**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to allow a resident to return to the facility after being out on a facility provided pass. The facility did not properly discharge the resident and did not have documentation of efforts to provide the resident with proper notice of discharge. This failure resulted in R1 being in the community unsupervised and without therapeutic medication. R1 was subsequently admitted to the hospital for aggression and presented with exacerbation of mood and psychotic symptoms. The Immediate Jeopardy began on 4/8/23 when the facility failed to allow a resident to return after being out on a facility provided pass. V1 (Administrator) was notified of the Immediate Jeopardy on 5/8/23 at 11:54AM. The survey team verified by observations, interviews, and record review, that the Immediate Jeopardy was removed on 5/9/23 but noncompliance remains at Level Two because additional time is needed to evaluate the effectiveness of the interventions implemented. Findings include: R1 is a 37- year-old male who was admitted to the facility on [DATE], with past medical history including, but not limited to bipolar disorder unspecified, moderate intellectual disability, essential primary hypertension, hyperlipidemia, type 2 diabetes mellitus without complications, nicotine dependence, other symptoms and signs involving appearance and behavior. The facility's Release of Responsibility for Leave of Absence form is used as the facility's sign out sheet for all residents. This form showed that R1 signed out at 10:15AM on 3/28/2023 to go out to the front of the building but never signed back in. On 5/2/23 at 10:40am, V2 (Chief Nurse Officer Regional) said that the plan was for R1 to discharge back to a similar (supportive living) facility as he was previously in, before June. R1 is alert and oriented with a BIMS 15. R1 was taking his medication and was not part of the [NAME] Program because he was short term. He was last seen by the psychologist on 3/20/23. R1 left on 3/28. He signed out on pass and had no guardian or POA. We found out that he wasn't coming back when we spoke with his mother on 4/5; that's when his mother confirmed that he wasn't coming back. On 3/31 R1's mother said that he's probably at a relative's house or a shelter. Then we reached out to shelters to see if he was anywhere. We did not have his cell phone number and the mother would not give it to us. He never came back for his medication and his belongings. R1's sister came to pick up his personal belongings on 4/23. 5/5/2023 at 11:23AM, R1 was interviewed over the phone with V21 (Family Member) on a three-way call by the survey team and he said, I was on a red pass and went outside and kept going. I went to see if I could find another nursing home to go to. I was hoping to transition to an independent facility with a single room and I didn't know that I would be sharing a room with three other people before I got here. I was gone for about a week. I am staying at (homeless shelter) now. When I left, I went to my sister's house and she gave me $15, that's all the money that I had. I came back to the facility but a white woman in the therapy office said I couldn't come back unless I went to the hospital first. I went to the hospital, and they said I still couldn't come back. They didn't help me get there. I walked to the fire department across the street and told them that they wouldn't let me come back and they took me to the hospital, then they sent me to another hospital, and I stayed there for about a week. I still had belongings like a bag of clothes and stuff, but they didn't tell me I could get it. My previous facility sent me to the current one because I told them that I didn't want to be there anymore. V21 added that R1 can't manage his own money. If it were left up to him, he would never pay his rent or eat nutritious food. His grandmother was his payee before she died and now my daughter (R1's sister) is the payee. Hospital record dated 4/8/2023 at 6:23PM documents the following: [AGE] year-old male presents to ED for psych eval, patient reportedly left a nursing home and is wanting to go back, however patient was told he needs to come to ED for evaluation prior to returning. Patient denies HI, delusions, hallucination. There are no other complaints at this time. At 10:33PM, the same hospital record documents: Patient discharged , instructions given, follow ups discussed. Patient verbalized understanding, shows no signs of distress, patient is alert and oriented. Patient going back to previous facility, blood pressure elevated, Ed MD aware, patient has no other questions or concerns at this time. At 11:44PM, same medical record documented the following: Facility RN called after receiving over the phone report stating that patient was discharged a week ago, this RN explained to the nurse that was not communicated. What was explained is that the worker and the previous RN was told that patient needed to have psychiatrist evaluation prior to being discharged back to the nursing home. The nursing home RN stated, I just came on shift and was told about this and (ambulance company) won't take him back to you. This is the same nurse who took report prior to patient's departure, she also stated, I am just fulfilling orders and will speak to my management. 5/5/2023 at 10:57AM V27 and V28 (Emergency Medical Technician from the local Fire Department) said that R1 walked up to the station and knocked on the door. He said he came from the nursing home across the street, and they told him to go to the hospital. We didn't talk to the facility at all because we didn't see that there was any point in that once we had assessed him and got him situated on the stretcher. We were pressed for time. I have personally gotten a call from (R1) before, so I was familiar with him and knew that he lived at (facility). R1 called 911 back in January because they were trying to send him to the hospital, and he said that the private ambulance was taking too long. He said he wanted to go somewhere else but ultimately, we ended up not taking him because he needed a psychiatric evaluation, and the nearest hospital wouldn't have been able to treat him for that. I haven't had any additional calls or any instances where a resident has come over to say they are being denied entry. Emergency department physician progress note dated 4/9/2023 at 3:35AM documented: [AGE] year-old developmentally delayed presents for psychiatric evaluation after voluntarily leaving nursing home, returning after 8 days. He states he would like to go back; they are requesting that he be evaluated. Denies any SI, HI hallucinations, bizarre, however this appears to be his baseline. No physical complaints of shortness of breath, vomiting, abdominal pain, calm cooperative .he was subsequently transported via EMS (Emergency Medical System). I was informed subsequently that the supervisor at the nursing home had discharged the resident from their facility, RN (Registered Nurse) did explain to them that this is inappropriate, we were not informed of this, and patient has already been discharged and accepted back to the facility, they will speak to their superior. Hospital record also included hospital nurse's note dated 4/9/2023 at 10:13AM, which documented: patient received from EMS with reports of aggressive behavior .came to this ED yesterday for evaluation, then sent back to the facility but was told he needs inpatient stay and that his medications need to be adjusted. Emergency department nurse's note dated 4/9/2023 at 11:11AM includes received a call from facility administrator stating that patient was out on pass and never returned and was discharged from the system. He reported that patient has displayed this behavior before, administrator was given a fax number to send discharge instructions so that alternative placement can be secured, patient made aware that he cannot return to the facility. On 5/3/2023 at 2:20PM, V12 (Facility 2 representative) stated that the resident was admitted to their facility from 4/18 to 4/24/2023 with a diagnosis of schizophrenia. R1 was admitted from a psychiatric hospital from [DATE] to 4/18/2023 before coming to their facility. Hospital record dated 4/10/2023 states the following: Patient presents as 37yr year old male previously diagnosed with schizophrenia/schizoaffective disorder presents to the emergency room after exacerbation of mood and psychotic symptoms. Per petition, patient received from EMS with reports of aggressive behavior, patient received alert and cooperative, endorses that he was out on pass for 6 days, attempted to go back to facility and they informed him that he needs a psychiatrist evaluation, and he came to this emergency room yesterday for evaluation, patient then went back to the facility and was told that he needs an inpatient stay and that his medications needs to be adjusted. 5/4/2023 at 3:30PM, V18 (Licensed Practical Nurse/LPN) said that she recalls the resident, he was assigned to the set with R1 on 3/28/2023 but R1 was already gone by the time she came to work on second shift. It was reported to her that R1 was out on community pass and did not return. When they had a head count around 8PM they noticed that the resident was still not back, they searched all the rooms and did not find him. V18 notified the administrator who instructed her to inform all the MHTs (Mental Health Technician) to go out and search for R1 within the area. The administrator also told her to call the police. V18 said that she called the police and gave them a description of the resident. The police asked her if she wanted to file a missing person report and she said no because she was thinking that the resident would come back. V18 stated that she also called the family. V18 was asked if R1 ever expressed the need to leave the facility and she said no, but one time he brought a paper for her to sign stating that he has been of good behavior and taking his medications. V18 said she told him that she could not sign the paper because she does not know him well enough to sign that. V18 also said that she heard that the resident came back to the facility a couple of days later but was sent to the hospital. 5/5/2023 at 1:11PM V4 (Director of Behavioral Health) said that she does not know of anytime R1 returned to the facility after he left. V4 does not normally work the weekend. If resident showed up, the facility could have given him verbal direction on how to get to the hospital. Surveyor asked V4 why the facility would give the resident verbal direction and she said, he is independent and out in the community, he was considered as gone AMA (against medical advice) after he signed out on a pass and did not return. V4 was asked if R1 still had belongings at the facility after he went out on a pass and she said that she is not sure if the resident had any belongings; if he did, staff could have assisted him. V4 added that R1 never told her that he wanted to be discharged . 5/5/2023 at 1:39PM, V1 (Administrator) said that R1 came back to the facility after he left, inquiring about food and they explained to him that he has gone AMA and would have to go to the hospital for evaluation. V1 said that the facility called the hospital ahead of time and they were requesting a referral. They went back and forth with the hospital about it. V1 added that he was not present at the facility when R1 returned, a staff member called him, and he cannot recall who the staff was because he does not work on weekends. V1 was asked if they asked R1 to sign the AMA paper at that point and he said, no, I am not sure why not. V1 said that he asked someone at the facility to give R1 a sandwich since R1 said that he was hungry. 5/9/2023 at 2:02PM, V29 (Medical Director) said that that when a resident leaves the facility and does not return, the first thing is to file a missing person report, even if the resident was gone for 10 minutes. If for any reason the facility cannot find a copy of the report, it should be re-filed. V29 added that AMA is not when a resident signs out and absconded from the facility. If a resident wants to leave AMA, they should sign the AMA form; even if they refuse to sign, the facility should explain to the resident the risks of leaving AMA. V29 said that when R1 came back to the facility after being away for several days, telling him to go to the hospital on his own is the worst thing to do, especially for someone with a history, they should have put him in a safe place and made sure that he is stable and called an ambulance to take him to the hospital and take it from there. Review of facility AMA (Against Medical Advice) policy revised 3/22/22 stated in part that it is the policy of the facility to acknowledge the right of a resident to sign him/herself out of the facility without the consent of or an order from the attending physician providing that the resident has the decisional capacity to do so. Under procedure, the policy states that prior to leaving the facility, discharge planning must identify the discharge destination, and ensure it meets the resident's health and safety needs as well as preferences. The resident's physician will be notified of the resident's request to leave the facility against medical advice. The nurse on duty will provide the resident and/or legal guardian of information regarding the resident's current treatment and medication regimen. Medications will be provided to the resident or the legal representative with physician conversation that harm would ensue without such medications. Any resident or legal representative choosing to discharge or be discharged without the consent of, or an order from the attending physician is expected to sign the AMA form. In the event that resident is signing himself/herself out AMA, his/her legal representative and /or family member will be notified by facility personnel. Resident leaving the facility against medical advice is responsible for their own transportation with the safety of the resident maintained. If resident is unable to physically transfer/discharge self from the facility safely, the facility will notify the resident's representative/POA, and ombudsman. APS (Adult Protective Services) will be notified if the facility feels the AMA discharge setting does not meet the resident's post discharge and appears unsafe. The Immediate Jeopardy that began on 4/8/23 was removed on 5/9/23 when the facility took the following actions to remove the immediacy. 1. R1 no longer resides at the facility. 2. Education will be provided to the IDT team, admissions, Social Service staff and Nurses on proper discharge and transfer using revised policy for Bed hold/discharge transfer policy. Director of Nurses, Assistant Director of Nurses and Psychiatric Rehabilitation Services Director will be responsible for in-service. Initiated 5/9/23 3. Elopement risk, unauthorized leave, community survival assessment will be revised by corporate and will be used to provide education to the nursing and social service staff. Initiated 5/9/23 4.The following policies were reviewed and revised: -Therapeutic pass -Bed/hold discharge/transfer notice -AMA policy -ALL WILL INCLUDE circumstances under which we would not accept the patient back and any conditions required prior to re-admission. Initiated 5/9/23 to be completed by 5/11/23 5. These policies and revised assessment will be used to provide training to all nursing staff, social service staff and IDT. The training will be provided by corporate staff. All prn, part time and on leave staff will be re-educated prior to next scheduled shift. Staff will acknowledge information via signature. Initiated 5/9/23 to be completed by 5/11/23 6. The Medical Director was notified by the Administrator and reviewed the facility's immediate action plan. He agrees with immediate action plan. Initiated 5/8/23 7. QA team met to review policy and procedures changes including the Medical Director. Administrator, Assistant Administrator will conduct audit of discharged residents weekly. To be completed on 5/10/23 8. Policy on bed/hold/discharge transfer and therapeutic pass will be sent to each responsible party and each resident who is their own responsible party and acknowledged by signature. Mail will be sent certified. Any returned not signed will have a call placed and will be witnessed by two staff and documented as such. To be completed on 5/10/23

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** There are multiple deficiencies identified. 1.) Based on interview and record review, the facility failed to properly supervise a resident with a known history of elopement who was assessed as requiring staff supervision for ambulation on and off unit; failed to supervise the resident while smoking; failed to have a physician order for unsupervised outside pass privileges; failed to follow their policy for missing resident/elopement; and failed to follow their behavior management level program agreement. These failures affected one of one (R1) resident reviewed for supervision and resulted in R1 leaving the facility on 3/28/23 while on an unsupervised smoke break. While out in the community, R1 was without access to food, shelter, or therapeutic medication and was subsequently admitted to the hospital on [DATE] for aggression and presented with exacerbation of mood and psychotic symptoms. The Immediate Jeopardy that began on 3/28/23 when the facility failed to monitor R1 with a known history of elopement, which resulted in the resident leaving the building unsupervised. V1 (Administrator) was notified of the Immediate Jeopardy on 5/8/23 at 11:54AM. The survey team verified by observations, interviews, and record review, that the Immediate Jeopardy was removed on 5/9/23 but noncompliance remains at Level Two because additional time is needed to evaluate the effectiveness of the interventions implemented. Findings include: R1 is a 37- year-old male who was admitted to the facility on [DATE], with past medical history including, but not limited to bipolar disorder unspecified, moderate intellectual disability, essential primary hypertension, hyperlipidemia, type 2 diabetes, nicotine dependence, other symptoms and signs involving appearance and behavior. Review of facility Minimum Data Set (MDS) dated [DATE], section G (functional) coded R1 as requiring supervision for all ADLs including ambulation on and off unit. Facility sign-out/in record presented by the facility shows that R1 signed out to the front on 3/28/23 at 10:15AM. Progress note dated 3/28/23 reads that R1 was granted an independent community pass. During an unsupervised smoke break, R1 left the facility and did not return. During an interview with R1's relative on 5/3/23 at 2:49PM V20 (Family Member) said, R1 never finished high school and has exhibited psychiatric problems since he was a young adult. V20 said, R1 can feed himself and dress himself, but he needs help with his other needs such as cueing for maintaining hygiene and taking medications. V20 indicated that R1 cannot make sound decisions and because of this, she became his representative payee after his grandmother, who was the previous payee, passed away. V20 said, R1 ended up in another nursing facility in (name of city), after being hospitalized at some point when he left this facility. Review of resident's medical record show the following progress note documented by V10 (Psychiatric Rehabilitation Services Coordinator/PRSC) on 1/31/2023 at 9:32AM: Resident approached writer (for the seventh time) about getting an independent pass. Writer denied resident request and explained that because he was just readmitted