracture of the distal radius epiphysis which is more distinctly evident on the (Anterior Posterior) view than on the previous study of the left wrist." On 1/14/2014 at 4:00 pm E17 stated that on 7/4/2013 R5 was ambulated to the bathroom by E17 and that a gait belt was not used. "I forgot the gait belt at the nursing station, but went ahead and ambulated and transferred (R5). She lost her balance and fell into the door hitting her left arm." E17 acknowledged that a gait belt was supposed to be used when ambulating or transferring R5 due to the disease process of Huntington's Chorea. On 1/15/2014 at 10:45 am, E2, Director of Nursing and E18, Assistant Director of Nursing, both acknowledged that their expectation is that "a gait belt is used in all assisted transfers."

Based on interview and record review the facility failed to follow documented fall prevention approaches to prevent a fall for one of 11 residents (R2) reviewed for falls in a sample of 24. Findings include: A physicians order sheet dated 4-01-12 to 4-30-12 documents that R2 has [DIAGNOSES REDACTED]. Incontinence, Right Ankle Fracture, Vertebral Compression Fracture, Osteoporosis, Anemia, [DIAGNOSES REDACTED], and Osteoarthritis. An annual Minimum Data Set ((MDS) dated [DATE] under section G Activities of Daily Living Assistance documents that R2 requires extensive assistance to transfer, dress, use the toilet, and perform personal hygiene. The MDS also documents under section G0300 Balance During Transitions and Walking documents that R2 is not steady, only able to stabilize with human assistance when moving from a seated to standing position, moving on and off the toilet, and while transferring from surface to surface. A Facility Quality Care Reporting form dated 12-25-11 and signed by E1 (Administrator), E2 (Director of Nursing), and Z1(Medical Director) documents that R2 fell in the bathroom and while attempting to put herself on the toilet. The document also indicates that a fall prevention recommendation would be to not leave R2 unattended in the bathroom that staff may stay outside the bathroom door for R2's privacy. A Facility quality Care Reporting form dated 3-22-12 and signed by E1 and E2 documents that R2 fell in the bathroom while on the toilet. The document also indicates that R2's fall was unwitnessed and that the possible cause was that R2 was trying to get up from the toilet without assistance or possibly fell asleep on the toilet. An acute care facility Medical History report dated 3-23-12 indicates that R2 was admitted to that facility with a fracture to the right arm following a fall in the bathroom at the nursing home. A care plan dated 3-30-11 documents that R2 is at high risk for falling. R2's care plan also documents that after R2 fell [DATE] that a fall prevention approach was added to the care plan indicating that facility staff should not leave R2 unattended in the bathroom. On 4-10-12 at 3:00 p.m. E4 (Licensed Practical Nurse) stated that she was the nurse on duty on 3-23-12 when R2 fell while in the bathroom. E4 stated that on 3-23-12 at 7:00p.m. R2 was left unattended in the bathroom by E5 (Certified Nurse Aide). E4 also stated that E5 checked on R2 after about ten minutes and found R2 on the bathroom floor. On 4-11-12 at 12:05 p.m. E3 (Assistant Director of Nursing) stated that R2 fell and broke her right arm after being left unattended in the bathroom by E5.