Every finding on record at Sharon Health Care Pines

Based on interviews and record reviews, the facility failed to prevent abuse of five (R2, R4, R5, R6, R7) of 7 residents reviewed for abuse. This failure resulted in R1 picking up a chair and hitting R2 in the head causing R2 to go unconscious, sustaining a bleeding laceration to upper lip requiring sutures and sustaining a laceration to left side of head requiring three staples. Findings include:The facility policy, Abuse Prevention Program Facility Procedure, reviewed 9/1/25, documents not in its entirety, This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment.1. Facility incident report dated 5/24/26 documents that R1 and R2 got into a physical altercation after R2 became agitated at R1 over table seating in the dining room. R1 asked R2 to go to another table causing R2 to strike out at R1 and R1 picking up a chair and hitting R2 in the head causing R2 to go unconscious and receive 2 lacerations requiring medical intervention of sutures and staples at local hospital.R1's admission record documents R1's date of admission to the facility was 1/29/24 and his diagnoses included but are not limited to: Major Depressive Disorder, Recurrent, Schizoaffective Disorder, Cocaine Abuse, Anxiety Disorder, Anoxic Brain Damage, Hypertension, Cerebrovascular Disease and Personal History of Traumatic Brain Injury.R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 has a BIMS (Brief Interview of Mental Status) score of 12/15, indicating cognition is moderately impaired, has delusions and has had no behavioral symptoms.R1's current care plan documents R1 has impaired cognition and thought processes related to head injury, impaired decision-making, short-term memory loss, and poor impulse control.On 6/16/26 at 10:30am, R1 stated that on 5/24/26 he was sitting at the dining room table that he always sat at when R2 came up to him. R1 asked him to leave and R2 gave him the middle finger so R1 asked R2 again to leave and R2 told R1 to F*** off, came toward R1 and hit him. R1 stated at this point it angered him, so he picked up a chair and hit R2 with it. I got arrested and he (R2) went to the hospital. When I got back to the facility I was moved to a different room across the building from him (R2), placed at a different seat in the dining room away from him (R2) and they (management) asked me if I want to move to another facility and I told them yes so we are waiting on my mom to approve the move.On 6/24/26 at 11:40am, V4 (Registered Nurse) stated on 5/24/26 she was sitting at the nurse's station that oversees the dining room doing some charting right before supper. I happened to look up and saw R2 sitting in his wheelchair facing toward the kitchen doors in front of the table against the wall. (R2) had his hand up as if he was going to hit (R1) and (R1) was pushing (R2) away so I got up and was yelling to (R2) NO as I was going toward them. Before I could get there (R1) picked up a chair and hit (R2) in the head with it. The other nurses working, (V5/Registered Nurse) and another one I don't recall were already with (R2) and (R1) started walking away. I went back to the desk and called the police and the ambulance and as (R1) was walking by the desk I told him that he was going to go to jail, and the police had already been called. I finished notifying everyone and doing the paperwork to send out (R2) to the hospital. It all happened so fast.On 6/24/26 at 12:24pm V7 (Certified Nursing Assistant) stated on 5/24/26 he was going into the kitchen when he heard (R1) state get away from me. (R1) is pretty chill, so I didn't think anything of it and did not know he was talking to (R2). I went into the kitchen at which point I heard a loud bang. I came back out of the kitchen and saw that the residents were already separated, a nurse (unsure which nurse) was holding towels to (R2)'s head and (R1) was walking away from the table. (R2) was pretty messed up, he had a cut to his nose, looked like he had some broken teeth, and he had a cut to the side of his head. (R2) will usually leave when you tell him to, but he is also known to hit people and (R1) isn't known for hitting unless he is hit.R2's admission record documents R2's date of admission to the facility was 12/2/16 and his diagnoses included but are not limited to: Intracranial Injury without loss of Consciousness, Alcohol Abuse, Bipolar Disorder, Current Episode Manic without psychotic features, Sleep Terrors, Personal History of Traumatic Brain Injury, Anxiety Disorder, Restlessness and Agitation, and Hemiplegia Affecting Left Dominant Side.R2's Minimum Data Set (MDS) assessment dated [DATE] documents R2 has a BIMS (Brief Interview of Mental Status) score of 4/15, indicating cognition is severely impaired, vision is moderately impaired, has delusions and has no behavioral symptoms.R2's current care plan documents R2 has a behavior problem verbal/physical aggression, threatening language, resistive to care related to cognitive impairments, delusional thought process, poor planning, poor insight/judgement, and emotion management poor coping skills and impulsivity. R2's current care plan also documents that R2 has impaired vision related to blindness in left eye.On 6/16/26 at 3:00pm, R2 stated three weeks ago another resident (does not recall who) punched me on the left side of my face, I have a scar now and am blind in this eye (points to left eye). R2 stated that he does not recall why the other resident hit him, but he's not here anymore. When R2 was asked if he feels safe in the facility he stated, No I don't. I'm scared. I watch the room constantly for him (referring to the other resident). It makes me scared he is coming back. The staff didn't do anything, just let him beat me and I went to the hospital for three weeks.On 6/24/26 at 1:30pm, V4 (Abuse Coordinator) stated she does not recall exactly what all happened but knows that R1 and R2 got into a physical altercation in the dining room over table seating. R1 told R2 to move, which agitated R2 causing R2 to roll his wheelchair over to R1 and strike out at him. R1 then got up and hit R2 with a chair. Staff immediately intervened, R1 got up and went to his room, R2 went to local hospital for treatment of his injuries and R1 was arrested. Upon R1's return to the facility he was moved to a room across the facility from R2 and he was moved to a different table across the room from R2 in the dining room. Counseling R1 to manage his behaviors, both care plans reviewed and updated, and nursing notified of interventions placed. When asked if V7 (Certified Nursing Assistant) should have intervened when hearing R1 say get away from me, V4 stated, We know our residents here and we know which ones need us to intervene right away. R1 wasn't known to be physically aggressive. V4 also stated, Whatever is in the facility report is the most accurate information as I cannot recall every detail of the incident.2. On 6/24/26 Final State Investigation to facility reported incident dated 6/10/26 documents, (R3) became agitated with (R4) in the TV (television) area in the Main Dining Room and became physically confrontational. Staff immediately intervened and separated the clients. (R3) was counseled and escorted to his personal room as an environmental intervention. A few minutes later, (R3) struck out at his roommate (R5), walked out of his room and became physically aggressive with other peers (R6, R7). Staff immediately intervened and separated all of the involved parties to ensure the safety of all individuals involved.R3's admission record documents R3's date of admission to the facility was 6/1/26 and his diagnoses included but are not limited to: Schizoaffective Disorder Bipolar Type, Anxiety Disorder, Insomnia, Alcohol Abuse, Hypothyroidism, and Patient's Noncompliance with other medical treatment and regimen due to unspecified reason.R3's Minimum Data Set (MDS) assessment dated [DATE] documents R3 has a BIMS (Brief Interview of Mental Status) score of 10/15, indicating cognition is moderately impaired, has hallucinations, delusions and has had behavioral symptoms of rejecting care.R3's current care plan documents R3 has recent history of refusing treatment, verbal aggression, increased agitation, responds to hallucinations, difficulty thinking through or completing task, serious difficulty interacting with others related to delusional thinking and he has impulse control deficits.On 6/24/26 at 10:40am, V15 (Licensed Practical Nurse) stated on the morning of 6/10/26 he was finishing his medication pass when he heard a commotion coming from the dining area. V15 went to the dining area and a CNA (Certified Nursing Assistant) came to me, not sure who it was, and said (R3) was attacking people and they needed my help since I was the only male in the building. At this time a resident who I was told was (R5) came to the doorway over by the pool table room stating to call the police because his roommate just hit him. I went down to help and that's when I saw staff bringing (R3) up the hallway to the day room. Security (V12) came and made (R3) sit down on the floor until the police got here but (R3) got up and hit (R6). V12 was able to separate them and made (R3) sit back down. Police arrived and stood (R3) up and were escorting him out of the building when I saw (R7) walking by (R3) saying something like why you hit me, I don't recall exactly what he (R7) said but something along those lines. I saw (R3) get away from the police and head toward (R7), but I was able to move (R7), and the police got to (R3) and then handcuffed him (R3) and escorted him out of the building.On 6/24/26 at 12:48pm, V11 (Licensed Practical Nurse) stated that she was working on 6/10/26 when R3 became physically aggressive toward multiple peers. V11 stated approximately 5:15am on 6/10/26 R4 came to the television lounge per his usual routine and V11 was at the nurse's station across from the lounge charting. V11 heard R4 scream and looked up to see R3 hitting R4. V11 immediately intervened, assessed R4 for injuries with none noted and yelled for V12 (Security) who was in front of the building. V12 came down to the lounge and assisted V11 in walking R3 back to his room to separate him from R4. V12 stayed and talked with R3 for a couple of minutes before going back to the front desk and V11 went back to the nurse's station to finish her medication pass. V11 stated approximately 5 minutes later R5 came up to her stating to call the police because his roommate had just hit him. V11 assessed R5 for injuries with none noted and V14 (Certified Nursing Assistant) went down to check on R3. V11 then followed to check on R3 and noted V14 walking R3 up the hallway and V14 told V11 that she noted R3 going into R7's room and when she got to him, he was hitting R7. V11 stated by this time V12 had come down the hallway and all three of them (V11, V12, V14) took R3 to the lounge and R3 then went after R6 attempting to hit him, V11 stated, I don't think he hit R6 but I'm not sure. I grabbed R3 and along with V12 we did a CPI (Crisis Prevention Institute) hold and got R3 to sit on the floor by the vending machines. Police were called and came as well as the ambulance to take R3 for a psychiatric evaluation. V11 stated that the police told her that they could not take R3 for a psychiatric evaluation without involuntary discharge paperwork so V2 (Director of Nursing) was called and stated she was on her way to the facility. As police were walking R3 to the front of the building R3 attempted to go after R7 again, so the police handcuffed R3 and escorted him out of the building.On 6/24/26 at 2:43pm, V12 (Security) stated he was sitting at the front desk by the entrance of the building when he heard someone calling for security from the dining room. V12 got up and went down to the dining room and noted R3 hitting another resident (unsure of resident name). V12 walked R3 to his room, before V12 left R3 came out of his room talking about prisoners beating up and killing his girlfriend, V12 talked with R3 and calmed him before heading back up to the front of the building. V12 heard someone yelling for security again so he went back down and witnessed R3 hit another resident (unsure of this resident's name also) so assisted in getting R3 to sit on the floor until police arrived. Police were walking R3 to the front of the building and V12 heard R3 telling the police about the prisoners raping, beating and murdering his girlfriend. I didn't see R3 once they got him out of the building. All in all, I believe R3 hit four or five other residents before he left the building, but I only saw him hit 2 and I am not good with remembering the resident's names.R4's admission record documents R4's date of admission to the facility was 8/14/98 and his diagnoses included but are not limited to: Schizoaffective Disorder, Major Depressive Disorder, Recurrent, and Convulsions.On 6/25/26 at 9:15am, R4 stated he recalls being hit by someone, does not remember who but stated, I'm fine.R5's admission record documents R5's date of admission to the facility was 9/30/19 and his diagnoses included but are not limited to: Encephalopathy, Intermittent Explosive Disorder, Mood Disorder due to known Physiological condition with Manic Features, Obsessive-Compulsive Disorder, Paraphilia, and Acute Ischemic Heart Disease.On 6/25/26 at 9:18pm, R5 stated he does not remember being hit by anyone.R6's admission record documents R6's date of admission to the facility was 9/14/21 and his diagnoses included but are not limited to: Other Specified Intracranial Injury without Loss of Consciousness, Anemia, Major Depressive Disorder, Recurrent, Anxiety Disorder, Intermittent Explosive Disorder, Anoxic Brain Damage, and Post Traumatic Seizures.On 6/25/26 at 9:20am, R6 stated, Nobody has tried to hit me or have hit me here that I can remember.R7's admission record documents R7's date of admission to the facility was 2/15/18 and his diagnoses included but are not limited to: Other Specified Intracranial Injury without Loss of Consciousness, Cannabis Abuse with Intoxication, Schizoaffective Disorder Bipolar Type, Frontotemporal Neurocognitive Disorder, Bipolar Disorder, and antisocial personality disorder.On 6/25/26 at 9:30am, R7 stated, I remember a guy hitting me because I asked for a cigarette, but I don't remember when that was or who he was. I haven't had any issues since.On 6/24/26 at 1:30pm, V4 stated when asked about the incident involving R3, What is in the facility report is accurate. R3 hit multiple peers and was taken to the hospital for a psychiatric evaluation. R3 discharged home from the hospital and will not be returning to the facility.

Based on interview and record review the facility failed to report a resident-to-resident abuse allegation to the state agency for one (R1) of seven residents reviewed for abuse. Findings include:Facility policy, Abuse Prevention Program Facility Procedures, reviewed 9/1/25, documents not in its entirety, Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported and is being investigated. The report shall include the following information, if known at the time of the report: Name, age, diagnosis and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom property was misappropriated, type of abuse reported (physical, sexual, neglect, verbal or mental abuse, misappropriation of resident property), date, time, location and circumstances of the alleged incident, any obvious injuries or complaints of injuries, steps the facility has taken to protect the resident. This report shall be made immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or resulted in serious bodily injury; or not less than 24 hours if the events that cause the allegation do not involve abuse and did not result in serious injury.Facility incident report dated 5/24/26 documents that R1 and R2 got into a physical altercation after R2 became agitated at R1 over table seating in the dining room. R1 asked R2 to go to another table causing R2 to strike out at R1 and R1 picking up a chair and hitting R2 in the head causing R2 to go unconscious and receive 2 lacerations requiring medical intervention of sutures and staples at local hospital.On 6/24/26 at 1:30pm, V4 (Abuse Coordinator) confirmed that they have no documentation that state agency was notified of incident regarding allegation of resident-to-resident abuse on 5/24/26.

Based on observation, interview, and record review the facility failed to prevent abuse for one (R2) of three residents reviewed for abuse in a total sample of ten.The facility's Abuse Prevention Program Policy revised 12/18/24 documents that the facility affirms the right of our residents to be free from abuse.R2's medical record documents R2 was admitted to the facility on [DATE] with diagnoses to include Alcohol Abuse, Diabetes, Anxiety Disorder, and Psychoactive Substance Abuse.R2's Nursing Progress Note dated 1/18/26 at 12:21 PM documents Resident in a physical altercation with peer, resident separated by staff, no injuries noted.R2's Brief Interview for Mental Status dated 3/10/26 documents a score of 14, indicating R2 has little or no or little cognitive impairment. R3's medical record documents R3 was admitted to the facility on [DATE] with diagnoses to include Obsessive-Compulsive Disorder, Ischemic Heart Disease, Mood Disorder with Manic Features, and Encephalopathy.R3's Nursing Progress Note dated 1/18/26 at 12:21 PM documents Resident in a physical altercation with peer, resident separated by staff, no injuries noted.R3's Brief Interview for Mental Status dated 2/10/26 documents a score of 10, indicating R3 has moderate cognitive impairment.The Facility Reported Incident Investigation for the incident occurring 1/18/26 documents The incident occurred after R3 became agitated with R2 for removing black pepper packets from another resident's meal tray. During the initial interaction, R3 confronted R2 and removed the pepper packets from R2's possession. Staff intervened promptly during the original altercation, redirected both residents, and separated them. A few minutes later, while R2 was walking past R3, R3 stood up and struck R2 on the back of the head. Staff immediately intervened, separated the residents, and ensured the safety of all individuals involved.On 3/31/26 at 10:46 AM V5 (CNA) reported on 1/18/26 at breakfast in the dining room R3 became upset with R2 and staff directed R2 away from the dining room. V5 reported R2 and R3 were in the C hallway, R3 jumped up and grabbed R2. V5 reported R3 hit R2 and pulled on his shirt collar. Staff intervened at that time.On 3/31/26 at 2:59 PM V9 (Security) reported R2 reached onto R3's tablemates tray and took pepper packets which upset R3. Staff then directed R2 away from the table. V9 reported that V9 left the dining room to check the front door and upon return to the dining room R3 and R2 were in the C hallway and R2 was on the ground. On 4/9/26 at 10:09 AM V8 (RN) reported when V8 assisted to separate R3 from R2, R2 was on his knees in the C hallway.

Based on observation, interview, and record review the facility failed to initiate and implement safety interventions for a resident who was on a restricted pass due to impaired thought process and poor safety awareness to prevent an elopement, failed to ensure staff were educated on identifying residents with restricted passes to leave the facility, failed to assess a resident after elopement, and failed to educate staff or implement additional safety interventions once a resident eloped for three (R37, R72, and R75) of four residents reviewed for elopement. These failures resulted in R75, who the facility identified as not being capable of unsupervised outside pass privileges due to poor safety awareness, impaired thought process, and psychiatric diagnoses (including Schizophrenia), from exiting the facility without staff knowledge or supervision on 8/24/25 when R75 left the grounds in a Taxi. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 8-24-25 when R75 left the Facility grounds unsupervised. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 8-28-25 at 11:50 AM. While the immediacy was removed on 8-29-25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings include:The facility's Elopement Protocol/Missing person policy updated 4/23/25 documents upon locating the resident, the search coordinator initiates the following activities as appropriate: Direct that an assessment be initiated on the resident, notify family that resident was found, complete appropriate documentation in the resident's medical record, any in-services deemed needed by those involved in process. Immediately upon a residents return to the facility following an elopement/wandering episode, the resident shall be placed on elopement/wandering precautions. The nurse on duty shall review the facility sign-out procedure with the resident immediately upon return to the facility. Designate staff to monitor the resident's whereabouts, such as implementing 15-minute checks. The time periods for monitoring to be determined by the IDT (Interdisciplinary Team) with input from the staff. The above applies for a minimum of 24 hours at which time a reassessment will be made by IDT regarding any continuance. Should the resident be noncompliant with precautions, the procedure shall be extended for additional time as indicated by IDT. The management staff are to review all documentation as indicated. The facility's undated Resident Pass Policy documents each resident will be evaluated for community access at their initial MDS (Minimum Data Set) assessment. All residents will have no pass until that time. New residents that need to leave the building during this probationary period should do so with staff and/or family. The IDT will review and determine the individual's ability to access the community with or without staff/family. Residents going out on pass must sign out with the front door monitor prior to leaving.1) R75's Nurse Progress Note dated 8/24/25 documents Resident has left the faciity on a pass violation. She called herself a cab, walked out the front door and got into the cab before staff could stop her. Staff tried to stop the car, but the resident was inside yelling drive, drive, drive. Another nurse called the cab company, and they stated they would be on their way back to drop the resident back off.R75s Pines Community Access assessment dated [DATE] documents R75 is not capable of unsupervised outside community passes related to Schizophrenia Disorder. This same assessment documents R75 does not know the facility address or how to contact someone in case of an emergency. R75's Psychiatric Evaluation dated 6/10/25 documents that R75 struggles with medication compliance and experiences paranoia. The evaluation documented a recent psychiatric hospitalization in February 2025 due to paranoia. R75 was noted to have a history of delusions, including beliefs that her food was being poisoned, and reported auditory hallucinations involving voices that conveyed negative messages. The assessment further described R75 as having poor insight and judgment, along with a scattered thought process. R75's psychiatric history includes diagnoses of Disorganized Schizophrenia, Bipolar II Disorder, Delusional Disorder, Personality Disorder, and Anxiety.R75's Medical Diagnosis List documents R75 has Paranoid Schizophrenia, Anxiety Disorder, and Personality Disorder.R75's mobility assessment dated [DATE] documents R75 is independent with ambulation. On 8/26/25, review of R75's current care plan did not include safety interventions related to R75's restricted community pass status and did not contain documentation of R75's pass restriction, despite prior assessments identifying R75 as incapable of unsupervised community access due to impaired thought process, poor safety awareness, and multiple psychiatric diagnoses.On 8/26/25 at 10:30 PM, R75 was observed ambulating independently within the facility. During the observation, R75 stated she remembered calling a taxi to pick her up on 8/24/25 and said she was trying to leave the facility to go anywhere but here. R75 further stated she disliked being at the facility, describing it as too loud and that there is too much going on. R75 then asked, Can you help me get out of here?On 8/27/25 at 8:45 AM, V20 (Social Services Director) stated she conducted R75s Community Access Assessment on 8/13/25 which revealed R75 had poor decision-making skills and poor safety awareness. V20 stated R75 is very paranoid and V20 does not believe that R75 would be able to ask for help or know where to go if R75 left the facility alone.On 8/27/25 at 9:15 AM, V9 (Registered Nurse) stated that on 8/24/25, R75 called a taxi using her personal cell phone and exited the facility without staff supervision. V9 stated that staff attempted to prevent R75 from entering the cab, but R75 got into the vehicle and instructed the driver to leave yelling drive, drive. V9 reported she contacted the cab dispatch company to inform them that R75 was a resident of the facility, did not have funds to pay for the ride, and needed to be returned. The cab driver subsequently returned R75 to the facility. V9 stated she did not document the incident in R75's medical record because V2 (Director of Nursing) indicated she would chart the note. V9 further stated that she did not chart the event due to staffing shortages and high workload on 8/24/25.On 8/27/25 at 9:15 AM, V24 (Security) stated he arrived at the facility around 3:00 PM on 8/24/25. V24 stated he observed R75 standing outside the facility using a cell phone but did not consider the behavior unusual. After clocking in, V24 returned outside and witnessed R75 entering a taxi. V24 reported yelling, Hey, you can't leave, you don't have a pass, but R75 instructed the driver to go, go, and the taxi departed. V24 stated he informed facility staff that R75 had left the grounds in a taxi. Staff subsequently contacted the taxi company to report that R75 was not authorized to leave the facility and did not have funds to pay for transportation. R75 was returned to the facility at an unknown time after. V24 confirmed that the front desk maintains a binder listing residents with community passes and those with restricted status. V25 also stated that all residents are required to check in with security and sign out before leaving the facility.On 8/27/25 at 9:30 AM, V25 (Security) stated he was assigned to the front entrance on 8/24/25, the date of R75's elopement. V25 stated he was not familiar with R75 and asked, Is she a new resident? He further explained that he typically works in housekeeping and is occasionally reassigned to the front desk for security duties. V25 stated he does not know all the residents and did not recall any residents leaving the facility on 8/24/25. V25 confirmed that a binder is kept at the front desk listing residents with restricted and community passes. However, he was unaware that R75 had exited the facility while he was on duty.On 8/27/25 at 3:00 PM, V32 (Taxicab Manager) stated on 8/24/25 at 2:01 PM, the first call was received from (R75) to be picked up from the facility. The driver attempted to call her back but did not get an answer, so he did not go to pick her up. The next call was received at 3:11 PM to be picked up at the facility. R75 was picked up at 3:15 PM, and the driver brought her back to the facility between approximately 3:35 PM and 3:45 PM.On 8/27/25 at 9:20 AM, V16 (Certified Nursing Assistant) stated, I have only worked at the facility for four months. I do not know all the residents in the building who are on pass or does not have a pass. There is a book located at the security desk that has a list of residents who do not have a pass. We (staff) cannot memorize every resident who does not have a pass. If a resident does leave who is not supposed to and arrives back at the facility, that resident would be on 15-minute checks. The 15 minutes are in point click care under tasks if the resident is on 15-minute checks. (R75) is one of them that is constantly going out the door. (R75) has never left the building to my knowledge, at least no one has told me that she has, and I have not seen where she has been on 15-minute checks at.On 8/27/25 at 9:43 AM, V26 (Certified Nursing Assistant) stated I am not sure who is on pass and who is not in this facility, there are too many residents. The security guard up front is typically the one who knows. I am not aware that (R75) left the facility. (R75) does go out the door a lot but typically she comes back in. I am not aware of any resident getting out of the facility. Honestly, no one communicates around here. If someone gets out, they don't let us know. We might see them on a 15-minute check in our tasks, but we don't know why they are on 15-minute checks. If it didn't happen on the shift, I work then most of the time we are unaware of it.On 8/27/2025 at 9:15 AM, V22 (Certified Nurse Assistant) stated she was not aware of R75 eloping on 8/24/2025. V22 stated this information was not passed onto her. V22 stated R75 stays close to her roommate and pushes her roommate around in her wheelchair. V22 stated R75 does express she wants to leave frequently. V22 stated she does not know what R75's ground pass is, but she knows she is new and assumes she is restricted because all new residents are restricted for a certain amount of time. V22 stated there is a book at the front desk that tells what each resident's ground pass is or V22 said she will ask the nurse. V22 stated she was working 8/24/2025. V22 stated some days are better than other days when it comes to having enough staff.On 8/27/2025 at 9:40 AM, V23 (Registered Nurse) stated she was working on 8/24/2025 and was not aware that R75 had eloped, and the information was not passed onto her. V23 does not know R75's ground pass, but she knows new admissions are to stay on the grounds for a certain amount of time. V23 stated she does not feel that she can monitor residents effectively because they are constantly short staffed. V23 stated if a resident does elope, she will try and find them, call the police if she cannot find them, and call the Director of Nursing and the Administrator, and the doctor. If a resident is still adamant about leaving, she will have them sign AMA (Against Medical Advice) paperwork and discharge themselves. V23 stated there is no protocol for elopement, and if there is she is unaware of the protocol due to not having any education. V23 stated 15-minute checks will be put in the residents' chart by the nurse, and the certified nurse assistants chart them in (Electron Medical Record). V23 stated she will still check the residents on 15-minute checks because some staff are lazy, and she will make sure those checks are done.On 8/26/25 at 2:05 PM, V19 (Certified Nursing Assistant) stated that none of the floor staff were aware that R75 had exited the facility unsupervised on 8/24/25. V19 stated, If we had known, we could have been monitoring (R75). V19 further reported that there is a communication issue within the facility and that management does not tell us anything. V19 explained that when a resident leaves the facility and returns, standard protocol includes assessing the resident, initiating monitoring, and documenting safety checks in the electronic medical record. V19 confirmed that these procedures were not initiated for R75 following her return on 8/24/25.On 8/26/25 at 12:30 PM, V4 (Licensed Practical Nurse) stated she was not aware that R75 had exited the facility in a vehicle on 8/24/25. V4 reported that unless staff are present during an incident, most things are not passed along to the next shift. V4 stated that when a resident leaves the facility in violation of pass restrictions and returns, staff are expected to monitor the resident and document safety checks in the medical record. V4 confirmed that no documentation of safety checks was present in R75's chart following her return.On 8/27/25 at 2:30 PM, V31 (R75's family member) stated that approximately two to three months prior, R75 had left her former assisted living facility in a taxi and traveled approximately 48 miles and was later found at a bus stop. V31 reported that R75 is very paranoid of people and is not safe to be on her own. V31 stated that due to R75's impaired judgment and psychiatric history, the family chose placement in a long-term care facility to ensure R75 received increased supervision and monitoring. V31 stated she was not aware that R75 had left the facility in a taxicab on 8/24/25.On 8/27/25 at 10:33 AM, R75's electronic medical record continued to lack updated safety interventions to prevent further elopement. The care plan did not reflect R75's restricted pass status or include monitoring strategies, despite the resident's recent unsupervised departure from the facility on 8/24/25.On 8/27/25 at 2:30 PM, R75 was observed entering the facility through the front doors from outside, following two other residents. This occurred without staff supervision or intervention, despite R75's documented restricted pass status and history of leaving the facility.R37's incident/accident report dated 8/29/25 at 12:00 PM documents R37 exited out the open side door located on the D/E hallway. R37 was observed in front of the facility standing near the main entrance. R37 was escorted back into the facility by staff. Physician, management, and family notified of incident via phone.On 9/3/25 V5 (Registered Nurse) stated on August 29, 2025, at approximately 12:00 PM, V5 was administering medications in the common area of the facility. At that time, an outside vendor was present, working on the heating and cooling unit. The vendor had propped open a door to facilitate their work. While V5 was engaged in medication pass, one of the vendors alerted V5 that someone had exited through the propped door. V5 immediately proceeded outside, walking along the sidewalk between the buildings to investigate. Upon returning to the front of the building, multiple staff members informed V5 that Resident R37 had already re-entered the facility.On 9/3/25 at 8:50 AM, V1 (Administrator) stated that immediately following the incident in which Resident R37 exited the facility through a door propped open by an outside vendor, the facility's Outside Vendor Safety Policy was revised. The updated policy now requires that: A designated staff member must be assigned to monitor the area whenever an outside vendor is working within the facility. V1 confirmed that on 8/29/25 R37 and R72 both had restricted passes and were not to leave the facility without a staff member.On 9/3/25 at 9:15 AM, R37 stated he does not remember walking outside and walked away. R37 is independently ambulatory in the facility.On 9/3/25 at 9:00 AM, R72 stated he saw R37 step out the door so R72 followed R37 to make sure he didn't leave. R72 stated he yelled for staff when he saw R37 go outside. The immediate jeopardy was determined not to be removed upon review of the implementation of the facility's abatement plan after the facility failed to prevent R37 and R72, who had Community Pass Restrictions, from exiting the facility unsupervised on 8/29/25. On 9/03/25 the facility provided a revised abatement plan.On 9/03/25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy:1) On 8/28/25 a whole house audit was completed by V1 (Administrator), V2 (DON), V11 (Activity Director), V27, (Administrative Assistant) and V11 (Social Services Director) to evaluate residents for any potential discrepancies in pass status or need for increased supervision. All residents were evaluated to ensure they were correctly assessed. The reviewed/confirmed pass list was given to the front desk personnel.2) On 8/28/25 R75 was placed on 15-minuite checks by V2 (Director of Nursing) for increased supervision.3) On 8/28/25 R75's Community Access Assessment was re-done by V20 (Social Service Director) to ensure accuracy.4) On 8/28/25 R75's care plan was reviewed and updated by V20 (Social Service Director) with additional interventions to reflect R75's Pass status/safe community access.5) On 8/28/25 the facility's Elopement Policy and The Pass Policy was updated and reviewed by IDT (Interdisciplinary Team).6) On 8/28/25 an All-Staff Training was initiated by V2 (Director of Nursing) and V20 (Social Services Director) on the Elopement Policy and the Facility Pass Policy.7) On 8/28/25 Human Resources placed a reminder sign by the timeclock to ensure all staff on subsequent shifts review the mandatory material in the Inservice prior to working the floor. 8) On 8/28/25 Human Resources developed a mandatory checklist to track compliance with the mandatory training.9) On 8/28/25 a separate section on community access and Facility pass policy was added by V1 (Administrator) to the Facility's Quality Assurance/Quality Assurance Policy improvement agenda. 10) On 8/29/25 a whole house audit was conducted by the V2 (DON) after R37 and R72 were able to leave the Facility to ensure the incident was isolated.11) On 8/29 R 37's Care Plan was reviewed by V20 (Social Services Director) and R37 was put on 15-minute checks for increased supervision. 12) On 8/29/25 V1 (Administrator) modified the Outside Vendors Safety Policy to reflect a staff member must accompany vendors when working at the facility to ensure resident safety. An All-Staff Inservice was conducted to educate staff on Vendor Policy update.13) The V1(Administrator)and IDT (Interdisciplinary Team) to monitor for ongoing compliance.Completion Date: 8-29-25

Based on interview and record review, the facility failed to ensure there are sufficient number of licensed nursing staff to provide care and supervision for dependent residents. This has the potential to affect all 110 residents residing in the facility. Findings include: The facility's Staffing Policy, dated 4/30/25, documents, It is the policy of the facility that minimum numbers of nursing staff members within the facility be established and maintained. Staffing levels may vary by shift and by the day of the week and should be based on census, and level of care needed/medical acuity of the in-house resident population.The facility Staffing Requirements calculators, dated 8/5/25, 8/12/25, 8/16/25, 8/17/25, 8/23/25, 8/24/25, documents the number of licensed nursing staff required for day shift (7:00 a.m. to 3:00 p.m.) was four nurses/32 licensed nursing hours, for evening shift (3:00 p.m. to 11:00 p.m.) three nurses/24 licensed nursing hours, and for night shift (11:00 p.m. to 7:00 a.m.) two nurses/16 licensed nursing hours.On 8/28/25 at 8:30 AM, V2 (Director of Nursing) provided all nurse timecard reports for 8/5/25 through 8/24/25. The timecard reports document the following licensed nursing staff hours worked: On 8/5/25 V4 Licensed Practical Nurse (LPN), V34 Registered Nurse (RN), and V3 RN each worked eight hours on day shift/24 licensed nursing hours. V34 RN, V4 LPN, and V36 LPN each worked four hours on evening shift/12 licensed nursing hours. V36 worked eight hours on night shift.On 8/12/25 V4 LPN worked eight hours on day shift. V4 and V36 LPN each worked four hours on evening shift/8 licensed nursing hours. V36 worked 8 hours on night shift.On 8/16/25 V4 LPN, V33 LPN, and V23 RN each worked eight hours on day shift/24 licensed nursing hours. V4 LPN, V36 LPN, and V23 RN each worked four hours on evening shift/12 licensed nursing hours. V36 worked eight hours on night shift.On 8/17/25 V34 RN and V23 RN each worked eight hours and V3 worked four hours on day shift/20 licensed nursing hours. V34, V36 LPN, and V23 each worked 4 hours on evening shift/12 licensed nursing hours. V36 worked 8 hours night shift.On 8/23/25 V9 RN, V23 RN, and V3 RN each worked eight hours on day shift/24 licensed nursing hours. V23 worked 8 hours and V9 and V35 RN each worked 4 hours on evening shift/16 licensed nursing hours. V35 RN worked 8 hours night shift.On 8/24/25 V9 RN and V23 RN each worked eight hours on day shift/16 licensed nursing hours. V9 worked eight hours and V23 RN and V35 RN each worked 4 hours on evening shift/16 licensed nursing hours. V35 RN worked 8 hours night shift. On 8/27/25 at 9:15 AM, V9 (Registered Nurse) stated she did not chart on her residents on 8/24/25 because things were too busy in the facility and there was not enough staff. On 08/28/2025 at 10:15 AM, V2 stated when doing the schedule for nurses she strives to have 2 nurses for each shift (days, evenings, and nights). V2 confirmed the following staffing shortages: 8/5/25 three nurses worked day shift, one and a half nurses worked evening shift, one nurse worked night shift; 8/12/25 one nurse worked day shift, one nurse worked evening shift, and one nurse worked night shift; 8/16/25 three nurses worked day shift, one and a half nurses worked evening shift, one nurse worked night shift; 8/17/25 two and half nurses worked day shift, one and a half nurses worked evening shift, one nurse worked night shift; 8/23/25 three nurses worked day shift, two nurses worked evening shift, one nurse worked night shift; 8/24/25 two nurses worked day shift, two nurses worked on evening shift, one nurse worked night shift. V2 also stated staffing is an issue. I wasn't aware the staffing calculator stated we should have four nurses on day shift, three nurses on evening shift, and two nurses working on night shift. The nurses complain about our staffing numbers and tell us they can't get things done. The MARs (Medication Administration Record) and TARs (Treatment Administration Record) have holes in the charting, and the nurses say they can't get them done because they don't have time related to low staffing. The facility's Center's for Medicare and Medicaid Services Long Term Care Application, dated 8/25/25 and signed by V1 (Administrator), documents there are 110 residents residing in the facility.

Based on record review and interview the facility failed to ensure a Registered Nurse was working eight consecutive hours in a twenty four hour period. This has the potential to affect all 110 residents residing in the facility. On 8/28/25 at 8:30 AM, V2 (Director of Nursing) provided all nurse timecard reports for 8/5/25 through 8/24/25. The timecard reports have no documentation of a registered nurse working eight consecutive hours on 8/12/25. On 08/28/2025 at 10:15 AM, V2 confirmed there was not a Registered Nurse working on 8/12/25.The facility's Center's for Medicare and Medicaid Services Long Term Care Application, dated 8/25/25 and signed by V1 (Administrator), documents there are 110 residents residing in the facility.

Based on observation, interview, and record review the facility failed to label, and date opened food items in the kitchen's refrigerator and freezer and discard expired food, ensure kitchen ceiling tiles/vents were kept clean, and ensure kitchen freezer was maintaining proper temperature. This failure has the potential to affect all 110 residents. Findings include:The facility's Labeling and Dating and Food Policy, dated 4/25/25, documents Purpose: To prevent foodborne illness and ensure safe storage, handling, and consumption of all foods served to resident by clearly labeling and dating all food items upon receipt, preparation, or opening, in accordance will Illinois state regulations and facility policies. This policy applies to: All dietary services staff, caregivers, and any staff handling food. All food items stored in the main kitchen, refrigerators, freezers, pantries, meal prep areas, and resident rooms (as applicable). Definitions: Label: A written or printed tag or marker attached to or placed on a food item that identifies the item, date opened, and any other required information. Date: the date on which the item is opened, prepared, or received, depending on the item's status and Illinois food safety guidelines. Labeling Requirements: All unpackaged foods and leftovers must be labeled with: Item name (generic name accepted if obvious), date of opening or preparation (or receipt), and use-by or discard-by date when applicable, based on safe food handling guidelines. For pre-packaged items opened in the facility, label with the date opened and discard date if applicable.The facility's Sample Cleaning Schedule Policy, dated 2017, documents Refer to Housekeeping: Ceilings.On 8/25/25 at 9:10 AM a kitchen tour was conducted with V6/Dietary Manager. During this tour, inside a three-door refrigerator, a five-pound tub of cottage cheese, which was one-quarter full, was found to be undated and past its August 20, 2025, expiration date. Three gallon-sized plastic bags of thawed, pre-cooked chicken, and a gallon bag of thawed, precooked hamburger patties were stored without dates. Additionally, two boxes of waffles, which are to be kept frozen according to the packaging, were observed thawed and undated. Three sealed, undated packages of bologna were found thawed in the freezer. The kitchen's freezer thermometer registered 42 degrees Fahrenheit. V6 stated the unit had failed that morning and a maintenance request had been submitted. V6 verified the packages of bologna should have been thrown away and the freezer should have been put out of order until Maintenance could address the issue. On the preparation table, next to the stove, a plate with a piece of ham and two pancakes, covered in plastic wrap were observed undated. On the dry storage rack a 24-ounce container of gravy mix powder was found opened, half-full, and undated. On 8/25/25 at 9:16 AM V6/Dietary Manager verified the cottage cheese was expired and should have been disposed of, the three gallon-sized bags of thawed pre-cooked chicken and the gallon bag of precooked hamburger should have been labeled and dated with the date it was thawed, and the two boxes of waffles should have been labeled with the date opened and stored in the freezer not refrigerator. V6 also verified the plate of ham and two pancakes with plastic wrap covering it should have been dated, and the 24-ounce container of gravy mix powder should have been dated after opening. On 8/25/25 at 9:23 AM, during drink preparation, heavy accumulation of black, stringy dust was observed hanging from the ceiling vent and surrounding tiles directly over the uncovered prepared beverage area. V6 verified the black stringy dust on the ceiling vent and tiles. V6 stated, Maintenance is responsible for cleaning the kitchen ceiling and vents. They have been aware of it.The facility's Center's for Medicare and Medicaid Services Long Term Care Application, dated 8/25/25 and signed by V1 (Administrator), documents there are 110 residents residing in the facility.

