Every finding on record at Warren Park Health & Living CTR

Based on interview and record review the facility failed to ensure their IDPH (Illinois Department of Public Health) Reportable initial and final Incident Report Form was transmitted correctly for 7 (R20, R28, R45, R50,R82, R86, R121) of 7 residents identified on four (4) Facility Reportable documents reviewed. This failure has the potential to affect 123 residents residing in the facility.Findings Include:On 12/10/25 during review of the facility Reportable Fax Transmittal Form document, it was observed that the facility transmittal sheet document in part: Result: No answer . IDPH did not receive the following reportable of 09/18/25, 10/27/25 (regarding R20 and R28), 10/28/25 (regarding R121), 11/19/25 (regarding R28 and R86), and 9/19/25 regarding R50, R45 and R82.On 12/10/25 at 10:23 AM V1 (Administrator) stated that is the number (referring to the fax number on the Result Report) that we have been submitting the reportable to since I have been here. I have worked here for 10 years but I have been submitting it for 2 years. The receipt of confirmation, that is what that (referring to the Fax Result Report) is and come out after we send/fax the reportable. I am not aware the reportable was not being transmitted correctly. I looked at the result ok and that is what I was accustomed to, so I did not go any further than that. I was given the correct fax number and email. I have not had to send any other reportable in since I was given the correct fax number. V1 was made aware that the facility was being placed in Substandard Quality of Care/Extended Survey and that a plan of correction needs to be put in place at this time.On 12/10/25 at 11:21 AM V1 (Administrator) presented the surveyor with a plan of correction and stated I put a plan together. I updated the reporting form with the new fax number, and I am actively going around to in-service the staff with the new reporting fax number. I will be reviewing all the reportable confirmations for the IDPH (Illinois Department of Public Health) reportable. We will review them in the QAPI (Quality Assurance and Performance Improvement) meeting for compliance. I updated the IDPH Incident Report Form fax number and completed a plan of correction for substandard quality of care.V1 presented the surveyor with an IDPH Incident Report Form with the updated fax number and a sheet with the plan of correction dated 12/10/25 documenting in part: Situation - This plan is to address the facility reporting of incidents to IDPH via fax, to an outdated number. The facility was updated on the new contact information by an IDPH surveyor on 12/06/25 during a complaint investigation. The facility now has current fax and email information to submit reportable incidents to. Plan - The facility Administrator updated the reporting forms to display the updated contact information for IDPH reporting. The staff designees will be in-serviced on the updated reporting information. The facility Administrator will review all fax confirmations r/t (related/to) IDPH reporting for compliance on an ongoing basis. All reportable incidents will be added to QAPI for monitoring of compliance.Policy:Titled Abuse Prevention Program dated 10/22 document in part: Any allegation of abuse of any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but no more than two hours of the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. VIII. External Reporting 1. Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator, or designee, shall notify Department of Public Health's regional office immediately 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 to the administrator and is being investigated. 2. Five-day Final Investigation Report. Within five working days after the report of the occurrence, a complete written report of conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.

Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program. This has the potential to affect all 123 residents residing in the facility.Findings include: On 12/09/2025 at 10:55 AM, R7 was lying in bed. There was a black flying insect flying around in R7's room during the interview. On 12/09/2025 at 11:20 AM, R113 was lying in bed. During interview, there was a black, flying insect flying in the room. R113 stated seeing flies at least once a week. R113 has also seen roaches and spiders in the bedroom. On 12/09/2025 at 12:09 PM, V9 (Ombudsman) stated residents complained about cockroaches in the past and is an ongoing issue. On 12/09/2025 at approximately 2:38 PM, V8 (Maintenance and Housekeeping Director) stated facility contracts a pest control company that comes out weekly and as needed to treat the facility. V8 stated staff occasionally report bugs in the laundry room. On 12/10/2025 at 10:08 AM, R121 was in the basement dining room. During interview, there was a black flying insect in the dining room. In the far end of the dining room near the north wall, there was a brown bug crawling on the floor. R121 mentioned roaches being around the vending machines. On 12/10/2025 at 11:22 AM, R11 was lying in bed. There was a rodent glue trap under heater vent. R11 stated maintenance staff put the trap a while ago but it doesn't work because R11 saw a small mouse last night. On 12/10/2025 at 11:23 AM, R27 stated seeing a cockroach on the third-floor hallway a couple of weeks ago. On 12/10/2025 at 11:24 AM V11 (Housekeeping) stated there are roaches in the residents' bedrooms. V11 stated seeing them in the corners of bedrooms or in the residents' bathrooms. V11 stated seeing a roach downstairs in the women's locker room that morning. V11 stated to be honest they're everywhere. V11 also stated seeing a mouse in R120's room last week. V11 stated the activity room in the basement also has a lot of pest and rodent activity. V11 stated pest control comes out weekly but staff and residents continue to see pests and rodents. V11 stated It's just not working. On 12/10/2025 at 11:28 AM, R120 stated seeing a roach here and there. R120 declined to talk about rodents but mentioned needing to request a personal fridge to protect R120's snacks from the rodents. On 12/10/2025 at 11:33 AM, V12 (Housekeeping/Floor Tech) was moping the second-floor hallway. V12 stated usually seeing a cockroach in the vending machine room (dining room) in the basement. On 12/10/2025 at 11:34 AM, R41 stated seeing mice in the bedroom three days ago. R41 also sees water bugs and roaches in the bedroom. R41 stated last sighting was three to four days ago. On 12/11/2025 at 10:35 AM, V2 (Director of Nursing) stated pest control company comes to service the building weekly and as needed. V2 stated staff are to report all sightings in the communication dashboard in the electronic system. V2 stated if staff and residents continue to see pests and rodents then the interventions are not effective. V2 stated the facility needs to see what else they can do to prevent and get rid of the pests and rodents. Facility's 'Service Inspection Reports' from their contracted pest control company document in part that a mouse was found in the kitchen dry storage area on 11/21/2025, a resident's room was attracting flies and roaches on 10/15/2025, and there were German roaches in the kitchen dish room on 10/06/2025. Facility's undated Policy on Pest Control documents in part: It is the policy of the facility will be free of pest/rodents. Facility's admission Packet contains the Illinois Long-Term Care Ombudsman Program's Resident Rights for People in Long-Term Care Facilities. It documents in part that residents have the right to have a safe, clean, comfortable, and homelike environment.

Based on observation, interviews and review of record the facility failed to maintain toilet rails inside the shower in safe working condition and they also failed to ensure that there is a shower head and shower curtain that covers entire shower area for all residents living on the 2nd floor. These failures have the potential to affect fifty-five (55) residents on their safety and comfort when using the shower room.Findings include: On 12/09/2025 at 12:11 PM, With V9 (State Ombudsman) inside shower room, left and right rails of the toilet are not properly attached to the floor (wobble like about to detach when pressure applied). Screws on both left and right rails are missing and full of rust. Missing shower head was found inside one of the shower areas. Also the shower curtain has a tear on the part where it attaches to the 3 rings unable to cover shower area when fully expand. At 12:25 PM, V8 (Maintenance Director) went inside the shower room stated that rails on the toilet are not properly attached on the floor and there are many missing screws that it wobbles wide when moved. V8 stated it looks as it has been for a while due to the rust showing on the metal part of the rails. V8 stated that residents are at risk for fall if it detached on the floor while using the rails on the toilet. On 12/10/2025 at 10:00 AM, V1 (Administrator) was informed about rails on the toilet inside the shower room. V1 stated that she was not aware about the problem. On 12/11/2025 at 12:33 PM, V8 (Maintenance Director) stated that he did not have any record on maintaining or checking shower areas. And that was the first time he knew about the rails problem on the shower room second floor. Maintenance Policy dated 12/2019: To ensure the facility is maintained in proper repair and equipment is functioning appropriately. The maintenance staff will have designated assignments to ensure the facility remains in proper repair on a daily basis and PRN (as needed). Maintenance will be alerted of any ill repair or concerns that need to be addressed as related to the environment upkeep. Maintenance will communicate with the Administration any facility needs that are identified to ensure a safe well-maintained environment at all times.

Based on observation, interview and record review the facility failed to ensure an enteral bolus feeding was administered per physician orders for one (R103) resident with an order of NPO (Nothing by Mouth) reviewed for g-(gastric) tube feedings in a sample of 26.Findings Include:R103 has diagnosis not limited to Chronic Systolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Asthma, , Gastrostomy, Essential (Primary) Hypertension and Hyperlipidemia. R103's Medication Review Report document in part: NPO (nothing by mouth) diet. Enteral Feed Order four times a day Enteral feeding G (gastric)-Tube: Jevity 1.2cal, Bolus: 2 cans. Flush g-tube with 120ml (milliliter) of water before & after each bolus feed. Enteral Feed Order one time a day for G-tube Care [Enteral] Change syringe daily. Oral /Enteral Syringe with Enfit Connector 60ml.R103's Care Plan document in part: The resident requires tube feeding r/t (related /to) dysphagia, Swallowing problem. 03/14/24: On Bolus feeding of Jevity 1.2 2 cans 4x/day. NPO TF (Tube feeding).On 12/09/25 at 12:05 PM R103 was observed in bed in a semi-Fowler_position with a left-hand splint in place. V19 (Registered Nurse) was observed administering R103's bolus feeding with a 60 ml (milliliter) syringe via the gastric tube with a short tip allowing some of the gastric feeding to leak onto a blanket that was covering R103's abdomen. V19 aspirated the feeding into the syringe from a plastic cup, placed the short tip of the syringe into the gastric tube, then pushed the feeding into the gastric tube using the plunger. V19 said this is not the right kind of syringe. V19 then flushed the gastric tube with 120 ml of water. 12/11/25 at 09:23 AM V2 (Director of Nursing) stated G-tube feeding, the nurse has to make sure there is an order, check placement, proper position and wash hands. The syringe plunger (piston with a rubber tip/gasket for suction and pushing) should not be used to give a bolus feeding. We use the bolus feeding and the bolus feeding is done by gravity. If the bolus feeding is leaking, there is a potential the resident is not receiving enough feeding according to the order.12/11/25 at 09:45 the surveyor accompanied V2 (Director of Nursing) to the supply room. V2 picked up a syringe from the shelf and stated, the enteral feeding syringe is a flat top piston. V2 proceeded to pick up a g-tube tray that contained a cannister and syringe then stated, this syringe does not work with the kind of g-tubes they are placing.Policy:Titled Enteral Nutrition revised 11/18 document in part: Adequate nutritional support through enteral nutrition is provided to residents as ordered. Policy Interpretation and Implementation. 11. The Nurse confirms that orders for enteral nutrition are complete. Complete orders include: a. The enteral nutrition product; b. Delivery site (tip placement); c. The specific enteral access device (nasogastric, gastric, jejunostomy tube, etc.; d. Administration method (continuous, bolus, intermittent); Central supply is responsible for ordering all tube feeding supplies. The staff may use products from a basic formulary until any specialized products can be delivered.

Based on observations, interviews, and record reviews the facility failed to follow their Change in Condition Policy to promptly notify the physician of skin rashes for three [R23, R97, R113] residents reviewed in a sample of 26. This failure resulted in a delay of treatment. Findings include, On 12/9/25 at 9:30 AM, during the facility's tour, several residents expressed concern in reference to their body rashes. On 12/9/25 at 9:42 AM, V30 [Certified Nurse Assistant] stated, There are a few residents I noticed with a body rash over the past month. R23, R46 and R113. The nurse was made aware. On 12/9/25 at 10:20 AM, R23 stated, I have been itching for a month. The rash started on my feet, between my toes, then moved to my lower legs, stomach, back, and under my breast. I showed V14 a few times and they are not doing anything about my rashes. R23 gave V14 [Registered Nurse] and surveyor permission to observe her rashes and noted red and black bumps some with crust on top, other bumps have a tiny whole in the middle. The rash was noted from R23's feet, ankles, lower legs, buttocks, back of thigh, back, stomach and underneath the breast areas. V14 stated, I notified one of the nurse practitioners, but I do not remember who I told or when. On 12/9/25 at 11:42 AM, R97 stated, My feet, legs and my butt won't stop itching. I been itching for a long time. On 12/9/25 at 11:45 AM, V28 [Certified Nurse Assistant], V13 [Licensed Practical Nurse] and surveyor observed R97's skin. Observed R97's feet, lower legs, buttocks, stomach, and arms with red and black bumps some with crust on top, other bumps have a tiny whole in the middle. V28 stated, I noticed R97's rash about two weeks ago. I did notify the nurse, but I cannot remember who it was. V13 stated, I thought R97 had skin cream ordered for his rash, it looks like it has spread. On 12/10/25 at 1:00 PM, V2 [Director of Nursing] stated, Once certified nurse assistants note a change in a resident's skin, they must report the change to the nurse immediately. The nurse must document the change in condition and notify the physician or nurse practitioner timely. If the nurse fails to notify the physician regarding a change in condition, it could potentially delay prompt treatment and worsening of a medical condition. A delay in treatment could potentially cause harm to the resident. Policy documented in part: Change in Condition or Status dated 5/2026. Our facility shall promptly notify the resident attending physician of changes of condition. The nurse will notify the physician for [in part]: Adverse reactions to medications, significant change in resident's physical, emotional, or mental conditions. Refusal of treatment or medications. Significant change of condition is a condition that will not normally resolve itself without intervention by staff or my implementing standard disease related clinical interventions. Findings include: On 12/09/2025 at 11:20 AM, R113 stated had rash to left hip for the past two weeks. R113 stated it itches. R113 stated getting it from the linen at this facility. On 12/09/2025 at 11:22 AM, V7 (Nurse) came into R113's room to look at the rash. V7 stated new to the facility and was not aware of R113's rash. R113 stated informing another nurse about the rash. R113 pulled down pants and pointed to legs. R113's skin was dry with multiple raised bumps up and down both legs from hip down to lower legs. Some bumps with indentation in the middle. V7 stated R113's skin was dry and scaly.

