**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide pain medication to 1 of 3 residents (R3) reviewed for pain control in the sample of 8. This failure resulted in R3 having excruciating pain and having trouble functioning during that time in pain. The Findings Include:R3's admission Record, dated 7/21/25, documents R3 was admitted to the facility on [DATE] with diagnosis of Diabetes Mellitus (DM), Pneumonia, Bacteremia, and a Lung Abscess with Methicillin Resistant Staphylococcus Aureus (MRSA) infection.R3's Care Plan, dated 7/9/25, documents R3 Is Independent with Activities of Daily Living (ADLs). R3 has an alteration in comfort with interventions including administer pain meds and treatments as ordered, assess pain characteristics: duration, location, quality, encourage to report any pain, monitor for nonverbal indicators of pain (moaning, crying, grimacing, wincing), report any acute changes to Physician. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact, is independent on all ADLs. R3 is always continent of both bowel and bladder. On 7/21/25 at 1:25 PM, R3 stated They cut my pain meds in half to 5 MG twice a day, then added a muscle relaxer, and right now my pain is an 8.On 7/22/25 at 9:00 AM, R3 stated They ran out of my pain medication, and I had to wait around 6 days for my pain medication. The nurses kept telling me that they were waiting on pharmacy to send the medication. They may have given me Tylenol once or twice, but that did not help. I was in excruciating pain and had trouble functioning day to day during that time while I was in pain. My pain right now is between a 6 or an 8. On 7/22/25 at 9:15 AM, V7, Registered Nurse (RN)/Nurse Practitioner (NP), stated If a resident has an order for a pain medication and runs out, we have to print out the actual hard script/order and then either fax it to the physician or NP to sign it, or catch them while they are here. We do carry Oxycodone in the medication machine; however, we cannot just get one out. We have to have pharmacy on the phone, with the signed hard script, then they have to send a code to the nurse in order to get the medication out of the machine. V7 stated that is probably why R3 was waiting so long to get his meds.On 7/22/25 at 10:20 AM, V2, Director of Nursing (DON), stated If a resident has an active order for Oxycodone, such as (R3), all the nurse has to do is call the pharmacy and they will release a dose from the E-Kit (machine) to be dispensed. If it is a refill, then it has to have a hard script with the physician's signature. There are instructions on the entire process at the nurse's desk, but a lot of our nurses are agency, and they don't seem to understand the process.On 7/23/25 at 8:55 AM, V10, NP, stated I was not notified that (R3) was not receiving his Oxycodone for pain. I did meet with (R3) and the DON about (R3's) pain and I was not sure if it was lung pain or muscular pain and the way the Oxycodone was ordered, I wasn't sure if he was getting 5 MG or 10 MG, so I just made it 5 MG every 6 hours and added the muscle relaxer Cyclobenzaprine to help. I would expect the nurses to give (R3) his pain medication to keep up with his pain control. Any foreign substance in our lungs causes pain and with (R3) having a lesion with MRSA in his lung, it definitely has the potential to be painful.On 7/23/25 at 9:20 AM, R3 stated he did get his morning pain pill but stated they never ask him what his pain level is, they just hand him his pills. R3 stated right now, his pain is an 8 and it typically is between 6 to 8 depending on if he is lying down or up moving around.On 7/23/25 at 9:30 AM, V2 stated I would expect the nurses to provide pain medications as ordered to maintain the resident's level of pain to a minimum and if they run out of the medication, I would expect the nurses to order the medications when they run out in a timely manner, so the resident does not go without getting them. I would expect the nurses to administer antibiotics as ordered for any resident.R3's Physician Order (PO), dated 6/28/25, documents Oxycodone HCl (Hydrochloride) Oral Tablet 5 MG (milligram), give 1 tablet by mouth every 6 hours as needed for pain take 1-2-tab 5-10 MG by mouth every 6 hours as needed. Max daily amount 40 MG. This order was discontinued on 7/1/25. R3's PO, dated 7/1/25, documents Oxycodone HCl Oral Tablet 5 MG, give 1 tablet by mouth every 6 hours as needed for pain take 1 tab (5 MG) for pain scale 1-4 and 2 tabs (10 MG) for pain scale 5-10 by mouth every 6 hours as needed. Max daily amount 40 MG. This order was discontinued on 7/16/25.R3's PO, dated 7/16/25, documents Oxycodone HCl Oral Tablet 5 MG, give 1 tablet by mouth every 6 hours as needed for pain. This order was discontinued on 7/18/25. R3's PO, dated 7/18/25, documents Oxycodone HCl Oral Tablet 5 MG, give 1 tablet by mouth every 6 hours related to Methicillin Resistant Staphylococcus Aureus Infection.V2 provided the Controlled Substance Receipt/Record/Disposition Form for R3's Oxycodone, dated 6/29/25. This form documents R3 did receive Oxycodone from 6/29/25 up to 7/6/25 with nothing documented past 7/6/25. V2 stated this is what they have for documentation of R3 getting his Oxycodone.R3's Electronic Health Record (EHR), Weights/Vitals, Pain Level, documents R3 was experiencing pain on 7/7/25 at a 6 with no Oxycodone given, on 7/8/25 at 00:21 AM at a 5 with no Oxycodone given, on 7/8/25 at 6:19 AM at a 3 with no Oxycodone given, on 7/8/25 at 9:08 AM at a 5 with no Oxycodone given, on 7/8/25 at 9:09 AM at a 5 with no Oxycodone given, and on 7/9/25 at 7:36 AM at a 3 with no Oxycodone given. R3's Medication Administration Record (MAR), dated July 2025, documents R3's Pain Level on 7/7/25 during evening was a 5, on 7/8/25 during days was a 5, on 7/9/25 during days was a 3 and during evenings was also a 3. There was no Oxycodone given to R3 during the time frame from 7/5/25 at 5:30 PM through 7/12/25 at 7:58 AM. The Facility's Pain Management Policy, dated 10/2024, documents General: To facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our resident's the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. Guideline: The pain management program is based on a facility-wide commitment to resident comfort. pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Policy: 1. Pain is assessed using the Comprehensive Pain Assessment form: Upon admission, quarterly, with significant change, following a fall, when new pain is identified, when existing pain worsens. 2. Pain will be assessed at least once every shift and documented in the EMAR using the pain scale appropriate for the patient.3. Development of the Care Plan. 4. If nursing recognizes pain, the staff may attempt non-pharmacological interventions, physical modalities, body alignment, rehabilitation therapy, exercises, and/or cognitive/behavioral interventions. 5. Licensed Nursing may notify the Health Care Provider of any new development of pain, change in pain, change in condition that could potentially cause pain, for pharmacological interventions based on the individual's pain factors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations, and record review, the facility failed to provide an antibiotic for 1 of 1 resident (R3) reviewed for medication administration in the sample of 6. This failure resulted in R3 not receiving his antibiotic as ordered, his Vancomycin Trough levels subtherapeutic therefore not sufficient in treating R3's Methicillin Resistant Staphylococcus Aureus (MRSA) infection in his lungs. The Findings Include:R3's admission Record, dated 7/21/25, documents R3 was admitted to the facility on [DATE] with diagnosis of Diabetes Mellitus Type 2 (DM2), Pneumonia, Bacteremia, and a Lung Abscess with Methicillin Resistant Staphylococcus Aureus (MRSA) infection.R3's Care Plan, dated 7/9/25, documents R3 Is Independent with Activities of Daily Living (ADLs). R3 has an alteration in comfort with interventions including administer pain meds and treatments as ordered, assess pain characteristics: duration, location, quality, encourage to report any pain, monitor for nonverbal indicators of pain (moaning, crying, grimacing, wincing), report any acute changes to Physician. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact, is independent on all ADLs. R3 is always continent of both bowel and bladder. On 7/21/25 at 1:25 PM, R3 stated I have a PICC (Peripherally Inserted Central Catheter) line in my right arm and I am supposed to get antibiotics in it twice a day. I have not received my antibiotic yet today that I was supposed to get this am. I think the IV pump is broke and that is why I am not receiving it.On 7/21/25 at 1:37 PM, V7, Registered Nurse/Nurse Practitioner (NP), stated I did not give (R3) his antibiotic this morning because he had a trough drawn and I have to wait until that result comes back in order to give this dose, in case I have to hold the dose.On 7/22/25 at 9:00 AM, R3 stated That bag is still hanging from yesterday because the nurse could not give it to me because the pump was broke. A bag of Vancomycin 1750 MG (milligram)/500 ML (milliliter) was seen hanging and attached to the IV pump which was turned off. On 7/22/25 at 9:15 AM, V7 stated The bag of antibiotics hanging in (R3's) room is the one from yesterday. I got the trough level back yesterday and went to hang it and the IV pump would not work. I even had another nurse try and the same thing. I called the pharmacy this morning and spoke with them, and they stated they would bring us a new pump today. The pharmacy showed up this morning and only delivered bags of antibiotics and no pump, so we still can't give (R3) his antibiotic. I told the DON of the situation.On 7/23/25 at 8:55 AM, V10, NP, stated I was not notified that (R3) was not receiving his antibiotic. I would expect the nurses to give the antibiotics as ordered. There is definitely a potential that (R3's) condition could get worse, or not get any better, by not getting his antibiotic. I also was not notified that (R3) was not receiving his Oxycodone for pain. I did meet with (R3) and the DON about (R3's) pain and I was not sure if it was lung pain or muscular pain and the way the Oxycodone was ordered, I wasn't sure if he was getting 5 MG or 10 MG, so I just made it 5 MG every 6 hours and added the Cyclobenzaprine to help with his muscles. I would expect the nurses to give (R3) his pain medication to keep up with his pain control. Any foreign substance in our lungs causes pain and with (R3) having a lesion with MRSA in his lung, it definitely has the potential to be painful, especially if it is not getting any better.On 7/23/25 at 9:30 AM, V2 stated I would expect the nurses to order the medications when they run out in a timely manner, so the resident does not go without getting them. I would also expect the nurses to administer antibiotics as ordered for any resident.R3's Physician Order (PO), dated 6/28/25, documents Micafungin Sodium Intravenous Solution Reconstituted 100 MG, use 100 MG intravenously (IV) one time a day for Antifungal for 12 Days inject 1 dose by IV every 24hrs. This was discontinued on 7/8/25.R3's PO, dated 7/8/25, documents Micafungin Sodium Intravenous Solution Reconstituted 100 MG, use 100 mg intravenously one time a day for Antifungal for 12 Days inject 1 dose by IV every 24hrs.R3's PO, dated 6/28/25, documents Vancomycin HCl Intravenous Solution 1500 MG/300ML, use 1 dose intravenously every 12 hours for Anti- infection for 41 Days. This was discontinued on 7/18/25.R3's PO, dated 7/18/25, documents Vancomycin HCl Intravenous Solution 1750 MG/350ML, use 1 dose intravenously every 12 hours related to Methicillin Resistant Staphylococcus Aureus Infection. This was discontinued 7/18/25.R3's PO, dated 7/18/25, documents Vancomycin HCl Intravenous Solution 1500 MG/300ML, use 1 dose intravenously every 12 hours for Anti- infection until 07/18/2025 23:59. This was discontinued 7/18/25.R3's PO, dated 7/18/25, documents Vancomycin HCl Intravenous Solution 1750 MG/350ML, use 1 dose intravenously every 12 hours related to Methicillin Resistant Staphylococcus Aureus Infection. This is the current order. R3's Medication Administration Record (MAR), dated July 2025, does not show that R3 received Vancomycin IV as ordered on 7/6/25 AM dose, 7/9/25 AM dose, 7/13/25 AM dose, 7/20/25 AM dose, and 7/21/25 both AM and PM doses. R3's MAR, dated July 2025, does not show that R3 received Micafungin IV as ordered on 7/7/25, 7/8/25, 7/15/25, and on 7/20/25. R3's Nursing Note, dated 7/21/25 at 3:56 PM, documents Resident missed AM dose of IV Vancomycin yesterday. NP notified. No signs/symptoms of infection noted.R3's Nurses Note, dated 7/21/25 at 4:11 PM, documents Nurse informed (facility pharmacy) about the malfunction of the IV pump. The IV pump will be sent out today along with the medication run. Dr. (doctor) ordered that the PICC line dressing be changed weekly.R3's Nurses Note, dated 7/22/25 at 8:28 AM, documents the nurse contacted (facility pharmacy) to discuss the delivery issue with the IV pump. (Pharmacy) explained that the courier had left the pump, and another pump would be delivered promptly. The courier and DON were notified about the missing dose of medication. The corporate nurse delivered the pump from an affiliate facility. The IV medication was administered to the patient without any difficulties. The PICC line was flushed and found to be patent, with no signs of redness or warmth at the site. Monitoring will continue.R3's Nurses Note, dated 7/22/25 at 3:24 PM, documents NP on call notified of missed Vancomycin doses and verbal order received to extend medication x 2 doses. Resident is afebrile, no s/s (signs/symptoms) of infection noted at this time.R3's Acute Care (NP) Note, dated 7/23/25 at 00:35 AM, documents in part Nurse reports pt (patient) missed 2 doses of Vancomycin. (R3) is a [AGE] year-old male with PMH (primary medical history) of DM2, and acute on chronic pancreatitis. He was admitted to the hospital on [DATE]rd after previously leaving AMA (against medical advice). He was found to have MRSA bacteremia with a right upper lobe abscess versus infarct and perirenal abscess. Bronchoscopy on June 18th showed MRSA, Group B-Strep, and Serratia. He received a PICC line, and he was on vancomycin and Ceftazidime, with Fluconazole added due to thrush. He was admitted to (this facility) on 6/28 for LTC (long term care) and continuation of IV abx (antibiotics).R3's Lab Result, Vancomycin Trough Level, dated 7/11/25, documents R3's Vancomycin level was 8.5 (Low) with a reference range of 10.0 to 20.0. R3's Lab Result, Vancomycin Trough Level, dated 7/17/25, documents R3's Vancomycin level was 9.0 (Low) with a reference range of 10.0 to 20.0. R3's Lab Result, Vancomycin Trough Level, dated 7/21/25, documents R3's Vancomycin level was 8.6 (Low) with a reference range of 10.0 to 20.0. The Facility's Medication Administration Policy, dated 4/2024, documents in part General: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Licensed staff will administer medications as ordered by the physician. Guideline: 22. If a medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required. 26. If medication is ordered, but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication. If available, obtain it from the contingency or convenience box. 27. If the physician's order cannot be followed for any reason, the physician should be notified in a timely manner (depending on the situation), and a note should reflect the situation in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely incontinent/colostomy care in 1 of 1 resident (R2) reviewed for ADL (Activities of Daily Living) care in the sample of 6. This failure resulted in R2 developing painful, red excoriation around his colostomy site extending down to the abdomen, perineal area and buttocks. Findings include: On 4/23/25 at 8:45 AM, R2 was observed in bed with V8, R2's family member at bedside. R2's colostomy site and abdomen were observed with V8. There was a towel covering R2's abdomen, V8 removed the towel and R2's colostomy bag was about 3/4 full and was leaking moderate amounts of liquid stool onto R2's abdomen, down into R2's abdominal folds, perineal area and under R2's bottom. R2's abdomen was red and excoriated. R2 was stating don't touch it, it hurts, burns and was shaking, appearing to be apprehensive and in pain. On 4/23/25 at 8:55 AM, R2 turned his call light on, V9, CNA (Certified Nurse's Assistant) came into the room, asked what was needed and then left the room to gather supplies. Upon V9's return, V9 explained to R2 that she was going to clean him up, R2 was shaking his head no and stating it hurts, it burns, don't use the cleaner in the white bottle pointing to a bottle of wound cleanser. V9 was able to calm R2 and R2 agreed to allow V9 to clean him up. V9 attempted to clean R2, but liquid feces continued to leak from the bottom of the colostomy wafer that attaches to the bag. During this time R2 continued to shake and appeared to be in pain. V9 stated the nurse would need to change the colostomy bag because it kept leaking. V9 then left the room and notified V10, RN (Registered Nurse). On 4/23/25 at 9:20 AM, V10, RN, came into R2's room to change R2's colostomy wafer and bag. The wafer and bag was removed with red excoriation noted around the colostomy site extending down to R2's abdomen, abdominal folds and perineal area. V10 cleaned around R2's colostomy site and abdomen with incontinence wipes, then applied a new wafer and bag. V10 told R2 and V8 that she would need to get a CNA to finish cleaning R2 up because she still had a lot of medications to give. The liquid feces remained on R2's lower pubic area, buttocks on the incontinence pad underneath R2. On 4/23/25 at 10:30 AM, R2 was observed still soiled with liquid feces on his lower pubic area, buttocks and incontinence pad. An aide from Hospice, came in R2's room to see him, V8 told her that he had been waiting over an hour to get cleaned up. The aide then cleaned R2 up. R2's perineal area and buttocks were red. V8 was in R2's room and stated she has been at R2's bedside and no one from the facility came in to change R2, so the hospice aide did it, the facility CNAs never came to R2's room after V10 left the room. On 4/26/2025 at 9:42 PM, V18, family member, came to the nurse's station and put a container on the counter and stated, R2 just threw up and nobody has been checking on him. I told you two hours ago he said he was not feeling well. His call light in his room does not work and if I had not been here, he would have thrown up all over himself because nobody is checking on him. This is not right. On 4/26/2025 at 9:46 PM, R2's call light was tested and did not work. On 4/26/2025 at 9:52 PM, V18, R2's family member, stated I told them at 8:00 PM, that he was not feeling well, and nobody has been down here to check on him. He is like a kid; his call light does not work. I told them he needed checked on, but they don't care. What would have happened if I was not here? On 4/26/2025 at 9:58 PM, V23, CNA stated I am not sure what is happening with (R2). R2's Face Sheet, undated, documents R2 has the following diagnoses: Unspecified Kidney Injury, Pituitary Dependent Cushing's Disease, Hypertension, Autism, Congenital Renal Failure, Acquired Absence of Parts of the Digestive Tract, Presence of Functional Implants, Acute Infarction of the Large Intestine, Chronic Kidney Disease and Critical Illness Polyneuropathy. R2's (MDS) Minimum Data Set, dated [DATE], documents R2 has a BIMS (Brief Interview of Mental Status) score of 8, indicating R2 has moderate cognitive impairment, is dependent with toileting and has no skin issues. R2's Care Plan, dated 4/21/25, documents R2 requires assist with daily care needs, is incontinent of bowel and bladder, has a potential risk for complications related to altered elimination for bowel elimination, as evidenced by a colostomy and is at risk for skin complications related to Stoma Incontinence Associated Dermatitis with an intervention to provide skin care after each incontinence episode. R2's Wound Care Note, dated 4/8/25, documents R2 has incontinence associated dermatitis. Treatment: cleanse wound with soap and water, pat dry and apply triad and miconazole cream BID (Twice Daily) and PRN (As Needed). Leave open to air. R2's Grievance, dated 4/16/25, filed by V8, documents R2 was put in diapers and not attended to throughout the night. Findings: CNA educated on the needs of the resident and customer service. On 4/23/25 at 8:45 AM, V8, R2's family member, stated R2 is Autistic and doesn't always know or understand what is going on. V8 stated about a year ago, he had his gallbladder removed at a local hospital, he developed an infection in his blood and surgical wound resulting in the colostomy. V8 stated R2 was transferred to a higher acuity hospital, then to 2 different rehab hospitals and before coming to this facility. V8 stated R2 has been at the facility for a short time and the staff isn't changing his colostomy bag, so feces is coming out and sitting on his skin for long periods of time resulting in a painful red rash all over his belly. V8 stated when R2's bag is full, that is when it leaks onto his belly and into his folds. On 4/23/25 at 11:00 AM, V1, Administrator, stated he spoke with V8, R2's family member, regarding her concerns with R2's care. V1 stated they had placed a diaper on R2, so he put a sign on R2's wall, not to use diapers and educated the staff. V1 stated he isn't familiar with colostomies, so he spoke with V5, Wound Nurse, who explained to him that when the feces sits on the skin it can make it excoriated and he recommended to place a towel under and below the colostomy in case it starts leaking. V1 has instructed the nursing staff to make sure it is checked frequently, and care provided as needed. V1 stated the problem occurred (referring to the grievance) during the night with an agency nurse that wasn't familiar with R2's care or how he is because they don't have any other residents like him, so that agency nurse was also educated. V1 stated he checks on R2 and speaks with V8 everyday to make sure R2 is being cared for. On 4/24/25 at 10:50 AM, V5, Wound Nurse, stated feces shouldn't be left on the skin because it causes excoriation. V5 stated he would expect the nursing staff to keep R2 clean, change his bag and apply the creams as ordered. The Incontinence Care Policy, dated 1/2025, documents incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide colostomy care to 1 of 1 resident (R2) reviewed for ostomy care in the sample of 6. This failure resulted in R2 developing painful, red excoriation around the colostomy site extending down to the abdomen and perineal area. Findings include: On 4/23/25 at 8:45 AM, R2 was observed in bed with V8, R2's family member at bedside. R2's colostomy site and abdomen were observed with V8. There was a towel covering R2's abdomen, no abdominal binder present, V8 removed the towel and R2's colostomy bag was about 3/4 full and was leaking moderate amounts of liquid stool onto R2's abdomen, down into R2's abdominal folds, perineal area and under R2's bottom. R2's abdomen was red and excoriated. R2 was stating don't touch it, it hurts, burns and was shaking, appearing to be apprehensive and in pain. On 4/23/25 at 8:55 AM, R2 turned his call light on, V9, CNA (Certified Nurse's Assistant) came into the room, asked what was needed and then left the room to gather supplies. Upon V9's return, V9 explained to R2 that she was going to clean him up, R2 was shaking his head no and stating it hurts, it burns, don't use the cleaner in the white bottle pointing to a bottle of wound cleanser. V9 was able to calm R2 and R2 agreed to allow V9 to clean him up. V9 attempted to clean R2, but liquid feces continued to leak from the bottom of the colostomy wafer that attaches to the bag. During this time R2 continued to shake and appeared to be in pain. V9 stated the nurse would need to change the colostomy bag because it kept leaking. V9 then left the room and notified V10, RN (Registered Nurse). On 4/23/25 at 9:20 AM, V10, RN, came into R2's room to change R2's colostomy wafer and bag. The wafer and bag was removed with red excoriation noted around the colostomy site extending down to R2's abdomen, abdominal folds and perineal area. V10 cleaned around R2's colostomy site and abdomen with incontinence wipes, then applied a new wafer and bag. V10 told R2 and V8 that she would need to get a CNA to finish cleaning R2 up because she still had a lot of medications to give. The liquid feces remained on R2's lower pubic area, buttocks on on the incontinence pad underneath R2. On 4/23/25 at 10:30 AM, R2 was observed still soiled with liquid feces on his lower pubic area, buttocks and incontinence pad. An aide from Hospice, came in R2's room to see him, V8 told her that he had been waiting over an hour to get cleaned up. The aide then cleaned R2 up. R2's perineal area and buttocks were red. V8 was in R2's room and stated she has been at R2's bedside and no one from the facility came in to change R2, so the hospice aide did it, the facility CNAs never came to R2's room after V10 left the room. On 4/23/25 and 4/24/25, R2 was observed without the abdominal binder in place. R2's Face Sheet, undated, documents R2 has the following diagnoses: Unspecified Kidney Injury, Pituitary Dependent Cushing's Disease, Hypertension, Autism, Congenital Renal Failure, Acquired Absence of Parts of the Digestive Tract, Presence of Functional Implants, Acute Infarction of the Large Intestine, Chronic Kidney Disease and Critical Illness Polyneuropathy. R2's (MDS) Minimum Data Set, dated [DATE], documents R2 has a BIMS (Brief Interview of Mental Status) score of 8, indicating R2 has moderate cognitive impairment, is dependent with toileting and has no skin issues. R2's Care Plan, dated 4/21/25, documents R2 requires assist with daily care needs, is incontinent of bowel and bladder, has a potential risk for complications related to altered elimination for bowel elimination, as evidenced by a colostomy and is at risk for skin complications related to Stoma Incontinence Associated Dermatitis with an intervention to provide skin care after each incontinence episode. R2's Progress Note, dated 3/25/25 at 11:44 AM, documents the following: Patient arrived at nursing facility via EMS (Emergency Medical Services. Patient transferred from gurney into bed. Patient oriented to room and call light system. Patient was able to give return demonstration on using the call light. Patient alert and oriented times 3. The patient reports feeling nervous and afraid. Patient reassured that he was safe, and the nursing staff will attend to his needs. Patient mother at bed side. The patient denied pain at time of assessment. Patient respiration even and not-labored. Patient lungs clear throughout. Patient noted to have a g-tube (gastrostomy tube) at left mid abdomen- patent and intact, colostomy at right mid abdomen- no stoma noted. Patient has an opening to the right mid abdomen, but stoma is submerged in abdominal cavity. Abdominal area surrounding opening red and excoriated. Patient abdomen soft and non-distended. Patient bowel sound present. The patient is noted to have redness to pannus and groin and perineal area. Patient to bed sent to ER (Emergency Room) for evaluation for stoma evaluation. R2's Progress Note, dated 3/25/25 at 5:32 PM, documents the following: Patient back from hospital at 1733 (5:33 PM) via 2 EMT (Emergency Medical Technician). Resident's stoma looks normal. Resident is resting in bed with his family around. No c/o (complaints) pain and distress. Will continue to monitor. R2's Progress Note, dated 4/8/25 at 9:21 PM, documents the following: Patient continues on hospice care, g-tube patent/intact, remains afebrile. Colostomy intact, patient keeps messing with it, so it keeps leaking. Skin on abdomen has redness. Patient cleaned as needed. Plan of care ongoing. R2's Progress Note, dated 4/9/25 at 10:39 AM, This Care Plan nurse met with resident and residents' mother regarding resident pulling and tampering with colostomy device after being placed on resident. Residents mother expressed that resident has no understanding due to his diagnosis of why he shouldn't mess with the colostomy device and the risk of further damaging the skin integrity by doing so. Resident was encouraged to notify staff if his colostomy was bothering him which he agreed. Resident colostomy bag is currently in place and intake. Staff will be encouraged to check resident for any signs of colostomy bag being compromised. R2's Wound Care Note, dated 4/8/25, documents R2 has incontinence associated dermatitis. Treatment: cleanse wound with soap and water, pat dry and apply triad and miconazole cream BID (twice daily) and PRN (as needed). Leave open to air. R2's Wound Care Note, dated 4/15/25, documents R2's incontinence associated dermatitis is resolved and triad and miconazole cream was changed to PRN. R2's (POS) Physician Order Sheets were reviewed with the following orders noted: 3/28/25, Comfort focused treatment; 3/28/25 - Abdominal Binder/Elastic Large Miscellaneous (Elastic Bandages & Supports). Apply to Abdomen topically one time a day for skin redness; Excoriation; 4/15/25 - Triad Hydrophilic Wound Dress External Paste. Apply to Abdomen and Groin topically as needed for skin redness; 4/15/25 - Micatin Cream 2 % (Miconazole Nitrate). Apply to Abdomen and Groin topically as needed for skin redness. There were no orders for colostomy care or how often to change the colostomy bag on the POS. R2's (TAR) Treatment Administration Record, documents the following: Micatin (Miconazole) and Triad cream was not applied as ordered on 4/8/25, 4/9, 4/12/25, or 4/15/25. The new orders on 4/15/25, changing them to PRN has not been applied since the new order was received. There was no documentation of colostomy care or when the colostomy bag was changed on the TAR. R2's Grievance, dated 4/16/25, filed by V8, documents R2 was put in diapers and not attended to throughout the night. Findings: CNA educated on the needs of the resident and customer service. On 4/23/25 at 8:45 AM, V8, R2's, family member, stated R2 is Autistic and doesn't always know or understand what is going on. V8 stated about a year ago, he had his gallbladder removed at a local hospital, he developed an infection in his blood and surgical wound resulting in the colostomy and he has a feeding tube that they use for his medications because he won't take them by mouth. V8 stated R2 was transferred to a higher acuity hospital, then to 2 different rehab hospitals and then to this facility. V8 stated he has been at the facility for a short time and the staff isn't changing his colostomy bag, so feces is coming out and sitting on his skin for long periods of time resulting in a painful red rash all over his belly. V8 stated when R2's bag get's full, that is when it leaks onto his belly and into his folds. V8 stated some of the nurses told her that he messes with it, but that isn't true, he doesn't like it to be changed because it hurts, but he does allow them to do it, he just moves around. V8 stated sometimes he'll remove the towel to look and see what it looks like when it's leaking and then covers it back up. V8 stated the problem was mainly on the night shift. V8 stated R2 is on hospice because his kidneys are failing, and they decided not to put him on hemodialysis. V8 stated hospice provides all of R2's colostomy, incontinent supplies and medications/creams/powders. On 4/24/25 at 8:30 AM, V8, family member at bedside and stated no one has come into R2's room to check on him this morning. On 4/23/25 at 9:20 AM, V10, RN, stated the nurses change the colostomy bags as needed. V10 stated, R2 is picky with his changes, because he knows what makes him hurt and what doesn't, so he only likes certain products used. V10 stated hospice provides R2's colostomy supplies, wound care medications/powders/creams, incontinent wipes and incontinent pads. On 4/23/25 at 9:30 AM, V4, MDS/Care Plan Coordinator, stated R2 picks at the colostomy bag so it becomes loose and leaks. On 4/23/25 at 11:00 AM, V1, Administrator, stated he spoke with V8, regarding her concerns with R2's care. V1 stated they had placed a diaper on R2, so he put a sign on R2's wall, not to use diapers and educated the staff. V1 stated he isn't familiar with colostomies, so he spoke with V5, Wound Nurse, who explained to him that when the feces sits on the skin it can make it excoriated and he recommended to place a towel under and below the colostomy in case it starts leaking. V1 has instructed the nursing staff to make sure it is checked frequently, and care provided as needed. V1 stated the problem occurred (referring to the grievance) during the night with an agency nurse that wasn't familiar with R2's care or how he is because they don't have any other residents like him, so that agency nurse was also educated. V1 stated he checks on R2 and speaks with V8 everyday to make sure R2 is being cared for. On 4/24/25 at 10:50 AM, V5, Wound Nurse, stated they are using Miconazole and Triad creams for R2's excoriation to his abdomen. V5 stated it helps with the excoriation and the burning sensation/pain caused by the excoriation. V5 stated the excoriation is chronic, comes and goes. V5 stated R2's reaction to the excoriation is 50/50 pain and anxiety, R2 has Autism, so it causes him anxiety and he guards that area. V5 stated R2 does pick/mess with the bag, and it leaks constantly. V5 stated feces shouldn't be left on the skin because it causes excoriation. V5 stated he would expect the nursing staff to keep R2 clean, change his bag and apply the creams as ordered. The Colostomy/Ileostomy Care Policy, dated 6/2015, documents the purpose is to provide guidelines that will promote cleanliness, protect peritoneal skin from irritation and infection and exposure to fecal matter. Colostomy/Ileostomy bags will be changed at a minimum once every 5 days and as needed. Apply barrier cream as indicated, document in the nursing notes any skin issues and the condition of the stoma, report these issues to the physician, and document the changing of the colostomy bag on the TAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify pain and provide pain relief to 1 of 1 resident (R2) reviewed for pain management in the sample of 6. This failure resulted in R2 having pain and discomfort related to excoriation around his colostomy site extending down to the abdomen and perineal area and that is not being treated or recognized. Findings include: On 4/23/25 at 8:45 AM, R2 was observed in bed with V8, family member, at bedside. R2's colostomy site and abdomen were observed with V8. There was a towel covering R2's abdomen, no abdominal binder present, V8 removed the towel and R2's colostomy bag was about 3/4 full and was leaking moderate amounts of liquid stool onto R2's abdomen, down into R2's abdominal folds, perineal area and under R2's bottom. R2's abdomen was red and excoriated. R2 was stating don't touch it, it hurts, burns and was shaking, appearing to be apprehensive and in pain. On 4/23/25 at 8:55 AM, R2 turned his call light on, V9, CNA (Certified Nurse's Assistant) came into the room, asked what was needed and then left the room to gather supplies. Upon V9's return, V9 explained to R2 that she was going to clean him up, R2 was shaking his head no and stating it hurts, it burns, don't use the cleaner in the white bottle pointing to a bottle of wound cleanser. V9 was able to calm R2 and R2 agreed to allow V9 to clean him up. V9 attempted to clean R2, but liquid feces continued to leak from the bottom of the colostomy wafer that attaches to the bag. During this time R2 continued to shake and appeared to be in pain. On 4/23/25 at 9:20 AM, V10, RN, came into R2's room to change the colostomy bag. The bag was removed and there was red excoriation noted around the colostomy site extending down to R2's pubic area. V10 cleaned around the colostomy site, R2's abdomen and pubic area with incontinent wipes, this is what R2 prefers to be used. V10 then placed a new colostomy bag and told R2 and V8 that she would need to get the CNA to finish cleaning him up because she still had a lot of medications to give. No creams were applied, and the feces remained on R2's lower pubic area, buttocks and on the disposable incontinence pad under R2. On 4/23/25 at 10:30 AM, R2 was still soiled and hadn't been cleaned up, hospice aid arrived and cleaned R2 up. R2's perineal area and buttocks were red. V8, R2's Mom, in room and stated she has been at R2's bedside and no one from the facility has changed R2 until now, the CNA never came back to the room after V10 left. R2's Face Sheet, undated, documents R2 has the following diagnoses: Unspecified Kidney Injury, Pituitary Dependent Cushing's Disease, Hypertension, Autism, Congenital Renal Failure, Acquired Absence of Parts of the Digestive Tract, Presence of Functional Implants, Acute Infarction of the Large Intestine, Chronic Kidney Disease and Critical Illness Polyneuropathy. R2's (MDS) Minimum Data Set, dated [DATE], documents R2 has a BIMS (Brief Interview of Mental Status) score of 8, indicating R2 has moderate cognitive impairment. R2's Care Plan, dated 4/21/25, documents R2 has an alteration in comfort due to advanced disease process with the following interventions: assess effectiveness of pain medication, assess pain characteristics: duration, location, quality, encourage to report any pain, and to report any acute changes to Physician. There are not any interventions for R2's pain from the excoriation or how to effectively assess and act on R2's pain in relationship to his diagnosis of Autism and cognitive disabilities. R2's Progress Note, dated 4/8/25 at 9:21 PM, documents the following: Patient continues on hospice care, g-tube patent/intact, remains afebrile. Colostomy intact, patient keeps messing with it, so it keeps leaking. Skin on abdomen has redness. Patient cleaned as needed. Plan of care ongoing. There was no documentation in R2's records of him being assessed for pain since 3/30/25. R2's Wound Care Note, dated 4/8/25, documents R2 has incontinence associated dermatitis. Treatment: cleanse wound with soap and water, pat dry and apply triad and miconazole cream BID (twice daily) and PRN (as needed). Leave open to air. R2's Wound Care Note, dated 4/15/25, documents R2's incontinence associated dermatitis is resolved and triad and miconazole cream was changed to PRN. R2's (POS) Physician Order Sheets were reviewed with the following orders noted: 3/28/25, Comfort focused treatment; 4/15/25 - Triad Hydrophilic Wound Dress External Paste. Apply to Abdomen and Groin topically as needed for skin redness; 4/15/25 - Micatin Cream 2 % (Miconazole Nitrate). Apply to Abdomen and Groin topically as needed for skin redness. R2's (TAR) Treatment Administration Record, documents the following: Micatin (Miconazole) and Triad cream has not been applied since 4/14/25. R2's Pain Assessment, dated 3/25/25, documents the following: pain scale for cognitively impaired: displays vocal c/o (complaints) pain, facial grimacing, bracing and restlessness, characteristics - aching, burning, Faces scale - hurts a little bit. On 4/23/25 at 8:45 AM, V8, family member, stated R2 is Autistic and doesn't always know or understand what is going on. V8 stated about a year ago, he had his gallbladder removed at a local hospital, he developed an infection in his blood and surgical wound resulting in the colostomy. V8 stated R2 was transferred to a higher acuity hospital, then to 2 different rehab hospitals and then to this facility. V8 stated he has been at the facility for a short time and the staff isn't changing his colostomy bag, so feces is coming out and sitting on his skin for long periods of time resulting in a horrible painful red rash all over his belly. V8 stated when R2's bag is full, that is when it leaks onto his belly and into his folds. V8 stated some of the nurses told her that he messes with it, but that isn't true, he doesn't like it to be changed because it hurts, but he does allow them to do it, he just moves around. On 4/24/25 at 8:30 AM, V8, R2's Mom at bedside and stated no one has come into R2's room to check on him this morning. On 4/24/25 at 10:50 AM, V5, Wound Nurse, stated they are using Miconazole and Triad creams for R2's excoriation to his abdomen. V5 stated it helps with the excoriation and the burning sensation/pain caused by the excoriation. V5 stated the excoriation is chronic, comes and goes. V5 stated R2's reaction to the excoriation is 50/50 pain and anxiety, R2 has Autism, so it causes him anxiety and he guards that area. V5 stated feces shouldn't be left on the skin because it causes excoriation and pain. V5 stated he would expect the nursing staff to keep R2 clean, change his bag and apply the creams as ordered. The Pain Management Policy, dated 1/20/20, documents the following: The purpose is to facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. The pain management is based on a facility-wide commitment to resident comfort. Pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical need. Pain management is a multidisciplinary care process that includes the following: effectively recognizing the presence of pain, identifying the characteristics of pain, addressing the underlying causes of the resident's pain, identifying and using specific strategies for different levels and sources of pain, monitoring for the effectiveness of interventions and modifying approaches as necessary. Pain will be assessed at least once every shift and documented in the EMAR (Electronic Medication Record) using the pain scale appropriate for the patient. Based on the documentation, a pain management care plan will be developed, maintained, and/or updated. If nursing staff recognizes pain, the staff may attempt non-pharmacological interventions, physical modalities, body alignment, rehabilitation therapy, exercises, and/or cognitive behavioral interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent physical abuse for 3 of 4 residents (R5, R6, R10) reviewed for Freedom from Abuse and Neglect in a sample of 16. This failure resulted in R6 acquiring a subarachnoid hemorrhage and left orbital wall fracture. Findings include: 1. R6's Face Sheet documented R6 was admitted to the facility on [DATE] with diagnosis of, in part, bipolar disorder, chronic obstructive pulmonary disease and dementia. R6's Minimum Data Set (MDS) dated [DATE] documented she was cognitively intact. R7's Face Sheet documented R7 was admitted to the facility on [DATE] with diagnosis of, in part, schizophrenia, bipolar disorder and dementia. R7's MDS dated [DATE] documented he was cognitively intact. Facility's Serious Injury Incident and Communicable Disease Report dated 3/21/25 documented, It was alleged that there was a resident to resident altercation between (R6) and (R7). Upon investigation, (R7) was in the bathroom when (R6) entered and stood in the doorway as he was using it with her back to him. When he was done, he exited the bathroom pushing her with one hand saying move out my way. (R6) stumbled forward and fell face first to the floor. She was immediately assessed and sent to hospital. I (V1, Administrator) was notified of her being transferred and admitted to another hospital and as a result from this incident she has a fracture of left orbital floor and subarachnoid hemorrhage. The report continued to document, Upon investigation, (R6) was standing in front of the resident restroom door by the nurse's station when a resident was coming out of the restroom. He tried to move her out of the way so he could get by, and she fell face first sustaining a head laceration. She was sent on 3/16/25 to the hospital for evaluation. I (V1) was notified on 3/21/25 when we received and reviewed documentation from the hospital. It was noted she was diagnosed with a subarachnoid hemorrhage with left orbital fracture. Hospital Progress Note dated 3/19/25, documented R6 was diagnosed with SAH (subarachnoid hemorrhage and a L(left) interior orbital wall fracture. Police report dated 3/18/25, documented On March 18, 2025, the office manager of the facility contacted detective from the number. The manager stated that the incident occurred around approximately 1400 - 1430 hours (2:00 PM-2:30 PM) but it was not captured on video due to the angle of the camera in relation to where the incident occurred. On 3/26/25 at 3:00 PM, R15 stated he saw R7 push R6 down and R6 was lying face down on the floor with blood around her. R15 stated R6 hit her head. R15 stated he did not hear any yelling. R15 stated he thinks R6 made R7 mad by walking in on him while he was using the restroom. On 3/25/25 at 12:35 PM, V1 stated R7 was on the toilet when R6 opened the door on him. R6 yelled and preceded to stand in the doorway with her back toward R7. R7 got up and told R6 to move out of the way while pushing her over. V1 stated he did not witness the incident, but V14 CNA did and R15 did. V1 stated R6 suffered a subarachnoid hemorrhage and was sent to the emergency room immediately. V1 stated he reported the incident. On 3/25/25 at 1:06 PM, V17, R6's daughter/guardian, stated R6's injuries don't seem to match with what the facility says happened. V17 stated R6 suffered life threatening injuries including a brain bleed and broken orbital socket and is still in the hospital now. V17 stated R6 could only remember she was with a staff member then blacked out and was in the ambulance. V17 stated she did talk to the police. On 3/26/25 at 12:30 PM V16, Licensed Practical Nurse, LPN stated R6 gets into a lot of issues and roams a lot, she never liked staying on the female side, would sleep over by the vending machines at the end of the hall down the men's side all the time. V16 stated R6 would get upset easily if someone said or did something she didn't like. V16 stated R6 was just really psychotic, she might be hearing different things not there. V16 stated she's not aware of anything the staff is/was supposed to be doing to try to prevent R6 and R7 from getting into an incident of abuse. On 3/26/25 at 1:15 PM, V15 LPN, stated R6 was noncompliant and very verbally abusive to staff, she was a lady with a lot of behaviors, and it put her in bad situations with other residents. V15 stated R6 was set in her own ways and dismissive to those around her. V15 stated R6 was just a time bomb waiting for something bad to occur, this place was not appropriate for her. V15 stated she's seen R7 hit and punch staff in the past, he doesn't care about others and doesn't understand others enough to prevent an altercation. V15 stated when physical abuse occurs between residents, she separates them first, tends to injuries, notifies the proper people and the administrator. V15 stated 1 on 1 observation interventions seem to really help improve prevention from abuse reoccurring. On 3/26/25 at 1:20 PM V5, Certified Nursing Assistant (CNA) stated R6 was aggressive and confrontational with verbal outbursts, also stubborn with how she wanted things, would curse a lot. V5 stated if R6 could have been strictly separated from the male's side we might not have failed to prevent the incident. On 3/26/25 at 1:43 PM V7, LPN stated V7 stated R6 used to use the restroom on the male's side and her behaviors put her at risk of abuse and she would try to relocate her as much as she could because the men on this side are easily agitated. On 3/26/25 at 4:00 PM, V14 CNA stated she saw the altercation between R6 and R7 take place. V14 stated she heard commotion from R7 yelling which got her attention. V14 stated she saw R6 hit the floor and then R7 came out of the restroom behind her and walked away. V14 stated R6 hit her head, was bleeding and loss consciousness. V14 stated R6 really liked to be over on the male's side but some of the male residents did not like her being over there. V14 stated R7 was probably upset R6 walked in on him using the restroom. 2. R11's face sheet documented R11 was admitted to the facility on [DATE] with diagnosis of, in part, encephalopathy, type two diabetes mellitus, and hemiplegia and hemiparesis. R5's Face Sheet documented R5 was admitted to the facility on [DATE] with diagnosis of, in part, paranoid schizophrenia, mild cognitive impairment and hypertension. The Facility's Serious Injury Incident and Communicable Disease Report dated 3/5/25 documented that R5 was the alleged victim of R11. The report further documented, It was reported that (R11) allegedly stuck (R5) in the dining room. Resident assessment no injuries noted. Local police notified. Investigation initiated. Final to follow. Upon investigation, (R5) took (R11's) food off his plate and ate it. (R11) was upset and made contact with (R5's) chest staff immediately intervened separating both residents removing them from the dining room. (R5) was assessed and no injuries noted. After interviewing him, an order was placed for double portions due to him saying he was still hungry. Staff explained to him that he could have asked for another helping of food. He said he understood. (R11) was educated on informing staff of any issues he may have so that staff can assist him, but it is not ok to put his hands on anyone. Also, both residents had psychosocial follow up interviews, updated care plans and all staff inserviced on abuse and neglect reporting. 