Based on observation and interview the facility failed to ensure the facility maintained an effective pest control program. This has the potential to affect all 110 residents. Findings include:The facility's Pest Control Policy, dated 4/25/25, documents Purpose: Ensure a safe, healthy, and comfortable living, environment for residents, staff, visitors, and guests by managed and preventing pest infestations. 2. Scope: Applies to all buildings and grounds owned, leased, or operated by the facility, including resident rooms, common areas, kitchens, dining areas, laundry, maintenance spaces, and storage areas. Covers all staff, contractors, vendors, volunteers, residents, and visitors. 3. Definitions: Pest: Any unwanted animal (insects, rodents, birds, etcetera) or related hazard affecting health, sanitation, and comfort. Integrated Pest Management: A holistic approach combining prevention, monitoring, sanitation, exclusion, mechanical and cultural controls, and limited, targeted use of pesticides as a last resort. 5. Policy Statements: Prevention and Sanitation: Maintain high standards of cleanliness, waste management, food storage, and routing cleaning schedules. 6. Procedures: Prevention: implement sanitation protocols (containerized waste, clean dining areas, promptly remove food attractants). The facility's Pest Control Invoices for March, April, May, June, July, and August 2025 does not include evidence of the facility being treated for flies. On 8/25/25 at 9:18 AM, during a kitchen tour with V6/Dietary Manager, multiple flies were observed in the vicinity of the juice machine, preparation sink, and cup storage area. V6 identified the frequent opening of the dining room door as the likely contributing factor to the flies being in the kitchen. V6 verified the flies at this time and stated she was unaware of any pest control preventatives the facility was doing to try to keep flies out of the kitchen. On 8/25/2025 at 10:16 AM R7 was sitting in her wheelchair at a table in the dining room. R7 reported that flies are constantly landing on her when she eats in the dining room. During this time, two flies were observed landing on her left arm, which prompted R7 to swat them away. On 8/25/2025 at10:54 AM R4 stated a trash can with no lid is located at the beginning of C-Hall where staff dispose of residents dirty depends. R4 stated, Flies are constantly swarming the trashcan. They are so annoying. On 8/25/25 at 10:58 AM a trashcan filled with soiled disposable resident undergarments was found without a lid at the entrance of C-Hall, attracting a swarm of flies.On 8/25/25, during the noon meal, a fly infestation was observed in the kitchen with flies landing on the steam table and food-contact surfaces.On 8/26/25 at 11:05 AM a trashcan remained at the entrance of C-Hall, filled with soiled disposable resident undergarments. Multiple flies were present around the bin.On 8/28/25 at 8:48 AM V1/Administrator verified the facility has not been treated by a pest control service for flies, but they are switching pest control companies and will start getting treated for flies around the facility.The facility's Center's for Medicare and Medicaid Services Long Term Care Application, dated 8/25/25 and signed by V1(Administrator), documents there are 110 residents residing in the facility.

Based on record review and interview the facility failed to ensure all staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to affect all 110 residents residing within the facility. Findings include:The facility's Center's for Medicare and Medicaid Services Long Term Care Application dated 8/25/25 and signed by V1 (Administrator), documents there are 110 residents residing in the facility. The facility's List of Staff In-services, dated 8/8/24 through 8/25/25, do not include documentation of facility staff receiving annual QAPI training.On 8/28/25 at 12:55 PM V21/Administrative Assistant verified no staff at the facility has received the annual QAPI training.

Based on observation, interview and record review, the facility failed to document medications at the time of administration for nine of nine residents (R3, R4, R6, R8, R13, R15, R18, R61 and R89), reviewed for medication administration, in a sample of 40. FINDINGS INCLUDE: The (undated) facility policy, Medication Administration directs staff, Documentation: Initial Medication Administration Record immediately after administering medications. No pre-signing or post-signing. A review of R4's current Medication Administration Record, dated August 2025 includes the following medications Aspirin 81 MG (milligrams), Escitalopram 15 MG, Fenofibrate 200 MG, Fluticasone Inhalation Aerosol, Incuse Ellipta Inhalation Aerosol 62.5 Mcg/ACT, Loratadine 10 MG, Omeprazole 20 MG, Oxybutynin Extended Release 10 MG, Albuterol Sulfate Inhalation 108 MCG/ACT 2, Eliquis 5 MG, Hydroxyzine 25 MG, Lasix 40 MG, Metformin 1000 MG, Risperidone 1 MG, Divalproex Delayed Release Sprinkle 125 MG and Pregabalin Oral Capsule 100 MG, not documented as administered 10+ times from August 1- August 25, 2025. A review of R6's current Medication Administration Record, dated August 2025, includes the following medications Amlodipine 10 MG, Apiprazole 5 MG, Aspirin 81 MG, Benztropine 1 MG, Docusate Sodium 100 MG, Fentanyl Transdermal Patch 25 MCG/HR, Flonase Nasal Suspension 50 MCG/ACT, Haldol Decanoate 50 MG injection, Isosorbide Mononitrate ER 60 MG, Lamictal 25 MG, Lasix 80 MG, Lexapro 10 MG, Lipitor 80 MG, Mirtazapine 30 MG, Tizandine 4 MG, Cardura 2 MG, Carvedilol 6.25 MG, Keppra 500 MG, Metformin 850 MG, Potassium Chloride ER 20 MEQ, Quetiapine 50 MG, Hydralazine 50 MG, and Lorazepam 1 MG not documented as administered 10+ times from August 1- August 25, 2025. A review of R8's current Medication Administration Record, dated August 2025, includes the following medications Apiprazole 20 MG, Aspirin 81 MG, Lactobacillus, Buprenorphine Transdermal 10 MCG/HR patch, Depakote 250 MG, Effexor 75 MG, Fenofibrate 160 MG, Folic Acid 1 MG, Insulin Lispro, Lantus Solostar Insulin, Levothyroxine 25 MCG, Omeprazole 40 MG, Ascorbic Acid 500 MG, Depakote 500 MG, Ipratropium- Albuterol Solution, Tolterodine 2 MG, Gabapentin 300 MG, Midodrine 5 MG not documented as administered 10+ times from August 1- August 25, 2025. A review of R13's current Medication Administration Record, dated August 2025 includes the following medications Atorvastatin, Benztropine 1 MG, Duloxetine 40 MG, Fenofibrate 160 MG, Ferrous Sulfate 325 MG, Paliperidone Palmitate 234 MG, Loratadine 10 MG, Memantine 5 MG, Norvasc 2.5 MG, Tamsulosin 0.4 MG, Vitamin B Complex, Albuterol Sulfate Aerosol Solution 108 MCG/ACT, Cyclobenzaprine 10 MG, Docusate Sodium 100 MG, Famotidine 20 MG, Ibuprofen 600 MG, Symbicort Inhalation 160-4.5 MCG/ACT, Gabapentin 600 MG, Tramadol 50 MG and Levsin 0.125 MG not documented as administered 7+ times from August 1- August 25, 2025. A review of R15's Medication Administration Record, dated August 2025 includes the following medications Amlodipine 5 MG, Escitalopram 10 MG, Melatonin 5 MG, Olanzapine 10 MG, Pantoprazole 40 MG, Valacyclovir 500 MG, Vitamin C 500 MG, Risperdal 2 MG, Keflex 500 MG and Tums 500 MG, not documented as administered 10+ times from August 1- August 25, 2025. A review of R18's Medication Administration Record, dated August 2025 includes the following medications Aripiprazole 2 MG, Escitalopram 20 MG, Ingrezza 40 MG, Levothyroxine 150 MCG, Insulin Glargine, Trazadone 25 MG, Vitamin B Complex, Benztropine Mesylate 2 MG, Lacosamide 100 MG, Lamictal 100 MG, Metformin 500 MG, Tramadol 50 MG and Insulin Aspart not documented as administered 5+ times from August 1- August 25, 2025. A review of R61's Medication Administration Record, dated August 2025 includes the following medications Anoro Ellipta Inhalation Aerosol 62.5- 25 MG/ACT, Vitamin C Complex, Duloxetine 30 MG, Flomax 0.4 MG, Lamotrigine 125 MG, Melatonin 15 MG, Mirtazapine 15 MG, Multiple Vitamin, Omeprazole 20 MG, Quetiapine 650 MG, Trazadone 100 MG, Clonazepam 0,5 MG, Metformin 850 MG, Symbicort Inhalation 160-4.5 MCG/ACT, Tylenol with Codeine 30 MG, Ipratropium ibuterol Solution 20-100 MCG/ACT and Carafate 1 GM (gram) not documented as administered 8+ times from August 1- August 25, 2025. A review of R89's Medication Administration Record, dated August 2025 includes the following medications Vitamin B Complex, Benztropine 1 MG, Cetirizine 10 MG, Clonazepam 0.5 MG, Desmopressin Acetate Nasal Spray, Escitalopram 20 MG, Flonase Suspension 50 MCG/ACT, Lithium Carbonate 600 MG, Melatonin 10 MG, Montelukast 10 MG, Guaifenesin 400 MG, Multivitamin Tablet, Oxybutynin 5 MG, Paliperidone 9 MG, MiraLAX Powder, Trazadone 150 MG, Wellbutrin 150 MG, Albuterol Sulfate Solution 108 MCG/ACT, Docusate Sodium 250 MG, Fish Oil Capsule 1000 MG, Cephalexin 500 MG, Gabapentin 400 MG and Tylenol with Codeine 30 MG not documented as administered 10+ times from August 1- August 25, 2025. On 8/28/25 at 10:20 A.M., V2/Director of Nurses verified the missing staff documentation of the medications for R4, R6, R8, R13, R15, R18, R61 and R89. At that time, V2 stated she doesn't have enough staff, so therefore the staff aren't able to document medications administered. R3's Face Sheet dated 8/28/2025 documents, R3 has a diagnosis of Type 2 Diabetes Mellitus without complications. R3's Physician Orders dated 8/28/2025 documents, Humulin R Injection Solution (Insulin Regular) Inject 5 units subcutaneously with meals, and Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 74 units subcutaneously two times a day. R3's MAR (Medication Administration Record) dated August 1st-August 27th, 2025, documents Humulin R was not given on August 7th, 8th, 10th, 15th, 23rd, and 24th, and Lantus Solostar was not given on August 7th, 8th, 10th, 15th, 23rd, and 24th. On 8/27/2025 at 9:45 AM, V23 (Registered Nurse) stated I was (R3) nurse that weekend and I do not know why I did not record giving Humulin R, and Lantus SoloStar that weekend. On 8/28/2025 at 9:20 AM, V2 (Director of Nursing) confirmed R3 did not have his Humulin R, and Lantus SoloStar recorded as given on the August 7th, 8th, 10th, 15th, 23rd, and 24th 2025.

Based on observation, record review and interview, the facility failed to give medications as ordered by the physician to three residents (R4, R8 and R18) of eleven residents reviewed for medication pass. This failure resulted in three errors out of twenty-five opportunities for a 12% medication error rate.FINDINGS INCLUDE:The (undated) facility policy, Medication Administration directs staff, Follow the seven rights- right patient, right medication, right dose, right time, right route, right documentation and right to be informed. Medication Preparation: Follow special directions: Shake Well, Do Not Crush, etc. Medication Errors: Manufacturer specifications/Professional Standards: Failure to Shake Well. Inhalers should be given with 1 minute between puffs of the same med and 5 minutes between puffs of different medications. Metered dose inhalers should be shaken well, and resident instructed on correct technique. 1. R4's current Physician Order Sheet, dated [DATE] includes the following medication: Albuterol Sulfate Inhalation Aerosol Solution MCG (Micrograms)/ACT (Actuation) 2 puffs inhale orally four times a day for Asthma. Shake well before administration and rinse mouth and spit afterwards.On [DATE] at 12:11 P.M., V4/Licensed Practical Nurse (LPN) handed R4 an Albuterol inhaler without shaking to mix the active ingredients, stood by while R4 inhaled 2 puffs then placed the inhaler in the medication cart without instructing R4 to rinse her mouth and spit afterwards. At that time V4/LPN verified R4's inhaler included instructions to shake before use and to rinse and spit afterwards. 2. R8's current Physician Order Sheet, dated [DATE] includes the following medications: Insulin Lispro 100 Unit/ML (Milliliter) Inject as per sliding scale: 70-139= 0; 140-163= 2; 164-187= 4; 188-211= 6; 212-235= 8; 236-259= 10; 260-283= 12; 284-307= 14; 308-331= 16; 332-355= 18; 356+ give 20 Units and call MD (Medical Doctor) subcutaneously for Diabetes Mellitus.On [DATE] 8:51 A.M., V4/Licensed Practical Nurse (LPN) performed a blood glucose test for R8 with R8's blood glucose test result of 389. V4/LPN then administered 18 units of Lispro Insulin in R8's abdomen. At that time, V4/LPN confirmed she should have administered 20 units of insulin.3. R18's current Physician Order Sheet, dated [DATE] includes the following medications: Insulin Aspart Solution 100 Unit/ML (Milliliter) Inject 6 units subcutaneously three times a day due to Diabetes Mellitus and Insulin Aspart per sliding scale: if 71-200 = 5 units; 201-260= 6 units; 251-300 = 7 units; 301-350 = 8 units; 351- 400 = 9 units; 401- 450 = 10 units; 451+ give 11 units and notify provider.On [DATE] at 12:15 P.M., V5/Registered Nurse (RN) performed a blood glucose test for R18 with a result of 348. V5/RN administered 14 units of Aspart Insulin into R18's left upper arm. At that time, V5/RN confirmed the bottle of Aspart Insulin had expired on [DATE].

Based on observation, interview and record review, the facility failed to date an opened bottle of insulin for two of two residents (R8 and R101) reviewed for insulin administration, in a sample of 40.FINDINGS INCLUDE:R8's current Physician Order Sheet, dated August 2025 includes the following medications: Insulin Lispro 100 Unit/ML (Milliliter) Inject as per sliding scale.On 8/25/2025 8:51 A.M., V4/Licensed Practical Nurse (LPN) prepared to administer insulin for R8. V4/LPN withdrew 18 units of insulin from an opened, undated insulin bottle and administered it to R8 in her abdomen. At that time, V4/LPN verified the opened, undated insulin and stated she didn't know what date the insulin bottle was first accessed.R101's current Physician Order Sheet, dated August 2025 includes the following medications: Insulin Lispro 100 Unit/ML inject as per sliding scale.On 8/25/2025 8:51 A.M., V5/Registered Nurse (RN) prepared to administer insulin for R101. V5/RN withdrew 2 units of insulin from an opened, undated insulin bottle and administered it to R101 in the left arm. At that time, V5/RN verified the opened, undated insulin and stated she didn't know what date the insulin bottle was first accessed.On 8/27/25 at 8:34 A.M, V2/Director of Nurses stated the facility policy was to date insulin bottles when first accessed for a period of 28 days. At which time the remaining insulin should be disposed of.

Based on interview and record review the facility failed to maintain an accurate medical record by documenting physician- ordered blood glucose testing for one of four residents (R101), reviewed for blood glucose monitoring, in a sample of 40.FINDINGS INCLUDE:R101's current Physician Order Sheet, dated August 2025 includes the following medications: Insulin Lispro 100 Unit/ML inject as per sliding scale, from blood glucose monitoring before each meal for Diabetes Mellitus.On 8/25/25 a review of R101's current Medication Administration Record, dated August 1- August 25, 2025, documents facility staff failed to document R101's fingerstick blood glucose result on August 6, 8, 10, 15, 17, 20, 21, 22, 23 and 24, 2025.On 8/27/2025 at 8:40 A.M., V2/Director of Nurses confirmed R101's current physician order for fingerstick blood glucose monitoring twice daily. At that time, V2 stated staff were to perform the testing and record the results in R101's medical record, for R101's physician to monitor R101's blood sugar levels.

Based on observation, interview and record review facility staff failed to disinfect a shared blood glucose monitoring machine after use for two of two residents (R8 and R103) reviewed for blood glucose monitoring, in a sample of 40. FINDINGS INCLUDE:The facility policy, Glucometer Cleaning Policy and Procedure, dated 6/5/25 directs staff, This procedure should be done as needed, but is expected to be performed after each use of the equipment. Open (disinfectant) packet, removed pre-moistened towelette, wipe desired surface to be disinfected, allow a 5-minute dry time.R8's current Physician Order Sheet, dated August 2025 includes the following physician's orders: Blood Glucose Monitoring three times daily.R103's current Physician Order Sheet, dated August 2025 includes the following physician's orders: Blood Glucose Monitoring three times daily.On 8/25/2025 at 11:52 A.M., V4\/Licensed Practical Nurse (LPN) performed a blood glucose finger stick on R8. After V4/LPN completed the finger stick blood glucose testing, V4 cleansed the glucometer with an alcohol pad and immediately placed the machine in the top drawer of the medication cart.On 8/25/2025 at 11:59 A.M., V4\/Licensed Practical Nurse (LPN) performed a blood glucose finger stick on R103 utilizing the same glucometer that was used to conduct R8's blood glucose testing. After V4/LPN completed the finger stick blood glucose testing, V4 cleansed the glucometer with an alcohol pad and immediately placed the machine in the top drawer of the medication cart.On 8/27/2025 at 11:34 A.M., V2/Director of Nurses confirmed that the facility shared glucometer machines were to be disinfected with a disinfecting wipe after each use, not an alcohol wipe.

Based on interview, observation, and record review, the facility failed to provide physician ordered treatments to one of one resident (R108) reviewed for skin conditions in the sample of 40. Findings include: On 8/25/25 at 10:41 AM, R108 had multiple round, red, raised, and flaky areas scattered throughout his bilateral upper and lower extremities. R108 stated the areas are psoriasis and eczema. R108 also stated the areas have gotten worse recently. R108's care plan, dated 8/14/25, documents R108 has psoriasis on his body and interventions to apply Nystatin powder to abdominal folds as ordered and triamcinolone as ordered. R108's physician's order, dated 8/26/25, documents R108 has the following orders: triamcinolone acetonide external cream 0.1 % apply to R108's affected area topically two times a day every Monday, Tuesday, Wednesday, Thursday, Friday for diagnosis of psoriasis ordered 8/22/25; antifungal powder apply to R108's abdominal fold topically three times a day for excoriation ordered 7/5/23. R108's MAR (Medication Administration Record), dated August 2025 documents as of 8/26/25 R108's triamcinolone cream has not been administered since being ordered on 8/22/25. The MAR also has no documentation of R108 receiving R108's physician ordered antifungal powder 50 out of 73 scheduled opportunities. On 8/27/25 at 10:42 AM, V9 (Registered Nurse) confirmed the blank areas on R108's MAR indicates R108's triamcinolone cream and antifungal powder were not administered as ordered. On 08/27/2025 at 1:13 PM, V2 (Director of Nursing) verified R108's triamcinolone cream and antifungal powder not documented on the MAR indicate they were not given as ordered.

Based on interview and record review, the facility failed to protect a resident from physical abuse for one of four residents (R2) reviewed for abuse in a sample of 11. Findings include: The Abuse Prevention Program Facility Policy, revised 12/18/24, documents that the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This form also documents that abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Instances of abuse of all residents, irrespective of a mental or physical condition, cause physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behaviors through corporal punishment. R2's Progress Notes, dated 8/6/25, documents that R2 was involved in a physical altercation with a peer. Peer (R10) pushed resident (R2). (R2) fell to the floor, landing on his left side. R2's Brief Interview for Mental Status, dated 6/3/25 documents a score of 3, indicating that R2 is cognitively impaired. R2's current care plan documents that R2 displays poor planning, poor insight, judgment, and decision-making ability, poor stress and emotion management, and poor impulse control. This form also documents that R2 has reactionary responses to situations. R2 reacts impulsively and without thought. R10's Progress Notes, dated 8/6/25, documents that R10 was involved in a physical altercation with a peer (R2). (R10) pushed (R2), causing him to fall and land on his left side. R10's Brief Interview for Mental Status, dated 6/9/25, documents a score of 15, indicating that R10 is alert and oriented to person, place, and time. R10's current care plan documents that R10 has issues with regulating emotions and outbursts. R10 can become verbally and physically aggressive. R10 will initiate the conflict but will take responsibility for her own behavior. R10's goal is not to harm self or others by the next review date and to seek out staff when agitated. On 8/22/25 at 11:30am, R10 stated that R2 was attempting to cut in front of her in line, so she pushed him away, and he fell. R10 became agitated and started to yell out and curse during the interview. On 8/22/25 at 10:30am, V1, Administrator, verified that V18, Registered Nurse, did not notify him of the incident, so there were no interventions implemented. V1 also verified that an investigation was not started until today when notified of the incident.

Based on interview and record review, the facility failed to report resident-to-resident physical abuse to the State Agency for one (R2) of four residents reviewed for abuse in a sample of 11. Findings include: The facility's Abuse Prevention Program Facility Policy, dated 8/12/25, documents that employees are required to report any incident allegation or suspicion of potential abuse, neglect, exploitation, mistreatment misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence. This form also documents that when an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. R2's Progress Notes, dated 8/6/25, documents that R2 was involved in a physical altercation with a peer. Peer (R10) pushed resident (R2). (R2) fell to the floor, landing on his left side. R10's Progress Notes, dated 8/6/25, documents that R10 was involved in a physical altercation with a peer (R2). (R10) pushed (R2), causing him to fall and land on his left side. On 8/22/25 at 10:30am, V1, Administrator, verified that he was not notified of this incident, so no investigation or reporting was done.

Based on interview and record review, the facility failed to investigate resident-to-resident physical abuse for one of four residents (R2) reviewed for abuse in a sample of 11. Findings include: The facility's Abuse Prevention Program Facility Policy, dated 8/12/25, documents that upon learning of the report of an allegation of abuse, the administrator or designee shall initiate an incident investigation. R2's Progress Notes, dated 8/6/25, documents that R2 was involved in a physical altercation with a peer. Peer (R10) pushed resident (R2). (R2) fell to the floor, landing on his left side. R10's Progress Notes, dated 8/6/25, documents that R10 was involved in a physical altercation with a peer (R2). (R10) pushed (R2), causing him to fall and land on his left side. On 8/22/25 at 10:30am, V1, Administrator, verified that he was not notified of this incident, so no investigation or reporting was done. V1 stated that any allegation or incident to supposed to be reported to him or V9 as soon as it happens. V1 also stated that an investigation is initiated immediately, even on weekends or after hours.

Based on record review and interview, the facility failed to protect a resident from physical abuse for two of four (R1 and R3) residents reviewed for abuse in a sample of four. This failure resulted in R1 sustaining a complex fracture of the left hip requiring surgical intervention. Findings include:The facility's Abuse Prevention Program, reviewed 7/21/25, documents that abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This form also documents that willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention.R1's electronic medical record documents the following diagnoses: Schizophrenia, Major Depression, Dementia, EPS, HTN, Thrombocytopenia, GERD, Hypercholesterolemia, BPH, Dysfunction of the bladder, chronic kidney disease stage four. R1's current care plan documents that R1 is delusional daily. He also experiences auditory hallucinations to which he responds. Often, he becomes agitated at the voices and will yell and curse.R1's Brief Interview for Mental Status, dated 5/5/24, documents a score of 14, indicating the R1 is alert and oriented to person, place, and time.R1's Progress Notes, dated 7/22/25, document that resident (R1) was involved in an altercation with a peer (R2) while outside on the smoking patio. (R1) was lying on the patio, stating his hip hurt. (R1) was lying on his left side near his wheelchair on the pavement of the smoking patio. (R1) stated that his right hip hurt; however, he was lying on his left side. (R1) stated that he was unable to stand up due to the pain. Orders were received to send (R1) to the emergency room for an evaluation.R1's emergency room Notes, dated 7/22/25, document that R1 presented after a ground-level fall when one of the residents of his nursing home pushed him out of his wheelchair and he fell to the ground on his left side, leading to a complex left hip fracture. The Patient states that he does not want to return to the SNF (skilled nursing facility) because of the other residents. R1's Radiology Report, dated 7/22/25, documents a complex fracture of the left hip including both intertrochanteric and suspected basicervical components. Femoral foreshortening and coxa vera deformity at the left hip. R2's electronic medical record documents the following diagnoses: Encephalopathy, Diverticulosis, Mood Disorder, Paraphilia, Seizures, Heart Disease, Chronic Embolism and Thrombosis, Toxic effect of alcohol abuse, and Obsessive Compulsive Disorder.R2's current care plan documents that R2 has a behavior problem: (R2 has a history of socially inappropriate behaviors. (R2) can be verbally and physically aggressive, intrusive, and property destruction. (R2) displays a delusional thought process as to his limitations and effects on self, others, and surroundings, as well as the safety of self and others.R2's Progress Notes, dated 7/22/25, document that R2 had an incident with a peer (R1) this morning. (R2) stated that the peer (R1) was Saying stuff that pissed me off and that's all I'm going to say.On 7/25/25 at 10:45am, R4 stated that R1 and R2 were bickering back and forth on the patio. R4 stated that all of a sudden, R2 got up and dumped R1 out of the wheelchair onto the concrete.On 7/25/25 at 11:00am, R3 stated that R1 was sitting in his wheelchair with his back to the wall, confused and yelling out. R3 also stated that R2 was sitting with his back to R1, yelling back at R1. R3 stated that R2 got tired of listening to R1, so R2 got up, pushed R1's wheelchair in front of the patio door, and tipped him out of the wheelchair. R3 stated that he got between R1 and R2. R3 stated that he got punched in the face during the altercation. R3 verified that R1 was yelling in pain and could not get up.On 7/25/25 at 1:00pm, V3, Administrative Quality Assurance/Grievance/Abuse Coordinator, stated that the majority of the resident population has a traumatic brain injury, so they are impulsive. V3 stated that this incident was an impulse, not abuse.

Based on interview and record review, the facility failed to notify local law enforcement of a resident-to-resident physical altercation resulting in an injury, for one of two residents (R1) reviewed for reporting abuse in a sample of four. The facility's Abuse Prevention Program Facility Procedures, reviewed 7/21/25, documents that the facility shall contact local law enforcement authorities (i.e., non-emergency police number or 911) in the following situations: Physical abuse involving physical injury inflicted on a resident by another resident, except in situations where the behavior is associated with dementia or developmental disability.R1's Progress Notes, dated 7/22/25, document that resident (R1) was involved in an altercation with a peer (R2) while outside on the smoking patio. (R1) was lying on the patio, stating his hip hurt. (R1) was lying on his left side near his wheelchair on the pavement of the smoking patio. (R1) stated that his right hip hurt; however, he was lying on his left side. (R1) stated that he was unable to stand up due to the pain. Orders were received to send (R1) to the emergency room for an evaluation. R1's Radiology Report, dated 7/22/25, documents a complex fracture of the left hip including both intertrochanteric and suspected basicervical components. Femoral foreshortening and coxa vera deformity at the left hip.R2's Progress Notes, dated 7/22/25, documents that R2 had an incident with a peer (R1) this morning. (R2) stated that the peer (R1) was Saying stuff that pissed me off and that's all I'm going to say. On 7/25/25 at 1:00pm, V3, Administrative Quality Assurance/Grievance/Abuse Coordinator stated that the local police were not notified of the incident between R1 and R2.

Based on interview and record review, the facility failed to prevent resident-to-resident physical and sexual abuse and failed to implement abuse risk assessment and care plans for four of four residents (R1-R4) reviewed for abuse in a sample of four. This failure resulted in R1 sustaining a left femoral neck fracture, requiring surgical intervention. Findings include: The Abuse Prevention Program Facility Policy, revised 12/18/24, documents that the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This form also documents that abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Instances of abuse of all residents, irrespective of a mental or physical condition, cause physical harm, pain, or mental anguish. This form documents that physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behaviors through corporal punishment. Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Resident Assessment: as part of the resident social history evaluation and MDS (Minimum Data Set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or misappropriation of resident property, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches that would reduce the chances of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. 1. R1's electronic medical record documents the following diagnosis: Schizophrenia, Dementia, Mood Disorder, Dyskinesia, Hypertension, and Seizures. R1's Mini Interview for Mental Status, dated 5/16/25, documents a score of 3, indicating that R1 is severely cognitively impaired. R1's Progress Notes, dated 7/15/25, documents that R1 was involved in a physical altercation with a peer (R2) while in the dining room during breakfast. During this altercation, (R1) fell to the floor and stated his right leg hurt and that he was unable to stand up. This form documents that orders were received to send R1 to the emergency room for an evaluation. R1's current care plan documents, (R1) may be belligerent at times and difficult to redirect. (R1) may walk into staff offices and take drinks, snacks, and money from desks or may take drinks and snacks from peers at times, (R1) also may take items from peers' trays. (R1's) intervention documents to anticipate (R1's) needs: food, thirst, toileting needs, comfort level, body positioning, and pain. R1's care plan also documents that R1 has memory impairments and displays poor impulse control, poor insight and judgment, poor decision making, which caused him serious difficulty interacting with others. R2's current electronic medical record documents the following diagnosis: Intracranial Injury, Facial Weakness following a Cerebral Infarct. Insomnia, Major Depression, Thrombosis, and Hyperlipidemia. R2's Progress Notes, dated 7/15/25, documents that R2 was involved in a physical altercation with a peer while at breakfast in the dining room. (R2) was not injured during this altercation, however, the other peer (R1) was injured; therefore, the Police were called and responded to the facility. R2's current care plan documents that R2 displays impulsivity, verbally/physically aggressive behaviors, false allegations, refuses meds, and feels that he does not need them. (R2) displays poor planning, poor insight, judgment, and decision-making ability, poor stress and emotion management, poor coping skills, and impulsivity. (R2) is very reactive to his surroundings. (R2) holds fast to/fixates on perceptions. (R2) is not easily redirected. (R2) feels his behaviors are appropriate/acceptable for any setting. The facility's Incident Description, dated 7/15/25 at 8:45am, that R1 attempted to take R2's oatmeal off his tray. R2 pushed R1 away from the table, R1 lost his balance, and ended up falling. R2's signed statement, dated 7/15/25, documents I (R2) pushed (R1) because he took my oatmeal. I am sorry I pushed him. I didn't push him hard, he just lost his balance. V5, Certified Nursing Assistant's, signed statement, dated 7/15/25, documents that (R1) took his breakfast tray to the trash, turned around, and grabbed (R2's) oatmeal off his tray. (R2) shoved (R1) to the floor. Staff immediately intervened. R1's emergency room Note, dated 7/15,25, documents R1 presented for left hip pain after a fall. (R1) was reportedly assaulted at the SNF (skilled nursing facility), and pushed to the ground by another resident over what each individual had for breakfast. R1's X-Ray of the left femur, dated 7/15/25, documents a transcervical femoral neck fracture with a 1-centimeter superior dislocation without significant angulation. (R1) was admitted to the Orthopedic surgical unit. On 7/19/25 at 11:00am, R2 stated that he was eating breakfast in the dining room when R1 grabbed his oatmeal. R2 stated that he attempted to grab his oatmeal back and pushed R1's hands away. That is when he lost his balance and fell. On 7/19/25 at 2:00pm, V4, Hospital Liaison, stated that R1 was admitted to the hospital with a fractured left hip, requiring surgical intervention. V4 stated that R1 has exhibited a decline in condition since being at the hospital. V4 stated that R1 was ambulatory before the fall. V4 stated that R1 will not stand and requires a mechanical lift for transfers. V4 verified that R1 will require several weeks of physical therapy. 2. R3's electronic medical record includes the following diagnosis: Intracranial Injury, Anxiety, Psychophysiological Insomnia, Traumatic Brain Injury, Antisocial Personality, Bipolar with Manic Severe, with Psychotic Features, Explosive Disorder and Cognitive Disorder. R3's Brief Interview for Mental Status, dated 3/17/25, documents a score of 3, indicating that R3 is severely cognitively impaired. R3's current care plan documents that R3 displays socially/sexually inappropriate behaviors; inappropriate comments, attention seeking, child-like behaviors at times. R3's Progress Notes, dated 7/17/25 at 4:05pm, documents that R3 had his hand in the back of another resident's pants. This incident was only no longer than a few seconds according to the CNA (V6/Certified Nursing Assistant) that reported the incident. The facility's Incident Description, dated 7/17/25, documents that (R3) was at roommates (R4) bedside with what looked like inappropriate touching. Staff intervened and R3 was redirected away from R4. The incident lasted a couple of seconds. Environmental interventions was done with a room move. R3 was moved off of C wing to the end of E wing. R3 and R4 were placed on 15-minute checks. V6's Certified Nursing Assistant, signed statement, dated 7/17/25, documents that (R3) was holding the hand of (R4), which I didn't find suspicious, then I went to see what (another resident) needed in his room, and when I came out of the room, I looked back in (R4's) room and saw (R3) with his hand down the (incontinent brief) of (R4). On 7/19/25 at 4:50pm, V6 verified that he checked R3 and R4 before assisting another resident. V6 stated that when he was walking back down the hall he looked into R3 and R4's room. V6 saw R3 with his hand down the back of R4's brief. V6 stated that he separated R3 and R4, then reported the incident. V6 verified that R3 was moved to another unit immediately. R1-R4's medical records did not contain abuse risk assessments or abuse risk care plans. On 7/21/25 at 10:30am, V1 verified that abuse risk assessments were not done as the policy documents, because of the population. V1 verified that the incidents between R1-R4 did happen.