Based on interview and record review the facility failed to ensure a Level II PASARR (Preadmission Screening and Annual Resident Review) yearly review was completed for 1 of 2 residents reviewed for PASARR in a sample of 26.Findings Include: R41 has diagnosis not limited to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Ulcerative Colitis, Morbid (Severe) Obesity due to Excess Calories, Abnormalities of Gait and Mobility, Insomnia, Overactive Bladder, Age-Related Osteoporosis, Mood [Affective] Disorder, Solitary Pulmonary Nodule Right lower lobe Lung Nodule, Bilateral Primary Osteoarthritis of Knee, Bipolar Disorder, Pulmonary Embolism and Infarction, Heart Failure, Congestive Heart Failure, Idiopathic Scoliosis, Atherosclerotic Heart Disease of Native Coronary Artery, Hyperlipidemia and Essential (Primary) Hypertension. R41's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response.R41's Medication Review Report document in part: Citalopram Hydrobromide Tablet 20 MG (milligram) Daily for depression, Lorazepam Oral Tablet 2 MG three times a day related to Unspecified Mood [Affective] Disorder and Trazodone HCl Oral Tablet 150 MG at bedtime related to bipolar disorder.R41's Care Plan document in part: Focus: SMI (Severe Mental Illness) Individualized Care Plan. R41 is in need of supportive counseling and/or psychotherapeutic services secondary to: (X) mental illness diagnosis of Bi-Polar Disorder (MI). (X) Signs and symptoms of clinical depression. (x) Observable medical/psychiatric/cognitive conditions that may require on-going assessment, consultation and intervention. Date Initiated: 10/14/25. Interventions: Staff will encourage the resident to follow mental health treatment plans to the best of capability in accordance with age and medical condition. Explain the benefits of continued mental health involvement and potential negative consequences from abstaining from treatment. Utilize assessment data (i.e., PASARR, MDS, Psychiatric Evaluation, Level of Functioning and Psychosocial History) to help determine the resident's present needs, deficits, abilities, strengths. Date Initiated: 10/14/25.During review of R41's Electronic Medical records, R41does not have a current PASRR (Preadmission Screening and Resident Review). R41's OBRA (Omnibus Budget Reconciliation Act) Screen dated 07/21/1992 document in part: There is a reasonable basis for suspecting DD (Developmental Disability) or severe MI (Mental Illness) as severe Mental Illness (SMI). R41 was originally admitted to the facility on [DATE] with a readmission date of 10/14/16. Electronic Medical Records document on 06/05/15 a diagnosis of bipolar disorder and on 10/27/17 a diagnosis of Unspecified Mood [Affective] Disorder. On 12/10/25 at 09:16 AM V3 (Social Service Director) stated The whole social service department is responsible for the PASARR (Preadmission Screening and Resident Review).On 12/10/25 at 12:59 PM V3 (Social Service Director) stated R41 have never left the facility. I only have to submit for the PASARR it if the residents are going to a different facility. There has not been a change to R41's mental illness not that I am aware of. Surveyor asked V3 if there is any documentation that she (V3) does not have to submit for a PASARR. V3 responded, where do you document that? I had a call with the help line.On 12/11/25 at 11:14 AM V3 (Social Service Director) stated R41 does not have a PASARR. R41 has the old OBRA because she was here prior to 2022. I don't have here original diagnosis.On 12/11/25 at 11:21 AM V18 (Psychotropic Nurse/Care Plan Coordinator) stated I am not the one who normally does the PASARR. Surveyor asked V18 to provide documentation that indicated R41 had diagnosis of Mood [Affective] Disorder and Bipolar Disorder prior to her initial admission date of 03/10/10.On 12/11/25 an undated typed document was presented to the surveyor from the facility via e mail that document in part: R41 was admitted in 2010 with diagnosis of bipolar disorder. After a hospital stay in 2017 a diagnosis of Mood Disorder was added to her list of diagnosis. There was no new PASARR completed as Mood disorder is an umbrella term for conditions where a primary disturbance of mood is central. All Bipolar Disorders are Mood Disorders. But not all Mood Disorders are bipolar disorders. And her (R41) added diagnosis was unspecified mood disorder. That did not warrant a new screening.Policy:Titled admission Criteria revised 03/22 document in part; Policy Statement: Our facility admits only residents whose medical and nursing care needs can be met. 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorder per Medicaid Pre-admission Screening and Resident Review (PASARR) process.

Based on observations, interviews, and record reviews, the facility failed to provide a home-like environment for three residents (R9, R133, and R134) out of a total sample of 26 residents. Findings include: On 12/09/2025 at 11:34 AM, R9 was oriented to self, place, and year. R9 stated there is a hole in the wall behind the bed. R9 stated it was there when R9 moved into the room. R9 requested facility to fix it but maintenance has not done it. Surveyor observed large break in the wall that was greater than R9's breakfast plate. Multiple pieces of the drywall are caved in. Multiple smaller pieces are on the floor below the hole. R9's 'Census List' documents in part that R9 has been in the room since 11/19/2025. On 12/09/2025 at 11:38 AM, R134 was oriented to self, place, and date. R134 stated previous roommate made a hole in the wall behind bedroom door. There was a crescent-shaped hole in the drywall that was about a foot long and eight inches high. R134 stated requesting facility to fix it but maintenance has not done it. R134 stated being scared that pests or rodents would come out from the hole. On 12/09/2025 at 11:40 AM, R133 (R134's current roommate) stated hole in the wall was there when R133 moved in. R133 stated informing staff about it as well but facility hasn't got to it. R133 also stated there were holes on the floor near R133's bed that needed to be fixed but facility hasn't done it. R133 showed surveyor a missing part of the flooring tile near the bottom right side of the bed and another tile near the left side of the bed. R133's 'Census List' documents in part that R133 has been in the room since 9/09/2025. On 12/09/2025 at 2:35 PM, V8 (Maintenance Director) and surveyor conducted a walk-through of R9, R133, and R134's rooms. V8 stated was not aware of the holes in the walls. V8 stated the holes in the wall could be fixed right away but staff did not communicate it to V8. V8 also stated that the floor is linoleum and that V8 was not aware there were holes near R133's bed. On 12/11/2025 at 10:35 AM, V2 (Director of Nursing) stated the staff are supposed to report all maintenance issues on the communication dashboard in the electronic system. Facility's undated [Company Name Omitted] Preventative Maintenance and Work Order Policy documents in part: Purpose: To track Life Safety Tasks, Manage Assets, Schedule Maintenance Services and Work Order Repairs. All employees and/or family members should report an issue. It also documents in part that the work order needs to be filled out in a timely manner. Facility's admission Packet contains the Illinois Long-Term Care Ombudsman Program's Resident Rights for People in Long-Term Care Facilities. It documents in part that residents have the right to have a safe, clean, comfortable, and homelike environment.

Based on observation, interview and record review the facility failed to (a.) follow the physician orders for a resident on continuous oxygen, (b.) failed to post oxygen in use signage at the entrance of R41's room, and (c.) failed to label and store oxygen tubing and a nebulizer set-up to prevent contamination for two (R41, R103) residents reviewed for respiratory treatments in a sample of 26.Findings include:R41 has diagnosis not limited to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Morbid (Severe) Obesity due to Excess Calories, Insomnia, Overactive Bladder, Age-Related Osteoporosis, Mood [Affective] Disorder, Bilateral Primary Osteoarthritis of Knee, Bipolar Disorder, Pulmonary Embolism and Infarction, Heart Failure, Congestive Heart Failure, Idiopathic Scoliosis, Atherosclerotic Heart Disease of Native Coronary Artery and Essential (Primary) Hypertension. R41's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response.R41's Medication Review Report document in part: Check pulse oximetry Q (every) Shift & as needed, Call Md (Medical Doctor) below 90% every 24 hours as needed. Continuous O2 (oxygen) Via (NC (nasal cannula)/Mask) at 2 liters per minute. Notified MD if Below 90. every shift for related to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation.R41's Care Plan document in part: Focus: The resident has oxygen therapy r/t (related /to) Respiratory illness. Pulmonary Nodule, Hypoxemia, COPD, Pulmonary Embolism diagnosis. R41 has a plug- in concentrator at the bedside.On 12/09/25 at 01:20 PM R41 was observed near the nurse station in a wheelchair with no oxygen in use. R41 asked to speak to this surveyor. Surveyor proceeded down the hallway and entered the room with R41. R41 said she has been in the facility for 15 years. My oxygen is broke. R41 applied the nasal cannula and turned on the oxygen concentrator that was located at her bedside. The oxygen tubing was unlabeled and undated. R41 stated V1 (Administrator) has the receipt for my oxygen box but where is my oxygen box. I would like to move around the floor and go to activities, but I feel like a prisoner in my own room. They ordered a battery for the other box, but it did not fit inside. I get nervous and end up with loose stools. I have a doctor appointment on 12/11/25 and have no oxygen tank. When I am out of the room I try to control my breathing. A small rectangular shaped bag was observed attached to the back of R41's wheelchair with a nasal cannula inside of it with no bag to prevent contamination.On 12/09/25 at 03:05 PM V1 (Administrator) stated I ordered a new battery-operated portable oxygen concentrator for R41. There is an oxygen concentrator in R41's room and we have a cannister that we can hook R41 to in the meantime. If the cannister is not working, we send R41 out to her doctor appointment with two oxygen tanks.On 12/10/25 at 8:30AM, surveyor observed R41 sitting in her wheelchair without a supplemental oxygen tank. R41 stated, I have no oxygen again this morning. I have a medical appointment tomorrow and I am afraid to go without oxygen.On 12/10/25 at 01:33 PM R41 was observed sitting by the shower room door near the nurse station with no oxygen in use. R41 said they don't give me oxygen tanks. I am trying to control my breathing. I need my inhaler. I am supposed to be on oxygen all the time. The small rectangular bag was observed on the back of R41's wheelchair with a nasal cannula inside of it with no bag to protect it from contamination. R41 said that is the bag that the oxygen machine goes in. On 12/10/25 at 01:37 PM V14 (Registered Nurse) was made aware by the surveyor the R41 was requesting her inhaler. V14 looked in R41's electronic medical records and said R41 gets prn (as needed) Ventolin. R41 said to V14 I need something to open my airway. V14 asked R41 to return to her room. Upon entering the room R41 placed the nasal cannula on then turned on the oxygen cannula set at 2 liters of oxygen. V14 placed the pulse oximeter on R41's right index finger with a reading of 82%. At 01:42 PM the pulse oximeter reading increased to 86%. At 01:45 PM the pulse oximeter reading was 91%. At 01:45 PM V14 administered 2 puffs of the Ventolin inhaler and at 01:47 the pulse oximeter reading was 95%.On 12/10/25 at 01:48 PM V14 (Registered Nurse) returned to the medication cart. Surveyor asked V14 to check R41's order for oxygen. V14 stated R41 is supposed to be on oxygen continuously. The portable oxygen was faulty that's why R41 do not have oxygen on. We do not have any portable oxygen tanks. R41's oxygen concentrator has to be plugged up in the dayroom, that's where we plug it up for her.On 12/10/25 at 01:56 PM there was no oxygen in use signage at R41's room entrance or postings in R41's room.12/11/25 at 09:23 AM V2 (Director of Nursing) stated The oxygen tubing is changed every Monday on the night shift. The nebulizer we make sure it is labeled before using it and it is supposed to be inside the bag because you don't want any bacteria or infection. The oxygen nasal cannula should be labeled and stored in a bag when they are not using it to prevent respiratory infection. We have portable oxygen tanks located at the end of the hallway on each floor. The nurses have access to the portable oxygen tanks 24 hours a day and the nurses are aware they have access to the portable oxygen tanks. R41 is always with oxygen, and she has a portable oxygen tank that we have to place it. R41 has an oxygen concentrator in her room. R41 is not supposed to be without her oxygen, she is on continuous oxygen. R41 is going to her doctor's appointment with the portable oxygen tank. R41 is supposed to have a portable oxygen tank on her wheelchair. If R41 does not have her oxygen there is a potential for shortness of breath. The oxygen tubing should not be in the bag on R41's wheelchair and not stored in a bag. If they saw R41 sitting and she is desaturating, they are not following the doctor's order. There should be oxygen signage at the door or at the resident's bedside.R103 has diagnosis not limited to Chronic Systolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Asthma, Insomnia, Hypothyroidism, Gastrostomy, Low Back Pain, Suicidal Ideations, Essential (Primary) Hypertension, Hyperlipidemia, Drug Induced Subacute Dyskinesia, Major Depressive Disorder, Atherosclerotic Heart Disease of Native Coronary Artery, Cardiomyopathy, Obstructive Sleep and Schizoaffective Disorder.R103's Medication Review Report document in part: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligram)/3ML (milliliter) (Ipratropium-Albuterol) 3 ml inhale orally every 4 hours as needed for SOB (Shortness of Breath).R103's Care Plan document in part: Focus: Resident is on respiratory therapy for improvement in pulmonary function. Focus: R41 has altered respiratory status/difficulty breathing r/t (related/to) Sleep Apnea.On 12/09/25 at 12:05 PM R103 was observed in bed in a semi-Fowler_position with a left-hand splint in place. The nebulizer set up mask was observed laying on the bedside table with no bag to prevent contamination. On 12/09/25 at 12:12 PM V19 (Registered Nurse) stated the nebulizer set up mask should be in a bag to protect it from bacteria and germs.Policy:Titled Administering Medications through a Small Volume (Handheld) Nebulizer revised 04/22 document in part: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. 30. 30. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 31. Change equipment and tubing every seven days, or according to facility protocol.Titled Oxygen Administration revised 03/20 document in part: The purpose of this procedure is to provide guidelines for safe oxygen administration. 4. Oxygen tubing and humidification bottles are to be changed weekly and as needed. Tubing and humidification bottles are to be dated at the time they are changed. 5. Oxygen tubing will be covered and stored when not in use. 2. Place an Oxygen in Use sign on the outside of the room entrance door. Close the door. 3. Place an Oxygen in Use sign in a designated place on or over the resident's bed. 5. Label the oxygen tubing with the resident's name and the date administered. Oxygen tubing, bottles and masks are labeled and changes every week on Sunday night shift.