from the hospital that he was ineligible for a pass at this time. Resident stated that he understood. Writer will revisit topic later. Another progress note dated 1/31/2023 at 14:30 states in part: It was brought to writers' attention that resident has an unauthorized exit from the facility. Resident Mother notified facility that resident visited sisters' home and was provided funding to return to [the facility]. Facility aware of resident exit. At this time, a missing person's report has been filed and awaiting Resident return. MD (Medical Doctor), Administration and Nursing aware of all the above. Review of resident's care plan did not show an active care plan for risk of elopement. On 5/3/23 at 2:50pm V10 (PRSC) said that I created the elopement care plan as part of the plan of correction for the elopement that occurred on 1/31/23. I discontinued the care plan 2/24/23 because we decided that R1 could work on getting a community pass. On 5/3/24 at 3:40pm V10 said, as far as the elopement assessments, from my understanding because R1 was trying to get a community pass, we couldn't mark him as being at risk for elopement. I scored it as no risk so that he would be eligible to petition for a pass even though he eloped in the past. On 5/1/23 at 10:38AM V21 (Family Member) said, R1 left the facility before in January, improperly dressed without coat and socks in the cold. He was originally transferred to this facility because he needed treatment for his mental health and assistance with activities of daily living. V21 said she begged staff not to give R1 a pass to the community because he was likely to leave and not return and he was unable to take care of himself without assistance. When V21 was notified that R1 left on pass and did not return on 3/28/23, she called the facility and asked why staff would give him a pass when R1 already showed that he can't take care of himself. On 5/5/23 at 11:23am R1 was interviewed over the phone. R1 was alert and oriented but responded slowly, speaking with disorganized thoughts. R1 said, I was on a red pass (independent) and went outside to smoke and kept going. I went to see if I could find another nursing home to go to. I was hoping to transition to an independent facility with a single room and I didn't know that I would be sharing a room with three other people before I got here. When I left, I was gone for about a week. I was hopping trains most of the time. I didn't take any medication from the facility and didn't have any food. Facility Policy titled Community Pass Guidelines revised 11/25/19 states in part: The resident has the right to community access with the consent of the facility, physicians' orders, and the resident' cooperation with the standards described within. Review of most recent physician orders for R1 did not show any order for independent community pass. Further review of facility, Release of Responsibility for Leave of Absence (sign in/out) form (dated 3/28/23) documented that R1 signed out of the facility at 10:15AM to go outside at the front of the facility. On 5/3/23 at 12:16PM, V1 (Administrator) said, when the residents write front on the sign-out sheet, it usually means they are going out to smoke. When R1 went outside, he was expected to smoke and come back in but since he had a community pass it wasn't unusual that he did not come back right away. On 5/4/23 at 1:45PM V15 (Mental Health Tech/MHT) said, I was working a double on the day that R1 went outside and did not return. He went outside to smoke and didn't come back in the with other residents, but I didn't think too much of it because he had an independent pass. We don't supervise residents who go out to smoke on the front because they have a peer or independent community pass. R1 had had the independent pass for a long time but they never told him about it, so he didn't know. Since I was there later that night, I noticed that it was around 7 or 8pm that he had not returned. I informed V10 (PRSC) and the nurse. I'm not sure what they did after that. Community Survival Skills assessment dated [DATE] was signed by V4 (Director of Behavioral Health) on 3/29/23. R1 left the facility unsupervised on 3/28/23. Most recent care plans reviewed for R1 documented that Level II (peer) and Level III (independent) pass were both implemented on 2/24/23. On 5/2/23 at 12:32PM, surveyor requested documentation that would support R1 going out with a peer pass. V1 said, unfortunately, those documents are not a part of the resident's record and are not kept. They are currently in the shred box. We have some people looking through them to see if we can find them. During the course of this survey, the facility did not provide documentation that R1 went out and was supervised on Level II pass at any time. Review of Smoking Safety Risk assessment dated [DATE] by V10 (PRSC) noted that R1 required supervision while smoking and was not able to store smoking materials. Progress Note dated 3/28/23 at 9:10PM written by V6 (Group Facilitator) reads: staff determined R1 had not returned from community pass. On 5/4/23 at 3:30PM, V18 (Licensed Practical Nurse/LPN) said, I worked 3-11PM shift the day that R1 left. The CNAs were doing head count and noticed that R1 was not in the building. I don't remember seeing him during my shift. I was informed that R1 was on community pass from the previous shift and had not returned around 8pm. I called V1 (Administrator), and he informed me to call the police and then he called and asked the MHTs (Mental Health Tech) that were in the building to go and look for him in the surrounding area. I called the police and gave them a description and they asked me if I wanted to file a missing person's report and I said no because I didn't think he was missing but still out on pass. I called the family to let them know that he had not returned. I heard that he came back to the facility some days later, but they wouldn't let him come back and sent him to the hospital. Facility policy titled, Code Pink- Missing Resident/Elopement revised 11/15/18 states in part: All personnel are responsible for reporting a cognitively [impaired] resident attempting to leave the premises, or suspected of missing, to the Charge Nurse as soon as practical. This includes any resident that did not sign out on pass and/or did not notify a staff member of his or her leaving. The following steps should occur: 3. Notify the sheriff and/or police department and file a missing person report. The facility was unable to provide any documentation that a missing person's police report was filed on 3/28/23 for R1. Facility progress note dated 3/29/23 at 8:02PM written by V26 (Assistant Director of Nurses/ADON) said that R1's mother was called and left a voicemail. Progress note dated 3/30/23 at 2:50PM said that R1's mother called the facility saying she needed to speak with a manager and wanted to know why we gave her son community access so he could run away. Progress note dated for 3/29/23 at 8:47 AM was written on 3/30/23 at 2:50pm and said that a missing person's report was filed for R1 with the local police department. Surveyor called the police department and a representative indicated that there was no report filed for R1 missing on that day. Further review of progress notes written on 3/29/23, 3/30/23 and 3/31/23 indicated that facility staff were calling various shelters, hospitals, and the morgue but they were unable to locate R1. Progress note written on 4/5/2023 at 6:53pm by V10 (PRSC) stated, Writer spoke with resident's mother. She confirmed that resident was located and prefers to be homeless over returning to the facility. Administration notified. Writer asked for resident's phone number, but mother declined. Writer encouraged mother to reach out to resident and see if he was interested in returning. Writer also explained the 10 Day policy. On 5/3/23 at 2:00PM, V12 (Facility 2 Representative) said, R1 was admitted to them from a local hospital on 4/18/23, where he had an inpatient psychiatric evaluation from 4/10/23 to 4/18/23. Hospital admission record dated 4/8/23 noted that R1 presented to the emergency room with no complaints reporting that he left the facility and wanted to go back, however was told that he needed to come to the Emergency Department prior to returning. He was evaluated and nurse to nurse communication was documented from the hospital to the facility at 9:32PM. The hospital discharged R1 back to the facility via private ambulance at 10:33PM. At 11:56PM, a nurse from the facility called back to the hospital stating that 'the patient was discharged a week ago'. This nurse was unable to be identified. Further notation states that a facility nurse said, 'I just came on shift and was just told about this and [the ambulance] won't take him back to you'. Facility nurse said, 'I am just fulfilling orders, I will speak to my management.' Fire Department run sheet dated 4/08/23 at 6:18PM stated, in summary, patient presented to EMS as a walk-in patient stating he needed to be mentally evaluated prior to returning to his housing. Patient was assisted to the ambulance and secured and assessed. Patient was transported to [local hospital]. ED (Emergency Department) contacted with report and received no orders. Patient arrived at the ED where care and report were transferred to the [ED RN]. Incident address on the report indicated this fire department station is located across the street within view of the facility. On 5/5/23 at 10:57AM V27 and V28 (Fire Department Paramedics) said, R1 walked up to the station and knocked on the door. He said he came from the nursing home across the street, and they told him to go to the hospital because he needed a psychiatric evaluation. We didn't talk to the facility at all because we didn't see that there was any point to that once we had assessed him and got him situated on the stretcher. We were pressed for time. I have personally gotten a call where I responded to him before in January, so I was familiar with him and knew that he lived at this facility. When R1 arrived at the Emergency Department, he was admitted , and staff filled out a Petition for Involuntary/Judicial admission form. The form dated 4/9/2023 states in part: this petition is being initiated by reason of 1. Emergency inpatient admission by certificate; 2. Emergency admission of the developmentally disabled. [R1] is a person with mental illness who: because of his or her illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed; in need of immediate hospitalization for the prevention of such harm. The petition goes on to state that this assessment was based on the following: [R1 was] received from EMS (Emergency Medical Service) with reports of aggressive behavior. [R1 was] received alert, oriented, calm, and cooperative, endorses that he was out on pass for 6 days and that he attempted to go back to facility, and they informed him that he needs a psych eval and he came to this ED yesterday for the evaluation. [Thereafter, R1 was] sent back to the facility and was told that he needs an inpatient stay and that his meds need to be adjusted. R1 was transferred to another hospital in (name of city) where he was admitted on [DATE] for a chief complaint of aggression. This hospital record dated 4/10/23 documented that R1 was diagnosed with schizoaffective disorder/ Schizophrenia and Mild interpersonal conflict and was started on quetiapine (an antipsychotic medication). During assessment, in the History and Physical section, it was noted that R1 exhibited psychotic disorganized thought process, appeared to be responding to internal stimuli and exhibited guarded demeanor and paranoid ideation. Behavior appeared impulsive and unpredictable. During this assessment, R1 admitted to having a previous history of poly substance abuse. On 5/5/23 at 1:11PM V4 (Director of Behavioral Health) said, I was not made aware of R1 returning to the facility. If he were to have showed up, we would ask him what he needed and give him verbal directions to the hospital because it was considered that he left against medical advice. If he was coming to pick up his belongings, the staff could've given them to him or called 911 if he was in serious need of care. According to google maps, the distance from the facility to the nearest hospital is 4 miles. On 5/5/23 at 3:40PM V34 (Assistant Administrator) said, it was administration who decided that R1 would be discharged . He did have some belongings that were left behind that his sister came to pick up about a week ago. On 5/9/23 at 2PM V29 (Medical Director) said, I was not made aware of R1 leaving the facility during a smoking break unsupervised. The staff should be supervising smoking breaks all the time. If the resident left even for 10 minutes, they should have enacted the protocol by going to look for him, to find him. In this case the resident absconded and would not be considered leaving against medical advice. Leaving against medical advice requires an understanding, provided to the resident that they are leaving the facility who is providing care for their needs. They must sign out to ensure their understanding that, even though they may not have access to food, medication, and safe shelter, they are choosing to leave the facility. If they refuse to sign, then that should be witnessed by more than one person and communicated to the administrator. My understanding of the peer pass system is that when a resident first comes into the facility, they have a three-week observation in order to determine if they can follow the rules and be safe in the community. The team says this resident is okay and gradually gives them a pass to go outside- usually for a limited time. Residents cannot be supervisory agents of one another. Someone who needs supervision can go outside and into the community, but they should be escorted by a staff member because staff has some legal standing and a level of responsibility for keeping the residents safe. At the very least, they will be able to observe the resident if they decided to go off and leave because then the staff member would be able to communicate that and the protocols for finding the resident will take place. Common sense tells me that residents cannot supervise each other. If smoking breaks were supervised, it would 100% prevent people from taking off. I haven't been made aware of anything like this happening before but occasionally if someone wants to leave and they let me know. I say to follow the protocol. The circumstances of allowing this resident who has absconded back into the facility, depends, such as how is the resident presenting? Does he appear to be safe to come back into the facility? Sending the patient away at the door would not be advised, particularly if the resident had a relationship with the facility and has recently been living there. They should not have told him to find his way to the hospital alone, but they could have sent him to the emergency room using an ambulance or emergency services to ensure safe transport. The Immediate Jeopardy that began on 3/28/23 was removed on 5/9/23 when the facility took the following actions to remove the immediacy. 1. R1 is no longer at the facility. 2. All residents who successfully petitioned for a community pass and have been deemed able to navigate in the community were reassessed to ensure that their community and elopement assessments are accurate. Initiated 5/5/23 3. All residents were reassessed to determine their ability to smoke unsupervised. Their smoking assessment indicates they are independent smokers. The assessments were updated as appropriate. The Psychiatric Rehabilitation Services Director and the Director of Behavioral Services were responsible for updating the assessments. Initiated 5/5/23 4. The level 2 pass program will be eliminated. Residents wanting independent passes will go on supervised outings with staff. These supervised outings will help facility assess residents trying to obtain an independent pass. Initiated 5/8/23 and ongoing 5.Assessments were reviewed to ensure accuracy, implement interventions as needed and update care plan accordingly. Assessments will be reviewed by Inter Disciplinary Team composed of Administrator, Director of Nurses, and Psychiatric Rehabilitation Services Director. Initiated 5/5/23 and ongoing 6. Ongoing education of all staff regarding supervision policy to address that staff are not to leave any area with residents present who require supervision and maintain supervision of any supervised exits, verifying residents' community access pass prior to allowing them to exit facility, and smoke break procedures. Facility will ensure staff understanding of the policy via a QA tool. If it is determined staff do not have a sufficient knowledge base, re-education will occur. All staff will be trained by 5/5/2023 and any staff on leave or unavailable were called and are being in serviced via phone, via zoom call and again before next scheduled shift. The Administrator, Assistant administrator, Human Resources Director, Assistant Director of Nurses were responsible for the staff training. Initiated 5/5/23 and ongoing 7. Elopement and community pass binder are at the front desk and each nurse's station. PRSD is responsible for maintaining and updating the elopement binder. Facility added residents with passes to the elopement binders. Completed 5/5/23 8. The Medical Director was notified by the Administrator and reviewed the facility's immediate action plan. He is in agreement with immediate action plan. Completed 5/5/23 9. QAPI review with Medical Director to review plan of action. IDT conducts assigned regular rounds during shift to ensure visual monitoring and staff supervision. Department heads will be responsible for QA monitoring. Action plan will be reviewed monthly at QAPI meeting. Initiated 5/5/23 2.) Based on interview and record review, the facility failed to monitor residents who were identified as needing staff supervision during smoking breaks and failed to supervise residents without an independent community pass while out in the community with other residents. These failures affected 19 of 25 residents who were reviewed for supervision while smoking with community access. Findings include: According to a list provided by the facility, nine residents (R6, R8, R9, R10, R11, R12, R13, R14 and R15) have been assessed to have a Level II Peer Pass. Of those nine residents, seven of them (R6, R8, R9, R10, R11, R12 and R14) smoke and were assessed to require supervision while smoking (Safe Smoking Assessment). 