**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents in the facility were free from abuse. This failure affected one of three (R4) residents reviewed for abuse and resulting in R4 acquiring a laceration to the head requiring sutures.Findings include:R4's medical diagnoses include but are not limited to schizophrenia, bipolar disorder, essential hypertension and major depressive disorder.R4's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 15, indicating R4's cognition is intact.R4's progress note dated 08/07/25 documents in part, Resident became agitated, pacing and engaged in a verbal altercation with peer that turned physical. Residents were separated and placed on 1:1. Hospitalization required.R4's progress note dated 08/08/25 documents in part, Resident has had an increase in anxiety and aggressive behavior.R4's progress note dated 08/16/25 documents in part, Writer made aware resident had and altercation as evidenced by pushing his co-peer.R4's care plan dated 09/18/25 documents in part, resident has the potential for/history of physical aggression towards others. History of physical aggression, poor impulse control.R5's medical diagnoses include but are not limited to schizoaffective disorder, violent behavior, bipolar disorder, chronic obstructive pulmonary disease.R5's MDS dated [DATE] has a BIMS score of 3, indicating R5's cognition is severely impaired.R5's progress note dated 08/16/25 documents in part, CNA (Certified Nursing Assistant) informed writer that resident had an altercation, and he was pushed to the floor, hitting the right side of his head. Some bleeding note by the right eyebrow and some swelling noted to the right side of his head.R5's care plan dated 07/01/25 documents in part, R5 is at risk for abuse related to: Has a dx (diagnosis) of severe mental illness and hx (history) of aggression.R5 will remain safe, calm and free from abuse.The Facility's Final Incident Investigation Report sent to the state agency on 08/21/25 documents in part, A follow up interview was conducted with R5 and he stated that while walking down the hallway R4 pushed him causing him to fall to the floor. R5 stated that he believes the incident was an accident. He doesn't feel it was intentional.The Facility's Final Incident Investigation Report sent to the state agency on 08/12/25 documents in part, CNA was interviewed and stated R4 was on his phone singing to himself and walking around the dining room. R7 returned to the dining room and approached R4. Both residents exchanged words. CNA called for help. When she returned to the dining room both residents were on the floor wrestling.On 09/27/25, surveyor attempted to interview R5 regarding the incident between R4 and R5. Surveyor was unsuccessful with interview due to R5's mumbled and distorted speech.On 09/27/25 at 1:00pm V18 (Licensed Practical Nurse/LPN) stated that she witnessed the altercation between R4 and R5 on 08/16/25. V18 stated that R4 and R5 were both walking in the hallway, going in opposite directions. V18 stated that when R4 and R5 were about to pass each other in the hallway, R4 pushed R5 to the floor. V18 stated that when R4 pushed R5 to the floor, R5 slid hit his head on the floor. V18 stated that she then ran to R5 because R5's head was bleeding. V18 stated that R5 was sent to the hospital for evaluation of R5's head wound and R5 received sutures to the head.On 09/27/25 at 1:52pm V16 (Certified Nursing Assistant/CNA) stated that R4 tries to intimidate other residents. V16 stated that R4 pushed R5 to the ground and R5 was sent to the hospital because R5's head was bleeding after being pushed to the ground. Facilities policy title abuse policy dated 07/2025 documents in part policy, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by:. 2. Orientating and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreatment, neglect and abuse;. 3. Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment;.4. Identifying occurrences and patterns of potential mistreatment; 5. Immediately protecting residents involved in identifying reports of possible abuse;. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. This facility will not knowingly employ individuals who have been convicted of abusing, neglecting or mistreating individuals.Definitions: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment.

Based on observation, interview, and record review, the facility failed to provide ordered oral nutritional supplements, and failed to follow Registered Dietitian's recommendations for one resident's (R78) reviewed for nutrition and significant weight loss in the sample of 50 residents. This failure resulted in R78 having continued weight loss including significant weight loss (13.44% change over 3 months and 18.50% change in 6 months). Finding include: R78's admission Record documents, in part, R78's diagnoses include cirrhosis of liver, diabetes, and vitamin D deficiency. R78's (1/5/23) Brief Interview of Mental Status (BIMS) score is 13. R78 is cognitively intact. R78's Monthly Weight Report documents September 13, 2022 - 251.4 lbs., October 11, 2022 - 252.0 lbs., November 21, 2022 - 248.2 lbs., December 07/2022 - 217.6 lbs., January (no specific date documented) - 202.2 lbs., February (no specific date documented) - 204.9 lbs. R78's Care plan, dated (1/5/23), documents, in part, Focus requires nutritional support secondary