Based on observations, interviews and review of records the facility failed to maintain medication storage free from expired and/or discontinued medications for 1 out of 4 medication carts and 1 out of 2 medication rooms. These failures have the risk that can affect two (2) residents (R38 and R121) on receiving medication that are either expired and/or discontinued.Findings include: On [DATE] at 09:41 AM, with (V13) Licensed Practical Nurse, surveyor observed inside medication cart R38's eye drop (Latanoprost 0.005 %) labeled opened on [DATE]. V13 stated that she does not know when it will expire. V13 said, I am not sure when it will expire, months may be. Facility submitted instruction from pharmacy that reads: Xalatan Ophthalmic Solution (latanoprost) date when opened and discard after 6 weeks. Six (6) weeks from [DATE] opening of eye drop will be [DATE]. Per pharmacy instruction, eye drop needs to be discarded on [DATE]. On [DATE] at 10:07 AM, V14 (Registered Nurse) was reviewing all controlled or narcotic medications inside medication cart. Per R121's Controlled Substance sheet, R121 has four (4) vials of Lorazepam 2 ML/ML. V14 went inside the medication room, open refrigerator where a plastic bag with R121's name. After opening the plastic bag there were 4 (four) vials of Lorazepam 2 ML/ML. V14 saw another plastic bag with R121's name. After opening the bag, another 4 vials of Lorazepam 2 ML/ML were seen with Controlled Substance sheet folded inside. Per R121's physician order, Lorazepam 2 ML/ML was already discontinued on [DATE]. On [DATE] at 08:59 AM, V2 (Director of Nursing) stated that nurses are supposed to give all expired and discontinued medication to her. Medications that are expired or discontinued have the risk of being given or administered even if medication are already expired or discontinued. Storage and Labeling of Medications dated 2001: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on interviews and record reviews, the facility failed to follow their Vaccination of Resident Policy. Failed to administer three [R23, R46, R113] residents their Covid Vaccine after consenting for the vaccine reviewed in a sample of 26. Findings includeReviewed the facility's immunization report provided by V27 [Infection Control Preventionist]. Noted R23, R46, and R113 consented for the Covid Vaccination, and was not administered per documentation provided.On 12/10/25 at 10:00 AM, R23 stated, I asked for the Covid Vaccine months ago, and I have not received the vaccine.On 12/10/25 at 10:38AM, R46 stated, I want the Covid Vaccine, but they would not give it to me.On 12/10/25 at 1:40 PM, R113 stated, I told the nurse I wanted the Covid Vaccine, but she never gave it to me.On 12/10/25 at 12:30 PM V27 [Infection Control Preventionist] stated, R23 consented to receive the Covid Vaccine on 2/6/25, R46 consented to receive the Covid Vaccine on 4/4/25, and R113 consented to receive the Covid Vaccine on 5/8/25. R23, R46 and R113 did not receive the Covid Vaccine, because I did not set up a in-house vaccine clinic. The Covid Vaccine potentially aid in preventing the disease from having a worsen outcome.On 12/20/25 at 1:50 PM, V2 [Director of Nursing] stated, All residents are offered the Covid Vaccine upon admission and annually. If a resident consent to receive the vaccine, the nurse should call their physician for an order and administer the vaccine timely.If the resident consented for the Covid Vaccine but did not receive the vaccine, it could potentially cause the resident worse symptoms or infection if contracted Covid.Policy document in part:Vaccination of Residents dated 9/2025All residents will be offered vaccines that aid in preventing infectious disease.Certain vaccines such as influenza, pneumococcal vaccines, herpes zoster, hep B or Covid may be administered per resident's request.

Based on observations, interviews and review of records the facility failed to follow policy on accounting controlled or narcotic medications for residents on the 2nd floor. These failures have the potential to affect 2 residents (R121 and R133) and an unknown resident on inaccurate accounting of controlled or narcotic medication.Findings include: On 12/09/2025 at 09:41 AM, V13 (Licensed Practical Nurse) was reviewing all controlled or narcotic medications inside medication cart. Inside the binder there was a controlled substance record sheet without resident name for Lorazepam - Intensol with instruction to take 0.25 ML (0.5 MG) by mouth or under tongue every 4 hours as needed (PRN). V13 cannot specify to which resident narcotic medication belongs. V13 stated that it may be inside medication room in the refrigerator. V13 went inside the medication room, open refrigerator where a box with R37's name labelled for Haldol/Ativan (Lorazepam). V13 opened the box and there was no Ativan (Lorazepam) medication. V13 cannot find narcotic medication anywhere, said that she did not account Lorazepam medication during change of shift review with the night nurse. On 12/09/2025 at 10:07 AM, V14 (Registered Nurse) was reviewing all controlled or narcotic medications inside medication cart. Per R121's Controlled Substance sheet, R121 has four (4) vials of Lorazepam 2 ML/ML. V14 went inside the medication room, opened refrigerator where a plastic bag with R121's name. After opening the plastic bag there were 4 (four) vials of Lorazepam 2 ML/ML. V14 saw another plastic bag with R121's name. After opening the bag, another 4 vials of Lorazepam 2 ML/ML were seen with Controlled Substance sheet folded inside. V14 stated that the other 4 vials of Lorazepam 2 ML/ML were not accounted and included in the counting during change of shift. V14 stated that it should be the receiving nurse that needs to fill up information to include in the binder to be accounted during change of shift. On 12/09/2025 at 10:35 AM, V7 (Registered Nurse) reviewing all controlled or narcotic medications inside medication cart. Per R133's Controlled Substance sheet for Lorazepam 0.5 MG tablet, it documents that R133 has twenty-eight (28) remaining tablets. After checking the actual bingo cards there were eighty-eight (88) remaining tablets. V7 recorded from eighty-nine (89) tablets to twenty-eight (28) tablets after documenting that 1 tablet was administered. V7 stated that she made a mistake, and all narcotic medication needs to be accounted. Since sixty (60) tablets were not recorded those narcotic medication will not be included in the counting during change of shift. On 12/11/2025 at 08:59 AM, V2 (Director of Nursing) stated that accounting of controlled or narcotic medication needs to be verify by nurse that narcotic medication is intact. The nurse sign and put the amount received. There supposed to be amount of narcotic medication, date when narcotic medicine was received and signature of the nurse that received narcotic medication. All narcotic medications need to be accounted by following proper procedure or else nurses can miss the counting and cannot account for the narcotic medication. Controlled Substances Policy dated December 2024: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with person delivering the medication, must count the controlled substances together. Both individuals must sign the designated control substance record. If the count is correct, an individual resident controlled substance record must be made for each resident who will be receiving a controlled substance. This record must contain:A. Name of resident;B. Name and strength of medication;C. Quantity received;D. Number on hand;E. Number of physician;F. Prescription number;G. Name of issuing pharmacy;H. Date and time received;I. Time of administration;J. Method of administration;K. Signature of person receiving medication; andL. Signature of nurse administering medication. Nursing staff must count controlled medications at the end of the shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.

Based on observations, interviews, and record reviews facility failed to follow their policy to ensure residents are free from sexual abuse for 1 (R4) out of 3 residents reviewed for sexual abuse in a sample of 8.Findings include:R5's Facesheet documents in part: R5 is a [AGE] year-old man with a medical diagnosis of schizoaffective disorder and bipolar disorder. R5's Minimum Data Sheet Section C (07/02/2025) documents in part: R5 have a Brief Interview of Mental Status (BIMS) of 11. R5 is moderately cognitively intact.R4's Minimum Data Sheet Section C (07/10/2025) documents in part: R4 have a Brief Interview of Mental Status (BIMS) of 14. R4 is cognitively intact.R3's Minimum Data Sheet Section C (08/22/2025) documents in part: R3 have a Brief Interview of Mental Status (BIMS) of 14. R4 is cognitively intact.On 09/18/2025 at 10:30 AM, surveyor observed R3 in her room. R3 stated that her boyfriend is R5. R3 stated that R5 usually gropes R4 but sometimes its consensual between R4 and R5. They will fool around with each other. R3 stated that last she heard, R4 told R5 that she doesn't like that anymore but R5 still touched her.On 09/18/2025 at 10:32 AM, R7 stated that she has witnessed R5 groping R4's butt.Attached to the basement activity/dining room was the activity office. On 09/18/2025 at 11:50 AM, surveyor asked for R4 to come into come into the activity office. V7 (Activity Aide) was sitting at the entrance of the office. As R4 passed by, V7 playfully tapped R4 on the rear. R4 didn't mind and joined the surveyor in the office. R4 stated that R5 touches her butt and that she doesn't like it. R4 stated that she has not said anything but has told R5 to stop touching her.On 09/18/2025, after speaking to R4, surveyor asked R5 to join him in the activity office. As R5 was walking towards the activity's office, surveyor observed R5 approach V7 (Activity Aide) with both his hands up and V7 gave R5 a hug.On 09/18/2025 at 12:12 PM, R5 stated that R3 is his girlfriend. R5 stated that he has not sexually groped R4.On 09/18/2025 at 12:15 PM, V7 (Activity Aide) stated that he knows R5 very well. V7 stated that she has seen R5 hug and kiss other residents. Sometimes its consensual and other times it is not. V7 stated that R5 will try hug and sometimes give me a kiss on the cheek and then I would redirect him. V7 stated that she has heard R5 touching and kissing R4, but she has never witnessed it. V7 stated that R5 is a guy. They will try to be touchy and feely but that doesn't mean they are being sexually abusive. It's just what guys do.On 09/18/2025 at 2:17 PM, V2 (Director of Nursing) stated that she is familiar with R5. V2 stated that R5 hugs other residents and staff. V2 stated that the intervention in place to for R4 is redirection. V2 stated that R5's care plan is not updated with that intervention. When surveyor told V2 that he witnessed V7 pat R4 on the bottom, V2 stated you're right. I have always seen her do that and she should not be doing that.On 09/23/2025 at 1:22 PM, V1 (Administrator) stated that she is familiar with the incident between R5 and R4. V1 stated that R3's case manager told her that R5 hugs on R4. We did do an investigation. V1 stated that when she interviewed R3, R3 could not give a date and a time. V1 stated that when she interviewed R4 and R5, both residents made it seem like the interaction was consensual. V1 stated that at any point R4 could rescind the consent to be affectionate which at that point, R5 should respect her boundaries and should not be touching her. V1 stated that she is aware of V7's behaviors and said that is totally unprofessional and could lead other residents to do the same.R5's behavior care plan documents in part: R5 is alert, aware and coherent and chooses to exercise his right to engage in an intimate/sexual relationship. He has received counseling, as appropriate, regarding safe sexual practices/behavior, only engaging in this type of relationship with a consenting party and monogamy. Resident is aware that he cannot ask for sexual favors in return for material things. Counseling has included education on sexually transmitted diseases. As necessary, he will receive future counseling on condom use, contraceptives, privacy issues and/or respect for his partner. Interventions: Review with appropriate responsible parties quarterly and as needed, behaviors and activities as necessary to protect patient and others. Facility's abuse policy (undated) documents in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to an individual. Sexual abuse includes, but not limited to, sexual harassment, sexual coercion, or sexual assault, including non-consensual or non-competent to consent sexual activity.