10 residents (R7, R16, R17, R18, R19, R20, R21, R22, R23 and R24) out of 15 residents who have an independent (Level III) community pass smoke and have been assessed to require supervision while smoking. Smoking assessments for R6, R7, R8, R9, R10, R11, R12, R14, R17, R18, R19, R20, R21, R22, R23 and R24 were reviewed and noted to be updated on 5/5/23. Elopement assessments for theses residents were also reviewed. On 5/8/23 at 12:54PM V4 (Director of Behavioral Health) said, we went and reassessed all the residents who have a community pass to make sure their assessments reflect that they are appropriate to be out in the community. We combined the community survival assessment with the elopement risk assessment. The smoking assessment has a point system that automatically generates the points, but I don't recall what the point scale is evaluating or what the numbers mean on the assessments. It is appropriate for residents to smoke in front of the facility unsupervised because they have a community peer or independent pass. Residents can't light their own cigarettes because they need supervision while smoking. The cigarettes are lit by the receptionist or the MHT (Mental Health Tech) that lets the residents out of the building during smoke breaks. On 5/08/23 at 2:00PM V1 (Administrator) said, we are working on the policy now, and have decided to get rid of the Peer Pass system. We will implement the policies tomorrow once they have been approved. V1 presented revised policy which was approved with the abatement plan on 5/9/23 at 10:30AM. In the Facility's Behavior Management Level Program Level II expectations were revised to indicate that this pass will be with staff only, whereas the previous system in place allowed residents to go out into the community with and be supervised by their peers. On 5/9/23 at 3:35 PM V3 (PRSD) said, per the new policy we have incorporated two additional smoke breaks at 10:45AM and 5:30 PM that will be supervised by either the activity staff or the MHT. We have taken all the blue passes (Peer) and the residents who don't have passes will continue to smoke supervised on the back patio. Residents are now able to go out into the community if they are with staff. All the residents who have been assessed to have a Level II (peer pass) have been reassessed and their care plans have been updated. I, (V4), the psychotropic nurse, V26 (ADON), and the medical team have been updated on the new policy. The goal is for every staff member to be updated on the new policy by the end of business day. Residents still have the opportunity to have a red independent pass where they can go out alone. On 5/9/23 at 3:35 PM V31 (MHT) and V32 (MHT) were interviewed regarding the new policy. V32 said we were just updated coming into the facility that there will be no more blue passes. Residents who leave the building need to be supervised and it will take 30 days to move up a level to get an independent pass. V31 said things that would be looked at in order for a resident to get a level three pass are hygiene, making sure they attend their groups regularly and supervision during group outings to see how they behave. V32 said the residents can go outside as long as activities or the MHT take them out. V31 said this new policy started today. I've been working here for about six months. V32 said I started two months ago. V31 said if a resident is missing or leaves the group while we're outside, we're supposed to report it to the Administrator right away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** There are multiple deficient practice statements. I of II. Based on interview and record review, the facility failed follow their abuse policy and prevent a vulnerable resident from being taking advantage of sexually by other residents. This affected 3 of 3 residents R15, R16 and R17 reviewed for manipulation and sexual abuse. This failure resulted in R16 and R17 manipulating R15 into performing sexual acts for a trade of money and food. The Immediate Jeopardy began on 2/1/23 when V35 (Emergency Medical Technician/EMT) witnessed R15 having a sexual encounter with R17 at the facility. V6 (Administrator) was informed of the Immediate Jeopardy on 2/21/23 at 12:18 pm. The surveyor confirmed by observation, record review, and interview that the Immediate Jeopardy was removed on 2/23/23. Although the immediacy was removed, the noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan. Findings Include: 1.R15 has the diagnosis of Schizophrenia. Brief interview for mental status dated 11/21/22 documents a score of ten which indicates moderately cognitively impaired. Care plan dated initiated (3/31/22) documents: I am at potential risk for abuse/neglect. On 2/2/23 at 1:02pm, R15 was assessed to be alert to self with a delusion thought process. R15 was unable to report the month, date, year, president's name, name of the facility, or type facility R15 resided. R15 reported she was the boss of the building. R15 said, I can fire/terminated you (state employee). Don't come in my room. Don't touch me. This is my room, and I don't have any room mates. R15 was not being touched by anyone. R17 observed standing outside of R15's doorway. R17 said, R15 is my lady friend. R15 was asked, who R17 was and what their relationship to each other was. R15 said, I don't know R17. On 2/2/23 at 1:10pm, R17 who was assessed to be alert to person, place, and time, said, R15 is my lady friend, and we have sex. R15 doesn't know any better. R15 is not right in the head. I can have sex with R15 for food or a few dollars ($2.00 or $3.00). R15 is always hungry. R15 doesn't have any money. I (R17) had sex with R15 for juice and a cracker. I (R17) did not have sex with R15 yesterday. On 2/23/23 at 11:40am R17 said the young ladies at the facility like older guys with money. R17 said he's one of the older guys that have money at the facility and the ladies know that. R17 said a lot of the women at the facility be hungry and they will have sex for chips, cigarettes, pop, money. R17 said it's one young lady, she's fine, she's pretty and if she approaches him for money, he's going to give it to her so that he can have sex with her. R17 said he will not turn her down, she's pretty. R17 did not give surveyor the name of the female that he was talking about. On 2/2/23 at 1:46pm, V34 (Mental Health Tech/MHT) said, I saw R15 giving R17 oral sex. I wasn't aware R15 was sexually active. R15's orientation comes and goes. R15 can keep a conversation at times and other times R15 is not able to engage in a tangential speech/thought process. On 2/2/23 at 3:05pm, V22 (Psychosocial Rehab Service Coordinator/PRSC) said, R15 does not have a capacity to consent for sex. The assessment was not done because R15 is not sexually active. We only complete that assessment if residents are participating is sexually activities. On 2/2/23 at 3:58pm, R16 said R15 asked me for five dollars. I gave R15 the money. It is expected that R15 performs a sexual act for the money. I have never had sex with R15 for free. R15 performed oral sex on me. On 2/23/23 at 2:15pm R16 said R15 approached him and said, You got money? R16 said when R15 ask for money, it's expected that the money is payment for sex. R16 said R15 does not say that the money is for sex. R15 has never said she will have sex with him for exchange of money. R16 said sex is expected. R16 said a lot of the women at the facility ask for money and it's understood that the money is an exchange for sex. R16 said it's like a prostitution ring at the facility. R16 said the chicks at the facility are hungry and they are needing money. On 2/7/23 at 8:56am V35 (Emergency Medical Technician/EMT) said, I entered R15's room after knocking. R15 and R17 were both naked from the waist down. R15 attempted to cover her vaginal area. R15 was unable to answered orientation questions related to date, month, year and unable to report R17's name. R15 started yelling, stop touching me, (R15 was not being touched) I'm a cop and I need help. R15 was alert and orient to self, had a psychiatric episode, and refused/failed to yield to verbal redirection. I could not de-escalate R15. I am normal good at de-escalation. On 2/7/23 at 10:05am, V36 (Psychotropic Nurse) said, I check orientation by asking basic questions that the average person with intact cognition will be able to answer. I checked R15 orientation on 2/6/23. I asked R15 questions about, the current date, year and who is the president was. R15 can recite the date if a calendar is around. R15 was unable to recite the date and who the president was. R15 knew where she was, able to tell me she was going to lunch, and walked away. Care plan dated initiated 6/29/2018 documents: I (R15) have a diagnosis and history of severe mental illness (SMI) as manifested by delusions-poor ability to reason. Care plan dated initiated (10/11/21) documents: I (R15) am able to exercise the right to engage in sexual/intimate relationship. I have received counseling, as appropriate regarding sexual practice and behavior, boundaries, respect for roommates, healthy relationship and only engaging in this type of relationship with consenting party. I will exercise safety and appropriateness when choosing to partake in sexual activity. R15's capacity for sexual consent dated 2/2/23 documents (Resident's awareness of relationship) Is the resident aware of who is initiating sexual contact - yes. (Resident's awareness of potential risk) documents: C2- can the resident described how (he/she) will react when the relationship ends- no. Conclusion: Resident (R15) is aware of what sexual activities she engages in. Sexuality- Capacity to Consent Determination Policy dated 1-7-19, documents: Purpose: To establish criteria for determining the capacity to consent when resident to resident sexual activities occur. Capacity and Consent: Residents without the capacity to consent to sexual activity may not engage in sexual activity. Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is considered to be sexual abuse. Abuse policy dated 11/28/16 documents: The facility affirms the right of our residents to be free from abuse, neglect, or exploitation. Sexual abuse includes but is not limited to sexual harassment, sexual coercion or sexual assault including non-consensual or non-competent to consent sexual activity. Generally. Sexual contact is nonconsensual if the resident either appears to want the contact to occur but lacks the cognitive ability to consent. A resident's apparent consent to engage in sexual activity is not valid if it obtained through intimidation, coercion, or fear, whether it is expressed by the resident or suspected by staff. The surveyor confirmed via observation, interview and record review the following removal plan was implemented by the facility: Aperion Care Chicago Heights Abatement Plan, action taken: 1. R15, R16, and R17 has an updated capacity to consent for sex assessment. This was completed as of 2/2/23. R15 has not displayed any emotional distress and remains at baseline for mood and behavior. R15, R16, and R17's capacity to consent were reassessed and are determined that they have the capacity to consent to sexual relationships. 2/21/23 completed. 2. Residents that have been identified being at risk from sexual exploitation have had their care plans updated to reflect interventions to prevent abuse. List updated on 02/22/23. List of identified residents was provided to survey team. 2/22/23 completed. 3. Residents that have been identified for being at risk from sexual exploitation were interviewed if they have been taken advantaged of or manipulated to perform sexual acts. None of them responded yes. 2/21/23 completed. 4. Residents that have been identified for being at risk from sexual exploitation will be placed on 1:1 education with the assigned PRSC to meet weekly and discuss how to protect themselves from being sexually exploited, coerced, or manipulated. 2/21/23 completed. 5. Residents that have been identified for being at risk from sexual exploitation will be assigned to rooms that are in immediate view of nursing station for more frequent monitoring. 6. R15 is placed on 1 on 1 counseling with PRSC. R15 is placed on money management program. R16 and R17 is placed on 1 on 1 counseling with PRSC. R16 and R17 will sign behavior contract for sexual solicitation and bartering. IDT conducts assigned regular rounds during shift to ensure visual monitoring and staff supervision. 2/22/23 and ongoing. 7. Staff will be in-serviced/trained on how to recognize sexual abuse and sexual exploitation and the facility's abuse protocol to prevent it from happening to other residents. The education will include Abuse prevention reporting policy specifically the definition of abuse, sexual abuse, sexual exploitation, sexual assault, rape and internal reporting requirements and identification of allegation and protection of residents. This training will include reporting of any observations or reports of exchange of money by residents and reporting any observations/reports of sex acts. Staff competency will be determined through a scenario based post- test and signature. All staff will be re-educated prior to next scheduled shift including staff that are on leave and are on vacation. Administrator and Assistant administrator are conducting the training. Administrator/Managers will continue to monitor all staff for compliance by a competency questionnaire. No revision of the current abuse policy has occurred. The noncompliance was a failure to follow current policy. 2/23/23 completed. II of II. Based on interviews and records reviewed the facility failed to follow their abuse prevention policy to prevent resident to resident physical assault. The facility also failed to ensure facility staff utilized safe crisis prevention intervention techniques during physical interactions with residents. This affected 6 of 8 residents (R5, R6, R8, R9, R10, and R14) reviewed for physical abuse prevention. Findings include: 1. R8's diagnosis includes but not limited to Bipolar Disorder, Chronic Obstructive Pulmonary Disease, Schizophrenia, Type 2 Diabetes, Atherosclerotic Heart Disease, Major Depressive Disorder, and Dementia. R8 was admitted to the facility on [DATE]. R8 is moderately cognitively impaired. On 2/16/23 at 1:24PM V29 (Certified Nursing Assistant/CNA), said on 1/25/23 she was in the dining room when she heard another CNA say R8 has a black eye. V29 said she then went and reported the incident. V29 said V31 (Restorative CNA) spotted it first. V29 said I reported to V6 (Administrator). V29 said then V3 (Registered Nurse) and I went to speak to R8. V29 said V3 entered R8's room, but because R8 does not like V29 she waited in the hallway. V29 said she heard R8 say one of the staff came in the room and jumped her. V29 said R8 said a young lady hit her in the mouth and in the face. V29 said she heard R12 (R8's roommate) say she saw the person. On 2/16/23 at 3:24PM V21 (Assistant Administrator) said she was in the office when V29 reported R8's black eye to V6. V21 said V29 said she saw R8 with a black eye. V21 said I sent the initial report to IDPH and then went to speak with R8. V21 said I tried to speak with R8 a few times all R8 said was some b----- had hit her. V21 said R8 said someone with braids. V21 said she spoke with R8 about 15 minutes after V29 had initially reported. V21 said I thought possibly the roommate R14 had hit R8. V21 said V29 said R14 had done it. V21 said I did not speak with V31 about this incident. V21 said on the first day of the investigation I got interviews from all staff in the facility. The surveyor asked V21 if staff had reported to her that R8 said a lady hit her. V21 said not that I am aware of. V21 said R12 had initially said someone with braids came in and struck R8. V21 said R8 was the victim in this incident. V21 said residents should not be putting hands on each other. On 2/17/23 at 10:38AM V31 (Restorative CNA) said when R8 walked into the dining room on 1/25/23, I saw R8 had a black eye. V31 said she heard R8 say She got her a** whooped. The surveyor attempted to interview R8 twice during the survey. R8 did not cooperate and cursed at the surveyor, both times. The surveyor attempted to interview R12 about the incident on 1/25/23, R12 stated I don't have a statement. R8's Abuse/Neglect Screening dated 12/8/22 notes resident triggers a potential high risk for abuse. R8's Abuse/Neglect Screening dated 1/25/23 notes R8's roommates reported I was struck in the face by an unknown person. R8's Risk Management documents R8 said a peer got aggressive with her. Progress notes dated 1/25/23 written by V5 (Director of Nurse/DON) documents it was reported that R8 was noted with discoloration to her right eye. Preliminary 24-hour Abuse Investigation Report dated 1/25/23 states R12 (R8's roommate) reported to V21 (Assistant Administrator) that R8 was struck in the eye by someone with braids. Review of R8's care plan revised on 6/18/22 does not include that R8 has been struck by another resident. Additionally, the care plan denotes I am at not current risk for abuse. The last intervention update is dated 7/12/22. 2. R14's diagnosis includes but not limited to Schizophrenia, Asthma, Diabetes, Anemia, and Delusional Disorder. R14's census list notes she was a roommate with R8 from 5/9/22 until 2/1/23. R14 had a room change on 2/1/23. R14's last Abuse/Neglect screening dated 12/2/22 notes she had an altercation with another resident. R14's Aggressive Behavior assessment dated [DATE] documents R14 has a history of recent episode of aggressive/agitated behavior and/or noncompliance with medications, treatment, regiment, and resisting care. R14 has a history of abuse/neglect either as a recipient or perpetrator including abusive and/or inappropriate sexual behavior. R14's care plan related to abuse was last updated on 12/2/22. No intervention noted following the 1/25/23 incident with R8. 3. R6's diagnosis includes but not limited to Schizoaffective Disorder, Psychotic Disorder, Physiological Condition, Schizophrenia, Adult Failure to Thrive, Delusional Disorder, Bipolar Disorder, Major Depressive Disorder, and Paranoid Personality Disorder. On 2/16/23 at 11:43AM V5 (Director of Nursing/DON) said I think R6 had an altercation with R8 on 1/29/23. On 2/16/23 at 12:42PM V28 (Licensed Practical Nurse/LPN) said R6 slapped R8. R6's progress notes denote It was reported to the writer that resident was aggressive towards peer in the hallway. R6's Aggressive Behavior assessment dated [DATE] documents R6 noted to be in a physical altercation where she was the aggressor. No other assessments after this date were noted. R6's Behavior/Mood Charting dated 1/29/23 denotes R6 was Physically aggressive and wandered. R6's Petition for Involuntary/Judicial admission dated 1/30/23 denotes Resident physical aggressive towards a peer without provocation. R6's care plan denotes she has potential to be verbally aggressive towards staff with 2 incidents in September 2022. R6's care plan denotes an incident of responding to internal stimuli and became physically aggressive towards a peer. Care plan initiated date listed as 1/6/23. R8's risk management record date of incident 1/29/23 notes R8 said peer got aggressive with her in the hallway. Per the surveyors record review this is the second incident for R8 with an injury observed on 1/25/23 and this incident dated 1/29/23. 