Based on interview and record review the facility failed to protect a resident (R1) from mental and verbal abuse and failed to protect residents from further potential abuse. This failure resulted in residents experiencing emotional distress and persistent fear of V3 (Certified Nursing Assistant). This failure has the potential to affect all 102 residents who reside in the facility. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/19/25 at approximately 5:00 pm, when V3 (Certified Nursing Assistant/CNA) responded inappropriately to R1. V3 taunted R1 by sticking her tongue out at R1; calling R1's significant other ugly; and asking if R1 was going to fight V3. R1 experienced emotional distress and fear of V3. V3's termination was rescinded and V3 returned to work in the facility, leaving residents fearful. While the immediacy was removed on 4/24/25, the facility remains out of compliance at Severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings include: The Facility Abuse Prevention Program Facility Policy, reviewed 12/18/24, documents: the Facility affirms the right to our Residents to be free from abuse and neglect; prohibits mistreatment, neglect or abuse of its Residents, and has attempted to establish a Resident sensitive and secure environment; purpose of this policy is to assure that the Facility is doing all this within its control to prevent occurrences of mistreatment, neglect or abuse of our Residents; by orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreatment, neglect and abuse; establishing an environment that promotes Resident sensitivity, security and prevention of mistreatment; identifying occurrences and patterns of potential mistreatment promptly and aggressively and making the necessary changes to prevent future occurrences; committed to protecting our Residents from Abuse by anyone including, but not limited to Facility staff, other Residents and staff from other Agencies, or any other individuals; this Facility will not knowingly employ individuals who have been convicted of abusing, neglecting or mistreating individuals; the following are based on Federal and State Regulations and interpretive guidelines; verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to Residents, within their hearing distance, regardless of their age, ability to comprehend, or disability; example of verbal abuse include, but no limited to, threats of harm or saying things to frighten a Resident; and mistreatment means inappropriate treatment. The Facility Resident Rights for People in Long-Term Care Facilities, revised 3/2011, documents: Your Facility must provide services to keep your physical and mental health and sense of satisfaction and you must not be abused by anyone, physically, verbally or mentally. The Facility Diffusing Behaviors Policy, undated, documents: do not raise voice; do not argue, scold or threaten; do not treat patients like they are your children, do not be condescending; do not talk about patients in his/her presence; and do not take it personally and get upset; do remain calm; do intervene early; do not try to reason with someone who is unreasonable; and do take time to listen. The facility's current Room Roster documents 102 residents currently reside in the facility. The Facility's local Report to the State Agency, dated 3/25/25, documents an Abuse incident on 3/19/25 between R1 and V3 (CNA). The Final Report documents an event that occurred in the Main Dining Room. R1 and V5 (Registered Nurse/RN) were discussing R1's request for a wheelchair to assist temporarily with mobility issues, when V3 (CNA) interrupted the conversation to comment that (R1) was not having any kind of difficulties with mobility earlier when your new girlfriend was visiting, then R1 told V3 to shut up, and called V3 a bitch. R1 stated, I am not talking to you (V3). V3 proceeded to tell R1 your girlfriend is ugly. R1 got upset and V3 remained argumentative and confrontational, raising both arms into fists, saying What are you going to do about it? Fight me? The Facility's local Report to the State Agency, dated 3/25/25, documents an interview with R1. R1 stated that while R1 was at the Nurse's Station, R1 was talking to V5 (Registered Nurse) and V3 (CNA) stated to me by the way, your girlfriend is ugly. So R1 stated, no she is not. R1 also stated, I also could have said more to her, but I do not recall. Then R1 stated that (V3) started to stick her tongue out and stated, I am going to take away your visitor pass and V3 was making threatening gestures. R1's Information Report, dated 3/21/25 at 1:45 pm, documents that V3 (CNA) told R1, Your girlfriend is ugly. R1 stated, Look, she is not ugly, she is beautiful. V3 then stuck her tongue out at (R1) three times. V1's (Administrator/ADM) Information Report, undated, documents that it was difficult getting V3 to write a statement regarding the incident with R1. V1 documents that V3 was very confrontational and aggressive. The Information Report also documents that V3 was fixated on wanting to know what was being done to (R1) personally and how (R1) was going to be punished for cussing at (V3). V1 attempted to explain to V3 that the Facility does not punish Residents and that the Resident population in the Facility has mental illnesses or brain injuries and consequently may have behaviors. V3 remained argumentative with minimal insight. V3's (CNA) Information Report, dated 3/19/25, documents that R5 was helping R1 walk, and V3 stated that V3 jokingly said to R5, Why are you holding her arm? She can walk. R1 told V3 to shut up. V3 then stated to R1, I was not even talking to you, why are you even talking to me? R1 told V3 because I can. V3 stated, that is when I said 'girl' by the way, yo (your) girlfriend ugly. V5's (Registered Nurse/RN) Informational Report, undated, documents that R1 was talking to V5 about obtaining a wheelchair. V5 stated (V3) 'chimed' in and responded to R1. R1 responded to V3 stating you are not my nurse or CNA so shut up. V5 then proceeded to ask R1 to calm down and go back to R1's hall. Then V3 proceeded to call (R1's) girlfriend ugly. R1 then called V3 a b*tch. V3 then responded to R1 fight me, fight me. V5 states that the staff grabbed (R1) and (V3) and proceeded to tell them to let her (R1) go. R1 went down the hallway. V5 stated that V3 was inappropriate and R1 told V5 that R1 felt disrespected and that R1 is afraid of (V3) when (V3) works down (R1's) hallway. V6's (Registered Nurse/RN) Informational Report, undated, documents that V3's response to R1 was over-the-top and inappropriate. R1 wanted to sit in a wheelchair because R1's foot hurt. V3 stated, you was not hurting earlier. R1 told V3 to shut the f*** up b****, I was not talking to you. V6 states that R1 was tired of being interrupted by (V3). V3 then told R1 well, your girlfriend is ugly. V6 stated that V3 would not stop and kept saying what (are) you gonna do about it? and like (V3) was trying to get (R1) to fight. V6 stated that V3's behavior was inappropriate and unprofessional. V7's (Registered Nurse/RN) Informational Report, undated, documents that V3 is confrontational, demeaning to the Residents and just talks down to them. V7 also stated that V3 acts like she does not provoke them (Residents) on purpose. V8's (Licensed Practical Nurse/LPN) Informational Report, undated, documents that V8 reports that V3 is borderline rude and not appropriate with Residents. V8 also reports that V3 is often confrontational with residents and talks down to them. V10's (Certified Nursing Assistant/CNA) Informational Report, undated, documents that V3 was grossly inappropriate and unprofessional. V10 also states that V3 presents as confrontational and argumentative with Residents. The Facility Nursing 24 Hour Staffing Reports (dated 4/1/25, 4/2/25, 4/3/25, 4/5/25, 4/6/25, 4/9/25, 4/10/25, 4/14/25, 4/15/25, 4/17/25, 4/19/25 and 4/20/25) document V3 (CNA) working Second Shift on the B Hall, C Hall, E Hall and Kitchen Window. V3's (CNA) Timecard Report, dated 3/20/25 through 4/22/25, documents that V3 worked a total of 119.65 hours (3/27/25, 3/28/25, 3/31/25, 4/1/25, /4/2/25, 4/3/25, 4/5/25, 4/6/25, 4/8/25, 4/9/25, 4/10/25, 4/14/25, 4/15/25, 4/17/25, 4/19/25 and 4/20/25). V3's (CNA) Employee Report, dated 3/19/25, documents V3's misconduct. The Employee Report documents that V3 was grossly inappropriate with a Resident offering unprofessional personal observations on a Resident's relationship. The Employee Report also documents that V3 presented as confrontational and argumentative with a Resident and that further issues will result in termination, as behavior will not be tolerated. V3's (CNA) Employee Report, dated 3/20/25, documents a suspension pending an investigation of possible verbal abuse and inappropriate dialogue with a Resident. V1's (ADM) letter to V11 (Union President), dated 3/28/25, documents that the Facility found that V3 (CNA) was found to have displayed actions and/or conduct that is not in keeping with the Facility Employee Guidelines and/or State and Federal Regulations. The letter documents that V3 was grossly inappropriate with a Resident (R1) during an unprovoked verbal interaction and that V3's demeanor was confrontational, threatening and unprofessional. Furthermore, the letter also documents that V3's exchange was borderline blatant emotional and verbal abuse. V1 advised V11 that, after much deliberation, V3's termination was modified to a suspension. On 4/19/25 at 10:30 am, R1 stated, (V3) was not joking with me, at all that day. (V3) says she is joking, but I never feel like she is joking. (V3) is always derogatory, insulting and threatening towards me and knows how to push my buttons. She knows that things bother me and continues to just poke and poke at me. My girlfriend had come down from Chicago to visit me earlier that day and I was walking fine at that time. Then around dinner time, (R5) was helping me walk to talk to V5 (Registered Nurse) at the Nurse's Station, and I was asking for a wheelchair because my legs had started hurting. I was not even talking to (V3) and (V3) just walked up and interrupted my conversation with (V5). I told (V3) to shut up, I was not even talking to (V3), and it was none of (V3's) business. Then (V3) told (V5) not to help me walk and that (V3) thought I did not need a wheelchair or any help because (V3) saw me walking earlier in the day with my girlfriend and (V3) told (V5) that I was walking just fine then. Then I got mad at (V3) and called (V3) a b*tch. (V3) put her fists up at me and asked me if I wanted to fight her and (V3) called my girlfriend ugly. I told (V3) that my girlfriend is not ugly, she is beautiful. Then (V3) stuck her tongue out at me and she did that like three times. (V3) causes so many problems for everyone here, I am scared of her. I walked back to my room to avoid her, but I was scared walking back down the hallway by myself, like (V3) was going to come after me. It is not right for (V3) to work in a place like this. (V3) is still rude to me and I feel like (V3) keeps bullying me and antagonizes me on purpose. (V3) constantly demeans me and harasses me, even when I am minding my own business. I have seen (V3) do this bullying and intimidation to so many people that are here and (V3) even does it to the employees. We all see it and it is very uncomfortable. I am scared to even be around her, it makes me nervous, so a lot of times I just have to go to a different area to be away from her. I think people are scared to say anything, I know that I am scared. On 4/19/25 at 7:59 am, R2 stated, I have had run-ins with (V3). (V3) has an attitude with me. We all think she is mean and are scared of her. (V3) is aggressive and hateful. I think (V3) does and says things on purpose to hurt people. (V3) is just not a nice person to anyone. (V3) works second shift, and usually works the kitchen window with serving food. When we are in the Dining Room, (V3) says mean things to all the residents. On 4/19/25 at 8:13 am, R3 stated, Oh, (V3) is not known as a nice person. What's sad is, I think (V3) is a good CNA. (V3) acts like (V3) is kidding with me, but I know that (V3) really is not. I never say anything because I really do not want to deal with it, so I just keep it to myself. I am just glad that (V3) really does not need to help me much, because it makes me nervous and uncomfortable when (V3) is around. On 4/19/25 at 10:45 am, R4 (Resident Council President) stated, (V3) is known to talk to people very harsh and people complain about it, but not everyone tells on (V3) because they are scared of (V3). On 4/19/25 at 10:45 am, V5 (Registered Nurse) stated, I was the nurse on duty the night that (R1) and (V3) got into it. (R1) walked up to me at the Nurses' Station in the Dining Room area and (R5) was holding on to (R1's) arm to help because (R1) wanted a wheelchair. (V3) just walked up to the Nurses' Station and interrupted our conversation and told me that (R1) did not even need a wheelchair. (R1) told (V3) to shut up and leave (R1) alone and that it was not any of (V3's) business. (R1) cursed at (V3) and (V3) put up (V3's) fists towards (R1) and asked (R1) to fight. (V3) also stuck out (V3's) tongue a couple times at (R1). (V3) is very rude and evil to people. I have been scared to walk out to my car by myself at night after Second Shift because of her. I am not gonna lie, (V3) is getting by with everything and (V3) tells everyone that (V3) is part of the Union, and they cannot do anything to (V3). On 4/22/25 at 8:17 am, V9 (Ombudsman) stated, I am aware of verbal situations with (V3/CNA). (V3) is a Second Shift CNA and let me tell you, (V3) is something else. I have heard from Residents that (V3) is very rude and they have even voiced concerns to me. It does also happen during the mealtimes too, when other Residents are around. (V3) has a nasty attitude, not only with Residents but also to staff, and the Residents are witnessing that. I do know that (V3) got suspended for talking to a Resident (R1) in an abusive manner. Even though these residents here in this Facility have a lot of psychological diagnoses and brain injuries, some are still very well with it. The way that (V3) talks to the residents, is still a form of abuse and (V3) should not be talking to them in that manner, and we know that is not right. On 4/19/25 at 1:01 pm, V3 (CNA) stated, (R5) was helping (R1) and was holding (R1's) hand; they were up at the Nurses' Station. I heard (R1) ask (V5/RN) for a wheelchair because (R1) said that (R1's) legs were weak, and I said 'that is funny you were just walking fine earlier today when your girlfriend was here. I did not think that she needed a wheelchair and said, you do not even need a wheelchair. (R1) then said to me 'b*tch shut up.' (R1) was cursing at me and telling me to shut up. So, I told (R1) that (R1's) girlfriend was ugly and just stuck my tongue out at (R1) to mess with (R1), because we are all like family and we all just joke around. I was kidding with (R1) that we were gonna fight. I do not even help or talk to half of them Residents anyway because I am on the other side of the building. I just stay in the break room and mind my own business. The only time I see the other residents is when I am in the Dining Room working the serving window. I think they have me mistaken with someone else, I never am rude to them. I ended up getting fired but then I grieved that and ended up getting suspended instead for that incident with (R1) about the wheelchair and had to do some additional training. On 4/22/25 at 11:58 am, V11 (Certified Nursing Assistant Union President) stated, I am aware of the incident with a Resident in the Facility (R1) and (V3). (V3) was discharged and then employment was re-instated. I cannot really get into it much because there is a Union Grievance, and it is going to Arbitration. We do expect our Union employees to follow the Federal and State Regulations for Nursing Homes for Abuse. I do not condone Verbal or Mental Abuse. On 4/22/25 at 9:10 am, V4 (Abuse Coordinator/Assistant Administrator/Quality Assurance) stated, I am the Abuse Coordinator. We became aware of (V3's) interaction with (R1) and completed a full investigation. (V3) is part of a Union, and we terminated (V3) over the incident, but then the Union became involved, so we had to just suspend (V3) and bring (V3) back to work, under the guidance of our attorney and the Union. We became aware of (V3's) demeanor and behaviors with the Residents and staff, but we had no choice but to bring (V3) back. We have put safety measures in place to monitor (V3's) behaviors because (V3) is very intimidating and insulting. On 4/19/25 at 8:52 am, V1 (Administrator) stated, I reported and investigated the allegation between (R1) and (V3). I actually terminated (V3) over it but (V3) is a Union employee and the Union made me reinstate (V3) after a five-day suspension. We had to backpay (V3) also. They contributed it to cultural interpretation according to the Union. Basically, staff reported to me that (V3) interrupted a conversation between (R1) and (V5) and was antagonizing (R1), told (R1) that (R1's) girlfriend is ugly and raised (V3's) fists at (R1) and wanting to fight, apparently (V3) states it was a joke. I told (V3) we do not joke like that. I had multiple staff and Residents that witness (V3's) aggressiveness and inappropriate language with the Residents. There are staff that are actually scared of (V3) too. After this incident, we started reviewing the camera footage and have a monitor on (V3's) shift. When I was investigating the incident, (V3) was more upset that (R1) cursed at (V3) than anything and wanted me to reprimand (R1). I tried to explain to (V3) that our Residents have mental issues, and we need to learn to de-escalate and not provoke behaviors, and to be patient with them. On 4/24/25 at 1:00 pm, V4 (Abuse Coordinator/Assistant Administrator/Quality Assurance) stated, (V1/ADM) is in firing (V3) right now and I can hear (V3) yelling through the door. V1 (Administrator/ADM) was notified of the Immediate Jeopardy on 4/24/25 at 8:50 am. On 4/23/25, the surveyor confirmed through interview, observation, and record review, the facility took the following actions to remove the Immediate Jeopardy: 1. V3 completed Abuse training and Behavior De-escalation training on 4/9/25 and was monitored continuously on Second Shift. 2. V3 was immediately terminated on 4/24/25 by V1 (ADM) and V2 (Director of Nursing/DON). 3. On 4/22/25, V1 (ADM), V2 (DON) and V4 (Abuse Coordinator) completed an entire whole house audit to evaluate Facility Residents at risk for potential abuse and no evidence was noted. 4. On 4/22/25, an all-Staff in-service by V1 (ADM) and V4 (Abuse Coordinator) was conducted on Resident Abuse and Reporting. A tracking sheet was expected to be completed by close of business on 4/23/25. 5. A sign was placed by the Facility timeclock to ensure employees complete the Abuse training prior to work on floor and direct care with Residents. 6. A checklist was developed to ensure one-hundred percent compliance with the mandatory training for employees/staff that are on vacation and as needed basis (PRN). 7. A current employee list was audited and over seen on 4/22/25, by V1 (ADM), V2 (DON) and V3 (Abuse Coordinator) to evaluate potential staff requiring one-on-one review and said employees to have additional training on Abuse and Mandatory Behavioral De-escalation courses. 8. An Abuse training module through the Facility computer program was initiated in April 2025 with trainings on Abuse prevention, sensitivity and respect to be scheduled and implemented for part of the progressive disciplinary process. 9. V1 (ADM), V4 (Abuse Coordinator) and Department Heads to monitor for compliance. Completion Date: 4/24/25.

Based on observation, interview, and record review, the facility failed to ensure a resident (R2) was free from physical abuse by another resident (R1) for two of four residents reviewed for abuse in a sample of four. This failure resulted in R2 receiving sutures at the hospital for a facial laceration. Findings include: The facility's undated Abuse Prevention Program Facility Policy documents Policy: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. the purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This policy continues to state, This facility is committed to protecting our residents from abuse by anyone including, but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. This policy also states Definitions: The following definitions are based on federal and state laws, regulations and interpretive guidelines. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. R1's current Face sheet documents diagnoses including, but not limited to Psychotic disorder, Mood disorder, Unspecified Dementia, Anxiety, and Traumatic Brain Injury/TBI. R1's Minimum Data Set/MDS Assessment, dated 11/11/24, documents R1 has fluctuations of inattention and disorganized thinking and is severely cognitively impaired. R1's Care plan includes but is not limited to (R1) can become verbally and physically aggressive due to TBI (Traumatic Brain Injury) diagnosis. (R1) is delusional and feels he can care for himself. (R1) displays poor planning, poor insight judgment and decision-making ability, poor stress and emotion management, poor impulse control, and poor coping skills. R1's Progress note, dated 11-15-24, documents Resident was in altercation with peer (R2). This RN (Registered Nurse) did not witness altercation. Per report, resident swung right hand striking (R2) in the face. On 12/6/24, at 11:55am, R2 sat in the TV (television) area with a suture line noted to his left cheek. R2 did not recall being hit or having any altercation with another resident (R1). R2's current Face sheet documents diagnoses including, but not limited to Unspecified Dementia, Anxiety, and Schizoaffective disorder, depressive type. R2's Minimum Data Set/MDS Assessment, dated 9/30/24, documents R2 has fluctuations of inattention and disorganized thinking and is moderately cognitively impaired. R2's Care plan includes but is not limited to (R2) displays (episodes) of verbal aggression, physical aggression, and agitation related to being over stimulation and to misinterpretation of others and situations. He displays poor decision making and poor impulse control. R2's Progress note, dated 11-15-24 by V5 Registered Nurse/RN, documents Resident was involved in an altercation. Resident was in the TV area, him and another peer (R1). First, they started arguing. As another nurse and I went to intervene to separate them, the other resident (R1) stood up and swung before we could stop him (R1). Resident (R2) has a wound on the left side of the cheek. This nurse applied pressure to wound to stop bleeding and area was cleaned. The patient (R2) was sent to (named hospital) for further evaluation. R2's progress note, dated 11-15-24, documents Resident returned from (named hospital) around (6:35pm). Laceration repair L (left) side of face; stitches to be removed in 7-10 days. The facility's abuse reportables include an altercation between R1 and R2; witness included V4 Certified Nurse Assistant/CNA and V5 Registered Nurse/RN. The Final Report, dated 11-20-24, by V3 Abuse Coordinator, documents the following: Residents (R2 and R1) sitting in TV dining room area 11-15-24 at approximately 2:45pm watching television. Video (camera) was watched. (R2) made a lunge like movement from his chair toward (R1). (R1) stood up from his chair and struck (R2). (R2) sent to hospital with a laceration on the left side of face. (R1) had superficial scratch on right hand. On 12/6/24, at 11:46am, V4 CNA stated the following: (On 11/15/24) I was behind the desk, and I saw (R2) yell at the TV. Then (R1) yelled. (R1) stood up so I tried to calm (R1) down. (R1) started hitting (R2) so I moved (R1) away from (R2). R2's face was bleeding. V4 continued to state (R1) was intentional and knew who his target was. On 12/6/24, at 11:51am, V5 RN stated the following: (On 11/15/24) I remember those two (R1 and R2) were sitting beside each other .Yelling was going on by (R2). (R1) gets very agitated with loud noises, banging and yelling. (R1) doesn't like it close to him and gets agitated. (R1) yelled and then stopped. I walked away from nurses' station then it started again. Now (R1) was standing up, when (R1) stood up staff tried to intervene, but (R1) had hit (R2) before we reached them. (R1) hit (R2) on the left side of (R2's) face and it was bleeding. At this time V5 confirmed (R1's) strike was on purpose and stated, 'Oh, he hit him.' On 12/10/24, at 11:53am, V3 Abuse Coordinator stated that V3 reviewed the video camera to see what had happened. V3 stated on 11/15/24, R1 and R2 were in the TV area talking and next thing (R1) got up and hit (R2) in the face. V3 stated R1 and R2 are very impulsive and reactive. There is no pre-meditation. They have no impulse control. Never know when those things are going to happen. V3 confirmed it was not an accident.

Based on interview and record review, the facility failed to protect a vulnerable resident (R1) who is known to become agitated with loud noises and too much stimulation, from being a victim of resident-to-resident abuse on 4/7/2024 and 4/11/2024 and failed to maintain the intervention of 15-minute monitoring for (R1). These failures resulted in an Immediate Jeopardy starting 4/7/2024. While the Immediate Jeopardy was removed on 5/2/2024, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits Findings Include: The facility's Abuse Prevention Program Facility Policy, reviewed 11/10/2023, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents., R1's Diagnosis List, dated 3/26/2024 through 4/26/2024, documents the following diagnosis: Intracranial Injury, Anxiety Disorder, Traumatic Brain Injury, Mood Disorder, Dementia with other Behavioral Disturbances, Psychotic Disorder, Affective Disorder, R1's Care Plan, dated 2/16/2022, documents the following: R1 can become verbally and physically aggressive due to the diagnosis of Traumatic Brain Injury. R1 is delusional. R1 displays poor planning, poor insight, judgement, and poor decision-making ability. R1 has poor stress and emotion management, poor impulse control, and poor coping skills. R1's episodes are triggered by over stimulation. R1's triggers for physical aggression are loud repetitive noise, yelling out. R1 has cognitive impairments. R1's Interventions are as follows: To de-escalate R1 remove him to a quiet area to assess anxiety and calm. 15-minute checks, when R1 becomes agitated: intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive staff is to calmly walk away and approach later. R1 only tolerates 2 to 3 people at a time, he becomes agitated if too many people are talking all at once. Monitor/ report to physician as needed risk for harming others, increased anger, and feels threatened by others. R1's Nurses Notes, dated 4/7/2024 at 10:45AM, documents, It was reported to V6/LPN (Licensed Practical Nurse) that R1 was involved in a physical altercation with a female resident. It was stated that R1 had been arguing with a female peer, charged towards R2, and punched R2 in the face. R2 picked up a chair and hit R1 in the face. R1 has a laceration between his nose and the top of the lip. R1 was sent to the local emergency for evaluation of injury. Upon return to the facility R1 was placed on 15-minute checks. R1's Nurses Notes, dated 4/7/2024 at 2:09PM, documents, The local hospital called with update. R1 received stitches and R1 also has a nasal fracture. R1's Nurses Notes, dated 4/11/2024 at 1:30PM, documents, V5/CNA (Certified Nursing Assistant) reported to V4/RN (Registered Nurse) that R1's roommate/R3 attacked R1 while R1 was sleeping in R3's bed. R1 is confused per baseline. R1 has visible injuries noted. R1 was sent to local emergency room for evaluation. R1's Nurses Notes, dated 4/11/2024 at 3:39PM, documents, Visible injuries from resident altercation with R3 include marble size lump to forehead and left side of head. and has abrasions to top and lower back. On 4/25/2024 at 11:07AM V1/DON (Director of Nurses) stated, R1 is extremely impulsive, gets overstimulated easily. Doesn't do well in a noisy environment. I really do not know what happened in the dining room for sure. R1 cannot say. R1 has had a Traumatic Brain Injury and these types of people get anxious easily. V2/QA Nurse watched the video and did the investigation. V2 knows much more about it then I do as far as what happened. The 2nd altercation between R1 and R3 happened in their room. R1 was laying in R3's bed and would not get out of his bed. R3 ended up pulling him out of the bed and punching him in the face several times. R3 had a few scratches on him but no serious injuries. R1 was sent to the local emergency room because he sustained several bumps to his head and scratches. R1 has no control at times. He is stimulated very easily by loud noise or someone talking loudly. This is part of his Traumatic Brain Injury. On 4/25/2024 at 11:25AM V3/SSD (Social Service Director) stated, I followed up with R1 that Monday following the altercation with R2. R1 remembers absolutely nothing of the incident. When R1 gets over stimulated, or it gets loud for him he becomes agitated and begins to yell out loud. When R1 get's loud and starts to scream all the staff know that they need to intervene and get to R1 fast and try to calm him down so R1 doesn't start an altercation with a resident. All staff know that R1 gets over stimulated easily and they need to know where R1 is seating so they can get to him fast. He does not sit in the same table all the time. This is why I am glad that our office is right in front of the main dining room. We can see and hear almost every resident. We can hear R1 when he becomes loud and out of control. We go out and try to redirect R1 or take him to a calmer area. R2 was hit by R1 but did not sustain injury. R2 said, R1 was fighting with her and punched R2 in the face. R2 then said she can take care of herself, and she did by picking up the chair and hitting R1 in the face. R1 was in another altercation a few days later. R1 was sleeping in his roommate's bed, R3. R3 was not happy and was trying to get him out of his bed because he says R1 pees and poops in his bed. R3 pulled him off his bed and punched him in the head several times. R1 sustained several bumps to his head, and he was sent out to be evaluated. R3 ended up with a few scratches and was arrested for domestic battery. The police said, R3 was very aware of what he did to R1, and this is why he was arrested, cuffed, and taken to the station. R3 came back to the facility with a court date and was moved right away out of R1's room. On 4/25/2024 at 1:05PM V10/CNA (Certified Nursing Assistant) stated, I was coming in from the outside from my break and I heard loud voices and residents fighting. As I hurried up and ran around the corner of the dining room, I seen R1 and R2 close to the windows far from where I was at, they were standing up fist fighting. I could see R2 pick up a chair and swung it across R1's face hitting him in the face. I tried to get to them as fast as I could, but they were too far from me. There was no staff in the dining room at the time this happened. V7/Housekeeper and V8/Activity were running into the dining room about the time I was. They were able to immediately intervene and separate them. R1 was hurt and bleeding he was taken to V6/LPN for assessment. R1 had a cut on his face. On 4/25/2024 at 1:14PM V6/CNA (Certified Nursing Assistant) stated, I had just come out of the bathroom that is close to the main dining room and I heard a loud screech as if the chair was being picked up. I immediately ran around the corner and saw R1 and R2, they were fighting. R2 had a chair and swung it around and hit R1 in the face with the chair causing them both to fall to the floor. I could not get to them fast enough because they were far from where I was at. There was no staff member in the dining room at the time this happened. R2 will talk to herself very loudly and sometimes scream. It is a possibility that R1 was overstimulated by that noise and started fighting with R2. On 4/25/2024 at 3PM V2/QA (Quality Assurance Nurse) stated, I watched the video regarding the altercation between R1 and R2 and did the investigation. What I can see from the video is that there was no one in the dining room when these 2 residents started fighting. R1 is impulsive and has a tendency to become very anxious and agitated when it gets too noisy, or it seems too noisy for him. In the video it looked like they were arguing and R1 walked over to R2. They were sitting at adjacent tables. R2 has a big tendency to talk to herself loudly. R1 probably felt R2 was being loud and that set him off. During the argument R2 picked up a chair striking R1 in the face causing a laceration to his lip and a broken nose. R1 did reciprocate by punching R2 in the face but R2 did not sustain any injuries. R1 was on a 15 min check done by the Certified Nursing Assistant. R1 had another incident in his room with his roommate-R3. R1 was laying in R3's bed. R3 asked R1 several times to get out of his bed but would not get out, so R3 pulled R1 out of his bed and struck him in the head several times. R3 sustained a few scratches but nothing major. On 4/26/2024 at 10:30AM V4/RN (Registered Nurses) stated, V9/CNA (Certified Nursing Assistant) was walking down the hall and heard screaming and yelling coming from R1 and R3's room. V9 ran into the room to see what was going on and witnessed R3 on top of R1. R3 was beating R1 in the face with his fist. V9/CNA was able to pull them apart and let me know about the fight. R1 was in R3's bed and he wanted R1 out of his bed. No, I do not believe R1 was on a 15 minute check. A written statement from V7/Housekeeping, dated 4/7/2024, documents the following: V7 was at the security desk at the front of the building and heard commotion in the main dining room. V7 ran to the area where me and other staff members separated the residents. R1 was walked to V6/RN. R1 needed care he had a nosebleed, and his lower lip was bleeding. V1 (Director of Nurses) was notified of the Immediate Jeopardy on 5/1/2024 at 12:45PM. The surveyor confirmed through Interviews and Record Review, that the facility took the following actions to remove the Immediate Jeopardy. 1.) The facility has re-assessed R1 as being high risk for abuse and the assessment for R1 has been added to R1's Care plan. 2.) The facility has informed all staff that there is to be one staff member in the main dining room prior to serving meals when the residents are coming into the dining room. This will provide supervision to maintain a safe environment and prevent resident abuse for all residents. 3.) On 5/1/2024 the facility did an all staff in- service to educate all staff on R1's high risk for abuse from other residents. They also educated all staff on the potential behaviors inducing triggers and provided education to protect all residents from resident abuse. This surveyor was present during the in-service and was able to verify the content of in-service. 4.) The facility has started to develop a QA/QAA plan for increased monitoring of resident safety prior to the serving of resident meals. This was presented during the in-service on 5/1/2024.

Based on interview and record review, the facility failed to ensure two (R1 and R6) of four residents were free from abuse in a sample of eight. These failures resulted in R1 and R6 both going to the hospital after R1 was struck in the head, and R6 getting a bloody nose. Findings include: Facility Abuse Prevention Program Facility Policy, reviewed 9/26/23, documents This facility affirms the right of our residents to be free from abuse. Abuse means any physical or mental injury or sexual assault inflicted upon a resident. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. 1. Facility reported incident, dated 10/7/23 documents R1 and R2 got in a verbal altercation, yelling at one another, R2 swung at R1, and both began pulling each other's hair. Altercation lasted about 20-30 seconds. Facility interview with V6 Registered Nurse, dated 10/7/23, documents This nurse was at the nurses desk when screaming was heard. (R1 and R2) were yelling at each other, they were able to grab each other's hair before staff was able to break them up. (R2) sent to hospital per request. Facility interview with V5 security, undated, documents (R1 and R2) were just hanging out and all of a sudden it escalated. (R2) just lunged out of nowhere and got to hair pulling (R1). Facility interview with R1, dated 10/10/23, documents (R2) approached (R1) and told (R1) to stop talking about her. (R2) then struck her and pulled (R1's) hair. Facility interview with R4, dated 10/10/23, documents (R1 and R2) just had a cat fight that was over immediately. Facility interview with R5, dated 10/10/23, documents (R1 and R2) just got to fighting. On 10/31/23 at 12:50pm, R2 was alert, oriented, and ambulatory, and stated (R1) wouldn't stop getting in my business. (R1) and (R5) were talking to one another. (R3) told me they were talking about me. I hit (R1) on the side of her head twice and pulled her hair. I did not pull her hair out. This happened in the hallway by the front door. R2's medical record, dated 9/21/22, documents R2 is cognitively intact. R2's social service assessment, dated 9/28/23 documents easily triggered, verbal, and physical aggression. R2's 10/7/23 nurses notes document altercation with another peer. On 10/31/23 at 2:00pm, R1 was alert, oriented, and ambulatory, and stated We were in the hall, me and (R5), we were talking about (R8), and (R2) thought we were talking about her. (R2) punched me and pulled my hair. Security (V5) broke it up and I went to the hospital. R1's medical record, dated 8/22/23, documents R1 is cognitively intact. R1's social service assessment, dated 8/21/23 documents behavioral incidents this quarter, verbally and physically aggressive. R1's 10/7/23 nurses notes document physical altercation with another resident and sent to the hospital. R1's 10/7/23 census report documents hospital for payor status. R1's current careplan documents R1 has Issues regulating emotions and outbursts. On 10/31/23 at 11:15am, V6 RN stated I was working second shift on 10/7/23. I was at the nurses desk when it happened. It happened in the hallway near the front. (R1) has behaviors frequently, and (R2) does not. (R1) kept passing by (R2) and making remarks to her. They were pulling each other's hair. On 10/31/23 at 11:45am, R8 was alert and oriented, and stated (R1) and (R2) got in a cat fight. On 10/31/23 at 12:45pm, R5 was alert and oriented, and stated (R2) punched (R1) twice and pulled her hair. (R2) accused me and (R1) of talking about her but we were talking about (R8) and her smoking. (R1) was the victim here, she went to the hospital. On 10/31/23 at 1:00pm, R4 was alert and oriented, and stated (R2) and (R1) got into it. On 10/31/23 at 2:00pm, R3 was alert and oriented, and stated (R2) and (R1) got into it. Then (R1) and (R8) had words. (R5) was talking to (R1) about (R2) giving cigarettes out. On 10/31/23 at 2:50pm, V5 Security stated I worked on 10/7/23 second shift. (R2) came up on a group of girls (R1), (R8), and (R3). (R2) grabbed (R1's) hair, not sure if she punched (R1) but she probably did because I heard a yell and seen (R2) with (R1's) hair in her hand. It happened towards the front of the building. (R1) wanted to go to the hospital so she went. On 11/1/23 at 9:03am, V1 Administrator stated (R1 and R2) got into it with hair pulling, and (R1) went to the hospital. 2. Facility Preliminary abuse investigation report, dated 9/1/23 at 6:35pm, documents (R6) involved in a physical altercation. Swelling and bleeding on nose and mouth. Facility Final Abuse Investigation Report, dated 9/6/23, documents (R6) was involved in an alleged altercation in resident room with (R7) resulting in (R6) getting a bloody nose. Facility incident/accident report dated 9/1/23 at 6:35pm, documents (R7) found (R6) in his room laying on his bed. (R7) became upset and struck (R6) with closed fist in the face. Facility incident/accident report dated 9/1/23 at 6:35pm, documents (R6) struck in face by peer. Redness and bleeding in nose and mouth. Sent to (local hospital). Facility interview with R6, dated 9/5/23, documents I got hit. Facility interview with R7, dated 9/5/23, documents (R7) stated he struck (R6) in the face. On 10/31/23 at 10:10am, R7 was alert, oriented, and ambulatory, and stated (On 9/1/23) the lights were off, I don't turn on the lights because I see flashes in my eyes at night if I do. The bathroom light was on, and the door cracked open for light. I went to my bed and saw something move; I wasn't sure if I was hallucinating. I asked a couple of time who was there, and no one answered. I struck out and hit (R6) in the face. (R6) had to go to the hospital and the police came and talked to me. I told (V1) I hit (R6) in the face. R7's medical record, dated 9/11/23, documents R7 is cognitively intact. R7's current careplan documents R7 is verbally aggressive and has poor impulse control. On 10/31/23 at 10:45am, R6 was alert, oriented, and ambulatory, and stated I was in (R7's) bed, we are friends, I knew I was in his bed, we got into it, he got me in the nose, and I went to the hospital. R6's 9/2/23 nurses note documents (R6) returned from the hospital after being punched in the face. R6's 9/1/23 census report documents hospital for payor status.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident (R2), for one of three residents (R1), reviewed for abuse, in a sample of five. Due to the physical abuse R1 experienced an abrasion to R (right) hand knuckles, skin tear to bridge of nose and laceration to L (Left) cheek. FINDINGS INCLUDE: The facility policy, Abuse Prevention and Reporting, dated (reviewed 7/11/23) directs staff, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. R1's Nursing Progress Notes, dated 8/1/2023 at 6:30 P.M. document, (R1) got in a physical altercation with peer (R2) at the smoking patio. Abrasion to R (right) hand knuckles, skin tear to bridge of nose and laceration to L (Left) cheek. Physician called, voicemail box not set up. Talked to (R1's) POA (Power of Attorney). Area cleansed, TAO (Triple Antibiotic Ointment) applied an ice pack given. (R1) started on neuro (neurological) checks. (Local) Police alerted. Ofc (Officer) #1283 assessed both residents and stated that they would not perform an arrest due to residents being unfit for commitment. Resident noted to be going back towards the smoking patio at around 7:34 P.M. The facility Final Abuse Investigation Report dated 8/6/23 and signed by V3/Abuse Coordinator documents, On 8/1/23 at approximately 6:30 P.M., in (facility) patio area, (R1) and (R2) were in a verbal altercation which escalated into a physical altercation. (R2) sustained scratches. (R1) using racial slurs in regard to (R2). (R2) continued provoking of (R1) per several witnesses. (R2) then struck (R1) several times in the face and pulled (R1) from the chair to the ground. Staff immediately intervened and separated residents. (R1) and (R2) having delusional thought processes secondary to TBI (Traumatic Brain Injury). (R1) displays impaired decision making and poor impulse control. (R2) jailed (due to outstanding warrant). On 8/14/23 at 11:30 A.M., V3/Abuse Coordinator stated, (R2) has a history of verbal disagreements with peers and staff. I interviewed all residents on the patio at the time of the incident (8/1/23) and all state (R1) instigated the verbal altercation, but (R2) became physically violent with (R1), pulled (R1) from his wheelchair and hit (R1). Local Police were called, investigated, and arrested (R2) and transported him to jail On 8/15/23 at 10:00 A.M. V1/Administrator stated that when the local police came to the facility after the incident between R1 and R2 on 8/1/23, they weren't going to arrest either resident. However, once they ran R2's name through their database, they arrested R2 due to an outstanding warrant from another county.

Based on observation, interview, and record review, the facility failed to obtain a physician ordered Dilantin level for one of two residents (R47) reviewed for hospitalization s in the sample of 30. This failure resulted in R47 being hospitalized with a critically high Dilantin level. Findings include: On 06/20/23 at 10:41 AM, R47 was alert self-propelling himself in the hallway. R47 stated, A few weeks ago, I had to go to the hospital because they messed something up with my medicine. R47's Care plan, dated 6/21/23, documents, (R47) has a seizure disorder. (R47) has a (vagal nerve) Interventions: Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness. Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated. R47's Nurses' notes, dated 4/15/23 at 10:23 a.m., document, This nurse was notified that (R47) was out on the patio having a seizure. (R47) was having a seizure for 4 minutes. No falls or no injuries. (R47) stayed in a catatonic state for 15 minutes. Doctor was notified and his orders are as follows add Dilantin 250 mg (milligrams) TID (three times a day), and also get a Dilantin level in two weeks. New orders updated in MAR (Medication Administration Record). Facility protocol put in place for seizure activity. Management notified of new orders. R47's Physician's orders, dated 6/22/23, document that on 4/15/23 Dilantin 250 mg by mouth three times a day was ordered to be received for convulsions. R47's Physician progress note, dated 5/10/23, documents, Feels weaker since starting Dilantin. Plan: Start Vimpat 100 mg BID (twice a day). Discontinue Dilantin. R47's Nurses's notes, dated 5/11/23 at 9:23 p.m., document, (R47) reported to this nurse that he has been feeling 'foggy' lately and that he feels like that he 'fades out' at times but only for a few seconds. Other residents stated that (R47) goes limp and that it lasts for only seconds. (R47) also stated that he has moments of slurred speech. This information was reported to Doctor and his recommendation was to send resident to local emergency room for evaluation/treatment. (R47) recently was put on Dilantin to which he stated made him feel worse and the Dilantin was then discontinued and replaced with Vimpat. R47's Laboratory form, dated 5/11/23, documents that R47's Dilantin level was not drawn until 5/10/23 and was at a critically high level at 38 mcg (microgram)/ml (milliliter). Normal therapuetic range for an adult is (10-20 mcg/ml). R47's Nurses's notes, dated 5/11/23 at 11:25 p.m., documents, Reported to this nurse from previous nurse (R47) at local hospital. This nurse called local hospital and obtained Information on (R47). (R47) being admitted to local hospital, admitting diagnosis: Seizures and Seizure medications. R47's Hospital After Visit Summary, dated 5/13/23, documents that on 5/11/23 a Dilantin level was drawn upon admission with critically high results of 38. On 6/22/23 at 11:20 a.m., V2 (Director of Nursing) confirmed that R47's Dilantin level was not obtained two weeks after the Dilantin was initially started as ordered by the physician.