to need for Therapeutic diet. Goal: Will adhere to therapeutic diet and maintain weight. On 3/05/23 at 11:32 am, R78 stated, I do not eat the food in the facility; the facility does not give me food that I can eat. I have lost a significant amount of weight. Surveyor asked R78 if he was receiving nutritional supplements. R78 stated, No. On 3/6/23 at 12:50 pm, surveyor observed R78's lunch tray which consisted of ham, broccoli, maccaroni and cheese, fruit cup, and a cup of yellow fluid. No ordered nutritional supplements were observed on R78's food tray. On 3/7/23 at 12:40 pm, surveyor observed R78's lunch tray which consisted of chicken, rice, mixed vegetables, biscuit, ice cream and a cup of yellow fluid. No ordered nutritional supplements observed on R78's food tray. R78's Order Summary Report, dated 3/7/23, with active orders, documents, in part, Diet: No Concentrated Sweets (NCS) diet Regular texture, M**** C** two times a day at lunch and dinner. M***** S**** no sugar added two times a day with lunch and dinner. On 3/7/23 at 12:45 pm, R78's Meal ticket, documents, name, room number, diet, NCS (No Concentrated Sugar) NAS (No Added Salt). Breakfast, Lunch, and Dinner section (blank). No Fish across ticket. Dislikes section (Blank). Coffee, Tea, Milk, Decaf, Water, Juice (Blank). On 3/7/23 at 3:45 pm, V1 presented an updated meal ticket for R78. On 3/8/23 at 1:13 pm, surveyor received a copy of R78's updated meal ticket with m**** c** and m***** s**** for lunch and dinner added to the ticket. R78's Nutrition Quarterly/Reassessment/ Assessment (1/4/23) documents, in part, 1. (d) Supplements: M***** S**** no sugar added, M**** C** or G*******. 3. (a) Most Recent Weight: 217.6 (date: 12/07/2022 at 19:03 (7:03pm) 3. (c) Weight History: current weight is pending 12/7/22 217lbs (pounds) triggering weight loss 30.6 lbs. Comparison Weight 11/21/2022, 248.2 lbs., RD (Registered Dietician) recommended re-weigh 10/11/22 252 lbs. 9/13/22 251.4 lbs . 4. (a) significant weight change in past 1 month? No. (b) Significant weight change in past 3 months? No, Significant weight change in past 6 months? No. On 3/7/23 at 1:50 pm, V10 (Dietary Supervisor) stated R78 is expected to get his m**** c** and m***** s**** for lunch and dinner daily. V10 stated, I do not know why the supplement was not on (R78's) tray, we are not out of it in the facility. Surveyor inquired how staff know to give R78 a supplement with lunch and dinner, because it is not on the meal ticket. V10 stated, The staff knows who gets a supplement. On 3/7/23 at 2:15 pm, V35 (Dietitian) stated the dietary supplement order for R78 should be given as ordered two times a day for lunch and dinner. Surveyor inquired if R78 was order dietary supplement, should it be on R78's tray whether he east or drinks it or not. V35 stated, That's correct. (R78) should still get it on his tray whether he eat or drink it or not, absolutely. On 3/8/23 at 12:45 pm, V39 (Nurse Practitioner) stated the supplements were ordered for R78's weight loss and decline in appetite. V39 stated the supplements should be on R78's tray for lunch and dinner. V39 stated the potential harm in not receiving the supplement is there could be continued weight loss. The supplement is provided to help assist in R78's weight loss. Facility Dietary Supplement Policy (1/18), documents, in part, Purpose: Dietary supplements may be required to enhance the resident's nutritional status. Facility Weights Policy (9/20) documents, in part, Policy: Residents will be weighed to established upon admission. The resident will be weighed weekly for 4 weeks after admission and monthly thereafter. Report to nursing supervisor, physician/NP, dietary supervisor, RD consultant and family/responsible party of any weight loss or gain greater than 5% within one (1) month, 7.5% within three (3) months or 10% within six (6) months. Facility Dietary Aide job description, documents, in part, Essential Functions: Prepare food for therapeutic diets in accordance with planned menu extensions. (As appropriate). Q. Prepare food in accordance with standardized recipes and special diet orders. Facility Food and Nutrition Services Manager job description, documents, in part, Essential Functions: C. Assess nutritional status of each resident per standards of care. M. Process diet changes and new diets as received from nursing department. P. Maintain an up-to-date list of all diets, blue cards, nourishment list, resident preferences, and resident diet census.

Based on record review and interview, the facility failed to follow their abuse policy for two residents (R1,R2) out of four residents reviewed abuse. This failure resulted in a staff members not immediately intervening before R1 became physically aggressive towards R2. This failure resulted in R1 hitting R2 on the head, causing R2 a laceration requiring five staples. The Findings Include: R1's care plan, dated 11/2/19, denotes R1 is at risk for abuse related to: Not easily redirected with challenging behaviors. He has a history of being easily upset and quick tempered being verbally aggressive toward staff and peer. On 1/24/2023 at 11:32, R2's Psychiatrist/Psychologist Note Text: Psychiatry Progress Note reads : Present History: 75yr old male, was seen for follow-up, and is alert and oriented to self. Staff reported occasional aggressive behavior but can be redirected, no