4. Facility final report to the department dated 2/1/2023 denotes in part date of incident 1/27/23, physical abuse, yes for injuries, no medical attention, minor scratches to face, R5 is person accused. Summary of person reporting incident R10, she just came in my room and hit me in my face. V3 (Nurse) reports R10 came up to her with scratches on his face and told V3 that R5 scratched him. R5 then told me that he R10 stole my tablet, and I (V3) explained to her that he (R10) did not steal her tablet because that is his (R10). R10 has history of having poor boundaries and physically aggression with peers. R5 has history of being verbally and physically aggressive with peers. While R10 was in his room after dinner, R5 went into his room and struck him in his face, reacting to internal stimuli, thinking he had stolen her tablet. This resulted in small scratches to face. First aide was administered. R10 received full body assessment. Resident remains at his baseline, with no emotional stress verbalized or observed. R10 scores a 15 on the BIMS assessment. R5 scores a 15 on the BIMS assessments. On 2/16/23 at 9:57am R5 said R10 had her tablet, the facility was aware of it. R5 said she told V6 (Administrator) about her missing tablet and that R10 had it. R5 said the first time the altercation is when she tripped R10 and attacked R10 while he was on the floor. R5 said she then went into R10's room and busted up R10's television. R5 said R10 had her tablet and that's why she did that. R5 said the second time she went into R10's room and had a physical altercation with R10 resulting in R10's face being scratched. R5 said she did this because R10 had her tablet. R5 said V22 (Psychiatric Rehabilitation Services Coordinator/PRSC) told her (R5) that she has a new tablet, but they must keep it in the office because the tablet was locked due to putting the password in wrong. R5 said she did not make a password for the tablet. R5 said she did not see the tablet. On 2/14/23 at 1:35p.m V21 (Assistant Administrator) said R5 was having delusions that R10 stole her tablet and went into R10's room and struck R10 in the face. V21 said R5 was recently in the hospital and her belongs were in a closet and the facility could not access her belongings at that time. V21 said she does not know if anyone spoke to R5 about her belongings and ensured her that her things were not stolen, that the facility could not get to them at that time, and that R10 did not steal her tablet. V21 said R5 was having delusion prior to striking R10. V21 said the facility did not substantiate abuse but did substantiate the incident occurred. V21 said R5 struck R10 first. R5's progress notes dated 1/12/23 denotes in-part resident noted increasingly delusional today. Reported to writer that she had a baby yesterday. She then broke a peer's television due to believing he had her tablet. MD (Medical Doctor) called, and the order was received to transfer resident to hospital. Ambulance service called with eta (expected time of arrival) of 45 minutes. R5's progress notes dated 1/12/23 Resident had a delusion that another resident stole her tablet, which resulted in a physical altercation. R5's progress notes dated 1/27/23 denotes in-part resident went to another resident room and hit him in the face, asked why she stated that peer stole her tablet MD (Medical Doctor), DON (Director of Nursing) aware. No injury at this time. Denies pain and discomfort. Will continue to monitor. Review of R5's inventory sheet dated 7/16/2021, it is denoted that R5, in fact does own a tablet while a resident of the facility. R10's progress notes dated 1/12/23 denotes in-part writer met with resident after an altercation occurred with peer due to her delusional. Writer counseled resident on coming to staff about concerns instead of engaging in altercation with peers. Resident stated that he still felt safe and wants to remain in facility until resident moves into his apartment. Staff will continue to monitor. R10's progress notes dated 1/27/23 denotes in-part resident had physical altercation with female peer in his room. When asked what happened, resident stated, peer came to my room and hit me in the face Female peer accused him of stealing tablet from her room, both were separated and redirected to their room. Nursing assessment revealed bruises in his face and neck, first aid rendered. MD (Medical Doctor), DON, brother notified, will continue monitor. During this survey it was concluded that R10 was the target of R5 physical aggression related to R5 believing that R10 had her tablet. The facility failed to present an initial concern form with resolution for R5 tablet from 1/12/23. R5 returned to the facility on 1/23/23 (after hospital stay for physical aggression). R5 continue to have concerns for her missing tablet on 1/27/23 prior to R5 physically assaulting R10, thinking R10 had her missing tablet. Facility policy titled abuse prevention and reporting with last revision date of 10/24/2022 denotes in-part this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefor prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatments of residents. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrence of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatments of residents. This will be done by establishing an environment that promotes residents' sensitivity, residents' security and prevent mistreatment, identifying occurrences and patterns of potential mistreatments. Abuse means any physical or mental injury, or sexual assault inflicted upon a resident other than by accidental means. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The term willful, in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. 5. R9's MDS dated [DATE], denotes R9 BIMS is 15. On 2/16/23 at 10:06am V26 (Mental Health Tech/MHT) said he worked on 12/23/22 on the 11:00pm to 7:00am shift. V26 said he did not refuse R9 to call the police. V26 said R9 was heard yelling at R13, about a cigarette, and R9 flipped over R13's table in his room. V26 said R9 did not hit R13. V26 said R9 was then redirected from R13's room to her room. R9 began throwing things in her room. R9 was standing in her doorway. V26 said R9 was saying You can't keep me in here. I didn't do anything. You can't trap me in here. I'm going to call the police. V26 said R9 start hitting him and scratched his face. V26 said he used CPI technique to restrain R9 from hitting him. V26 demonstrated that he held R9 by the wrist to stop her from hitting him, then he held R9 down on the bed and then brought R9 to the floor and continued to hold her down by holding her wrist. V26 said this was to prevent R9 from hitting him. V26 explained CPI is nonviolent techniques used to subdue a combative, aggressive resident. V26 said when a female staff arrived, he asked her to stay with R9 until she calmed down. V26 said once R9 calmed down he told the aide to let R9 up. (V26 does not know who the female CNA was) V26 said he called a 800 number and he reported the situation, and he was sent home for 2 days pending investigation. V26 said the police did come to the facility, but he does not have any information and he did not talk to the police. V26 said he doesn't know if a police report was filed, he left the facility pending investigation. V26 said the nurse did come to check R9 out, but he does not know who the nurse was. V26 said on 2/9/23 around 7:20-7:25am (after smoke break), R9 was having behaviors on the east wing. V26 said R9 asked the nurse for her meds or something and she became verbally aggressive and R9 was saying get the f away from me. V26 said the nurse told R9 to get water from the central nurse station (V26 said that's where R9 nurse is). V26 said when he responded to the code yellow (behavior) he observed R9 flaring her hands back and forth and yelling. V26 said he asked R9 to go to her room, R9 didn't. V26 said that when he and V37 (MHT) staff held R9 by the arms to escort her from that area, and R9 swung at V37. V26 said R9 stumbled and fell, R9's pants fell. R9 threw her pants. (V26 said this happen in the room next to the nurse station on east unit). V26 said they stood R9 up and R9 scratched his face. The nurse gave R9 a PRN (as needed medication). R9 was escorted to her room after that. V26 said there were no behaviors after that and R9 went to the hospital. V26 said he was not sent to home after that. On 2/16/23 at 12:41pm R9 is observed to be alert, and orient to person, place, time, and situation. R9 said around Christmas Eve her and R13 got into an altercation when she asked him for a cigarette. R9 said R13 threw a chair at her, but it did not hit her. R9 said she did not hit R13 either, it was a verbal altercation. R9 said she was escorted to her room by V26 (Mental Health Tech/MHT), and that's when V26 would not let her out her room. R9 demonstrated that V26 stood in doorway of her room, with his arms and legs spread out (blocking doorway). V9 said V26 also was trying to restrain her by holding her arms and hold her down to prevent her from leaving her room. R9 demonstrated that V26 was holding her by the wrist. R9 said V26 also hit her in the face after restraining her to the floor. R9 said she was trying to get out the room when V26 was blocking the doorway. R9 said at some point V26 got off her and the aide came in the room with her (R9). R9 said the police did arrive and spoke to her, and the police said she could stay at the facility. R9 said V26 should not be holding her by the wrist like that and V26 should not hit her in the face on 12/23/22. R9 said the facility don't listen to her or other residents when they report abuse to them and they're not going to do anything to V26. R9 said a man should not be handling a female like that. Facility final report to the department dated 2/11/23 denotes in-part R9's name, date of incident 2/9/23, date incident reported 2/10/23. R9 stated On December 25,2022, V26 did not allow me to contact the police after I was physically assaulted by another resident. V26 then began tussling with me while preventing to leave my room. Then on 2/9/23, V26 was verbally aggressive with me and hit me in my face. R9's document from the hospital social worker dated 2/10/23 denotes in-part R9 endorsed that a staff member named V26 has been physically abusive towards her during her stay at Aperion Care, with the first instance of abuse taking place on 12/25/22 in which R9 stated that V26 did not let allow her to contact the police after she was physically assaulted by another resident at Aperion Care and V26 began tussling with her while simultaneously preventing her from leaving her room. R9 endorsed that the second instance of abuse took place right before her admission at (hospital name listed), and she stated V26 was verbally aggressive towards her and physically assaulted her by hitting her in the face. On 2/14/23 at 1:27p.m V6 (Administrator) said the facility does not substantiate abuse and the facility waits for the department to investigate and substantiate the facilities abuse allegations. On 2/16/23 at 2:12pm V6 (Administrator) said he is not aware of any incidents with R9 and V26 on 12/23/22. V6 said he is not aware that V26 was sent home pending investigation for incident on 12/23/22. V6 said he is not aware of V26 sustaining and scratches to the face after attempting to redirect R9. Review of facility initial report to the department denotes V6 was CC in the email notification confirmation to the department on 2/10/23 at 4:34pm. Initial report to the department denotes R9 reported to the hospital that V26 (MHT), refused to let her call the police when another resident physically assaulted her. She also alleged that on 2/9/23, V26 struck her in the face and was verbally aggressive towards her. R9 did not report these allegations until she was at the hospital. MD (Medical Doctor), Ombudsman and (police department) notified. Full report to follow. On 2/16/23 at 2:37pm V21 (Assistant Administrator) said the hospital contact her and informed her that R9 reported being physically assaulted by V26 once on Christmas and on 2/9/23. V21 said she conducted the investigation of R9 allegation. V21 said the hospital sent her the email statement of R9. V21 said she did not ask V26 about the allegation of tussling with R9 because she did not know what that word meant. V21 said she did not look up the definition of tussling either. V21 said R9 has delusions. V21 said she watched the video recording of the incident with R9 and V26 on 2/9/23 and she observed R9 swing her arms out and kicking at V26. V21 was asked is it reasonable to believe that R9 did not want V26 to touch her since there was an altercation on 12/23/22. V21 said no, R9 has delusions. V21 was made aware that V26 alleged he used CPI on R9 and R9 scratched him in the face. V21 was made aware that R9 said V26 was physically aggressive with her and was holding her by the wrist. V21 said R9 has delusions, and she's not aware of anything happening on 12/23/22. V21 was made aware that V26 said he had to use CPI on R9 by hold her by the wrist. Webster dictionary defines, tussling/ tussled means engage in vigorous struggle. On 2/17/223 at 10:25am V5 (Director of Nursing) was asked if she was aware of the incident with R9 and V26 that occurred on 12/23/22. V5 said she was not aware of anything happening between V26 and R9. V5 was made aware that V26 alleged he used CPI on R9 and R9 scratched him in the face on 12/23/22. V5 was made aware that R9 said V26 was physically aggressive with her and was holding her by the wrist. V5 said R9 has delusions, and she's not aware of anything happening on 12/23/22. V5 was made aware that V26 said he had to use CPI on R9 by hold her by the wrist. V5 was asked is it reasonable to believe that R9 did not want V26 to touch her since there was an altercation on 12/23/22. V5 said yes, it's reasonable but R9 has delusions. V5 said she was aware of the incident when V26 used CPI on R9 on 2/9/23 and that entire situation arises due to R9 requesting water from the nurse and the nurse did not give R9 water. V5 was made aware that V26 alleged he used CPI on R9 and R9 scratched him in the face. V5 was made aware that R9 said V26 was physically aggressive with her and was holding her by the wrist. V5 said R9 has delusions, and she's not aware of anything happening on 12/23/22. During this survey, the facility failed to provide an incident report for R9 and V26 on 12/23/2022, and incident report for 2/9/23 when V26 used CPI on R9. The review of V26's timecard reveals V26 was on duty on 12/23/22 from 11:12pm until 12:32am. V26 employees report of injury dated 12/23/22 denotes in-part V26 was trying to stop a resident (R9) from attacking another resident when she punched him in the face and scratched him in the neck, under the left eye and above the nose. On 2/16/23 at 10:06 a.m.V26 denied that R9 had physical contact with R13 on 12/23/22. V26 injury report

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to supervise and monitor R3 during outdoor activity. This failure resulted in R3 leaving the facility while facility staff were playing basketball. The facility also failed to determine the pass privilege policy for R4. This failure resulted in the facility staff opening the door and allowing R4 that was assessed to be an elopement risk to leave the facility without checking the elopement book or verifying R4's pass privilege. The Immediate Jeopardy began on 1/31/23 when staff used the door code to allow R4 to leave the facility without checking that R4 was on elopement protocol and did not have pass privileges. V6 (Administrator) was notified of the Immediate Jeopardy on 2/16/23 at 12:15 pm. The surveyor confirmed by observation, record review, and interview that the Immediate Jeopardy was removed on 2/22/23 but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan. The findings include: 1.R3 has cognitive impairment. R3's diagnosis include, but are not limited to Schizoaffective Disorder, Bipolar, Suicidal Ideations, Patient's other non-compliance with Medication Regimen, Asthma, Cocaine Abuse, Depressive Disorder with Psychotic Symptoms, Auditory Hallucinations, and Dorsalgia. R3 admitted to the facility on [DATE] following a psychiatric hospitalization. R3's Notice of PASRR (Pre-admission Screening and Resident Review) Level II dated 12/21/22 states you came to hospital psychiatric unit on 12/13/22 as you were having increased mental health symptoms with thoughts to end your life by jumping in front of a car. When you are not at the hospital, you do not have a place to live. Important for a provider to know (in part) you need help from others to make safe decisions. You believe things to be true that others don't find to be true. You have a history of Cocaine abuse; you tested positive for Cocaine when you got to the hospital. R3's PASRR Grouping You fall into the category of having a diagnosis that the PASRR program was designed to assess. Your condition is likely to require expert treatment in the future. That diagnosis is A serious mental health condition. R3's smoking safety risk assessment dated [DATE] states R3 requires supervision only (no assistance) with smoking. This is the only smoking assessment in R3's record. Elopement risk assessment dated [DATE] denotes R3 does not have dementia and/or severe mental illness. (R3 has Schizoaffective disorder, Bipolar Type, Suicidal Ideations, and Major Depressive Disorder.) This assessment denotes R3 is not at risk for elopement. Community survival skills dated 12/29/23 denotes R3 does not appear to be capable of unsupervised outside pass privileges at this time. R3's Cognitive assessment dated [DATE] notes R3 has a score of 5, severely impaired. R3's Functional Status assessment dated [DATE] notes R3 requires supervision for bed mobility transfers and walking in the room. R3's care plan initiated on 1/4/23 denotes a history of severe mental illness (Schizoaffective) as manifested by: Delusions persecutory, delusions - paranoia, delusions - poor ability to reason, hallucinations -auditory, need for ongoing psychoactive medications. R3's care plan denotes he wishes to discharge to another facility and has a history of substance abuse, and R3 is a smoker. R3's orders do not state a pass privilege. R3's progress notes for 2/5/23-2/8/23 read eloped. On 2/11/23 at 11:38AM V3 (Registered Nurse) said R3 came in homeless. He had fingers and toes amputated in the past, but not recently. V3 said R3 would occasionally ask if I could give him a ride. V3 said she would ask him to where, but he was unable to give an address, somewhere on the northside. V3 said R3 was always sleeping. He was cooperative. He eats and then go back to bed. V3 said R3 walked stable. V3 said I was told that R3 eloped and I saw in the computer. V3 said the CNAs (Certified Nurse Assistants) stated, He ran out and He eloped. V3 said the CNAs stated they don't know how he got out. On 2/11/23 at 11:53AM V9 (Certified Nursing Assistant/CNA), said R3 would ask Can you call someone?. V9 said I don't know who he wanted to call so I would tell him to tell the nurse. V9 said R3 can walk and has a normal pace. V9 said R3 is not here today. I don't know where he is. I have not seen him. V9 said I asked my nurse (V3) where R3 was and V9 stated She said he eloped. V9 said she is expected to do a head count 3 times a day at 7:00AM, 10:00AM, and at 2:00PM. On 2/11/23 at 12:24PM V13 (CNA) said after 5:00PM we started looking for R3. V13 said we found out R3 was not there. V13 said we called a code pink and started looking. V13 said I was not assigned to R3 that day (2/5/23). On 2/11/23 at 12:32PM V11 (Licensed Practical Nurse) said on 2/5/23 V14 (CNA) reported he could not find R3. V11 said I went to go look for R3 and could not find him. V11 said we checked the whole building we called the Administrator and the Director of Nursing (DON). V11 said the police were called and they came out. V11 said it was around 5:00PM. V11 said I had not seen (R3) that day. V11 said I am not sure when they last saw him. V11 said I don't know what happened to him. No one has told me anything. V11 said R3 did not tell me he was leaving on 2/5/23. V11 said we called a code pink. V11 said we were still looking for R3 when the police came. V11 said we stopped looking after about an hour of searching. On 2/11/23 at 12:43PM V12 (CNA) said I worked on 2/5/23 but I did not see R3 at all that day. On 2/11/23 at 12:53PM V14 (CNA) said a Code Pink is elopement. V14 said a code pink was called for R3 on 2/5/23. V14 said we did not find him. The code started around 5:00PM or 5:30PM. V14 said when I didn't see him after taking him his dinner, I realized he was not there. V14 said I started my shift on 2/5/23 at 3:00PM. V14 said I did not see R3 on 2/5/23 at all. V14 said we don't have a head count until 6:00PM on my shift. V14 said We wait for after dinner to look for them. V14 said we could not find R3, and we stopped looking. V14 said