Based on observation, interview and record review the facility failed to prevent resident-to-resident physical abuse for three of three residents (R1, R2, R3) reviewed for abuse in a sample of nine. This failure resulted in R2 punching R1 in the face causing R1 to have a Periorbital Contusion of the Right Eye which required transfer to the hospital for evaluation and treatment. Findings include: An Abuse Prevention Program Facility Policy dated as reviewed 12/1/22 states, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. In addition, this policy states, This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Further, this policy states, Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. 1. R1's list of current diagnoses includes Intracranial Injury without loss of consciousness; Hemiplegia, unspecified affecting the left dominate side; Unspecified Psychosis not due to a substance or known physiological condition; Anxiety Disorder; Bipolar Disorder. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is cognitively intact but with inattention and disorganized thinking which comes and goes and changes in severity. This MDS also documents R1 requires extensive assistance from two people for transfers for most activities of daily living (ADLS). R1's care plan documents R1 has blindness in his left eye related to a Cerebral Vascular Accident and uses a wheelchair as his mode of transportation. R2's list of current diagnoses includes Intracranial Injury without loss of consciousness; Intermittent Explosive Disorder; Brief Psychotic Disorder; Bipolar Disorder, current episode manic severe with psychotic features. Frontotemporal Neurocognitive Disorder, Major Depressive Disorder. R2's MDS assessment dated [DATE] documents R2 is severely cognitively impaired with inattention and disorganized thinking which comes and goes and changes in severity. This MDS also documents R2 has physical behavioral symptoms directed towards others, which could include hitting, kicking, pushing, scratching, grabbing, abusing others sexually, one to three days per week and verbal behavioral symptoms directed towards others four to six days per week. In addition, R2's MDS documents R2 requires only supervision for walking in his room, in the corridor, or off and on the unit. R2's care plan dated as revised 10/27/21 documents, (R2) displays socially/sexually inappropriate (behaviors); inappropriate comments, attention seeking, child-like (behaviors) at times, non-compliance of care, non-compliant of diet, steals food from others, verbal/physical aggression, threatens others, makes false allegations of others at times, delusional thought processes. A Final Abuse Investigation Report with a dated fax transmission report of 3/31/23 states, On 3/27/23 at approximately 7:20p.m. an unwitnessed altercation took place in (R1 and R2's) room where roommate (R1) and (R2) reside. This report documents R1 received a contusion during this altercation. Included in that investigation was a written statement from V6 (Registered Nurse/RN) who wrote, This RN (V6) was made aware that (R1) was yelling for help from his room with closed door. This RN went to (R1's) room, (R1) was laying flat on floor. (R1) stated he was hit (punch) in his face by his roommate (R2). (R2) was not in room when this RN went into the room. 911 was called to report (R1) had been in altercation with roommate (R2) and that (R1) has bleeding from back of head. This investigation included an interview with R2 dated 3/30/23 in which R2 stated, I had enough, and tore into (R1's) as#! This investigation also included an interview with R1 dated 3/28/23 in which R1 stated, I got beat up last night. This investigation included a Domestic Violence Victim's Statement (Police Report) which indicated R1 was the victim and R2 was the suspect in which R1 stated to the police that his roommate (R2) punched him in the face four times. R1's After Visit Summary from the hospital dated 3/27/23 documents R1's reason for admission as Assault Victim. This summary listed R1's admitting diagnoses to the hospital as Assault and Periorbital Contusion of right eye, initial encounter. In addition, this summary defines a periorbital contusion as, A deep bruise under the eye or the area around the eye. Contusions are the result of a blunt injury to tissues and muscles fibers under the skin. On 4/12/23 at 9:05a.m. R2 walked down the hallway and into R2's room unassisted and using a steady gait. R2 verified that on 3/27/23 R2 hit R1 during the evening while R1 and R2 were in the same room together. R2 stated that R1 kept saying things to him that he didn't like. R2 stated that when R1 was saying these things to him, R2 placed his finger against his mouth and said 'Shhh' to R1. R2 stated that R1 rolled his wheelchair over to R2's bed and touched R2's chest while saying things, R2 said he couldn't repeat. R2 stated that after R1 touched his chest R2 punched R1 in the face and wanted to kill him. On 4/12/23 at 9:30a.m. V4 (Certified Nurse Aide) stated that after the altercation between R2 and R1 occurred on 3/27/23, R1 was sent to the hospital. V4 stated that when R1 returned from the hospital R1's face was swollen and bruised and R1's right eye was swollen shut. On 4/12/23 at 11:25a.m. R1 was lying in bed waiting for staff to provide cares before going to lunch. R1 stated that recently, while he and R2 were roommates, R2 came over to R1's bed and punched him in the face for no reason. R1 stated he had to go to the hospital for treatment. On 4/12/23 at 12:01p.m. V5 (Abuse Coordinator) stated that after the altercation between R2 and R1 occurred on 3/27/23, the police were called and ended up taking R2 into custody. V5 stated that R1 was sent to the hospital for evaluation and treatment. On 4/12/23 at approximately 3:15p.m. V1 (Administrator) stated that he does not believe R2 intended to abuse R1. R2 stated that both R1 and R2 have a history of Traumatic Brain Injuries which makes incidents of hitting and punching just a symptom of their condition and not abuse. When asked if R2's punching of R1 on 3/27/23 was accidental, V1 stated no. 2. R3's list of current diagnoses includes Unspecified Dementia, Paranoid Schizophrenia, Extrapyramidal and Movement Disorder, Major Depressive Disorder, Recurrent. R3's MDS assessment dated [DATE] documents R3 is cognitively intact but has inattention and disorganized thinking which comes and goes and changes in severity. R1's list of current diagnoses includes Intracranial Injury without loss of consciousness; Hemiplegia, unspecified affecting the left dominate side; Unspecified Psychosis not due to a substance or known physiological condition; Anxiety Disorder; Bipolar Disorder. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is cognitively intact but has inattention and disorganized thinking which comes and goes and changes in severity. R1's care plan dated as revised 7/25/22 documents,(R1) becomes agitated easily he has behaviors when in dining room and will strike out at peers at times. A Final Abuse Investigation Report dated with a fax transmission report of 12/23/22 states that, On 12/21/22 at approximately 9:52a.m. in the dining room area male peer, (R1), struck out at peer, (R3), with no injuries noted. This investigation documents that, Video reviewed showing (R3) in dining room area sitting at dining table. (R3) actively delusional, (with) hands pointing in different directions. (R1) approached table in w/c (wheelchair) and (with) forearm and hand struck (R3's) left side of face. Another peer in the area saw incident and called for staff assistance. This investigation documented by V7 (Social Services) under Informational Report, Spoke with (R1) regarding incident in dining room with female peer (R3). (R1) stated 'I punched her in the face because she was cussing someone out. I was stupid for doing it. This investigation documents an interview with R9 who witnessed the altercation, (R1) and (R3) were arguing and he hit her. This investigation documents the conclusion to the investigation as, Incident occurred. On 4/12/23 at 12:01p.m. V5 (Abuse Coordinator) stated V5 investigated the altercation between R1 and R3 which occurred on 12/21/22. V5 stated she watched the video of the incident from the surveillance camera located in the dining room. V5 stated that R3 was sitting by herself at a dining table while moving her hands around and talking to herself. V5 stated she thinks R1 interpreted R3's behaviors as though R3 was talking about R1. V5 stated that when she watched the video, R1 approached R3 and slapped R3 across the face.

Based on observation, interview and record review, the facility failed to prevent resident-to-resident physical abuse for two of three residents (R1 and R2) reviewed for abuse in the sample of three. This failure resulted in R1 and R2 being in a verbal altercation which then turned physical. R1 and R2 hit each other and then fell to the ground. R2 sustained a laceration to the left eyebrow which required transfer to the local area hospital for evaluation and treatment. Findings include: The Facility's Abuse Prevention Program Facility Policy, reviewed 12/1/22, states, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. Definitions: Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury. unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances 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 through 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. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. 1. R2's Facesheet documents R2 with diagnoses to include but not limited to: Paranoid Schizophrenia; Pseudobulbar Affect; Unspecified Dementia; Major Depressive Disorder. R2's Minimum Data Set/MDS Assessment, dated 9/5/22, documents R2 with moderately impaired cognition. R2's current Care Plan states,(R2) may exhibit behaviors due to his paranoid schizophrenia. (R2) has history of becoming physical aggression, lashing out at others, hitting others over small things like cigarette butts, verbal aggression, socially inappropriate, bizarre delusional threatening others. Intervention is stated as Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. This same Care Plan states, (R2) has cognitive impairments for daily decision making, needs reminders, verbal cues, redirection, encouragement, assistance for ADL/Activities of Daily Living cares/treatments/doctor appointments/etc. (R2) has memory impairments, impaired judgment, impaired decision making, very poor impulse control, anxiety, paranoia, very poor coping skills, very poor insight, very poor independent living skills. R2's Nursing Note on 11/15/2022 at 8:14 PM, states, (R2) on AB smoking patio at 7:15 (PM) when (R2) got into a physical altercation with another resident (R1). (R2) fell in the process and suffered a laceration to (R2's) left eyebrow. (R2) taken to (name of local area hospital) ED/ Emergency Department for eval (evaluation). Guardian notified. R2's Incident/Accident Report documents on 11/15/22 at 7:15 PM, R2 was in a physical altercation with a peer (R1) on the smoking patio and that R2 suffered a laceration above R2's left eye. R2 was sent to the local area hospital emergency room for evaluation and treatment. R2's Nursing Note on 11/16/2022 at 2:04 AM, states, (R2) returned from (name of local area hospital) ED/ Emergency Department via (local ambulance service). No new orders. Left eyebrow laceration was glued. No complaints of pain or discomfort. R2's After Visit Summary from the local area hospital on 11/15/22 documents R2 was seen for a fall, head pain and a forehead laceration. 2. R1's Facesheet documents R1 with diagnoses to include but not limited to: Bipolar Disorder; Anxiety Disorder; Conversion Disorder; and Dysthymic Disorder. R1's MDS Assessment, dated 10/18/22 documents R1 as cognitively intact. R1's current Care Plan states, (R1) displays socially inappropriate bx (behavior) many times daily. (R1) displays as intrusive, demanding, begs, threatens, verbally and physically aggressive, has hx (history) of self-harm, provokes peers, substance use, false allegations, attention seeking, childlike bx (behavior), refuse care and care expectations for health and wellbeing. (R1) curses, [NAME], yells in main areas at staff and peers. (R1's) bx's (behaviors) may affect how her peers may receive her socially. This same Care Plan documents R1 had a physical altercation on 7/9/22 in which resulted in peer going to hospital and (R1) being arrested. Interventions are stated as: (R1) triggers for physical/verbal aggression are derogatory comments, and verbal/physical aggression from peers. Staff will redirect (R1) to a quiet area to de-escalate aggressive physical/verbal behaviors; When (R1) becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. R1's Nursing Note on 11/15/2022 at 7:59 PM states, At approximately (7:10 PM) (R1) was hit by a peer (R2) in the head. (R1) hit peer (R2) back in return and both (R1 and R2) fell to the ground. (R1) has no visible injury noted. Police were requested to the facility to report the altercation. Report filed, case number 22-21404. Neuro (neurological) checks initiated for precaution. No new concerns at this time. R1's Incident/Accident Report documents that on 11/15/22 at 7:10 PM, R1 was hit in the head by a peer (R2) and that R1 hit R2 back and both R1 and R2 fell to the ground. The facility's Final Abuse Investigation Report to the local state agency, dated 11/19/22 states, Original Allegation: On 11/15/22 at 7:15 PM, on AB Smoking Patio, two peers (R1 and R2) engaged in a verbal and physical altercation. This resulted in (R2) receiving a laceration above left eye. Following facts were determined: Video reviewed and showed (R1) approaching (R2) and poking (R2) three times, (R2) stood up from picnic table and slapped (R1) with right hand. Both (R1 and R2) engaged in a physical altercation, and both (R1 and R2) fell to the ground. (R1 and R2) rose from the ground at the same time. Staff escorted residents (R1 and R2) separately into the facility. (R2) sent to (name of local area hospital) ER/emergency room for evaluation. Police contacted. No report written. 1:1 initiated with (R1). Witnesses interviewed. Following Conclusions have been determined about the original allegation: Incident occurred. (R2) reacted to (R1) poking him with physical aggression. (R1 and R2) have cognitive impairments such as their impulsivity, impaired decision making and poor insight and coping. (R1 and R2) have a current and long history of deficits in daily decision making skills. R3's written statement on 11/15/22 at 7:55 PM, states, (R3, R4, and R1) were sitting at the picnic table when we heard (R2) spitting on the ground. (R1) said, 'Please stop spitting on the ground!' (R2) said, 'F*** you, B****. (R1) walked over and acted like she was going to hit (R2) and (R2) said, 'You can't even hit.' (R1) said, 'Why don't you show me how to hit.' (R2) stood up and said, 'I will.' then (R2) hit (R1) two times in the head with a closed fist. (R1) hit (R2) back and they both fell to the ground. R4's written statement on 11/15/22 at 7:45 PM, states, (R2) was spitting on the ground. We all (R4, R3, and R1) told him to stop. (R2) started cussing at (R1). (R1) stood up and told (R2), 'Hit Me!' (R2) said, 'I'm not going to hit you B****.' Then (R2) stood up and hit (R1) two times in the head. Then (R1) hit (R2) back. They both ended up on the ground. R1's written statement on 11/15/22 at 7:30 PM, states, (R2) was coughing/spitting on the ground. (R1, R3 and R4) told him to stop because it was gross. (R2) said, 'F*** you.' We all said 'F**k you' back. Then (R2) said F***you' again over and over. I stood up and said, 'That's enough.' (R2) then hit me in the head twice. I hit (R2) back and he fell then I fell too. On 12/6/22 at 11:11 AM, video surveillance footage was reviewed with V3 (Human Resources). Video surveillance footage on 11/15/22 at 7:08 PM shows a resident, identified by V3 as R1, walking over and standing next to a resident, identified by V3 as R2, who was sitting on a bench. Both R1 and R2 are positioned at the end of the smoking patio, furthest from the patio doors. R1 is seen poking R2 near R2's head. R2 then stood up from R2's seated position and struck R1 near R1's head with R2's hand. R1, in return swung at R2. Both R1 and R2 swing at each other until both residents then fall to the ground. Both R1 and R2 stand up from the concrete patio and the altercation ends. Staff arrive as R1 and R2 are separating. On 12/6/22 at 1:01 PM, R2 was sitting in a chair near the AB smoking patio doors. R2 was noted with an adhesive bandage over R2's left eyebrow. An opened, reddened area could be seen at the base of the dressing which was not covered by the bandage. At this time, R2 stated that R2's bandage is covering an injury R2 received during a ''fight with (R1). R2 stated (on 11/15/22), I hit her (R1), and she hit me back. (R1) got mad at me for spitting on the sidewalk. I went to the hospital because of the cut on my eye. I know I hit her first but we both fell , and I think that's how I cut my eye. On 12/6/22 at 1:25 PM, R1 stated, (R2) was spitting and I asked him to stop. (R2) hit me in the head first, and I hit him back. We fell to the ground. I remember that the police came. I've had fights here before but never with (R2). On 12/6/22 at 10:36 AM, R4 stated, (On 11/15/22) (R2) was spitting on the ground. (R1) told him not to do that. (R1) stood up and went over to (R2). (R2) then hit (R1). (R1) hit (R2) back and then they both went down. (R1) doesn't like people spitting on the concrete. (R2) hit (R1) first in the head. On 12/6/22 at 10:41 AM, R3 stated, The staff has reiterated the rule of not spitting on the concrete. (On 11/15/22), (R2) kept spitting. (R1) said stop spitting. (R2) used some profanities to (R1). (R1 and R2) ended up hitting each other and then they both fell to the ground. Staff was right there, and it ended quickly. On 12/6/22 at 12:00 PM, V6 (RN) stated, (On 11/15/22) it was right at shift change, I was getting ready to clock out when someone called out that residents were fighting. I ran out (onto the AB smoking patio) to see if I could help. When I got out there, (R2) was sitting on the far back bench with blood dripping off his face. (R1) was still out there but was away from (R2). (R2) told me that he hit (R1) first. In a phone interview on 12/7/22 at 12:40 AM, V4 (Registered Nurse/RN) stated, (On 11/15/22), I was inside at my med (medication) cart. V5 (Certified Nursing Assistant) yelled that something was going on outside. I ran outside and (R1 and R2) were getting up off the ground and (R1) said that (R2) hit her in the head and that (R1) hit (R2) back. At this time, V4 verified that R2 was sent to the local area hospital for evaluation of R2's left eyebrow laceration. In a phone interview on 12/7/22 at 12:42 AM, V5 stated that on 11/15/22 around 7:00 PM, V5 was outside on the smoking patio passing out cigarettes. V5 stated that R1 and R2 were at the far end of the patio because the residents have to be so far from the patio doors when they are smoking. V5 stated, I didn't know what was going on until I heard the commotion. I looked up and saw (R1 and R2) fighting. I yelled inside for some help. (R1 and R2) both fell down and (R2) hit his head. (R1) can be easy to trigger. (R2) was spitting and that bothers them. (R2) got mouthy. (R2) usually is quiet and keeps to himself but he can have an explosive personality.

Based on observation, interview and record review the facility failed to prevent an occurrence of resident to resident physical abuse from a resident with a known history of physical behaviors directed towards others for two of three residents (R1 and R2) reviewed for abuse in the sample of four. This failure resulted in R2 punching R1 in the left side of the face with a closed fist and calling R1 a son of a b****. Findings include: The facility's Abuse Prevention Program Facility Procedures, revised 9/15/22, states, The facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. R2's Nursing Note on 9/30/22 at 9:57 PM documents R2 was displaying increased episodes of [CONDITION(S)] with aggression and that R2 was in a physical altercation. The facility's initial report to the local state agency, undated but with a fax submission date of 9/30/22, states, At 9:00 PM, in the main dining room another resident (R2) hit (R1) with a closed fist in the face. The other resident (R2) has been displaying increased episodes of [CONDITION(S)]. (R2) involved in a physical altercation while on one-on-one monitoring. Unable to redirect. Police notified. (R2) transferred to (the local area hospital) for psych eval (psychiatric evaluation) per police/EMS (Emergency Medical Services). Family notified of behavior. R2's Incident/Accident Report dated 9/30/22, states, (R2) has been displaying increased episodes of [CONDITION(S)]. (R2) involved in a physical altercation while on one-on-one monitoring. R1's Incident/Accident Report dated 9/30/22, states, (R1) was involved in physical altercation with another male peer (R1). V5's (Registered Nurse/RN) written statement states the following regarding the events on 9/30/22: They (R1 and R2) were out in the main dining room, and it looked like (R2) hit (R1) out of the blue. Staff was around and immediately separated them. It was over right away. No idea what triggered the episode. Police came and just had (R2) sent to (name of local area hospital). V4's (RN) written statement states the following regarding the events on 9/30/22: (R2) was in the main dining room. (R1) was wheeling toward his hallway when (R2) tripped over (R1's) feet. (R2) then yelled, 'you son of a b****' and struck (R1). Staff immediately intervened to separate residents however (R2) was unable to be redirected. Police were notified. (R2) left the facility and started walking on the sidewalk of road. (V4) followed behind resident with some distance for safety. Police arrived and discussed events with (R2). (R2) transferred to (name of local area hospital) for psych eval per (local police department and EMS). The facility's Final Abuse Investigation Report undated but with a fax submission date of 10/5/22, documents R1 and R2 were in the dining room when R2 struck at R1. No trigger was identified. R2 was sent to the local area hospital for evaluation of increased delusions. This same report documents the local police were notified. R2's Current Care Plan states, Focus: (R2) has potential to be verbally/physically aggressive r/t (related to) Poor impulse control. (R2) will use racial language directed at staff and peers. (R2) displays a delusional thought process. (R2) is attention seeking at times; may hit/punch himself or bang his head on the wall. (R2) will provoke fights and put himself in a situation to where he can be injured from a fall because he gains attention from staff. (R2) will make false accusations and fabricate stories. (R2) had aggression with weapon. (R2) had an altercation with another peer on 09/03/2022 hitting peer in the eye with a steel mug. The following are documented as interventions for the focused area: When (R2) becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; Allow (R2) to vent his feelings. Encourage (R2) to avoid his source of frustration to prevent escalation; Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document; Assess (R2's) understanding of the situation. Allow time for the resident to express self and feelings towards the situation; Educate (R2) on importance of not calling peers names and risk factors that could occur; Monitor behaviors Document observed behavior and attempted interventions; (R2) on 15-minute safety checks. CNA (Certified Nursing Assistant) to check room for weapons. On 10/4/22 at 1:15 PM, V4 (Registered Nurse) stated that V4 was R1's nurse on 9/30/22. V4 stated that on 9/30/22 around 8:30/9:00 PM, R1 was being pushed in R1's wheelchair by his roommate (R4) to go to the bathroom before smoke break. V4 stated, at this same time, R2 was walking to get in line against the wall for the smoke break. R2 tripped over R1's foot as R2 was walking to get in line. R2 immediately stated, You son of a bi*** and immediately punched R1 in the cheek with a closed fist. V4 stated other staff members were present in the main dining room where this occurred and R1 and R2 separated easily but R2 was hard to redirect to stay in building after. V4 stated the police were called and it was determined that R2 would be sent to the local area hospital for a psychiatric evaluation. On 10/6/22 at 11:51 AM, V4 stated on 9/30/22, V4 stated V4 worked a double shift and V4 saw R2's increased aggressive behavior. R2 threw a tea bottle and was displaying increased yelling and cussing outbursts for approximately three hours before R2 hit R1 in the main dining room. V4 stated that R1 was not the aggressor and that R2 was. V4 stated that it was decided that R2 would be placed on an informal one-on-one meaning that there was an understanding that if R2 was in the main common areas, a staff member would have eyes on R2 at all times. V4 denied that no specific staff member was designated to complete the one-to-one supervision for R2. V4 stated that if R2 was on a formal one-on-one it would mean that a specific staff member would be assigned to be within an arm's reach at all times of the resident on one-to-one supervision. V4 stated R2 is known to use racial slurs towards residents and staff. V4 stated, (R2) is unpredictable, it wasn't that long ago (9/3/22) that he hit the guy (R3) in the eye with a metal cup and broke his face. On 10/4/22 at 1:04 PM, R1 was sitting in R1's wheelchair in the main dining room. R1 was asked about the 9/30/22 incident and R1 stated, (R2) just walked up and hit me. I was on [MEDICATION(S)] to my room, and he hit me right here on my mouth. At this time, R1 pointed to the left side of R1's lower cheek/chin area near the lip. R1 continued to say, Been trying to avoid him all day. He always trying to fight me and call me (racial slurs) On 10/4/22 at 1:07 PM, R4 stated that R1 and R2 are always fighting. R4 stated, There are fights here all the time, man. On 10/4/22 at 11:28 AM, V2 (Director of Nursing) stated V2 was the weekend supervisor on 9/30/22. V2 stated V2 was made aware by the nursing staff that R2 was having escalating aggressive behaviors and that R2 had hit R1. V2 stated that V2 told the staff, We need to send (R2) out. On 10/4/22 at 12:23 PM, V8 (Licensed Practical Nurse/LPN) stated that R1 and R2 have to stay apart at all times. They seem to always clash. On 10/4/22 at 2:45 PM, V7 (Certified Nursing Assistant/CNA) stated, They (R1 and R2) can't stand the sight of each other. We try and keep them separate as much as we can. If they (R1 and R2) see each other, they are going to fight. On 10/6/22 at 9:29 AM, V16 (LPN/Restorative) stated, (R1 and R2) don't get along. They clash every time. We try our best to keep them separated. Some days (R2) is good, and some days (R2) is good at being bad. (R2) has impulse issues. (R1 and R2) are both the same. (R1) does stuff too. If they cross paths, they're going to fight. You can't predict what they are going to do. We can increase supervision on a resident at any time. It is not anything we would need a doctor's order for. If a resident was a one-to-one, someone would be assigned for that resident. (R2's) increased aggression is usually yelling and cussing. We would try to redirect to avoid anything happening. If we can't diffuse the situation, we would then put the resident on one-on-one supervision. On 10/4/22 at 1130 AM, V12 (Minimum Data Set/MDS Coordinator/LPN) stated, I've been off the last few days, so I don't know about (R1 and R2's) altercation. We try and keep them separated. Everyone knows when they see each other, it's never good. On 10/4/22 at 11:16 AM, R2 recalled being in a physical altercation with R1 but could not recall the details. R2 stated, He (R1) isn't supposed to be within 15 feet of me. I remember being angry and trying to walk away. One of the staff members kept following me. I'm tired of this s*** happening to me. On 10/6/22 at 11:00 AM, V1 (Administrator) stated that the facility was recently cited at a level of Immediate Jeopardy for R2 hitting R3 in the eye with a metal cup. R3's Accident/Incident Report dated 9/3/22 at 9:30 PM documents R3 was in a verbal altercation that turned physical. R3 was hit with an object on the left eye and sent to the local area hospital. This same form documents R3 sustained a skin tear and laceration. R2's Accident/Incident Report dated 9/3/22 at 9:30 PM documents R2 was in a verbal altercation turned physical. (Cited 9/15/22).

Based on interview, observation and record review, the facility failed to prevent an occurrence of resident to resident physical abuse from a resident with a history of physical behaviors directed toward others. R1 and R2 were separated following a verbal altercation on the evening of 09/03/22. Approximately three hours later, another verbal altercation ensued between R1 and R2 that escalated into a physical altercation. This resulted in R2 striking R1 in the head with a metal cup and biting R1 on the hand. R1 was subsequently transported to a local hospital for treatment of a left eyebrow laceration, a bite wound to his right hand requiring a prescription for an antibiotic and was also diagnosed with a left orbital fracture. R1 and R2 were two of four residents reviewed for abuse in the sample of six. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 09/16/22, the facility remains out of compliance at a Severity Level II as the facility implements the following: Conduct an audit to evaluate the facility residents for any potential risk for abuse and/or exhibiting potential abusive tendencies, and any resident identified will be placed on 15 minute checks or had their supplemental supervision verified; Update R1 and R2's Care Plans with additional interventions implemented to prevent further resident to resident altercations; Provide training to all staff on resident abuse prevention, recognizing behavioral triggers, recognizing signs of latent aggression, and techniques to de-escalate behaviors; Post a reminder sign by the employee time clock to ensure that all subsequent shifts review the mandatory materials prior to working on the floor; Revise the Abuse Prevention Policy and Procedure with an addendum regarding increased resident supervision following a physical altercation; Add a section to the facility's structured QA/QAPI (Quality Assurance/Quality Assurance Process Improvement) agenda to prompt the interdisciplinary team to increase in-house abuse evaluation; Ongoing compliance will be monitored by V1 (Administrator) and the facility's Abuse Committee. Findings include: The facility's Abuse Investigation (dated 09/03/22) documents R1 and R2 had a verbal altercation in the dining room around 5:30 PM, and R2 was removed from the dining room at that time. This same report also documents approximately three hours later, R1 and R2 had a verbal altercation on the facility's patio that escalated into a physical altercation, and R1 was sent to a local hospital for evaluation and treatment for the injuries he sustained. R1's Progress Note (dated 09/03/22) documents the following: Resident in verbal altercation that turned physical. Resident hit with a cup and has laceration to left eye. Resident also bit on his right hand. Resident sent to (local hospital) for evaluation. R1's Progress Note (dated 09/04/22) documents the following: Resident returned from (local hospital) following an altercation with peer. Resident was brought back to this facility traveling with EMT (emergency medical transport). (R1) has a laceration to left eyebrow. The resident diagnosis was an Orbital Fracture, closed, initial encounter. Resident's skin is pink, warm and dry. This nurse cleaned dried blood from left area of face with normal saline. Vitals are stable. Resident complains of pain he rates his pain six out of ten. This nurse gave resident two Tylenol 325 mg (milligrams). (R1) has a new order for Augmentin 875-125 for possible infection from a bite on his right anterior surface of palm he received in the altercation. Resident is to take one tablet twice a day for 10 days. Initial dose will start today 9/4/22 at 4:00 PM. Resident is resting in bed with call light in reach. R1's local hospital After Visit Summary (dated 09/04/22) documents the following: Diagnosis: Injury due to Physical Assault. Fracture of left side of orbital floor. Facial laceration repaired with adhesive. Take Augmentin as directed for bite wound. R1's current care plan documents, (R1) is to start on antibiotic for a prophylactic related to human bite on right hand. This same care plan documents the following problem: (R1) has a history of criminal behavior. (R1) was convicted of battery/bodily harm in 2019, and unlawful use of a weapon in 1982. Interventions: 1:1 if necessary; Attempt to identify any triggers that illicit negative behavior; When the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. On 09/12/22 at 3:00 PM, R1 was sitting in a chair in the hallway near the building's front entrance. R1 was dressed and groomed and had a cane in his possession that he stated he utilized to assist when ambulating. R1 had a large purple scabbed area present on his left eyebrow. A dark purple area of bruising was present in R1's left orbit area underneath R1's left eye. R1 stated, The doctor at the hospital glued the cut by my left eye and told me that it needed to be glued instead of getting stitches because the cut was so close to my eye. I have a broken eye orbit on the left side of my face. I have been blind in my left eye for quite some time. I have a headache and the entire left side of my face is numb all the way down to my jawbone. I saw an eye doctor, and he said I need to see an ENT (ear, nose and throat) doctor about the orbit fracture. R1 then lifted his right hand exposing an oval-shaped scabbed area resembling a tooth imprint pattern. R1 stated, He bit me here on my hand. R1 then stated the following occurred on 09/03/22: I was in the dining room around 5:30 PM. There were a couple of empty chairs at a table, and I sat in one of them. (R2) was seated at the table and he told me that I couldn't sit there. He started cussing at me. They took him out of the dining room at that point. Around 9:30 PM, I went out for a cigarette. (R2) was outside near the door. He started running his mouth at me, and the next thing I knew I was on the ground bleeding. R1 then stated, I have been avoiding (R2). He came after me again a few days ago. The supervised smokers came out early, and I was already outside. He came out and I told him to get back. Staff (unable to identify) sent him back inside. I do not feel safe. I cannot defend myself with the way my leg is. Every day someone is fighting here. All day every day. R2's Progress Note dated 09/03/22 documents the following: Resident in verbal altercation that turned physical. No apparent injury. Cup taken away that he hit the other resident with. Resident in room. VSS (vital signs stable). R2's current care plan documents the following: Focus: (R2) has potential to be verbally/physically aggressive related to poor impulse control. (R2) will use racial language directed at staff and peers. (R2) displays a delusional thought process. (R2) is attention seeking at times, may hit/punch himself or bang his head on the wall. (R2) will provoke fights and put himself in a situation to where he can be injured from a fall because he gains attention from staff. (R2) will make false accusations and fabricate stories. (R2) had aggression with a weapon. Interventions: Analyze of key times, places circumstances, triggers, and what de-escalates behavior and document; Educate on importance of not calling peers names and risk factors that could occur; Resident on 15 minutes checks. Staff to check room for weapons; (R2) triggers for verbal aggression and his behaviors are de-escalated by removing him to a quiet area to assess the situation with reality orientation; When (R2) becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, allow (R2) to vent his feelings, encourage (R2) to avoid the source of his frustration to prevent escalation. On 09/13/22 at 09:35 AM, R2 was sitting in a chair in the front lobby near the building's entrance. R2 stated the following regarding the 09/03/22 incident: I was sitting by the cigarette butt can by the door on the AB patio. (R1) approached me and started rapidly punching me. I swung my water bottle at him to block him. I lunged at him, bit him and did everything I needed to get him away from me. V3's (Human Resources) Written Statement (dated 09/12/22) documents the following: After watching camera surveillance for the incident between (R1 and R2) that occurred 09/03/22. The incident takes place on the AB Patio. I was unable to see what resident initiated the fight, however, within minutes both residents pull into view of the patio. Both residents were tussling and holding each other until (R2) appears to let go; in which (R1) looks to stumble, losing balance going face forward on the concrete. Afterwards several CNAs (Certified Nursing Assistants) come to, what appears diffuse the situation. Within minutes a nurse arrives to assess/assist (R1), who was sitting up and talking with staff. On 09/12/22 at 01:42 PM, V3 (Human Resources) verified her written statement dated 09/12/22 and stated, I watched the video footage from the AB Patio where (R1 and R2's) physical altercation occurred. Most residents go smoke there. It was around 9:30 PM. The camera lens was dirty and has since been cleaned off. I could not see the area clearly where the altercation began. They (R1 and R2) came into view and appeared to be tussling and holding onto each other. (R2) let go causing (R1) to stumble and fall, and his face struck the concrete patio. (R1) got up pretty quickly and was sitting there holding his head. No staff members were out there, but soon (V4 and V5, Certified Nursing Assistants) responded. By this time, (R2) was walking away. (V5) attended to (R1) and (V4) went to get additional help. Then, (V5, V6 and V7) (Certified Nursing Assistants) and V8 (Registered Nurse) all came out to the patio. (V8) assessed (R1), who was still sitting up at that point. V3 then stated that (R1) does not have a community pass, He is a newer resident and I do not know of any physical or verbal altercations he has been involved in. (R2) just earned a grounds pass, which gives him access to go outside on the grounds, but he cannot leave the grounds. I know (R2) has a history of verbal altercations. I am unsure if he's ever had a physical altercation. This surveyor observed video footage with V3 on 09/13/22 at 8:00 AM. V3's above written statement correlates with the video footage, as the beginning of altercation was out of view. A metal tumbler cup was observed rolling across the patio before R1 and R2 move into view. On 09/12/22 at 2:38 PM, V4 (Certified Nursing Assistant) stated she responded to the altercation that occurred between R1 and R2 on 09/03/22. V4 stated, (R1 and R2) had an argument around 5:30 PM at dinner. They were at the dining room table. (R1) sat down in one of the chairs and (R2) told him that he couldn't sit there. (R1) sat down anyways. (R1 and R2) started arguing. (R2) was removed from the dining room and was taken to the front of the building. (R1) stayed at the table and ate his dinner. Later around 9:00 PM, one of the residents (unable to identify) was yelling. Me and (V5, Certified Nursing Assistant) went out on the patio. (V5) stayed with (R1) and I went back in to get more help. When I returned, (R2) was walking away. V6 (Certified Nursing Assistant) and V8 (Registered Nurse) came out. (R1) was sent to the hospital to get looked at. On 09/12/22 at 3:20 PM, V5 (Certified Nursing Assistant) stated on the evening of 09/03/22 at approximately 9:30 PM, she overheard R5 yelling the following: 'There's a fight outside! They are hitting each other! Someone's bleeding!' V5 stated, When I got outside, (R1) was on the ground holding his head and was bleeding. (R2) was standing directly over (R1) with his hand balled up in a fist and when he saw me, he unclenched his fist and began rubbing his other forearm. The lid to the metal tumbler cup was on the ground. After (R2) hit (R1) he must have thrown his metal cup because it was out in the grass beyond the patio. I tried to get (R2) to go inside at that point, and he ignored me and walked out to the grass to retrieve his cup. (V8, Registered Nurse) had come outside and was assessing (R1). EMT (emergency medical transport) was contacted and (R1) was sent to the hospital. (R2) asked for his cup because we had taken it away. (V8) asked (R2) if he had hit (R1) with the cup and (R2) said, 'Yeah. I f*cking hit him with the cup.' Me, (V8), and (V7, Certified Nursing Assistant) heard him say it. (R1) also had teeth marks in his right hand and it was bleeding. It appeared that he had been bitten. There was blood all over. It was on the ground, on (R1's) face and on his hands. (R2) had been instigating and problematic all night. He started a fight with (R1) in the dining room at dinner around 6:00 PM. He also popped off at (R4) in passing in the smoking area after dinner. (R4) was coming inside while (R2) was heading outside. After the fight with (R1), (R2) was very mouthy with the staff. He could not be redirected. I've worked here for a couple of months, and (R2) has a smart mouth. He likes to provoke people. He is very noncompliant. He's an instigator. He picks and picks and picks at people. On 09/12/22 at 03:50 PM, V6 (Certified Nursing Assistant) stated the following occurred on 09/03/22: I was on break. I was out front of the building and (V7, Certified Nursing Assistant) came and got me and told me that (R2) attacked (R1). I immediately went out back to the patio. (R1) was sitting up. His face was bleeding. (V7) and (V8, Registered Nurse) were also present. (V8) assessed (R1), and then we got him up and called the ambulance. Someone took the cup (R2) used to hit (R1) with. After (R1) was sent out, (R2) was pacing around for a while. (R1) and (R2) were arguing at dinner earlier that night, it was about 5:30 PM. (R2) was then removed from the dining room. Around 6:00 PM, (R2) and (R4) exchanged words in passing at the patio. We try to keep those two separated. We also try to keep (R1) and (R2) separated. If we are busy and (R1) or (R4) cross paths with (R2), they usually end up having words. (R2) has been physical in the past. Mostly with (R4). On 09/12/22 at 08:50 PM, V8 (Registered Nurse) stated the following occurred on 09/03/22: (R1 and R2) had gotten into an argument earlier that night at dinner. (R1) sat at (R2's) table, and (R2) told (R1) he could not sit there. (R1) sat at the table anyways, and then they began to argue. Staff intervened and told them to stop. Later around 9:00 PM, one of the CNAs (Certified Nursing Assistants) came in and said a nurse was needed out on the patio. I went out and (R1) was sitting on the ground. He was bleeding from his left eyebrow. He said (R2) said something to him while he was walking out and then everything happened so fast. When I spoke to (R2), he said that (R1) started hitting him and then he fought back. (R2) did not have any marks or bruises and was not injured. (R2's) metal tumbler cup's lid was on the ground and the cup was on the ground several feet away in the grass. I said something to (R2) and he admitted hitting (R1) with the cup and he said, 'Hell yeah I hit him.' (R2) went inside and was trying to call somebody. I stayed with (R1). He didn't even know that his eye had been cut that bad. He is blind in his left eye. On his right hand, there was a skin tear with a small amount of blood present, and it certainly could have been a bite mark. I helped (R1) up into a chair outside on the patio. When the ambulance crew arrived, they came out on the patio. We didn't want to take (R1) back inside since (R2) was in there. (R2) was angry that we took his cup. (R2) has a history of physical aggression to other residents. As far as I know, (R1) has no known aggression. (R2) starts a lot of trouble here. He targets (R4). We try to keep them apart as much as possible. A few months ago, (R2) stabbed (R4) with a metal butter knife in the abdomen. Those two are rivals. Like the Bears and the Packers. 09/13/22 at 09:15 AM, V7 (Certified Nursing Assistant) stated the following regarding the 09/03/22 incident: (R1 and R2) had gotten into an argument in the dining room at dinner. (R2) was cussing so he was asked to leave the dining room. Later they got into a fight outside. (R1) was on the ground bleeding when I got outside. (R2) was yelling and cussing. (V8, Registered Nurse) went out and examined (R1). We got him up in a chair, called 911, and he went to the hospital. (R1) said (R2) bit him, and (R2) admitted that. (R2) is horrible. He is always using terrible language. He and (R4) don't get along at all. On 09/13/22 at 11:10 AM, R5 stated she witnessed the altercation between R1 and R2 on 09/03/22, and stated, (R2) knocked (R1) on the ground. There's a fight here every day. 09/13/22 at 12:56 PM, V9 (Social Service Director/Abuse Coordinator) stated the following regarding the recent altercation involving R1 and R2: (R1) has a problem with alcohol abuse. I am not aware of (R1) having any history of verbal or physical aggression. (R2) has been in several altercations lately. Mostly verbal and argumentative in nature. (R2) has been verbally aggressive with facility staff, and (R4). (R2) and (R4) don't get along. (R2) has been physical with (R4) in the past. Approximately four months ago, (R2) stabbed (R4) in the abdomen with a metal knife. On 09/13/22 at 01:20 PM, V10 (Social Services) stated the following in regard to the incident between R1 and R2 on 09/03/22: On 09/06/22, (R2) approached me and stated what had happened during the altercation. (R2) stated that (R1) tried to sit at the table and (R2) asked him to move. (R1) refused, and then an argument began. The two were separated. (R2) then stated that (R1) was banging his cane on a table, attacked (R2), and (R2) defended himself. V10 then stated, When I interviewed (R1), he told me that he was sitting outside on the smoking patio and (R2) was outside as well. (R1) stated that (R2) continued to argue about the dining room incident and then attacked him, struck him with a metal tumbler cup, and bit him on his right hand. V10 then stated, I went back through their care plans and reviewed the notes. (R2) has a history of previous altercations, both verbal and physical. So, I determined the incident occurred as a result of (R2's) mood disorder. On 09/12/22 at 01:20 PM, R3 was standing outside near the front entrance to the facility. R3 stated the following: I'd like to go somewhere else. There is always fighting here. I am not violent and do not like all the fighting. On 09/13/22 at 08:30 AM, R4 was sitting in a wheelchair in the hall outside his room. R4 stated he has issues with R2, All he wants to do is start a fight with me all the time. He is always running his mouth. R2 lifted his shirt up exposing a scar on his abdomen and stated, He stabbed me with a metal knife a while ago. R4 then stated, He was talking sh*t to me about a week ago. The facility's Abuse Investigation (dated 06/04/22) documents the following: On 06/04/22, in the dining room (R2) and (R4) engaged in a verbal altercation. During the course of the altercation, (R2) picked up a butter knife and poked (R4) in the left side of his stomach causing an abrasion to (R4's) stomach. (R2) then proceeded to stab (R4) again. Both residents were separated. This same investigation also documents, (R4) became angry because of verbal words exchanged between he and (R2). (R2) became delusional, believing peers were speaking and using derogatory language believing he was being threatened. (R2) picked up knife and began swinging the knife. Records show (R2) has poor impulse control. This same investigation documents the following statement was taken from R4: (R4) says that (R2) started yelling at him, 'I'm going to f*ck you up.' (R4) says he told (R2) to get the hell away from him. (R4) says at this time (R2) picked up a butter knife and stabbed him in the left side of his stomach. (R4) says he backed away from (R2) at this time. (R4) says (R2) then yelled, 'I'm going to kill you, n*gger.' (R4) says at this time (R2) stabbed him again on the right side of his stomach. On 09/15/22 at 08:25 AM, R6 was sitting on the picnic table bench on the AB Patio. R6 was dressed and groomed and stated he had just woken up and he is about to smoke a cigarette. R6 stated he recalls the altercation that occurred between R2 and him back in late May. R6 stated, (R2) was sweeping the patio, and I was sitting in a chair on the patio that was on the right side of the door. (R2) started sweeping sh*t at me, and I told him to stop. He continued to do it, so I got up, pushed him down and held him there. He bit me in the stomach while he was on the ground. He is a big troublemaker who is always trying to instigate people. He has issues with a lot of residents, especially (R4). Those two are always fighting. (R2) and I don't speak now. We just avoid each other. The facility's Abuse Investigation (dated 05/29/22) documents the following, (R2) was sweeping up cigarette butts on the patio outside the main dining room and got too close to (R6) and they began arguing. (R6) got up and began pushing against (R2) causing them both to fall to the ground where (R2) somehow bit (R6's) stomach with minimal injury. This same investigation documents R2's written statement as follows: (R2) reports that he was outside sweeping the patio because, 'somebody has to do it' and said that (R6) was getting upset that (R2) was too close to him. (R2) said he told (R6) to move but (R6) did not move and (R2) kept sweeping. (R2) stated that (R6) came toward him and hit him. After this, (R2) says staff helped him up. (R2) reported no injuries and said he was not hurt or in any pain from the incident. (R2) said he did attempt to hit (R6) with a broom. The Immediate Jeopardy was identified on 9/15/22 at 2:00 PM to have begun on 09/03/22 when R1 and R2 were involved in an occurrence of resident to resident physical abuse. V2 (Director of Nursing) was notified of the Immediate Jeopardy on 9/15/22 at 2:12 PM. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: On 09/19/22, V1 (Administrator) provided a resident room roster (dated 09/15/22) that indicated an audit was completed by V1 (Administrator), V2 (Director of Nursing), V20 (Floor Care Manager) and V9 (Social Service Director/Abuse Coordinator). On this form, any resident identified for being at risk for abuse and/or exhibiting potential abusive tendencies was indicated with a check mark. All residents identified with a check mark were having 15 minute checks conducted at the facility. On 09/19/22, R1 and R2's current care plans were reviewed, and both care plans document that on 09/15/22, additional interventions for R1 and R2 were added to prevent further resident to resident altercations. On 09/19/22 at 12:50 PM, a posted form stating the following: Attention all staff: Must review Abuse Training from 09/15/22 and sign in-service sheet prior to working the floor. Thanks for your cooperation. was hanging in a highly visible area next to the facility's employee time clock. On 09/19/22, V1 (Administrator) provided a copy of an In-Service Training Report (dated 09/15/22), which included 47 staff members signatures indicating that the required in-service training on abuse prevention, recognizing behavioral triggers, recognizing signs of latent aggression, and techniques to de-escalate behaviors had been completed. In addition, on 09/19/22, the following staff members were interviewed and verbalized knowledge of these same trainings: V1 (Administrator); V2 (Director of Nursing); V11 (Minimum Data Set Coordinator/Licensed Practical Nurse); V12, V13, V14, and V15 (Certified Nursing Assistants); V9 (Social Service Director); V16 (Licensed Practical Nurse/Restorative Nurse); V17 (Housekeeping); V18 (Registered Nurse); and V19 (Dietary). All staff interviewed stated the required training was completed prior to providing resident care. On 09/19/22, V1 (Administrator) provided a copy of the facility's current Abuse Prevention Policy and Procedure. Upon review, the following addendum was documented in the policy: Residents involved in a physical altercation will be separated and placed on one to one supervision for 12 hours. After the initial 12 hour period, the resident/residents involved will then transition to 15 minute checks for a minimum of one week, until the Quality Assurance/Abuse Committee members feel secure in the potential risk has been minimized. V1 stated the facility's policy was revised on 09/16/22 to reflect this addendum. On 09/19/22 at 12:25 PM, V1 (Administrator) provided a copy of the facility's QAPI (Quality Assurance Performance Improvement) Minutes form. V1 explained that the section titled, 'Social Service/Abuse Prevention' had been added to the required agenda on 09/15/22, which will be discussed in detail in future meetings. V1 then stated a record of monitoring of ongoing compliance of the facility's abatement plan will be maintained.