agitation or aggressive behavior was noted. Patient functioning at baseline. R1's 2/11/2023 at 20:29 nurses note text reads : Nurse was notified that resident hit another resident on the head with his walking stick. Resident voiced 'He was in my room so I told him to leave and he will not leave so I walked up to him and hit him on the head with my stick' . On getting to resident room nurse observed resident sitting in his bed complete body assessment done with no injury noted vitals taken at this time are as follow BP 132/68, P 78, T 98, R 18 spO2 98% RA (room air) resident remained in his room under security watched. Facility Administrator informed. NP (nurse practitioner) made aware order to petition resident out to (hospital) given. Order noted and carried out. Resident POA (Power of Attorney) made aware of resident situation and transferred. R2's 2/11/2023 at 23:33 nurses note text reads: Nurse was called to room (residents room number) by a staff that resident was bleeding from the head . rResident voiced 'I got hit on the head'. On getting to room (residents room), nurse observed resident lying in bed. Complete body assessment and neuro check done with an open area to the top of the head observed and no confusion noted. The site was cleaned with NS (normal saline) and bandage applied vitals taken at this time are as follow (BP) 155/85, P 88, R 20 T 98 spO2 99% RA (room air) . Resident was taken to the nursing station for close monitoring . Facility Administrator made aware per facility protocol. NP (Nurse Practitioner) made aware order to send resident to (hospital) given order noted and carried out . Resident POA (Power of Attorney) was informed of resident condition and transferred Facility's abuse report, dated 2/11/23, denotes Administrator was made aware both residents (R1,R2) were in a physical altercation. Both residents were immediately separated. Full body assessment done. R2 sustained an injury and was sent to the hospital per physician order. An investigation was immediately initiated. R2's hospital record, dated 2/11/22, denotes R2 was brought to emergency room for head injury, laceration. R2's hospital Computed Tomography Scan negative for any acute process . Laceration Wound closed with five staples. R2's 2/12/2023 at 05:23 Nurses Note Text reads : Writer spoke to RN (Registered Nurse) who verbalized Resident being admitted to the Acute Care Area (room and bed number) for 1) Dizziness, Head injury with Scalp Laceration ,closed.2) Uncontrolled HTN (hypertension) On 2/24/23 at 10:00 am, V20 (Doctor) stated R2 did sustain a cut to his head, which was superficial laceration. V20 stated, Fortunately (R2) was not seriously harmed because his CT (Computed Tomography) showed that no subdural/epidural or acute bleed which could be considered potentially serious injuries. V20 stated R2 was treated the same day at the hospital and sent back to the facility in stable condition. On 2/22/23 at 10:00 am, V1 (Social Worker) statedshe has worked on the third floor for nine years, and R1 been a resident on the third floor for a few years. V1 stated R2 has been a resident on the third floor for a couple of years. V1 stated R1 is confused at times and gets agitated sometimes when asked to do something he does not like to do. V1 stated R2 is very confused and sometimes can be verbally aggressive with staff or his peers. On 2/22/23 at 10:30 am,V6 (Certified Nursing Assistant) stated she was in another room serving dinner when she heard a loud commotion, then came out into the hallway, and saw R2 with blood with on his face. V6 stated she yelled for the nurse (V8) who came running towards R2. V6 stated sV6 aw the nurses assess R2, then took him to his room. V6 stated R2 has psych (psychiatric) issues, and his behavior changes from day to day. V6 stated whenever she has seen R2 getting into arguments with another resident, they have been able to redirect him. V6 stated R1 has a history of being aggressive when he has these mood swings. V6 stated she has never seen R1 hit another resident with his cane. V6 stated they have to redirect all the residents because it is a behavior unit with psych residents. On 2/22/23 at 11:00am, V8 (Licensed Practical Nurse) stated he has worked at the facility for several years and took care of both R1 and R2. V8 stated R1 was alert and oriented times 2-3 with some confusion. V8 stated most of the time, R1 would stay in his room, but would walk out of his room using his cane if he needed something. V8 stated R1 has a history of aggression and needed to be redirected when he got upset. V8 stated R2 was alert times 1-2, and would roll around on the unit in his wheelchair. V8 stated R2 sometimes gets confused and wanders into the wrong room, but they usually see him and redirect him to his room. V8 stated on Saturday (2/11/23) around dinner time, V8 was at the nurses station when another staff member told him R2 was bleeding. V8 stated V8 noticed R2 had cut on the top of his head. V8 stated cleaned the wound with normal saline and applied a clean band aide. V8 stated asked R2 who hit him, and pointed to R1's room. V8 stated he went to R1's room to interview him to ask what happened. V8 stated during the interview, R1 told him R2 would not leave his room, so he hit him with his cane. V8 stated he called the doctor, Administrator and family members. V8 stated R1 and R2 were both