3. R10's face sheet documented R10 was admitted to the facility on [DATE] with diagnosis of, in part, unspecified injury of head, traumatic subdural hemorrhage with loss of consciousness, and bipolar disorder. R14's face sheet documented R14 was admitted to the facility on [DATE] with diagnosis of, in part, bipolar disorder, type two diabetes mellitus, and major depressive disorder. The facility's incident report dated 12/19/24, documented, This nurse was alerted by nursing staff that help was needed. On assessment (R10) was in room (XXX) on the floor. Nursing staff stated another resident had pushed (R10) down after he was in their room touching their belongings. (R10) unable to give description. The report continued to document, Nursing staff alerted to (R14's) room. At that time another resident was found on the floor. Nursing staff states (R14) pushed another resident down when the resident entered his room without his knowledge. (R14) states I'm tired of him coming to my room taking my things! You cannot tell me physical abuse and mental abuse are not the same! On 3/27/25 at 1:05 PM, V2, Assistant Director of Nursing, stated all residents have the right to be free of abuse. On 3/27/25 at 9:13 AM, V1, Administrator, stated he agreed that the residents have a right to be free of abuse/neglect/misappropriation. The facility's Abuse Policy and Prevention Program dated 2022, documented, 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, or mistreatment of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews the facility failed to prevent development of additional pressure injuries for 1 of 3 residents, (R1) reviewed for treatment/services to prevent/heal pressure ulcers in a sample of 16. This failure resulted in R1 developing two new Stage 2 pressure injuries. Findings include: R1's Face Sheet, documented R1 was admitted to the facility on [DATE] with diagnosis of, in part, paranoid schizophrenia, pressure ulcer stage 3, and atherosclerotic heart disease. R1's Minimum Data Set (MDS) dated [DATE], documented he is moderately cognitively impaired and required partial/moderate assistance with toileting hygiene; substantial/maximal assistance with showering/bathing and all transfers; and partial/moderate assistance with rolling left to right in bed. R1's Care Plan dated 1/24/25 documented he is at risk for skin complications r/t (related to) psychotropic medications and impaired independence with activities of daily living functions. Stage 3 Pressure ulcer to Coccyx on 6/18/25 interventions to assess and document of progress of areas weekly. On 1/10/25 intervention to assist and encourage resident to turn and reposition every one to two hours and as needed. R1's care plan also documented he has a self-care deficit in bed mobility related to decreased ability to position or reposition self in bed/ turn from side to side; on 11/29/23 a halo bar was placed above the resident's bed for turning and repositioning and to assist with transfers; on 11/29/23 position and reposition resident in bed for comfort, joint support, and skin integrity. On 3/25/25 this surveyor observed R1 to be on his left side at 8:25 AM, 8:35 AM, 8:49 AM, 8:55 AM, 9:10 AM, 9:11 AM, 9:23 AM, 9:35 AM, 9:50 AM, 10:01 AM, 10:16 AM, 10:28 AM. R1's door was left closed from 10:32 AM until 11:22 AM. On 3/25/25 this surveyor observed R1 still on left side at 11:22 AM and 11:33 AM. On 3/24/25 at 9:50 AM, R1 had a sign above his bed stating, turn schedule. On 3/24/25 at 1:50 PM V7, Licensed Practical Nurse (LPN) stated she was not sure how long R1 has had his pressure ulcer but thinks it should be improving with the wound vac, he is typically compliant with that. On 3/24/25 at 2:00 PM, V8, Wound Nurse, stated R1's pressure ulcer was in house acquired and R1 has had it for about 6 months, it started out as moisture associated because he likes to pour liquids on himself leaving him wet. V8 stated the ulcer had slough around it at first and was small but then went to the hospital and came back with it debrided and a lot larger. V8 stated he emphasizes implementing care plans and following interventions to improve patient care. On 3/25/25 at 1:17 PM, V8, provided R1 wound care to his stage 4 pressure injury while he was on his left side. After pressure ulcer care was completed, V8 got V11, Certified Nursing Assistant (CNA) to come assist him with peri care on R1. While V11 turned R1 on to his right side, two pressure ulcers with no dressings on them were noticed. V8 stated these were new, facility acquired pressure ulcers. The pressure ulcer to R1's left ischial had approximately 5-6 centimeters of erythema surrounding a darken red wound bed of granulation tissue that was approximately 2 centimeters in diameter with a skin flap peeled open, this part of the wound did not blanch when V8 applied pressure to it. V8 stated he would call this an open blister. R1's new pressure ulcer to his left hip had erythema covering approximately 4 centimeters in width by 1.5 centimeters in length with a patch of open excoriated skin in the center approximately 0.5 centimeter in diameter. V8 stated that the hip pressure ulcer was from R1's catheter tubing being underneath him while on his left side, it has the exact indentation of it. V8 stated it could have been caused by excessive time being on top of the tubing without being repositioned. V8 preceded to take pictures of both the wounds, applied skin prep to them and a bordered foam dressing to the left ischial and an island dressing to the left hip. V8 stated he would notify the wound nurse practitioner and get new orders for care. At 2:23 PM, V11 and V8 turned R1 back on to his left side. V11 and V8 stated they turned R1 on his left side again because he won't stay on his right side. V11 and V8 stated we can turn R1 on his right side and show that he won't stay there. R1 was turned to his right side by V11 and V8 cooperatively without complaints or refusal. R1's Skin and Wound assessment dated [DATE] documented an in-house acquired blister to his left ischial tuberosity involving 100% granulation to the wound bed and to have erythema surrounding it. On 3/25/25, a second Skin and Wound Assessment documented a new in-house acquired skin tear to R1's rear left trochanter (hip) with 100% granulation to the wound bed and erythema surrounding. On 3/26/25 at 8:41, AM, R1 stated he doesn't mind being turned and doesn't refuse unless the staff reposition him roughly because his butt hurts. R1 stated the staff will sometimes drag my butt when they turn me and it hurts a lot but if they are gentle, I don't care what side I'm on. R1 stated no one asked or offered to turn me yesterday. R1 stated he was on his left side for most of the day 3/25/25. On 3/26/25 at 3:53 PM, R16, R1's roommate, stated he doesn't see staff come in and turn him frequently. On 3/26/25 at 12:30 PM, V16, LPN, stated residents are on turn schedules to prevent break down of the skin, if a resident is non-compliant V16 stated she would try to at least offer a wedge under one side to turn even slightly. On 3/26/25 at 1:20 PM, V5 CNA stated turning schedules prevent skin break down and wounds from worsening, typically occurring every 1-2 hours. V5 stated if a resident is noncompliant with turning, a wedge can be used to turn them slightly and offer encouragement. V5 stated if a resident is not turned it is likely to cause a sore. On 3/27/25 at 1:05 PM, V2, Assistant Director of Nursing, stated she expects the nursing staff to be turning residents that require it at least every two hours, if they do not turn a resident within that timeframe, they are at risk for causing skin break down. V2 stated she does not expect a resident to be lying on top of a catheter tube, this could cause skin sores. The facility's Turning and Reposition Policy dated 8/2024 documented all residents at risk of, or with existing pressure injuries, will be turned and repositions, unless it is contraindicated due to a medical condition. In this case, small shifts in repositions with be employed. Repositioning techniques in bed includes avoiding positioning the resident onto medical devices or other foreign objects and avoid positioning residents on surfaces with existing pressure injuries, including persistent redness. Repositioning techniques in chair include if the resident is unable to make position changes, reposition every hour. The facility's Skin Management: Pressure Injury Treatment/General Wound Treatment Policy dated 10/2024 documented for management of tissue loads, pressure redistribution devices offer an effective means of reducing interface pressure but because they cannot provide pressures consistently less than 25 to 32 mm/HG (millimeters of mercury), a turning schedule should be implemented as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent abuse for 3 of 7 (R20, R30, R62) residents investigated for resident-to-resident abuse in a sample of 39. Findings include: 1. R20's EMR (Electronic Medical Records) undated documents that the resident was admitted to the facility on [DATE]. R20's EMR dated 07/28/16 documents a diagnosis of Schizophrenia. R20's MDS (Minimum Data Set) dated 02/04/25 documents a BIMS (Brief Interview for Mental Status) score of 6 out of 15. The MDS documents that the resident has not exhibited physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, or other behavioral symptoms not directed towards others. R20's Care Plan dated 9/27/23 documents (R20) has a history of aggressive, inappropriate, attentions-seeking and/or maladaptive behavior. The resident has a diagnosis of paranoid schizophrenia. 06/14/22 (R20) was verbally and physically aggressive towards a peer. 02/19/23 Got mad and was verbally aggressive towards staff in the dining room and threw his drink on staff. 3/15/23 verbally aggressive with staff in dining room. 7/18/23 (R20) was noted being physically aggressive with staff. 9/9/2023 (R20) became physically aggressive towards another resident. 09/26/2023 - physically aggressive. R20's Nurses Notes dated 05/01/24 at 9:40 PM documents Per stated res was in dinning threw and hit resident (R31) with a chair, unknown why, called police report # 2024-025107, V18, NP (Nurse Practitioner), (V19) POA (Power of Attorney) aware at this time. Facility's Abuse Report dated 05/01/24 documents Resident (R20) tossed chair in dining room in the direction of resident (R31). She was assessed for injury and notifications made to respective RP's and doctors. Resident separated and ADM notified. Investigation started. Final report to follow. Based on resident and staff interviews and statements from residents involved, the allegation was substantiated. The perpetrator admitted that he threw the chair but gave no reason for the action. However, due to his diagnosis and the circumstance surrounding the incident, he gave no indication that he intended to harm the victim. It is possible that he tossed the chair in her direction because the other resident was merely in the dining room. R20's Nurses Note dated 12/22/24 at 3:50 PM documents The resident hit another resident with the caution floor sign. I redirected the resident to his room. I notified the on-call nurse at 1555 pm and she returned my call at 1611 pm. I notified the resident's POA (V19) at 1615 pm. Facility's abuse investigation dated 12/22/24 documents Res to Res incident. (R59) walked into (R20's) room to talk to his roommate and (R20) got upset. (R20) hit (R59) with the floor sign. Nurse assessed (R59) and he denied pain. No bruising or injury noted. QA (Quality Assurance) team met and will discuss with (R59) to not enter that room and to ask the roommate to go to his room. 2. R30's EMR undated documents that the resident was admitted to the facility on [DATE]. R30's EMR dated 4/12/19 documents a diagnosis of Schizophrenia, unspecified. R30's MDS dated [DATE] documents that a BIMS score could not be completed because resident is rarely/never understood. The MDS documents that the resident has not exhibited physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, or other behavioral symptoms not directed towards others. R30's Care Plan dated 5/10/24 documents (R30) is at risk for abuse and/or neglect related to Dx: Schizophrenia, psychotropic medications, diagnosis of dementia, confusion/disorientation/forgetfulness, poor judgement skills, difficulty in communication, history of verbal and physical aggression and poor personal hygiene. (R30) will mumble at times while walking around the facility. (R30) will curse at staff and peers. 9/29/23 resident was reported to have had an incident with peer. 10/5/23 chair was pushed into this resident's arm by peer. 5/1/24 resident physically aggressive with peer. There is no progress note for this incident. Facility's Abuse Investigation dated 12/14/24 documents (R30) went to grab (R31) cup of water and (R31) started to yell at her. (R30) punched (R31) in the face. No injuries noted. (R31) denied any pain. No swelling noted. Resident immediately separated by staff. 3. Facility's Abuse Investigation dated 07/05/24 documents (R92) a 60 y/o male whom is A/O to self with the following DX: other schizophrenia, diffuse traumatic brain injury without loss of consciousness, subsequent encounter. (R62) a 48 y/o female whom is A/O to person, place and situation with the following DX: Major depressive disorder, undifferentiated schizophrenia. (R92) made contact with (R62) to obtain attention causing (R62) to become agitated making contact back. Both residents moved to different tables to prevent further incidents. Both interviewed and both feel safe in facility. Both will remain in facility with no further incidents. Behavior tracking already in place and will continue. MD and POA notified. Care plan updated. There is no progress note noted for this incident. R62's EMR undated documents that the resident was admitted to the facility on [DATE]. R62's EMR dated 7/31/19 documents a diagnosis of undifferentiated schizophrenia. R62's MDS dated [DATE] documents a BIMS score of 13 out of 15. The MDS documents that the resident has not exhibit physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, or other behavioral symptoms not directed towards others. R62's Care Plan 7/12/24 documents (R62) is at risk for abuse and/or neglect related to DX: Schizophrenia, Major Depression, and Cognitive impairment, psychotropic medication use, poor judgement skills. 02/02/2022 resident was involved in an altercation with peer. 7/5/24 resident was physically aggressive with peer as well as a recipient. On 3/14/25 at 12:15 PM, V22, Social Worker stated that if residents are being aggressive with each other than we split them up. We have the residents sign a behavioral contract. With the behavioral contract the resident knows that there are consequences to their actions. The social workers will also do a 1 to 1 psychosocial meeting with the residents. We do behavior tracking on the residents. On 3/14/25 at 12:20 PM, V23, LPN (Licensed Practical Nurse) stated that the first thing she does is contact the administrator if there is an incident between two residents. She stated that the staff will try to de-escalate the situation. We separate the individuals. We are not allowed to touch the residents. We fill out an incident report. We notify the MD (Medical Director) and the guardian or POA. Sometimes we do room moves but that must be approved by administration. She stated they monitor all residents across the board. All residents are treated the same. She stated that with R20 it's all about tone. She stated that he is usually verbally aggressive. She stated that they monitor individuals that are prone to aggression a little closer. Facility's Abuse Prevention Program dated 9/2017 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property 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 and mistreatment of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess and document a head to toe skin assessment upon readmission to the facility for 1 (R44) of 1 resident reviewed for pressure wounds in the sample of 39. This failure resulted in the deterioration of the pressure ulcer from a stage II to a stage III. R44's Undated Face Sheet documents initial admission date 4/17/2020 diagnoses of spina bifida and pressure ulcer of sacral region unspecified stage. R44's Annual Minimum Data Set (MDS) dated [DATE] documents she is alert and no pressure ulcers, not at risk for pressure ulcers, no unhealed pressure ulcers. R44's Care Plan, addresses resident at risk for skin complications r/t (related to) skin spina bifida. Goal: area to right buttock will remain stable/heal. Interventions: assess and document progress of areas weekly, assist and encourage resident to turn and reposition every one to two hours and PRN (when needed) and skin assessment weekly. R44's Hospital Discharge Paperwork, dated 8/14/2024 documents sacral stage 2 pressure ulcer. R44's Nurses Note, dated 8/14/2024 at 6:12 PM, documents resident returned to the facility at 6p via ambulance. Resident transferred from stretcher to bed by 2 EMT workers. No c/o pain or discomfort at this time. Resident has a Foley catheter, suprapubic catheter, and cecostomy tube. The resident has a breakdown to her right butt. 97.6 120/74 20 82. Resident laying in bed with call light within reach. No documentation of readmission skin assessment documented. R44's Braden Scale for Predicting Pressure Ulcer Risk dated 8/15/2024 documents moderate risk. R44's Dietary Note, dated 8/15/2024 at 2:59 PM documents resident readmitted on [DATE]. Per staff, resident has 2 pressure wounds on buttocks. Recommend Prostat BID (twice a day) r/t wound healing. R44's NRSG admission Observation, dated 8/15/2025 documents no skin assessment. R44's Dietary Evaluation, dated 8/15/2024 documents no skin issues and recommend Prostat 30 ml (milliliters). R44's Medication Administration Record (MAR) dated 8/15/2024 documents no physician's order for Prostat BID. R44's Treatment Administration Record (TAR), dated 8/17/2024 through 8/31/2024 documents staff initial treatment administered to buttocks one time a day and PRN to promote wound healing calcium alginate, medihoney wound gel and foam bordered dressing. R44's Skin Screen dated 8/20/2024 documents stage 3 pressure ulcer. No other assessment documented. R44's Wound Evaluation, dated 8/20/2024 documents stage 3 pressure ulcer right ischial tuberosity 6 days old present on admission measured 6.11 centimeters (cm) x 3.01 cm x 2.77 cm. Wound bed assessment: 60% slough, 40% eschar, no exudate (drainage), periwound area attached, surrounding tissue intact. R44's Wound Assessment Report, dated 8/21/2024 documents right ischium Stage 3 pressure ulcer date wound acquired 8/14/2024, present on admission. Wound status: 90% granulation, 10% slough, wound edges attached, periwound: intact, exudate: moderate, exudate amount: serosanguineous drainage, no odor. Treatment: daily and PRN (when needed) cleanse with wound cleanser, medical grade honey, collagen particles, calcium alginate and bordered foam. R44's Physician's Order Sheet (POS), dated 8/2024 documents staff administered wound treatment start date 8/16/2024 calcium alginate, medihoney and a foam dressing apply to buttocks topically one time a day/PRN (when needed) to promote wound healing. No physician's order for Prostat 30 ml twice a day documented. R44's POS dated 9/2024 documents a physician's order dated 9/4/2024 Prostat two times a day for wound healing 30 ml. Staff documented it was administered 9/5/2024 through 9/30/2024. On 3/12/2025 at 8:36 AM V12, Wound Nurse/LPN provided wound care to R44. V12 entered room washed hands and donned gloves. He assisted R44 to roll to her left side and removed the intact dressing to her right buttocks/ischium area. Wound bed was approximately 30% slough and had serosanguinous drainage that measured approximately 4.0 centimeters (cm) x 5 cm. No concerns regarding infection control noted during treatment. R44 lying on a low air loss mattress and had a wedge pillow under her left side. The Facility's Pressure Injuries Policy, last reviewed date 4/2024 the facility will ensure that all residents have necessary assessments completed in a timely manner at the point of admission in order to provide the best possible, person-centered care. All new and re-admissions that have been out of the facility longer than 24 hours should be assessed within 1 day of arriving to the facility by a licensed nurse to ensure stability and safety of resident. Within 24 hours of admission, the following forms should be completed NRSG: admission Observation, Braden's Scale for Predicting Pressure Sore Risk and NRSG: Interim Baseline Care Plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report verbal abuse allegations to Illinois Department of Public Health for 1 of 3 residents (R2) reviewed for abuse. This failure resulted in R2 becoming upset, crying, refusing medications and refusing to eat. Findings include: R2's Face Sheet which is undated documents that R2 was originally admitted to the facility on [DATE] with diagnosis of weakness, need for assistance with personal care, major depressive disorder, anxiety disorder, persistent mood disorder, borderline personality disorder, schizoaffective disorder, unspecified psychological disorder. R2's Minimum Data Set (MDS) dated [DATE] documented R2 is cognitively intact. R2's mood is often down with little pleasure in activities. She has impairment to bilateral upper extremities and uses a wheelchair for mobility. She requires touching assistance or verbal clues with eating. R2's Care Plan dated 9/23/2024 documented problems that R2 can be socially isolative when she is in a bad mood. The goal is that she will increase social interaction with interventions that staff will encourage resident to spend more time in social activities. On 11/20/2024 at 9:55 am, R2 stated she had gone to shock treatments (on 11/13/2024) and had come back to the facility feeling excited afterwards because she felt better by feeling more confident and feeling less prone to outbursts. At about 4:30 or 5:00 pm, R2 asked V9, Medical Records, if she could lie down and eat in her room because she was tired. V9 stated that she could. V4, Certified Nurse Assistant (CNA) then came into the room and yelled at me and stated that I could not eat in my room. R2 stated she told V4 that V9 had said she could. R2 stated that she then started crying and told V4 that this was abuse. V4 started looking at her and laughing at her. R2 stated that she (R2) used to buy V4 sodas, but she (V4) has always been hateful to me. R2 added that she doesn't get along with her. R2 stated that V4 began laughing at her and making fun of her. R2 stated that she was so upset and mad that she didn't eat supper. R2 stated that it really hurt her feelings. R2 added that V4 often tells her she can't eat in her room, causing her to start crying and refuse to eat if she must go to the dining room for her meal when she doesn't want to on that day. R2 stated that this makes her feel really bad. R2 stated that she told the next nurse on the night shift, and she said she would call V1, Administrator and V2, Director of Nurses (DON) and told me not to worry about it. R2 stated that V4 told one her friends in the facility that R2 had lied on her. R2 is unable to remember which friend in the facility this was. On 11/20/2024 at 10:35 am, V5, CNA stated that the day after the incident V5, was told by staff that R2 got in wheelchair and went up front and spoke with V2, Director of Nursing (DON). V5 stated that V2 did nothing and did not send V4 home. V5 stated V4 came in to work the day after the incident and would walk in the hall past R2's room antagonizing her and laughing at her. When V4 would walk past R2's room, R2 would yell out that that was the staff member who was mean to her. V5 stated that staff do not have the same assigned halls that they work on all halls. V5 worked with R2 the next day after the incident and stated that R2 wouldn't take her medications or get out of bed because she was still upset. V5 stated that she has seen and heard V4 talk to some residents roughly in the past but is unable to remember which residents this was. V5 overheard V4 tell a resident down the 400-hall loudly that she was not going to get the resident up and down up because that means she is doing double the work, and she don't get paid enough for that. Facility Staffing sheets for November 14, 2024, documented that V4 was assigned for fifteen-minute checks on residents. Daily staffing sheets also documented V7 assigned to the 200-hall for the day and evening shifts on 11/14/24. On 11/20/2024 at 1:30 pm V6, Receptionist, stated she was aware of the incident on 11/13/2024. The next day after this, on 11/14/2024, V6 stated that R2 was pushed in a wheelchair to the receptionist desk and V6 witnessed her pointing at V4 and yelling that's her, that's her. V6 stated that R2 was very upset and crying hard. V6 stated that V2 was there talking with R2 also. V6's daily notebook was reviewed, and a page dated 11/14/2024 and line number four documented that R2 was very upset about V4. On 11/20/2024 at 2:50 pm, V7, Licensed Practical Nurse (LPN) stated she was working on 11/14/2024 and was assigned to the 200-hall. V7 stated that R2 was crying and wouldn't take her 11:00 medications. V7 stated R2 kept crying and wouldn't talk to me. V7 stated that R2 did get in a wheelchair and said that V4 was being mean to her and yelling at her (R2). Later that day, R2 would not take her medications. R2 would see V4 walk by and yell out that's her, that's her. V7 stated that R2 said she wanted to leave the facility and that she didn't feel safe. V7 stated that R2 received a one-time intramuscular (IM) injection for Zyprexa ordered because of R2's recent behaviors. V7 stated that she hadn't seen R2 exhibit this type of behavior in a long time. V7 stated that this only occurs when someone makes her very upset. V7 also stated that she had worked the evening shift on 11/13/2024 and R2 was lying in her bed crying and repeating it's over, it's over. V7 tried to console R2 and to ask her to talk about what was bothering her but R2 refused to talk with her about it. R2 stated that she didn't want to be here, she wanted to leave. On 11/20/2024, V2 stated via telephone that she was told that R2 had come back from her electroconvulsive therapy (ECT) treatment and went to the dining room. R2 then decided to go lie down. R2's tray had been delivered to the dining room and V4 told R2 she would have to go out in the dining room to eat. V2 said that she was then told that R2 refused her tray. V2 then asked other CNAs if they had ever refused to go get a tray or refused to bring it to a resident. An in-service was provided on customer service. V2 stated she was new to the DON position and had the guidance of V8, Regional Nurse Consultant. V2 stated that she didn't know anything about the events of 11/13/2024 until the next day, 11/14/024. Once she learned this, V2 stated that she assigned V4 to perform fifteen-minute checks on the 300 and 500 halls. On 11/20 /2024 at 2:30 pm, V1, Administrator stated that V2 called her on 11/14/2024 to tell her about the allegation of customer service incident involving R2 and V4. On 11/20/24 at 4:00 pm V10, transportation stated that R2 goes to ECT treatments the third Wednesday of every month. V10 stated that last Wednesday on 11/13/3024 that he and R2 left the facility around 8 am and returned about 11:30 am. He stated that R2 told him she felt great. V10 added that (R2) hadn't been that good in a long time. On 11/20/204 at 4:35 pm, V4 stated via telephone that she had been notified by one of the staff that people are there lying on me. V4 stated that on 11/13/2024 she worked the evening shift from 2:00 pm until 10:00 pm on the 200-hall. V4 stated that she had just left the dining room and came to help pass trays on the hall. V4 stated that she saw that R2 was in bed and went to V11, CNA who was assigned to R2 and told her that the nurses are wanting the residents to eat in the dining rooms. V4 stated that she told V11 that R2 was not going to eat. V4 stated that she never went back into R2's room. V4 stated that V11 verified with R2 that she was not going to eat supper that night. On 11/21/2024 at 10:50 am V11, agency CNA stated that she was working on the 200-hall on 11/13/2024. She stated that the time was around 5:00 pm and when she walked out of another resident's room, V12, CNA, told her that R2 was ready for bed. V11 told R2 that she would go get some gloves and come right back. When V11 returned, R2 had already put herself to bed. V11 told her that dinner was ready. R2 stated that she was not going to go to dinner because she was tired from getting up so early for her treatment today. V11 stated that she offered to bring a tray to her, but R2 refused. R2 told her that she wanted to sleep. V11 then went to the dining room to help pass out trays. When she returned to the 200-hall, V4 told her that R2 was not happy and was having behaviors. When V11 went into the room, R2 was crying and told her that V4 was mean to her. R2 said that V4 had told her if she wanted to eat, she needed to get up and go down to the dining room. R2 stated that she was upset because V4 was mean to her. V11 offered to go get her tray but she said she didn't want to eat. V11 stated that shortly after telling her she didn't want to eat, R2 went to sleep. On 11/20/2024 at 12:50 pm V1, Administrator, stated that she is the abuse coordinator. V1 was aware of an