Based on interview, observation and record review, the facility failed to perform 15 minute resident checks as indicated and provide additional supervision after a verbal altercation occurred. R1 and R2 were separated following a verbal altercation on the evening of 06/03/22. Approximately three hours later, another verbal altercation ensued between R1 and R2 that escalated into a physical altercation. R1 was subsequently transported to a local hospital for treatment of a left eyebrow laceration, a bite wound to his right hand, and was also diagnosed with a left orbital fracture. R1 and R2 were two of four residents reviewed for abuse in the sample of six. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 09/16/22, the facility remains out of compliance at a Severity Level II as the facility implements the following: Conduct an audit to evaluate all residents for the need for increased supervision; Administer mandatory in-servicing to all direct care staff on behavior documentation, 15 minute checks, and increased supervision/resident oversight; Post a reminder sign by the time clock to ensure all subsequent shifts review the mandatory training materials prior to working the floor; Monitor daily behavioral charting and 15 minute checks; Revise the Abuse Prevention Policy and Procedure with an addendum regarding increased supervision following a physical altercation; For a minimum of 72 hours, the unsupervised smoking patio will have continuous staff monitoring by a rotation of staff members from all departments until it is locked at 10:00 PM, and will be unlocked only with staff supervision for ten minute intervals on off hours. The supervised smoking patios will be unlocked only during the monitored smoke pass every two hours and then permanently locked from 10:00 PM until 7:00 AM; Ongoing compliance will be monitored. Findings include: The facility's Behavior Monitoring policy (updated 1/2/22) documents the following: At any time the interdisciplinary team may initiate resident checks for increased monitoring, either on an hourly, 15 minute or one-to-one staff basis. R1's Progress Note (dated 9/3/22) documents the following: Resident in verbal altercation that turned physical. Resident hit with a cup and has laceration to left eye. Resident also bit on his right hand. Resident sent to (local hospital) for evaluation. R1's Progress Note (dated 9/4/22) documents the following: Resident returned from (local hospital) following an altercation with peer. Resident was brought back to this facility traveling with EMT (emergency medical transport). (R1) has a laceration to left eyebrow. The resident diagnosis was an Orbital Fracture, closed, initial encounter. Resident's skin is pink, warm and dry. This nurse cleaned dried blood from left area of face with normal saline. Vitals are stable. Resident complains of pain he rates his pain six out of ten. This nurse gave resident two Tylenol 325 mg (milligrams). (R1) has a new order for Augmentin 875-125 for possible infection from a bite on his right anterior surface of palm he received in the altercation. Resident is to take one tablet twice a day for 10 days. Initial dose will start today 9/4/22 at 4:00 PM. Resident is resting in bed with call light in reach. R1's local hospital After Visit Summary (dated 09/04/22) documents the following: Diagnosis: Injury due to Physical Assault. Fracture of left side of orbital floor. Facial laceration repaired with adhesive. Take Augmentin as directed for bite wound. R1's current care plan documents, (R1) is to start on antibiotic for a prophylactic related to human bite on right hand. This same care plan documents the following problem: (R1) has a history of criminal behavior. (R1) was convicted of battery/bodily harm in 2019, and unlawful use of a weapon in 1982. Interventions: 1:1 if necessary; Attempt to identify any triggers that illicit negative behavior; When the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. On 09/12/22 at 3:00 PM, R1 was sitting in a chair in the hallway near the building's front entrance. R1 was dressed and groomed and had a cane in his possession that he stated he utilized to assist when ambulating. R1 had a large purple scabbed area present on his left eyebrow. A dark purple area of bruising was present in R1's left orbit area underneath R1's left eye. R1 stated, The doctor at the hospital glued the cut by my left eye and told me that it needed to be glued instead of getting stitches because the cut was so close to my eye. I have a broken eye orbit on the left side of my face. I have been blind in my left eye for quite some time. I have a headache and the entire left side of my face is numb all the way down to my jawbone. I saw an eye doctor, and he said I need to see an ENT (ear, nose and throat) doctor about the orbit fracture. R1 then lifted his right hand exposing an oval-shaped scabbed area resembling a tooth imprint pattern. R1 stated, He bit me here on my hand. R1 then stated the following occurred on 09/03/22: I was in the dining room around 5:30 PM. There were a couple of empty chairs at a table, and I sat in one of them. (R2) was seated at the table and he told me that I couldn't sit there. He started cussing at me. They took him out of the dining room at that point. Around 9:30 PM, I went out for a cigarette. (R2) was outside near the door. He started running his mouth at me, and the next thing I knew I was on the ground bleeding. R1 then stated, I have been avoiding (R2). He came after me again a few days ago. The supervised smokers came out early, and I was already outside. He came out and I told him to get back. Staff (unable to identify) sent him back inside. I do not feel safe. I cannot defend myself with the way my leg is. Every day someone is fighting here. All day every day. R2's Progress Note dated 09/03/22 documents the following: Resident in verbal altercation that turned physical. No apparent injury. Cup taken away that he hit the other resident with. Resident in room. VSS (vital signs stable). R2's current care plan documents the following: Focus: (R2) has potential to be verbally/physically aggressive related to poor impulse control. (R2) will use racial language directed at staff and peers. (R2) displays a delusional thought process. (R2) is attention seeking at times, may hit/punch himself or bang his head on the wall. (R2) will provoke fights and put himself in a situation to where he can be injured from a fall because he gains attention from staff. (R2) will make false accusations and fabricate stories. (R2) had aggression with a weapon. Interventions: Analyze of key times, places circumstances, triggers, and what de-escalates behavior and document; Educate on importance of not calling peers names and risk factors that could occur; Resident on 15 minutes checks. Staff to check room for weapons; (R2) triggers for verbal aggression and his behaviors are de-escalated by removing him to a quiet area to assess the situation with reality orientation; When (R2) becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, allow (R2) to vent his feelings, encourage (R2) to avoid the source of his frustration to prevent escalation. R2's Smoking Assessment (dated 07/12/22) documents R2 was assessed as an independent smoker. R2's Smoking Assessment (dated 09/06/22) documents R2's smoking status was assessed as supervision required. On 09/14/22 at 08:55 AM, V2 (Director of Nursing) stated R2 was an independent smoker, and following the 09/03/22 incident, R2 was re-assessed and now requires staff supervision when smoking. On 09/13/22 at 09:35 AM, R2 was sitting in a chair in the front lobby near the building's entrance. R2 stated the following regarding the 09/03/22 incident: I was sitting by the cigarette butt can by the door on the AB patio. (R1) approached me and started rapidly punching me. I swung my water bottle at him to block him. I lunged at him, bit him and did everything I needed to get him away from me. V3's (Human Resources) Written Statement (dated 09/12/22) documents the following: After watching camera surveillance for the incident between (R1 and R2) that occurred 09/03/22. The incident takes place on the AB Patio. I was unable to see what resident initiated the fight, however, within minutes both residents pull into view of the patio. Both residents were tussling and holding each other until (R2) appears to let go; in which (R1) looks to stumble, losing balance going face forward on the concrete. Afterwards several CNAs (Certified Nursing Assistants) come to, what appears diffuse the situation. Within minutes a nurse arrives to assess/assist (R1), who was sitting up and talking with staff. On 09/12/22 at 01:42 PM, V3 (Human Resources) verified her written statement dated 09/12/22 and stated, I watched the video footage from the AB Patio where (R1 and R2's) physical altercation occurred. Most residents go smoke there. It was around 9:30 PM. The camera lens was dirty and has since been cleaned off. I could not see the area clearly where the altercation began. They (R1 and R2) came into view and appeared to be tussling and holding onto each other. (R2) let go causing (R1) to stumble and fall, and his face struck the concrete patio. (R1) got up pretty quickly and was sitting there holding his head. No staff members were out there, but soon (V4 and V5, Certified Nursing Assistants) responded. By this time, (R2) was walking away. (V5) attended to (R1) and (V4) went to get additional help. Then, (V5, V6 and V7) (Certified Nursing Assistants) and V8 (Registered Nurse) all came out to the patio. (V8) assessed (R1), who was still sitting up at that point. V3 then stated that (R1) does not have a community pass, He is a newer resident and I do not know of any physical or verbal altercations he has been involved in. (R2) just earned a grounds pass, which gives him access to go outside on the grounds, but he cannot leave the grounds. I know (R2) has a history of verbal altercations. I am unsure if he's ever had a physical altercation. This surveyor observed video footage with V3 on 09/13/22 at 8:00 AM. V3's above written statement correlates with the video footage, as the beginning of altercation is out of view. A metal cup is observed rolling across the patio before R1 and R2 move into view. On 09/12/22 at 2:38 PM, V4 (Certified Nursing Assistant) stated she responded to the altercation that occurred between R1 and R2 on 09/03/22. V4 stated, (R1 and R2) had an argument around 5:30 PM at dinner. They were at the dining room table. (R1) sat down in one of the chairs and (R2) told him that he couldn't sit there. (R1) sat down anyways. (R1 and R2) started arguing. (R2) was removed from the dining room and was taken to the front of the building. (R1) stayed at the table and ate his dinner. Later around 9:00 PM, one of the residents (unable to identify) was yelling. Me and (V5, Certified Nursing Assistant) went out on the patio. (V5) stayed with (R1) and I went back in to get more help. When I returned, (R2) was walking away. V6 (Certified Nursing Assistant) and V8 (Registered Nurse) came out. (R1) was sent to the hospital to get looked at. On 09/12/22 at 3:20 PM, V5 (Certified Nursing Assistant) stated on the evening of 09/03/22 at approximately 9:30 PM, she overheard R5 yelling the following: 'There's a fight outside! They are hitting each other! Someone's bleeding!' V5 stated, When I got outside, (R1) was on the ground holding his head and was bleeding. (R2) was standing directly over (R1) with his hand balled up in a fist and when he saw me, he unclenched his fist and began rubbing his other forearm. The lid to the metal tumbler cup was on the ground. After (R2) hit (R1) he must have thrown his metal cup because it was out in the grass beyond the patio. I tried to get (R2) to go inside at that point, and he ignored me and walked out to the grass to retrieve his cup. (V8, Registered Nurse) had come outside and was assessing (R1). EMT (emergency medical transport) was contacted and (R1) was sent to the hospital. (R2) asked for his cup because we had taken it away. (V8) asked (R2) if he had hit (R1) with the cup and (R2) said, 'Yeah. I f*cking hit him with the cup.' Me, (V8), and (V7, Certified Nursing Assistant) heard him say it. (R1) also had teeth marks in his right hand and it was bleeding. It appeared that he had been bitten. There was blood all over. It was on the ground, on (R1's) face and on his hands. (R2) had been instigating and problematic all night. He started a fight with (R1) in the dining room at dinner around 6:00 PM. He also popped off at (R4) in passing in the smoking area after dinner. (R4) was coming inside while (R2) was heading outside. After the fight with (R1), (R2) was very mouthy with the staff. He could not be redirected. I've worked here for a couple of months, and (R2) has a smart mouth. He likes to provoke people. He is very noncompliant. He's an instigator. He picks and picks and picks at people. On 09/12/22 at 03:50 PM, V6 (Certified Nursing Assistant) stated the following occurred on 09/03/22: I was on break. I was out front of the building and (V7, Certified Nursing Assistant) came and got me and told me that (R2) attacked (R1). I immediately went out back to the patio. (R1) was sitting up. His face was bleeding. (V7) and (V8, Registered Nurse) were also present. (V8) assessed (R1), and then we got him up and called the ambulance. Someone took the cup (R2) used to hit (R1) with. After (R1) was sent out, (R2) was pacing around for a while. (R1) and (R2) were arguing at dinner earlier that night, it was about 5:30 PM. (R2) was then removed from the dining room. Around 6:00 PM, (R2) and (R4) exchanged words in passing at the patio. We try to keep those two separated. We also try to keep (R1) and (R2) separated. If we are busy and (R1) or (R4) cross paths with (R2), they usually end up having words. (R2) has been physical in the past. Mostly with (R4). On 09/12/22 at 08:50 PM, V8 (Registered Nurse) stated the following occurred on 09/03/22: (R1 and R2) had gotten into an argument earlier that night at dinner. (R1) sat at (R2's) table, and (R2) told (R1) he could not sit there. (R1) sat at the table anyways, and then they began to argue. Staff intervened and told them to stop. Later around 9:00 PM, one of the CNAs (Certified Nursing Assistants) came in and said a nurse was needed out on the patio. I went out and (R1) was sitting on the ground. He was bleeding from his left eyebrow. He said (R2) said something to him while he was walking out and then everything happened so fast. When I spoke to (R2), he said that (R1) started hitting him and then he fought back. (R2) did not have any marks or bruises and was not injured. (R2's) metal tumbler cup's lid was on the ground and the cup was on the ground several feet away in the grass. I said something to (R2) and he admitted hitting (R1) with the cup and he said, 'Hell yeah I hit him.' (R2) went inside and was trying to call somebody. I stayed with (R1). He didn't even know that his eye had been cut that bad. He is blind in his left eye. On his right hand, there was a skin tear with a small amount of blood present, and it certainly could have been a bite mark. I helped (R1) up into a chair outside on the patio. When the ambulance crew arrived, they came out on the patio. We didn't want to take (R1) back inside since (R2) was in there. (R2) was angry that we took his cup. (R2) has a history of physical aggression to other residents. As far as I know, (R1) has no known aggression. (R2) starts a lot of trouble here. He targets (R4). We try to keep them apart as much as possible. A few months ago, (R2) stabbed (R4) with a metal butter knife in the abdomen. Those two are rivals. Like the Bears and the Packers. 09/13/22 at 09:15 AM, V7 (Certified Nursing Assistant) stated the following regarding the 09/03/22 incident: (R1 and R2) had gotten into an argument in the dining room at dinner. (R2) was cussing so he was asked to leave the dining room. Later they got into a fight outside. (R1) was on the ground bleeding when I got outside. (R2) was yelling and cussing. (V8, Registered Nurse) went out and examined (R1). We got him up in a chair, called 911, and he went to the hospital. (R1) said (R2) bit him, and (R2) admitted that. (R2) is horrible. He is always using terrible language. He and (R4) don't get along at all. On 09/13/22 at 11:10 AM, R5 stated she witnessed the altercation between R1 and R2 on 09/03/22, and stated, (R2) knocked (R1) on the ground. There's a fight here every day. On 09/13/22 at 08:30 AM, R4 was sitting in a wheelchair in the hall outside his room. R4 stated he has issues with R2, All he wants to do is start a fight with me all the time. He is always running his mouth. R2 lifted his shirt up exposing a scar on his abdomen and stated, He stabbed me with a metal knife a while ago. R4 then stated, He was talking sh*t to me about a week ago. On 09/12/22 at 01:20 PM, R3 was standing outside near the front entrance to the facility. R3 stated the following: I'd like to go somewhere else. There is always fighting here. I am not violent and do not like all the fighting. 09/13/22 at 12:56 PM, V9 (Social Service Director/Abuse Coordinator) stated the following regarding the recent altercation involving R1 and R2: (R1) has a problem with alcohol abuse. I am not aware of (R1) having any history of verbal or physical aggression. (R2) has been in several altercations lately. Mostly verbal and argumentative in nature. (R2) has been verbally aggressive with facility staff, and (R4). (R2) and (R4) don't get along. (R2) has been physical with (R4) in the past. Approximately four months ago, (R2) stabbed (R4) in the abdomen with a metal knife. On 09/13/22 at 01:20 PM, V10 (Social Services) stated the following in regard to the incident between R1 and R2 on 09/03/22: On 09/06/22, (R2) approached me and stated what had happened during the altercation. (R2) stated that (R1) tried to sit at the table and (R2) asked him to move. (R1) refused, and then an argument began. The two were separated. (R2) then stated that (R1) was banging his cane on a table, attacked (R2), and (R2) defended himself. V10 then stated, When I interviewed (R1), he told me that he was sitting outside on the smoking patio and (R2) was outside as well. (R1) stated that (R2) continued to argue about the dining room incident and then attacked him, struck him with a metal tumbler cup, and bit him on his right hand. V10 then stated, I went back through their care plans and reviewed the notes. (R2) has a history of previous altercations, both verbal and physical. So, I determined the incident occurred as a result of (R2's) mood disorder. R2's electronic Tasks document the following: 15 Minute Safety Checks due to monitoring. Check resident's room for weapons (date of initiation 06/10/22). R2's Task History (dated 09/03/22) document no 15 minute checks were completed for the remainder of 09/03/22 after 3:30 PM. On 09/14/22 at 12:00 PM, V2 (Director of Nursing) stated that 15 minutes were not completed on R2 on 09/03/22 and should have been. V2 confirmed that no additional supervision was implemented after the verbal altercation occurred between R1 and R2 at the dinner table on 09/03/22. The Immediate Jeopardy was identified on 9/15/22 at 2:00 PM to have begun on 09/03/22 when visual checks were not conducted on R2 every 15 minutes and additional supervision was not implemented after the verbal altercation occurred between R1 and R2. V2 (Director of Nursing) was notified of the Immediate Jeopardy on 9/15/22 at 2:16 PM. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: On 09/19/22, V1 (Administrator) provided a copy of a resident roster (dated 09/15/22) that indicated an audit was completed by V1 (Administrator), V2 (Director of Nursing), and V9 (Social Service Director/Abuse Coordinator). On this form, all residents in the facility were evaluated for a need for increased supervision. V1 indicated no additional residents were identified. On 09/19/22, V1 (Administrator) provided a copy of an In-Service Training Report (dated 09/15/22), which included multiple staff signatures indicating that the required in-service training on behavior documentation, the process of 15 minute checks, and increased supervision/resident oversight had been completed. In addition, on 09/19/22, the following staff members were interviewed and verbalized knowledge of these same trainings: V1 (Administrator); V2 (Director of Nursing); V11 (Minimum Data Set Coordinator/Licensed Practical Nurse); V12, V13, V14, and V15 (Certified Nursing Assistants); V9 (Social Service Director); V16 (Licensed Practical Nurse/Restorative Nurse); V17 (Housekeeping); V18 (Registered Nurse); and V19 (Dietary). All staff interviewed stated the required training was completed prior to providing resident care. On 09/19/22 at 12:50 PM, a posted form stating the following: Attention all staff: Must review Abuse Training from 09/15/22 and sign in-service sheet prior to working the floor. Thanks for your cooperation. was hanging in a highly visible area next to the facility's employee time clock. On 09/19/22, V1 (Administrator) provided a copy of a scheduled titled 'Daily Documentation Check.' V1 explained this scheduled indicates which staff member is responsible for monitoring daily behavioral charting and 15 minute checks in the facility's electronic documentation system. On this same date at 12:35 PM, V2 (Director of Nursing) accessed the electric documentation system and explained the areas that staff is responsible for monitoring. Both daily behavior charting and 15 minute checks had been completed on the residents who require this documentation. On 09/19/22, V1 (Administrator) provided a copy of the facility's current Abuse Prevention Policy and Procedure. Upon review, the following addendum was documented in the policy: Residents involved in a physical altercation will be separated and placed on one to one supervision for 12 hours. After the initial 12 hour period, the resident/residents involved will then transition to 15 minute checks for a minimum of one week, until the Quality Assurance/Abuse Committee members feel secure in the potential risk has been minimized. V1 stated the facility's policy was revised on 09/16/22 to reflect this addendum. On 09/19/22, V1 (Administrator) provided copies of the facility's Daily Staffing Assignment Sheets (dated 9/16/22 - 9/18/22). On these forms, several staff members were assigned a time to monitor the smoking patio. On this same date from 12:30 PM until 3:30 PM, observations of the facility's unsupervised and supervised patios were conducted. A staff member was present on the unsupervised smoking patio throughout this time. The facility's supervised smoking patio remained locked and was unlocked with a staff member present providing supervision at 3:05 PM while the supervised smokers were out on the patio. On 09/19/22 at 12:25 PM, V1 (Administrator) stated that ongoing compliance will be monitored and discussed daily amongst V1 and the members of the interdisciplinary team.

Based on observation, record review and interview the facility failed to prevent an occurrence of resident-to-resident physical abuse from occurring for 2 residents (R106 and R204) reviewed for abuse in the sample of 11. This failure resulted in R204 aggressively pushing R106 resulting in an acute right rib fracture. Findings Include: The facility policy, Abuse Prevention Program Facility Procedures, dated (revised) 9/15/22 documents, The facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. 1. R204's current Medical Diagnosis Sheet, documents the following diagnosis: Intracranial Injury, Bipolar Disorder, Anti-social Personality Disorder. R204's MDS (Minimum Data Sheet) Assessment, dated 9/27/2022, documents, under E.) Behavior-B.) Potential Indicator of Psychosis. Yes-Delusions (Misconceptions or beliefs that are firmly held, contrary to reality.) R204's Care Plan dated, 10/4/2022. Documents, R204 has a behavior problem, displays a delusional thought process as to limitations of diagnosis, effects on self-others, environment and surroundings. R204 has been seen being threatening and verbally aggressive with staff and peers. R204's Progress Notes, dated 11/11/2022 at 10:39 AM, R204 has displayed aggressive behavior, R204 threw two full pitchers of water on V12/ CNA (Certified Nursing Assistant). R204 got into an altercation with a peer where R204 was the aggressor. R204 was redirected and has been put on a 1 to 1 with a CNA or staff member for 24 hours. On 11/10/2022 at 11:20 AM R204 was observed standing in front of the nurse's station, R204, appeared to be irritated and anxious with staff. R204 had a water pitcher in each hand and threw them at V12/ CNA (Certified Nursing Assistant) that was behind the nurse's station. R204 was heard yelling very loudly at R106. V5/Social Service Assistant was able to intervene and remove R204 from the occurrence. R204 was taken into a nearby office to calm down. After just a few minutes R204 was seen walking out of the office in front of V5/ Social Service Assistant towards R106. R204 was observed to violently hit R106 in the back causing R106 to fall on R106's knees, landing in a fetal position. R204 was removed from the scene and taken to R204's room. On 11/10/2022 at 12:10 PM V12 stated, I am not sure what was going on with R204, but R204 threw 2 full water pitchers at me for no reason. Got the front of my uniform all wet. R204 can be very impulsive, it doesn't take much for R204 to get agitated and combative. R204 can be hard to redirect from an altercation. On 11/10/2022 at 12:20 PM V14/RN (Registered Nurse) stated, R106 was pushed very hard, R106 was complaining of right sided rib pain and was having some shortness of breath. He also had a large abrasion down R106's right side. The impact from R106 being pushed was very hard, it could have really hurt R106. I don't know what started the altercation, but it occurred fast for anyone to try and stop it. R106's Hospital ED (Emergency Department) Notes, dated 11/10/22 document, (R106) presented to the ER (emergency room ) complaining of right sided chest pain after being pushed down prior to arrival. (R106) states he was pushed down by another member of the facility he lives at. (R106) presenting with right rib pain after being pushed. Tenderness overlying area of bruising to the right chest wall. Chest x-ray shows what might be a fracture to lateral fifth rib. Clinical Impression: Closed fracture of one rib right side. On 11/11/22 at 8:45 AM R106 was lying in bed on his left side. R106 had no incentive spirometer in his room. R106 stated, I got pushed down yesterday. I did not appreciate it. That resident (R204) is mean. I am hurting whenever I move. My ribs hurt. I haven't gotten anything for pain, and no one has had me do deep breathing.

Based on observation, record review and interview the facility failed to prevent an occurrence of resident-to-resident physical abuse from occurring for 2 residents (R106 and R204) reviewed for abuse in the sample of 11. This failure resulted in R204 aggressively pushing R106 resulting in an acute right rib fracture. Findings Include: The facility policy, Abuse Prevention Program Facility Procedures, dated (revised) 9/15/22 documents, The facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. 1. R204's current Medical Diagnosis Sheet, documents the following diagnosis: Intracranial Injury, Bipolar Disorder, Anti-social Personality Disorder. R204's MDS (Minimum Data Sheet) Assessment, dated 9/27/2022, documents, under E.) Behavior-B.) Potential Indicator of Psychosis. Yes-Delusions (Misconceptions or beliefs that are firmly held, contrary to reality.) R204's Care Plan dated, 10/4/2022. Documents, R204 has a behavior problem, displays a delusional thought process as to limitations of diagnosis, effects on self-others, environment and surroundings. R204 has been seen being threatening and verbally aggressive with staff and peers. R204's Progress Notes, dated 11/11/2022 at 10:39 AM, R204 has displayed aggressive behavior, R204 threw two full pitchers of water on V12/ CNA (Certified Nursing Assistant). R204 got into an altercation with a peer where R204 was the aggressor. R204 was redirected and has been put on a 1 to 1 with a CNA or staff member for 24 hours. On 11/10/2022 at 11:20 AM R204 was observed standing in front of the nurse's station, R204, appeared to be irritated and anxious with staff. R204 had a water pitcher in each hand and threw them at V12/ CNA (Certified Nursing Assistant) that was behind the nurse's station. R204 was heard yelling very loudly at R106. V5/Social Service Assistant was able to intervene and remove R204 from the occurrence. R204 was taken into a nearby office to calm down. After just a few minutes R204 was seen walking out of the office in front of V5/ Social Service Assistant towards R106. R204 was observed to violently hit R106 in the back causing R106 to fall on R106's knees, landing in a fetal position. R204 was removed from the scene and taken to R204's room. On 11/10/2022 at 12:10 PM V12 stated, I am not sure what was going on with R204, but R204 threw 2 full water pitchers at me for no reason. Got the front of my uniform all wet. R204 can be very impulsive, it doesn't take much for R204 to get agitated and combative. R204 can be hard to redirect from an altercation. On 11/10/2022 at 12:20 PM V14/RN (Registered Nurse) stated, R106 was pushed very hard, R106 was complaining of right sided rib pain and was having some shortness of breath. He also had a large abrasion down R106's right side. The impact from R106 being pushed was very hard, it could have really hurt R106. I don't know what started the altercation, but it occurred fast for anyone to try and stop it. R106's Hospital ED (Emergency Department) Notes, dated 11/10/22 document, (R106) presented to the ER (Emergency Room) complaining of right sided chest pain after being pushed down prior to arrival. (R106) states he was pushed down by another member of the facility he lives at. (R106) presenting with right rib pain after being pushed. Tenderness overlying area of bruising to the right chest wall. Chest x-ray shows what might be a fracture to lateral fifth rib. Clinical Impression: Closed fracture of one rib right side. On 11/11/22 at 8:45 AM R106 was lying in bed on his left side. R106 had no incentive spirometer in his room. R106 stated, I got pushed down yesterday. I did not appreciate it. That resident (R204) is mean. I am hurting whenever I move. My ribs hurt. I haven't gotten anything for pain, and no one has had me do deep breathing.

Based on observation, interview, and record review, the facility failed to protect a resident (R1) from physical and verbal abuse by a staff member for one of three abuse allegations reviewed. This failure resulted in (R1) being verbally abused by (V4) and forcefully pushed to the ground. Then, (R1) was struck in the right side of his face with an open hand and struck on the left side of his face with a closed fist causing (R1) to fall to the floor. (R1) was sent to the ER (emergency room ) where he was diagnosed with skin tear of left upper arm, closed head injury, and strain of lumbar region. This had the potential to affect all 95 residents residing in the facility. These failures resulted in an Immediate Jeopardy: Findings include: While the immediacy was removed on 7/28/22, the facility remained out of compliance at a Severity Level 2. The facility is ensuring that all staff are in serviced on the facility's policies and procedures regarding abuse and de-escalation of resident behaviors. The facility is also providing a CPI (Crisis Prevention Institute) refresher training to all security personnel. The facility's Abuse Prevention Program, no date available, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. The facility Security Monitor Job Description, no date available, documents, A Security Monitor is to provide a safe and secure environment for the residents of this facility. All security staff shall present themselves in a professional manner at all times. Your duties as Security Monitor at [NAME] Healthcare Pines are as follows: You are hired in a security position, and you shall carry yourself as a security person at all times when working. On 7/18/22 at 12:07 p.m., (R1) was standing in the dining room. (R1) stated, That worker (V4/Security) at the front desk hit me and shoved me down for no reason. I was just trying to talk to someone about going to my wife's house, and he pushed me down. (R1) went on to say, Look at my arm (pointing at several irregular shaped dark brown scab areas to his left elbow) (V4) messed it up. While speaking with (R1), he pointed to these areas. On 7/19/22 at 2:00 p.m., video surveillance of 7/5/22 was reviewed with (V2/Director of Nursing). At 8:39 p.m., (V4) walking down hallway towards the dining room. (V5/Certified Nurse Aide/CNA) was standing with (R1). (R1) was agitated and (V5) was attempting to redirect him. (V4) walked up to (V5) and (R1). (V4) was behind (V5) and (R1) was in front of (V5). (V5) suddenly jumped out of the way. (R1) attempted to swing at (V4) with his right arm. (V4) ducked back, but at the same time swung his left arm striking (R1) on the left side of his face with an open hand. (R1) attempted to hit (V4) again. (V4) was holding a key with a PVC ([MEDICATION(S)] chloride) pipe attached to it in his right hand. When (R1) attempted to hit (V4) again, (V4) hit (R1) with a closed fist that was also holding the PVC pipe on the left side of (R1's) face knocking (R1) to the ground. As soon as (R1) hit the floor, (V4) looked at (R1) on the ground and walked away. (V5) began assisting (R1). At 8:43 p.m., (R1) walked up to the security desk, picked up a box of surgical masks and threw them at (V4) who was sitting behind the desk. (V4) picked up the box and threw it back at (R1) hitting him in the left shoulder. At 8:49 p.m., (V6 /Social Services) showed up to the facility and asked (V4) to leave. (V4) exited the facility at 8:51 p.m. At 8:54 p.m., the ambulance arrived to the facility to transport (R1) to the emergency room . On 7/26/22 at 10:10 a.m., video surveillance was reviewed with (V5) and (V13/Social Services/Human Resources): The camera angles were changed from previous viewing to now point at the nurses' desk. At 8:37 p.m., (R1) was standing at the nurse's station, on the nurses' station phone behind the desk. (V4) walked up to the nurses' desk and removed the phone from (R1's) hand. (V4) got in between (R1) and the desk. (R1) swung at (V4) with his right closed fist. (V4) raised his right arm and forcefully pushed (R1) in the chest using the back side of (V4's) forearm. (R1) fell to floor. (V4) did not assist, nor did he summons any staff. (V4) walked behind the desk while (R1) got himself up off of the floor. (V4) was on the phone while (R1) stood there watching (V4). At this point of viewing, (V5) and (V13) stated that no one was aware (V4) shoved (R1) down while standing at the nurses' station. (V13) stated, (R1) normally isn't this violent. So, I've always felt like something must have happened to really make him mad at (V4). Well, he was obviously mad because (V4) shoved him down at the nurses' desk before the other incident even happened. Continuing with the video surveillance: At 8:38 p.m., (V4) left the desk. (V5) walked up to the desk, and (R4) approached (V5) talking to (V5) over excitedly. (V5) stated, (R4) told me someone had pushed (R1) down, but that was it. (V4) entered the men's restroom with a key attached to an approximately 12 inch long by 1 inch wide PVC pipe attached to it. Once (V4) exited the bathroom, he walked up the hallway towards (R1) and (V5). On 7/20/22 at 10:45 a.m., (V5/CNA) stated, I'm not sure what led to the argument between (R1) and (V4/Security). When I came back into the building all I heard was (R1) yelling. (V4) was walking towards me and I asked him what was going on. (V4) told me that (R1) was upset because (V4) told him that he couldn't use the nurses' station phone. (R1) was wanting to get to (V4) at the front desk. I was trying to defuse this situation and I was pushed out of the way by (R1). (R1) yelled at (V4) that he was going to beat the s*** out of him. (R1) charged (V4) and (V4) hit him a few times. (V4) slapped (R1) in the face twice and caused (R1) to hit the floor. After (V4) hit him, when (V4 walked away he called (R1) a 'b***h a*s mother f****r'. I was trying to defuse the situation as much as I could. (R1) tried to get up to (V4) two different times at the front desk. I stayed with him the whole time. The first time we were up there, (R1) threw a bottle of hand sanitizer at (V4) behind the desk. (R1) said, 'That mother f****r smacked me.' (V4) responded back to him, 'If you're trying to come back here, I'm going to whip your a*s.' I got (R1) to walk back up the hall, but he went right back to the desk. (R1) grabbed a box of surgical masks and threw them at (V4). (V4) then threw the box back at (R1) hitting him in the shoulder. (V4) said, 'Let him back here. The facility's 24-hour Abuse Investigation Report, dated 7/6/22, documents, 7/5/22 at 8:40 p.m., (R1) in dining area, had altercation and fell causing injury. Skin tear to elbow. The facility's Final Abuse Investigation Report, dated 7/5/22, documents, (R1) was in the front lobby on 7/5/22 at 8:40 p.m. Got involved in a verbal altercation escalated to physical confrontation resulting in resident falling with resulting in injury to his elbow. (R1) was agitated in the front lobby was yelling at (V4/Security). (R1) continued to cuss and yell at staff. (R1) tried to hit (V4) and (V4) hit him back. (R1) tried to hit (V4) again and (V4) again hit (R1) causing him to fall. An abusive incident occurred resulting in (V4) being terminated. Facility Information report, no date available but signed by (V6 /Social Services), documents, Watched incident (security camera footage) from 7/5/22 on 7/6/22. (R1) was seen approaching my staff (V4) in an agitated manner. (R1) attempted to hit (V4) twice but (V4) hit him back both times caused (R1) to fall. Facility Information report dated 7/6/22 and signed by (V3/Assistant Director of Nursing), documents, I observed video surveillance of an incident that occurred between a staff member (V4) and a resident (R1) that took place on 7/5/22 during the evening hours. While watching the video footage, I observed a female staff member (V5) attempting to redirect (R1) who was ambulating toward the front exit. I then observed another staff member (V4) approach (R1) and the other staff member. (V4) stood between the female staff member (V5) and (R1) in an attempt to resolve the situation. I then observed (R1) then swing his arm/fist at (V4's) head however, (V4) ducked and no contact was made. (V4) then swung at (R1) making contact causing (R1) to fall to the floor. (V4) then turned and walked away while the other staff member along with several others tended to (R1). Facility Information report dated 7/5/22 and signed by (V5/ CNA), documents, I came in from outside to (V4) and (R1) going back and forth about (R1) answering the nurse phone. (V4/Security) began to call (R1) names and (R1) started following (V4) calling him names back. (V4) then turned around and started to approach (R1). (V4) then got into (R1's) face and (R1) swung at (V4). (V4) then hit (R1). (R1) swung again and missed (V4) then hit (R1) again in the face causing (R1) to fall to the ground and start to bleed. Facility Information report dated 7/6/22 and signed by (V6/Social Services), documents, There was a physical altercation between my staff/front desk person (V4) and the resident (R1) resulting in a fall for the resident with an injury. (V4) was suspended pending abuse investigation. (R1) told me, 'I didn't fall that black man up front pushed me down. (R1's) emergency room Progress notes, dated 7/5/22, document, (R1) presents to emergency department today after ground level-fall. He notes that he was shoved, and he fell backwards. He is complaining of head and neck pain as well as some lower right lumbar pain. He also notes that he has a skin tear to his left elbow. (R1's) emergency room After Visit Summary, dated 7/5/22, documents, Reason for visit: Neck pain. Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/20/22 at 12:10 p.m., (V7/Registered Nurse) stated, I didn't witness the actual incident, but I helped with the laceration on (R1's) arm up. I could hear (V4) yelling, but I can't recall what was said. The other nurse and myself took care of (R1). The jagged laceration was on his left elbow. It was about 2 inches long and deep enough that it needed something to close it. We couldn't get it to stop bleeding, he was complaining of back pain, and since he had been hit in the head, we made sure and sent him to the ER. We wanted to make sure there was no fractures or any other injuries and get that wound closed up. (R1) has mental health issues and likes to instigate things, but (V4) should know what population he works in. You can't react to that. (V4) needed to just walk away. On 7/26/22 at 1:10 p.m., (R5) stated, (R1) and (V4) got into a verbal argument in the dining room. It seemed like (R1) wanted to fight (V4). I heard them yelling back and forth, but I don't know what they said. I didn't see (V4) hit (R1). All I saw was (R1) falling to the ground. (R1) told me that (V4) had pushed him down. On 7/26/22 at 1:40 p.m., (R4) stated, There was arguing between (R1 & V4). There was a lot of cuss words going on back and forth between the two of them. It seemed like (V4) got frustrated, snapped, and pushed (R1) down. I told (V4) that (R1) got shoved down onto the floor, but I didn't tell her who it was. On 7/20/22 at 2:30 p.m. (V2/Director of Nursing) stated, (V4) physically abused (R1). He hit him not once but twice. It makes me sick. He was suspended immediately, and then terminated the following day for abuse. V4's Employee Report, dated 7/6/22, documents that (V4) was terminated for abuse. The facility's Census Number, dated 7/26/22, documents that 95 residents reside in the facility. An Immediate Jeopardy situation was identified on 7/26/22. The Immediate Jeopardy was identified to have begun on 7/5/22 when (R1) and (V4) were in a verbal altercation that led to (V4) physically pushing (R1) to the floor. Then, just minutes later, (R1) and (V4) were in another verbally abusive altercation that led (V4) to open-handed slap (R1) to the right side of (R1's) face and hitting (R1) in the left side of his face with a closed fist that was holding a PVC pipe. (V4) continued to verbally abuse (R1) and threw a box of surgical masks striking (R1). (R1) was later sent to the emergency room where he was diagnosed with skin tear of left upper arm, closed head injury, and strain of lumbar region. On 7/27/22 at 9:45 a.m., (V1/Administrator) and (V2) were notified of the Immediate Jeopardy situation. On 7/28/22, the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. (V4) was terminated on 7/6/22 by (V1 and V6). 2. A facility audit was completed on 7/27/22 by (V1, V2, and V14/SSD) to evaluate the residents for any potential risk for abuse and/or exploitation. 3. All staff were in-serviced on abuse and de-escalation of resident behaviors on 7/28/22 by (V1 and V14). 4. An audit of all facility staff was completed on 7/27/22 by (V1, V2, V3), and (V13/Social Services/Human Resources) to evaluate any staff that may require a 1:1 review of the mandatory training. 5. A CPI refresher course for all Security Personnel was completed on 7/28/22 by (V16/Certified CPI Instructor).