sent to the hospital for evaluation. V8 stated this has never happened before while he was taking care of R1. On 2/22/23 at 9:30 am, V2 (Administrator) stated all abuse reports should be sent to IDPH (Illinois Department of Public Health) within 24 hours according to the facility abuse protocol. V2 stated any allegation of abuse is filled out on the incident form, but the preliminary 24-hour abuse form then faxed to IDPH within 24 hours. V2 stated she got a call on Saturday R1 hit R2 on the head with his walking cane. V2 stated staff had separated both residents, doctor and family notified. V2 stated staff told her R2 sustained a cut to his head. V2 stated at this time ,she is not sure if R1 is coming back to the facility. Facility's abuse policy denotes, This facility prohibits mistreatment, neglect, or abuse of its residents and attempted to establish a resident sensitive and resident secure environment. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers and staff from other agencies providing services. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident safety for one resident (R7) of three residents reviewed for elopement on a secured psychiatric unit. This failure resulted in R7 jumping from his room window. R7 sustained right left leg and ankle foot fracture. R7 was hospitalized and received a plaster cast to his right leg. Findings include: Social Services Assessment under Exit Seeking/wandering/Elopement risk assessment, dated 06/3/2022, documents: R7 has the physical ability to leave the building on his own. R7 has a current diagnosis of severe mental health illness, and information was provided by R7 and staff interview/observation. Also documents R7 has experienced two or more psychiatric hospitalizations. R7's care plan, dated 06/07/2022, documents: Resident(R7) is content with current placement and discharge to the community is not feasible due to mental health and lack of support as determined by interdisciplinary team, physician, resident, or regal representative. R7's care plan, dated 06/07/2022, documents: Resident(R7) has been evaluated to be placed on a Level One Behavioral Health Pass Program. This level allows the resident (R7) dependent time with a responsible party. R7's care plan, dated 06/09/2022, documents: R7 displays delusional behavior problem, R/t (related to) Yelling out, and confused, and negative thinking. Difficult to reason with. Social Services note, dated 06/1/2022, documents: R7 met with staff 1:1 concerning R7 temper and how he responded towards staff. Social services note, dated 7/31/2022, documents R7 washing his clothes in his room sink instead of sending clothes to laundry. Social services note, dated 08/17/2022, documents R7 was not changing his clothes and staff met with R7 to discuss importance of changing his clothes. Social services note, dated 10/12/2022, documents R7 was spilling water on floors. R7's social services progress notes, dated 11/01/2022, document: R1 engaged in an incident of peer-to-peer incident in which R1 threw beverages. Interdisciplinary note, dated 11/2/2022, documents R7 has not recollection of incident of 11/1/2022, R7 communicates some cognitive deficits and laughs in place of responses at times Facility reported incident report, dated 12/05/2022, documents: On 11/29/2022 at approximately 8:00am. (R7) exited the facility via window resulting in a fall. (R7) was observed outside of the facility. (R7) was alert to person and place with periods of confusion. (R7) was observed with swelling to lower extremities. Physician notified; Guardian notified. (R7) transferred to nearby community hospital emergency room for further evaluation. (R7) was admitted with bilateral broken ankles, fractured lumbar and thoracic spine. The facility's incident report further documents R7's diagnoses, not limited to: unspecified psychosis, Unspecified symptoms, and signs involving cognitive functions and awareness, TBI (traumatic brain injury), restlessness and agitation. R7's X-ray results, dated 11/29/2022, documents: Findings: Left tib/fib: Redemonstrated acute comminuted fracture of the distal left tibia and fibula, better evaluated on dedicated left ankle radiographs, Acute comminuted, minimally displaced fracture of the proximal fibula with mild apex posterior angulation. There is soft tissue swelling about the proximal leg. Left foot: Right tib/fib: Redemonstrated acute comminuted fracture of the distal left tibia and fibula, better evaluated on dedicated left ankle radiographs. On 1/10/2023 at 11:33am, R7 was observed lying in bed awake, with R7's right leg in a plaster cast from the toe to mid upper thigh. R7 was alert and oriented to name and place. R7 stated he fell from 3rd floor roof to the ground. R7 said, I used to live on the 3rd floor, they would not give me speech (sic). I was not feeling good, and I wanted to go home so I jumped from the roof. He (unknown person) denied me speech (sic) to go outside, so I wanted to go home, so I jumped out window and tried to go home, which is my right because I am not incarcerated. It was a paranoid thing. On 1/10/2023 at 12:09pm, V9 (Clinical Director-social worker) said on 12/29/2022 at about 7:30am, V9 went to R7's room and did not see R7. V9 stated she saw the lower half of the window against the wall. V9 stated she observed a gap/hole where the bottom window was supposed to be. V9 