I am not sure if someone looked outside for R3. V14 said I was the first person to report R3 missing. On 2/11/23 at 1:22PM V16 (Mental Health Tech) said R3 walked slow, he does not move fast, his thinking process is not there. V16 said R3 would not stay outside for long, he would not even finish his cigarette, he was always cold. When V16 was talking about R3 he said you would have to ignore him for him to get out. On 2/11/23 at 1:43PM V15 (CNA) said I started my shift on 2/5/23 at 3:00PM. V15 said we had cigarette breaks and then dinner. V15 said I was outside for smoke break from 3:15PM and 3:30PM. V15 said I did not see R3 at that break. V15 said R3 usually walks around the facility, he walks normal at a normal pace. V15 said a code pink was called for R3 on 2/5/23. V15 said I don't know when the last time anyone saw him was. V15 said we stopped looking for him after dinner time. V15 said I did not go outside to look for him. V15 said I believe staff is supposed to look outside for a code pink. V15 said I don't think anyone knows where he is. On 2/11/23 at 3:11PM V1 (CNA) said during the 6:00PM head count it was noticed that R3 was missing. V1 said R3's baseline was to walk normal without assistive devices. V1 said R3 had a normal pace. V1 said during a code pink, no one is assigned to look outside. V1 said I did not look outside on 2/5/23. V1 said I don't know if anyone looked outside. V1 said the code pink was called clear code for (R3), but that is not clear. V1 said R3 was not found during the code pink on 2/5/23. On 2/11/23 at 3:35PM V2 (Human Resources) said V18 (Former Mental Health Tech) was terminated due to not supervising the residents during the smoke break between 1:15PM and 3:15PM on 2/5/23. On 2/12/23 at 9:12AM V6 (Administrator) said V18 was terminated for not being in his assigned spot, in the building working on 2/5/23. V6 said V18 was playing basketball. V6 said he was told the activity room patio door was open. V6 said V19 and V20 (Activity Aide) were terminated because the activity door was open and V19 and V20 were not doing a good enough job to supervise the residents. V6 said I did the investigation because during the 6:00PM head count on 2/5/23, it was reported that R3 was missing. V6 said he watched the surveillance video and saw R3 playing basketball on the activity patio around 2:40PM. V6 said then I saw him leave thru the gate. V6 said he was able to see R3 went east on the street saw him go past 1 house on the video. V6 said I did not see staff go after him. V6 said from the video the 2 activity aides (V19 and V20) were inside the facility while the doors were open. V6 said there was no staff on the patio while the residents were outside. V6 said V19 and V20 were telling me they were watching the patio from the doorway. V6 said I could not see them watching from the doorway on the video. V6 said We are unsure where R3 is at this time. At 9:42AM V6 provided V11's phone number as the person who spoke with the police. V6 provided the police report number. V6 said when he came to work on Monday, 2/6/23, the gate latch to the sidewalk/street at the end of the driveway that leads to the patio, was not latched. On 2/12/23 at 9:31AM V8 (Activity Aide) accompanied the surveyor on a tour of the activity patio. V8 said the residents play basketball out here. V8 said if we open the patio, we have a Mental Health Tech or Activity Aide sitting by the chairs by the gates. The surveyor observed 3 gates with latches. 1 gate off the activity patio leading into the smoking patio. Second gate leads from smoking patio to the facility driveway, where the facility vehicles are parked. This gate is shorter, about 4 feet. A third gate was noted at the end of the driveway from the driveway leading to the sidewalk and street. On 2/12/23 at 11:20AM the surveyor was accompanied by V17 (Maintenance Staff) who measured the distance from the activity patio to the street. Total distance was 144 feet. R3 walked about 144 feet around the outside of the facility to leave. On 2/12/23 at 11:28AM V3 said we always have done head count forever. V3 said we started doing this specific head count (green sheet) on 12/2/22. V3 said the CNAs take a census sheet and sign off when the resident is here. V3 said I take the papers and leave them on the table. On 2/12/23 at 12:49PM V5 (Director of Nursing/DON), said CNAs are expected to do rounds on residents every 2 hours. V5 said CNAs should do a bed check at the start of the shift. V5 said CNAs should lay eyes on everyone at the start of the shift. On 2/14/23 at 12:13PM V6 said I was told surveyors can't watch the video. At 12:20PM V6 said I did not report to IDPH that R3 was missing because I was told we would report if there were an injury. At 12:27PM V6 said I do not know what staff searched the surrounding areas. At 1:37PM V6 said the staff did not document the date or time the hospitals were contacted in search of R3. 2. R4's diagnosis includes but not limited to Bipolar, Moderate Intellectual Disabilities, Hypertension, Hyperlipidemia Type 2 Diabetes, Constipation, Morbid Obesity, and Nicotine Dependence, Cigarettes. R4 was admitted on [DATE] from another facility. On 2/12/23 at 12:49PM V5 (DON) said she was informed on 1/31/23 that R4 was not located. V5 said she as notified around 2:00PM from the head count. V5 said a code pink was called. V5 stated while doing the search, R4's family called and spoke with V4 (Psychiatric Rehabilitation Services Coordinator/PRSC) and said R4 was at his sister's house. V5 said R4's sister did not pick R4 up from the facility. V5 said I have no idea how he got out. V5 said R4 left unauthorized. V5 said the sister brought R4 back to the facility a couple of days later. On 2/14/23 at 10:21AM V6 (Administrator) said R4 was trying to obtain a community pass and wanted to visit his sister. V6 said R4 had told his caseworker (V4). V6 said on 1/31/23 V23 (Minimum Data Set/MDS Coordinator) did not verify R4's pass status and entered the code and let R4 out of the facility. V6 said he was made aware that R4 was missing after a head count. V6 said R4 went to his sister's house, and she brought him back. At 2:33PM the surveyor asked V6 if a resident comes missing and the whereabouts of the resident are found, does the facility have the ability to pick up the resident. V6 said We have the capability with 3 vans to pick up residents. We would coordinate the transport back to the facility. The surveyor asked if the family asked the facility to come pick up the resident from an unauthorized leave, would the facility pick the resident up? V6 said yes. On 2/14/23 at 10:47AM V4 (PRSC) said V4 completes the elopement assessments when a resident comes into the facility. V4 said R4 had expressed he wanted to go to another facility, specifically he wanted to go to a condominium, a 1 bedroom. V4 said he was working with R4's family towards that. V4 said R4 had said he did not want to share a room. V4 said R4's judgment was off. V4 gave the examples of R4 saying he wanted to leave and go to a shelter with four dollars, leaving his personal items out, he constantly left his shoes and phone out. V4 said R4 makes poor decisions. V4 said he did a second elopement risk assessment on 1/30/23 because he was at my office door a lot and expressed he wanted to leave. V4 said R4 gave him the thought that R4 might elope. V4 said there had been a couple times when R4 expressed he wanted to get a pass. V4 said he reported those times to V5 or V6. V4 said I sent out an email about it. (V4 did not provide a requested copy of the email.) At 10:58AM V4 said he was in the facility on 1/31/23 when they noticed R4 was gone. V4 said R4's mother called me and asked how he got a pass because R4 was at his sister's house. V4 said I put R4's mother on hold and called the Mental Health Techs and they did a room search and that is when we were aware that R4 was missing. R4 said we did a code pink. V4 said I was the first to be aware that R4 was gone. V4 said R4 was not eligible for a community pass because he was still within his 30- or 60-day review period. V4 said at 21 days R4 would have been able to go out with family. V4 said R4 had just reached the limit to be considered for a pass. V4 said I think we were going to be deny his community pass. V4 said when speaking with R4's family they told him that R4 could not be out on his own. V4 said R4's sister said R4 got on the bus to get to her house. V4 said a Community Skills Assessment is to be done on admission, or within 72 hours from admission. On 2/14/23 at 11:57AM V22 (PRSC) said Community Skills Assessment are done initially after admission, update quarterly, change of condition, or if the resident requests a pass. V22 said the purpose of the Community Skills Assessment is to find out if residents are capable of functioning in the community. V22 said these are done within a week from admission. V22 said the nurses should communicate expressions of residents requesting to leave or if residents are making statements of wanting to leave. V22 said from there we would do an elopement assessment or update the care plan. V22 said if a resident is found at risk for elopement it should be on the care plan. On 2/14/23 at 12:30PM V25 (R4's family) said on 1/31/23 R4 came by here. I called the facility and they said they did not know he got out. V25 said R4 grabbed his coat but had no shirt on when he arrived at her house. R4 said I live in XXXX and R4 got on the bus to get here. V25 said R4 walked from the bus stop to her house. V25 said she was told by V4, that the facility could not come out and get him and that she needed to bring him. V25 said she gave R4 twenty dollars and told him to go back to the facility. V25 said later she called the facility and they said he was not back. V25 said 2 days later R4 returned to her home and asked for more money. V25 said she took R4 back to the facility. On 2/14/23 at 12:56PM R4 was asked how he got out of the facility on 1/31/23 and R4 told the surveyor I left out, I walked out the front door. R4 said he walked to Lincolnwood Highway. R4 said he left after lunch. R4 said he took the bus, and it dropped him off at the mall and he we walked a couple blocks to his sister's home. R4 said it took him about 30 minutes to get to his sister's home. The surveyor asked R4 where he stayed the 2 nights he was not in the facility. R4 said I stayed on the bus. R4's progress notes dated 1/20/23 at 3:00PM document R4 was increasingly aggressive toward staff, exit seeking behavior and difficulty in redirection. A social service progress note documents R4 approached the writer (V4) about signing out against medical advice (AMA). R4 reported he did not want to be in the facility anymore. R4 said he would prefer to be at the shelter. Per progress notes R4 was taken to the hospital. R4 returned to the facility on 1/26/23. R4's progress notes dated 1/31/23 at 9:32 written by V4 documents R4 approached V4 (for the seventh time) about getting an independent pass. V4 denied R4's request and said R4 was just readmitted from the hospital and was ineligible for a pass. V4 documented R4 understood. R4's progress notes dated 1/31/23 at 2:30 document it was brought to the writer's attention V5 that R4 has an unauthorized exit from the facility. R4's mother notified the facility that R4 visited his sister and was provided funding to return to the facility. Facility aware of resident exit. At this time, a missing person's report has been filed and awaiting resident return. R4's progress notes dated 2/2/23 documenting R4 was brought back to the facility by his sister. R4's elopement/unauthorized leave risk review dated 12/22/23 notes 1b.is there a diagnosis of dementia and/or severe mental illness - No. (R4's diagnosis includes Bipolar.) 2b. Signs of compromised decisional capacity and substantially impaired judgement and/or physical status limitations that would place the resident at risk in the community -yes. 4e. Has the physical ability to leave the building? No 5a. Elopement risk decision 3. Not at risk. R4's elopement/unauthorized leave risk review dated 1/30/23 at 6:59PM notes 1b.is there a diagnosis of dementia and/or severe mental illness -yes. 4c. Verbalizes a serious/strong intent to leave the facility in the absence of an appropriate discharge plan. 4e. Has the physical ability to leave the building? No 5a. Elopement risk decision 1. At risk to elope and should be placed on the Elopement Risk Protocol. A care plan for elopement is indicated. R4's smoking risk assessment dated [DATE] denotes he can smoke independently with supervision only. Review of R4's January - February 2023 physician orders do not include an order for a community pass or outing. Review of R4's hospital records dated 1/21/23 note R4's petition states R4 was displaying exit seeking behaviors. R4's care plan printed by the facility on 2/14/23 does not include his risk for elopement. Review of a facility provided letter dated 1/24/23 at 8:36AM denotes R4 reported to staff that he became aggressive and wanted to leave the facility. Census report for R4 denotes he was on therapeutic leave of the facility on 1/31/23. Facility Human Resources Notice of Correction Action for V23 (MDS Coordinator) dated 2/1/23 documents on 1/31/23 employee opened door from secured section of facility for resident without verifying resident community access. The facility undated Smoking policy notes assigned staff will monitor the residents in the smoking program. Staff will remain in the designated area, during the entire scheduled smoking times with the residents. The facility undated Security, Supervision, and Safety Policy states the facility has incorporated the practice of making regular rounds at regular identified intervals throughout each day. Maintains a stringent smoking program which prohibits indoor smoking, limits smoking times, access to materials and allows for ongoing supervision of resident smoking. Code Pink Missing Resident/Elopement revised 11/15/18 states an incident report and notification to the state agency should be made. The policy states the facility should contact the morgue if the residents has not been located for 24 hours. Upon return the nurse should complete a new elopement risk assessment and update the plan of care. The facility's Community Pass Guidelines revised on 11/17/17 states a community skills assessment will be completed upon admission. The surveyor through observation, interview and record review confirmed the following removal plan was implemented by the facility: Aperion Care Chicago Heights Removal Plan, action taken: 1. Complete and submit an elopement investigation for resident. Date: 2/22/23 2. Review all resident's community survival assessment, update interventions as appropriate. Audit will be completed by PRSC's. Date: 2/16/23 3.Review of all community access passes for residents. Audit will be completed by PRSC and reviewed by PRSD. Date: 2/16/23 4. Educate all staff on supervision policy to address staff are not to leave any area with residents present and to keep supervision of any exits, verifying residents' community access pass prior to unlocking exit door, and smoke break procedures. All staff will be trained by 2/16/2023 via skills presentation and any staff on leave or unavailable staff will be educated via phone and again before next scheduled shift. Facility will ensure understanding of policy through drills. Date: 02/16/2023 and ongoing 5.Complete an elopement risk, restricted leave binder at the front desk and each nurse's station. This binder shall have an identifiable picture of all at risk residents. PRSD is responsible for maintaining and updating the elopement, restricted leave binder. Binder was available during R4 elopement. Elopement binder protocol was changed to include residents with community access within elopement binder. Date 2/22/23 6. Elopement risk policy reviewed and updated. All staff will be trained by 2/16/2023 via skills presentation and any staff on leave or unavailable staff will be educated via phone and again before next scheduled shift. Facility will ensure understanding of policy via QA tool. Date: 2/22/23 7. Review all elopement risk assessments to ensure accurate assessment, implement interventions as needed and update care plan accordingly. Elopement risks assessments will be reviewed by IDT team composed of Administrator, DON, and PRSD. Date 2/22/23 8. Ensure all exit doors are checked every shift for alarm function, alarmed at all times, and in working order. All doors secured with an alarm and will be tested daily by Maintenance Director and manager on duty during the weekend. This will be tested every shift for 30 days then daily. Facility will work with alarm vendor is repair or replace mag lock for dining room door. QA tool in place and will be completed by maintenance and manager on duty. Date: 2/22/23 9. Code Pink Policy was not updated due to incident, but supervision policy was updated to address issue from incidents. Code Pink (Elopement-missing person) drill was performed on 02/16/2023 by administrator and will be performed weekly for one month and monthly thereafter. Staff will be re-in-service on code pink (elopement-missing person) if/when revisions are made and upon annual review of annual policy by social services, nurse management, and administration. New hires will be in-serviced on code pink (elopement/missing person) during their general orientation. Facility had been completing elopement drills monthly. Facility will evaluate effectiveness by staff recognition of missing patient and timely response of all staff. Code Pink drills will be performed by IDT team (Administrator, DON, and PRSD) three times a week for a month, then weekly thereafter for 6 months. Date: 2/16/23 and ongoing 10. Medical director notified of incident on 02/16/2023 by the facility by the Administrator and reviewed the facility's immediate action plan. He agreed with immediate action plan. Date: 2/16/23 11. QAPI review with Medical Director to review elopement incident and plan of action. IDT conducts assigned regular rounds during shift to ensure visual monitoring and staff supervision. Action plan will be reviewed monthly at QAPI meeting. Date: 2/22/23