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility is free of pests. This has the potential to affect all residents residing on the 2nd and 3rd floor. Findings include: On 2/18/25 mouse droppings observed on the toilet room floor of R6's room on 2nd floor. On 2/18/25 mouse droppings were observed in corner on floor next to wardrobe dresser of R7's room on 2nd floor. On 2/18/25 numerous mouse droppings (100 plus) observed on the floor next to wardrobe cabinet of R9's room of 3rd floor. On 2/18/25 at 10:05AM, R3 stated I haven't seen mice in my room but R6's room has mice in it. On 2/18/25 at 10:07AM R4 stated yes there are mice in the building. On 2/18/25 at 12:48PM R9 stated yes there are mice in my room. About two days ago I stomped and killed one with my foot. I am leaving this place today because I have an apartment. On 2/18/25 at 12:35PM R8 stated yes there are mice. If you go across the hall in R9's room there are mice in his room. On 2/18/25 at 1:45PM V5 (Maintenance Director) stated we have a pest control company come to the facility for regular service. I don't know why the pest control reports show no mouse activity. Tomorrow I will have the pest control company go through all residents' rooms to observe and treat for rodents and other insect pests. Facility policy titled Policy On Pest Control includes statement: General: It is the policy of the facility will be free of pest/ rodents. Responsible Party: Administrator, Maintenance.

Based on observations, interviews, and record reviews, the facility failed to discard expired food based on use by guidelines and labeled use by date, failed to ensure food items were labeled and dated with use by date, and failed to sanitize cooking equipment based on manufacturers' directions. These failures have the potential to affect all 123 residents receiving food prepared in the facility's kitchen. Findings include: On [DATE] at 9:15 AM, V19 (Dietary Manager) stated all items should be labeled with an open and use by date and prepared items should be thrown out after seven days. V19 stated day one is the day the item was prepared and day seven is the date the item must be discarded on. V19 stated the purpose of labeling, dating, and discarding items after seven days is to ensure food is safe for the residents to eat and that there is a potential to make residents sick if they are served expired foods. On [DATE] at 9:45 AM, during initial kitchen tour observed found container of tuna salad dated [DATE] in the reach-in refrigerator. The tuna salad had areas of white material pooling with liquid. V19 stated the tuna fish was mixed with mayonnaise and that it was mislabeled because the item has not been in the cooler for over one year. V19 stated the tuna fish salad should have been discarded seven days from the day it was prepared on ,d+[DATE] and that the item should have been labeled with a use by or discard date of ,d+[DATE]. V19 stated the kitchen would not serve that to the residents based on the date it was prepared because it has the potential to make the residents sick if that was served to them. Observed V19 discard the tuna salad into the trash. On [DATE] at 9:48 AM, observed sliced deli turkey in metal container labeled [DATE]. There was no use by date on the item. V19 stated the turkey should be labeled with a use by date of [DATE] so the staff knows when to throw out the item. On [DATE] at 9:54 AM, observed V20 (Dishwasher) at three-compartment sink washing pots and pans with a collection of cleaned items being stored on the side of the sink to air dry. V19 stated the kitchen uses a Quat (Quaternary) solution to disinfect the kitchen equipment being cleaned in the three-compartment sink and that the concentration of the third sink containing the sanitation solution should be between ,d+[DATE] ppm (parts per million) per the manufacturer guidelines. V19 stated any concentration less than that means the items are not being sanitized 100% which is important to prevent cross contamination and food borne illness. V19 checked the three-compartment sink concentration using a test strip and it read 100 ppm. V19 stated the concentration is not high enough which means that the items are not being disinfected properly. V19 stated that all the items that have been washed will need to be re-sanitized. V19 stated the concentration should be checked prior to cleaning items in the three-compartment sink, On [DATE] at 10:00 AM, V20 was asked if V20 checked the concentration of the sanitizer in the three-compartment sink and V20 stated I didn't check it this morning. On [DATE] at 10:04 AM, V21 (Dietary Aide) stated V21 filled up the third sink with water and added three pumps of sanitizing solution and then checked the concentration using the test strip. V21 stated the test strip reading was 100 ppm at 6:30 AM. On [DATE] at 10:07 AM, observed V22 (Cook) empty and refill the third compartment sink with water and then add four pumps of sanitizing solution. V22 checked the concentration using a test trip and the reading obtained was 200 ppm. On [DATE] at 10:09 AM, this surveyor heard V19 tell V20 to sanitize all the items V20 had previously cleaned because they were not sanitized correctly. Facility provided list of diet orders for all residents in the facility as of [DATE]. The diet order list indicates there are total of 125 residents of which 2 residents are receiving nothing by mouth (NPO) and 123 residents are receiving diets (not NPO). Facility provided policy titled Labeling and Dating dated 2017 documents in part, to decrease the risk of food borne illness and to provide the highest quality, food is labeled with the date received, the date opened and the date by which the item should be discarded and refrigerated food prepared is labeled with the date to discard or to use by. This includes leftovers. The discard/use by date will be a maximum of six days after preparation. The day of preparation is counted as day 1. Facility provided policy titled Time/Temperature Control for Safety Food (TCS) dated 2021 documents in part, foods that require time and temperature control to prevent the growth of microorganisms (bacteria) which cause foodborne illness are known as TCS foods and some foods are more likely than other to be TCS foods including but not limited to milk/dairy products, eggs, and fish. Facility provide policy titled Manual Sanitizing in Three-Compartment Sink dated 2017 which documents in part, a sink with three compartments is used for manually washing, rinsing, and sanitizing utensils and equipment and manufacturer's instructions on the wall poster above the three-compartment sink are followed. Facility provided copy of manufacturer's signage posted above the three-compartment sink titled Sanitizer Test Procedures documents in part, for Quaternary test paper reading ,d+[DATE] ppm.

Based on observation, interview, and record review, the facility failed to ensure that reusable cloth incontinence briefs intended for resident use were in good condition, this failure has the potential to affect 40 incontinent residents residing in the facility. Findings include: On 12/10/2024 at 12:23PM, a tour of the laundry room was conducted with V13 (Laundry Aide). Surveyor observed the following inside of the laundry room in the basement of the facility: One cloth incontinence brief with multiple, permanent dark colored stains folded on a linen cart intended for resident use. V13 stated she is aware that she should throw the stained incontinence briefs away when the facility receives new cloth incontinence briefs. V13 stated she washed the cloth incontinence brief twice and since it is not ripped/torn, she assumed it was okay for residents to continue to use it. On 12/10/2024 at 12:47PM, V14 (Housekeeping Director) now located in the laundry room and observes the multiple, permanent dark stains on the incontinence brief. V14 states the permanent stains on the incontinence briefs appears to be a result of urine and feces. V14 stated V13 (Laundry Aide) is responsible for notifying him when incontinence briefs and other linen need to be reordered in the facility. V14 stated V13 is also responsible for discarding old, stained, and worn linen in the facility that can no longer be used for resident use. V14 stated the multiple, permanently dark stained incontinence brief should not be on the linen cart to be distributed for resident use in the facility. Facility policy dated 10/2022, titled Laundry and Bedding documents in part, Policy Statement: Soiled laundry/bedding shall be handled, transported, and processed according to best practices for infection prevention and control. Mattresses, Pillows and Overlays: 5. Pillows that are torn, damaged, or permanently stained are discarded. Facility policy dated 05/2020, titled Quality of Life-Homelike Environment documents in part, Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. 1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.2. e. Clean bed and bath linens are in good condition, Residents' Rights for People in Long-Term Care Facilities documents in part, Your facility must be safe, clean, comfortable, and homelike. Facility document undated, titled Incontinence List documents that there are a total of 40 incontinent residents residing in the facility.

Based on interview and record review, the facility failed to refer four (R41, R66, R72, R90) residents with serious mental illness to the appropriate state-designated authority for PASARR (Pre-Admission Screening and Resident Review) level II evaluation and determination in a total sample of 25 residents reviewed. Findings Include: R41s' Face sheet documents that R41 was admitted to the facility on [DATE] with diagnoses not limited to: bipolar disorder and anxiety disorder. R41s' PASARR screening dated 05/25/2005 titled OBRA-1 Initial Screen documents that there is reasonable basis to suspect a mental illness for R41. There is no documentation to show that R41 was referred to the appropriate state-designated authority for a Level II PASARR evaluation and determination. R66s' Face sheet documents that R66 was admitted to the facility on [DATE] with diagnoses not limited to: schizophrenia, schizoaffective disorder, and bipolar disorder. R66s' PASARR screening dated 10/28/2013 titled Assessment Summary Information documents that R66 has a mental illness diagnosis of paranoid schizophrenia. There is no documentation to show that R66 was referred to the appropriate state-designated authority for a Level II PASARR evaluation and determination. R90s' Face sheet documents that R90 was admitted to the facility on [DATE] with diagnoses not limited to: schizoaffective disorder, panic disorder, and major depressive disorder. R90s' PASARR screening dated 06/05/2020 titled Interagency Certification of Screening Results documents R90s' serious medical issues as a primary focus. There is no documentation to show that R90 was referred to the appropriate state-designated authority for a Level II PASARR evaluation and determination. Facility Policy dated 03/2022, titled Admission Criteria documents in part, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payor source, to determine if the individual meets the criteria for a MD, ID, or RD. b. If the Level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. c. upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. 44103 On 12/10/24 at 11:10 AM, interviewed V10 (Social Service Director) and stated that the resident's PASARR Level I or II should be completed prior to admitting in the facility to make sure that resident being admitted is eligible and meet the requirements to come to the nursing facility. V10 stated that the facility does not run or re-run the residents' PASARR until instructed by the outside agency in charge of PASARR screenings. R72's clinical records show an original admitted [DATE] with included diagnoses but not limited to Schizoaffective Disorder and Major Depressive Disorder. The facility provided R72's OBRA - I INITIAL SCREEN completed by outside agency and is dated 10/22/18. R72's screen shows there is a reasonable basis for suspecting DD (Developmental Delay) or MI (Mental Illness). R72's Level II Preadmission Screening and Resident Review (PASARR) was not completed.

Based on observation, interview, and record review the facility failed to ensure medications were locked and secured while unattended. This failure has the potential to affect all 68 residents residing on the 1st and 3rd floors. Findings Include: On 12/09/2024 at 11:15AM, surveyor located on the first floor of the facility. Surveyor observes a medication cart unlocked and unattended with medication cart keys left inside of the medication carts' lock. V6 (Registered Nurse/RN) states she is responsible for the unlocked and unattended medication cart. V6 states this medication cart stores medications for residents on the 1st and 3rd floors of the facility. V6 states she must have gotten busy with other things and forgot to lock the medication cart and retrieve the keys. V6 states that residents can potentially get access to the medications if the cart is left unlocked and unattended. V6 states residents could potentially overdose, have an adverse reaction, or other life-threatening complications if they get access to the medications. Surveyor observes inside of V6s' medication cart that a total of 35 residents have medications stored inside the medication cart. On 12/11/20224 at 1:42PM, V2 (Director of Nursing/DON) states it is dangerous to leave medication carts unlocked and unattended. V2 states residents can remove the medications, self-administer the wrong medications, and have life threatening and adverse reactions. Facility policy dated 04/2021, titled Storage of Medications documents in part, 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. 9. Unlocked medication carts should not be left unattended unless, it is within visible supervision of the nurse. 14. Access to controlled medications is limited to authorized personnel. Facility census dated 12/09/2024 documents that a total of 19 residents reside on the 3rd floor of the facility and 49 residents reside on the 1st floor of the facility.