Based on interview and record review the facility failed to prevent sexual abuse for two of three residents (R4 and R5) reviewed for abuse in the sample of three. This failure resulted in two cognitively impaired (non-consenting) residents with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 6/30/22, the facility remains out of compliance at Severity level II as the facility continues to assess all residents for behavioral disturbances prior to admission, R4's sexual behavior interventions are implemented, and the facility continues to in-service all staff on the Abuse Policy. Findings include: The facility's Abuse Prevention Program Facility Policy undated, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Sexual Abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. According to R4's current POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's MDS (Minimum Data Set) assessment dated , 6/20/22, documents R4 has a BIMS (Brief Interview of Mental Status) of 06 (cognitively impaired) and is completely dependent on staff for ADL's (Activities of Daily Living). R4's current Impaired Cognitive Function care plan revised 10/20/21, documents, (R4) may need to be taken to a quiet area to assess confusion and have message related. (R4) understands consistent, simple, directive sentences. R4's Limited Physical Mobility plan of care revised on 1/12/22, documents, Limited Physical mobility related to traumatic brain injury and is completely dependent on staff. Interventions include: Encourage (R4) to do ROM/Range of Motion with staff giving verbal cues, assistance with ROM as needed. R4's Behavior plan of care revised on 10/20/21, documents, May be resistive to care, refuse medications, anxious at times, sexually inappropriate at times. This same plan of care does not specify the inappropriate sexual behavior or any interventions addressing the sexual behavior. According to R5's current POS, R5 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Interim plan of care dated 6/15/22, documents R5 is independent ambulating with a walker and did display inappropriate sexual behavior on admission. The facility's IDPH (Illinois Department of Public Health) Final Notification Investigation Report for incident of 6/15/22, signed by V1(Administrator), documents, Name of Resident Abused or Neglected: (R4). diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Original Allegation: On third shift in resident (R4's) room, roommate (R5) was potentially sexually inappropriate with (R4). CNA/Certified Nursing Assistant (V11) walked in on incident during facility round. No injury with resident (R4). During the process of investigation, medical record review and interview of witnesses the following facts were determined: No history of sexually inappropriate behavior with new admit (R5). (R4) has a history of sexually inappropriate behavior including exposing himself and inappropriate touching with staff. Based on the Known Facts, the following conclusions have been determined about the original allegation: Residents (R4 and R5) engaged in a sexual act with (R5) performing oral sex on (R4), no evidence to confirm abuse but unable to assess consent so residents' (R4 and R5) were interrupted and separated. The following Actions taken based on the facts and conclusion of the investigation: (R5) moved to another room for the night, his family was not comfortable and discharged (R5) back home. A written investigation report dated 6/16/22 and signed by V5 (Social Service Director) documents, I had a one-on-one interview with (R5) regarding the incident that happened with (R5's) roommate (R4). (R5) stated '(I) was just in my room and my roommate pulled his sheet down and started rubbing himself until he was 'hard' looking at me, so (I) just did it and (R4) liked it. On 6/24/22, at 11:55 am., V1 (Administrator) stated, I did an investigation regarding (R4) and (R5). (R4) has sexual behaviors of exposing himself at times. (R4) has exposed himself to me. I did not receive any information on or before admission about any sexual behaviors by (R5) On 6/25/22 at 6:30 pm., V7 (CNA/Certified Nursing Assistant) stated, (R4) cannot speak but does shake his head yes and no and does understand what we are asking. (R4) sometimes won't respond to certain staff or people but will if he wants to. (R4) really likes V11/CNA and will always respond to her. On 6/24/22 at 6:45 pm., V11 stated she has taken care of R4 for years. V11 stated R4 will communicate with her by shaking his head yes or no and does understand cognitively. V11 stated, (R5) was admitted on [DATE]. (R5) was put in (R4's) room as roommate. I was doing rounds that night and knocked on (R4) and (R5's) door and then opened it and walked in. (R4) was lying in the bed with his legs dangling off the bed with a full erection. (R5) was bent over performing oral sex on (R4). (R4's) eyes were big and he looked scared and didn't know what to do. I said what are you doing and (R5) stopped at this time and crawled back to bed. I asked (R4) if he would have wanted that to happen and he shook his head no. I separated the two and got the nurse (V10/RN/Registered Nurse). We moved (R5) to another room for the night. (R4) has never had any sexual activity with any other males or has tried to. (R4) would not be able to stop (R5) if he wanted to, (R4) is totally dependent on staff. V11 also stated (R5) was somewhat confused and was independent with ADL's. On 6/24/22 at 6:38 pm., R4 was sitting in his wheelchair and did not have full ROM with his arms and legs and was unable to move around freely per self. R4 responded to questions asked by shaking his head yes and no. R4 shook his head correctly to simple questions. When asked if anyone has done anything to him, he did not like, R4 responded by shaking his head yes. When asked if someone performed oral sex on him, (R4) responded shaking his head yes. (R4) shook his head no when asked if he wanted the oral sex. On 6/25/22 at 10:22 am., V12 (R5's mother) stated, R5 has been in a group home from the time he was 24 and is now 53. (R5) has had behaviors of flirting with women and sometimes grabbing the nurses but I have never got any reports of sexual misconduct from (R5) towards any residents and certainly not any male residents. (R5) was in a group home with all men and it has never been reported to me any sexual contact with any of them. (I) am shocked to hear that this even happened especially with another male, as he would have never done this prior to his brain injury. (R5) has always talked about liking women and never any men. (I) am upset this even happened. (R5) is now living back at home with me. V12 also stated (R5) has a brain injury and does not remember things of short term and would not remember if that happened. On 6/25/22 at 10:28 am., R5 was oriented to place but not date or time. When asked if R5 remembered staying at a local nursing home for one night approximately one week ago, R5 responded no. R5 stated he lived at (the group home) and now lives at home. R5 stated he did not have oral sex with a male and would never do that. R5 stated I like women not men. On 6/26/22 at 1:58 pm., V13 (LPN/Licensed Practical Nurse) stated, (R4) is not capable of protecting himself. No way (R4) could have stopped (R5) from the sexual incident. On 6/27/22, at 2:00 pm., V2 (DON/Director of Nursing) stated, (R4) has inappropriate sexual behaviors of pulling it out penis wherever he is sitting rather it be in the dining room, television room, or his own room. On 6/27/22 at 2:05 pm., V14 (ADON/Assistant Director of Nursing) stated, (R5) was alert but had very short memory. (R5) upon admission kept grabbing at me and I would redirect his and he would then do it again. Then all the sudden (R5) would say 'my name is (R5) what's your name.' (R5) didn't know what he answered a few minutes after he was asked questions. On 6/27/22 at 2:15 pm., V15 (Care Plan Coordinator) stated, When (R5) was admitted (R5) kept groping at the CNAs constantly. (R5) would have to be directed constantly, he was alert but confused. V15 also stated (R4) was care planned for sexual inappropriate behaviors before I was here, I have only known him to pull down his covers at times. He really can't do anything but slide down in his chair. Knowing (R4) I don't think he would have liked (R5) having oral sex on him. An Immediate Jeopardy was identified on 6/28/22. The Immediate Jeopardy began on 6/15/22 when R4 was found on R4's bed with his legs dangling off the bed with a full erection and R5 performing oral sex on R4. On 6/28/22 at 2:46 pm., V1 (Administrator), and V2 (Director of Nursing) were notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. The Administrator (V1) and DON (Director of Nursing) initiated a whole house audit on 6/28/22 which was conducted by the Interdisciplinary Team to evaluate the whole house for residents at potential risk for sexual abuse and/or exploitation with no evidence of additional at-risk clientele noted. On 6/28/22, V16 (Social Service Director) initiated a facility audit to assess all residents for potential risk for sexual abuse and/or exploitation with no further risk individuals identified. 2. An all-staff-in-service was conducted on 6/28/22 by Social Service Director (V16) on Resident Abuse-Sexual abuse with 1st and 2nd shift. The Care Plan Coordination (V15), Administrator (V1), and the D.O.N. (Director of Nursing) (V2) were included in the training to review the abuse policy specific to resident-to-resident sexual abuse and identifying and implementing interventions to prevent sexual abuse for resident with a history of inappropriate sexual behavior. Materials to be reviewed on 6/28/22 with the 3rd shift staff by the charge nurse. The Facility's check off sheet for all staff in-serviced and staff not yet in-serviced was reviewed on 6/28/22 with 37 staff were in-serviced. 29 staff had not yet in-serviced as of this date. 3. R4's care plan has been reviewed and updated on 6/28/22 by the Care Plan Coordinator (V15) and DON (V2) with interventions added to address potential sexually inappropriate behaviors. R4's Care Plan was specifically modified to address R4's exposing himself to others and to provide privacy. On 6/28/22, R4's care plan was reviewed and updated by V2 and V15 (Care Plan Coordinator) with interventions added to address R4's exposing himself to others and to provide privacy. 4. R4 was interviewed and evaluated by the Social Service Director (V16) on 6/23/22, who administered a Depression Assessment Scale (PHQ9) to evaluate R4 for mental well-being and provide support interventions if indicated. Resident displayed no signs or symptoms of distress at the time of the interview and did not show a decline in mood state since his prior assessments. On 6/28/22, V16 completed an interview and a Depression Assessment Scale (PHQ9) with R4 to evaluate R4 for mental wellbeing and provide support interventions. R4 did not show any signs of distress and did not show a decline in mood state since his prior assessment. 5. All residents are assessed for potential behavioral disturbances prior to admission. These screening are conducted to specifically evaluate behaviors that could be potentially abusive or put other residents at risk. Routine background checks are additionally done with each potential admission, as a further reference to reduce behavioral risks. Although done in conjunction with routine screenings, the prospective resident sheet was modified on 6/28/22 to specifically prompt personnel to evaluate the admission candidate for history of and ongoing deviant sexual behavior. Administrator (V1), SSD (V16), and Abuse Committee to monitor for ongoing compliance. The Prospective Resident Sheet was modified on 6/28/22 to specifically prompt personnel to evaluate the admission candidate for history of and ongoing deviant sexual behavior. V1, V16, and the Abuse committee to monitor for ongoing compliance. On 6-29-22, at 2:00 pm, V5/Social Service stated she was in-serviced by the facility on the Abuse Policy including resident to resident sexual abuse by V16 (Social Service Director). On 6-29-22 at 2:05 pm., V21/Certified Nursing Assistant stated she was in-serviced by V16 on Abuse which included identifying resident to resident sexual abuse and interventions. On 6-29-22 at 2:07 pm., V42/Activities stated she was educated on the Abuse Policy including Resident to Resident sexual abuse by V16. On 6/29/22 at 2:09, V43/Certified Nursing Assistant verified she had been in-serviced by V16 regarding Resident to Resident sexual abuse including identifying sexual abuse. On 6/29/22 at 2:12 pm. V44/Certified Nursing Assistant stated she was in-serviced on Resident to Resident sexual abuse by V16. On 6/29/22 at 2:15 pm., V45/Certified Nursing Assistant stated she was in-serviced by V16 regarding Resident to Resident sexual abuse. Completion Date: 6/30/2022

Based on observation, interview, and record review the facility failed to prevent resident-to-resident physical abuse for three of six residents (R1, R2, R3) reviewed for abuse in a sample of seven. This failure resulted in R1 pushing R2 causing R2 to fall hitting her nose, sustaining two black eyes, and lacerating her scalp. R2's injuries required hospitalization to close R2's laceration using staples. Findings include: An Abuse Prevention Program Facility Policy dated as reviewed 1/2/22 states, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility(,) therefore(,) prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of its policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This policy also states, Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. In addition, this policy states, 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. This policy states, Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. 1. R1's list of current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's list of current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Preliminary 24-hour Abuse Investigation Report dated 2/2/22 documents, On 2/22/22 at 7:05p.m. on B Hall, a male peer hit (R2) in the face with a closed fist. This same report documents that R2 sustained a laceration to the head during the altercation. A Final Abuse Investigation Report dated 2/22/22 and completed by V4 (Social Services Director) documents, (R2) and (R1) was in the hallway. (R2) said something to (R1). (R1) pushed (R2) on her face. This report documents as the conclusion, Incident occurred. (R2) admitted to provoking (R1) throughout the day for no reason. On 3/2/22 at 9:35a.m. V4 verified investigating the altercation between R1 and R2. V4 stated that the investigation determined that on 2/22/22 R1 hit R2 in the face after R2 cussed at R1. V4 stated that when she interviewed R2, R2 verified that R1 hit her. V4 stated she interviewed R4 who was a witness to the altercation. V4 stated that R4 said she was in the hallway talking to R2 when R1 walked up to R2 then hit her. On 3/2/22 at 9:50a.m. R4 was standing in the hallway outside of her room. R4 stated that on 2/2/22 she witnessed part of the altercation between R1 and R2. R4 stated that on 2/22/22, while out in the B hallway, R2 was calling R1 names. R4 stated, (R1) got tired of it and turned around to go after (R2). R4 stated she thinks R1 pushed R2 but doesn't think R1 hit R2. On 3/2/22 at 9:55a.m. R1 was walking down the hallway and stopped to look outside through the fire door. R1 would not make eye contact or respond when spoken to. On 3/2/22 at 10:00a.m. R2 was seated in the dining room wearing a coat and stocking cap. R2 had purple and green discoloration around both of her eyes. R2 stated that on 2/22/22 R2 was going back to her room when R1 approached her and intentionally pushed her to the ground. R2 stated that she hit her head during the fall causing a cut to the top of her head and also causing R2 to hit her nose which then caused bruising to both of R2's eyes. R2 proceeded to remove her stocking cap and part the hair on the top right side of her head to reveal a laceration held together with staples. On 3/2/22 at 10:35a.m. R6 stated on 2/22/22 he heard a noise in the hall and stepped out to see what had happened. R6 stated R2 was on the floor and bleeding while R1 was walking away. On 3/2/22 at 11:18a.m. V10 (Certified Nurse Aide) stated an incident occurred between R1 and R2 on the B hall near the AB shower room at approximately 6:30p.m.-7:00p.m. on 2/22/22 after dinner. V10 stated the incident between R1 and R2 resulted in R2 sustaining a laceration to the head. V10 stated that she helped V8 (Licensed Practical Nurse) wash blood out of R2's hair so V8 could inspect the laceration to the top of R2's head. V10 stated that R2 told V10 and V8 that R1 hit her. V10 stated that R1 usually paces the floor constantly. V10 stated that R2, likes to say things to people. She curses them. She says, 'F##k you!' or calls you a 'F##kin B##ch!' V10 stated that when R1 hears cursing or if someone curses at R1; it triggers R1 and makes him have behaviors. V10 stated, It doesn't take much to set (R1) off. On 3/2/22 at 11:34a.m. and on 3/3/22 at 8:40a.m. V8 verified she was R1 and R2's nurse on 2/22/22 when an altercation occurred between R1 and R2. V8 stated that throughout that day on 2/2/22, R2 was following R1 around the building and cursing at R1. V8 stated that R2 sometimes gets fixated on other residents and she will follow them around. V8 stated R2 following R1 around and was cursing at him which caused an altercation between them. V8 stated that R2 told her that R1 pushed her down. V8 stated that when R1 pushed R2 down, R2 sustained a laceration to her head and two black eyes. V8 stated the police were notified of the incident and R2 was sent to the hospital where she received staples to treat R2's scalp laceration. R2's After Visit Summary from the hospital dated 2/23/22 documents as the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This summary also documents R2 required Sutures Staples or Adhesive Wound Closure as a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 2. R1's list of current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's list of current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Final Abuse Investigations Report dated 11/3/21 documents that on that date at approximately 9:02a.m. R1 and R3 were involved in a physical altercation in which R1 sustained minor injuries. This report indicates that R1 was walking down the hall near R3's room and as R3 exited his room, R1 called R3 a F##king B##ch. This report states that R3 put R1 in a headlock and started punching R1. This report documents, Based on the known facts, the following conclusions have been determined about the original allegation: Incident occurred. This abuse investigation report documents that when R1 was interviewed regarding the incident he stated that he, Was walking down the A hallway and cursed out (R3) for no reason and (R3) hit (R1). This report documents that when R3 was interviewed he admitted to punching R1 several times in the face then threw R1 to the floor. This report also documents that R1 sustained abrasions and a laceration during the altercation. On 3/2/22 at 9:55a.m. R1 was walking down the hallway and stopped to look outside through the fire door. R1 would not make eye contact or respond to questions when spoken to. On 3/2/22 at 2:50p.m. R3 was lying in bed resting. R3 stated he did not remember having an altercation with R1 on 11/3/21. On 3/2/22 at 3:00p.m. V1 (Administrator) verified that on 11/3/21 there was an altercation between R3 and R1 in which R3, put (R1) in a headlock and started punching him.

Based on observation, interview and record review the facility failed to ensure a resident was not injured by another resident with known verbal and physical aggression for one(R1) of three residents reviewed for resident injuries in a sample of three. This failure resulted in R1 receiving a laceration to R1's head and fractures to R1's humerus and left maxillary. Findings include: The facility's Final Abuse Investigation Report dated 8/16/21 documents, During the process of investigation, medical record review and interview of witnesses, the following facts were determined: Camera was reviewed. (R1) was in a manual wheelchair wheeling himself backwards and bumped into (R2) and (R2) turned around with force and flipped (R1) out of his wheelchair. (R1) went out of his wheelchair and landed on his face. (R2) had his fists balled up after this incident and sat in the dining area and watched staff assist (R1). (R2) seemed upset and continued to have his fists balled up. On 8/24/21 at 12:30 PM video camera footage of the 8/16/21 incident involving R1 and R2 was reviewed with V2/Director of Nurses/DON. Video footage shows R1 hanging up the phone at the main nurse's station in the main dining room. R1 rolls himself backward around the desk and bumped into R2. R2 instantly grabs R1's wheelchair handles and shoves the wheelchair forward resulting in R1 flying forward out of the chair and landing on his face on the floor. R1's face was noted to be bleeding and staff were assisting R1 to roll over. R2 looked at R1 approximately two seconds then walked and sat in a chair in the main dining room. Staff are noted removing R2 from the dining room to the front office with security. R1's Progress Note dated 8/16/21 11:07 PM documents, (R1) was transported to the emergency room related to left shoulder pain and laceration to left eye. (R1) was involved in an incident with another peer(R2). Awaiting updated status on (R1) at this time. R1's Progress Notes dated 8/17/21 at 5:33 AM documents, (R1) came back from the hospital at 5 AM related to physical altercation with male peer(R2) on 8/16/21. Laceration of head, closed fracture of supracondylar humerus and left maxillary fracture. R1's After Visit Summary from a local hospital dated 8/17/21 documents, Reason for Visit: Fall; Assault Victim. Diagnoses: Closed fracture of supracondylar humerus, left maxillary fracture, laceration of head, fall, head injury. Schedule an appointment with local Orthopedic Surgeon as soon as possible (8/18/21) for visit. On 8/26/21 at 12:18 PM V5/Certified Nurse's Assistant/CNA stated, R1 bumped into R2 and R2 lifted R1's wheelchair and shoved it forward, throwing R1 onto the floor. V5 also stated R2 stood there for a few seconds afterwards with clinched fists staring at R1 and then sat in a chair in the dining room with clinched fists for several minutes. On 8/24/21 at 12:30 PM V2/DON confirmed R1 bumped into R2 with his wheelchair and R2 flung R1 from his wheelchair and R1 landed on the floor and had a fractured elbow and cheekbone. At this time V2 confirmed R2 is care planned for verbal and physical aggression and poor impulse control. V2 confirmed the facility has one security guard per shift. Resident Council minutes dated 4/30/21 and 7/28/21 documents, Security: Residents would like to see more staff in general, residents are requesting security on the floor. Relayed to supervisor. R2's Current Care Plan documents, (R2) is verbally aggressive related to poor impulse control, may be physically aggressive at times as well. R2's Progress Note dated 8/18/21 at 3:45 PM and signed by V6/Social Service Director documents, 1:1 with (R2). (R2) and this writer discussed a recent physical altercation from 8/16/21. (R2) feels that he was not in the wrong and that peer(R1) ran over his feet. (R2) stated peer(R1) got what he deserved. This writer discussed with (R2) appropriate ways he could have handled the situation.

Based on observation, interview and record review, the facility failed to implement the facility's COVID 19 policies and procedures and the Centers for Disease Control and Protection (CDC) guidance regarding Personal Protective Equipment (PPE) usage, hand hygiene and isolation precautions, and failed to identify and prepare designated areas with dedicated staff to care for and monitor residents with confirmed COVID-19, immediately notify staff of residents testing positive for COVID-19, and follow CDC guidance regarding a PUI (person under investigation) resident (R83). These failures resulted in facility staff going in-between COVID-19 positive resident rooms (R50 and R8) and an observational isolation resident room (R83) passing meal trays, medications and providing cares without changing PPE and performing hand hygiene, and then leaving R8, R50, and R83's rooms without disinfecting their eye protection to pass trays and assist residents in the main dining room. These failures have the potential to affect all 98 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on August 11, 2021 the facility remains out of compliance at Severity Level 2. The facility is in the process of monitoring the following to ensure compliance: designated staff on the COVID-19 unit 24 hours per day; staff compliance with PPE usage, disinfecting eye protection, hand hygiene, quarantine and isolation precautions, and outbreak procedures according to CDC recommendations; COVID-19 testing for all residents and staff twice weekly for 14 days regardless of vaccination status; designated supplies, PPE, and hand sanitizer are available for COVID-19 unit staff use; plastic barrier remains in good repair at the COVID-19 unit entrance. The facility is also continuing its ongoing monitoring of compliance through the structured Quality Assurance Performance Improvement (QAPI) program. Findings include: The CDC recommendations, dated 3/29/21, document, Determine the location of the COVID-19 care unit and create a staffing plan. -Doing this before residents or HCP (Healthcare Personnel) with [CONDITION(S)]-CoV-2 (COVID-19) infection are identified in the facility will allow time for residents to be relocated to create space for the unit and to identify HCP to work on this unit. The location of the COVID-19 care unit should ideally be physically separated from other rooms or units housing residents without confirmed [CONDITION(S)]-CoV-2 infection. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with [CONDITION(S)]-CoV-2 infection. Identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use. At a minimum, this should include the primary nursing assistants (CNAs) and nurses assigned to care for these residents. The CDC recommendations dated 2/23/21, document, Residents should only be placed in a COVID-19 care unit if they have confirmed [CONDITION(S)]-CoV-2 infection. Roommates of residents with [CONDITION(S)]-CoV-2 infection should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents while they are in quarantine (i.e., for the 14 days following the date their roommate was moved to the COVID-19 care unit). Hand Hygiene -HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. HCP should perform hand hygiene by using ABHS (Alcohol Based Hand Sanitizer) with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHS. Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location. Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. Facilities should have policies and procedures describing a recommended sequence for safely donning and doffing PPE. The Facility's Coronavirus/COVID-19 policy (undated) documents, The Infection Control Nurse (V2/Director of Nursing) will monitor bulletins from national health authorities, state and certified local health departments, as well as healthcare associations for guidance. The (Infection Control Nurse) may also call those authorities for updates and clarification of new or unclear guidance; Every attempt will be made to assign designated staff to work with the residents in isolation. Likewise, those in quarantine will have staff members dedicated to work with them; Should residents insist upon smoking, they will only be allowed to go to the smoking patio as long as each resident is able to maintain a distance of at least 6 feet apart. The Facility's Personal Protective Equipment (PPE) Procedure: Donning and Removal policy (undated), documents, Once patient-care tasks are complete, carefully remove PPE and discard it in the receptacles provided. Immediately perform hand hygiene. R50's [CONDITION(S)]-COV-2 Virus PCR (Polymerase Chain Reaction) Test Report dated 7/30/21, documents R50 was positive for COVID-19. On 8/9/21 at 11:27 a.m., there was a plastic barrier on the C-Hall labeled, Airborne Isolation Precautions that had a large opening where the two pieces of plastic were supposed to meet. The opening was approximately the size of a basketball. There were two resident rooms on the COVID-19 unit, behind the plastic barrier. On 8/9/21 at 11:30 a.m., V5 (Certified Nurse Aide/CNA) exited the COVID-19 unit. V5 stated there were two rooms and three residents on the COVID-19 unit. V5 stated R50 was the only COVID-19 positive resident in the facility and resided in one of the rooms and then R8 and R83 resided together in the room directly across the hall from R50. V5 stated R50 needed assistance to get out of the back door to smoke. V5 stated both R50's room and R8/R83's room doors were open. V5 stated both R8 and R83 needed hands on assistance with cares. V5 stated, I'm not for sure why (R8 and R83) are in isolation but I can find out. V5 stated R83 is non-compliant with the isolation due to her mental status and was out in the dining room sitting with other residents at this time. V5 stated V5 had the entire C-Hall assignment which included both the COVID-19 unit and the rest of C-Hall that were COVID-19 negative. On 8/9/21 at 11:50 a.m., V5 was in the common dining room passing trays and assisting residents with their food. On 8/9/21 at 12:00 p.m., R83 was sitting in the dining room at a table with peers and did not have a face covering/mask on R83's face. On 8/9/21 at 2:15 p.m., V2 (Director of Nursing/Infection Preventionist) stated R50 tested positive for COVID-19 on 7/30/21. V2 stated R8's positive COVID-19 test results came this morning (8/9/21). V2 stated R83 is quarantined due to being R8's roommate. V2 stated R83 was left in the same room (on the COVID-19 unit) and R8 was moved to another room on the COVID-19 unit. R8's [CONDITION(S)]-COV-2 PCR Test Report dated 8/8/21, documents R8 was positive for COVID-19. On 8/10/21 at 8:40 a.m., V6 CNA (Certified Nurse Aide) was passing breakfast trays to R50 and R8. V6 was wearing an N95 mask, gloves, gown, and face shield. V6 went from R50's room to R8's room to provide care without changing gloves, gown, mask, or face shield. On 8/10/21 at 8:40 a.m., the plastic barrier at the entrance of the COVID-19 unit had a large opening. On 8/10/21 at 8:47 a.m., V4 (Licensed Practical Nurse) entered the COVID-19 unit wearing an N95 mask, gown, gloves and eye protection. V4 went into R50's room to give him his medications. V4 then came out of R50's room and entered R83's room to give her a breakfast tray without changing gloves, gown, mask, and eye protection. V4 then removed her gown and gloves and exited the COVID-19 unit. V4 looked for hand sanitizer on the PPE container but there was none present. V4 then reached into her shirt pocket and grabbed a small bottle of hand sanitizer and sanitized her hands. V4 then walked back to the nurses' station in the resident dining room area and started passing medication to other residents. On 8/9/21 at 8:52 a.m., V4 stated there are no dedicated staff for the COVID-19 unit. V4 stated we just change gloves and gowns and sanitize hands when leaving the COVID-19 unit. On 8/10/21 at 8:51 a.m., V6 removed and disposed her gown and gloves and then exited the COVID-19 unit. V6 was unable to locate hand sanitizer at the PPE station. V6 stated, I needed (V4) to wait on me so I could use her hand sanitizer. V6 then walked down the C-Hall into the common area, went up to a staff member and had a conversation and then went to the sink behind the nurse's station to wash her hands. V6 stated that V6 was not working the C-Hall today but was just helping get breakfast trays passed. V6 stated the facility does not have staff designated to work the COVID-19 unit. On 8/10/21 at 2:20 p.m., the plastic barrier at the entrance of the COVID-19 unit continued to have a large opening. On 8/10/21 at 2:25 p.m., V4 (Licensed Practical Nurse) stated R83 is quarantined on the COVID-19 unit due to being R8's roommate at the time R8 tested positive for COVID-19 (8/9/21). V4 stated R83 will remain on the COVID-19 unit for 14 days. V4 stated the facility does not have designated staff for the COVID-19 unit. On 8/10/21 at 1:57 p.m., V2 (Director of Nursing) stated the facility does not have enough staff to have dedicated staff on the COVID-19 unit. V2 stated the facility does not have a written plan to designate an area for PUIs (Person Under Investigation) and V2 was unable to verbalize the current CDC guidance on the difference between housing COVID-19 residents and PUIs. V2 stated R83 is quarantined due to being R8's roommate who tested positive for COVID-19 on 8/9/21. V2 stated R83 will be quarantined for 14 days and then tested for COVID-19 prior to discharging her from quarantine. V2 stated the staff should be changing their PPE and washing their hands when going from one resident to another in the COVID-19 unit and when leaving the COVID-19 unit. V2 stated there is supposed to be a bottle of hand sanitizer just outside of the COVID-19 unit and had no knowledge as to why there was no sanitizer for staff to use when leaving the COVID-19 unit. V2 stated the staff wear re-usable face shields and those should be disinfected when leaving the COVID-19 unit. V2 stated the staff should also be changing into a clean mask when leaving the COVID-19 unit and going into non-COVID areas of the building. V2 stated the plastic barrier at the COVID-19-unit entrance should always remain intact and closed. V2 stated she was not aware of the plastic barrier having a large opening. On 8/11/21 at 9:09 a.m., R8 was behind the plastic barrier for COVID-19 isolation. V5 CNA (Certified Nurse Aide) came down the hall as R8 was trying to break through the plastic barrier because she heard it was time to smoke. R8 required much encouragement from V5 to keep R8 behind the plastic barrier. V5 stated that R8 is blind and needs help to go outside to smoke. V5 stated V5 was the CNA for the COVID isolation residents, R53, R8 and R83, and also for the two male residents in non-isolation room on the same hall. V5 stated that both those residents, in the non-isolation rooms are dependent on staff for cares and V5 had to assist one of those residents (R53) with eating breakfast this morning. On 8/11/21 at 9:15a.m., V14 CNA walked down to the COVID barrier and stated to V5 CNA that all three residents, R50, R8, and R83, should not go out together to smoke. But V5 CNA took all three outside together to smoke. R50 was able to go out without V5's assistance but R8 and R83 needed V5's assistance. V5 had to push R83's wheelchair out the door and then V5 held onto R8 while R8 walked outside. V14 stated that R83 was R8's roommate at the time R8 tested COVID positive, but R83 is not currently positive, just in quarantine with the two COVID positive residents. V14 stated that the facility is awaiting another COVID test result for R83. On 8/11/21 at 9:25 a.m., V5 CNA walked R8 back to her room after smoking. A large gap was noted in the plastic barrier at the COVID unit the entire time V5 was working in the isolation area. V5 wore the same gown, gloves, mask, and face shield to assist R83 as she had worn to assist R8. On 8/11/21 at 9:30a.m., V5 removed her gown and gloves, exited the COVID isolation area then removed her face shield and placed it on top of the isolation cart located outside the plastic barrier area where non-isolation residents reside, applied a new gown and gloves, reapplied the shield then went back into isolation, into R8's room to see what R8 needed. During all observations, both R83 and R8 had their doors open to the hall. V5 removed her soiled gown and gloves, exited the isolation area, then went back in the isolation area again without a gown to remove her shoe coverings. V5 used hand sanitizer and then exited isolation to get a washcloth for R8. V5 then reapplied new shoe covers. After V5 exited the isolation area, she kept taking her N95 mask off and on while touching the mask with the palm of her hand. V5 wore the same mask and face shield down the non-isolation hall without sanitizing the face shield or changing her mask. On 8/11/21 at 10:12a.m., V5 CNA was walking all around the dining room with multiple residents seated in the dining room. V5 was observed touching her face shield and mask, which she had worn in the COVID unit, to adjust them repeatedly and without performing hand hygiene. On 8/11/21 at 10:31a.m., V5 returned to the isolation wing, applied a gown, gloves, shoe covers, was still wearing the same face shield and mask, then entered the isolation area. V5 removed a biohazard bag from the isolation area, placed it on the floor outside the isolation unit, then removed her gown, gloves, and shoe covers. V5 continued to wear the same face shield and mask. On 8/11/21 at 1:19 p.m., V9 (Local Health Department Infectious Disease Specialist) stated V9 has not received any phone calls or emails from the facility asking for guidance on room placement for residents with COVID-19 or PUIs. V9 stated the PUIs should not be residing on the COVID unit. V9 stated the PUIs need to be quarantined in a different area. V9 stated the facility is also required to have dedicated staff for the COVID-19 unit. V9 stated the facility has not contacted V9 for guidance or to report a staffing crisis. V9 stated the cross contamination from R83 and not having dedicated staff on the COVID-19 unit, has potentially exposed all staff and residents. The Facility Nursing 24-hour Daily Staffing sheets dated 7/30/21 through 8/9/21, do not document designated staff for the COVID-19 unit. The Centers for Medicare and Medicaid Services, Resident Census and Condition of Residents, completed by V11 (Minimum Data Set Coordinator) on 8/10/21, documents there are 98 residents residing in the facility. An Immediate Jeopardy was identified on 8/10/21 at 2:45 p.m. The Immediate Jeopardy began on 7/30/21 when R50 tested positive for COVID-19 and the facility failed to provide designated staff to care for R50 and failed to provide a dedicated area for quarantined residents potentially exposed to COVID-19. On 8/11/21 at 12:45 p.m., V1 (Administrator) was notified of the Immediate Jeopardy. On 8/12/2021 at 5:00 p.m., the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V1 and V2 verified that only R50 and R8 were located on the COVID-19 unit and that R83 was moved outside of the COVID-19 unit and her quarantine was extended 14 days. The plastic barrier at the entrance of the COVID-19 unit was restructured and there were no openings in the barrier other than when staff were entering and exiting the unit. 2. V2 (Director of Nursing and Infection Preventionist) was educated by V22 (Director of Quality Improvement) on the most current updates in all aspects of COVID-19, in accordance with the CDC and the State Agency. 3. V1, V2, V6 (CNA), V16 (CNA), V19 (Licensed Practical Nurse), V20 (Licensed Practical Nurse), and V23 (Certified Nurse Aide) were all wearing N95 masks and eye protections. V19 and V20 were the COVID unit dedicated staff and were able to verbalize the proper process for disinfecting eye protection, replacing N95 mask, and changing PPE when going from dirty to clean. These same staff verified that dedicated staff have been assigned to the COVID-19 unit 24 hours per day. 4. V2 stated she would be responsible with the assistance of V3 (Assistant Director of Nursing) to ensure designated staff coverage of the COVID unit. 5. Signature Sheets and Interviews with V1, V2, V6, V16, V19, V20, and V23 verified all staff were educated on COVID-19 Outbreak Guidance, PPE usage, hand hygiene, isolation precautions and quarantine. 6. Additional signage was observed throughout the facility, in staff areas, regarding Quarantine and PPE protocols. 7. V1 and V2 verified that PCR (Polymerase chain reaction) COVID-19 testing will be extended to include twice weekly testing for 14 days for all residents and staff regardless of vaccination status and POC (point of care) [MEDICATION(S)] testing will be performed on any staff or resident who displays COVID-19 symptoms. 8. Housekeeping supplies were observed on the COVID-19 unit. V16 (Licensed Practical Nurse) stated those cleaning supplies are designated for the COVID-19 unit only and not to come out of the unit. Additional hand sanitizing stations were observed throughout the facility. The Air Purifiers were observed on the C-hall. V1 and V2 verified the Electrostatic disinfectant spraying devices. 9. V16 and V21 (LPN) verified the protocol for administering medications to residents on the COVID-19 unit. 10. V2 verified that V2 and V3 (Assistant Director of Nursing) would ensure compliance of staff handwashing and PPE compliance.