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Based on interview and record review the facility failed to prevent a resident-to-resident sexual assault. This failure affected 4 (R39, R74, R171, and R427 ) residents reviewed for sexual assault. This failure resulted in R39 being sexually attacked by R427 and R74 to pull R171's pants down and attempt to provide R74 with oral sex. Findings Include: A. Police report dated 11/3/22 documents: while in R39's room, R427 used forced to push R39 backwards onto her bed. While lying on her back R427 laid his body on top of R39. R427 place his hand on R39's mouth, place his other hand inside the front of R39's pants and touched R39's vagina, after R427 removed his hand from R39's pants, he sniffed his hand. Progress noted dated 11/3/22 documents: At around 1:30am a call was received from the police department stating that R39 called them and alleged that a male client (R427) attempted to sexually assault her. R39 stated that (R427) attempted to fondle her and hold her down against her will. R39 was noted with a small superficial scratch under the right nostril. Resident (R427) was being sexually inappropriate with female peer. R427's hospital paperwork dated 11/4/22 documents: R427stated, I am just compelled to touch women. Diagnosis: sexually aggression and physical aggression. R39's brief interview for mental status dated 12/8/22 with a score of 14 which indicated cognitively intact. Care plan 4/15/22 documents: I (R39) am at potential risk for abuse/neglect. Abuse and neglect screening dated 10/5/22 documents: Resident (R39) triggers as potential high risk for abuse related to mental illness and history of poor and dysfunctional behaviors. On 1/11/23 at 10:59am, V29 (PRSC) said, R427 pushed R39 down on the bed and reached under R39's skirt to touch R39's vaginal area/perineal area. R427 tried to sexually assault R39. On 1/11/23 at 11:07am, V9 (PRSC) said, R39 reported R427 entered her room and was sexually inappropriate. R427 pushed R39 down on the bed and tried to penetrate R39. On 1/12/23 at 1:36pm, V37 (Nurse) said R427 helped R39 into her room. Both residents were sitting on R39's bed. R427 attempted to pin R39 down by the shoulders. R427 touched R39's breast and vaginal area through R39's clothes. On 1/12/23 at 3:29pm, V28 (former PRSD) said R427 attempted to sexually assault R39. On 1/20/23 at 2:24pm, R39 who was assessed to be alert to person, place and time said, R427 pushed me on my bed by my shoulders, covered my mouth, I couldn't scream out. R427 held me down with his chest. R427 pulled his pants down, I saw his penis. R427 squeezed my breast and my nipples hard. R427 put his hand down to reach my vaginal area but my stomach was in the way. I felt violated. Abuse Policy revised 4/29/22 documents: The resident has the right to be free abuse. Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to unwanted intimated touching of any kind especially of breasts or perineal area. Generally, sexual contact is non-consensual if the resident does not want the contact to occur. B. On 1/18/2023 at 2:57 pm, R171 who was alert and oriented at time of interview stated that 3 days ago, R74 entered R171's room without permission. R171 stated that R171 was lying in bed after breakfast. R171 stated that R74 approached R171 and started pulling down R171's pants to perform oral sex. R171 stated that R171 grabbed R171's pants to prevent R74 from R74 removing pants any further and yelled. R171 stated that R171 informed R74 to stop and pushed R74's head away. R171 stated that R74 then pulled R74's pants down and attempted to get in bed with R171. R171 stated that again R171 pushed R74 away. R74 pulled pants up and exited R171's room. R171 stated that R171 felt like he was being molested. R171 stated that during smoke break in the evening, R171 reported incident to V59 (Activity Aide). On 1/18/2023 at 3:19 pm, R173 who was alert and oriented at time of interview, stated that 3 days ago R173 was talking with R171 in their room when R74 came into R173's room without permission and asked R173 if R173 wanted to have sex. R173 stated that R173 declined and told R74 to leave. R173 stated that R173 witnessed R74 go to R171 and began pulling R171's pants down to try to have sex with R171. R173 said he heard R171 say no and then R74 left the room. R173 stated that R173 did not report the incident. On 1/18/23 at 3:40 pm, R171 identified R74 at smoke break as the resident who pulled R171's pants down. On 1/18/23 at 3:54 pm, V59 (Activity Aide) stated that during smoke break on Sunday, R171 informed V59 of incident involving R74. V59 stated that she reported this incident to MHT staff member. V59 does not recall which Mental Health Tech she spoke with. On 1/19/2023 at 11:25 am, V29 (PRSC/Psychiatric Rehabilitation Services Coordinator) stated that R74 was assigned to V29's caseload upon his admission. V29 stated that R74 was admitted to this facility because of his mental illness, R74's family was unable to provide care for R74, and R74 is delusional. When questioned if V29 reviewed R74's pre-admission hospital record, V29 responded I reviewed everything I needed to review. V29 stated that R74's hospital record notes R74 has an abusive history in which R74 is the abuser. V29 stated that there are no group therapy programs offered. V29 stated that V29 meets with R74 for 1:1 session to discuss ADLs (activities of daily living), dressing appropriately for the weather, getting help with what R74 wants to do with his life, and aggression issues. V29 stated that V29 documents these sessions in R74's progress notes. V29 stated that V29 tries to have 1:1 session with R74 once a week or once every two weeks. V29 stated that V29 has 39 residents on his caseload. When questioned if V29 feels he is meeting the needs of R74, V29 responded absolutely. V29 was unable to provide specific dates, times, details of these 1:1 session, or documentation to support V29 has provided any mental health services/support to meet the needs of R74. Review of R74's pre-admission hospital record, dated 7/21/22-11/10/22, notes R74 is dually diagnosed, but has not received services that take into account R74's intellectual disability for most of R74's adult life. R74's trauma history notes R74 was the victim of sexual abuse as a child. R74 has poor to no insight, impulsive, intellectually disabled and has limited social skills and coping skills. There is no documentation found in R74's hospital record noting R74 has a history of being abusive to others. Review of R74's medical record notes R74 was admitted to this facility on 11/10/2022 with diagnoses including schizoaffective disorder, bipolar type, insomnia, mild intellectual disabilities, intermittent explosive disorder, and auditory hallucinations. There is no documentation found in R74's medical record noting R74 was receiving group therapy or 1:1 session with any PRSC from 11/10/22 through 1/18/23 when R74 was transported to the hospital for aggressive and socially inappropriate behaviors. Review of V29's documentation in R74's medical record notes on 11/11/22, V29 completed an initial social history assessment and held an introductory meeting with R74. R74 was informed of reason for admission, all facility policies and procedures and case management office hours and location. V29 explained behavior contract. V29's next note, dated 1/18/23, notes V29 spoke with R74 about allegations that R74 was being sexually inappropriate with his peers. R74 denied these allegations but assured V29 that any relation that he has had with his peers has been consensual. Review of R74's PASRR II, dated 10/28/22, notes R74 was approved for short term nursing facility services. R74 does not require specialized services, such as psychiatric hospitalization. R74 needs a living environment with supervision and medication environment. R74 has a diagnosis of severe mental health condition. R74 will need to be provided the following services and/or supports: pharmacotherapy including administration and monitoring of the effectiveness and side effects of medications prescribed to change inappropriate behavior or to alter manifestations of psychiatric illness. Development, maintenance, and consistent implementation of those programs designed to teach 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. Individual, group, and family psychotherapy to develop effective coping skills to manage mental health symptoms, improve insight and increase positive social supports. Review of R74's PASRR I, dated 10/10/22, notes R74 has an intellectual disability that began prior to the age of 18. IQ testing was administered on 10/4/22 with results 52. V. Based on observation, interview and record review, the facility staff failed to follow their abuse policy and protect a resident from being recorded by staff posted the resident on social media. This failure affected 1 resident (R136) reviewed for abuse involving social media. Findings include: On 1/19/23 at 10:33am, R136 was observed on two different (social media) videos with V56 (Activity Aide). One video was of R136 and V56 dancing and turning around. The second video was of V56 looking up at R136 then looking back at the phone screen smiling with the caption, when my resident say the wrong (ninja emoji) name on ft (facetime). Both videos had V56's (social media) name and the (social media) symbols and wording. On 1 /20/23 at 2:24pm, V40 (Activity Director) said, my employees are not supposed to be making/recording (social media) of residents on their personal social media accounts. Our audio, video and photographic release form is for facility activities or facility related things only. On 1/20/23 at 2:46pm, R136 who was assessed to be alert and orient to person, place and time said, I have never given anyone permission to post any videos of me on social media. I don't know what (social media) is. V56 (Activity Aide) took videos of me on her phone moving around and dancing. R136 identified V56 via photo. I don't want everyone to see me dancing because I wasn't dressed up in pretty clothing. Acknowledgment of Receipt of employee handbook dated 11/1/22 documents: V56's electronical signature. Termination papers dated 1/19/23 documents: V56 failed to comply with social media section per employee handbook page 22 by posting a (social media) of a resident. On 1/19/23, V1 (administrator) was provide video evidence that employee (V56) posted (social media) with resident (R136) of facility. Abuse policy dated 4/29/22 documents: Photographing and recording resident/social media. Staff photographing or recording resident or their private space (even if the resident is not present) for other than medical or facility purpose as described in a signed audio, video and photographic release form is strictly prohibited. Staff posting or sending a photo recording on social media or otherwise keeping or sending a photo or record thorough multimedia messaging other than for facility purpose as described in a signed audio, video and photographic release form is strictly prohibited. III. Based on interview and record review the facility failed to prevent incidents of resident-to-resident physical assault. These failures affected 6 (R119, R29, R56, R60, R96, and R167) residents reviewed for physical abuse in the sample of 35. This failure resulted int R56 being assaulted and sustaining an abrasion to the chin area and a laceration to the left side of her head requiring 21 staples to the occipital area and treated for occipital condyle fracture. Findings include: A. R56's diagnosis including, but not limited to Parkinson's Disease, Bipolar Disorder, Anxiety, Alzheimer's Disease, Dementia, Schizoaffective Disorder, and Dementia. R56's Abuse/Neglect Screening dated 9/6/22 notes a score of 4= Moderate. Presents with a moderate level for abuse and neglect. Progress Notes dated 1/6/23 notes R56 verbalized to writer that she was hit in the head from the back by peer, noted with slight blood at the side of her head. Noted with laceration in the scalp. First aid rendered and 911 called. Progress Notes dated 1/8/23 notes R56 back from hospital with 21 staples in the head and neck brace because of fracture of the neck. R119's diagnosis including, but not limited to Psychotic Disorder and Schizophrenia. R119's Aggressive Behavior assessment dated [DATE] documents she was involved in a physical altercation with a male peer and admitted to being the initial aggressor. R119's care plan initiated on 11/14/18 documents she has the potential to be physically aggressive related to a diagnosis of psychosis. Documented behaviors directed towards other residents include scratching, pushing, physical altercations and aggression. Progress Notes for R119 dated 12/28/22 documents R119 is reported to be aggressively throwing punches when no one is there and talking to self. On 1/8/23 the surveyor observed R56 during initial observation made between 10:30-11:00 am. R56 was lying in bed, flat on her back, and wearing a neck brace. R56 was in an isolation room. Staff sitting, V23 (Certified Nurse Assistant/CNA) outside her room said she has COVID. The surveyor asked V23 what happened to R56. V23 replied I don't know what happened to her, it was last night . Surveyor did not enter the room to finish screening all other residents and then returned to kitchen for observations. Upon return to the unit 2:00 pm R56 was no longer in the facility. On 1/9/23 at 12:00 V6 (Registered Nurse) said she was on break in the Central Nurses' stations and R56 walked in and said R119 hit me from the back and she mad, she hit me. V6 said R56 said I don't know with what. V6 said R56 was alert. V6 said R119 won't speak to say why she hit R56. V6 said R119 was hallucinating, and I sent her out immediately. V6 said I saw the laceration on R56, and I called 911. V6 said I saw the laceration on the top of R56's head. V6 said R119 and R56 was walking in the hallway. V6 said R119 is no one's friend. V6 said this happened in the evening. V6 said I asked the CNAs about the incident, and they said they didn't see anything. V6 said R56's behavior does not include fighting; she has occasional anxiety. V6 said R119 always talks to herself, hallucinates, and when the psych doctor comes in, I tell them to evaluate R119. She talks like she is in conversations with 10 people. She was compliant with her medication. V6 said whatever they have done, it was not effective. V6 said R119 had been yelling and hollering all the time and verbally aggressive. V6 said when she spoke to Psych doctors about the behavior, they said that was her baseline. V6 said I told them she was not a baseline. V6 said I don't know what R119 used to hit R56 with. V6 said the incident happened in the back hallway. On 1/9/23 at 12:24 pm V20 (Licensed Practical Nurse) said R119 and R56 are not physically aggressive, I never seen her hit anyone. On 1/9/23 at 2:01 pm V9 (Social Services) said I am not aware of the situation with R56 and R119. V9 said she was not notified to perform an assessment or implement new intervention for R56 or R119. On 1/10/23 at 9:57 pm V22 (CNA), said R119 is pleasant, calm, does not cause any problems, quiet, and she does not bother anyone. On 1/10/23 at 2:06 pm V23 (CNA) said on 1/8/23 she sat outside of R56's room to monitor her. V23 said before the incident R56 used to walk around. On 1/11/23 V35 (Doctor) was asked by the surveyor if he expects his patients to be safe in the facility? V35 responded Yeah, absolutely. V35 said I would want my residents to be safe in the facility. B. R60's diagnosis including, but not limited to Paranoid Schizophrenia, Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. Abuse investigation form documents on 10/13/22 R60 has history of poor boundaries and impaired thought process. R29 has history of poor boundaries and physical aggression. It is documented that R60 and R29 were served at lunch and sat at the same table. R60 attempted to grab food off R29's tray. [This is different than V22's interview with surveyor.] R29 displayed poor boundaries and impulse control by striking R60. Nursing staff attempted to apply first aid to R60's superficial cut on lip, but R60 refused treatment. R60's care plan initiated on 4/21/20 documents R60 displays poor boundaries. Care plan initiated on 9/20/16 notes R60 has a behavior problem, poor insight regarding mental illness, noncompliance with medications related to diagnosis of Schizophrenia. Care plan initiated on 11/10/16 documents R60 has impaired cognitive function/dementia or impaired thought process as evidenced by disorientation, recall deficit, disorganized thoughts. R29's diagnosis including, but not limited to unspecified Psychosis, Schizoaffective Disorder, Bipolar Type, and Restlessness and Agitation. R29's PAS/MH Level II Notice of Determination dated 10/5/18 identified R29's findings to benefit from aggression/anger management R29's care plan dated 10/13/22 documents I have the potential to be physically aggressive towards others related to Anger and poor impulse control. R29's Aggressive Behavior assessment dated [DATE] notes R29 was involved in a physical altercation with a female peer and admitted to being the aggressor after she snatched food items off his breakfast tray. On 1/9/23 at 12:00 pm V6 (Registered Nurse) said I didn't see the incident with R29 and R60. V6 said R29 does not get along with others. He does not have friends. He just talks to himself. V6 said R29 still eats in the dining room. On 1/10/23 at 9:57 am V22 (Certified Nursing Assistant) said on 10/13/22 R60 grabbed R29's food tray. V22 said R60 and R29 were sitting at separate tables. V22 said R60 grabbed R29's food in front of him. V22 said R60 took the food off the tray, R29 got up and hit R60 and then R60 sat back down. V22 said R29 quickly fisted R60 and made direct contact with her lip. V22 said I was sitting at back table in the dining room. V22 said I saw R60 grab the food. V22 said I did not get up the Mental Health Tech was walking towards R29 and R60. On 1/11/23 at 10:31AM V2 (Director of Nursing) said residents should not be hitting other residents. V2 said that is considered abuse. V2 said the residents should absolutely be safe in the facility. C. R96's diagnosis including, but not limited to Epilepsy, Schizophrenia, Depressive Disorder, Anxiety Disorder, Insomnia, and Tremor. R167's diagnosis including, but not limited to Schizoaffective Disorder, Bipolar Type, Vitamin D Deficiency, Cannabis Dependence, Nicotine Dependence, Delusional Disorder. R167's care plan initiated on 9/20/22 notes he has the potential to be aggressive. On 11/8/22 R167 was in a physical altercation with a peer due to hallucinations. R167's Aggressive Behavior assessment dated [DATE] notes R167 has a history of aggressive/agitated behavior or noncompliance with medications, treatment, regimen, or resisting care. R167 was involved in a physical altercation with a peer as he admitted to being the aggressor. Due to his hallucinations, he mistakes peer saying something disrespectful to him, resulting in physical aggression. Progress note dated 12/12/22 notes a peer(R167) entered R96's room and became physically aggressive towards R96. Incident report dated 12/12/22 documents physical abuse allegation. Summary of interview witness documents V19 said he observed R167 becoming physically aggressive towards R96. R167's statement was R96 was peeing on my bed. R96's statement was I didn't do anything. Investigation Findings states R167 has a history of physical Aggression, hallucinations, and confabulations. R167 was having hallucinations at the time of the incident believing R96 had urinated in R167's room. R167 approached R96 and struck him. On 1/9/23 at 1:17 pm V15 (PRSC) said she followed up with R167 following the incident with R96. V15 said I was not in the facility the day of the incident. V15 said when she spoke with R167 he would not give me more information. V15 said I spoke with R167 about better ways to cope with his anger. V15 said I think R167 has a history of behaviors, he has shown aggression in the past. V15 said R167 can be aggressive with staff and residents, he was yelling at me the other day. On 1/9/23 at 2:01 pm V9 (Social Services) said R167 was hallucinating and thought that R96 had gone into his room and peed on the towels. V9 said R167 is known to be delusional. V9 said R167 was the on schedule for anger management group. V9 said the goal of programs is to maintain safety. On 1/10/23 at 1:22 V19, (Mental Health Tech Supervisor/MHT) said on 12/12/22 R167 struck R96. V19 said I did not see R167 hit R96. V19 said I went into the resident room to break it up. V19 said R167 said it was because R96 peed on his stuff. V19 said R96 had not been up that night shift, he was in his room, in his bed. V19 said I believe he (R167) just wanted to get him (R96). V19 said he checked both resident's rooms and didn't see anything wet with urine. On 1/11/23 at 10:31 am V2 (Director of Nursing) said resident should not be hitting other residents. V2 said that is considered abuse. V2 said the residents should absolutely be safe in the facility. The facility policy titled Abuse Prevention and Reporting revised 4/29/22 states as follows: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. There are multiple deficient practice statements. I. Based on observation, interview, and record review the facility failed to address and implement interventions to stop and/or prevent residents from sexually assaulting and exposing genitalia inappropriately to residents and visitors in the facility and failed to ensure female residents were protected from these behaviors. This failure resulted in R33 inappropriately touching female visitors (V43, V44 and V45) and exposing himself to other residents (R2, R113) in common areas with the potential to touch or harm other female residents within the facility. This affected 6 residents (R2, R113, R51, R98, R171 and R173). The Immediate Jeopardy began on 1/8/23 V1 (Administrator) was notified on 1/11/23 at 2:11 pm of the Immediate Jeopardy. The facility presented an initial removal plan on 1/11/23 at 4:08 pm. The plan was accepted, and 1/18/23 the surveyor conducted an onsite record reviews and interviews and could not confirm the removal plan was implemented. The facility presented a modified removal plan on 1/20/23 at 8:18 am. The surveyor conducted an onsite record reviews and interview on 1/20/23 to confirm the removal plan was implemented. V3 (Assistant Administrator) was informed the Immediate Jeopardy was removed on 1/20/23. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings include: A. R33's medical record notes R33 with diagnoses including paranoid schizophrenia, bipolar disorder, and major depressive disorder. R33 progress notes dated 7/28/22 documents: Writer witnessed resident displaying inappropriate behaviors, including exposing himself while in the central area in front of peers. Staff immediately redirected his behavior. R33 involuntary petition dated 8/23/22 documents: Resident is increasing agitated and socially inappropriate. He is slamming items in the facility to the floor, he is exposing himself to staff. R33's aggressive behavior assessment dated [DATE] documents resident has history of abuse/neglect either as a recipient or perpetrator including abusive and/or inappropriate sexual behavior: moderate problem. R33 progress notes dated 12/17/2022 at 13:02: Resident noted to be increasingly socially inappropriate. Res noted to be walking down the hall attempting to touch female staff and female residents on their breasts and behinds. Writer counseled resident on keeping hands to himself. Male MHT staff also redirecting resident. Staff will continue to monitor and redirect to ensure staff and resident safety. Review of R33's MDS (Minimum Data Set), dated 12/14/22, notes section E for behavior other behavior symptoms not directed towards others (physical symptoms such as hitting or scratches self, pacing rummaging, public sexual act, disrobing in public, throwing, or smearing food or bodily waste or verbal/ vocal symptoms like screaming, disruptive sounds) behavior of this occurred 1 to 3 days. Review of R33's behaviors care plan, initiated 2/7/22, notes R33 exhibits sexually inappropriate behavior towards staff and co-peers. This care plan was last updated on 5/20/22. It has a target date 3/20/2023 denotes I (R33) exhibit sexually inappropriate behavior toward staff & co-peers. These behavioral symptoms are manifested by making crude, sexually orientated, profane, or suggestive remarks, and co-peers displaying sexually inappropriate behaviors. On 6/26/19- I was verbally displaying sexually inappropriate behavior towards female peer. On 8/13/19- I was displaying sexually inappropriate toward staff (nurse practitioner). On 2/6/2020: I allegedly displayed sexually inappropriate behavior toward female co-peer. On 9/30/21: I touched a female staff on the behind. On 10/30/21: I touched two female staff inappropriately on the behind and breast. On 12/1/21 and 2/16/22: I touched a female staff on the behind. On 12/7/2021: I attempted to grab a female staff's chest inappropriately. On 5/20/22: I touched a female staff on her behind. I will accept redirection, behave in a safe and respectful manner, and refrain from displaying sexually inappropriate behave. I will refrain from making sexually inappropriate remarks and displaying sexually inappropriate behavior through next review. Administer PRN medication as ordered. Implement limit setting with me. Specify appropriate versus inappropriate behavior. If I attempt to touch inappropriately place your hand over mine and gently (but firmly) push it down and away, clarifying it is not appropriate. R33 redirected to maintain appropriate boundaries w/ staff and peers - 5/13/22. R33 will be placed on 1:1 monitoring. Staff will intervene and redirect me when sexually inappropriate behavior is observed - 2/16/22. I (R33) have a behavior problem touching others inappropriately, as evidenced by it has been reported by staff that resident has tried and/or touched their butt or chest area. 8/17/2021: I inappropriately grabbed activity staff on her buttocks. I will display minimal episodes of touching others inappropriate behaviors related to grabbing at staff's chest or behind through next review date. Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Assist the resident to develop more appropriate methods of coping and interacting with others. Encourage the resident to express feelings appropriately. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. If reasonable, discuss R33's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Maintain an appropriate distance from resident when interacting. On 1/8/23 around 9:45 am, V43 (surveyor) was in the common hallway near central nursing office talking to another resident when R33 came from behind and touched her chest. On 1/8/23 around 10:00 am, V44 (surveyor) was talking with another resident when R33 touched her breast. Another female V45 (surveyor), was in the hallway facing R150's room when R33 walked behind her and touched right buttocks as he passed by. About 15 minutes later, V44 (surveyor) was speaking with other residents (R113, R2) in the hall when R33 came up and pulled his penis out. R33 then began making inappropriate comments and abruptly walked away. On 1/8/23 10:30 am, V45(surveyor) said R169 stopped V45 in the hallway. V45 her back against wall. R33 approached V45, leaned forward, and touched V45's left breast and then walked away. R33 returned a few minutes later and attempted to touch V45 again. On 1/8/23 at lunchtime, R33 pulled penis out at the central monitoring station area, in front of mental health techs, residents, and V43. On 1/9/23 around 10:15AM, V44 (surveyor) was in the dining room speaking with a resident when R33 came from behind V44, R33 touched her bottom and made inappropriate comments. On 1/9/23 12:34 pm, V7(Mental Health Tech) said she heard the residents say R33 just touched a surveyor. R33 walked and sat down and V7 asked him if he touched the surveyor he just said [NAME], [NAME]. V7 said she told R33 about personal space and he sat in central area for about 5 minutes and left. V7 said she reported the incident to V13(Supervisor) on 1/8/23 at 12:13PM. On 1/10/23 at 9:55am, V9 (PRSC/psychiatric rehabilitation services coordinator) stated that R33 exhibits sexually inappropriate behaviors, R33 touches the buttocks and breasts of female staff. V9 stated that R33 was on V28's (former PRSD) caseload until she resigned in early December 2022. At 3:00pm, V9's documentation on 12/17/2022 of R33's behavior was reviewed with V9. V9 stated that V9 does not recall which staff or residents R33 touched. V9 stated that if she documented it, then it happened. V9 stated that V9 does not recall reporting this incident to any staff other than the MHT staff. V9 stated that R33 does not exhibit sexually inappropriate behaviors daily, possibly weekly. V9 stated that right before V9 came to speak with this surveyor, R33 attempted to touch her inappropriately. V9 stated that staff are expected to report all behaviors to the PRSCs . On 1/10/23 at 2:40pm, V13 (Mental Health Supervisor) stated that V7 (MHT) notified V13 of an incident of inappropriate behaviors with a female, possibly CNA (Certified Nurse Assistant). When questioned if V13 reported this incident to V1 (Administrator), V13 responded No. V13 stated I guess I should have reported it to V1. When questioned if V13 reported it to V1 on 1/9/23, V13 responded 'V13 did not work yesterday. When questioned if he notified V1 today, V13 stated that he thought it resolved on own. On 1/10/23 at 2:58pm R113 was interviewed about the incident with R33 that occurred on 01/08/23. R113 stated. He took out his private parts while we were standing here talking. He will show it to people for no reason. When I see him in the halls, he is always bothering people. I would say he pulls out his penis about once or twice a week that I see. He shows it to all different people. Sometimes staff is there and see him do it. They will just tell him to put it away. Sometimes he listens and other times they must give him a shot because he won't calm down. They don't do much more than that. I do see him touching people. I don't really see how many times he does that, but he grabs at girls' breasts and their butts. He does it to staff and other residents. On 1/13/23 at 11:14AM, R113 who was alert and oriented at time of interview said it made her feel bad and not safe at that time because she knew it was wrong. On 1/12/23 at 3:19PM, V28 (former PRSD) said R33 has history of sexual inappropriate actions towards [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R68's diagnosis includes but not limited to Epilepsy, Schizoaffective Disorder, Dementia, Psychotic Disturbances, Mood Disturbances, and Anxiety, and Severe Intellectual Disability. Incident report dated 11/26/21 notes R68 noted running in the hallway when he slipped and fell. Progress Notes dated 10/22/22 documents maintain fall/safety precautions. Incident report dated 1/2/23 notes R68 was running in the hallway and fell. Report noted R68 was unable to provide description. Nothing was cited on precipitating and contributing factors. Report notes R68 sustained a swollen eye. Fall Initial Occurrence for R68 dated 1/2/23 documents a fall occurred in the hallway. Description notes R68 was running in the hallway and fell. It is documented R68 was unable to provide a description. Precipitating and Contributing Factor has nothing selected. [NAME]-checks notes the this was witnessed and R68 struck his head. Orientation of R68 notes e is alert and oriented to time, person, place, and situation. New injury observed swollen eye. Report completed by V20 (Licensed Practical Nurse/LPN). On 1/8/23 at 9:58 am, the surveyor observed R68 walking in the hallway without socks or shoes. On 1/8/23 during initial round approximately 10:00 am R68 was observed ambulating without shoes or socks on in the hallway. On 1/8/23 between 10:30 am-11:00 am R68 was walking barefoot, no shoes or socks on in the hallway. R68 was observed with dark bruised, black eye, to left eye. On 1/9/23 between 10:30 am-11:00 am R68 was observed by the surveyor walking from the west unit to the central unit with no socks or shoes on. The surveyor did not observe any staff offering him socks, grip socks, shoes, approach, or redirect R68 for footwear. On 1/9/23 at 12:00 pm V6 (Registered Nurse) said they told me R68 fell. V6 said she was told R68 fell face down and got a black eye. V6 said R68 goes running in the halls. V6 said she saw R68 running in the hall on 1/2/23 and I told his nurse to do something. On 1/9/23 at 12:24 pm V20 (Licensed Practical Nurse/LPN), said I was told earlier that R68 was running up and down the hall (V20 unable to say who told her or when). V20 said V21 (Mental Health Tech/MHT), called me and said R68 fell in the hallway. V20 said I didn't see him on the floor. V20 said R68 had been at baseline before he fell. V20 said after the fall I assessed R68. V20 said R68 is not verbal, he just made his noises, his vitals were normal, and the bruising and swelling started later that day. V20 said the bruising and swelling progressed overnight. The surveyor asked V20 if R68 was at risk for falls and V20 said R68 doesn't have falls. V20 said I think R68 was running, and he fell. On 1/9/23 at 12:36 pm V21 (MHT), said he saw R68 was running in the halls on 1/2/23. V21 said when R68 is running we usually redirect him. V21 said he told R68 to stop running and then R68 fell. V21 said he saw R68 tripped and hit the wall or the floor, and then bounced up like nothing happened. V21 said it was loud when he fell, you heard it. The surveyor asked what footwear R68 was wearing when he fell, V21 responded he is almost positive barefoot. On 1/9/23 at 12:46 pm V7 (MHT), said I have seen R68 running in the halls. On 1/10/23 at 9:57 am V22 (Certified Nurse Assistant/CNA) said R68 is compliant. V22 said R68 gets the zoomies, fast running like he is doing the track. On 1/10/23 at 10:20 am the surveyor observed R68 sitting in his bed with regular socks on. The surveyor asked V32 (CNA) to show the surveyor R68's shoes. V32 said R68 doesn't have any shoes. 1/10/23 at 12:52 pm V17 (Restorative Nurse) said when a fall occurs, we do team root cause analysis. V17 said I will enter the intervention in the care plan once determined. V17 said I would expect staff to carry out the interventions listed on the care plan. V17 said R68 is complaint with care. On 1/11/23 at 10:31 am V2 (Director of Nursing) said on 1/2/23 R68 was observed by staff running in the hall and fell and hit his face on the floor. V2 said running is not a new behavior for R68. V2 said when R68 is observed running staff can redirect him. V2 said most of the time R68 responds to redirection, is cooperative, and I don't think he has fallen before. V2 said I do not think he was wearing footwear when he fell on 1/2/23. V2 said R68 is notorious for walking barefoot. V2 said staff should be offering to apply footwear if R68 has no shoes on. V2 said if R68 refuses then the staff should let the nurse know that they offered footwear and R68 said no. V2 said interventions for R68 can be trying to walk with him, offer a snack, and offer nonpharmacological interventions. V2 said R68 responds fairly well to nonpharmacological interventions. V2 said when R68 is running back and forth, it is not every day, and I would have someone with him to monitor him. Care plan initiated on 4/5/17 notes R68 has impaired cognitive function and impaired thought process related to impaired decision making related to Dementia. On 11/16/21 a care plan was initiated for potential for falls related to use of psychotropic medication and seizure disorder Intervention dated 11/16/21 noted appropriate footwear. No intervention is documented on the care plan following R68's fall on 1/2/23. No behavior of R68 running while inside the facility is documented. Additional, care plan initiated on 11/30/21 notes I am at risk for fall/injury related to wandering/poor safety awareness. The facility Fall Prevention Program revised on 11/21/17 states the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Care plan incorporates identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, preventative measures. Footwear will be monitored to ensure the resident had proper fitting shoes and/or footwear is non-skid. II. Based on interview and record review, the facility failed follow the physician order to monitor and conduct neuro checks after a head injury. This failure affected 1 resident R43 reviewed for post injury monitoring. Findings include: R43 was admitted to the facility on [DATE] with a diagnosis of schizophrenia and hypertension. Progress note dated 1/8/23 at 3:08 pm: Resident walked out of his room and was sleeping walking towards the exit door. He was bumping his forehead into walls and doors. Laceration with dried blood noted to his forehead with minimal swollen. On 1/8/23 at 4:20 pm, R43 was observed with dried blood on his forehead and swelling noted to the bridge of nose and forehead. R43 was unable to say what happened. On 1/8/23 at 4:22 pm, V4 (Nurse) said she observed R43 wandering, and staff reported that he bumped his head into something. V4 said R43 had dried blood on his head. V4 said she did not notify the doctor or conduct neuro checks on the residents. V4 said R43 was placed on one-to-one monitoring with staff. On 1/8/23 5:30 pm, V34(Nurse) said R43 head was swollen. V34 said she did not call the doctor or the family about change in condition and the nurse who was assigned prior should have completed notification. V34 said they were not conducting any neuro checks at this time. On 1/11/23 at 10:30AM, V2(Director of Nurse) said any resident that experiences a head injury the doctor should be notified, and neuro checks should be initiated, documented in the resident chart. V2 unable to provide any further monitoring for R34. R43's progress note dated 1/11/23 11:51 am documents: R43 was sent to local hospital. On 1/11/23 at 6:00 pm documents resident returned with a diagnosis of head trauma and abrasion. On 1/12/23 at1 12:35 pm, V36(MD) said he was notified of incident with R43 but unable to recall who contacted him and instructed staff to conduct neuro checks. V36 said he would expect staff to follow orders. III. Based on observation, interview, and record review, the facility failed to monitor residents during smoking breaks to prevent resident from bringing in smoking materials and smoking in an undesignated area. This affected 1 resident R98 reviewed for inappropriate smoking in the sample of 35. Findings include: R98 was admitted to facility on 5/2/22 with a diagnosis of schizoaffective disorder, alcohol abuse, major depressive disorder, nicotine dependence. R98 smoking risk assessment dated [DATE] documents: minimal problem for potential risk recommended require supervision only not able to store smoking materials. On 1/8/23 at 10:04 am, R98 was observed smoking in her room. R98 said she took cigarettes in from smoke break this morning. R98 had a pop bottle on nightstand with 5 cigarette buds in it and verified with V7 (Mental Health Tech). R98 denied having a lighter. On 1/8/23 at 10:40 am, the East smoking area was observed with multiple cigarette buds scattered on the ground. R98's care plan revised on 7/11/22 documents: I am an inappropriate smoker with following interventions dated 5/2/22: Resident will keep smoking materials in a secured location. Resident requires supervision while smoking; intervention dated 7/11/22. Resident will watch a smoking cessation video. R98's care plan and progress notes did not document any smoking violations on 1/8/23. Smoking Policy documents: Staff responsibilities: staff will monitor residents removing cigarette buds from ashtrays or form the ground. Staff will empty and sweep before leaving the smoking areas as needed. All reports of residents who have smoking violations must be reported, documented, and followed up. IV.Based on observation, interview and record review, the facility failed to develop and implement effective fall prevention interventions for 2 residents (R68, R327) with a history of falls. This affected 2 residents (R68, R327) reviewed for fall prevention in the sample of 35. This failure results in R327 sustaining a fall requiring 6 sutures to her lower lip and R68 falling and sustaining bruising to his left eye. Findings include: 1. R327 was admitted to the facility on [DATE] with a diagnosis of epilepsy, unsteadiness on feet and schizophrenia. R327's Minimum Data Set, dated [DATE] documents under balance during transitions a score of one which indicates not steady but able to stabilize without staff assistance for moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface to surface transfer. Under mobility device it indicates a walker. R327's therapy notes 9/24/22 under fall assessment documents: does patient feel unsteady when standing-Yes; Does patient feel unsteady when walking- Yes; Does patient worry about falling- Yes. Under ambulation documents walk 10 -50 feet requires partial to moderate assistance. R327's progress note dated 9/26/22 at 5:30 pm, Narrative: Writer notified by Mental Health Tech resident had fallen as she was coming out her room. Resident assisted to her bed. R327's Progress note 10/2/22 at 9:07 am documents: Nurse was informed by residents' roommate that she found her on the floor after coming in from breakfast. Full body assessment was preformed, vitals were checked and were within normal limits. Resident states that she hit her head and busted her lip on the nightstand. R327's hospital record dated 10/2/22 documents: R327 states she tripped on something and fell on her face. 6centimeter laceration to lower lip down to subcutaneous tissue. Six sutures placed to lower lip. R327's fall care plan dated 1/9/23 documents: 9/26/22 Physical therapy consult for strength and mobility; assessed for injury. 