Based on observations, interviews and record review, the facility failed to ensure shared equipment was cleaned and decontaminated between each use for 4 [R27, R92, R104, R116] of 6 residents reviewed for medication administration observation. Findings included: On 12/9/24 at 9:38 AM, V23 obtained R116's blood pressure with a wrist blood pressure cuff device. V23 placed the device on R116 left wrist, blood pressure measured 134/99, heart rate 90. After use, V23 did not sanitize the blood pressure device, placed the device inside the top drawer of the medication cart and proceeded to prepare R116 medications. On 12/9/24 at 9:52 AM, V23 obtained R104's blood pressure with same wrist blood pressure device. Prior to use, V23 did not sanitize the device. V23 placed the blood pressure device on R104's left wrist, blood pressure measured 127/87, heart rate 82. After use V23 did not sanitize the device and placed it on top of the medication cart. On 12/9/24 at 10:10 AM, V23 obtained R92's blood pressure with same wrist blood pressure device. Prior to use, V23 did not sanitize the device and placed it on R92's left wrist. R92's blood pressure measured 112/86 and heart rate 80. After use V23 did not sanitize the device and placed the device inside the top drawer of the medication cart and proceeded to prepare R92's medications. During the same medication pass observation, prior to use, V23 did not sanitize the device and placed it on R27's left wrist, blood pressure measured 120/72, heart rate 62. After use V23 did not sanitize the device and placed it on top of the medication cart. On 12/9/24 at 10:42 AM, V23 [Registered Nurse] stated, Between each resident I should have used the sanitizing wipes to disinfect the wrist blood pressure device to prevent the spread of infection. I was nervous and forgot to clean off the device. On 12/11/24 at 12:30 PM, V2 [Director of Nursing] stated, All shared medical equipment among residents must be sanitized before and after each use on each resident. If the shared equipment is not sanitized between residents, it could potentially spread infection from one resident to another. Policy document in part: Cleaning and Disinfection of Resident Care Items and Equipment Resident care equipment including reusable items and durable medical equipment will be cleaned and disinfected according to the current CDC recommendations for disinfection of blood borne pathogens standards noncritical items are those that come in contact to scan but not mucus membranes noncritical resident care items include bed pants, blood pressure cuffs, crutches and computers. Reusable resident care equipment will be decontaminated and or sterilized between residents according to the manufacturer's instructions.

Based on observations, interviews, and record reviews, the facility failed to provide dignity for two (R41, R226) residents in a total sample of 25 residents reviewed. Findings include: 1. On 12/09/2024 at 10:19 AM, R226 observed lying in bed inside of his room in a left lateral position. R226 observed with a shirt on with a white blanket half-way covering the mid-section of his body. R226 is observed without any under briefs on and his buttocks exposed. R226 states a staff member took his incontinence briefs off because they were too small. R226 states the facility does not have any incontinence briefs that are his size to place on him. On 12/09/2024 at 10:22AM, V4 (Certified Nursing Assistant/CNA) now located inside of R226s' room. V4 observes that R226 is not wearing any incontinence briefs. V4 stated she offered to place reusable incontinence briefs on R226 but R226 stated that he was not comfortable wearing the diaper. V4 stated the facility uses reusable incontinence briefs for residents who are mostly bed bound. V4 stated some residents have disposable incontinence briefs in their own rooms in the closet and are purchased by their own family. Surveyor toured the 1st floor unit with V4. There were four linen carts observed on the first floor. Surveyor did not observe any disposable incontinence briefs located on any of the linen carts. Surveyor observed several reusable cloth incontinence briefs on the shelves of the linen carts. R226s' Face sheet documents that R226 has diagnoses not limited to: unspecified dementia, major depressive disorder, schizophrenia, delusional disorders, and chronic kidney disease. R226s' MDS/Minimum Data Set, dated dated dated [DATE] documents that R226 has a BIMS/Brief Interview for Mental Status score of 13/15, which indicates that R226 is cognitively intact. R226 is incontinent of bowel and bladder and has an indwelling urinary catheter. R226s' care plan dated 12/09/2024 documents that R226 is care planned for Activities of Daily Living/ADL self-care deficit related to weakness. 2. On 12/09/2024 at 12:17 PM, R41 observed lying in bed inside of his room in a supine position. R41 observed with a white blanket covering his body. R41 observed moving around and attempting to get out of bed. Surveyor observes that R41 does not have on any clothes on underneath the blanket. R41 was completely naked without a gown or incontinence briefs on. R41 is not alert and unable to make his needs known. R41 was also observed to have multiple finger contractures on both of his hands. On 12/09/2024 at 12:17PM, V7 (Certified Nursing Assistant/CNA) also located inside of R41s' room. V7 acknowledged that R41 was not wearing any clothing and was completely naked underneath the blanket. V7 stated she is not R41s' assigned CNA today. V7 stated she is assigned to care for residents on the third floor but came to the first floor to help assist some of the residents with their care. V7 stated the facility uses reusable incontinence briefs for residents who are mostly bed bound. V7 stated she was informed by her supervisor to use the reusable incontinence briefs for R41 also. V7 stated residents who are mobile and able to get out of bed are the residents who use the disposable incontinence briefs. V7 stated it is a dignity issue for R41 not to have on any clothing underneath his blanket. V7 stated she will gather supplies to help clothe R41. R41s' Face sheet documents that R41 has diagnoses not limited to: External constriction of unspecified finger, abnormalities of gait and mobility, unsteadiness on feet, muscle weakness, lack of coordination, and extrapyramidal and movement disorder. R41s' MDS/Minimum Data Set, dated dated dated [DATE] documents that R41 has a BIMS/Brief Interview for Mental Status score of 09/15, which indicates that R41 is cognitively impaired. R41 requires partial/moderate assistance with ADL/Activities of Daily Living care. R41 is incontinent of bowel and bladder. R41s' care plan documents that R41 is care planned for incontinence. On 12/11/2024 at 1:42PM, V2 (Director of Nursing/DON) stated if residents are left without any clothes or incontinence briefs on, then this is a dignity issue and does not promote dignity for the resident. Facility policy undated, titled Resident Rights documents in part, Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence. b. be treated with respect, kindness, and dignity. Facility's document, undated, titled Residents' Rights for People in Long-Term Care Facilities documents in part You have a right to make your own choices. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Facility policy dated 02/2020, titled Quality of Life- Dignity documents in part, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times.

Based on observations, interviews and record reviews, the facility failed to correctly set air loss mattress based on weight for one (R75) of 8 residents reviewed for pressure wound treatment services in a total sample of 25 . Findings include: On 12/09/24 at 1:25 PM, R75 was observed lying in bed on an air loss mattress. Air loss mattress dial setting was in the middle of the 240-320-pound weight per the low air mattress' display panel. Surveyor felt the pressure of R75's low air loss mattress and it was hard and very firm to touch. On 12/09/24 at 1:30 PM, V2 (Director of Nursing) stated the low air loss mattress is set based on the resident's weight. V2 observed R75's low air loss mattress setting and stated R75 must weigh between 240-320 pounds since that is what the air loss mattress is set at. On 12/11/24 at 8:40 AM, V31 (Restorative Nurse/Fall Coordinator/Wound Coordinator) stated the purpose of low air loss mattress is to eliminate pressure from concentrating in one area so the pressure is distributed to the whole body and is used to prevent a pressure wound from getting worse and/or to prevent a pressure wound from developing. V31 stated the mattress should not be hard and should have some bounciness to it because if the mattress is too hard it would prevent the pressure from being evenly distributed which would defeat the purpose of the air loss mattress causing the mattress to function like a regular mattress. V31 stated the air low mattress setting is based on the resident's weight. V31 stated the nursing staff should be monitoring the setting on a daily to make sure it is on the correct setting based on the resident's weight. V31 stated R75 has a stage IV pressure wound on sacrum and is under hospice care. V31 stated R75 weighs between 100-110 pounds, not between 240-320 pounds. V31 stated R75's low air loss mattress should not have been set between 240-320 pounds. V31 stated V2 notified V31 about the error of R75's weight setting, and it was corrected, and training was done with the nursing staff to ensure the air low mattress is set properly to minimize pressure on the skin. V31 stated the potential of the low air loss mattress not being set correctly is that it could make the pressure wound worse and impair wound healing. R75 has diagnosis which includes but not limited to Dementia, Adult Failure to Thrive, Weakness, Need for Assistance with Personal Care, Muscle Wasting and Atrophy, Muscle Weakness (Generalized), Unsteadiness on Feet, Lack of Coordination, Reduced Mobility, Abnormalities of Gait And Mobility, Abnormal Posture, Schizoaffective Disorder, Drug Induced Subacute Dyskinesia. R75's Braden Risk Assessment History printed 12/10/24 documents in part, R75's at high risk for acquiring pressure wounds based on Braden Score of 10. R75's MDS (Minimum Data Set) from 10/16/24 documents in part, R75 has functional limitation in range of motion impairments to both sides of upper and lower extremities and is dependent on staff for all self-care activities except feeding and is dependent on staff for mobility. R75's MDS also indicates R74 has a pressure ulcer/injury over bony prominence stage 4 and skin treatments include pressure reducing device for bed and pressure ulcer/injury care. R75's Wound Rounds assessment dated [DATE] documents, facility acquired identified 12/05/23 pressure ulcer to coccyx (0.5x0.5x0.1). R75's Order Summary Report dated 12/10/24 documents in part, clean coccyx area with Normal Saline, apply alginate dressing cover with Hydrocolloid dressing every other day and PRN (as needed) every 8 hours as needed for wound care with order date 10/29/24. R75's Monthly Weight Report printed 12/11/24 documents December 2024 weight 104 pounds, November 2024 weight 108 pounds. Facility provided policy titled, Support Surface Guidelines dated September 2022 documents in part, the redistributing support surfaces are to promote comfort for al bed or chairbound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction. Facility provided Owner's Manual for R75's air loss mattress documents in part, this product is intended to help and reduce the incidence of pressure ulcers while optimizing patient comfort and operation according to the weight and height of the patient.