Based on observation, interview and record review, the facility failed to provide supervision to prevent resident to resident physical abuse for one of four residents (R53) reviewed for abuse in the sample of 44. These failures resulted in R53 being hit in the face on two different occasions, 6/16/21 and 7/18/21, subsequently sustaining an abrasion and bruised left eye. Findings include: The Facility's Abuse Prevention Program Facility Policy dated 2/24/21, documents, Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. R53's current computerized medical record, documents R53 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R53's Minimum Data Set assessment dated [DATE], documents R53 has moderately impaired cognition and Delusions, and requires limited assistance with ambulation with no mobility devices. R53's Care Plan dated 6/22/21, documents R53 has, Very poor impulse control and psychotic unpredictable behaviors with interventions that include, Cue, reorient, and supervise as needed. R53's Incident/Accident Report dated 6/16/21 at 5:40 p.m., documents R53 was observed taking food from a peer's (R17) dinner tray and (R17) struck R53 in the face causing an abrasion under R53's left eye. R53's Care Plan dated 6/17/21, documents to redirect R53 away from peers' food trays, get him more food, and if combative to remove him from the dining room to a quiet place. R53's Incident/Accident Report dated 7/18/21 at 11:35 a.m., documents R53 walked up and drank another resident's (R65) drink during lunch and R65 struck R53 in the left eye with no apparent injuries. On 8/9/21 at 10:45 a.m., R53 was out on the smoking patio smoking a cigarette with a large group of his peers. On 8/10/21 at 12:10 p.m., R53 was sitting at a dining room table with his peers eating lunch. On 8/11/21 at 10:30 a.m., R53 was outside on the smoking patio with a large group of peers. On 8/11/21 at 12:25 p.m., R53 was sitting in the dining room with his peers eating lunch. On 8/11/21 at 1:15 p.m., R53 had a verbal and physical behavioral outburst in the middle of the dining room with peers sitting in the dining room all around him. R53 was screaming and hit a staff member in the head and pulled her hair. It took 4 staff members to re-direct R53 away from the dining room and peers and get him back to his room. On 8/11/21 at 11:30 a.m., V17 (Licensed Practical Nurse) stated she witnessed R17 hit R53 in the face on 6/16/21. V15 stated (R53) ended up with a black (bruised) eye. I could not get to (R53) fast enough to stop (R17) from hitting him. On 8/11/21 at 12:31 p.m., V10 (Case Manager), stated R53 was involved in two physical abuse incidents where R53 was struck by other residents on 6/16/21 and 7/18/21. V10 stated the incident on 6/16/21 resulted in V9 having a black eye for a few days.

Based on observation, interview, and record review the facility failed to ensure a resident with a decline in mobility status received Therapy Services to assess for rehabilitative needs or mobility aides for one of one resident (R1) reviewed for multiple falls and a declining mobility status in a sample of three. This failure resulted in R1 sustaining a Closed Nondisplaced Fracture of the Fourth Cervical Vertebrae on 6/28/21 after a known decline in mobility and an increase in falls. Findings include: An Admission Policy dated 1/20/21 states that for a resident to be admitted to the facility, The Facility must be able to meet the resident's needs. A Facility assessment dated [DATE] states, (The facility) has a variety of types of residents. The target population of the facility is for Acquired and Traumatic Brain Injuries. There is additionally a component comprised of individuals with a Mental Illness Diagnosis, often with a concurrent medical and/ or neurological diagnosis, which needs monitoring, and physical assist. This policy also states, Some of the clientele of the facility is here for rehab following brain injury and Our resident care level varies from independent in activities of daily living to partially-totally dependent on staff for all care. The Facility Assessment also documents, We are contracted with (a Rehabilitation Service) to provide Speech, Physical, and Occupational Therapy in house as needed, Additionally, the Facility Assessment includes in its list of offered services, Mobility and fall/fall with injury prevention. This policy also states that the facility accepts residents with current or who develop diseases or conditions to include disorders of the Neurological System, and Musculoskeletal System. R1's Admission Record Sheet dated 8/2/21 documents R1 was admitted to the facility 5/21/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) assessment dated [DATE] documents that, at the time of R1's admission to the facility, he was independent with all activities of daily living (ADLs) including bed mobility, transfers, walking, dressing, eating, toilet use, and personal hygiene. This same MDS assessment documents R1 has no range of motion impairment to his upper or lower extremities and does not use any mobility devices such as a wheelchair or walker. In addition, this MDS assessment documents that R1's Functional Rehabilitation Potential assessment shows that R1 believed he was capable of increased independence and the facility's direct care staff believed R1 was capable of increased independence with ADLs. R1's MDS also documents R1 did not have any falls in the six months prior to his admission to the facility. R1's MDS assessment dated [DATE] documents R1 had two falls in the four months prior to that assessment including one fall with a minor injury, requires no assistance with ADL's, and does not use a mobility aide. R1's MDS assessment dated [DATE] documents R1 required the assistance of staff for bed mobility, transfers, walking, and dressing. R1's MDS assessment 7/21/21 documents R1 required the assistance of one person for transfers, walking, dressing, personal hygiene, and has a functional limitation in range of motion to both upper and lower extremities. This MDS assessment also documents that R1 had started using a wheelchair as a mobility aide. R1's medical record does not document R1 was evaluated for his change in ability to perform ADL's including walking, or that he was evaluated for new onset of limitation in range of motion to both upper and lower extremities. R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Fall Follow up forms dated 5/11/21 to 7/21/21 document R1 fell 14 times during that time period with each fall resulting from R1 getting up independently or losing his balance. R1's 5/22/21 fall investigation signed by V2 (Director of Nurses) documents that R1 would be provided a wheelchair as needed for a fall prevention measure. None of R1's fall investigations recommend R1 be evaluated by physical or occupational therapy to determine the cause of his increasing falls from loss of balance. R1's fall investigation dated 6/28/21 documents R1 fell out of his chair after losing his balance sustaining a laceration to the chin. R1's nurse's note dated 6/28/21 at 10:47a.m. documents R1 fell in his room after attempting to ambulate without assistance. This same note documents R1 was transferred to the hospital for a laceration to the chin. R1's hospital After Visit Summary dated 6/28/21 to 7/2/21 documents R1 was admitted with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/2/21 at 11:25a.m. V10 (Licensed Practical Nurse/LPN) and V11 (LPN) were standing at their medication carts in front of the nurses' station. V10 and V11 stated they have both provided nursing care to R1. V10 and V11 stated that R1 has always had an unsteady gait but it has worsened in the last few months causing R1 to have repeated falls. V10 and V11 stated that R1 is now supposed to use a wheelchair but he either pushes it from behind or refuses to use it. On 8/3/21 at 12:20p.m. V9 (R1's Power of Attorney/POA) stated regarding R1's care at the facility, They haven't provided him the care they said they would when he originally was admitted there. V9 stated that R1 was a little unsteady on his feet when he was first admitted to the facility 5/21/20 but he was able to walk independently. V9 stated that now R1 must sit in a wheelchair instead of walking and has frequent falls. V9 stated the facility did not have their physical therapy department evaluate him as she had asked stating, I have been asking for physical therapy for (R1) for the last eight months. During Care Plan meetings both V12 (R1's Family) and myself talked to V2 (Director of Nurses) several times and also the nursing staff about getting (R1) some physical therapy. V9 stated that if R1 had been provided with physical therapy within the last eight months, as she had requested, R1 may not have gotten so weak. V9 stated if R1 had gotten therapy he may still be able to walk and would not have fallen so many times. On 8/3/21 at 12:00p.m. and 1:00p.m. V3 (MDS/Care Plan Coordinator) verified that V9 had asked for a physical therapy evaluation for R1 stating, (V9) asked about therapy and we told her we were going to do a restorative program. That restorative started 6/8/21 but he was uncooperative with it. V3 stated that R1 was able to walk independently until a few months ago when he started having more and more falls. V3 stated that she is part if the Interdisciplinary Team (IDT) who determine new interventions for fall prevention whenever a resident has a fall. V3 stated the IDT never recommended a physical or occupational therapy evaluation for R1 but instead the fall prevention interventions the IDT put into place included having R1 start using a wheelchair for mobility. V3 stated that when R1 started falling out of the wheelchair, the IDT recommended a seat belt restraint. On 8/2/21 at 12:55p.m. V4 (Restorative Nurse) stated that she started a walking program with R1 in early 6/2021 but when R1 kept falling more and more V4 discontinued R1's walking program. V4 stated, (R1) doesn't realize his impairments. After a while it started taking two people to hold him up. On 8/2/21 at 1:15p.m. three residents in wheelchairs were stopped in a line in front of R1's room. R1 was standing inside his room behind his wheelchair waiting to exit his room. When the first resident outside R1's door was unable to propel herself forward, R1 walked from behind his wheelchair then pushed the resident's wheelchair forward so he and the other residents could pass. R1 appeared unsteady, leaned to the right, and had a limp when he walked. On 8/3/21 at 11:35a.m. V7 (R1's Physician) stated that R1 has had a recent increase in falls while at the facility. V7 stated that R1's recent falls resulted in injuries which included bruises, head injuries and a fractured cervical vertebra. V7 stated the facility offered R1 a wheelchair and a helmet. V7 stated R1 has not been offered a physical therapy or an occupational therapy evaluation stating, They wouldn't take him anyway because he now has an unstable cervical vertebra fracture. V7 stated that the facility is just an Intermediate Care Facility and doesn't offer the medical care that a skilled facility can offer which is what R1 needs. On 8/3/21 at 9:30a.m. V5 (Social Worker) stated that the facility was trying to get R1 transferred to a skilled nursing facility where they provide skilled services such as physical therapy. V5 stated that this facility offers limited therapy services. V5 stated that the therapy department from their sister facility nearby will come to this facility and provide residents with therapy services. V5 stated she doesn't know why R1 was not offered those limited therapy services. On 8/3/21 at 3:00p.m. V2 stated R1 has never been evaluated or received physical or occupational services (PT/OT) while admitted to the facility. V2 stated that after R1 returned from the hospital 7/28/21 the facility did request a PT/OT evaluation but that it has not started yet. V2 was unable to explain why R1 was provided a wheelchair as a fall prevention measure without a therapist evaluating what type of mobility aide would be most appropriate for R1's condition. On 8/2/21 at 2:35p.m. V1 stated that this facility is an Intermediate Care Facility and doesn't offer the medical care R1 needs. V1 stated that, instead, R1 needs to be transferred to a skilled care facility. V1 verified the Facility Assessment states that the facility can treat residents with conditions that require complex medical care and management such as Traumatic Brain Injuries, Neurological Disorders, Musculoskeletal System problems, Mobility and fall/falls with injury, and who may require physical and occupational therapy services.

Based on observation, interview, and record review the facility failed to supervise a resident with known verbally and aggressive behaviors, failed to follow a resident's care plan interventions for aggression, failed to implement new care plan interventions after a fall and failed to follow facility policy to complete updated fall assessments for one of 15 residents (R1) reviewed for accidents and supervision in the sample of 17. This failure lead to R1 sustaining a laceration to his nose, cheek, multiple bruises and ongoing verbal threats of further physical violence. Findings include: The facility's Fall Policy and Procedure policy, not dated, states, It is the policy of our facility to maintain a safe environment and applying maximum measurements to prevent falls for our residents. Procedure: 1. Fall assessments will be completed on admission and quarterly thereafter. PRN (as needed) assessments will be completed with any change of conditions and/or repetitive falls. 2. Care Plans will be initiated on residents, who have significant predisposing risk factors that may place the individual at risk for falls. Individualized interventions will be developed for each resident to prevent falls and injuries included on the care plan. 5. Care Plans will be put into place for any individual who has had a fall. This will include: a. Outdated, ineffective approaches deleted and new approaches dated and added at the time of each new fall. b. an updated, realistic goal related to the fall prn. 7. Adjustments to ensure maximum safety for the resident will be made in the residents care plan when recurring falls continue despite current plan of care, identifying the resident's risk factors, and need for any changes in plan of care and fall prevention devices if necessary. The facility's Behavior Monitoring policy, updated [DATE], states, At any time the IDT (Interdisciplinary Team) may initiate resident checks for increased monitoring, either at an hourly, 15 minute or one-to-one staff basis .IDT will review residents on increased monitoring and may discontinue checks at any time if they determine the monitoring is no longer necessary. R1's current care plan states, Focus: (R1) is potential to be verbally/physically aggressive related to poor impulse control. (R1) displays a delusional thought process as related to acceptance of limitations of DX (diagnosis)/unaware of effects on others and self which fluctuates throughout the day. (R1) displays poor planning poor insight judgement and decision making ability, poor stress and emotion management poor coping skills . This same care plan states, Interventions: (R1) triggers for verbal aggression and his behaviors is de-escalated by removing to a quiet area to assess situation with reality orientation. (R1) tolerates a few people at a time. (R1) needs his personal space, appears paranoid at times. (R1) reacts to touch negatively. When (R1) becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation. If response is aggressive, staff to walk calmly away, and approach later. R1's Facesheet documents R1 was admitted to the facility on [DATE] with a diagnosis of intracranial injury without loss of consciousness. R1's Incident/Accident Report, dated [DATE] at 1:15 P.M., states, Resident involved in verbal altercation with another peer while smoking on outside patio. Verbal altercation escalated to physical altercation. During altercation, resident fell to the pavement and stated peer then struck (R1) with his hand in/about (R1's) face. R9's witness statement to the [DATE] altercation states, (R16) was in a bad mood. (R16) said to (R1), Don't f**k with me, I'm not in the mood. (R1) kept running his mouth. (R16) just hit him. (R1) hit him back. No one else was out there. R16's statement to the [DATE] incident states, I was already mad and he kept making racial slurs and call me 'boy'. My brother had just died last week and I was on edge. (I) Just snapped. It won't happen again. The investigation report also documents, No additional witnesses per (R1), (R16), and (R9). R1's Incident/Accident Report, dated [DATE] at 8:30 P.M., states, (R1) seated on outside smoking patio when (R1) was involved in a physical altercation. R1's Final Abuse Investigation Report, dated [DATE], states, On [DATE] at 8:30 P.M., (R1) got into a verbal altercation with peer (R12) which escalated to physical altercation resulting in minor injury over right eye (0.5 cm/centimeter laceration). An incident occurred between two residents (R1 and R12) with dxs (diagnoses) of traumatic brain injuries. Verbal altercation escalated to racial slurs which triggered a physical altercation resulting in minimal injury. R12's handwritten witness statement to the [DATE] incident states, (R1) was and does intagonize (sic) me dayly (sic). (R1) called me a nigger 4x (times) was asked not to stand behind me and that it made me nervous. He continued to call me a nigger and insult me I punched him. R7's witness statement to the [DATE] incident states, There was a lot of yelling, cussing, and the N-word, so I made myself get out of there. R1's Incident/Accident Report, dated [DATE] at 7:30 P.M., states, (R1) involved in verbal and physical altercation with another peer (R14) while outside during supervised smoking time. (R1) did not receive injuries; however peer (R14) received scratch to right side of face and laceration to inside of rt. (right) bottom lip R14's psychosocial note on [DATE] at 10:14 A.M., states, (R14) states peer (R1) was provoking him, so he started to hit him (R1). R1's Incident/Accident Report, dated [DATE] at 6:55 P.M., states, (R1) involved in physical altercation with male peer (R14). (R1) stated (R14) just came up to him and stated hitting him with a closed fist. R14's Incident/Accident Report, dated [DATE], states, Not sure of what ensued issue, but (R14) and (R1) ended up in a physical altercation. (R14's) Rt (right) ear was bleeding, this nurse assessed area and cleansed it and applied TAO (triple antibiotic ointment). R1's Psychosocial Note, dated [DATE] at 12:47 P.M., states, 1:1 with (R1) this day for incident on previous evening, (R1) is in a verbal to physically aggressive incident with a male peer (R14). This same note documents R1 was not receptive of 1:1 this day and continues delusional thought process to his behaviors and effects on others. R1's Nursing Note dated [DATE] at 8:51 A.M., signed by V4 (Registered Nurse), states, (R1) was in an altercation with another patient, (R1) has a small laceration in left eyebrow. Laceration cleansed and gauze applied by this nurse. Doctor and sister notified. Neuros started. R1's Nursing Note dated [DATE] at 1:45 P.M. signed by V4, states, (R1) was in an altercation with another patient outside in the smoking area at 1:20 P.M.(R1) was hit in the face with a closed fist. Nose swollen and bleeding, small laceration on the right side of nose. This nurse cleansed area and (R1) is now resting quietly in his room. Physician notified, sister notified per detailed voicemail. Neuros continue. VS WNL (vital signs within normal limits). (R1) denies any pain at this time. R1's Psychosocial Note on [DATE] at 8:42 A.M., signed by V14 (Social Worker) states, (R1) continues aggressive (behaviors) into the weekend with his peers.(R1) also again this morning while in the smoke line. (R1) is given redirection as well as reality orientation as to his (behavior) and its effect on others and surroundings. (R1) continues to be argumentative and challenging as well as demanding. (R1) is encouraged to be compliant and mindful of others. (R1) is not receptive. R1's Incident/Accident Report, dated [DATE] at 7:00 P.M., states, (R1) was involved in an altercation and he fell . Full assessment done and neuros started. This same form states, Type of injury: Laceration. R1's Nursing Notes on [DATE] at 22:25 P.M. states, At approximately 1900 hours on this date, (R1) was involved in a verbal & (and) physical altercation with another peer (R14). (R1) sustained a laceration to the right side of his nose which required no dressing after minimal bleeding. Neuros initiated per facility protocol and all neuro checks/vitals are within normal limits. All notifications completed. Peer (R14) did not sustain any injuries. R1's psychosocial notes on [DATE] at 7:25 A.M., states, Bx (Behavior) note: 1:1 with (R1) for verbal aggression that leads to physical aggression on previous evening. Discussed (R1's) role in his (behaviors) and how they may effect how others receive him as well as (R1's) perceptions of others and their (behaviors) .(R1) is not receptive of 1:1 this day. R1's Incident/Accident Report, dated [DATE] at 7:00 P.M., states in the smoking area, (R1) and peer (R2) fighting outside. (R1) hit (R2) and (R2) hit back. Laceration to back of left side of head. R2's Incident/Accident Report, dated [DATE] at 7:00 P.M. states, (R2) fighting with (R1) outside patio (A-B) right hand swollen, laceration to bridge of (R2's) nose. R1's witness statement dated [DATE] states, I just wheeled over and she (R2) started yelling and cussing. She told me to f**king move, but I have rights to be there too. I didn't do anything. R11's witness statement states, (R2) told him to move cause she didn't want him sitting there. Then she yelled, 'f**king move.' Then she tried pushing him. He hit her in response and she hit back. He was just retaliating. R2's witness statement states, (R1) ran over my foot with his wheelchair and it set me off. They won't give me the meds I need, so I can't control my temper. I blacked out and don't remember. R1's Incident/Accident Report, dated [DATE] at 3:30 P.M. states, On smoking patio reported to this writer by (R1) that he was involved in a physical altercation with male peer (R3). (R1) reported that (R3) approached (R1) and started striking him with a closed hand repeatedly in his face. (R1) placed on neuro checks. This same form documents types of injury as lacerations, bloody nose, and swelling. R1's witness statement on [DATE] at 4:00 P.M., states, While speaking with (R17) outside on the smoking patio (R6) became upset and called (R1) a 'F*cking bit*h' (R1) responded by calling (R6) a 'b*tch' which caused (R6) to throw a lit cigarette at (R1). Then (R3) stood up and said to (R1), 'Don't talk to my girlfriend or I will f*ck you up!' (R1) said to (R3) that he wouldn't to which (R3) grabbed (R1) by the throat in an attempt to choke (R1). (R1) said something to (R3) but cannot recall what (R1) said. This caused (R3) to slap (R1) and then to pull (R1) out of (R1's) wheelchair. Once (R1) was on the ground, (R3) kept hitting (R1) in the face and head. R6's witness statement on [DATE] states, (R6) stated she was sitting on the A/B patio and (R1) called her a nigger lover and she threw her cigarette at him and her boyfriend (R3) started to beat the crap out of him and she sat there and watched. On [DATE] at 10:03 A.M., R3 was smoking on the AB patio. R3 stated, (On [DATE], R1) was out here and a couple other girls were out here. (R1) was calling them racial slurs such as nigger lover. (R1) told my girlfriend (R6) he was going to kick her ass. I stood up and grabbed (R1) and then we started fighting. (R1) causes fights with everyone up in here. He's an instigator. He gets into it with (R14) all the time. Sometimes the staff is out here during smoking, but not present a lot. No staff was outside at the time of my altercation with (R1). I had to yell in the door and told staff they better get him away from me and then they came out. They separated us and took him away to calm down. He antagonizes a lot of people. He was in a wheelchair when that happened, he can walk, but is unsteady. He makes a lot of racist remarks to people. At this time, R3 showed scratches and bruises R3 received in the altercation. Greenish-yellow bruising with dried scratches was noted to R3's left upper arm. R3's right elbow, right cheek, and right side of nose had healing dried scabs from scratches. On [DATE] at 11:09 A.M. R12 stated, (R1) insists on inciting violence. He provokes the residents here and they retaliate with violence. (On [DATE], R1) was calling (R6) racial words like 'nigger lover.' He provoked her. He was also saying (R6) has 'mixed b*st*rd children.' The fighting and provoking has to stop. There has been increased fighting since (R1) came here. He likes attention and drama. On [DATE] at 11:21 A.M., R5 was sitting outside on the AB smoking patio. R5 stated, He calls us all 'nigger lovers.' (R6) said something to (R1) because she has mixed children. He threatened to kick her ass. (R3) got up and kicked his ass. There was not any staff out here. (R3) then got up and peeked his head in the door and told them to come get (R1). (R1) likes to cause fights and (R1) doesn't know when to quit. Everyone wants (R1) out. Even the staff don't want him here. It (the fighting) could stop sooner if staff was out here. On [DATE] at 11:30 A.M., R6 was outside smoking on the AB patio. R6 stated, (On [DATE], R1) made a remark to me and (R1) went to stand up towards me. (R3) then stood up to intercept. (R1) was calling me a 'nigger lover.' (R3) then went inside and had to get staff out here to get (R1) away. On [DATE] at 11:41 A.M., R8 was outside smoking on the AB patio. R8 stated, There was no staff out here when (R1) was outside smoking during R1's altercations. If (R1) doesn't get his way, he'll start an altercation. He's mean period. He always plays the victim role. This place was a lot quieter and calmer before he came here and the staff knows it too. On [DATE] at 11:45 A.M., R7 and R10 were outside smoking on the AB Patio. R7 and R10 stated R1 is outside on the patio smoking without staff present all the time. On [DATE] at 12:02 P.M., V10 (Certified Nursing Assistant) stated, (R1) is very combative and attention seeking. He falls almost everyday. On [DATE] at 12:25 P.M., R14 stated, I don't feel safe when I am around him (R1). It feels like he wants to fight me every single day. Two weeks ago, I was already outside by the door. (R1) got up out of chair and said to me, 'I don't like you niggas.' I said 'go f*ck yourself.' and then (R1) hit me in my left ear. That's the problem, every time (R1) starts fights, no one is around. On [DATE] at 12:39 P.M., R1 was not able to specifically recall altercations with residents in the facility or falls in the facility. R1 stated, I don't know. I guess. At this time R1 removed R1's shirt, scattered bruising in various stages of healing were noted to R1's back, sides, abdomen, and arms. R1's left arm was noticeably swollen and bruised with scratches. The bridge of R1's nose, left side of forehead, and left eyebrow had a dried, scabbed areas noted. R1 winced in pain while moving left arm to take off R1's shirt. On [DATE] at 1:45 P.M. R11 stated, (On [DATE], R2) just whooped (R1's) ass. They had to run inside and get staff to separate (R1) and (R2). (R2) didn't stop hitting (R1) until she got pulled off of him. (R1's) a problem child. I wanted to beat his ass several times. On [DATE] at 2:40 P.M. V6 (Social Service Director) stated that R1 makes a lot of racial remarks which leads to fights with the other residents. V6 was not aware of R1 ever being placed on increased supervision. On [DATE] at 2:55 P.M., video camera footage of the [DATE] and [DATE] altercations with R1 were reviewed with V6. Video camera footage shows that no staff was present on the smoking patio during the verbal altercation that turned physical with R1 and R2 nor R1 and R3. On [DATE] at 4:50 P.M., V4 (Registered Nurse) stated, (R1) instigates the residents verbally and then it turns physical. On [DATE] at 5:24 P.M., V7 (Certified Nursing Assistant) stated, (R1) gets into a lot of fights. He starts talking and the residents respond physically. He is always saying something they don't like. R1's Nursing Note on [DATE] at 10:16 P.M. signed by V15 (LPN) documents R1 was provoking peers by making socially inappropriate comments. On [DATE] at 3:30 P.M., V1 (Administrator) and V2 (Director of Nursing) verified most of R1's altercations occurred on the outside smoking patio without staff present. V1 verified that the activity aide who usually sits with the residents outside when they smoke has been off on maternity leave and stated that the supervision in the facility's smoking policy needs looked at again. R1's most recent fall assessment was completed [DATE] and documents R1 as a low risk for falls. No other fall assessments could be located in R1's medical record. R1's Fall Follow Up form on [DATE] documents R1 had a fall on [DATE] at 7:00 P.M. with an injury of laceration above left eye. This same form documents Suggestions for Prevention as Use Caution-Take time when doing tasks. R1's Fall Follow Up form on [DATE] documents R1 had a fall on [DATE] at 2:40 P.M. with an injury of laceration to left side of head. This same form documents any environmental causes, such as wet floor/obstacles as No and Suggestions for Prevention as Use caution in room-keep room free of obstacles. R1's Fall Follow Up form on [DATE] documents R1 had a fall on [DATE] at 9:15 A.M. with no injuries. This same form documents Suggestions for Prevention as use w/c (wheelchair) prn (as needed)-ask for assist as needed. R1's Fall Follow Up form on [DATE] documents R1 had a fall on [DATE] at 12:45 A.M. with laceration over left eye and complaints of neck and back pain. This same form documents Suggestions for Prevention as ask for staff assist. R1's Nursing note on [DATE] at 1:00 A.M. documents R1 was transferred to the local area emergency room for treatment. R1's Fall Follow Up form on [DATE] documents R1 had a fall on [DATE] at 6:55 P.M. with an injury of a scalp laceration. This same form documents Suggestions for Prevention as use w/c prn-take time. Safety Measures Initiated documents, use w/c prn-put in w/c. R1's Nursing Note on [DATE] at 7:21 P.M. documents R1 was transferred to the local area emergency room for evaluation and treatment. On [DATE] at 11:12 A.M. V2 (Director of Nursing) verified that R1 is high risk for falls and has been falling more often. V2 also verified new and updated fall interventions should be added to a resident's care plan after each fall. V2 could not recall a time when R1 had increased supervision or checks.

Based on record review and interview, the facility failed to prevent physical abuse for one of three residents (R1) reviewed for abuse in a sample of three. This failure resulted in R1 being repetitively struck in the head and subsequently being hospitalized for [REDACTED]. Findings include: The facility Abuse Prevention Program Facility Policy dated 6/3/19 documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporation punishment. R1's current computerized medical record documents R1 remains hospitalized at a local hospital since the resident to resident physical assault which occurred on 2/24/2020. An Incident/Accident report dated 2/24/2020 at 7:00 p.m. documents R1 was located on the unsupervised smoking patio and that R6 (witness) reported that R2 punched R1 and pulled her out of her wheelchair onto the ground. R1 was sent to the local hospital and R2 was arrested and taken to jail. R1's local hospital admission record dated 2/24/2020 documents R1 was intubated and transferred to the intensive care unit. R1's CT (Computed Tomography) of the brain dated 2/25/2020 indicates Critical Result of New [MEDICAL CONDITION] Identified. On 3/3/2020 at 9:55 a.m., R6 stated that (R1) keeps coming out on the patio where she is not supposed to be and (R1) called the new girl (R2) some bad name and cussed her out and then (R1) threw her helmet at (R2) and then (R2) took the helmet and kept hitting (R1) in the head until I yelled stop. On 3/2/2020 at 12:45 p.m., V2 (Director of Nursing) verified that an unwitnessed resident altercation occurred on 2/24/2020 between R1 and R2. On 3/2/2020 at 10:55 AM, V1 (Administrator) stated: (R1) is always getting out onto the unsupervised smoking patio, where she isn't supposed to be, and either soliciting cigarettes for money or trying to bum a cigarette and that is why the altercation happened.

Based on interview and record review, the facility failed to provide supervision to prevent a resident to resident altercation for two of three residents (R1, R2) reviewed for supervision in the sample of three. This failure resulted in R2 physically assaulting R1 and R1 being hospitalized for [REDACTED]. Findings include: A facility Smoking Safety Policy and Procedure dated 6/3/19 documents: Supervision, in addition to periodic observation, regular checks are made by staff of the patio smoking area at the time of the scheduled passes. A Facility Smoking Report (undated) documents, that both R1 and R2 are Managed (Supervised) smokers and can only go out to smoke with supervision. An Incident/Accident report dated 2/24/2020 at 7:00 p.m. documents R1 was located on the unsupervised smoking patio and that R6 (witness) reported that R2 punched R1 and pulled her out of her wheelchair onto the ground. R1 was sent to the local hospital and R2 was arrested and taken to jail. On 3/2/2020 at 11:56 a.m. V3 (Registered Nurse) stated that on 2/24/2020 in the evening, she was doing a medication pass for approximately 50 residents when a certified nursing aide came up to her and said there is a fight on the unsupervised smoking patio. V3 stated One of the residents was yelling fight, fight and (R1) was on the ground in front of her wheelchair. I took R1's vitals and kept her on 15 minute neurological checks and within an hour or so she was not herself and her blood pressure was dropping and getting low, her respirations were more shallow and her neurological assessment (Glasgow coma scale) was a 7. (R1) became more lethargic so we called 911 and she was transferred out to a local emergency room . (R1) did not have her helmet on when I assessed her. The unsupervised smoking patio continues to be a problem, because I cannot keep my eye on all these residents and pass medications at the same time. (R1) should never be allowed to go out that door to the unsupervised patio so easily, the door is unlocked and she is able to push it out and open and then she is out there and you can't see her if you don't physically go out on the patio. I have mentioned that this is a problem and some of (R1's) altercations happen on the unsupervised smoking patio. R1's facility Smoking assessment dated [DATE] documents that R1 requires managed/supervised smoking materials, (R1) is on a managed smoking program. R2's facility Smoking assessment dated [DATE] documents that R2 requires managed/supervised smoking materials. R1's current computerized medical record documents R1 remains hospitalized at a local hospital since the resident to resident physical assault occurred on 2/24/2020. R1's local hospital admission record dated 2/24/2020 documents that upon arrival to the emergency room , R1 would not open her eyes to command, did not have a gag reflex, was not making any understandable words or noises, had bruising to her face, had a posttraumatic right frontal scalp hematoma and a critical result of new [MEDICAL CONDITION] identified. This same hospital record documents R1 was hypotensive on arrival with shallow respirations, R1 was intubated and transferred to the intensive care unit. R1's CT (Computed Tomography) of the brain dated 2/25/2020 indicates Critical Result of New [MEDICAL CONDITION] Identified. On 3/2/2020 at 10:55 a.m. V1 (Administrator) stated: (R1) is always getting out onto the unsupervised smoking patio, where she isn't supposed to be, and was either soliciting cigarettes for money or trying to bum a cigarette and that is why the altercation happened. On 3/3/2020 at 9:55 a.m. R6 stated that (R1) keeps coming out on the patio where she is not supposed to be and (R1) called the new girl (R2) some bad name and cussed her out and then (R1) threw her helmet at (R2) and then (R2) took the helmet and kept hitting (R1) in the head until I yelled stop. On 3/2/2020 at 12:45 p.m. V2 (Director of Nursing) stated that there are residents who are allowed to go out and smoke without supervision and they use the unsupervised (independent) smoking patio and can go in and out when they want because that door is unlocked at all times. V2 further stated that there are residents who require supervision and are only allowed to be on the Supervised (Managed) Smoking Patio during scheduled smoke break times. V2 stated: (R1) was not supposed to be out on the Independent Unsupervised Patio because she requires supervision when she goes out to smoke. (R1) is constantly getting out onto the unsupervised patio begging or bartering for cigarettes. The door to the unsupervised patio is located directly beside the nursing station in the main area, but that doesn't mean someone is always watching that door to see who goes in and out. It's impossible to supervise her at all times. On 3/4/2020 at 11:10 a.m. V5 (Case Manager) stated (R1) is not supposed to be out (on the unsupervised patio) and goes anyway and is able to get out there before staff see her. (R1) has been known to throw her helmet and hit people and she should have better supervision. Even after redirected, (R1) will get right back out there on the unsupervised patio.