10/2/22 documents: continue with physical therapy for strengthening and mobility; neuro checks for 72 hours; refer to pharmacy for medication review. On 1/10/23 at 12:30 pm, V17(Restorative Nurse) said she was unsure if R327 was on therapy prior to first fall. V17 said the interventions were to continue therapy for strength and mobility. V17 said they offered R327 a walker after the second fall, but she refused. V17 said she was unable to provide any documentation related to medication review or neuro checks performed. V17 was unable to provide another care plan with initiated dates for care plan interventions. On 1/13/23 at 3:56PM, V21 (Mental Health Tech) said he recalls R327 falling a couple of times but unable to recall exact dates. V21 said R327 could not stand by herself, and he would sit outside her room to assist with getting things for her. R327 needed to hold on your arm or side rail to keep herself up when walking. R327's fall risk assessment dated [DATE] documents not at risk for falls. Under gait/balance documents: balance problem when walking. Facility fall prevention program reviewed 1/22 documents: care plan incorporates identification of all risk/issue, addresses each fall; interventions are changed with each fall; preventative measure. Resident environment will be kept clear of clutter which would affect ambulation and remove hazards. I.Based on observations, interviews, and record reviews, the facility failed to adequately supervise/monitor and implement effective interventions for one male resident (R33) with a history of having sexually inappropriate behaviors. The facility failed to prevent an incident of sexual assault of three female visitors as well as inappropriate exposure of himself. The lack of the adequate supervision and effective interventions upon the onset of R33's behaviors had the immediate potential to affect all 59 female residents who has the potential to encountered R33. The Immediate Jeopardy began on 1/8/23 V1 (Administrator) was notified on 1/11/23 at 2:11 pm of the Immediate Jeopardy. The facility presented an initial removal plan on 1/11/23 at 4:08 pm. The plan was accepted, and 1/18/23 the surveyor conducted an onsite record reviews and interviews and could not confirm the removal plan was implemented. The facility presented a modified removal plan on 1/20/23 at 8:18 am. The surveyor conducted an onsite record reviews and interview on 1/20/23 to confirm the removal plan was implemented. V3 (Assistant Administrator) was informed the Immediate Jeopardy was removed on 1/20/23. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings include: 1. R33's medical record notes R33 with diagnoses including: paranoid schizophrenia, bipolar disorder, and major depressive disorder. R33's MDS (minimum data set), dated 12/14/22, notes section E for behavior shows R33 has hallucinations, delusions, verbal symptoms directed towards others (threating others, screaming at others) that occurred 1 to 3 days, other behavior symptoms not directed towards others (physical symptoms such as hitting or scratches self, pacing rummaging, public sexual act, disrobing in public, throwing or smearing food or bodily waste or verbal/ vocal symptoms like screaming, disruptive sounds) behavior of this occurred 1 to 3 days. R33 has behaviors of wandering, behavior of this occurred 1 to 3 days. Section E1100 shows R33 current behavior status in comparison to prior assessment is the same. R33's behaviors care plan, initiated 2/7/22, notes R33 exhibits sexually inappropriate behavior towards staff and co-peers. This care plan was last updated on 5/20/22. It has a target date 3/20/2023 denotes I (R33) exhibit sexually inappropriate behavior toward staff & co-peers. These behavioral symptoms are manifested by making crude, sexually orientated, profane, or suggestive remarks, and co-peers displaying sexually inappropriate behaviors. On 6/26/19- I was verbally displaying sexually inappropriate behavior towards female peer. On 8/13/19- I was displaying sexually inappropriate toward staff (nurse practitioner). On 2/6/2020: I allegedly displayed sexually inappropriate behavior toward female co-peer. On 9/30/21: I touched a female staff on the behind. On 10/30/21: I touched two female staff inappropriately on the behind and breast. On 12/1/21 & 2/16/22: I touched a female staff on the behind. On 12/7/2021: I attempted to grab a female staff's chest inappropriately. On 5/20/22: I touched a female staff on her behind. I will accept redirection, behave in a safe and respectful manner, and refrain from displaying sexually inappropriate behave. I will refrain from making sexually inappropriate remarks and displaying sexually inappropriate behavior through next review. Administer PRN medication as ordered. Implement limit setting with me. Specify appropriate versus inappropriate behavior. If I attempt to touch inappropriately place your hand over mine and gently (but firmly) push it down and away, clarifying it is not appropriate. R33 redirected to maintain appropriate boundaries w/ staff & peers - 5/13/22. R33 will be placed on 1:1 monitoring. Staff will intervene and redirect me when sexually inappropriate behavior is observed - 2/16/22. I (R33) have a behavior problem touching others inappropriately, as evidenced by it has been reported by staff that resident has tried and/or touched their butt or chest area. 8/17/2021: I inappropriately grabbed activity staff on her buttocks. I will display minimal episodes of touching others inappropriate behaviors related to grabbing at staff's chest or behind through next review date. Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Assist the resident to develop more appropriate methods of coping and interacting with others. Encourage the resident to express feelings appropriately. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. If reasonable, discuss R33's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Maintain an appropriate distance from resident when interacting. Per PAS/MH Level II Notice of Determination, I (R33) may be able to benefit from: medication monitoring/ management; - ADL (activities of daily living) training/reinforcement; - mental health rehabilitation; illness self-management; - incentive program to improve participation in treatment and community re-integration activities. I will meet with my PRSC as needed to address symptom management issues as well as negative behaviors through next review date. Encourage group attendance, encourage resident to participate in mental health treatment. PRN one on one sessions with PRSC to address behaviors and symptom management. 2. On 1/8/23 around 9:45am, R33 was observed in the common hallway near the central nursing office approach V43 (surveyor) from behind and touch her breast. V7 MHT (Mental Health Tech/MHT) and other residents were present. V7 re-directed R33 away and into an area between the dining room and hallway. On 1/8/23 around 10:00 am, V44 (surveyor) was walking through the central station area after leaving the dining room. R33 was observed approaching V44 from the opposite direction and touch her right breast. Staff's back was turned while this happened. About 15 minutes later, V44 was speaking with R2 and R113 in the hall when R33 came up and pulled his penis out. V44 attempted to redirect R33 back to his room but was unsuccessful. R33 then began making inappropriate comments and abruptly walked away. No staff witnessed these incidents. On 1/8/23 at 2:58pm, R113 was interviewed about the incident with R33 that occurred on 01/08/23. R113 stated. He took out his private parts while we were standing here talking. He will show it to people for no reason. When I see him in the halls, he is always bothering people. I would say he pulls out his penis about once or twice a week that I see. He shows it to all different people. Sometimes staff is there and see him do it. They will just tell him to put it away. Sometimes he listens and other times they have to give him a shot because he won't calm down. They don't do much more than that. I do see him touching people. I don't really see how many times he does that, but he grabs at girls' breasts and their butts. He does it to staff and other residents. On 1/8/23 at 10:20am, R33 was observed walking past V45 (surveyor) and touch her right buttocks. At 10:30am, V45 was speaking with R169 in the hallway. R33 was observed approaching V45, leaning forward, and touching her left breast. R33 then abruptly walked away. A few minutes later, R33 approached V45 and attempted to touch her lower abdomen. There were no staff present during these incidents. On 1/9/23 around 10:15am, V44 was observed in the dining room speaking with a resident. R33 was observed approaching female visitor touching her buttocks and making inappropriate comments. V44 re-directed R33 not to touch her. R33 quickly walked away. On 1/9/23 12:34pm, V7 (MHT) stated V7 heard the residents say R33 just touched a female visitor. R33 walked and sat down. V7 asked R33 if he touched the visitor, R33 just said Hee, Hee. V7 told R33 about personal space and he sat in central area for about 5 minutes and then left. According to V7 there were only two mental health techs working day shift for 174 residents. V7 texted V13 (mental health supervisor) at 12:13pm about the incident with R33 and the visitor. V7 stated that V13 telephoned V7 and acknowledged that he received her text message. 3. Additional interviews were conducted regarding R33's behavior and planned intervention for recognized behaviors as follows: On 1/9/23 at 2:00pm, V9 (Psychiatric Rehabilitation Services Coordinator/PRSC) stated that at this time, there is no facilitator for group therapy programs. V9 reported, the PRSC staff are doing 1:1 session with each resident. V9 stated, social services discuss with the resident the behaviors identified in group therapy. V9 stated, there is no PRSD (psychiatric rehabilitation services director). On 1/10/23 at 9:55am, V9 reported R33 exhibits sexually inappropriate behaviors, R33 touches the buttocks and breasts of female staff. V9 stated R33 was on V28's (former PRSD) caseload until she resigned in early December 2022. At 3:00pm, the surveyor reviewed with V9, V9's documentation on 12/17/2022 of R33's inappropriate behavior. V9 reported, she does not recall which staff or residents R33 touched. V9 stated that if she documented it, then it happened. V9 stated she does not recall reporting this incident to any staff other than the MHT staff. V9 stated, R33 does not exhibit sexually inappropriate behaviors daily, possibly weekly. V9 reported to the surveyor, right before she came to speak with this surveyor, R33 attempted to touch her inappropriately. V9 stated that staff are expected to report all behaviors to the PRSCs On 1/10/23 at 9:00am, V1 (Administrator) stated that the group facilitator and PRSCs should be doing 1:1 session with every resident. V1 stated that the group facilitator resigned in early December. V1 stated that the last day for group programs was on 12/9/22. V1 stated 1:1 session with residents should be weekly same as the frequency group meetings were held. V1 stated that V1 can't recollect if he told staff right away to start doing 1:1 session with residents after the group facilitator resigned. V1 stated 1:1 session is documented in the resident's progress notes. On 1/10/23 at 10:30am, V15 (PRSC) stated that V15 has been covering R33 since PRSD left in December, about 2-3 weeks. V15 stated that R33 is receiving 1:1 session. V15 stated that R33 is not receiving any group therapy programs. V15 stated that she is not aware of R33 exhibiting any behaviors since R33 was re-admitted to facility in December 2022 when R33 was hospitalized for aggressive behaviors. On 1/10/23 at 2:40pm, V13 (Mental Health Supervisor) stated that V7 (MHT) notified V13 of an incident of inappropriate behaviors with a female, possibly CNA (certified nurse aide). When questioned if V13 reported this incident to V1 (Administrator), V13 responded 'no'. V13 stated I guess I should have reported it to V1. When questioned if V13 reported it to V1 on 1/9/23, V13 responded 'V13 did not work yesterday. When questioned if he notified V1 today, V13 stated that he thought it was resolved. On 1/13/23 at 10:15am, V7 (MHT) stated R33 exhibits sexually inappropriate behaviors daily. V7 stated that all of the staff are aware of R33's inappropriate behaviors. V7 stated that R33 frequently pulls his pants down in front of staff/residents or pulls penis out. V7 stated on 1/8/23, R33 was calm and walking at a normal pace. V7 stated the behaviors R33 was exhibiting were level one behaviors. V7 stated that R33 does not get sent out to the psychiatric hospital until he is exhibiting behaviors at a level 5, such as running through hallway, cursing staff and other residents, and destroying property. On 1/13/23 at 11:25am, V9 stated that the PRSCs talk to residents 1:1 as needed, not once a week. V9 stated that the expectation is for the PRSC to document in the resident's care plan and progress notes. V9 stated that the PRSCs should be documenting every 1:1 session with a resident in his/her progress notes. V9 acknowledged that these 1:1 session should be occurring routinely, not after the resident exhibits inappropriate behaviors. V9 acknowledged that if it isn't charted, it didn't happen. On 1/17/23 at 10:20am, V46 (Psychiatric Doctor) stated that R33 should have been placed on 1:1 supervision after the first incident on 1/8/23, to prevent the second and the third incidents of inappropriate touching. A behavior contract should have been created. V46 stated that V46 was not informed about R33 touching the staff the first time. V46 stated that V46 would have sent R33 to the nearest hospital at that time. 4. R33's medical record documented the following regarding R33's negative behaviors R33's Social Service Progress Review dated 7/28/22 by V28 (former PRSD /psychiatric rehabilitation services director) noted: V28 witnessed R33 displaying inappropriate behaviors, including exposing himself while in the central area in front of peers. Staff immediately re-directed R33's behavior. Progress note dated 8/23/22 by V2 (DON /director of nursing) noted: R33 is increasingly agitated and socially inappropriate. R33 is slamming items in the facility to the floor, R33 is exposing himself to staff, and threw water pitcher at floor nurse, and is not receptive to re-direction, an as needed medication administered and ineffective. R33's petition for involuntary admission, dated 8/23/2022, notes R33 increasingly agitated and socially inappropriate. R33 was slamming items on the floor and exposing self to staff. R33 is not receptive to re-direction. These behaviors were witnessed by V2 DON and V13 (mental health supervisor). R33's hospital admission record, dated 8/23/22-8/30/2022, notes R33 to continue the following therapies: assertive community treatment, cognitive behavior therapy (therapy to help change certain behaviors), illness-management skills, and social skills training. R33's medical record, dated 7/28/22 - 1/10/2023, does not note R33 was receiving group therapy or 1:1 session with PRSCs. R33's medical record, dated 11/14/22 and 11/30/22, R33 was sent to the hospital each time for exhibiting verbal and physical aggression. R33's medical record, dated 12/17/22, notes V9 noted: R33 noted to be increasingly socially inappropriate. R33 noted to be walking down the hall attempting to touch female staff and female residents on their breasts and behinds. V9 counseled R33 on keeping hands to himself. Male MHT (mental health tech) staff also redirecting R33. Staff will continue to monitor and redirect to ensure staff and resident safety. On 01/20/23 the surveyor verified by observations, record review and interview that the facility implemented the following to remove the immediacy: 1.R33 is no longer at the facility. Psychiatrist ordered a discharge to the hospital for a psychiatric evaluation on 1/10/23. Resident was placed on supervision prior to transfer to hospital. Facility will re-evaluate R33 after completion of treatment. Upon return, resident will be placed on increased staff supervision, provided a room change closer to the nurses' station, evaluated by the psychiatrist, and assessed for appropriate therapeutic programming. 1/10/23 started and ongoing. 2.Staff were in-serviced/trained on how to recognize sexual abuse and the facility's abuse protocol to prevent it from happening to other residents. All staff will be re-educated prior to next scheduled shift including staff that are on leave and are on vacation. Administrator and Assistant administrator are conducting the training. The training includes the Abuse prevention reporting policy, specifically the definition of abuse, Sexual abuse, sexual assault, rape and internal reporting requirements and identification of allegation and protection of residents. Staff acknowledged information via signature. Administrator/Managers will continue to monitor all staff for compliance by a competency questionnaire. The abuse prevention training program posttest questionnaire is the material utilized. No revision of the current abuse policy has occurred. The noncompliance was a failure to follow current policy IDT conducts assigned regular rounds during shift to ensure visual monitoring and staff supervision. 1/10/23 started at 2:45pm. 3.Residents that have been identified for being at risk for sexual abuse have had their care plans updated to reflect interventions to prevent abuse. List of identified residents was provided to survey team. Intervention implemented 1/10/23 . 4.Resident identified with sexually inappropriate behavior was counseled and placed on close staff supervision, was educated on symptom management, maintaining boundaries and importance of utilizing coping skills to manage symptoms, and will be followed up with by staff and/or psychiatrist regularly. QA tool titled Abuse reporting, interventions and investigation will be completed weekly by the Administer or Assistant Administrator. Observations noted during regular rounds will be discussed at the QA Committee. Concerns will be discussed among the members, a plan of action is devised, and past plans of actions evaluated. Intervention implemented 1/10/23