Based on interview and record review, the facility failed to ensure that a resident was free from physical abuse which affected one (R70) in the sample of 58 residents reviewed for abuse. This failure caused harm to R70 who was physically struck, fell , and suffered a laceration to R70's left forehead which required 4 sutures as treatment in the hospital. Findings include: On 11/12/23 at 11:14 am, R70 observed in wheelchair propelling self out of R70's room using R70's right arm to move the wheelchair wheel and right foot to move on floor. R70's left arm laying on R70's lap. This surveyor noted a healed, pink laceration, approximately 3 centimeters (cm) in length. When asked about the laceration, R70 stated, I (R70) fell and hit my head. R70 stated, it was in the basement in the dining room by the vending machine (on 10/12/23). R70 said R49 and R70 were in the dining room with no one else there. R70 said, R70 doesn't remember exactly what R49 said to R70 but that all of a sudden, I (R70) fell and hit my head. R70 said, R70 yelled, and the nurses and CNAs came and helped R70. R70 stated, I (R70) was bleeding from above my eye pointing to R70's left eyebrow. R70 stated, I (R70) went to hospital and got stitches. R70's Admission Record documents, in part, diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, pseudobulbar affect, schizophrenia, hypertension, chronic obstructive pulmonary disease, unsteadiness on feet, lack of coordination and reduced mobility. R70's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 15 which indicates R70 is cognitively intact. In R70's hospital records, V38 (Emergency Hospital Physician) documents, in part, R70 presenting to the emergency department with forehead laceration after a fall. Per EMS (emergency medical system), (R70) was in physical altercation with another member (R49) of nursing home. (R70) was pushed and fell on to the ground. (R70) hit (R70's) head on the ground and sustained a laceration of (R70's) left forehead and (R70) has left-sided deficits from prior stroke. R70's hospital records indicate that R70's laceration repair to the left forehead, 3-centimeter laceration was performed with 4 sutures. On 11/13/23 at 12:26 pm, R49 observed in room, dressed, groomed, and ambulatory. Surveyor asked about an incident with R70 on 10/12/23. R49 said, R49 was by R49's self in basement by the vending machine with R70. R49 stated, I (R49) was just doing this as R49 is demonstrating that R49 was smacking on R70's forearm when R70 was in the wheelchair in front of the vending machine. R49 said, then R70 hit me (R49) on my face, and R49 hit R70 to the point that (R70) fell . R49 showed this surveyor again that R49 hit R70 on the left arm. R49's Admission Record documents, in part, diagnoses of type 2 diabetes mellitus, asthma, paranoid schizophrenia, bipolar disorder, heart failure, hypertension, acute kidney failure, major depressive disorder, altered mental status, and cognitive communication deficit. R49's MDS, dated [DATE], documents, in part, a BIMS score of 12 which indicates R49 has moderate cognitive impairment. Facility document undated and titled Emergency Codes, documents, in part, that a Code [NAME] is for resident is alert but has fallen. On 11/14/23 at 1:40 pm, V33 (Receptionist) stated, while monitoring the video camera footage of the facility from the receptionist front desk, V33 observed (on 10/12/23 after lunch) R70 on the floor in the basement dining room with R49 off to the side of the room. V33 stated, V33 called the code white on the overhead paging system to alert staff to attend to R70. On 11/14/23 at 12:39 pm, V18 (Psychotropic Nurse, Licensed Practical Nurse, LPN) stated, R70 is oriented times 2 to 3 (person, place, and time) and R70 uses a wheelchair to be mobile due to left sided weakness. V18 stated, R49 is oriented times 2 to 3, is ambulatory and can be feisty with being verbally aggressive with peers. V18 stated, on 10/12/23 in the afternoon, V18 was in the office in the basement hallway and heard that commotion coming from the basement dining room; so V18 went running to see what was happening. When asked what V18 was hearing, V18 stated, V18 heard R70 screaming. V18 stated, on V18's way in the basement hallway, V18 heard the Code [NAME] to the lower-level dining room announced on the overhead paging system. V18 stated, a code white is when a resident has fallen but is still alert, and V33 (Receptionist) was the staff member who paged the code white. V18 stated, As I (V18) got closer (to the basement dining room), I heard (R70) screaming. I didn't hear (R49) at all. V18 stated, V18 observed no other residents or staff in the basement dining room or coming from the basement dining room. V18 stated, V18 observed R70 face down on the floor with blood on the floor coming from (R70, and R49 was walking away from (R70). V18 stated, R49 went to sit on a bench in the basement dining room, and R70 was on the floor, laying the middle of the room in front of the vending machine with R70's wheelchair behind R70. V18 stated, R70 was saying, my arm, my arm, because R70 was laying on R70's left weak arm (from the hemiplegia). V18 stated, other staff then arrived and retrieved gauze dressings for V18 to provide initial first aide to R70's facial laceration. Facility document titled Resident/Employee Statement signed by V18 and dated 10/12/23, V18 documents, in part, I (V18) arrived to the main dining room in basement because I heard yelling. When I entered dining room, I saw (R70) on the floor face down. When I approached (R70), I saw (R49) walking away from (R70). I saw blood coming out of (R70) left eye brown and on opening. I applied pressure to opening and other staff assisted me to get (R70) to seated position then lifted to be seated in wheelchair. On 11/14/23 at 9:47 am, surveyor asked about the incident on 10/12/23 with R49 and R70. V23 (Psychological Rehabilitation Services Coordinator, PRSC) stated, V23 was present in the facility and responded to the basement dining room. V23 stated, Basically, (R70) was using the vending machine and (R49) asked for soda and they had an altercation together. V23 stated, when V23 arrived to the dining room, R49 and R70 were the only two residents in there. V23 stated, V18 was present tending to R70 and that R70's eyeglasses were broken on the floor with R70 bleeding from R70's face with blood on the floor around R70's head. V23 stated, R70 was face down with body on the floor with R70's wheelchair by R70. On 10/12/23 at 2:30 pm, V23 (PRSC) documents, in part, in R70's progress notes, (R70) made contact with (R49) in the basement dining area. Staff immediately intervened and separated residents. On 10/12/23 at 2:45 pm, V23 (Psychological Rehabilitation Services Coordinator, PRSC) documents, in part, in R49's progress notes, (R49) made contact with co-peer in basement in the dining area. On 11/14/23 at 11:28 am, V21 (Registered Nurse, RN) stated, V21 was R70's nurse on 10/12/23 for the day shift. V21 stated, V21 heard the code white to the lower level called overhead on the paging system, and V21 responded immediately. V21 stated, when V21 entered the basement dining room, R70 was bleeding from R70's face and R49 moved away from R70 in the dining room. V21 stated, R70 didn't want to talk about what had just happened with R49 as V21 was tending to R70's care. V21 stated, when R70 was brought upstairs, V21 talked to R70, and R70 said, I (R70) was pushed and (R49) started it. R70 said, R49 pushed R70 out of the wheelchair. R70's incident report, prepared by V21 (RN), documents, in part, Nursing Description: (R70) was in physical altercation with (R49). (R70) with the receiver in the contact, at the lower-level dinning (dining) hall. On 10/12/23 at 3:11 pm, V21 (RN) documents, in part, in R70's progress notes, Responded to code white in the dinning (dining) room, (R70) found on the floor, noted with laceration on upper left lid, (R70) assisted back to wheelchair, wheeled back to (R70) room for further assessment. (R70) stated, I (R70) got tired of being bordered by (R49), told (R49) to stop and we got in a fight. On 10/12/23 at 2:30 pm, V21 (RN) documents, in part, in R49's progress notes, (R49) was in a physical altercation with (R70). (R49) initiated the contact, at the lower-level dinning (dining) hall. No injuries on (R49). R49's Care Plan, dated 10/12/23, documents, in part, a focus of (R49) has potential to be physically aggressive towards others, such as hitting others . history of harm to others . (R49) made contact with (R70) in basement dining area. On 11/14/23 at 2:19 pm, V2 (Director of Nursing, DON) stated, V2 was not a witness or did not respond to the code white called in the facility on 10/12/23 for R49 and R70's physical altercation due to V2 responding to another code white incident (in a different location in facility) that occurred near the same time on 10/12/23. V2 stated, with reports from staff and R70's hospitalization records, V2 stated, R70's fall was a result from the physical altercation. (R70) came back with sutures. That is a serious injury. On 11/15/23 at 3:00 pm, when asked what are V37's (Medical Director) expectations of the facility staff to ensure that residents are safe from physical harm. V37 stated, residents should have a safe environment in the facility, and residents must be free from abuse. When speaking to V37 about R49 and R70's incident on 10/12/23 with R70 falling from a wheelchair after physical hitting from R49 and suffering a forehead laceration requiring suture repair in the hospital, V37 stated, That's a serious injury. When asked how staff are to ensure that residents don't experience physical harm from other residents, V37 stated, An altercation like this should never happen. Of course, they (staff) should be watching the residents. And they should know who starts to fight. Facility policy dated 10/2022 and titled Abuse Prevention Program, documents, in part, Policy: This (facility) affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and 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 abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: . Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment; identifying a current says and patterns of potential mistreatment . Implementing says stones to prompt away and aggressively investigate all reports in allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment . 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 . 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.

Based on interview and record review, facility failed to follow their abuse policy to ensure residents are free from physical abuse by providing necessary care in services thus resulting in a male resident (R80) physically assaulting a female resident (108) for two (R80 and R108) out of 24 residents reviewed for physical abuse. The failure resulted in R108 hitting her head and having swelling to the right part of her (R108) head. Findings include: On 01/18/2023 at 12:42 PM, V8 (Social Worker) stated that she (V8) came in on Monday (1/9/23) and found out the incident happened Sunday night (1/8/23). V8 stated, When I (V8) spoke to R80, he (R80) stated he (R80) was trying to get (R108) out of the way. He (R80) stated that he (R80) picked her (R108) up and pushed her (R108) out of the way. She (R108) stated she (R108) hit her (R108) head and was hurt. She (R108) was sent to outside hospital. On 01/18/2023 at 1:18 PM, R80 stated, Yea I pushed her (R108). She was raising hell. I (R80) picked her (R108) up and pushed her (R108) out the door. On 01/18/2023 at 1:21 PM, R108 stated, I (R108) went to buy a soda and he (R80) was in my way. He (R80) wouldn't let me buy a soda. So, when I (R108) tried to buy a soda, he (R80) grabbed me (R108) from the back, picked me (R108) up and threw me (R108) on the floor. I (R108) hit my head and it felt like my (R108) head cracked open. On 01/18/2023 at 1:30 PM, V19 (Social Services Director) stated, R108 hit her (R108) head and had swelling. So, we sent her (R108) out to the hospital for evaluation. On 01/18/2023 at 1:35 PM, V1 (Administrator) stated, R108 hit her head after R80 pushed her (R108) and had swelling on her (R108) head. An incident witness statement (1/8/23) documents in part: R80 went to her (R108) by the soda machine and carried her outside. R80's incident statement (1/8/23) documents in part: She (R108) was by the pop machine. I (R80) just grabbed her (R108) and pushed her (R108) out of the way. She (R108) fell down. R108's incident statement (1/8/23) documents in part: He (R80) squeezed me (R108) and threw me (R108) and I (R108) landed on the floor. I'm (R108) hurt. An incident witness statement (1/8/23) by the activity aide documents in part: R80 pushed R108 on the hallway floor and she (R108) hit her (R108) head on the floor. R80's care plan documents in part: R80 has the potential to be physically aggressive, such as attempting to hit others, making aggressive remarks, and gestures towards others when agitated. R80 reportedly involved in physical altercation with co-peer on 8/8/2020. R80 reportedly involved with co-peer on 3rd floor on 4/29/20. Facility's final incident report investigation (1/10/2023) documents in part: R80 displayed physical aggression towards R108. R108 was noted with swelling to top of head. Facility's Abuse Prevention Policy (10/2022) documents in part: The facility affirms the right of our residents to be free from abuse. This facility prohibits abuse. Abuse means any physical, mental, or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury with resulting due to physical harm, pain or mental anguish to a resident. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means.