incident between R2 and V4 and stated that she was on vacation during that time. V1 stated that she did receive a phone call from V2 telling her about the situation. V1 stated that V2 had told her that R2 had reported that V4 was refusing to give her food and yelling at her. V4 told V2 that R2's meal tray was in the dining room, and she was going to get it for her. V2 had told her that she had interviewed the staff on the hall and the other residents who stated they hadn't heard anything. V1 was not told by V2 if V4 was sent home. The customer concern and feedback form were signed by V1 on 11/19/2024 since there were no findings reported and customer in-service regarding tray delivery had been performed. On 11/20/2024 at 3:40 pm spoke with V8, Regional Nurse Consultant by phone. V8 remembered that V2 had called her regarding the incident between R2 and V4. V8 had been told this was a customer service issue and she recommended that V2 perform an in-service regarding customer service for meal trays. V8 stated that no allegations of abuse had been reported to her. V8 stated that if this had been reported as any type of abuse that the employee would be suspended until the investigation was complete. Abuse prevention program policy reviewed last on 9/2017 was reviewed. It stated that the facility desires to prevent abuse, neglect, exploitation, mistreatment, and misappropriation of resident property by establishing a resident sensitive and resident secure environment. It stated that employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property is unsubstantiated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate verbal abuse allegations for 1 of 3 residents (R2) reviewed for abuse. This failure resulted in R2 becoming upset, crying, refusing medications and refusing to eat. Findings include: R2's Face Sheet which is undated documents that R2 was originally admitted to the facility on [DATE] with diagnosis of weakness, need for assistance with personal care, major depressive disorder, anxiety disorder, persistent mood disorder, borderline personality disorder, schizoaffective disorder, unspecified psychological disorder. R2's Minimum Data Set (MDS) dated [DATE] documented R2 is cognitively intact. On 11/20/2024 at 9:55 am, R2 stated she had gone to shock treatments (on 11/13/2024) and had come back to the facility feeling excited afterwards because she felt better by feeling more confident and feeling less prone to outbursts. At about 4:30 or 5:00 pm, R2 asked V9, Medical Records, if she could lie down and eat in her room because she was tired. V9 stated that she could. V4 then came into the room and yelled at me and stated that I could not eat in my room. R2 told V4 that V9 had said she could. R2 stated that she then started crying and told V4 that this was abuse. V4 started looking at her and laughing at her. R2 stated that she used to buy V4 sodas, but she has always been hateful to me. R2 added that she doesn't get along with her. R2 stated that V4 began laughing at her and making fun of her. R2 stated that she was so upset and mad that she didn't eat supper. R2 stated that it really hurt her feelings. R2 added that V4 often tells her she can't eat in her room, causing her to start crying and refuse to eat if she must go to the dining room for her meal when she doesn't want to on that day. R2 stated that this makes her feel really bad. R2 stated that she told the next nurse on the night shift, and she said she would call V1, Administrator and V2, Director of Nurses (DON) and told me not to worry about it. R2 stated that V4 had told one of her friends in the facility that R2 had lied on her. R2 is unable to remember which friend in the facility this was. On 11/20/2024 at 2:50 pm, V7, Licensed Practical Nurse (LPN) stated she was working on 11/14/2024 and was assigned to the 200-hall. V7 stated that R2 was crying and wouldn't take her 11:00 medications. V7 stated R2 kept crying and wouldn't talk to me. V7 stated that R2 did get in a wheelchair and stated that R2 was being mean to me and yelling at me. Later that day, R2 would not take her medications. R2 would see V4 walk by and yell out that's her, that's her. V7 stated that R2 said that she wanted to leave the facility and that she didn't feel safe. V7 stated that R2 received a one-time intramuscular (IM) injection for Zyprexa ordered because of her recent behaviors. V7 stated that she hadn't seen R2 exhibit this type of behavior in a long time. V7 stated that this only occurs when someone makes her very upset. V7 also stated that she had worked the evening shift on 11/13/2024 and R2 was lying in her bed crying and repeating it's over, it's over. V7 tried to console R2 and to ask her to talk about what was bothering her but R2 refused to talk with her about it. R2 stated that she didn't want to be here, she wanted to leave. R2 did take her evening medications that night. On 11/20/2024 at 2:30 pm, V1 stated that V2 called her on 11/14/2024 to tell her about the allegation of customer service incident involving R2 and V4. On 11/20/2024 at 12:50 pm V1, Administrator, stated that she is the abuse coordinator. V1 was aware of an incident between R2 and V4 and stated that she was on vacation during that time. V1 stated that she did receive a phone call from V2 telling her about the situation. V1 stated that V2 had told her that R2 had reported that V4 was refusing to give her food and yelling at her. V4 told V2 that R2's meal tray was in the dining room, and she was going to get it for her. V2 had told her that she had interviewed the staff on the hall and the other residents who stated they hadn't heard anything. V1 was not told by V2 if V4 was sent home. The customer concern and feedback form were signed by V1 on 11/19/2024 since there were no findings reported and customer in-service regarding tray delivery had been performed. On 11/20/2024 at 3:40 pm spoke with V8, Regional Nurse Consultant by phone. V8 remembered that V2 had called her regarding the incident between R2 and V4. V8 had been told this was a customer service issue and she recommended that V2 perform an in-service regarding customer service for meal trays. V8 stated that no allegations of abuse had been reported to her. V8 stated that if this had been reported as any type of abuse that the employee would be suspended until the investigation was complete. There was no abuse investigation provided by the facility for R2 and V4. Abuse prevention program policy reviewed last on 9/2017 was reviewed. It stated that the facility desires to prevent abuse, neglect, exploitation, mistreatment, and misappropriation of resident property by establishing a resident sensitive and resident secure environment. It stated that employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property is unsubstantiated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure wound treatments were consistently provided for 1 of 3 residents (R2) reviewed for wound care. This failure resulted in R2 requiring transfer to the hospital, maggots developing in R2's wound, a diagnosis of osteomyelitis and needing IV antibiotics therapy. Findings include: R2's face sheet, dated 8/28/24, documented R2 has diagnoses of unspecified open wound on right lower leg, osteomyelitis, local infection of the skin and subcutaneous tissue, type 2 diabetes, bipolar disorder, coronary angioplasty implant and graft, traumatic compartment syndrome of right lower extremity, hypertension, and depression. R2's MDS (Minimum Data Set), dated 7/29/24, documented R2 is cognitively intact. R2's MDS, dated [DATE], documented R2 has not exhibited any rejection of care behaviors. R2's MDS, dated [DATE], documented R2 has not exhibited any rejection of care behaviors. R2's weekly skin assessment of right lower leg wound, dated 8/14/24, documented surgical wound with delayed closure wound. Wound has moderate serosanguinous drainage present. Wound bed appearance is red with 80% granulation and 20% slough. Wound edges are attached. Peri wound is fragile and red. Wound is undermining 0.3 cm from 12 o'clock to 2 o'clock. Zero odor observed. Zero complaint of pain voiced. R2's TAR (Treatment Administration Record), dated August 2024, documented an order for xeroform petrolatum dressing to right lateral calf topically one time a day every Monday, Wednesday, and Friday to promote wound healing with a /start date of 8/16/24 and discontinue date of 8/19/24. R2's TAR documented wound care was completed on 8/16/24, however the facility was unable to provide documentation of when the treatment was signed off since V16, Licensed Practical Nurse (LPN) in an interview stated the treatment was not signed off on 8/16/24 when she worked on 8/18/24. R2's progress note, dated 8/18/24 at 10:37 am, documented another resident came to the nursing station being very aggressive toward this nurse demanding that resident's dressing be changed daily. R2 has an order for the dressing to be changed Monday, Wednesday, and Friday. This nurse and another staff went to observe the resident. This nurse removed the ace wrap and inspected the dressing. The dressing is securely intact and dry. The resident was educated on the importance of keeping the dressing intact and covered for the number of days in order to promote wound healing. R2's progress note, dated 8/19/24 at 5:55 am, documented nurse was called to resident room by CNA to assess resident; maggots were found in the sheets; upon further investigation, nurse found a maggot on resident dressing on RLE (right lower extremity), dressing was then unwrapped and found maggots within wound bed; on call MD (Medical Doctor) made aware, order to send to ED (Emergency Department) for eval (evaluation) and tx (treatment). Wound was then cleaned with wound cleanser per order and wrapped with kerlix. EMS (Emergency Medical Service) was called for transport to local hospital. R2's local hospital progress note, dated 8/19/24, documented R2 presented to the ED with complaint of worsening pain to RLE wound and maggots in wound. She states dressing is to be changed every MWF (Monday, Wednesday, Friday), but staff hadn't changed since last Wednesday. Maggots were noted in her wound this morning, so she was brought to the ED for further evaluation. It continues, Patient to be admitted for further evaluation and management of acute on chronic OM (osteomyelitis) as well as vascular and ID (Infectious Disease) consultations. R2's local hospital progress note, dated 8/19/24, documented XR (x-ray) of tibia and fibula date of service 8/19/24 at 7:52 am provided clinical information: 59 years, female, pain, this morning there were maggots found in her bed and when looking at her leg maggots were found there. Procedure and materials: AP (anterior to posterior) and lateral view of the right tibia and fibula. Comparison studies: April 23, 2024. Observations: there is a large soft tissue defect that is present about the lateral aspect of the right lower leg. Severe soft tissue swelling is present. The soft tissue swelling is increased compared to prior examination. The soft tissue defect now extends through to the underlying fibula. There are lucent areas that are present within the fibula concerning for areas of osteomyelitis. R2's local hospital progress note, dated 8/22/24, documented right leg wound culture positive for MRSA (methicillin-resistant staphylococcus aureus), pseudomonas aeruginosa, and proteus klebsiella. R2's re-admission orders to facility, dated 8/23/24, documented orders for cefepime 2 grams in sodium chloride IV (intravenous) every 12 hours for 42 days and vancomycin 1.5 grams IV daily for 42 days. On 8/27/24 at 4:25 pm R2 stated that the facility Wound Nurse V3 was on vacation the week that she developed the maggots in her leg wound. R2 stated that no staff changed nor offered to change her dressing on Friday, August 16, 2024. R2 stated that she could feel the maggots moving over the weekend and she asked a nurse to look at it, but none did. Observed many flies in resident's room during this interview. On 8/28/24 at 11:02 am R2 stated that the DON nor any nurse changed her dressing on 8/16/24. R2 stated that she tried to get her nurse to change the dressing over the weekend and that she even told the nurse that she had creepy crawlies in her leg. R2 stated that the leg wound was oozing, and her dressing was saturated. R2 stated that her nurse on Sunday, 8/18/24 was rude, rolled her eyes at her, and replied that is not my job in response to her complaint of feeling creepy crawlies in her leg and to her request of getting her wound looked at and her dressing changed. R2 stated that her nurse looked at her dressing but did not remove the dressing to assess the wound. R2 stated that her friend, R7, a fellow resident, even tried to get the nurse to change her dressing to her leg but she still didn't get the wound assessed nor the dressing changed. On 8/28/24 at 9:50 am V2 DON (Director of Nursing) stated that she changed R2's RLE dressing on 8/16/24 and that she did not observe any maggots on the wound at this time. V2 stated that R2 has a history of being noncompliant with dressing changes and with keeping the dressings on the wound but that the facility does not have any of this documented. V2 stated that she would have expected her nurse to remove the dressing and assess the wound when R2 complained of discomfort in her wound on 8/18/24. On 8/29/24 at 10:07 am V16 LPN (Licensed Practical Nurse) stated that she was R2's nurse on 8/18/24 and that another resident, R7, became verbally aggressive with her and stated that R2's dressing needed to be changed daily. V16 stated that she informed R7 that is a HIPPA issue. V16 stated that she looked at R2's TAR (Treatment Administration Record) and she saw that R2's dressing did not get changed on Friday, August 16, 2024, and that the TAR was red for that date because it was not completed. V16 stated the last time it had been signed off was on 8/14/24. V16 stated that R2 told her that her leg dressing had not been changed since Wednesday, August 14, 2024. V16 stated that she looked at the dressing but did not change it because R2 did not complain to her about any discomfort. On 8/28/24 at 12:45 pm R7 stated that on 8/18/24 around 8:45 am he went to R2's nurse and asked her to change R2's right leg dressing because the dressing was saturated and that R2 told him she was having discomfort and could feel something crawling in the wound. R7 stated that it was obvious that the dressing needed changed because he could see the drainage on the outside of the dressing. R7 stated that R2's nurse told him that he needed to mind his own business. R7 stated that he was outside of R2's room in the hallway at 10:30 am waiting in line to go out and smoke on that same day. R7 stated that he observed R2's nurse in her room looking at R2's leg dressing. R7 stated that he heard the nurse tell R2 it's not due to be changed until Monday, I am not changing it. R7 stated that the nurse slammed the door shut when she saw him looking at her. R7's MDS, dated [DATE], documented that R7 is cognitively intact. On 8/28/24 at 1:58 pm V2 DON stated that she gave R2 her personal cell phone number in case she ever has issues again with getting her dressing changed. V2 stated that R2 told her that the weekend nurse on 8/17/24 and 8/18/24 refused to assess her wound and change the dressing even after R2 informed the nurse that she felt something crawling on the wound. V2 stated that she will be providing 1:1 education with that nurse because that was not appropriate for her not to look at the wound. V2 stated that R2 was moved to a different room today because she had been in a room next to the exit door where the residents go out to smoke resulting in more flies in R2's previous room. The facility Skin Management: Monitoring of Wounds and Documentation policy, dated 1/2022, documented it is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. Responsible party: All nursing staff. General guidelines: An evaluation of the PU/PI (pressure ulcer/pressure injury), if no dressing is present. An evaluation of the status of the dressing, if present (whether it is intact and whether drainage, if present, is or is not leaking); The status of the area surrounding the PU/PI. The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection (for example: increased redness or swelling around the wound or increased drainage from the wound); and whether pain, if present, is being adequately controlled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents do not have access to chemicals for 1 of 3 residents (R3) reviewed for supervision to prevent accidents in the sample of 5. This failure resulted in R3 drinking a liquid containing bleach, being transported to the hospital for evaluation and medical treatment. R3, as a person with altered mental status and Schizophrenia would be afraid and apprehensive of being sent to the hospital. Findings include: R3's admission Record, not dated, documents R3 was admitted on [DATE] and lists Major Depressive Disorder, Recurrent, Mild Unspecified Severe Protein-Calorie Malnutrition, Catatonic Disorder Due to Known Physiological Condition, Unspecified Psychosis not due to a Substance or known, Mood Affective Disorder, Altered Mental Status, Undifferentiated Schizophrenia as diagnoses. R3's Care Plan, dated 4/26/23, documents that R3's memory is impaired, and he has difficulty with decision-making, insight, logic, planning, and organization of thoughts. R3 ' s Care Plan documents R3 will put paper in his mouth and staff must get it out of his mouth. It also documents staff should provide clear explanations regarding expectations and procedures prior to providing care. Provide orientation to the immediate environment to enable the resident to be aware of surroundings and, provide reality-based orientation throughout the day to help the increase his/her comfort level and awareness of the environment. R3's Minimum Data Set, dated [DATE], documents that R3 is rarely/never understood, requires assistance with activities of daily living (ADL's). R3's MDS documents R3 and has short and long term memory problems with modified independence for decision regarding tasks of daily life. It also documents that R3 does not wander. R3's Late Entry Nurses Note, created date 4/23/2024 at 12:45 PM for effective date 4/17/2024 at 1:38 PM, documents This nurse was notified by CNA (certified nurse's assistant) that Resident was sitting in his room with a bottle of unknown liquid, Resident normal baseline is A&0 (alert and oriented) x 1, therefore he is unable to verify if any amount was ingested, vs (vital signs) 98.0 (temperature) 76 (pulse) 20 (respirations) 128/72 (blood pressure), Resident sent out to (local hospital) for evaluation. This Nurse attempted to contact Residents Daughters to advise them of the occurrence and their phone numbers were no longer in service. Resident was transported via stretcher in an Ambulance to (local hospital). R3's Progress Note-Acute Care, dated 4/17/2024, documents that (R3) is a [AGE] year old male with a pmhx (past medical history) of Drug induced parkinsonism, Schizophrenia with catatonia, orthostatic hypotension, MDD (Major Depressive Disorder), psychosis, HLD (hyperlipidemia), HTN (hypertension), protein calorie malnutrition, and weakness. He is a LTC (long-term care) resident at (facility). Resident seen today after receiving notification that he ingested an unknown substance assumed to be chemical. At approximately 1341 received notification that resident was observed drinking from a bottle which contained an unknown chemical substance. Nursing given order to call EMS (emergency medical service) for transport to hospital for potential poisoning. On assessment resident was at baseline orientation of A/O (alert/oriented) x1- at baseline he's minimally verbal- he made no verbal communication at time of assessment when he was asked what he was drinking or if he had any pain. Observed drooling excessive amount. Responded and complied with command to open mouth for assessment, no redness or swelling to tongue or throat noted on exam. Resident was not having any respiratory issues at time of assessment. EMS arrived during assessment. Resident transferred to stretcher- alert and stable upon exit from facility. Nursing unaware of amount consumed or identity of chemical substance. Admin (V1 Administrator), DON (V2, Director of Nursing), and appropriate parties notified of incident. R3's After Visit Summary from (Local Hospital), dated 4/17/2024, documents Today you were seen and evaluated for your consuming of bleach. Your labs and imaging were reassuring. Follow the instructions provided. Follow-up with your doctor as below. If you have any worsening or concerning symptoms, please return to the emergency room. It also documents Reason for Visit: Ingestion. Diagnosis: Ingestion of bleach, accidental or unintentional initial encounter. It also documents EXAM DESCRIPTION: CT SOFT TISSUE NECK W CONTRAST, dated 4/17/2024, documents REASON FOR STUDY: other, liquefactive ingestion. Pt (patient) BIBEMS (brought in by emergency services) from (facility) for ingestion of unknown substance PTA (prior to admission). Pt was seen drinking unknown substance out of water bottle that was labeled do not drink Pt AAO (alert and oriented) x1-2. Per EMS patient at baseline. Pt unable to answer all questions but following some commands. RR (respirations) even/nl (not labored). Pt speaking in garbled speech unsure if baseline. EMS unable to give exact baseline from healthcare facility. Denies pain at this time when asked. R3's Nurse's Notes, dated 4/18/2024 at 9:25 PM, documents Note Text: Cont (continue) IFU (incident follow up) day 2/3 without further occurrences noted. 0 acute distress noted. Resting quietly at this time with call light in reach. Clear po (oral) fluids offered, encouraged and made available. R3's Progress Note-Follow Up, dated 4/18/2024, documents that History of Present Illness: (R3) is a [AGE] year old male with a pmhx (past medical history) of Drug induced parkinsonism, Schizophrenia with catatonia, orthostatic hypotension, MDD, psychosis, HLD, HTN, protein calorie malnutrition, and weakness. He is a LTC resident at (facility). Resident seen today seen today after return from hospital ED for ingestion of bleach/ accidental or unintentional and constipation. Resident is at baseline orientation and functional status. no acute distress noted at time of assessment. He denies any pain. in hospital blood work, EKG- NSR- CT of neck-no abnormality's [sic] of neck and CT of abdomen- stomach distended (possible delayed gastric emptying), Severely increased amount of stool in entire colon- no obstruction, small hiatal hernia diffuse bladder wall thickening (d/t overdistention vs cystitis), Paget's disease of the right hemipelvis, mild subcutaneous induration overlying the coccyx ( potential to developing decub- no fluid collection) preformed- results noted accordingly. Resident returned to facility with no new orders and stable per hospital documentation. R3's Nurse's notes, dated 4/19/2024 at 2:36 AM, documents Note Text: Cont IFU day 2/3 without further occurrences noted. 