said, I saw bed sheets hanging from the gaping window to the outside. I left to notify (V1, Administrator). (V1) was on the 3rd floor by the nursing station. V9 stated she called Code [NAME] (Missing resident) and all the staff started to look for R7. V9 commented she got in her car and started driving around the facility looking for R7. V9 said, I got a text from (V12, Assistant Administrator) notifying me that (R7) was found by the parking lot and police were already there with (R7). V9 further commented when she got to the parking lot, R7 was on a stretcher, ready to be transported to the hospital for evaluation. On 1/12/2023 at 4:10pm, V25 (R7's State Guardian) stated she was notified by facility when R7 jumped out of the window, attempting to elope. V25 commentated R7 is head strong and strong physically, and R7 is very smart. V25 said R7 went to college and was R7's major was in engineering. V25 said R7 was living alone independently in the community, but about seven months ago, R7 got into a fight in his neighborhood, and R7 was beat up and sustained a traumatic brain injury (TBI). V25 said that is when R7 went into state guardianship, and V25 started working with R7 as his state appointed guardian. V25 said before R7 come to this facility, R7 was in another facility. V25 further stated R7 used to live in New York with his sister (V26), who used to take care of R7, but R7 became too much for V26 to handle. V26 also takes care of R7's mother. V25 said R7 tried to jump from another facility in New York. V25 commented R7 has been calling his mother and upsets her during the calls, so V26 has restricted R7's phone calls to R7's mother, who is elderly. R25 said R7 is delusional and thinks people are watching him from space, and that is why R7 was not compliant with medications at the last facility. On 1/13/2023 at 2:04pm, V27 (R7's physician) said because R7 has a diagnosis of psychosis, agitation, and restlessness, and R7 was exhibiting signs and symptoms of agitation, R7 should have been on treatment to manage R7's behavior. V27 stated during R7's mood and behavior assessments, the facility should have looked at risks and benefits of R7 receiving psychotropic medication. V27 further said that given R7's previous actions and diagnosis of mental health condition, R7 have been on a scheduled mood/ behavior medication. On 1/13/2023 at 10:49am, V26 (R7's family member said R7 has never been in the military, and she stated R7 was diagnosed with schizophrenia around 1998 in New York, where R7 and family were living. V26 said she was helping R7 and took R7 in to help him, and would make sure every time R7 had a mental breakdown, R7 was admitted to the hospital for treatment stabilization. V26 said at that time, R7 did not like living with V26, because V26 would call 911 to take R7 to the hospital any time R7 stopped taking his behavioral health medication and R7 started showing signs of paranoia and laughing uncontrollably. V26 said R7 tried to elope from the hospital when R7 was first diagnosed with mental health illness. V26 said R7 does not believe R7 has mental health challenges and is in denial. She commented R7 cannot stay at one place because of R7 living with schizophrenia. V26 said she was monitoring R7, but when she left New York for work, R7 left his apartment and started wandering, and at one point, R7 was incarcerated. V26 further commented R7 eventually left New York and ended up in Chicago where R7 does not have any family. V26 said because of R7's mental health issues, R7 can be paranoid, and these behaviors might have led to R7 being involved in a fight in Chicago where R7 was terribly hurt. V26 said R7 calls his mother screaming and saying he wants to visit her, and this upsets R7's mother, who is [AGE] years old. V26 said she has now restricted R7's calls to his mother. V26 commented she takes care of her and R7's parents, who are both [AGE] years old, and V26 cannot take on R7 because V26 is already overwhelmed with taking care of both parents. V26 said when R7's mental health issues are under control, and R7 is properly medicated, R27 is the sweetest person you will ever met. V26 said R7 wants to visit his parents, especially his mother, but V26 said this is not possible at this time because V27 cannot take care of R7. On 1/13/2023 at 12:18pm, V9 said there were no discharge plans when R7 was first admitted , and he never said he wanted to leave. V9 said V9 did not think R7 was not a risk for elopement prior to R7 jumping out the window, and R7 had an accompanied pass to go out with guardian/staff. On 1/17/2023 at 3:28pm, V29 (R7's Psychiatrist) said R7 was visited two times by the psychiatry Nurse Practitioner in November and December 2022 for further assessments, but both times R7 was not in the building. V29 stated the facility never notified V29 about any behavioral issues/hallucinations R7 was experiencing before R7 jumped out of the window on the 3rd floor. V29 said even after R7 jumped out of the window, the facility never notified V29 of the incident, and V29 just recently learned (after Christmas) R7 had jumped out of the window. V29 said it is documented on several occasions R7 was preoccupied with going out of the facility see his mother, and R7 should have been moved to the 1st floor for supervision and monitoring in case R7 tried to leave the facility. V29 said, If the