Based on observations, interviews and records review the facility failed to maintain safety measures to prevent falls or accidents, to follow the fall policy on interventions to help prevent falls for 1 (R2) out of 4 residents (R1, R2, R3 and R4) reviewed for fall prevention in the total sample of 4 residents. These failures resulted in R2 falling multiple times and sustaining multiple injuries. R2's 8/1/21 fall injuries included an anterior frontal lobe subdural brain hemorrhage (or subdural hematoma, or bleeding) a right forehead laceration closed with 11 stitches, right eye bruising and a left leg abrasion. Findings include: R2 is [AGE] years old, originally admitted to the facility on [DATE]. Medical diagnosis includes Traumatic Subdural Hemorrhage dated 8/3/21 due to history of falling. On 8/24/21 at 10:14 AM, R2 was seen in her room alert and verbally able to express her thoughts. R2 stated, I was having problem falling big and small falls. I mean big because I went to the hospital and the rest are small falls. Twice I fell on the stairwell, I cannot remember the most recent fall on the stairwell because I lost consciousness. It was all so blurred that I cannot recall. But I also fell around 9 to 10 months ago and went to the hospital. I used the stairwell by myself going up and down the 3rd Floor to visit a friend. Yes, I visit R3 on the 3rd Floor. Today I am scheduled to have my stitches out (showing me the staples on her right forehead). Now they told me not to use the stairwell anymore. On 8/24/21 at 10:50 AM, the 2nd floor and 3rd floor were reviewed. On the 2nd floor there were 3 doors that can be used to gain access to the stairwell. North door, middle door, and the south door. All doors have a keypad to disable the alarm when opening the door. The alarm can be silenced easily without using the keypad by pushing a large square button. On the 3rd Floor there are 2 doors that lead to the stairwell. The first door is near the elevator and with alarm keypads. The Second door connects to the middle door on the 2nd Floor. There was no nursing staff stationed on the 3rd Floor. On 8/26/21 at 12:40 PM, on tour with V14 (Social Worker) of the 3rd Floor, the middle door was opened but the alarm was not sounding. When asked, V14 stated that she didn't know why the door was not closed and the alarm was not sounding. Then V14 closed the door and re-opened it again and the alarm still wasn't sounding. V14 stated, Oops, I didn't know the alarm was not working. On 8/26/21 at 11:10 AM, V2 (Director of Nursing) stated that on R2's recent fall of 8/1/21, R2 was found on the stairwell near the middle door on the 2nd Floor level. R2 went to the hospital and had injuries including a subdural hematoma. V2 was not aware about R2's incident dated 7/24/20 also on the same stairwell. V2 stated that there are no nursing staff stationed on the 3rd Floor and the 1st and 2nd floor nurses were assigned to 3rd floor residents. On 8/26/21 at 11:31 AM, V6 (Registered Nurse) stated that R2 was a resident on the 3rd Floor before R2 fell on [DATE]. After the fall R2 was transferred to the 2nd Floor. V6 said that R2 was sent to the hospital due to the fall. On 8/26/21 at 11:54 AM, V8 (Rehab Nurse) stated that R2 can ambulate by herself but needs redirection. R2 needs monitoring and supervision and that the care plan should have addressed the identified problem of falling on the stairwell. On 8/26/21 at 12:12 PM, V7 (Licensed Practical Nurse) stated that she was the nurse assigned during R2's fall incident that happened on 8/1/21. V7 stated she heard a loud sound. When checking the stairwell, R2 was found on the 2nd floor level by the middle door with a bad injury to the forehead. R2 was then transferred to the hospital and was admitted . V7 stated that R2 was transferred from 3rd Floor to 2nd Floor to be monitored, since there are no nursing staff stationed on the 3rd floor.The alarm sound cannot be heard on the 2nd floor if it was sounding on the 3rd floor. V7 stated that the 2nd floor alarm can be silenced easily by just a single press of the button. On 8/26/21 at 3:15 PM, V1 (Administrator) was notified about the door on the 3rd Floor that it was left open and that the alarm was not working. V1 stated that he was informed by staff regarding the alarm not working on the 3rd Floor door going to the stairwell. And that he called an outside vendor to fix it by the next day. On 8/27/21 at 11:35 AM, V16 (Primary Care Physician) stated, R2's fall was preventable and that it was very unfortunate. R2 should not be in the stairwell. During the most recent fall (8/1/21), R2 sustained subdural hematoma or basically bleeding of the brain. This should not have happened nor should it happen again to R2 or anyone else. Record review shows R2 had multiple fall incidents, as follows: Notes dated 2/20/20, at 3:38 PM documents R2 fell in the basement hallway, small bruise was noted on the left knee. Notes dated 10/28/20, at 12:06 AM documents R2 was observed on the floor next to her bed. Notes dated 4/17/21, at 10:46 PM documents R2 was found sitting on the floor. Notes dated 7/24/20, at 12:30 PM documents R2 fell in the stairwell. R2 stated, I lost my balance and tumbled down the stairwell. R2 was transferred to the hospital around 1:30 PM. The 7/25/2020 at 2:25 AM note documents, R2 returned to the facility at 1:35 AM and has a sling on her left arm from the hospital. Hospital records dated 7/24/20 read that R2's reason for the visit was due to fall and shoulder injury. Notes dated 8/1/21 at 5:00 PM documents R2 was noted at the bottom of the stairwell to door # 3 from the 3rd Floor. R2 was then transferred to the hospital and came back on 8/3/21 were the following injuries were present: right forehead laceration closed with 11 stitches, right eye bruising and left leg abrasion. Hospital records dated 8/1/21 read that R2, based on a computerized tomography scan (CT Scan) of the head, sustained an acute 4 mm subdural hemorrhage in the anterior frontal lobe or subdural hematoma. R2's Minimum Data Set Assessment under reads that R2 needs 1 supervision on both walking in the room or corridor. The following activity was not attempted: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor) and the ability to go up and down a curb and/or up and down one step due to medical condition of safety concerns. R2's Morse Fall Scale assessment dated [DATE] results read that resident was low risk for falling although resident has history of multiple falls. R2's Care Plan history reads that although R2 was still using the stairwell and fell on [DATE] on the stairs with multiple falls in between, almost all interventions including reminding R2 to use elevator instead of the stairwell was resolved dated 6/4/21. On 8/1/21, R2 fell and sustained an injury of subdural hematoma The care plan intervention does not address R2's risk, accident, or falls related to using the stairwell. Falls and Fall Risk Management Policy dated 3/2018 reads: Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident-Centered Approaches to Managing Falls and Fall Risk 5.If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. 6.If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. Monitoring Subsequent Falls and Fall Risk 1.The staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. 3.If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.

Based on interview and observation, the facility failed to protect the right to be free from abuse for two of four residents (R5 and R14) reviewed for abuse in the sample of 14. This failure affected R5 and R14 who was physically hit in the back and the head, resulting in R5's fall and sustaining injury and pain, R5 stated he was afraid for his life at the time. R5 was sent to local hospital. Findings include: On 8/31/20 at 10:23am, R5 was noted on the 3rd floor hall way standing by his room. R5 stated he would like to talk to the surveyor about how another resident hit him in the back and head on 8/8/20 without any provocation. R5 stated he was waiting for his medication when it happened and he suffered bruises, swollen, busted lips and pain all over his body. R5 stated he was afraid for his life at the time but not anymore because the resident is now at the hospital. R5 identified the resident as R13. R5 stated the facility did nothing when it happened. R5 stated R13 had injured another resident which R5 identified as R14. R5's medical record progress note dated 8/8/20, V13 LPN (Licensed Practical Nurse) documented the incident that showed that R5 was attacked as R5 described. V13 documented that R5 was pushed down, with bruises noted to left knee and lips. And R5 had pain scaled at 8/10 (Eight out of Ten, with 10 being the worse pain). On the same day on 8/8/20, R13 physically assaulted R14 without provocation by hitting him in the back and another staff member was hit in the head on the same day. On 9/2/20 at 9:52am, interview conducted with V19 PRSC (Psychiatrist Rehabilitation Services Coordinator) in the Human Resources Office. V19 stated R13 hit R14 in the back without any provocation. At 10:17am, V20 (Activity Director) stated R13 hit her on the back of the head. On 8/31/20, V2 DON (Director of Nurse's) identified the resident as R13 and stated he is now on admission at the local hospital. V2 identified V1 (Administrator) as the abuse coordinator. When V1 was asked about what investigation was done and whether it was reported to the State Agency, V1 replied it was V20 (Social Service Director) who was in charge of faxing abuse investigations. V2 told the surveyor that she will have to go and look for the paper work in his office because V20 is no longer working at the facility. On 8/31/20 at 1:30pm, the facility was unable to present any documentation of reporting this incident to the State Agency or that any investigation was done. V1 was unable to show how the facility notified the State Agency. On 9/1/20 at 10:28am, review of R14's electronic medical records showed that R14 was hit in the back of the head without provocation but no injury recorded. The facility abuse Prevention Program policy presented with no date pointed out under policy statement that the facility residents have the right to be free from and abuse that includes but not limited to physical abuse. The policy documented under the Policy Interpretation and Implementation that the residents will be protected from abuse by anyone including and not limited to other resident or any other individual, identify and assess all possible incident of abuse and investigate and report any allegation of abuse with time frames by the federal requirements.

Based on interview and record review, the facility failed to implement appropriate measures to ensure adequate supervision was provided for three of three residents (R5, R13 and R14) reviewed for physical abuse in the sample. This failure affects R5 and R14 who were physically abused resulting in R5 sustaining bruises, lip injury and generalized pain. R5 stated he was afraid for his life at the time. Findings include: On 8/31/20 at 10:23am, R5 was noted on the 3rd floor hallway standing by his room. R5 stated he would like to talk to the surveyor about how another resident hit him in the back and head on 8/8/20 without any provocation. R5 stated he was waiting for his medication when it happened and he suffered bruises, swollen, busted lips and pain all over his body. R5 stated he was afraid for his life at the time but not anymore because the resident is now at the hospital. R5 identified the resident as R13. R5 stated the facility did nothing when it happened. R5 stated R13 had injured another resident which R5 identified as R14. R5's medical record progress note dated 8/8/20, V13 LPN (Licensed Practical Nurse) documented the incident that showed that R5 was attacked as was described by R5. V13 documented that R5 was pushed down, with bruises noted to left knee and lips. And R5 had pain scaled at 8/10 (Eight out of Ten with ten being the worse pain). On the same day on 8/8/20, R13 physically assaulted R14 without provocation by hitting him in the back and another staff member was hit in the head on the same day. On 9/2/20 at 9:52am, interview with V19 PRSC (Psychiatrist Rehabilitation Services) explained that R13 can be physically and verbally aggressive towards male co-peers. V19 stated some-how R13 made his way to the basement of the facility and she was surprised to see R13 because he was on 1:1 supervision. V19 stated that R13 was on 1:1 supervision with a PRSA because he had hit R5. V19 stated R13 was talking to her in her office when R13 hit R14 in the back. V19 was unable to present the name of the facility staff that was in-charge of 1:1 with R13 on 8/8/20. V19 could not present any 1:1 documentation pertaining to R13 from 8/6/20 to 8/8/20. On 9/2/20, V2 presented, a facility Preliminary Incident Report completed by V19 which showed that R13 physically abused R5 and R14 on the same day. The report indicated that it should be faxed to the State Agency. The report documented that R5 was injured, bruised lips and had swelling to right side of the forehead. On 9/2/20 at 11:14am, V2 DON (Director of Nurse's) stated the facility didn't a supervision policy addressing at risk behaviors. The Facility Policy Regarding at Risk Behaviors presented dated 11/2013 pointed out under procedure guideline that includes but not limited to making sure that person presenting the harmful behavior will be monitored and placed under 1:1 monitoring and it will not be discontinued until the behavior has subsided. The resident will remain on 1:1 until discontinued.