0 acute distress noted. Resting quietly at this time with call light in reach. Clear po fluids made available. On 4/24/2024 at 8:16 AM R3 was sitting in wheelchair in room. R3 was sitting in front of the bedside table rummaging through drawer. On 4/24/2024 at 12:07 PM there was a 1-pound 3ounce container of bleach wipes in R3's bedside table door to bed side table was opened and visible. The container had multiple bleach-soaked wipes and liquid in the container. Microdot Bleach wipes container documents Keep out of reach of children caution. Precautionary statements: Hazards to humans and domesticated animals. On 4/24/2024 at 12:08 PM V12, Housekeeper, verified that the bleach wipes were in R3's bedside table. On 4/24/2024 at 12:11 PM V11, Licensed Practical Nurse, LPN, verified that the bleach wipes were in R3's bedside table in R3's reach. V11 stated that the wipes are supposed to be locked in a cabinet and not in R3's room. V11 stated that this puts R3 at risk for significant injury from ingesting, skin irritation and eye problems. On 4/23/2024 at 1:23 PM V5, Certified Nurse's Aide, CNA, stated that he was not working the hall on the day of the incident. V5 stated that he is normally assigned to R3. V5 stated that R3 eats and drinks anything in front of him. V5 stated that R3 is always hungry and thirsty. V5 stated that R3 is normally total care. V5 stated that R3 does not roam into others room and if it was in their it would have had to be brought into the room. V5 stated that R3 is alert to name only. V5 stated that R3 would not know if a liquid was harmful. V5 stated that if it is in his (R3) reach, he will grab it and drink it. V5 stated that R3 grabs at things and in the dining room they make sure nothing is in front of him. V5 stated that the staff feeds him. V5 stated that as soon as he gets to the dining room a staff member is always with him to keep him from grabbing things and eating them. V5 stated that R3 eats plastic and Styrofoam cups. V5 stated that this has always been the case with R3. V5 stated that when in his room they don't bring things into his room and lay him down. On 4/23/2024 at 1:26 PM V6, CNA, stated that she took care of R3 on the day of incident. V6 stated that she was walking the hall checking on her residents and saw R3 sitting in his room drinking out of a water bottle. V6 stated that it struck her odd because the liquid was yellow. V6 stated at that time V8, Restorative Aide, came past and looked as well. V6 stated they took the bottle away. V6 stated that she did not smell the liquid. V6 stated that R3 was drinking the liquid out of the bottle. V6 stated that R3 was initially in the dining room and had previously returned. V6 stated that she had not seen R3 with this water bottle at all that day. V6 stated that R3 does not roam into other rooms. V6 stated that she is not sure how it got into R3's room but someone would have had to bring it in there. On 4/23/2024 at 1:32 PM, V8, Restorative Aide, stated that she was walking past R3's room and saw R3 drinking from a clear water bottle. V8 stated that she thought it odd because water is clear. V7 stated that she and V6 entered the room. V8 stated that she took the water bottle from R3 and smelled it, and it smelled like bleach. V8 stated that when she observed R3 he was actively drinking the liquid. V8 stated that then V9, LPN, checked R3 out and he went to the hospital. V8 stated that she does not know how R3 got a hold of the bottle of bleach. V8 stated that R3 is total care, and the bottle would have to be brought into his room and placed in his reach. On 4/23/2024 at 1:35 PM, V9 stated that she was told by V8 that R3 was drinking a yellow liquid out of a water bottle. V9 stated that V8 at that time was not sure if it was urine or what. V9 stated that she smelled it, and it smelled like bleach. V9 stated that she went down and assessed R3. V9 stated that she did not know how much R3 drank and felt he needed to go to the emergency room. V9 stated that R3 was sent out at that time. V9 stated that she is not aware of how R3 got a hold of the bleach. V9 stated that the CNAs have a history of bringing bleach and cleaning products in the building from outside the facility. On 4/23/2024 at 8:36 AM, V14, Restorative Aide, stated that she does not work the floor. V14 stated that at lunch she did feed R3. V14 stated that he ate all his food. V14 stated that his drinks were in cups and R3 did not have a bottle while eating in the dining room. On 4/24/2024 at 12: 40 PM V2, Director of Nursing, DON, stated that she is aware of the incident that occurred with R3. V2 stated that nursing notified management that R3 was drinking a chemical substance. V2 stated that they felt that R3 needed to go to the hospital for evaluation and treatment. V2 stated that R3 returned without new orders and the facility monitored him. V2 stated that she is not for sure how R3 got the liquid. V2 stated that during the investigation she was able to determine that the liquid was brought in by staff. V2 stated they were unable to identify the specific person. V2 stated that no one would admit to it. V2 stated that the chemical should not have been in the facility let alone in R3's room and in reach. V2 stated that could have caused R3 serious injury. V2 stated that she was made aware by her staff that R3 had bleach wipes in his bedside tables today. V2 stated that R3 does not have access to the bleach wipes. V2 stated that staff have access. V2 stated R3 sits in front of the bedside table. V2 stated that the wipes in the bedside table would be considered in R3's reach. V2 stated that this puts R3 at risk for bleach being ingested, get in his eyes, and cause significant injury to R3. V2 stated that the bleach wipes were placed inside R3's beside table and R3 does not have the mental compacity to do so. On 4/24/2024 at 3:41 PM V20, Nurse Practitioner, stated that she was at the facility, lower level seeing patients, at the time of the event. V20 stated that she was called and notified that R3 had drank an unknown chemical substance. V20 stated that she assessed R3 at that time. V20 stated that because it was not sure at that time how much of the chemical was consumed, she felt R3 needed to go to the emergency room for evaluation and treatment as needed. V20 stated that she received confirmation from the hospital that the liquid was bleach. V20 stated that she did not see the liquid herself. V20 stated that she would expect that the facility and staff would not have bleach and chemicals in resident's room. V20 stated that if this liquid was in the room, she would expect the resident to be supervised. V20 stated that access to these chemicals puts residents at risk for serious and significant injury. The facility's Management of Hazardous Chemicals, dated 10/2023, documents that POLICY: Hazardous Chemicals shall be handled in a manner which poses no substantial hazard to human health, and shall not be deliberately discarded with the general waste or by any route into the sanitary sewer system. The handling and disposal of these materials shall be in compliance with this policy and Federal and State regulations to ensure that hazardous materials generated at this facility do not pose a substantial hazard to human health or the environment. It also documents Storage: 1. All chemicals shall be dated when opened. Excess Hazardous Chemicals: I. The contents of all containers must be clearly identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observation, interview, and record review, the facility failed to ensure resident's coffee was served at temperatures that would not burn aresident for 1 of 12 residents (R30) reviewed for accidents in the sample of 59. This failure resulted in hot coffee being spilled on R30 and R30 sustaining burns to thigh and abdomen. Findings include: 1. R30's Physician Order Sheet (POS) for February 2024 documents diagnoses of unspecified psychosis not due to a substance or known physiological condition, unspecified asthma, morbid obesity, hypertension, major depression disorder, anxiety disorder, Schizophrenia, legal blindness, post-traumatic stress disorder. R30's POS has an order dated 3/12/2024 at 3:07 PM, Silvadene external cream 1%, apply to abdomen topically every day shift for blister. Clean with wound cleaner then apply Silvadene and cover with dry dressing daily until healed. Apply to abdomen topically every day shift to promote wound healing. R30's Minimum Data Set (MDS) dated [DATE] documents R30 was severely impaired for cognition. R30's Care Plan date initiated of 8/2/2023 documents, (R30) is legally blind. He stated he was born with blindness in both eyes. (R30) qualifies for Subpart S programming to diagnosis major depression disorder, recurrent, severe, focus areas include community living, medication management and self-maintenance. Diagnosis of mental illness. At risk for abuse and neglect related psychosis, anxiety, and schizophrenia. R30's Nurse's Notes dated 2/20/2024 at 3:52 PM, documents Resident witnessed with open red area to upper left abdomen. (Medical Doctor) notified new orders Silvadene and dry dressing to affected area until healed. Resident is own responsible party. Plan of care will continue. (Draft). There was no documentation to how R30 sustained this wound. R30's Progress Notes dated 2/26/2024 at 3:52 PM, Resident witnessed with open area to upper low left abdomen. MD (Medical Doctor) notified, new order Silvadene and dry dressing to affected area until healed. R30's Wound Report dated 2/27/2024 documents, Burn wound of left abdomen partial thickness, wound size 13 (length) x 15 (width) x 0.1 cm (centimeters), surface area 195.00 cm2, cluster wound open ulceration area of 78.00 cm2, no exudate, skin 60%. Silver sulfadiazine apply twice daily for 30 days. Secondary dressing, gauze island w/ bdr apply twice daily for 30 days. Burn Wound of the left thigh, partial thickness, etiology, burn, further etiology detail, 'hot liquid', duration less than four days, wound size Length 0.8 L x 0.6 w x d 0.1 c. Incident Reports provided by the facility do not document any incident for R30. R30's Nurse's Notes do not document when R30's accident/burn occurred or how the incident occurred. R30's Wound Notes dated 3/1/2024 at 9:00 AM, Resident has reddened area on left abdomen upper and lower, scabbed over, purulent drainage noted, cleansed area, applied Silvadene and a bordered gauze, applied Silvadene to left upper leg at this time, resident is scratching at wound at this time. R30's Wound Report dated 3/5/2024 documents hot liquid burn, wound size 13 (length) x 9 (width) x 0.1 cm. Patient has a wound on his left abdomen, left thigh. Further etiology detail: Hot liquid. Silver sulfadiazine apply twice daily for 30 days. Secondary dressing, gauze island w/ bdr apply twice daily for 30 days. R30's Skin and Wound Evaluation dated 3/5/2024 at 9:28 AM, Burn, second degree, front left thigh, New, Wound measurement area 3.2 cm (centimeters), length 2.3 cm, width 2.1 cm. On 4/11/2024 at 9:22 AM, R30 stated, I got that area on my belly from coffee that spilled on me. I can hold the cup and the (V20, certified nursing assistant CNA) spilled the coffee on me and it burned me on my stomach and thigh. I was in my room when the coffee was spilled. I burnt my stomach and thigh. On 4/11/2024 at 9:24 AM, R30 had a wound on his left stomach approximately 4 inches in length and 2 inches in width, pinkish in color, appearing as old wound, with an area in the center the size of a dime that had healed over. No exudate or pus was present, or foul odors. R30's thigh was healed over and had no open areas. On 4/11/2024 at 9:32 AM, V18, Licensed Practical Nurse (LPN) stated, (R30) use to be upstairs but they moved him down here with me now. He is legally blind, and he can see shadows. He has that area on his belly that is almost healed up. I can do treatments on him without any issues. He got burnt when coffee was spilled on him. I am not sure when this happened. He had an area on his thigh and stomach from the coffee burn. On 4/11/2024 at 9:52 AM, V20, Certified Nursing Assistant (CNA) stated, (R30) had a cup of coffee that he tipped over and it burnt him. I was not there but that is what (R30) told me. (R30) had a burn on his thigh and stomach. On 4/11/2024 at 8:02 AM, V10, Dietary Manager stated, The coffee machine breaker part has been ordered and we are waiting for the part for the coffee hot water machine to work. It was not working correctly. On 4/11/2024 at 4:30 PM, V1, Administrator stated there was no policy on heat/burns. B. Based on observation, and interview the Facility failed to provide supervision to residents to ensure they do not have access to areas of facility under construction for 1 of 3 residents (R63) reviewed for potential accident hazards in the sample of 59. Findings include: On 4/16/2024 at 8:00 AM, on the 400-halls, there was a sign posted on the two doors upon entering the hall not to proceed and not to enter the area. The doors did not lock and opened with no issues. On 4/16/2024 at 8:05 AM, no staff was observed sitting at the nurse's station or monitoring the 400-hall entrance for residents. On 4/16/2024 at 8:07 AM, V2, Director of Nursing (DON) stated, We are in the process of redoing the floors and remodeling on the 400-hall. The 400 hall is closed off for residents. We do not allow residents on that hall. On 4/16/2024 at 8:09 AM, construction work is being conducted on the 400-hall. There were various tools, and instruments being used for the flooring sitting in the unoccupied rooms. On 4/16/2024 at 2:24 PM, R63 entered the area walked down the hall into the conference room. On 4/16/2024 at 2:29 PM, R63 stated, I knew that state was in the building and so I was looking around trying to find where they put you. I just came through those doors and had no issues. On 4/16/2024 at 5:15 PM, the 400-hall at the end of the hall there was an exit door. When the door was open, the alarm did not sound or go off. On 4/16/2024 at 5:18 PM, V1, Interim Administrator stated, We have a construction crew that are putting in new floors and painting the 400- hall. We have moved all of the residents on the 400-hall and once everything is done, they will be moved back to the 400-hall. Residents are not allowed on the 400-hall until the work is completed. Staff are monitoring them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide interventions to address weight loss for 1of 9 residents (R108) reviewed for weight loss in the sample of 59. This failure resulted in R108 losing 45.5 pounds (#s), a 16.98% loss of body weight in less than 2 months. Findings include: R108's Face sheet documents R108's admission date of 2/15/2024 with diagnoses of Hemiplegia, Hemiparesis following Cerebral Vascular Accident, Weakness, Dysphagia, Gastronomy tube status. R108's hospital discharge records dated 2/15/2024 documents R108's discharge weight of 268 pounds (#s). R108's admission Observation dated 2/16/2024 documents Formula 250 milliliters every 6 hours. R108's order sheet dated 2/16/2024 documents Nepro at (@) 250 milliliters (ml) every 6 hours via gastric tube. Discontinued 4/11/2024. R108's Minimum Data Set, MDS, dated [DATE] documents R108 cognition is severely impaired. R108's MDS documents upper extremity left side impairment and is dependent on staff for all Activities of Daily Living. R108's Care Plan dated, 3/7/2024, documents R108 is nutritionally compromised as evidenced by obesity. The Care Plan documents R108 is at risk for further compromise in nutrition and hydration status due to diagnosis of dysphagia, aphasia, hypertension, and dependence on tube feeding for all nutrition and hydration. R108's Progress notes dated 2/23/2024 at 4:18PM, written by V24, Registered Dietician, RD, documents Note Text: Nutrition at Risk Review Monitoring for admission, 2/15, and Tube Feeding. Weights. Diet: Jevity 1.5 Cal/Fiber Oral Liquid. Give 250 ml/hour via G-Tube four times a day until Nepro comes in. R108 is Nothing by Mouth, NPO, No weight/height in chart. Plan/Monitoring: Recommend adding height/weight to chart for complete assessment. Will follow with weekly weights. Continue plan of care. Registered Dietician available as needed. R108's Dietary Nutrition at Risk Initial dated 2/27/2024 documents weight at 240#. Will follow up with weekly weights. Recommend clarifying tube feed order, continue plan of care. Registered Dietician available as needed. R108's Dietary Evaluation dated 3/7/2024, written by V58, RD, documents no known weight loss, and no weight changes. R108's facility weight log documents weights dated 2/28/2024 240#, 3/5/2024 240#, 3/14/2024 230.2#, 3/21/2024 236#, 3/27/2024 234#, 4/5/2024 221.5#, and 4/9/2024 222.5#. R108's Progress notes dated 3/21/2024 at 2:29PM, written by V58, documents Nutrition at Risk Review. Monitoring for admission, 2/15, and Tube feeding, TF. Weights: 236# (3/21), 230.2# (3/14), 240# (2/28), 240# (3/5) BMI: 33.9 Diet: Nothing by Mouth, NPO; Nepro @ 250 ml/hour via G-Tube four times a day Skin: intact Review: Tolerating TF well, will continue to follow. Plan/Monitoring: Continue with weekly weights. Continue plan of care, Registered Dietician available as needed. R108's order sheet dated 4/11/2024 documents Six times a day for nutritional support 250ml. Nepro bolus via g tube every 4 hours for nutrition. R108's progress notes dated 4/11/2024 at 2:28PM documents Monitoring for Tube Feeding. BMI 31.9. Diet: Nothing by Mouth. Nepro @ 250milliliters an hour via G tube four times a day. Skin intact. Review R108 has had -7.7% weight loss since admission. Current order meeting caloric needs yet weight loss occurring, no tolerance issues noted. Plan/monitoring: Recommend changing tube feed order to Nepro 55ml/hour times 20 hours, 350ml flushes every 4 hours (providing 2004kcals, 95g PRO, 177g carbs, 106g fat, 2900mL total fluids). Continues with weekly weights. Continue plan of care, Registered Dietician available as needed. On 4/11/2024 at 12:00PM V11, Licensed Practical Nurse, LPN, provided nutritional supplement to R108 with no issues. V11, LPN, stated R108 has lost weight. V11 stated I am not sure why he has been losing weight. On 4/11/2024 at 11:00AM V23, Nurse Practitioner, stated R108 had a lot of edema when he first arrived. Some of his weight loss is probably related to the edema. His supplement was just increased from every 6 hours to every 4 hours. On 4/11/2024 at 2:45PM V24, Registered Dietician, stated A resident on a tube feeding should not be losing weight. I was not notified of (R108's) weight loss. We had a meeting today and changed his feeding to 55ml an hour for 20 hours a day with 50cc of water three times daily. Facility Tube Feeding policy with a review date of 4/2024 states Continuous tube feedings are based upon a 22-hour consumption period or other time frame based on individual resident need per Registered Dietician assessment and delivered over a 24-hour period. All residents admitted on a tube feeding will be reviewed at the first care conference and quarterly to determine if the tube feeding is till congruent with the resident and family goals for care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on interview and record review, the facility failed to ensure residents were free from abuse for 9 of 25 residents (R30, R35, R36, R39, R50, R63, R64, R85 and R88) reviewed for abuse, in the sample of 59. This failure resulted in R30 biting R50 and R50 being treated for a human bite and seeing the wound nurse for treatment. This failure also resulted in R85 being thrown out of wheelchair by R39, and R39 attempting to smash R85's head with the wheelchair causing an abrasion to R85's left ear, upper left arm, and face. Findings include: 1.R30's Physician Order Sheet (POS) for February 2024 documented a diagnosis of Unspecified psychosis not due to a substance or known physiological condition, unspecified asthma, morbid obesity, hypertension, major depression disorder, anxiety disorder, Schizophrenia, legal blindness, and post-traumatic stress disorder. R30's Minimum Data Set (MDS), dated [DATE], documented that R30 was severely impaired for cognition for activities of daily living. R30 was able to walk ten feet and required supervision or touching assistance. R30 had no impairments on the upper or lower extremities. R30' Care Plan, with multiple dates, documented, (R30) is at risk for abuse and/or neglect related to anxiety and major recurrent due to suicidal ideations and significant mental health issues. On 10/11/2022, it documented, (R30) was physically and verbally aggressive towards another resident that he shared a room with. (R30) will destroy his own property, i.e., guitar. Resident has diagnosis of Schizophrenia and may display symptoms that include but are not limited to; being out of touch with reality (delusional or hallucinations), may have disorganized speech or erratic behavior, decrease in activities. Diagnosis of mental illness. On 2/16/23 it documented, Having delusional thoughts. It continued, dated 09/30/23, Experienced delusions. On 10/12/2023, it continues, Experienced delusions. R30's care Plan did not address the altercation on 2/1/2024. R30's Care Plan, dated 8/2/2023, documented, (R30) is legally blind. He stated he was born with blindness in both eyes. (R30) qualifies for Subpart S programming to diagnosis major depression disorder, recurrent, sever, focus areas include community living, medication management and self-maintenance. Diagnosis of mental illness. At risk for abuse and neglect related psychosis, anxiety, and schizophrenia. R30's Initial Incident Report, dated 2/1/2024 at 8:30 AM, documented, Resident (R30) and (R50) entered into a verbal disagreement about (R50) working for a seed company that (R30) used to work for. The verbal argument became physical and (R30) bit (R50) on the right hand. Puncture wound/bite marks that drew blood to right hand of resident (R50). On 4/11/2024 at 9:22 AM, R30 stated, (R50) and I were roommates. (R50) was aggressive, and I am legally blind. (R50) was always threatening me and stealing my chips and candy bars. (R50) came right up into my space and I had to do something, so I bit him. I can see shadows and he was threatening me, so I bit him on the arm. They moved me downstairs now and I like it better. (R50) was always threatening me and they never did anything about it. When (R50) got close to me on my side of the room, I bit him to defend myself, he said he was going to beat me up. I did not do anything wrong. An Incident Report, dated 2/14/2024, documented, (R50) got into a verbal disagreement with roommate (R30) about working at the same seed company in the past then (R30) bit him on the right hand. Root cause: Both residents are cognitively impaired and became agitated resulting in (R50) being bit by (R30) on the right hand. Intervention: Residents were moved to separate rooms on a different hall. Supervision provided to both residents for change in status. R30's Progress Notes/Nurse's Notes did not document anything related to R30 biting R50. On 4/11/2024 at 9:32 AM, V18, Licensed Practical Nurse (LPN) stated, (R30) use to be upstairs but they moved him down here with me now. He is legally blind, and he can see shadows. When he was upstairs, he bit (R50) and then they moved him down here and I have not had any issues with him. He told me (R50) was taking his stuff and threatening him and he was defending himself. (R50) has a history of starting stuff with residents. On 4/9/2024 at 8:00 AM, all abuse investigations were requested for the past year. On 4/9/2024 at 5:15 PM, V21, Corporate Nurse stated, We had a change in Administration, and we were only able to find one abuse investigation. At this point, we do not have any other abuse investigations in the building, and we have looked in multiple places and this is all we have. I do not have any other abuse investigations. No abuse investigation for R30 was provided by the facility for the incident on 2/1/24. 2. R85's POS for April 2024, documented a diagnosis of dissociative and conversion disorder, chronic obstructive pulmonary disease, idiopathic aseptic necrosis of bone, psychoses, hypertension, peripheral vascular disease bipolar disorder, major depression, and suicidal ideations. R85's MDS, dated [DATE], documented that he was cognitively intact for decision making of activities of daily living (ADL). R85's Care Plan, dated 10/27/2022, documented, (R85) has an alteration in comfort related to idiopathic aseptic necrosis of the bone in his hip. R85's Care Plan Focus Area, dated 7/30/2022, documented, Resident reported being the recipient of verbal/physical aggression. On 8/19/2023, it documented, (R85) was on the receiving end of peer-to-peer incident. It continues, Intervention: Both residents separated and had psychosocial follow-up. On 4/16/2024 at 3:35 PM, R85 stated, I got thrown out of my wheelchair and onto the floor. (R39) is a hot head and he was mad at me in the dining room, and he can walk but I can't, and he got mad, he rushed me and threw me out of my chair. I think he would have killed me if he would have had more time. R85's Nurse Notes, dated 8/19/203 at 4:53 PM, As told by the 400 hall CNA, resident was thrown out of his wheelchair by another resident to the floor. As told by the resident he was thrown out of his wheelchair by another resident. Both residents separated from each other by staff. 911 was called. R85's Incident Report, dated 8/19/2023, documented, As told by the 400 hall CNA, resident was thrown out of his wheelchair by another resident to the floor. Both residents were separated by staff. Abrasion to left ear, upper left arm, and face. On 4/17/2024 at 3:12 PM, V2, Director of Nursing stated, We have had a lot of staff changes and I was not working at the time or the interim Administrator when this happened. On 4/17/2024 at 3:23 PM, V27, Certified Nursing Assistant (CNA), stated, I was in the dining room and (R85) bumped into (R39) and (R39) turned around and picked (R85) up and threw him out of his wheelchair and then he picked up the wheelchair and was going to try and smash his head in and I got there in time and stopped him from hitting him with the wheelchair but (R85) was slammed on the floor. It happened a while ago, and I do not remember all of the other details, but I know he wanted to smash his head in and would have if I would have not got there in time. 3. R39's Progress Note, dated 8/19/2023 at 5:38 PM, documented, Approximately 1530 (3:30 PM) this said RN (Registered Nurse) was down the hall when I heard loud voices coming from the 300 hall. I ran to assist, and that is when I saw (R85) on the floor with CNA holding (R85's) wheelchair. CNA stated that he stopped (R39) from hitting (R85) with the wheelchair, and that (R39) had thrown/knocked (R85) out of his wheelchair. I assessed the situation and called 911 believing that (R39) was still a threat to others. While on the 911 call, I notified the Administrator, DON, NP (Nurse Practitioner) for DR (doctor). The Facility's Incident Report, dated 8/19/24 at 4:19 PM, documented, Nursing Description: As told by the 400 Hall CNA resident (R85) was thrown out of his w/c (wheelchair) by another resident (R39) to the floor. Resident Description: As told by the resident he was thrown out of his w/c by another resident. Immediate Action Taken: Both residents were separated from each other by staff. No other information regarding investigation of this resident-to-resident altercation was provided by the facility when requested. R39's Face Sheet, printed 4/10/24, documented that his diagnoses were Schizophrenia, Vitamin D Deficiency, Hyperlipidemia, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Bipolar Disorder and Hypertension. R39's MDS, dated [DATE], documented that he was cognitively impaired, and has rejected care daily. R39's Care Plan, dated 11/26/18, documented, (R39) is at risk for abuse and/or neglect related to history of physical/verbal aggression, use of psychotropic medications, hallucinations/delusions, confusion/disorientation/forgetfulness, offensive anti-social habits, poor personal hygiene and DX; SCHIZOPHRENIA, BIPOLAR DISORDER, and DEMENTIA. It continues, Interventions: 1:1 counseling as needed and as resident allows. Administer medications as per MD orders. Notify MD if behaviors are worsening. If resident becomes aggressive attempt to remove resident from situation and assist him/her to a quiet place. Encourage resident to vent his/her feelings about situation. Remind resident that behavior is not acceptable. Resident is involved in anger management focus groups learning different techniques on maintaining his anger. Resident was sent to the ER for evaluated. He was admitted . Staff to encourage resident to attend daily group therapy. On 04/12/24 at 12:57 PM, V1, Administrator, stated that he has not been able to locate the investigations surveyors have requested of the resident-to-resident abuse investigations and abuse investigations. He stated he has reached out to the two previous administrators who stated the investigations should be here, but he has looked in all the file cabinets and closets and the abuse investigations are not here anywhere. 