Based on interview and record review, the facility failed to verify a resident's advance directive regarding cardiopulmonary resuscitation (CPR) as directed by the facility's policy and procedures for one of 21 residents (R103) reviewed for advance directives in a sample of 31. This failure resulted in facility staff not performing cardiopulmonary resuscitation on R103, contrary to R103's advance directive to be resuscitated as documented in the resident's medical record. R103 expired in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2 as the facility continues to educate the staff on Cardio [MEDICAL CONDITION] Resuscitation. Findings include: The Cardiopulmonary Resuscitation (CPR) policy/procedure (2012) documents the following, Purpose: To ventilate and establish circulation for a resident with absence of respirations and pulse. Do not perform CPR unless: The resident has stopped breathing; The resident is unresponsive and does not have signs of circulation and respirations, such as pulse, normal breathing or coughing. Determine responsiveness by tapping or gently shaking the resident and shouting, 'Are you okay?' Delegate a specific individual to check the resident's orders and care plan for CPR or no CPR order; have individual call paramedics, attending physician administrative personnel per facility procedure and report back to you as soon as possible. Place the resident on his or her back, supporting head and neck, on a hard surface. Perform CPR if the resident is unresponsive and not breathing or no normal breathing (i.e only gasping) The Do Not Resuscitate (DNR) Order policy and procedure (,[DATE]) documents: In order to optimize patient care, code orders are written for the following purposes: To resuscitate patients according to their wishes and in keeping with best medical practice as determined in discussion with their physicians. To give clear instructions to nursing staff that will assist them in carrying out the above goal. All residents will be 'Full Code' until such time as the universal DNR form is provided to the facility and has been duly signed by the resident, physician and responsible party (where appropriate). The facility's Change of Condition Policy and Procedure, dated ,[DATE], documents, The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The nurse will continue to document follow up notes on condition status and/or treatment orders. Documentation should reflect at minimum the following: Specific changes in condition; Communication with family/legal guardian about changes; Communication with physician; Orders received from physician; Follow-through of physician orders. R103's POLST (Practitioner Orders For Life-Sustaining Treatment) Form, dated [DATE], documents, If patient has no pulse and is not breathing: Attempt Resuscitation/CPR. R103's Admission Record, dated [DATE], documents that R103 is a Full Code, and that V8 is R103's primary emergency contact. R103's Incident/Accident Report, dated [DATE], documents, On [DATE] at 7:05 p.m., CNA (unidentified) Care givers report to this writer (V5) that R103 is unresponsive. Upon investigation the following is observed. R103 is sitting on toilet and is unresponsive. Unable to auscultate/palpate pulse or respirations. Paramedics called at 7:08 p.m. Paramedics here at 7:13 p.m. R103's Progress Note documented the following on [DATE] at 19:05 (7:05 PM): CNA caregivers report to this writer (V5, RN) that resident (R103) is unresponsive. Upon investigation the following is observed. Resident is sitting on the toilet and is unresponsive. Unable to auscultate/palpate pulse or respirations. R103's Progress Note documented the following on [DATE] 19:08 (7:08 PM): EMT (Emergency Medical Transport) are called at this time. R103's Progress Note documented the following on [DATE] at 19:13 (7:13pm): EMT are here at this time. R103's Progress notes dated [DATE] at 23:43 (11:43pm) documents the following regarding R103: At 1915 (7:15 pm) this writer (V6, Registered Nurse/RN) returned from dinner break and noted EMTs (Emergency Medical Transport) in (R103's) room. (V6, RN) was told by EMTs that she (R103) had passed away minutes ago. V10's CNA (Certified Nursing Assistant) Facility Investigation Written Statement, dated [DATE], documents, (R103) had her call light on and when I came into her room she was already in her bathroom on the toilet. (R103) said she needed some help to put a gown on. (R103) didn't have any (adult brief) on so I told her stay put as I had to go get a gown and (adult brief) off my cart. As I returned she was on her left side leaning. I tried to help her sit up. I noticed she wasn't breathing right. I went to get help. (V11, CNA) came down and we tried to get her into her wheel chair, but she will still to heavy. (V11) left to get more help and (R103) was turning colors pale like. (V11, CNA) came back with crash cart, and tried to hook her (R103) up by this time paramedics came, but myself, (V11), and (V7) still got her in wheel chair and paramedics took her. (R103) was already gone. R103's (Emergency Medical Service) EMS Note dated [DATE] documented the following: Dispatched to (the facility) for 'a female unresponsive (R103); CPR in progress.' Upon arrival on scene, as ALS (Advanced Life Support) was making their way to the patient's room, the nurse (V5, RN, Registered Nurse) passed by going in the opposite direction stating, 'I did a finger sweep.' Upon arrival at the patient's room, the patient (R103) was found in a wheelchair with her head tilted back, mouth agape. She had an (adult brief) around her ankles. She was ashen and mottled. She (R103) had a strong odor of urine on or about her person. There was a trail of what appeared to be urine on the floor leading from the washroom to the spot the wheelchair was situated. Patient (R103) was unresponsive, pulseless, apneic with dilated pupils. The seat of the patient's wheelchair was saturated in what appeared to be urine,and her shoes and socks were soaked in the same. (The local fire department) personnel were on scene when ALS arrived; they reported that the nurse (V5, RN) had told them that the patient had a DNR (Do Not Resuscitate), and that he (V5) was going to get it. They had no other information. The patient's top and bra were cut off and she was placed on cardiac monitor using Defibrillator pads. She was noted to be in asystole with no signs of life present. The patient was lifted out of the wheelchair and lowered to the floor. As the patient was placed on the floor the nurse returned with the form. The paperwork stated that resuscitation was to be attempted on the patient. ALS (Advanced Life Support) was never able to get a definitive time line as to how long the patient had been unresponsive. ALS contacted Medical Control by telephone due to the situation. Due to the lividity and the patient being in asystole with no signs of life, Medical Control agreed that CPR should not be attempted. (The Local Fire Department) personnel contacted the coroner's office. ALS cleared the scene with a DAS (Dead at Scene). R103's Interdisciplinary Discharge Summary, dated [DATE], states that R103 was discharged on this date with no pulse, respirations, or blood pressure. On [DATE] at 12:25 pm, V12 (local paramedic) recalled responding to incident regarding R103 at (the facility) on [DATE]. V12 stated the following: Dispatch told us someone was unresponsive and that CPR was in progress. When I walked in there were two CNAs arguing in the doorway to the patient's room. Nothing was being done for the patient. She was sitting in a wheelchair with her head hanging back and her mouth was agape. She had no pulse, was not breathing, and was soiled in urine. The (local fire department) arrived at the same time that we did, and the first thing we said to each other was 'didn't they say CPR was in progress?' Nothing was being done. Me and the local fireman moved her onto the floor from the wheelchair that she was in. She wasn't hard to move, not a big lady. When we initially walked in the building, the nurse said the patient was a DNR and was getting the paperwork, and said someone did a finger sweep, and I'm not sure what the significance of that was. There was nothing on the resident. No ambu bag, I didn't see a crash cart around or a monitor/defibrillator. The first thing that touched her was our monitor. The monitor read asystole. And then the nurse handed me the paperwork indicating she was a full code. I don't even think he read the papers. I noticed some lividity to her back, so I went ahead and called Medcom (Medical Control), and she was pronounced dead. On [DATE] at 3:30pm V11 (CNA) stated the following: I went to (R103's) room to help V10 (CNA) get R103 off of the toilet. When I entered the bathroom (R103) did not look right. She was trying to talk but could not. I went and told (V5, Registered Nurse) that (R103) did not look right and he (V5) needed to check (R103) because she did not look right. (V5) said, 'Ok, I'm busy passing medications. I'll check her later.' (V11) then went back to (R103)'s bathroom where he (V11) found (R103) leaning and turning blue. (V11) then ran to get the crash cart and told (V5) to get in the room now. (V5) walked into (R103)'s bathroom, looked at (R103) and stated, 'She's (R103) gone' and walked back out of the room. V11 then stated, She (R103) was not gone. She had agonal breathing and was gasping. (V5) did not help the CNAs do anything or help (R103) at all. (V5) did not listen to (R103), touch (R103) or direct us (CNAs) as to what actions we should take. Approximately seven minutes after (V5) left the room, (Emergency Medical Services) arrived. On [DATE] at 12:00 PM V9 (CNA) stated, On (MONTH) 6, 2019 I was in the dining room serving trays and (V5/Registered Nurse) yelled at me 'go help (R103).' V10 (CNA) had the call light on wanting help and was yelling for help with (R103). (V11/CNA) was trying to get the defibrillator working but a piece was missing. When I arrived to (R103's) room, (V11) and (V10) tried to get (R103) off the toilet. The bathroom was too small so (R103) was transferred to the wheelchair. (V11) did a finger sweep. I was not sure whether (R103) was a full code or DNR (Do Not Resuscitate). (R103) was completely lifeless and gray. (V5, RN, Registered Nurse) stayed at the desk making phone calls the entire time and then finally went down to (R103's) room and stated, 'R103 is gone.' I did not witness any staff performing CPR on (R103). I did not perform CPR. Once EMS arrived, EMS transferred (R103) to the bed and began resuscitation efforts. (V5, RN) should have went to the room and helped us, and one of the CNA's could have called 911. On [DATE] at 1:05 PM, V7 (CNA) stated, On the night that (R103) passed away, (V5/Registered Nurse) came to me and said that there is a situation with (R103) and that I needed to go help. I was working on another hallway. When I went to (R103's) room, (R103) was on the toilet. (V5, RN) told us that she did not have a pulse. (V5) left the CNA's with (R103) and did not give us (CNA's) any direction. Myself, (V7, CNA), (V10, CNA), and (V11, CNA) transferred (R103) to the wheelchair. We did not think to put (R103) on the floor and start CPR. No one started CPR as we (CNA's) were told by (V5, RN) that (R103) did not need CPR. V7 stated, I am not certified to do CPR. On [DATE] at 10:51 AM, V6 (Registered Nurse/RN) stated, I had left the building for break and when I came back (V5/RN) informed me that (R103), which was my resident, had passed away while I was gone. When I returned the EMT's (Emergency Medical Technicians) were already removing the electrocardiogram leads. I asked (V5, RN) if he had performed CPR (Cardiopulmonary Resuscitation) and he said 'no' he did not. (V5, RN) said he only did a finger sweep. I was disturbed that the nurse (V5, RN) did not start CPR immediately and had left (R103) unresponsive with a new CNA (V10, CNA) and another CNA (V11, CNA). The resident should have been lowered to the floor and CPR should have been started immediately by the nurse (V5) and CNA's. We do have a CPR board to use. (R103) did not have any signs of medical issues prior to becoming unresponsive. On [DATE] at 10:40 am V5 (RN) stated the following: The CNA (V11) reported to me (V5, RN) that the resident (R103) was unresponsive, so I went and grabbed the crash cart, the resident was on the toilet. She (R103) was unresponsive with no pulse. The CNA did a finger sweep and placed the ambu bag on her. I (V5, RN) then left the room, leaving the nursing assistants with her (R103), to call EMS and when I returned to the room EMS had her on the floor. V11 stated, CPR was not initiated (for R103). On [DATE] at 12:30 PM, V2 (Director of Nursing) provided a list of current employee CPR certification. This list documents V9 (CNA), V11 (CNA) and V6 (RN) had current CPR certification. This list also documents neither V5 (RN) nor V10 (CNA) hold a current CPR certification. On [DATE] at 2:45 PM, V2 stated she would expect nurses to provide direction and clarification to the CNAs in an emergent situation. V2 stated that V5 should have directed the CNAs on what to do for R103 on [DATE]. V2 stated that V5 should have initiated CPR on R103 and sent V9, V10 or V11 (CNA) to check the POLST form and make appropriate calls to Emergency Medical Services. V2 stated that in the absence of the nurse (V5), one of the CNAs (V9, V10 or V11) could have gone to check the POLST form while one of the other CNAs initiated CPR. V2 stated that if R103 was too heavy to transfer off the toilet, then the staff member should have immediately placed R103 on the floor to begin resuscitation. The Immediate Jeopardy was identified on [DATE] at 2:00 pm. The Immediate Jeopardy began on [DATE] at 7:05 pm when the facility failed to perform CPR to R103. The facility was notified of the Immediate Jeopardy on [DATE] at 3:40 pm. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: *V5, RN (Registered Nurse) was immediately suspended on [DATE] and employment terminated on [DATE]. This was completed on [DATE]. *A complete audit of Full code and Advanced Directives was completed by the Social Services Department to ensure POLST form, physicians orders and care plans were in place and documented appropriately. *A complete audit of all employees CPR cards was completed by the Human Resources Director on [DATE]. 80% of employees had active certifications. The remaining 20% are scheduled for the CPR class on [DATE]. This was completed on [DATE]. *An all staff inservice was held on [DATE] and [DATE] to review the CPR Policy and procedure. Staff were also educated on the location and proper usage of the AED machine. The next all staff mandatory inservice presented by the director of nursing will be held on [DATE] and will again review the material in detail to ensure 100% compliance. This is to be completed by the Director of Nursing by [DATE]. *The CPR and AED policy to be presented in an all staff inservice two times a year and on an as needed basis by the Director of Nursing. *Detailed guidelines regarding the use of CPR and the AED machine to be included in the new employee orientation by nursing management. *A POLST Directive-Full Code or DNR Quality Assurance tool was developed and implemented to be completed monthly for three months by the social service director. *The facility currently has charts marked with red dots to indicate a DNR order to enhance the visual representation of residents with a DNR status. *The QAPI committee to review the completed QA tools, POLST statuses and employee CPR certifications on a quarterly basis.

Based on observation, interview and record review, the facility failed to prevent abuse and monitor two high-risk residents with a history of physical altercations resulting in a resident to resident physical altercation for two of three residents (R1 and R2) reviewed for supervision in the sample of three. This failure resulted in R1 obtaining a facial fracture and requiring emergency medical attention. Findings include: The facility's undated Resident Pass policy documents Restricted = Resident is deemed high risk for safety concerns and not to be out of the building independently. The facility's monthly resident council minutes for the months of March, (MONTH) and (MONTH) 2019, all document Residents are requesting more security and would like security to react faster to altercations. R1's current care plan, dated 6/10/19, documents R1 has [DIAGNOSES REDACTED]. This same care plan documents (R1) has the potential to be verbally and physically aggressive related to poor impulse control. (R1) is noncompliant of care often resulting in (R1's) safety being compromised. (R1's) cognitive impairments not accepting/unaware of limitations of [DIAGNOSES REDACTED]. R1's care plan also documents (R1) has impaired cognitive function or impaired thought processes related to difficulty in making decisions, head injury, impaired decision making, delusional thought process mood and emotion management as well as behaviors. On 6/18/19 from 9:00 AM- 3:00 PM, R1 was observed multiple times self propelling in her wheelchair throughout the facility. R1's nursing progress note, dated 6/5/19 at 11:43 PM, documents At 8:30 PM (R1) went out to the A/B patio where she was not authorized to be at that time and was involved in an altercation with a peer (R2). Peer witnesses state that (R1) threw a soda can at a peer (R2) and then tried to grab his eye. Peer witnesses state that the peer (R2) then struck (R1) in the nose with a closed fist causing it to bleed. Pressure was applied and nose was cleansed with a cloth. Swelling noted in the nose and left fourth and fifth fingers. (R1) remained alert and oriented after the incident. Physician, family and administrator were notified. Orders received to send (R1) to the emergency room . R1's nursing progress note, dated 6/6/19 at 4:15 AM, documents (R1) returned to the facility via advanced medical transport wheelchair from being treated at (local hospital) emergency room . After visit summary indicates fracture of (R1's) nose. R2's current care plan, dated 3/21/19, documents R2 has [DIAGNOSES REDACTED]. This same care plan documents (R2) has a background of violence, order of protection 2009, 1995, 1994, criminal damage to property 2009, aggravated stalking 1996, possession of controlled substance 1994, domestic battery 1988, (R2) has a [DIAGNOSES REDACTED]. R2's care plan also documents (R2) has a behavior problem related to not accepting/unaware of limitations of diagnosis, poor impulse control, poor insight and decision making, poor coping skills and poor emotion management. (R2) displays behaviors' of verbal and physical aggression, intrusive, swears, threatens, inappropriate comments and demanding with staff, provokes peers and property damage, noncompliant with facility policies and activities of daily living. On 6/17/19 at 11:05 AM, R2 was in his room in bed. R2 stated that on 6/5/19 he was involved in an incident with R1. R2 stated I don't like it when (R1) is around; she is always picking on me. R2's nursing progress note, dated 6/5/19 at 9:18 PM, documents At approximately 8:30 PM this resident was on outside back patio (designated smoking area) when a peer (R1) threw a can of soda at him and attempted to grab at (R2's) face. (R2) responded by striking peer (R1) in the nose with a closed fist causing peers nose to bleed. Peer (R1) was sent to the emergency room for evaluation and treatment via advanced medical transport. (R2) did not sustain any obvious injuries; however, stated that his lower back hurt as a result of this altercation. On 6/17/19 at 10:55 AM, V6 (Licensed Practical Nurse) stated The supervised patio is labeled the A/B patio and there are set times for residents to go there for smoking. On the supervised patio, staff are to be out there with the residents. On 6/18/19 at 10:10 AM, V9 (Certified Nursing Assistant) stated (R1) is allowed to be out on the patio when she's not smoking. But anyone on the supervised side (A/B patio) should have some supervision to be out there. If they're on that side, there should be staff there to supervise them. (R1) has a lot of behaviors. She's always touching and irritating people and then people get mad and want to kick her butt. (R1) provokes people and she knows who she can irritate. (R1's) pretty equal at who she picks on. There's several that she gets into a lot of arguments with. On 6/17/19 at 11:15 AM, V4 (Registered Nurse) stated I wasn't on the patio the night of 6/5/19. I was down the hall doing a medication pass and (V5, Registered Nurse) came and told me about what happened. I went and talked with (R2). He was not injured but then later said he had a little back pain. (R2) said (R1) threw a full soda can at him and he said he pushed her, but (V5) said (R2) hit her with a closed fist. (R1) is not supposed to go outside unless she is supervised. (R1) tends to get hostile and irritated with pretty much everyone, but particularly she doesn't like (R2). On 6/18/19 at 12:15 PM, V7 (Certified Nursing Assistant) stated I wasn't out on the patio at all that evening. I didn't see the incident between (R1 and R2) happen. All I remember is (R2) hit (R1) in the face and she was bleeding. We take turns watching the front area and the door. I remember there was blood all over (R1's) face. (R1) and (R2) are always sneaking around, maybe they snuck out to the patio. I don't think any staff were on the patio with them. They (R1 and R2) are not supposed to be out on the patio by themselves. There's not enough staff and too many people. The residents have a lot of fights, all the time. On 6/18/19 at 2:30 PM, V2 (Director of Nursing) stated (R1) and (R2) do not have any passes; they are Restricted. So they cannot leave the grounds or go into un-gated areas. Both of them are not appropriate to be in the community alone. They (R1 and R2) are both prone to getting into altercations. We always try to keep them apart from each other. (R1) kind of aggravates more residents than just (R2). Staff are supposed to re-direct (R1). Both (R1 and R2) should be supervised when in common areas or groups especially. On 6/17/19 at 11:30 AM, V1 (Administrator) stated I don't have any staff witnesses to the incident between (R1) and (R2). There were no staff on the patio at that time and none of the other residents will talk to me about it, or offer any information. I'm going to guess they were out there on a unauthorized smoke time and shouldn't have been out there. No actual staff were physically on the patio during this particular incident.

Based on observation, interview, and record review the facility failed to create and implement fall interventions for two of 10 residents (R5 and R17) reviewed for falls in the sample of 20. This failure resulted in R5 experiencing several falls and eventually being hospitalized for [REDACTED]. Findings include: The facility Fall Policy and Procedure, dated 2/2017, documents 2. Individualized interventions will be developed for each resident to prevent falls and injuries, and included on the care plan. 4. The incident report will include a follow-up investigation to the fall which will include the date, time, type, and location of the fall, assigned staff and any injuries sustained from the fall. 5. Care Plans will be put into place for any individual who has had a fall. This will include (b.) An updated, realistic goal related to the fall prn (as needed). 6. Adjustments to ensure maximum safety for the resident will be made in the residents care plan when recurring falls continue despite current plan of care, identifying the resident's risk factors, and need for any changes in plan of care and fall prevention devices if necessary. The facility Fall Follow-Up Procedure, dated 2/2017, documents, It is the policy of our facility to perform fall follow-up investigation to ensure adequate care plan measures are in place. Investigation to include at minimum: 8. Suggestions for prevention and/or recommendations in relation to care plan for prevention. 1. Admission Record for R5 dated 06/09/17 documents the following Diagnoses: [REDACTED].>Chronic Obstructive Pulmonary Disease; Dysphagia; Dysarthria and Anarthria; Bipolar Disorder; [DIAGNOSES REDACTED] left side; and Reduced Mobility. R5 most current MDS (Minimum Data Set) of 07/04/17 documents that R5 is ambulatory with assistance and needs assistance with transfers. On 8/15/17 at 10:30 am to 4:00 pm and on 8/16/17 at 8:00 am to 3:00 pm, R5 was sitting in (R5's) wheel chair propelling self inside and outside the facility independently. The Incident/Accident Report for R5, dated 11/15/16, documents R5 stood up from (R5's) wheel chair, at the Nurses Station and fell to the floor and received an abrasion to (R5's) right eye, bridge of nose, and to left knee. The Care Plan for R5, dated November 2016 through August 2017, does not include fall intervention's for R5's 11/15/16 fall. The Incident/Accident Report, dated 3/11/17 at 5:20 pm, document R5 stood up from (R5's) wheel chair at the Nurses Station and fell to the floor, sustained no injuries, and was stationed close to nurse for observation. The Incident/Accident Report, dated 3/11/17 at 5:50 pm, documents R5 stood up again from (R5's) wheel chair at the Nurses Station, fell to the floor, hitting (R5's) head, and (R5) became unresponsive with unresponsive pupils. The hospital Discharge Summary, dated 3/28/17, documents R5 was hospitalized for [REDACTED]. The History and Physical for R5, dated 3/31/17, documented and signed by E5 PCP (R5's Primary Care Physician)/Medical Director, documents R5 fell recently and went to (local hospital) March 11, found to have a cerebral bleed. On 8/18/17 at 9:00 am, when asked, E4 CPC (Care Plan Coordinator) confirmed there are no new fall prevention interventions for R5's 11/15/16 or 3/11/17 falls. E4, CPC stated (E4) will update a resident's fall care plan by inputing the fall date and medical treatments related to injuries but does not include new fall prevention interventions On 8/17/17 at 12:00 pm, E3 DON (Director of Nursing) stated We don't do root cause analysis here, the nurses fill out the Incident/Accident Report forms, complete the Follow-Up reports, and forward the forms to (E3). E3 also stated, E4 CPC (Care Plan Coordinator) is responsible to put new fall interventions onto the care plans. On 8/17/17 at 11:00 am, E5 PCP (Primary Care Physician)/Medical Director, stated he would 100 percent expect the facility to do a fall investigation, find the root cause of a fall, and to implement appropriate fall interventions for each resident. 2. Facility MDS for R17 dated 07/03/17 docments that R17 requires extensive assistance for transfer and ambulation. On 8/16/17 at 11:20 am R17 was laying in bed with eyes closed, swelling and dark purple discoloration surrounding (R17's) entire left eye area, with four intact sutures to R17's left lateral eye area. On 8/16/17 at 12:00 pm to 3:10 pm and on 8/17/17 at 8:30 am to 12:00 pm, during cares, while sitting in the dining room, and while sitting in television room, R17 repeatedly stood up independently with an unsteady balance and attempted to ambulate with an unsteady gait. The following Incident/Accident Reports for R17, dated 3/13/17, 3/31/17, 4/28/17, 6/16/17, 7/15/17, 8/7/17, and 8/10/17, document R17 falling to the floor with the following injuries: 3/13/17 two lip wounds, 4/28/17 laceration and bruise to right eyebrow, 6/16/17 laceration to upper lip and jaw, 7/15/17 laceration to nose and head bruising, 8/7/17 laceration and Hematoma to right cheek, and 8/10/17 with gash to left eye brow. The Incident/Accident Reports for R17, dated 8/7/17 and 8/10/17 document R17 going to the hospital emergency department and receiving sutures. On 8/18/17 at 9:00 am, when asked, E4 CPC (Care Plan Coordinator) confirmed there are no fall prevention interventions for R17's falls on 3/13/17, 3/31/17, 4/28/17, 6/16/17, 7/15/17, 8/7/17, and 8/10/17.

Based on observation, interview and record review the facility failed follow their policy by not using tray cards to ensure correct diets are followed for one of three residents (R1) reviewed for therapeutic diets in the sample of 12. This failure resulted in R1 being served the wrong diet, choking and requiring hospitalization for aspiration pneumonia. Findings include: The facility policy for Resident Tray Identification Card documents, Purpose: to identify the resident's diet and food preferences in order to ensure correct meal service .the resident tray identification card will contain at least the following information: Resident name, room number, diet as ordered by the physician, resident dislikes, special items to be served: either by the resident request or per care plan approaches, adaptive equipment and dining location. The Facility policy Feeding the Impaired Resident documents, Purpose: The primary purpose for feeding an impaired resident is to provide the resident who needs assistance with eating a well-balanced diet. Key Procedural Points: .Make sure the right tray is served to the right resident .Be observant during the feeding process. Watch for signs of choking or anything unusual . An Incident Report for R1 on 2/5/2017 at 6:30PM documents, Resident choked on a bratwurst at dinner. Certified Nurse Aide (CNA) performed [MEDICATION NAME] and meat expelled. On 2/8/2017 at 3:15PM E9 Certified Nurse Aide (CNA), stated, I was passing meal trays. I passed by (R1) who started to cough. (R1) couldn't speak and was drooling. I did the [MEDICATION NAME] several times. I swiped his mouth and took out a quarter-size piece of meat. It was about 6:15 or 6:20PM. R1 had a regular (consistency) tray . (E10) Registered Nurse came over while I was doing the [MEDICATION NAME] and looked at him and in his mouth .Sometimes we use the tray cards and sometimes we don't. We did not use the tray cards on Sunday (2/5/2017). The Hospital Emergency Department notes dated 2/5/2017 at 10:12PM document, (R1) .presenting to the emergency department due to choking. Patient was sent here from (Facility). Per (Emergency Responders) EMS patient was eating around 5:00PM tonight when choked on a piece of meat. R1's 2/6/2017 Nursing progress notes at 1:04AM document, (R1) being admitted to (hospital) due to Aspiration Pneumonia. R1's current physician's orders [REDACTED]. R1's Tray/Diet card documents R1 is to receive a Mechanical Soft diet. R1's Care Plan developed 4/18/2016 documents, The resident has a [DIAGNOSES REDACTED]. The goal is documented, The resident will remain free of injury related to aspiration that requires hospitalization . The Care Plan interventions are listed as: Diet to be followed as prescribed, Monitor for shortness of breath, choking, labored respirations, lung congestion. Monitor/document/report (as needed) any (signs and symptoms) of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing .appearing concerned during meals. On 2/7/2017 at 5:45PM, E2 Assistant Director of Nursing (ADON) stated, Sunday night (2/5/2017) the Staff did not use the Tray cards on the trays. On 2/7/2017 from 12:10 - 12:45PM and again from 6:00 - 6:45PM an observation of the meal service: A CNA standing outside the meal serving window pulled a resident's tray card for a resident seated and waiting in the dining room. The cook inside the kitchen would then be told by the CNA what diet to serve: Mechanical soft, General, double portions, no gravy, etc. The cook then prepared the tray as requested without visualizing the tray card. In the mean time, if a resident left the dining room or wanted a substitution, the tray and card would be brought back to the CNA with the tray cards and the tray was assigned to another resident with a General, Mechanical soft diet by the CNA near the serving window. Meals served for R1 - 15 were observed during both meals. On 2/8/2017 at 11:20AM E5 Dietary staff, who prepared food on the meal trays 2/5/2017, stated, The CNAs (Certified Nurse Aides) outside the window pull the (tray) cards for the resident's sitting in the dining room and ready to eat. They try to pull the Special diets first, then Mechanicals then the General, then the puree when the CNAs are available to watch/assist them to eat. The CNAs don't say who the tray is for but the CNAs say what diet should be served and if they need double portions or a sub. On 2/8/2017 at 11:20AM, E4 Dietary Manager for the nursing Complex states, All residents have a tray (diet) card. The Tray cards are in the kitchen and the dietary staff are to use the cards to set-up each tray for each resident then send the tray out to be delivered. There is no way for the cook to serve according to the tray cards for likes, dislikes, allergies [REDACTED].

Based on observation, interview, and record review, the facility failed to provide supervision to prevent the elopement of one resident (R1) with severe cognitive deficits of three reviewed for supervision in a sample of five. R1 eloped from the facility on three different occasions without facility knowledge and was found without shoes on one occasion at a community residence. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 9/9/14 at 4:40 p.m., the facility remains out of compliance at a severity level two as the facility continues to review all residents at risk for elopement with care plan adjustments, reassessing, and revising Pass statuses. The facility also continues to inservice staff for elopement, order and install window stops, and do maintenance whole house environment rounds. Findings include: The facility's Wander Management Policy and Procedure, dated 9/19/14, states, "It is the policy of this facility to provide a safe, structured environment for residents who have been identified by the interdisciplinary care plan team as at risk for elopement due to cognitive impairment and accompanying exit-seeking behaviors...elopement is defined as leaving the facility premises without following the facility's policy and procedures for leave of absence." The facility's Resident Pass Policy, dated 9/19/14, states, "Each resident will be evaluated for community access at their initial MDS (Minimum Data Set) assessment...The Interdisciplinary Team will review and determine the individual's ability to access the community with or without staff/family. Based on the Interdisciplinary Team's decision (and with the Guardian's permission) a resident will be considered to have no pass (out with staff/family only) or will be given a pass which reflects the conditions of their pass status." R1's Physician orders, dated 10/2014, document R1 has [DIAGNOSES REDACTED]. A Pass list report, no date available, documents R1 is only allowed to go on walks with staff as of 7/24/14. R1's Brief Interview and Mental Status assessment, dated 10/9/14, documents R1 has a score of "five", indicating a severe cognitive impairment on a scale of 0-15. On 10/9/14 at 11:30 a.m., E10 (Traumatic Brain Injury Coordinator) stated, "(R1) was a traumatic brain injury at birth with severe development disorder. (R1) functions at a two year old's level with poor safety awareness and poor memory. (R1) gets confused easily. (R1) has a history of attempting to leave the facility. Shortly after (R1) got here (R1) started making attempts to leave. (R1) has an electronic monitoring bracelet to alarm staff if (R1) leaves the facility, but there has been a few times staff have had to go out to the community to get (R1) when (R1's) gotten out. (R1) would not be safe for a pass to leave the building unattended because (R1) has no safety awareness of what is safe and what is not safe." R1's Clinical Mental Health Progress notes, dated 7/23/14 and written by E10, states, "Went on a walk in the neighborhood with (R1), per (R1's) request. (R1) would like to walk by self or with a peer. Throughout the walk, (R1) wanted to do various unsafe activities, for example, walk on the side of the highway, go into people's yards, visit a stranger's home, etc. We worked on defining what is safe vs. unsafe behavior. (R1) had a difficult time understanding what was appropriate." R1's Care plan, dated 9/2/14, states, "R1 has cognitive impairments, needs reminders, verbal cues and redirection. R1 has inattention and disorganized thinking. R1 is easily startled, which fluctuates. R1 has memory impairments, poor impulse control, poor insight, poor judgement, and poor independent living skills." R1's Nurses notes, dated 8/4/14 at 9:00 p.m., documents R1 went for a walk with a peer and returned by the local police department, and ten minute checks were initiated. R1's Incident/Accident Report, dated 8/4/14 at 9 p.m., states, "(R1) went for a walk with a peer. Peer returned without (R1). Police returned (R1) to the facility at around 9 p.m. (R1) in no distress...Additional comments and/or steps taken to prevent recurrence: (R1) placed on 10 minute checks." On 10/14/14 at 2:45 p.m., R7 stated, "I went on a walk with (R1) just the one time back in August. (R1) ran off while we were walking. It happened while it was raining. The police brought (R1) back sometime after I got back." On 10/9/14 at 10:55 a.m., E11 (Licensed Practical Nurse) stated, "(R1) was out walking with (R7) on 8/4/14...(R7) returned to the facility prior to (R1). (R1) left prior to my arrival at 6:30 p.m. Medication pass is at 7:30-8 p.m. and that is when we recognized (R1) was missing. We started a search, including outside. We received a phone call from the sister facility next door stating they had a lady who didn't know who self was. As soon as our staff left to see if it was (R1), the police walked in with (R1). The police were not called when we noticed (R1) was missing. Following this incident we just continued 10 minute checks. R1's Nurses Notes, dated 9/2/14 at 12:00 p.m., states, "(R1) attempted to elope today. Intervened by staff. (R1) was brought back to the facility. Ten minute checks remain in effect." R1's Nurse's Notes, dated 9/21/14 at 12:08 p.m., states, "(R1) was going out on a walk with activities and tried to run away as soon as (R1) was outside." R1's Nurse's Notes, dated 9/28/14 at 10:45 a.m., states, "...Got out the front door and had to be retrieved by security...(R1) is still asking other residents to help (R1) get out a window or help (R1) get over the fence..." R1's Nurse's Notes On 9/30/14 at 10:24 p.m., states, "(R1) left out of a window on pass violation but was retrieved by security." On 10/9/14 at 3:30 p.m., E12 (Licensed Practical Nurse) stated, "It was 9/30/14 when I worked and we could not find (R1). The Certified Nursing Assistant (CNA) that was doing (R1's) ten minute checks said they could not find (R1) and (R1) got out of the window. I didn't fill out an Accident/Incident report because we got (R1) back and there was no injuries. This happens a lot where residents get out and we call the police and if they are ok I do not fill anything out or bother the Director of Nursing or Administrator with it. (R1) has taken off before, but we see (R1) and staff brings (R1) back. (R1) tries to get out all the time...(R1) doesn't have a pass to leave because (R1) will run away." R1's Incident/Accident report, dated 10/6/14 at 7:15 p.m., states, "(R6) states that (R1) climbed out of (R6's) window. Search is done and (R1) is not found in the facility or on the grounds." R1's Incident Report form, dated 10/6/14 at 7:15 p.m., states, "(R1) climbed out peer's window. Staff could not find (R1). Missing persons initiated. (R1) was found by staff and returned to the facility. Orders were received for direct admit to local hospital with increased psychosis." R1's Nurse's Notes, dated 10/6/14 at 7:15 p.m., states, "(R6) states that (R1) came into (R6's) room and climbed out the window. A facility wide check is initiated and ground check is done. R1 is not found at this time." At 8:45 p.m. the same day, R1's Nurse's notes state, "Security received call that (R1) has been found. Staff members sent to pick (R1) up." At 8:50 p.m. Nurse's notes state, "(R1) returns to facility at this time via car and a staff member." At 9:15 p.m. Nurse's notes state, "(R1) is transported to local hospital via ambulance." On 10/7/14 at 8:30 a.m., R1's Nurse's notes state, "(R1) returns from local hospital via facility staff. (R1) escorted to (R1's) room where (R1) directly went to bed...Continue on 10 minute checks..." R1's Emergency Department Discharge Safety Plan, dated 10/7/14, states, "It is recommended that the facility revise (R1's) sleeping arrangement so that (R1) is able to be observed at night to prevent (R1) from escaping out of the window, and keeping (R1) safe providing (R1) with one on one assistance." On 10/9/14 at 4:25 p.m., E16 (Registered Nurse) stated, "On 10/6/14, R6 notified me that a female resident climbed out of (R6's) window at the same time that a Certified Nursing Assistant said they couldn't find (R1). Immediately I started a search on the grounds, called (R1's) mother, and the police. Then we got the call from a person in the community saying that (R1) was at their house. Then, we sent staff to pick (R1) up. (R1) returned with no injuries. We kept (R1) in the main lobby area until she left to go to the hospital. My concern is that the more (R1) gets out the more it increases (R1's) risk for injury. (R1) needs a one to one to keep (R1) in the building. (R1) has the mind of a child." On 10/9/14 at 10:45 a.m., E6 (Certified Nursing Assistant) stated, "On 10/6/14, the last time I saw (R1) was in the dining room eating supper between 6-7 p.m.. A little bit after that I went looking for (R1) and didn't find (R1). I went into (R1's) room and the window was open. (R6) told me (R1) climbed out of (R6's) window. (R1's) shoes were underneath the window. (R1) must have taken them off before (R1) went out the window. I immediately told the nurse then we all started looking for (R1), while the nurse called the police...When (R1) got back to the facility we kept a close eye on (R1) and the nurse called the doctor. (R1) was sent to the hospital. (R1) had a history of [REDACTED]. (R1) likes to take walks with staff, but when (R1) gets outside (R1) attempts to run off. (R1) has attempted to climb out (R1's) window before, also." On 10/9/14 at 9:10 a.m., E9 (Registered Nurse) stated, "(R1) returned to the facility at 8:30 a.m. on 10/7/14 per the facility vehicle from the local hospital. (R1) had orders for one on one cares, but we can't provide one on one care. We are not a locked unit. We do not provide one on one care." On 10/9/14 at 11:45 a.m., Z2 (R1's Mother) stated, "(R1) climbed out of another resident's window. (R1) was found a couple of blocks from the facility. I had to tell the facility (R1) was missing. I spoke with E2 (Director of Nursing) and E2 said it was a staff error that (R1) got out. (R1) has not ran away for the last [AGE] years. (R1) hates it at the facility." On 10/9/14 at 11:45 a.m., Z1 (Citizen in community who lives approximately one mile from the facility) stated, "I found (R1) Monday night (10/6/14). My older daughter and her son pulled into my driveway and (R1) walked up to my daughter and asked my daughter to take (R1) to (another town approximately 80 miles from the facility.) (R1) was walking in socks with no shoes. (R1) pointed to my daughter's son and asked him to walk (R1) to church. I said I'm sorry I can't help you. (R1) was walking down the main avenue nearby and I told (R1) I would call someone. We fed (R1) dinner. We called (R1's) Grandmother in (the town 80 miles away) and (R1's) mother. (R1) was very confused. We spoke with the facility and they said we aren't missing anyone. Then (R1's) mother called the facility and told them yes you are missing someone. The facility came to get (R1). (R1) was at our house for over an hour to an hour and a half, (R1) first arrived about 7:00 p.m." On 10/9/14 at 11:10 a.m., R1 was in the conference room, confused, asking to see R1's mother. R1 exhibited a flat affect on R1's face with a blank stare. R1 repeatedly asked where R1's mother was. R1 was unable to answer questions regarding R1's attempts to leave the facility, disoriented, and kept talking about R1's mother. On 10/14/14 at 1:30 p.m., R6's room was empty. R6's window faces a neighboring apartment complex with a sidewalk beneath it. On 10/14/14 at 2:45 p.m., E13 (Maintenance) stated, "After (R1) left I heard the window screen in R1's room was missing, so I fixed it. Then (R1) was moved to another room. I put a new screen in room B11." On 10/9/14 at 9:35 a.m., E5 (Certified Nursing Assistant) stated, "(R1) has left several times. (R1) jumps out (R1's) window and gets out the front door when someone else goes out...(R1) is on ten minute checks and has been since (R1) has been here..." On 10/9/14 at 1:10 p.m., E4 (Licensed Practical Nurse) stated, "Certified Nursing Assistants (CNAs) are to watch (R1) every ten minutes. (R1) has not been a one on one currently or since (R1) has returned on 10/7/14. The CNAs check on (R1) in (R1's) room every ten minutes. (R1) is not always with the staff..." On 10/9/14 at 1:20 p.m., R1 was walking in R1's room with a flat affect and nonverbal. R1's room window opens to a fenced courtyard. On 10/9/14 at 1:25 p.m., E7 (Certified Nursing Assistant) stated, "I check on (R1) every ten minutes. We do not stay with (R1) at all times. (R1) is usually in (R1's) room or a sitting area....(R1) doesn't follow us..." On 10/9/14 at 12:30 p.m., E2 (Director of Nursing) stated, "(R1) has not had a pass to leave...(R1) went out with a peer on 8/4/14 when the police returned (R1). If (R1) left with a peer I would hope she would have had a pass. (R1) came back to the facility 10 minutes after the male peer returned. (R1) was put on 10 minute checks after this, but (R1) was started on 10 minute checks from the time (R1's) been here...I'm not aware that (R1) attempted to climb out of the window prior to 10/6/14, just that (R1) tries to get out of the door. No one has said anything to me about (R1) attempting to get out of (R1's) window. (R1's) window screen was out the night we noticed (R1) was missing...When (R1) returned from the emergency roiagnom on [DATE], (R1) was put on one to one where (R1) follows staff around. We do not document (R1) being on one to one checks. (R1) is on written 10 minute checks. (R1) is with staff at all times and if (R1) is not on one to ones, then (R1) is on 10 minute checks. Someone is constantly watching (R1) and knows where (R1) is at all times. If we didn't watch (R1) constantly, (R1) would be out. (R1) constantly tries to get out any chance with any open door. (R1's) room was changed when (R1) returned so if (R1) got out (R1) would go into fenced area, and so staff can see (R1) at all times...No new interventions were implemented on the care plan for the 8/4/14 and 10/6/14 incidents." On 10/14/14 at 4:40 p.m., E2 (Director of Nursing) stated, "I was unaware of (R1) leaving the building on 9/30/14...The nurse did not notify me and I did not receive an accident/incident report. The nurse knows better than that." On 10/9/14 at 3 p.m., an Immediate Jeopardy was identified to have begun on 8/4/14 when R1's first elopement occurred. E2 (Director of Nursing) was notified of the Immediate Jeopardy on 10/9/14 at 3 p.m.. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy. 1. A whole-house review of residents at risk for elopement was done by the Interdisciplinary team, and five residents were identified (R1, R2, R8, R9, R10) on 10/9/14. 2. On 10/9/14, R1 was placed on continuous one on one by E2 and E8 adjusted R1's Care plan. R1 was also reassessed for BIMS (Brief Interview and Mental Status), SLUMS (St. Louis University Mental Status), Community Access, and Elopement risk by E8. R1's Pass Status was revised by the Interdisciplinary team. 3. On 10/9/14, R2 was placed on continuous one on one by E2 and adjusted R2's Care plan by E18 (PRSC-Psychiatric Rehabilitation Services Coordinator). R1 was also reassessed for BIMS, SLUMS, Community Access, and Elopement risk by E18. R2's Pass Status was revised by the Interdisciplinary team. 4. On 10/9/14, R8's Care plan was adjusted by E20 (PRSC). R8 was also reassessed for BIMS, SLUMS, Community Access, and Elopement risk by E20. R8's Pass Status was revised by the Interdisciplinary team. 5. On 10/9/14,R9's Care plan was adjusted by E8. R9 was also reassessed for BIMS, SLUMS, Community Access, and Elopement risk by E8. R9's Pass Status was revised by the Interdisciplinary team. 6. On 10/9/14, R10's Care plan was adjusted by E20. R10 was also reassessed for BIMS, SLUMS, Community Access, and Elopement risk by E20. R10's Pass Status was revised by the Interdisciplinary team. 7. Staff was inserviced on elopement, resident safety, and the specifics of increased monitoring including one on one supervision duties on 10/10/14 by E2. 8. A Maintenance Whole House Environment round was completed on 10/9/14 by E19 (Maintenance). 9. Window stops were ordered on [DATE] and installed on windows of A, B, C, D, and E Wing residents and windows in A/B and C/D sitting areas on 10/14/14 by E19.