facility staff had called me to let me know R7 wanted to leave the facility to visit his mother, I would have instructed them to move him (R7) to the first floor since he (R7) has cognitive deficits. V29 commented having R7 on the first floor could have prevented R7 from sustaining serious injuries from falling out of the 3rd floor window. V29 further commented R7 is on psychotropic medications, which were started while at the hospital for treatments for injuries sustained during the fall on 11/29/2022. Fall Policy, dated 08/2020, titled: Fall Management Program, documents: The facility is committed to minimizing resident falls and/or injury so as to maximize each resident's physical, metal and psychosocial wellbeing. While preventing all residents' falls is not possible, it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment. Facility window maintenance log, dated 11/29/22, documents R7's window on the 3rd floor was not properly secured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on obervation, interview, and record review, the facility failed to provide appropriate treatment and services for assesed delusional thoughts and aggressive behaviour for one resident (R7) out of three residents reviewed for psychological treatment. This failure resulted in R7 jumping out of his 3rd floor bedroom window to the ground on 11/29/2022. The fall resulted in R7 being hospitalized with left and right fractured legs, fractured ankles, and fractured lumbar and throracic spine. Findings includes: Nurses Note, dated 5/30/2022 at 16:59, documents, Resident is alert & confused. No complain of pain. Barricade self in his room, compliance with all is medication vital check. Very talkative, complaint with isolation protocols. Will continue to monitor. admission Note, dated 5/31/2022 at 06:15, documents, N/A 3/3 Alert/confused. Comes to doorway at times. Verbalized wanting to go home. Resident is reluctant at times to cooperate with care needs. Able to get Resident to comply with taking all Q 4 hr VS this noc shift and the taking of Med Therapy. Continue current plan of care and continue to monitor behavior. No C/O pain. Let in no distress. Social services note, dated 06/1/22, documents: R7 met with staff 1:1 concerning R7 temper and how he responded towards staff. Nurses Note, dated 6/2/2022 at 08:50, documents, Resident started going off on one of the housekeepers while Writer on the phone with DON (Director of Nursing) about another matter. Security call to assist in calming Resident down as not easily re-directable. Resident does not fully understand the PUI (Patient Under Investigation) protocol and started shouting, 'I am not an animal! F u and this place, I want to go home, I want get out of here and if necessary I want you to release me to the streets/sign me out.' Endorsing f/u care needs to the relieving Nurse. Able to get Resident to calm down w/o having to medicate at this time. Resident is not easy to reason with/he is confused and laughing at times after his negative outburst. Continue to monitor. Left in No distress and w/o any physical violence at present. Social Services Assessment under Exit Seeking/wandering/Elopement risk assessment, dated 06/3/2022, documents: R7 has the physical ability to leave the building on his own. R7 has a current diagnosis of severe mental health illness, and information was provided by R7 and staff interview/observation. Also documents R7 has experienced two or more psychiatric hospitalizations R7's care plan, dated 06/09/2022, documents: R7 displays delusional behavior problem, R/t (related to) Yelling out, and confused, and negative thinking. Difficult to reason with. Social services noted, dated 7/31/2022, documents R7 washing his clothes in his room sink instead of sending clothes to laundry. Social services note, dated 08/17/2022, documents R7 was not changing his clothes and staff met with R7 to discuss importance of changing his clothes. Nurses Note, dated 8/24/2022 at 18:12, documents, Resident is alert and able to make needs known. Assisted with meal set up and performed ADL tasks with staff supervision. Avoids lying flat due to diagnosis of Heart Failure. Resident is anxious, verbally aggressive as exhibited in talking and laughing loudly, internally preoccupied and noted with frequent auditory hallucination. Resident is easy to redirect and medication compliant. Nurses Note, dated 8/25/2022 at 14:25, Late Entry: Resident is alert and able to make needs known. Assisted with meal set up and performed ADL tasks with staff supervision. Avoids lying flat due to diagnosis of Heart Failure. Resident is anxious, verbally aggressive as exhibited in talking and laughing loudly, internally preoccupied and noted with frequent auditory hallucination. Resident is easy to redirect and medication compliant. Nurses Note, dated 8/26/2022 at 17:25, documents, Resident is alert and able to make needs known. Assisted with meal set up and performed ADL tasks with staff supervision. Avoids lying flat due to diagnosis of Heart Failure. Resident is anxious, verbally aggressive as exhibited in talking and laughing loudly, internally preoccupied and noted with frequent auditory hallucination. Resident is easy to redirect and medication compliant. Social services note, dated 10/12/2022, documents R7 was spilling water on floors R7's social services progress note, dated 11/01/2022, documents: R1 engaged in an incident of peer-to-peer incident in which R1 threw beverages. Interdisciplinary note, dated 11/2/2022, documents R7 has not recollection of incident of 11/1/2022, R7 communicates some cognitive deficits and laughs in place of responses at times. admission Note, dated, 11/7/2022 at 17:25, documents, Re-admit [AGE] years old resident from St. [NAME] Hospital. Alert and oriented x2. Resident appear anxious, labile with disorganized thoughts and flight of ideas during admission processes. Breathing non-labored with no shortness of breath noted. Denies any pain at this moment. Lung sound clear upon auscultation. Abdomen soft and non-distended with bowel sound present in all 4 quadrants. Skin warm and dry to touch with no breakdown or wound noted. Resident denies any auditory or visual hallucination. Denies any suicidal or homicidal ideation. Resident educated about management of his blood pressure, the importance of complying with medications and prescribed diet. Resident verbalized understanding of the teaching and readiness to comply with medications and diet. Resident medications verified with NP and orders carried out as given. Staff will continue to monitor resident for safety and comfort. admission Note, dated 11/9/2022 at 18:33, documents, Resident received in room alert and able to make needs known. Resident endorses auditory hallucination with disorganized thoughts and flight of ideas. Breathing non-labored with no shortness of breath noted. Denies any pain at this moment. Lung sound clear upon auscultation. Abdomen soft and non-distended with bowel sound present in all 4 quadrants. Skin warm and dry to touch with no breakdown or wound noted. Assisted with meal set-up and performed ADL tasks with staff supervision. Resident educated about management of his blood pressure, the importance of complying with medications and prescribed diet. Resident verbalized understanding of the teaching and readiness to comply with medications and diet. Resident blood pressure managed with prescribed medications during the shift. Staff will continue to monitor resident for safety and comfort. Nurses Note, dated 11/16/2022 at 18:32, documents, Resident is alert and able to make needs known. Assisted with meal set up and performed ADL tasks with staff supervision. Avoids lying flat due to diagnosis of Heart Failure. Resident is anxious, verbally aggressive as exhibited in talking and laughing loudly, internally preoccupied and noted with frequent auditory hallucination. Resident has order for Haloperidol lactate solution 1 mL every 4 hours as needed for symptoms of agitation. Resident is easy to redirect and medication compliant. Nurses Note, dated 11/19/2022 at 17:22, documents, Resident is alert and able to make needs known. Assisted with meal set up and performed ADL tasks with staff supervision. Avoids lying flat due to diagnosis of Heart Failure. Resident is anxious, verbally aggressive as exhibited in talking and laughing loudly, internally preoccupied and noted with frequent auditory hallucination. Resident has order for Haloperidol lactate solution 1 mL every 4 hours as needed for symptoms of agitation. Resident is easy to redirect and medication compliant. Nurses Note, dated 11/20/22 at 18:00, documents, Resident is alert and able to make needs known. Assisted with meal set up and performed ADL tasks with staff supervision. Avoids lying flat due to diagnosis of Heart Failure. Resident is anxious, verbally aggressive as exhibited in talking and laughing loudly, internally preoccupied and noted with frequent auditory hallucination. Resident has order for Haloperidol lactate solution 1 mL every 4 hours as needed for symptoms of agitation. Resident is easy to redirect and medication compliant. Nurses Note, dated 11/22/22 at 18:55 documents, Resident is alert and able to make needs known. Assisted with meal set up and performed ADL (Activities of Daily Living) tasks with staff supervision. Avoids lying flat due to diagnosis of Heart Failure. Resident is anxious, verbally aggressive as exhibited in talking and laughing loudly, internally preoccupied and noted with frequent auditory hallucination. Resident has order for Haloperidol lactate solution 1 mL every 4 hours as needed for symptoms of agitation. Resident is easy to redirect and medication compliant. Nursing notes, dated 11/29/2022 at 08:00, documents, At the start of my (V4-(Licensed Practical Nurse/LPN) shift approximately 7:30 AM, it was identified that (R7) was not in his room. A CODE GREEN was called, a search of the floor and outside ground was conducted. R4 was noticed on the ground outside of the facility. R4 complained of pain to bilateral legs. Police on scene and ambulance. R4 transported to community hospital). PPHP NP (Nurse Practitioner) notified of occurrence and transfer to Hospital NP aware. Facility reported incident report, dated 12/05/2022, documents: On 11/29/2022 at approximately 8:00am. (R7) exited the facility via window resulting in a fall. (R7) was observed outside of the facility. (R7) was alert to person and place with periods of confusion. (R7) was observed with swelling to lower extremities. Physician notified; Guardian notified. (R7) transferred to nearby community hospital emergency room for further evaluation. (R7) was admitted with bilateral broken ankles, fractured lumbar and thoracic spine. The