4. On 4/11/24 at 11:18 AM R50 was lying on his bed. He had a crusty yellow scab at the base right first finger with no dressing or drainage noted. R50 shook his head when asked if he had any pain in his right hand from being bit. R50's Wound Physician Note, dated 2/6/24, documented the description of the bite wound to his right hand as a full thickness open ulceration wound measuring 6-centimeter (cm) x 1.3 cm x 0.2 cm with light serous exudate that is being treated with Augmentin (antibiotic). R50's Treatment order, dated 2/6/24, documented, Silver Sulfadiazine, apply twice daily, cover with bordered gauze and wrap with kerlix. R50's Wound Physician Progress note, dated 4/9/24, documented, (R50's) wound is now a scab and he removes his dressings, so treatment was changed to skin prep daily. R50's Face Sheet, print date 4/10/24, documented that he was initially admitted to the facility on [DATE] and his diagnoses included Schizophrenia, Maxillary Fracture, Left Side, Fracture of Nasal Bones, Fracture of Orbit, Unspecified Psychosis Not Due to a Substance or Known Physiological Condition, Paranoid Personality Disorder, Unspecified Lack of Coordination, Major Depressive Disorder, Anxiety Disorder, and Insomnia. R50's MDS, dated [DATE], documented that he was severely cognitively impaired, and had no behavior symptoms during the look-back period for that assessment. R50's Care Plan, dated 8/20/20, documented, (R50) is at risk for abuse and neglect related to use of psychotropic medication, physical/verbal aggression, isolation, resistive to care, poor hygiene and diagnosis of Anxiety, Schizophrenia, Depression, and Psychosis. It continued, Interventions: 1:1 visits for emotional support as needed. It continues, Administer medications as directed by MD and monitor for possible side effects and for effectiveness. If resident becomes difficult during care, make sure resident is safe and walk away. Allow resident time to calm down, then reapproach. Keep resident safe from harm at all times. Report any suspected abuse and/or neglect immediately to Administrator. Social Services to provide information regarding Hotline, Ombudsman, Community resources and residents rights as needed. Social services to review/assess resident history and assess risk factors for Abuse/Neglect quarterly and PRN. Staff to provide education/counseling if behaviors are noted. Staff will demonstrate respectful/non-threatening approaches. R50's Progress Note, dated 2/1/2024 at 12:08 PM, documented, Resident noted with blood stains on his coat. Resident assessed for injuries and noted abrasion to right hand. MD (Medical Doctor) notified new orders clean with wound cleaner and apply Triple Antibiotic Ointment daily until healed. Resident is own responsible party. R50's Progress Notes, dated 2/4/2024 at 12:05 PM, documented, Resident on abt (antibiotic) therapy r/t (related to) bite to hand; no ase (adverse side effects) noted. Will continue to monitor. R50's Progress Notes, dated 2/9/2024 at 2:50 PM, documented, Resident changed rooms; resident notified and aware; resident own responsible party; attempted to call (R50's family) but the number was disconnected; called placed to (R50 family) with no answer; (R50 family) called and notified of room change; said he would let the family know; no concerns voiced. R50's Order Summary Report, dated 4/11/24, documented, Silvadene External Cream 1 % (Silver Sulfadiazine) Apply to Right Hand topically every day shift for To Promote Wound Healing; Telfa Non-Adherent Pad (Gauze Pads & Dressings) Apply to right hand topically every day shift for To Promote Wound Healing; Kerlix Gauze Roll Medium Miscellaneous (Gauze Pads & Dressings) Apply to right hand topically every day shift for To Promote Wound Healing. R50 Physicians order, dated 4/10/24, documented, Skin Prep Wipes Miscellaneous (Ostomy Supplies) Apply to Right Hand topically everyday shift for To Promote Wound Healing for 30 Days. On 4/10/24 at 3:00 PM, V2, Director of Nursing, stated that she has not been able to find any abuse investigations regarding abuse allegations or resident to resident physical altercations involving R50. R50's Incident Report, dated 2/1/24 at 8:30 AM, documented, Nursing Description: Resident was bit by peer RB (R30). Refused to go to the hospital. Resident Description: Resident unable to give description. Immediate action taken: Description: Immediately separated, both refused to go to the hospital. Both skin assessed. NP (Nurse Practitioner) notified. Injuries Type: No injuries observed at time of incident. This incident report also documented that R50 was alert and ambulatory without assistance. R50's Incident Report, dated 9/30/23, documented, Nursing Description: Resident was seen in bed laying down with his roommate standing over him yelling about being hit. Resident description: Stated he did not do anything to that man. Immediate Action Taken: Resident was put on a one to one; and rooms are being changed. Mental status: Oriented to person; Predisposing Environmental Factors: Other; Predisposing Physiological Factors: Non-compliant with safety guidance, recent change in cognition, and Predisposing Situation Factors: Recent room change. R50's Incident Report, dated 9/28/23 at 2:01 AM, documented, Nursing Description: CNA (Certified Nursing Assistant) shouted out to this nurse that they were fighting. This nurse entered the room and observed this resident and another punching each other in the face and chest area while in the bathroom. I attempted to close the bathroom door to cease the fighting and this resident put his feet in the door in attempts to reopen. The other resident has sat down and calmed himself at this this time. this resident was then screaming, I said turn off the lights, turn them off. I asked the resident to if he could stop screaming in attempts to not awake other sleeping residents. He then responded, Fuck you, you, you, you I will kill all you guys. Several attempts were made to redirect/calm this resident by it only agitated him even more so I allowed him space to calm himself. Resident still at this time continued screaming, making gestures and threats. Resident Description: Unable to give description. Immediate Action Taken: Residents were separated. The aggressor was escorted from the room to ensure safety of other residents. MD called/texted. Management contacted. EMS (Emergency Medical Services/Police contacted. Resident sent to Gateway for a psych eval. The incident report documented R50 is ambulatory without assistance, oriented to person, place, time and situation. Predisposing Environmental Factors: other, poor lighting. Predisposing Situation Factors: Dislikes roommate, recent room change. R50's Incident Report, dated 9/9/23 at 4:00 PM, documented, Nursing Description: resident was seen by a staff member blood on resident masked. This nurse examined all that I could. Resident was angry yelling. A scratch examined on resident nose and under eye. Resident description: Resident states a guy hit him and he fell. Resident stated he does not know who hit him. Immediate Action Taken: Skin assessed. 2 small scratches noted under his eye near his nose. Skin cleansed with normal saline. Physician, police, and resident's responsible party resident sent to ER (emergency room) for eval and treatment. Predisposing Environmental Factors: other. Predisposing Physiological Factors: confused, gait imbalance. Predisposing Situation Factors: Ambulating without assist. R50's Progress Note dated 9/9/2023 at 3:07 PM, documented, Note Text: resident was seen by a staff member blood on resident masked. This nurse examined all that I could. resident was angry yelling. a scratch was examined on resident nose and under eye. R50's Progress note dated 9/30/23 at 7:11 AM documented, Resident roommate c/o being physically assaulted by him. Resident denied allegations of abuse. Resident was yelling w/ roommate; roommate stated that he was struck by (sic); MD was notified, order was given to send resident to ED for eval of altered mental status; [NAME] PD were called to assist EMS; resident's roommate filed report; this resident refused to go to ED for eval; residents were separated immediately, this resident remains on one to one; MD made aware of changes. On 4/11/24 at 11:08, V16, LPN/Scheduler stated that she did the incident report on 2/1/24 when (R30) bit R50 on his hand but she did not witness what happened and could not remember who reported it to her. She also stated that she did provide wound care to R50's bite and that the bite did break the skin and it was bleeding. She also stated that he was followed by the wound nurse practitioner for a while because of the wound. V16 continued to state she did not know anything about R50 being hit by another resident on 9/9/23 causing facial fractures. On 4/11/24 at 11:25 AM V21, Corporate Nurse and V22, Corporate Travelling Administrator, both stated that they do not have any investigations for abuse allegations or resident to resident altercations for R50. V21 stated, We have given you (surveyors) everything we can find. We have looked everyplace for investigations and have not found them. On 4/11/24 at 11:40 AM V23, Nurse Practitioner stated that she assessed R50's wound from another resident biting him on the day after it happened. She stated the bite did break his skin and they always treat a human bite with antibiotics, but she did not feel that the wound from the bite was ever infected. She stated that R50 had prolonged healing from the bite because he is non-compliant with treatment and refuses hygiene most of the time. 04/12/24 at 12:57 PM, V1, Administrator, stated that he has not been able to locate the investigations surveyors have requested of the resident-to-resident abuse investigations and abuse investigations. He stated he has reached out to the two previous administrators who stated the investigations should be here, but he has looked in all the file cabinets and closets and the abuse investigations are not here anywhere. 5. The facility report to the State Agency, dated 3/30/24 at 12:23 PM, documented, Resident/ Victim/Perpetrator: (R63/R64) Initial Incident Description: Resident reported that he got into an argument with another resident over the food cart and the other resident poked him and hit him. Residents were separated and assessed for injury and minor injury was treated. Residents monitored to prevent recurrence. The Initial Report documents R63, as the victim and R64, as the perpetrator. The facility's Follow-up Investigation Report, undated, documented, The victim describes the incident as a disagreement over the access to the hallway meal cart during lunch. The victim states that he asked the other party to close the door to the cart and not to take food out of it. This discussion escalated to a verbal argument followed by the other resident approaching the victim and, with cupped hands, shoving his hands into the neck area of the victim and lightly poking him with a fork. Victim said there were no staff or residents present as the location was out of view of the nursing staff at the time. The victim stated that the other resident said he was allowed to access the cart. The victim displayed no expression of distress after the incident and during the follow up discussion with the Administrator on 4/1 and 4/2. He appeared to be in good spirits and expressed understanding of the other residents' initial actions due to the misunderstanding of the access allowed to the meal cart by residents. Under interview of alleged perpetrator, it documented, The resident is not cognitively able to express himself as to the intent of his actions due to a past brain injury but is alert. It continues, Based on staff interviews there were no additional reports of similar incidents uncovered involving these or other residents. A staff member did indicate that the victim has a history of directing other residents and that the alleged perpetrator coincidentally does not take direction well from other resident. It continued, Conclusion statement, Not verified. Unsubstantiated. It continues, The facility residents have diagnosis of bipolar, depressive disorders and behavior histories. The investigation uncovered the source of the altercation as a misunderstanding of the facility procedures for access to the hallway meal cart rather than a deliberate attempt by the alleged perpetrator to willfully harm the victim. The victim expressed this in his statements as well. The injury sustained by the victim were relatively minor and required basic first aid and apparently resulted from an initial verbal disagreement. Upon further discussions, the victim expressed no fear or feelings of being unsafe. Based on review of the medical records, resident history, as well as the disagreement involved and related to his need for behavior intervention plan, which is in place. At this point the police report has not been received but has been requested by the facility. If there are changes to the results of the investigation based on the content of the police report, the final report will be adjusted. R63's Face Sheet, undated, documented diagnoses included Bipolar Disorder, Current Episode Mixed, Moderate, Major Depressive Disorder, Single Episode, Unspecified and Anxiety Disorder, Unspecified. R63's MDS, dated [DATE], documented that R63 was alert and oriented and had no behaviors. R63's Care Plan dated 5/18/23, documented, Has symptoms such as mood swings, impulsive behavior and attention seeking behavior related to a diagnosis of bipolar disorder and major depression disorder. Goal: Resident will demonstrate an ability to manage affect/mood swing without difficulty at least twice/week; Resident will not have a relapse of symptoms through the next review. Interventions: Administer Medication as prescribed by the physician. Encourage and counsel on the importance of medication compliance as needed. Encourage participation in activities. Encourage participation in recommended programming. R63's Care Plan, dated 5/18/23, documented, ABUSE: (R63) is at risk for abuse and neglect r/t Bipolar Disorder, MDD, and Anxiety. It continues, Assess resident for abuse and neglect upon admission and quarterly. Continue to in-service the staff about abuse and neglect. 6. R64's Face Sheet, printed 4/12/24, documented diagnoses of Type 2 Diabetes Mellitus, Aphasia Following Non-Traumatic Subarachnoid Hemorrhage; Mixed Receptive-Expressive Language Disorder; Epilepsy, Unspecified, Intractable, with Status Epilepticus; Muscle Weakness; Bipolar Disorder; Cognitive Communication Deficit; Major Depressive Disorder; Personal History Traumatic Brain Injury; and Alcohol Abuse. R64's MDS, dated [DATE], documented that he was alert and oriented. R64's Care Plan, dated 3/30/24 documented, (R64) is at risk for abuse and/or neglect related to: history of TBI, Schizoaffective, depression, history of chemical/substance abuse, persistent anger/fear/anxiety, confusion/disorientation/forgetfulness, and poor judgement skills. Has difficulty in communications, history of verbal and physical aggression. It continues, Administer medications as directed by MD and monitor for possible side effects and for effectiveness. If resident becomes difficult during care, make sure resident is safe and walk away. Allow resident time to calm down, then reapproach. Keep resident safe from harm at all times. Provide resident with psychosocial programming for anger management. Report any suspected abuse and/or neglect immediately to Administrator. Social Services to provide information regarding Hotline, Ombudsman, Community resources and residents rights as needed. Social services to review/assess resident history and assess risk factors for Abuse/Neglect quarterly and PRN. Staff to provide education/counseling if behaviors are noted. Staff will demonstrate respectful/non-threatening approaches. It continues, 1:1 Anger management counseling with social services when res is aggressive. 1:1 counseling as needed and as resident allows. If resident becomes aggressive attempt to remove resident from situation and assist him/her to a quiet place. Encourage resident to vent his/her feelings about situation. Remind resident that behavior is not acceptable. If resident becomes upset, give him/her time to calm down before re-approaching. If resident refuses care, care giver should leave room and try again later. Separate residents as needed. Staff will ensure that each resident is safe. Staff to encourage resident to attend daily group therapy. Will be encouraged to attend Reality Awareness group. On 4/16/24 at 12:50 PM, V9, Social Service Designee, stated that they did have a point system for attending groups, but they no longer have any funding for groups and therefore there is no country store to offer the residents a place to spend their points. She stated attendance in groups has declined since they no longer have incentives to offer for attending them. She stated after residents are involved in 1:1 altercation with other residents she or her psycho-social staff do 1:1 with those residents to see if there is any post-traumatic stress following the incident and they make sure they are staying separated. She stated they are encouraged to attend psycho-social groups. V9 also stated that R63 does not attend psycho-social groups and R64 rarely attends them. On 4/17/24 at 2:55 PM V1, Administrator, stated that he did not feel abuse was substantiated in regard to the incident between R63 and R64 because, based on the facility's population, there was no willful intent to cause harm. V1 also stated that R63 likes to tell others what to do and R64 does not like anyone to direct him. V1 stated that there was superficial harm when R64 scratched R63 on the right cheek, but due to there being no intent, abuse was not substantiated. 7. Resident to resident Initial Investigation, dated 2/26/24, documented that V34, LPN heard yelling coming from the dining area. She then went to assess and noted R36 laying on her back against a chair with staff in between her and a peer. R36 then voiced that R35 had taken her bag from a table in the dining room and when R36 attempted to retrieve her belongings, R35 pushed her away and hit her. Then R35 voiced that R36 grabbed R35's hair resulting in them falling back on to chair. Attempted to call V34, LPN without answer and R36 refused interview. When R35 was asked about the incident, he didn't remember the incident. An Investigation was requested from the facility, and V1, Administrator, stated that he has called the former staff, and they were not helpful. The final report staff and resident interviews were not provided during this investigation. R35's Care Plan, dated 2/3/24, documented that R35 can be verbally and physically aggressive. R35's intervention was to remove resident from the situation and administer medications. R35's Electronic Health Record, undated, documented that R35 has the diagnoses of Schizophrenia, Unspecified Dementia, and Unspecified Psychosis. R36's MDS, dated [DATE], documented that R36 was cognitively intact. R36's Care Plan, dated 3/14/24 documented that R36 qualified for subpart S. R36 displayed difficult behavior when dealing with peers and/ or staff and by the next review, R36 will not insult or direct vulgar behavior toward staff or peers. R36's Electronic Health Record Diagnoses list, undated, documented that R36 was bipolar disorder and Schizoaffective. On 4/17/24 at 12:50 PM, V2, DON stated that if one resident takes the other residents belongings then they would Initially separate the residents and assess them for injuries and then we would monitor them for 72 hours. The Facility Abuse Policy and Prevention Program, dated 2022, documented, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, and misappropriation of property, deprivation of goods, and services by staff or mistreatment. The facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his and her safely as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including but not limited to the separation of residents. B. Based on interview and record review, the facility failed to investigate injuries of unknown origin for 2 of 2 residents (R36 and R88), reviewed for abuse of unknown origin. This failure resulted in R88's fracture of T9 and T10 not being investigated as to the cause. Findings Include: 8. R88's Nurses Note, dated 8/12/23, documented, Resident complained of lower back pain, NP (Nurse Practitioner) notified. N.O (New Order) for lidocaine patch and Xray- Lumbar and sacral spine 4 view. R88's Nurses Note, dated 8/14/23, Resident came to nurses' station and stated that she is having back pain. R88's Nurses Note, dated 8/13/23, documented, Resident returned to facility with new orders for hydro-acet 5-325 PRN q6 d/t (Hydrocodone/Acetaminophen 5milligrams (mg)-325mg) Cat Scan resu[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed notify the physician of changes related wound infections including failure to give medications and treatments as ordered for 1 of 3 residents (R4) reviewed for notification in the sample of 13. This failure resulted on [DATE], R4 was sent to the hospital and admitted with sepsis and expired on [DATE] from septic shock and bacteremia. Findings include: R4's [DATE] Physician Order Sheet, POS, documents R4 has diagnoses of Cerebral Infarction due to unspecified occlusion or stenosis of unspecified cerebral artery; Generalized anxiety disorder; Alcohol abuse, insomnia; Anemia; hyperlipidemia; Vitamin deficiency; Hypertension, Schizoaffective disorder; Major depression disorder, and other skin changes. R4's Care Plan with a Focus Area of Skin: documents, (R4) is at risk for skin complications related to Anemia, psychotropic medications. (R4) has no open areas to skin. Date [DATE]. (R4) has open areas, are to left lower leg and left dorsal foot dated, [DATE]. No open area was documented in the Care Plan before [DATE]. R4's Nurse's Notes dated [DATE] at 11:34 AM. Late Entry: Note Text: Resident noted with swollen lower left leg. MD (Medical Doctor) notified new order venous doppler lower left leg. R4's Nurse's Notes dated [DATE] at 1:56 PM, Note Text, Medical diagnostic services arrived. Venous doppler lower leg completed. R4's Radiology Results dated [DATE] document Left lower extremity venous doppler ultrasound, Reason: Swelling, left lower leg. R4's Nurse's Notes dated [DATE] at 3:12 PM, Note Text: results negative for DVT, Doctor notified, new order cefixime (antibiotic) 200 milligrams (mg) by mouth two times a day for 10 days. There was no documentation on R4's [DATE] Medication Administration Record (MAR) for cefixime 200 mg by mouth two times a day, for 10 days with a start date of [DATE]. There was no documentation R4 started receiving this medication on [DATE]. There was no documentation V22, R4's Physician, was notified of why R4's antibiotic was not initiated on [DATE]. On [DATE] at 1:15 PM, V18, Licensed Practical Nurse (LPN) stated, When I talked with (V17, Nurse Practitioner) she gave me an order and I received the order for the antibiotic (cefixime) but when I went to put it on the system, I got a red flag because of possible drug allergy, and I could not enter the medication in the system. I called (V17) back to let her know what was going on and I told (V7), Wound Nurse that I could not put the order in and (V7) told me not to worry about and he would take care of it. I only did treatment on (R4's) leg once before it had opened up. The wound actually started on his foot. Any wound notes would be documented in the Nurse's Notes. There was no documentation on R4's [DATE] MAR that R4 received Cefixime, 200 mg, twice daily from 9/14 through [DATE]. This would be 10 doses of antibiotic. There was no documentation of R4's physician, V22, being notified that R4 missed 10 doses of Cefixime from 9/14 through [DATE]. R4's Nurse's Notes dated [DATE] at 11:54 AM, Late Entry: Note Text: Resident has discoloration to left lower leg and weeping dorsal left foot. Resident states he does not know how his leg became discolored. MD (Medical Doctor) notified new order resident started on Cefixime 200 mg BID x 10 days to promote wound healing. This Nurse's Note was created on [DATE] as a late entry at 11:58 AM by V7, Wound Nurse. R4's [DATE] MAR documented R4's antibiotic order for Cefixime oral tablet chewable, 200 mg, give 200 mg by mouth two times a day to promote wound healing for 10 days. This was the same order which was given by V22 on [DATE]. R4's original order was not initiated and therefore, the antibiotic was not started, and was reordered again on [DATE]. There was no documentation in R4's medical record that V31, Wound Physician, was notified of the deterioration R4's left leg. R4's Nurse's Notes dated [DATE] at 12:07 PM, Late Entry: Note Text: MD (Medical Doctor) notified r/t (related to) left lower leg deteriorating. Awaiting orders. R4's Wound Evaluation and Management Summary Report dated [DATE] (11 days later) documents Patient has wound on his left anterior leg, left dorsal foot. Etiology (quality: infection), Wound of the left, anterior leg full thickness, etiology: Infection, duration: less than 7 days; wound size Length 20 x width 12 x Diameter 0.6 centimeters (cm), Surface area 250.00 CM2; exudate moderate serous, thick adherent devitalized necrotic tissues: 100 %. Dressing treatment plan Sodium hypochlorite solution (Dakin's) apply twice daily for 30 days: ½. Secondary dressing (s) Gauze roll (kerlix) 4.5 inches apply twice daily for 30 days. A surgical excisional debridement procedure was performed that day to the left, anterior leg. The Report also documents a wound of the left, dorsal foot, Etiology (quality) infection, full thickness, etiology: Infection, duration: less than 7 days; wound size length 10 x width 8 x diameter 0.9 cm, exudate: moderate serous, thick adherent devitalized necrotic tissues 100%. Primary dressing Sodium hypochlorite solution (Dakin's) apply twice daily for 30 days, Secondary dressing gauze roll (kerlix) 4.5 apply twice daily for 30 days. Recommendations: Antibiotic choice Bactrim DS (double strength) 1 tablet by mouth two times a day for 14 days. A surgical excisional debridement procedure was performed that day to the left dorsal foot. On [DATE] at 11:18 AM, V31, Wound Doctor stated, By the time I was notified of (R4's) wound it was already really bad. I am not sure why they even waited so long for me to see him. The size of this wound was not something that would just appear overnight. His whole left leg was a big bag of pus. I had never seen anything like it. I started seeing him and ordered a culture and was trying to treat it. I only saw him twice and I was supposed to see him again, but he was out at the hospital at that time. I would expect that all my orders to be followed including medication, monitoring, vital signs, temperatures all of that should have been done. If temperatures were being done it could have been an indication that the infection was progressing, and he could have been sent out sooner. I think in this case there was a delay in treatment. I remember even speaking with (V2) about how bad the wound was on (R4) and to watch for signs of infection. The facility should have been monitoring (R4) more closely. On [DATE] at 8:33 AM, V7, Wound Nurse stated, (R4's) leg issue started as a bump and then an abscess. His foot was always dry, and he had bad dry skin. I am not sure what happened with his foot. I did not notice anything before he was sent out. I did his last treatment on Friday, and he was sent out to the hospital on Monday. When I am not here the floor nurse will do the treatments. I was not aware he was having any issues before he was sent out. On [DATE] at 9:12 AM, V17, Nurse Practitioner stated, If a resident has an infection/wound we would turn that over to the Wound Doctor and expect the facility to be following the Wound Doctor's orders. With any infections I would expect staff to actually be looking at the wound, applying the treatments, changing the dressings, monitoring the wound, taking vitals and temperatures every day to ensure and documenting in the TAR and watching for any changes. I cannot get into (R4's) chart from here as I am not at the facility, but if we sent an order, I would expect it be followed and communicated to us if it was not given in a timely manner. The Facility Notification Intervention and Reporting Policy with a Revision date of 2/2020 documents, The center will notify the resident's physician and the resident's representative whenever: there is a significant change in the resident's health, mental or psychosocial status there is a change in the resident's condition that although not significant is prudent to report using good nursing judgment. There is a need to significantly alter or discontinue treatment because of adverse consequences. Document in the nurse's notes: A description of the change in condition/incident/accident/unusual occurrence. Results of any assessment performed. Description of any care or emergency measures performed. Notification of the physician including what was reported to the physician and physician response including whether new orders were received. Notification to resident and/or resident's representative. Follow up assessment and care as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility neglected to ensure residents were receiving timely assessment, monitoring, and treatment to address wounds and wound infections for one of three residents (R4) reviewed for neglect in the sample of 13. This failure resulted in R4 not receiving an antibiotic as ordered on [DATE] which delayed treatment of an infection, not receiving ordered wound treatments, not having timely assessments, and monitoring of his left leg which resulted in the development of two large infected necrotic wounds, and not monitoring the overall condition of R4 during his treatment of the infection. On [DATE], R4 was sent to the hospital and admitted with sepsis and expired on [DATE] from septic shock and bacteremia. Findings include: The Abuse Policy 2022 documents The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods, and services by staff or mistreatment. The facility 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. The policy documents Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, or mental anguish. (42 CFR 483.5). Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish or mental illness of a resident. R4's [DATE] Physician Order Sheet, POS, documents R4 has diagnoses of Cerebral Infarction due to unspecified occlusion or stenosis of unspecified cerebral artery; Generalized anxiety disorder; Alcohol abuse, insomnia; Anemia; hyperlipidemia; Vitamin deficiency; Hypertension, Schizoaffective disorder; Major depression disorder, and other skin changes. R4's Nurse's Notes dated [DATE] at 11:34 AM. Late Entry: Note Text: Resident noted with swollen lower left leg. MD (Medical Doctor) notified new order venous doppler lower left leg. R4's Radiology Results dated [DATE] document Left lower extremity venous doppler ultrasound, Reason: Swelling, left lower leg. Findings: There is no intraluminal filling defect demonstrated. Findings: Negative for DVT. R4's Nurse's Notes dated [DATE] at 2:15 PM Note Text: medical diagnostic faxing results of venous Doppler lower leg. R4's Nurse's Notes dated [DATE] at 3:12 PM, Note Text: results negative for DVT (deep vein thrombosis), Doctor notified, new order cefixime (antibiotic) 200 milligrams (mg) by mouth two times a day for 10 days. There was no documentation on R4's [DATE] Medication Administration Record (MAR) for cefixime 200 mg by mouth two times a day, for 10 days with a start date of [DATE]. There was no documentation R4 started receiving this medication on [DATE]. On [DATE] at 1:15 PM, V18, Licensed Practical Nurse (LPN) stated, When I talked with V17, Nurse Practitioner she gave me an order and I received the order for the antibiotic (cefixime) but when I went to put it on the system, I got a red flag because of possible drug allergy, and I could not enter the medication in the system. I called (V17) back to let her know what was going on and I told (V7), Wound Nurse that I could not put the order in and (V7) told me not to worry about and he would take care of it. I only did treatment on R4's leg once before it had opened up. The wound actually started on his foot. Any wound notes would be documented in the Nurse's Notes. There was no documentation on R4's [DATE] MAR, R4 received Cefixime, 200 mg, twice daily from 9/14 through [DATE]. This would be 10 doses of antibiotic. On [DATE] at 11:01 AM, V7, Wound Nurse stated, I was out the week of [DATE] and I only remember vaguely of what happened. In our computer system PCC (Point Click Care) if an allergy pops up the system will not let you enter that particular order, and it is not transferred to the MAR. We were waiting for confirmation from the physician because of the drug allergy. Again, I vaguely even remember that week. I would expect all notes and wound notes and descriptions and doctor conversations to be documented in the Nurse's Notes. I can see there are no notes for the reason the antibiotic was not given timely. R4's Nurse's Notes does not document any wound notes or description of R4's left leg from [DATE] to [DATE]. R4's Nurse's Notes dated [DATE] at 11:54 AM, Late Entry: Note Text: Resident has discoloration to left lower leg and weeping dorsal left foot. Resident states he does not know how his leg became discolored. MD (Medical Doctor) notified new order resident started on Cefixime 200 mg BID x 10 days to promote wound healing. This Nurse's Note was created on [DATE] at 11:58 AM by V7, Wound Nurse. R4's [DATE] MAR documented R4's antibiotic order for Cefixime oral tablet chewable, 200 mg, give 200 mg by mouth two times a day to promote wound healing for 10 days. This was the same order which was given by V22 on [DATE]. R4's original order was not initiated and therefore, the antibiotic was not started, and was reordered again on [DATE]. On [DATE] at 12:55 PM, V30, Pharmacist stated, We did not receive any order for cefixime until [DATE] and then we filled that order. I looked at all of the faxes and orders and we did not receive this order until [DATE]. I do not have an order for [DATE]. R4's Nurse's Notes dated [DATE] at 7:28 PM, documents, Note Text, Cefixime oral started on this day due to medication in refrigerator, not aware that medication was in refrigerator. R4's Medication Administration Records (MAR) for [DATE] documents Cefixime was given on [DATE] at 8 AM, but no dose was given at 8 PM. On [DATE], R4 missed his 8:00 PM dose. On [DATE], R4 missed both his 8:00 AM and 8:00 PM dose. On [DATE] at 2:37 PM, V18, Licensed Practical Nurse (LPN) stated, I saw (R4) had an order for the antibiotic and I was looking everywhere for it and could not find it. The POS documents an oral tablet chewable. I called the pharmacy, because I could not find it anywhere and they said the medication had been delivered. Finally, we figured out the medication was not in a pill form but rather it was in a liquid. There was a delay in the medications because of the confusion and the order did not say it was in liquid form, but rather oral form and it was in the refrigerator. There was no documentation in R4's medical record from 9/19 to [DATE] as to the condition of R4's left leg. R4's Nurse's Notes dated [DATE] at 12:07 PM, Late Entry: Note Text: MD (Medical Doctor) notified r/t (related to) left lower leg deteriorating. Awaiting orders. R4's Wound Evaluation and Management Summary Report dated [DATE] (11 days later) documents Patient has wound on his left anterior leg, left dorsal foot. Etiology (quality: infection), Wound of the left, anterior leg full thickness, etiology: Infection, duration: less than 7 days; wound size Length 20 x width 12 x Diameter 0.6 centimeters (cm), Surface area 250.00 CM2; exudate moderate serous, thick adherent devitalized necrotic tissues: 100 %. Dressing treatment plan Sodium hypochlorite solution (Dakin's) apply twice daily for 30 days: ½. Secondary dressing (s) Gauze roll (kerlix) 4.5 inches apply twice daily for 30 days. A surgical excisional debridement procedure was performed that day to the left, anterior leg. The Report also documents a wound of the left, dorsal foot, Etiology (quality) infection, full thickness, etiology: Infection, duration: less than 7 days; wound size length 10 x width 8 x diameter 0.9 cm, exudate: moderate serous, thick adherent devitalized necrotic tissues 100%. Primary dressing Sodium hypochlorite solution (Dakin's) apply twice daily for 30 days, Secondary dressing gauze roll (kerlix) 4.5 apply twice daily for 30 days. Recommendations: Antibiotic choice Bactrim DS (double strength) 1 tablet by mouth two times a day for 14 days. A surgical excisional debridement procedure was performed that day to the left dorsal foot. On [DATE] at 11:18 AM, V31, Wound Doctor stated, By the time I was notified of (R4's) wound it was already really bad. I am not sure why they even waited so long for me to see him. The size of this wound was not something that would just appear overnight. His whole left leg was a big bag of pus. I had never seen anything like it. I started seeing him and ordered a culture and was trying to treat it. I only saw him twice and I was supposed to see him again, but he was out at the hospital at that time. I would expect that all my orders to be followed including medication, monitoring, vital signs, temperatures all of that should have been done. If temperatures were being done it could have been an indication that the infection was progressing, and he could have been sent out sooner. I think in this case there was a delay in treatment. I remember even speaking with V2 (Director of Nursing-DON) about how bad the wound was on (R4) and to watch for signs of infection. The facility should have been monitoring (R4) more closely. R4's Nurse's Note dated [DATE] at 2:58 PM, Note Text: MD was notified of open area to left lower leg and dorsal foot new orders Bactrim DS (double strength) BID (two times a day) x 14 days, and Clean open areas with wound cleaner apply soaked Dakin's 1/2 strength 4x4 to wound bed and cover with ABD (abdominal gauze pad) and kerlix BID x 14 days. R4's [DATE] Treatment Administration Record (TAR) documents an order for Dakin's (1/2 strength) external solution (sodium hypochlorite), Apply to left leg and foot topically two times a day related to other skin changes for 14 days. R4's [DATE] TAR documents R4 did not receive this treatment at 5:00 PM on 9/27, 8:00 AM and 5:00 PM on 9/28 and 9/29 and at 8:00 AM on [DATE]. The order regarding a 4 x4 to R4's wound bed and cover with ABD and kerlix BID x 14 was not transcribed to R4's [DATE] TAR and therefore was not documented as completed. R4's [DATE] TAR, documented an order for Dakin's (1/2 strength) external solution (sodium hypochlorite), apply to left leg and foot topically two times a day related to other skin changes for 14 days. There was no documentation R4 received this treatment at 8:00 AM on 10/1 and on [DATE] at 5:00 PM. The order regarding a 4 x4 to R4's wound bed and cover with ABD and kerlix BID x 14 was not transcribed to R4's [DATE] TAR and therefore was not documented as completed. There was no documentation in R4's medical record that V22 (Medical Director) or V31 were notified that R4 did not receive the treatments in September and [DATE]. R4's Wound Evaluation and Management Summary Report dated [DATE], documents, Patient has wounds on his left anterior leg; left dorsal foot; right second toe. At the request of the referring provider, V22, Medical Director, a thorough wound care assessment and evaluation was performed today. He has condition(s) as listed above. Details about current wound(s) and any skin conditions are outlined below. There is no indication of pain associated with this condition. (Site 1 was not documented), Focused Wound Exam (Site 2); Wound of the left, anterior leg full thickness. etiology: Infection, duration: less than 13 days; wound size Length 15.5 x width 8 x Diameter 0.6 centimeters (cm), Surface area 124.00 CM2; exudate moderate serous, thick adherent devitalized necrotic tissues: 70 %, granulation tissues 30%. Dressing treatment plan Sodium hypochlorite solution (Dakin's) apply twice daily for 23 days: ½. Secondary dressing (s) Gauze roll (kerlix) 4.5 inches apply twice daily for 23 days. A surgical excisional debridement procedure was performed that day to the left, anterior leg. Site 3, Wound of the left, dorsal foot full thickness, etiology: Infection, duration: less than 13 days; wound size Length 5 x width 7.5 x Diameter 0.9 centimeters (cm), Surface area 37.50 cm2; exudate moderate serous, thick adherent devitalized necrotic tissues: Wound progress: improved by decreased surface area. Site 4: Arterial wound of the right, second toe full thickness. Etiology arterial, duration less than 2 days, wound size length 0.5 x width x1 x diameter 01.cm. Surface area .50 cm2, exudate moderate serous, granulation tissue 100%. Alginate calcium apply once daily for 30 days, Betadine apply once daily for 30 days. Secondary dressing Gauze roll (kerlix) 4.5 inches apply once daily for 30 days. R4's wounds have increased from one area to three or four areas. R4's wounds were documented as improved evidenced by decreased necrotic tissue, and decreased surface area however, R4 now had a new wound on his right, second toe. R4's [DATE] does not document any treatment regarding the new wound to R4's right second toe although V31 saw R4 on [DATE] and ordered Alginate calcium to be applied once daily for 30 days, Betadine applied once daily for 20 days with gauze roll (kerlix). There is no documentation that this treatment was being completed by the facility. R4's [DATE] POS documents an order for Bactrim DS (double strength), oral tables 800-160 mg, 1 tablet by mouth two times a day, related to other skin changes for 14 days, with an order date of [DATE]. The MAR documents R4 did not receive the Bactrim on [DATE] at 8:00 AM. R4's September and [DATE] MAR and TAR does not document any order for vital signs to be being taken daily or for R4 to be monitored for infection and antibiotic use. R4's vital signs were not documented in R4's medical record every day for R4 even though he had an infection. For [DATE], R4's temperatures were taken on [DATE] and [DATE]. No vitals were available from [DATE] to [DATE] in R4's medical record. No blood pressure, oxygen saturations, pulse, or temperature were documented for seven days prior to R4 going to the hospital. R4's Progress Notes dated [DATE] at 7:13 AM, This nurse upon entering patient's room noted resident eyes closed and restless. Spoke to resident good morning, resident moaning, noting being lethargic, decreased verbalization, no clear speech, mumbling. Resident baseline is alert and orientated x 3. Able to make needs known. Resident made no eye contact at this time. Does not verbalize and physical stimuli; notes pale color unable to obtain vitals, patient movements. Management team notified transferring resident to the hospital for evaluation. Facility medical team notified. Transferring resident to the hospital. Emergency Report given to nurse at hospital. On [DATE] at 10:33 AM, V6, Licensed Practical Nurse (LPN) stated, (R4) was usually alert and oriented x 3. He transferred to my side of the building on Friday. On Friday he was doing good, sitting on the side of the bed, making jokes. The last time I saw him was on Friday around 3:20 PM and he was fine. I don't work the weekends and when I came in on Monday, he had a change of condition and I sent him out. Nobody told me anything about his decline and I don't know when it started but when I started my shift and went to say hello he was not responding. I immediate sent him out. On [DATE] at 9:24 AM, V21, Hospital Nurse stated, When patients come into the hospital it is very important for us to know if they are not cognitively intact or confused, to know if this is the normal or if this not their normal, how long have they been like this. This is a good indicator of a stroke for example, so we need to know whenever there is an altered mental status. When (R4) arrived, he was not able to answer any questions and was not alert. We were told this was not his baseline and he is normally alert x 3. I personally called the facility to try and find out how long and when this condition started that he was no longer alert and orientated. I talked with 3 different staff members, and nobody could tell me the last time anybody laid eyes on him and how long he had been like this, when this started. I find this very concerning because staff should know these things. R4's Hospital Records dated [DATE] at 9:12 AM, [AGE] year old male, NH (Nursing Home) resident with past medical history significant for HLD (hyperlipidemia), CAD (Coronary Artery Disease), HTN (Hypertension), psychiatric history, schizoaffective disorder, CVA (Cerebral vascular accident), (no motor deficits, baseline AO (alert and orientated x 3) at baseline now x1 on arrival, hypoglycemia with initial glucose recorded at 42, severe macrocytic anemia, hypotension, hypothermia and other lab findings, consistent with severe sepsis. On admission he was initially responding to painful stimuli only, now AO x 1, moving all extremities. R4's admission Hospital Records document on [DATE] at 9:00 AM, (R4) is a [AGE] year-old male with history of hypertension, CAD, HLD, schizoaffective disorder, history of CVA. He was sent from nursing home yesterday with AMS (Altered Mental Status); it was reported that he is AAOx3 at baseline and was AAOx1 prior to transfer. He also was hypoglycemic with Blood sugar of 42 and has been anemic with hypotension/hypothermic. On admission HG (hemoglobin) at 5.5, PH 7.1, LA was around 5, noted AKI with CR of 4.2 He is lethargic/sleeping and not much communicative. He has a bad wound over the left leg. His BP (Blood pressure) when I saw him this AM blood pressure was 102/51 (Normal 120/80). Reason for admission: Shock. R4's Death Certification dated [DATE] documents: Cause of death septic shock and bacteremia. On [DATE] at 8:33 AM, V7, Wound Nurse stated, (R4's) leg issue started as a bump and then an abscess. His foot was always dry, and he had bad dry skin. I am not sure what happened with his foot. I did not notice anything before he was sent out. I did his last treatment on Friday, and he was sent out to the hospital on Monday. When I am not here the floor nurse will do the treatments. I was not aware he was having any issues before he was sent out. On [DATE] at 11:01 AM, V32, LPN stated, I did wound treatments on (R4) over the weekend before he was sent out. I am not aware of any issues. I don't remember anything. V32, Licensed Practical Nurse (LPN) was documented as the charge nurse working on Saturday, [DATE], and Sunday, [DATE]. On [DATE] at 9:11 AM, V7 stated, I was not here working when (R4) went out to the hospital so I cannot say what happened. I know, I get a lot of complaints from residents when I do not work but I cannot be here 24 hours a day, seven days a week. I have been told by the residents, multiple times that nobody is doing wound treatments over the weekends. I would consider missing wound treatments to be a bad thing and not good for the resident. On [DATE] at 9:12 AM, V17, Nurse Practitioner stated, If a resident has an infection/wound we would turn that over to the Wound Doctor and expect the facility to be following the Wound Doctor's orders. With any infections I would expect staff to actually be looking at the wound, applying the treatments, changing the dressings, monitoring the wound, taking vitals and temperatures every day to ensure and documenting in the TAR and watching for any changes. I cannot get into (R4's) chart from here as I am not at the facility, but if we sent an order, I would expect it be followed and communicated to us if it was not given in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide behavioral health service for mental illness to maintain/improve resident's psychosocial well-being for 1 of 3 residents (R2) reviewed for behavioral health services for mental illness in the sample of 14. This resulted in R2 having ongoing behaviors of self-harm, suicidal ideations, impulsive and explosive verbal and physical aggression resulting in recurrent emergency room evaluation and treatment. Findings include: R2's Face Sheet documents that resident was admitted on [DATE]. R2's Illinois PASRR (Preadmission Screening and Resident Review) Summary of Findings, dated 4/17/22, documents R2 has been diagnosed with an Intellectual Disability. R2 was approved for short term/120 days at this Nursing Facility Level of Care. The PASRR also documents that R2 will require Rehabilitative Services and/or Supports of Pharmacotherapy, including administration and monitoring of the effectiveness and side effects of medications which have been prescribed to change inappropriate behavior or to alter manifestations of psychiatric illness. This further explains that Medication Management can help the resident take medication correctly. The provision of a structured environment for those individuals who are determined to need such structure (e.g., structured socialization activities to diminish tendencies toward isolation and withdrawal). It further explains that a resident should take part in social activities to help with depression and anxiety. The development, maintenance, and consistent implementation across settings of those programs designed to teach individuals daily living skills necessary to become more independent and self-determining including, but not limited to, grooming, personal hygiene, mobility, nutrition, vocational skill, health, drug therapy, mental health education, money management, and maintenance of the living environment. It further explains that Psychiatric education on your disorder and medications, Crisis intervention services or plan, a safety and crisis plan will help your nursing home staff if you have thoughts of hurting yourself, Individual, group, and family psychotherapy, Counseling from a therapist or counselor could help you learn coping skills. It further explains that you enjoy sports, such as, football and kickball, you like playing games, a good day is Good things make my day good. Nice day walking outside stuff like that. R2's Physician Order dated 8/14/18 documents Unspecified recurrent Major Depressive Disorder, unspecified Schizophrenia, and unspecified bipolar disorder. R2's Physician Order dated 04/19/22 documents Major Depressive Disorder, single episode, unspecified. R2's Physician Order dated 09/14/22 and discontinued 12/07/22 documents May be seen by Psychiatrist/Psychologist. R2's Minimum Data Set (MDS) dated [DATE] documents that resident has Brief Interview for Mental Status (BIMS) score 15 out of 15 indicating R2 is cognitively intact. R2's MDS documents R2 had the following behaviors 1 to 3 days: physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, and abusing others sexually). R2's MDS documents R2 had behavior of this type occurred 4 to 6 days: verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). The MDS documents that R2 is at significant risk for physical illness or injury, significantly interfere with the resident's care, and significantly interfere with the resident's participation in activities or social interactions. The MDS documents that R2's symptoms put others at significant risk of physical injury, significantly intrude on the privacy or activity of others, and significantly disrupt care or living environment. The MDS documents that R2 had the following behaviors 4 to 6 days: rejection of evaluation or care. The MDS documents that R2 had the following behavior daily: wandering. The MDS documents that R2's wandering places the resident at significant risk for getting to a dangerous place (e.g., stairs, outside of the facility) and the wandering significantly intrude of the privacy or activities of others. R2's Care Plan dated 11/22/22 documents (R2) can become verbally and physically aggressive when he does not get his way. 05/02/22 verbal and physical aggression towards staff. 05/04/2022 (R2) was verbally aggressive with staff/peer. 05/07/2022 res was Verbally aggressive with staff. 05/24/22 (R2) got into a verbal and physical altercation with another resident. 04/25/22 Physical altercation (R2) threw a picture frame in the hallway and hit another resident. 04/25/22 Verbal aggression in the evening time 06/04/22 (R2) will call 911 06/07/22 (R2) punched a hole in the wall on 400-hall. 06/11/22 verbal and physical aggression 07/08/22 (R2) was verbally aggressive towards staff. 07/09/22 (R2) punched a staff member in the face. 07/25/22 (R2) was throwing chairs at staff members on evening shift and was chasing staff members. (R2) was sent out to hospital for evaluation. 