Based on observation, interview, and record review, the facility failed to eliminate fall hazards, failed to ensure appropriate footwear, failed to follow fall policies, and failed to accurately document a fall assessment in the MDS (Minimum Data Set) for one of four residents (R1) reviewed for falls in a sample of four. These failures resulted in R1 falling and sustaining a hip fracture that required surgical repair. Findings include: On 12/22/2016 at 11:40am, R1 was sitting on a wheelchair and stated that she had surgery and pointed to surgical incision on right hip. R1 stated that she had some breakfast and fell downstairs and tripped by the doorway. At 12:44pm, E9 (Certified Nursing Assistant/CNA) wheeled R1 to the basement and showed the surveyor where R1 fell . R1 stated in part that her sandal got caught because there should be tape or something there on the floor so that she doesn't trip and fall. The surveyor noted a gap from the new flooring and old flooring between the basement hallway and entryway of the dining/activity room where R1 pointed to where R1 fell . On 12/22/2016 at 1:01pm, E5 (Maintenance Supervisor) stated that they started remodeling the floors about six months ago. E5 pointed to the same entryway to the basement activity/dining room and stated that there should be no gaps on the floor, and there should be a threshold so that the floors are even. E5 stated that he will call the company right away to fix the floors as soon as possible. On 12/22/2016 at 4:01pm, E1 (Administrator) measured the gap at the entryway of the basement dining/activity room that measured 43 inches in length and approximately 5 inches in width. There were two grooves to the floor tile that each measured approximately 1/16 inch in depth. (The grooves on the floor tile is where R1 previously stated her sandal got caught in causing her to trip and fall). R1's progress notes reads in part:11/29/2016 7:49am - incident note: Resident noted coming out of activity room post breakfast. Resident had a fall that was witnessed by staff in the lower level basement hallway. Resident noted with sandals on and hallway floor wet with caution signs visible. Resident assisted to sitting position then to a chair by staff. Resident noted with no injury at this time and verbalizes no pain. Resident is able to move lower extremities with no distress or discomfort noted. Staff able to take sandals off of resident and replace with gym shoes with grip for traction. Resident educated on importance of wearing shoes with grip to prevent falls. Resident able to ambulate with steady gait. Resident's MD (medical doctor) will be notified for any orders. Resident has no emergency contact to notify of incident. 12/6/2016 - Resident came to writer with complaints of pain to the right hip area. Upon assessment resident noted with bruising to right hip area. Resident had a recent fall noted in area of bruising. MD (medical doctor) notified of resident's complaint of pain and bruising. 12/12/2016 11:24pm - Resident x-ray on right hip was done. Right hip x-ray was received and relayed to physician with an order to transfer resident to (local) hospital for medical evaluation due to right femoral neck fracture. On 12/22/2016 at 2:35pm, Z1 (Attending Physician) stated he was notified of (R1's) fall the day he ordered the first x-ray (12/6/2016). Z1 stated that the facility should have told him (R1) fell when they were aware of the fall. Z1 stated that he saw (R1) a few days later (12/10) and (R1) still had pain, so the first x-ray didn't make sense and ordered another one which showed a fracture. The first x-ray may have not caught the fracture depending on the location. (R1) has osteopenia, and that causes the bones to break easily, but osteopenia does not cause a hip to break. (R1's) hip fracture is from the fall. On 12/22/2016 at 2:24pm, E6 (Licensed Practical Nurse/LPN) stated in part that she witnessed (R1's) fall. (R1) had flip-flops on, not much grip on the floor, and the floor was wet because housekeeping finished mopping the floors and there were signs around. (R1) was on the cell phone and just got done eating breakfast. (R1) was leaving the activity/dining room and slipped and fell because the floor was wet. (E6) stated when she got to (R1), (R1) was still talking on the cell phone. E6 stated that the floor nurse called the doctor, she didn't. R1's Incident/Accident Unusual Occurrence report filled out by E6 reads in part:11/29/16 7:35am- Brief description - Resident noted coming out of activity room. Hallway noted wet with floor signs visible. Resident asked what happened and stated, My sandal got caught there (pointing to floor by activity room door) and I fell . Resident's fall witnessed by staff. Resident fell on right side. Resident assisted to sitting position and staff brought gym shoes down from room. Resident noted with no injury at this time. Resident has no complaints of pain at this time and is able to ambulate with steady gait. Physician (Z1) notified 11/29/16 8a. Immediate intervention - Resident's sandals changed to gym shoes with grip. Resident educated on importance of wearing gym shoes for better traction. R1's Morse Fall Scale dated 9/27/2016 shows moderate risk for falling, weak gait, and overestimates or forgets limits. On 12/22/2016 at 3:03pm, E7 (Restorative Nurse) stated in part that she's in charge of the falls program and (R1) was at moderate risk for falls. E7 also stated that flip-flops were not appropriate footwear and she educated (R1) to wear gym shoes instead. E7 stated that the nurse who filled out the incident report calls the doctor and that the doctor should be notified of the incident within the same day. On 12/22/2016 at 11:58am, E4 (LPN) stated that she was the floor nurse assigned to (R1) the day (R1) fell in the basement. E4 stated she did not call the doctor or write a progress note on 11/28 , but that (E6) did because (E6) witnessed the fall. E4 stated that the doctor (Z1) was notified on 12/6 when (R1) had complaints of pain and an x-ray was done. E4 stated that (Z1) saw (R1) on 12/10, ordered a repeat x-ray and when the results came, (Z1) ordered for (R1) to go to the hospital on 12/12. R1's MDS (Minimum Data Set) with Assessment Reference Date (ARD) of 12/12/2016 reads in part: 1 for number of falls since prior assessment, A. no injury, and supervision for locomotion off unit and dressing.On 12/27/2016 at 10:09am, E7 stated in part that she should have clicked on C. for major injury. R1's MDS with ARD of 9/27/2016 shows that R1 has no cognitive impairment, needs supervision and setup help only for locomotion off unit and dressing. R1's radiology reports reads in part:12/6/2016- Examination: Hip unilateral w (with) pelvis. Results: No fracture or dislocation identified. Subtle irregularity noted at femoral head neck junction but no fracture plane seen. Conclusion: Fracture is not identified, if persistent pain of high suspicion for fracture recommend CT (computed tomography). 12/12/2016- Examination: Hip unilateral w (with) pelvis. Results: There is a right femoral neck fracture with modest displacement. The joint shows no dislocation. Pubic rami are intact. There is osteopenia. Conclusion: Acute appearing right hip fracture as described above. The fracture is not visible or new compared to prior exam dated 12/6/2016. R1's hospital discharge instructions (12/16/2016) reads in part:12/13/2016 - Problem List: Closed displaced fracture of right femoral neckProcedure: Right hip hemiarthroplasty The facility's policy and procedure titled Incident/Accident Reporting Fall Management Program with revision date 12/2015 reads in part: 6. Notification to the Physician/Health Care Provider and Family will be done promptly and recorded. The facility's policy and procedure titled, Fall Risk with revision date of 11/2013 reads in part: 7. The staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. 8. The staff and Attending Physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. These policies were not followed.

Based on observation, record review and interview the facility failed to safely turn and maintain correct position of siderail for 1 resident (R3) out of 5 residents reviewed for falls in a sample of 24. This failure resulted in R3 sliding from the bed while receiving care, sustaining an injury. The facility also failed to ensure that resident environment remains free of hazards and that residents receive adequate supervision for 11 residents (R4, R5, R6, R7, R8, R11, R12, R15, R18, R19, R20) in a sample of 24 and 7 residents (R25, R26, R27, R30 to R33) in the supplemental sample reviewed for accidents. Findings include: 1. An incident report dated [DATE] at 2:45 PM indicated R3 slid from bed and sustained a laceration to his right eyebrow. R3 was transported to the hospital for evaluation. Per Nurses Notes dated [DATE] at 4:00 AM, R3 received one suture and was returned to the facility. An Addendum to the incident report and Nurse's Notes dated [DATE] at 2:00 PM indicate the facility was notified that x-rays taken at the hospital on [DATE] reveal a right femoral fracture. R3 was transported back to the hospital for treatment of [REDACTED]. The Fall Risk Assessment Tool for R3 completed [DATE] indicates a score of 14 and no use of side rails. A risk score of 14 or greater indicates risk for falls. On [DATE], the risk score was 17. No notation was made regarding use of side rails. A Care Plan dated [DATE] regarding fall risk reads "Keep call light within (R3's) reach at all times." A Care Plan dated [DATE] regarding risk for fracture reads "Resident slid from bed to floor during ADL care." On [DATE] at 9:20 AM, R3 told state surveyor and the ambulance emergency medical technicians that staff "forgot to put the rails up. She was in such a hurry she didn't put up the rail before turning me." On [DATE], the facility presented a new care plan dated [DATE] addressing Rolling to the Side that reads "Make sure call light is attached to right or left side as preferred by the Resident, where he can reach it with his left hand." A physician's orders [REDACTED]." On [DATE] at 9:05 AM, E2 (Director of Nursing) was performing wound care with a CNA positioned on R3's left side of bed and E2 on the right side of the bed. Both upper side rails were down. Upon completion of the dressing change at 9:15 AM, both staff left the room without raising the side rails. The call light was not in reach. E2 had stated the CNA and nurse would return to help transfer R3 to a stretcher for transport to a medical appointment. R3 stated he can't reach the call light with the rails down and that staff don't know what they are doing. "One day they're up, then they're down." Staff returned at 9:20 AM. On [DATE] at 9:15 AM, R3 was sleeping in bed with both upper half rails elevated. On [DATE] at 2:45 PM, R3 was observed in bed with both side rails lowered and the call light cord clipped to the upper corner of the bed sheet, above R3's right shoulder. R3 stated he was in pain and wanted medication. R3 could not locate or reach the call light and was assisted by his roommate to turn on the call light. A CNA entered to ask R3 what was needed and reattached the call light cord to the middle of the mattress length along the right side of the bed. The side rails remained down. On [DATE] at 2:50 PM, R3 stated he was told the facility could not keep the side rails up "because of the law", but R3 stated he would like the half railings up to reach his call light, help him adjust slightly in bed and as a sense of security, since he previously fell from bed. Cognitive assessment for R3 on the Minimum Data Set listed his scores as 15 out of 15 on [DATE] and ,[DATE] on [DATE], indicating normal/good cognition and recall. 2. During the environmental tour on [DATE] from 1:00PM to 3:00 PM, E7 (Maintenance Director) showed/demonstrated that the keys to the four rooms holding emergency response carts (crash carts) and oxygen were attached to the upper left door frame and could be pulled down with a retractable tether cord as needed to open the door. None of the crash carts were locked within the rooms where they were stored. On the third floor, two expired butterfly needle kits were in the crash cart; no oxygen tanks were in the room. The second and first floor rooms contained oxygen tanks and needles in the crash cart. The lower level barber shop/crash cart storage room was found to have the key missing from the ring affixed to the door and had seven intravenous insertion needles in the unlocked crash cart drawer. No oxygen was stored in this location. E7 was not aware the key was missing and did not know who might have taken it. On [DATE] at 4:30 PM during the Daily Status meeting, the missing key to the lower level barber shop/crash cart storeroom was reported to E1 (Administrator), E2 (Director of Nursing) and E8 (Nursing Consultant). The location of the key was not reported as known, nor had it been intentionally removed. On [DATE] at 1:20 PM, E6 (Licensed Practical Nurse) stated that she can see the third floor hallway where the crash cart is stored by viewing the video camera at the second floor nurse's station and generally monitors the second floor hallway, so would see if a resident went into the crash cart/oxygen storage room. On [DATE] at 2:30 PM, the second floor crash cart contained four butterfly needle insertion kits, eight intravenous insertion needles and three small oxygen tanks. One large/tall linen cart was along the wall outside room 202, blocking the sight line from the nurse's station to the doorway of the crash cart/oxygen storage location. On [DATE] at 2:35 PM, the first floor crash cart contained two butterfly needle insertion kits, 16 intravenous insertion needles, one large oxygen tank, three small oxygen tanks and three oxygen tanks marked empty. Three linen carts (two small carts and one large/tall cart) were along the wall outside room 102, blocking the sight line from the nurse's station to the doorway of the crash cart/oxygen storage location. During the survey from [DATE] to [DATE], residents were observed freely ambulating on all floors of the facility and exiting the floors via alarmed doors. Ambulatory residents in the sample and supplemental sample included R4, R5, R6, R7, R8, R11, R12, R15, R18, R19, R20, R25, R26, R27, R30, R31, R32 and R33. The Resident Census and Condition of Residents report (CMS Form 672) indicates the facility has 88 residents who ambulate independently, 93 residents with psychiatric diagnoses, 25 residents with dementia and 43 residents with behavioral problems. A list titled "Ideation, No Harm" provided by E4 (Psychiatric Rehabilitative Services Director) on [DATE] in response to a request for residents with a history of suicidal ideation lists 29 residents, among which are R6, R7, R8, R20, R30 and R33 in the sample and supplemental sample who are ambulatory. 3. During the initial tour on [DATE] and continuing ,[DATE] and [DATE], rooms containing bath tubs and toilets on the first, second and third floors were open for resident use. On [DATE] at 12:32 PM, the floor of the second floor tub room had a large puddle of water (two feet by two feet in area) on the left side of the tub; no wet hazard sign was posted. The facility policy titled "Tub Room Supervision" dated ,[DATE], reads "the resident will notify nursing when they are going to take a tub bath." On [DATE] at 1:20 PM, E6 (Licensed Practical Nurse) stated three to four residents routinely take tub baths on the second and third floors and certified nurse aides (CNA) monitor the rooms every 15 minutes. E6 stated that residents might not ask for supplies, may have their own soap and can get towels form the linen carts. On [DATE] at 2:40 PM, E9 (Registered Nurse) stated first floor residents take tub baths three to four days per week. E9 stated that residents tell the CNA when they want to use the tub room and obtain soap and towels. The CNA records the use on the "Tub In Use Log" and monitors the resident until done. When asked if it was possible for residents to take baths without telling the staff, E9 sign yes, but staff keeps encouraging residents to inform them. The Resident Census and Condition of Residents report (CMS Form 672) indicates the facility has 88 residents who ambulate independently, 93 residents with psychiatric diagnoses, 25 residents with dementia and 43 residents with behavioral problems. A list titled "Ideation, No Harm" provided by E4 (Psychiatric Rehabilitative Services Director) on [DATE] in response to a request for residents with a history of suicidal ideation lists 29 residents, among which are R6, R7, R8, R20, R30 and R33 in the sample and supplemental sample who are ambulatory. As of [DATE] at 2:45 PM, the Tub In Use logs indicate routine tub baths taken by three residents (R30, R32 and R33). Two of these (R30 and R33) are listed as having a history of suicidal ideation. On [DATE] at 10:30 AM, E4 (Psychiatric Rehabilitative Services Director) stated no current residents have been assessed as having active suicidal intent with a plan. When asked if residents with history of suicidal thoughts or previous attempts might be at risk even if they do not have a current stated plan, E4 stated his staff would assess on a case by case basis for behavior changes. 4. During initial facility tour with E15 (LPN/License Practical Nurse/Psychotropic Nurse Supervisor) the following were observed on the 2nd floor: R4's bedside 3 drawer on top had a 32 inch TV (television) and on top of the TV piled on top of each other is audio equipment. R34's bedside table had a 12 inch TV and radio; the long cords from the wall socket were unsecured on the floor. R35's refrigerator had no thermometer. Inside the refrigerator were medium sized container of mayonnaise, 3 plastic containers with food, milk cartons and soda. R36's bedside table unstable, leaning at the end area had a 12 inch TV. R8's door knob underneath had a hole approximately 5 x 12 inches like an irregular pie shape with sharp edges all around, and door knob plate has also sharp edges. The veneers of the standing wood cabinet in R6's room were ripped and door panels were off with sharp edges. The veneers of the standing cabinet in R37's room were ripped with sharp edges.