10/25/22 (R2) became upset and punched the glass cabinet. Interventions: 04/25/22 Encouraged to use phone in the privacy of his room. 04/25/22 R2 was informed that it is unacceptable behavior to throw objects. 1:1 counseling as needed and as resident allows. 4/25/22 R2 transferred to Hospital for evaluation. Upon return from hospital, discussed with R2 to contact his guardian about placement at facility. 5/2/22 Encourage R2 to allow staff time to retrieve items he is requesting. 5/24/22 Staff to encourage (R2) when he has problem with peer to notify staff to assist. R2 moved to another hall. 5/4/22 If R2 becomes upset, give him time to calm down then re-approach. Staff to allow R2 to vent feelings. Administer medications as per MD (physician) orders. Notify MD if behaviors are worsening. Call R2's guardian to see if he can assist in calming (R2). Staff to encourage R2 to attend daily group therapy. If R2 becomes aggressive attempt to remove resident from situation and assist him/her to a quiet place. Encourage R2 to vent his/her feelings about situation. Remind R2 that behavior is not acceptable. If R2 refuses care, care giver should leave room and try again later. Separate residents as needed. Staff will ensure that each resident is safe. R2's Care Plan does not address engaging R2 in activities that interest him as identified on PASRR to proactively occupy R2 or use those activities to distract and engage R2. No new interventions added for aggression noted on 05/28/22, 06/22/22, 07/02/22, 07/25/22 x 2, 08/05/22, 09/05/22, 09/06/22, 09/24/22, 12/04/22, 12/11/22, and 01/05/23. R2's Nurse's Note, dated 4/24/22 at 3:37 PM, documents an incident of verbal aggression with R8 and they were separated. R2 began punching walls and throwing objects down the hall. R2 then eloped from facility with staff member right behind and was redirected back to the building by staff member. R2 sent out to hospital per V19, Physician, orders. R2's Nurses Note, dated 4/24/22 at 6:50 PM, documents R2 returned from hospital with no new orders, did not meet criteria to be admitted . R2's Nurses Note, dated 4/25/22 at 12:32 PM, documents R2 exited building with 1:1 staff following behind him. Able to redirect resident back to the facility with difficulty. R2 made suicidal and homicidal statements. R2 sent to ER (Emergency Room) per MD order. There was nothing further documented after arrival back to facility. R2's Nurses Note, dated 4/25/22 at 2:21 PM, documents R2 sent to ER per (V19, Physician) for aggressive behavior toward residents and staff, throwing objects down hall, eloped outside to parking lot, hitting and beating on staffs' cars in the parking lot, unable to redirect, ambulance and police called to transfer resident. R2's Nurses Note, dated 4/26/22 at 11:21 AM, documents R2 returned to facility. R2 told staff he would slap someone. R2 became upset after phone call with family member and threw phone down while in administrator's office. Hall monitor redirected resident to calm down because he would not be able to go into hallway while being aggressive. R2 threw himself against wall. R2 sent to ER per V19, Physician, order with assist of police. R2's Nurse's Note, dated 5/2/22 at 9:47 PM, documents R2 became verbally and aggressive. R2 expressed he wanted a blanket and pillow sooner. R2 set off door alarm and walked away from door, R2 knocked off covering to exit sign. Attempts to redirect resident resulted in R2 verbally aggressive again. R2 expressed self-harming thought. Upon R2 receiving the items he wanted, went back to room. R2 more calm. R2 stated he was mad he wanted the items, but he didn't know that the hall monitor had already went to get them items for him. R2 stated he wasn't going to do anything to himself, he was just mad. Behaviors addressed with R2 and discussed the proper way to handle things. R2 will continue on frequent checks throughout the night. The Facility's Final IDPH Incident and/or Abuse Notification, dated 5/4/22, documents On 5/4/22 an altercation occurred involving (R2), a [AGE] year-old male with a diagnosis of Bipolar, and (R6), a [AGE] year-old male with a diagnosis of Schizophrenia. (R2) was sitting at the nursing station talking with nurse while charging his phone. At the same time, (R6) wheeled up and started being verbally aggressive towards the nurse. It was reported that when (R6) became aggressive with the nurses, (R2) told him You shouldn't talk to women that way. (R6) reacted to (R2) comment and became aggressive towards him, resulting in a physical altercation with both residents making contact with each other. R2 was sent out to ER. R2's One to One Sheet, dated 05/06/22 started at 6:00 AM and ended at 5:40 am on 05/07/22. R2's Nurses Notes dated 05/06/22 at 2:03 PM documents R2 returned from hospital via cab. R2's Nurses Notes dated 05/07/22 at 8:07 PM documents (R2) voiced to this nurse that CNA was lying on him, he voiced that the CNA asked him to stop taking pictures of her, (R2) voiced that he wasn't taking pictures. Became verbally aggressive voicing that she is picking on him and he wants to leave, he doesn't feel safe here with female staff, asked this nurse if he could go to the hospital because he doesn't want to be here. This nurse called (V19), Psychiatrist gave orders for 1:1 with male staff. There was no documentation in R2's medical record of a One to One Sheet for 05/07/22. R2's Nurses Note dated 05/21/22 at 7:49 PM documents (R2) eloped out of the dining room exit door, alarm didn't sound. Hall monitor voiced that he attempted to go out of the smoke door on 100-hall redirected by staff to come back to 300-hall, as (R2) walked back to this side he exited out of the dining area door. Staff members saw (R2) from 100 hall exit door walking across the parking lot, while walking away from the building (R2) being to cut his right arm with a butter knife, staff followed him and redirected him back into the facility as he's walking back into the facility he threw the knife. Once in the facility he's placed on 1:1, multiple superficial cuts noted to the right arm, areas cleaned with w/c and triple antibiotic cream applied, no bleeding noted. (R2) sat down and talked with this nurse and voiced that he's just frustrated that he's not able to see his pregnant girlfriend, this nurse asked him if he used any coping skills when he gets upset and emotional like this he voiced no, this nurse gave suggestions on things he can do, he voiced understanding. (R2) voiced that he's still feeling suicidal, and he wants to go to the hospital. R2 was sent to ER to evaluate and treat. There was no documentation in R2's medical record of a One to One Sheet for 05/21/22. R2's Nurse's Note, dated 5/28/22 at 8:36 PM, documents R2 became upset when asked to put mask on, verbally aggressive toward staff, broke a plate, pulled hand sanitizer off the wall throwing things, unable to redirect, sent to ER for evaluation per V13, MD. There was nothing documented in R2's Care Plan related to his aggressive behavior on 5/28/22. R2's Nurses Notes dated 06/06/22 at 10:42 AM documents R2 on 1:1 for behaviors. There was no documentation in R2's medical record of a One to One Sheet for 06/06/22. R2's Nurses Note, dated 6/7/22 at 3:05 PM, documents R2 brought cell phone with V19, Physician, on the line. R2 sent to ER for evaluation and treatment related to suicidal thoughts per V19 order. R2's Nurses Note, dated 6/11/22 at 8:11 PM, documents Resident told this nurse that he called police because he did not want to be here. At 5:20 PM, Resident was lying on the floor telling other residents he could not breathe. When this nurse went to assess him he became verbally abusive and started breaking the sanitizer dispensers on the wall on 400-hall. At 5:23 PM, Resident went out of 400-hall exit door and started exiting through the doors in the building. Resident was walking around the parking lot while staff was trying to get him back into the building. R2 sent to ER per V19, Physician. R2's Nurses Notes dated 06/15/22 at 10:54 AM documents R2 continue on 1 to 1 observation. There was no documentation in R2's medical record of a One to One Sheet for 06/15/22. R2's Nurses Note, dated 6/22/22 at 3:08 PM, documents R2 throwing tables in the dining room, hitting the windows, threatening staff members. Unable to redirect. Sent to ER. R2's Nurse's Note, dated 7/2/22 at 9:22 PM, documents R2 yelling cursing at staff, walking up and down the hallway to the dining room, pulling pictures off the wall, slamming tables down in the dining room unable to redirect, 1:1 in place, called ambulance and police. There was no documentation in R2's medical record of a One to One Sheet for 07/02/22. R2's Nurses Notes dated 07/05/22 at 2:37 PM, documents R2 arrived at facility as readmit from hospital. R2's One to One Sheet documents starting 07/05/22 at 6:00 AM through 07/06/22 at 5:40 AM. R2's Nurse's Note, dated 7/25/22 at 2:21 PM, documents R2 flipping tables and chairs in the dining room, knocking things off the table. R2 mad that he overheard a staff ask if it was okay for R2 to be off the hall due to COVID isolation restriction. Was able to redirect residents and calm R2 down and address his concerns. R2's Nurses Note, dated 7/25/22 at 6:15 PM, documents R2 in dining room throwing chairs and tables, chasing staff, and being combative. R2 stated staff asked him to return to room and he got upset. Sent to ER for psychiatric evaluation per V19. R2's Nurses Notes dated 07/28/22 at 8:03 PM, documents This nurse notified that (R2) was attempting to leave from exit door in the kitchen, this nurse noted that (R2) was running away from the exit door and slipped on a wet spot. He got up in a hurry and picked up a chair and swung it multiple times at staff. (R2) threw the chair down and exited from kitchen door, alarm sounded, staff stayed with (R2) this nurse called 911, (R2) redirected back on to the facilities parking lot. (local police department) arrival, (R2) is calm and voiced that he's upset about his Dad's house flooding, he voiced he wants to go to (Regional hospital). R2 sent to ER per V19 orders. R2's Nurses Notes dated 08/05/22 at 5:26 PM, documents R2 sitting himself on the floor and running out of facility multiple times. R2 hitting walls in hallway and threatening to kick teeth out of other resident. Sent to ER per V13 order. R2's Nurses Notes dated 08/06/22 at 6:01 PM, documents R2 returned to facility. R2's Nurses Notes dated 08/08/22 at 11:04 AM, documents R2 threatening to leave facility having behaviors. Sent to ER. R2's Nurses Notes dated 08/08/22 at 6:32 PM, documents R2 returned from hospital. R2's One to One Sheet documents starting 08/05/22 at 6:00 AM and ending 08/09/22 at 5:40am although R2 out of facility for 2 different trips to the ER. R2's One to One Sheet documents starting 08/29/22 at 6:00 AM and ending 09/02/22 at 5:40 AM. R2's Social Service Note dated 08/29/22 at 11:42 AM, documents (R2) has been reminded constantly to remain behind the door of the quarantine floor of 400. He gets highly upset and curses at staff. R2's Social Service Note dated 08/29/22 at 11:46 AM, documents (R2) was discovered walking around on the 100-hall floor. He was reminded again that he is on quarantine and should not be off of his assigned floor (400). (R2) became upset began to curse and make threats that he would kill himself. R2's Nurses Notes dated 08/31/22 at 12:07 PM, documents R2 flipping table and chairs and knocking things off the table was in the dining room due to being mad that over covid isolation restriction. able to redirect residents and calm him down. R2's Nurse's Note, dated 9/5/22 at 3:30 PM, documents R2 became loud walked away screaming no one here cared about him, he became loud and verbally aggressive walked over the stairway exit opened door and went downstairs. R2 was yelling loudly, cursing and had his fist balled up and pulled back to hit aide in her face. R2 was interrupted and attempted to talk to him when he bolted out the exit door yelling how no one cares about him. Two Staff members with resident. Police notified about resident behavior and walking off. V19 notified awaiting return call. R2's Nurses Note, dated 9/5/22 at 5:35 PM, documents when observed R2 with aid, R2 yelled at aid and pushed aid backwards with his chest. R2's Nurses Notes dated 09/05/22 at 9:49 PM, documents Resident tried to elope and leave facility this nurse called 911 and along with other staff redirected resident back down the street to building resident was transported to (local hospital) and returned at approx. 6pm this nurse spoke with him trying to find ways to cope. The resident took medication for anxiety and was able to go to bed this nurse assisted him to room will continue to monitor. R2's Nurses Note, dated 9/6/22 at 10:37 PM, documents R2 sent to ER per V19 related to aggressive behavior toward staff, destroying facility property, and trying to cut wrist with glass from broken picture frame which R2 broke by throwing pictures onto floor. R2's One to One Sheet documents date starting 09/05/22 at 6:00 AM and ending 09/07/22 at 5:40 AM. R2's Nurses Notes dated 09/13/22 at 9:54 PM, documents resident returned to facility by two ems drivers no complaints at this time resident able to ambulate from the stretcher resident. resident currently resting in bed with no complaints. R2's One to One Sheet documents date starting 09/13/22 at 6:00am and ending 09/15/22 at 5:40 AM. R2's Nurses Notes dated 09/15/22 at 9:37 PM, documents Resident in reception area yelling staff was told that resident called the police resident stated he did not call police this nurse was headed to speak with resident then resident proceeded to run out of the door this nurse along with other staff went out to stop resident from leaving property resident became aggressive punched facility van window then punched out facility window this nurse and staff tried to intervene resident then picked up glass from the ground an attempted to cut himself this nurse was able to get resident to drop the glass then he began banging his head against the building this nurse redirected resident to sit in chair and talk about what happened resident stated he wanted to go and not be at facility anymore and he wanted harm himself. Ambulance and police were called. R2 sent to ER. R2's Nurses Notes dated 09/15/22 at 11:45 PM, documents R2 returned from hospital. R2's Nurse's Note, dated 9/24/22 at 9:24 AM, documents R2 sent out to hospital and admitted due to behaviors and throwing chairs, threatening to harm self and staff. R2's One to One Sheet documents date starting 09/27/22 at 6:00 AM and ending 09/30/22 at 5:40 AM. R2 in the hospital during this period. R2's One to One Sheet documents date starting 10/03/22 at 6:00 AM and ending 10/11/22 at 10:40 PM. R2's Nurses Notes dated 10/11/22 at 10:25 AM, documents R2 left at this time with a guardian for court date. R2's Nurses Notes dated 10/11/22 at 11:32 AM, documents R2 returned from court visit at this time. There was no documentation in R2's medical record of a One to One Sheet for 10/14/22. R2's Nurses Notes dated 10/14/22 at 6:18 PM, documents R2 stated he was hearing voices and he wrapped a sheet around his neck. Contacts made to send to ER. 1 to 1 continues. R2's Nurses Notes dated 10/24/22 at 1:11 PM, documents At this time (R2) is yelling through the hallway that he wants to get out of here. This nurse asked (R2) if he wants to talk about what got him so upset, he voiced no and stormed off into the dining area, he walked up to the dining cabinet and punched the glass out, he then picked up a piece of the glass up and proceeded to attempt to cut right arm, staff intervened taking the glass away. Superficial cut noted to arm, (R2) then walks over to dining room exit door and walks out, staff with him. Door alarm didn't sound. (R2) redirected back into the facility by staff. R2 placed on 1:1. R2's One to One Sheet documents date starting 10/24/22 at 6:00 AM and ending 10/28/22 at 5:40 AM. R2's One to One Sheet documents date starting 11/01/22 at 5:00 PM and ending 11/02/22 at 8:10 AM. R2's Nurses Notes dated 11/01/22 at 5:51 PM, documents (R2) voiced to this nurse that he's feeling suicidal and he's hearing voices. He said the voices are telling him to kill himself, (R2) denies having a plan at this time. 1:1 initiated at this time. (R2) encouraged to use coping skills such as music therapy, walking and a snack. (R2) agreed at this time. Will cont. to follow up. R2's Nurses Notes dated 11/01/22 at 7: 48 PM, documents (Local Police Department) here at this time, voiced they received a call from a resident here, (R2) came to the nurses station voicing that he called and wanted to go to (local hospital) because he isn't feeling any better. (Local Police Department) dispatched EMS. R2's Nurses Notes dated 11/01/22 at 8:00 PM, documents Ambulance here at this time to transport R2 to local hospital. R2's Nurses Notes dated 11/02/22 at 8:31 AM, documents This nurse received report from off going nurse that (R2) was transported to (local hospital) from (local hospital) and orders and face sheet was faxed to (hospital staff). Spoke with nurse from (Psych Unit) at (local hospital) voiced that (R2) was admitted from suicidal ideation. R2's Nurses Note, dated 12/4/22 at 11:30 AM, documents (R2) voiced that he was using his personal phone on the phone with his dad, roommate (R3) self-talking and (R2) assumed that roommate (R3) threaten his dad, (R2) became homicidal toward roommate, voicing that he's going to kill him. (R2) called 911 from his personal phone, voicing that he wants to go to (Regional Hospital). R2 transferred to hospital. R2's One to One Sheet documents date starting at 12/05/22 at 3:00 PM and ending 12/05/22 at 11:10 PM. No Progress Notes noted for any behaviors on 12/05/22. The Facility's Incident Report Form - Final Report, dated 12/5/22, documents Description of Occurrence: Resident told nurse he was having homicidal thoughts against residents and family member. Residents were immediately separated from the room. 1:1 support given. (R2) stated that he became upset with his roommate for talking to himself and threatened to harm (R3) and his father. No physical contact was made. (R2) was sent to ER for evaluation. A nursing assessment shows no injuries. There was no documentation in R2's medical record of a One to One Sheet for 12/06/22. R2's Nurses Notes dated 12/06/22 at 12:45 AM documents (12:40 AM) Resident came and asked for his HS (evening) meds and this nurse told him she could not give them to him and then he started cursing at this nurse. (12:42 AM) (Local Police Department) called and informed this nurse that resident had called 911 and was talking about committing suicide. (Local Ambulance Service) arrived to transport resident. R2's One to One Sheet documents date starting 12/08/22 at 2:40 PM and ending 12/11/22. No Progress Notes noted for behaviors during this period. R2's Nurse's Note, dated 12/11/22 at 6:03 PM, documents R2 was walking through dining room and pushed R1 onto floor and walked away, stated she yelled at him. R2 sent to psychiatric hospital for evaluation and treat per MD. R2's One to One Sheet documents date starting 12/11/22 at 6:00 AM and ending 12/15/22 at 5:40 AM. R2's Nurses Notes 12/11/22 at 6:03 PM, documents Resident was walking through dining room and pushed another resident onto floor and walked away stated she yelled at him this nurse received order to send resident to (local hospital) for eval and treat per (V13). R2's Nurses Notes dated 12/11/22 at 11:00 PM, documents Resident returned to facility via (local ambulance service) accompanied by 2 attendants. Resident reintroduced to assigned room. R2's Social Service Note dated 12/15/22 at 11:53 AM, documents (R2) has successfully completed his 72-hour psych evaluation. No behaviors were previously noted or mentioned. The 1 on 1 does not need to continue. R2's One to One Sheet documents date starting on 12/20/22 at 6:00 AM and ending 12/24/22 at 12:40 PM. R2's Social Service Note dated 12/23/22 at 10:10 AM, documents This staff interviewed (R2) to determine if he was still in need of a 1 on 1. During the interview, (R2) stated that he was no longer angry. He stated that he understands that whenever he gets angry, he can't bolt out of the facility. He knows what resources are available to him when he gets angry. He stated that when it comes to things he wants or want to do, he has to learn not accept that he can't have them, and not get angry. It is this staff opinion that (R2) no longer needs a 1 on 1. On 1/12/23 at 3:20 PM, R1 stated, (R2) pushed me purposely. (R2) was standing in the doorway in the dining room and people were trying to get through so I told him he needed to move. (R2) started to yell at me and when I stood up, he walked over to me and pushed me. I went into a chair and me and the chair fell to the floor with the chair on top of me. My leg was hurting me afterwards and I believe they did do an x-ray. I have seen (R2) hit and push other people too. (R2's) very violent and nobody does anything about it. I don't recall seeing a worker walking around next to him. He was by himself when he pushed me over. (R2's) always yelling and cursing at everyone. I am scared of him, and I think some of the staff is scared of him too. R2's Nurse's Note, dated 1/5/23 at 11:22 PM, documents R2 upset about not getting a second ice cream started punching the walls knocking down hand sanitizer stations an also ripping up facility décor. R2 called police from his personal cell phone and stated he wanted to leave and not come back here and also that he is homicidal. EMS arrived and resident requested to go to hospital. On 1/18/23 at 3:10 PM, R8 stated I remember when (R2) was down here with us. (R2) was very upset about something one day and hitting the walls and tearing things up. He took a picture frame off the wall and threw it down the hall and I happen to be hit by it. I believe my neighbor (R9) had an issue one day with (R2). You might want to talk to him. On 1/18/23 at 3:15 PM, R9 stated When (R2) first came down here, he was being loud in the hall and when I asked him to quiet it down, he became verbally aggressive towards me and threatened to kill me. I told the staff and they sent him out to the hospital. I wasn't afraid of him until he threatened to kill me. Then I was afraid of him because I wasn't sure if he would follow through with it. R2's Care Plan dated 12/05/22 documents (R2) has a history of self-harming as a form of attention seeking. (R2) uses a bell in place of a call light due to self-harming behaviors. 5/22 resident used plastic knife to place superficial cuts on arms. 10/02/22 Walked outside of the building over the weekend multiple times and had self-harming behavior 12/4/22 (R2) was having homicidal thoughts against his roommate. Interventions: Assess seriousness of suicidal ideation, noting behaviors such as gestures, threats, giving away possessions. Conduct appropriate interdisciplinary assessments upon admission. Review transfer forms, including screening material to determine any history of self-harm. Dietary to provide resident with metal spoon only with meals. Document all episodes of suicidal ideations. Provide experience/interactions that enhance self-esteem, sense of personal power. R2's Care Plan dated 08/05/22 documents (R2) is at high risk for elopement. He has a history of leaving home when he is upset. Interventions: 1:1 as needed. Divert resident's attention to another subject or activity. Place resident's picture in elopement books kept at nurse's stations. Redirect resident when she is exit seeking. Interventions dated 04/21/22 and 08/05/22. No interventions added for elopements on 04/24/22, 04/25/22 x 2, 06/11/22, and 09/05/22. On 01/12/23 at 11:45 AM, R2 was lying in bed, propped up by blankets, plate of food on his stomach while he eats. V3, CNA, sitting in chair next to his bed documenting his behaviors. R2's One to One Sheet documents date starting on 01/12/23 at 6:00 AM and ending 01/16/22 at 6:15 AM. R2's Nurses Notes dated 01/13/22 at 10:28 PM documents resident made staff aware that he was having chest pain and stomach was bothering him. staff let resident know that they would notify the nurse. while staff went to go get this resident's nurse resident proceeded to call 911. resident called stating he was having chest pain and wanted to go to the hospital. this nurse arrived after resident made phone call to PD. resident stated he called because he needed to go and did not want to be treated at the facility he wanted to go to the hospital for treatment. 2 EMS arrived at 9:20 as well as 2 (local police department) officers. resident became agitated with EMS questions and became homicidal towards staff members and suicidal towards self. resident walked to stretcher and exited facility with no bruises noted A&Ox3 when resident sat on stretcher resident began hitting self with phone in the head and then proceeded to throw phone to the groundbreaking the front screen to the phone. the nurse made resident aware of screen being broken due to resident throwing it resident examined phone and stated he didn't care. phone was locked away in med cart on 400-hall. resident exited facility headed to (local hospital) for eval and treatment. admin and NP (V26) made aware. R2's Nurses Notes dated 01/13/22 at 11:59 AM documents res returned from ER on stretcher with 2 AMB (ambulance) attendants. in pleasant mood, has no c/o (complaint of). all test at hospital came back neg for Dx (diagnosis): chest pain. On 01/17/23 at 8:50 AM, R2 lying in bed. V8, Hall Monitor, sitting in room. On 01/19/23 at 9:30 AM, R2 lying in bed with hall monitor sitting in his room with him. On 01/24/23 at 10:10 AM, R2 sitting outside on the patio with hall monitor standing next to him. R2's Care Plan/Behavior Tracking Record dated May 2022 documents Resident has a history of homicidal ideations. Resident is at risk for harm to others. Resident had issues on 05/17/22 and 05/18/22 during the day shift. Resident has a history of being verbally aggressive. Resident had issues on 05/02/22, 05/04/22, 05/17/22, 05/20/22, and 05/28/22 during the day shift. Resident had issues on 05/02/22, 05/04/22, 05/09/22, 05/15/22, and 05/23/22 during the evening shift. Resident is at