facility's incident report further documents R7's diagnoses, not limited to: unspecified psychosis, Unspecified symptoms, and signs involving cognitive functions and awareness, TBI (traumatic brain injury), restlessness and agitation. Physician Order Summary: QUEtiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) Active date 1/17/2023 12:15 Give 1 tablet by mouth every 6 hours as needed for Psychosis/agitation for 14 Days Physician Order Summary: QUEtiapine Fumarate Tablet 25 MG Active date: 12/15/2022 21:00 Give 1 tablet by mouth at bedtime related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION (F29) Physician Order Summary: QUEtiapine Fumarate Tablet 50 MG Active date 12/15/2022 09:00 Give 1 tablet by mouth every 12 hours related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION (F29) On 1/10/2023 at 11:33am, R7 was observed lying in bed awake, with R7's right leg in a plaster cast from the toe to mid upper thigh. R7 was alert and oriented to name and place. R7 stated he fell from 3rd floor roof to the ground. R7 said, I used to live on the 3rd floor, they would not give me speech (sic). I was not feeling good, and I wanted to go home so I jumped from the roof. He (unknown person) denied me speech (sic) to go outside, so I wanted to go home, so I jumped out window and tried to go home, which is my right because I am not incarcerated. It was a paranoid thing. On 1/13/2023 at 10:49am, V26 (R7's family member) said R7 has never been in the military, and she stated R7 was diagnosed with schizophrenia around 1998 in New York, where R7 and family were living. V26 said she was helping R7, and took R7 in to help him, and would make sure every time R7 had a mental breakdown, R7 was admitted to the hospital for treatment stabilization. V26 said at that time, R7 did not like living with V26, because V26 would call 911 to take R7 to the hospital any time R7 stopped taking his behavioral health medication and R7 started showing signs of paranoia and laughing uncontrollably. V26 said R7 tried to elope from the hospital when R7 was first diagnosed with mental health illness. V26 said R7 does not believe R7 has mental health challenges and is in denial. She commented R7 cannot stay at one place because of R7 living with schizophrenia. V26 said she was monitoring R7, but when she left New York for work, R7 left his apartment and started wandering, and at one point, R7 was incarcerated. V26 further commented R7 eventually left New York, and ended up in Chicago where R7 does not have any family. V26 said because of R7's mental health issues, R7 can be paranoid, and these behaviors might have led to R7 being involved in a fight in Chicago, where R7 was terribly hurt. V26 said R7 calls his mother screaming and saying he wants to visit her, and this upsets R7's mother, who is [AGE] years old. V26 said she has now restricted R7's calls to his mother. V26 commented she takes care of her and R7's parents, who are both [AGE] years old, and V26 cannot be able to take on R7, because V26 is already overwhelmed with taking care of both parents. V26 said when R7's mental health issues are under control, and R7 is properly medicated, R27 is the sweetest person you will ever met. V26 said R7 wants to visit his parents, especially his mother, but V26 said this is not possible at this time because V27 cannot be able to take care of R7. On 1/12/2023 at 4:10pm, V25( R7's State Guardian) stated she was notified by facility when R7 jumped out of the window, attempting to elope. V25 commentated R7 is head strong and strong physically, and R7 is very smart. V25 said R7 went to college and was R7's major was in engineering. V25 said R7 was living alone independently in the community, but about seven months ago, R7 got into a fight in his neighborhood, and R7 was beat up and sustained a traumatic brain injury (TBI). V25 said that is when R7 went into state guardianship, and V25 started working with R7 as his state appointed guardian. V25 said before R7 come to this facility, R7 was in another facility after the TBI. V25 further stated R7 used to live in New York with his sister(V26), who used to take care of R7, but R7 became too much for V26 to handle. V26 also takes care of R7's mother. V25 said R7 tried to jump from another facility in New York. V25 commented R7 has been calling his mother and upsets her during the calls, so V26 has restricted R7's phone calls to R7's mother, who is elderly. R25 said R7 is delusional and thinks people are watching him from space, and that is why R7 was not compliant with medications at the last facility. On 1/13/2023 at 2:04pm, V27 (R7's physician) said because R7 has a diagnosis of psychosis, agitation, and restlessness, and R7 was exhibiting signs and symptoms of agitation, R7 should have been on treatment to manage R7's behavior. V27 stated during R7's mood and behavior assessments, the facility should have looked at risks and benefits of R7 receiving psychotropic medication. V27 further said given R7's previous actions and diagnosis of mental health condition, R7 have been on a scheduled mood/ behavior medication. On 1/17/2023 at 3:28pm V29 (R7's Psychiatrist) said R7 was visited two times by the psychiatry Nurse Practitioner in November and December 2022 for further assessments, but both times R7 was not in the building. V29 stated the facility never notified V29 about any behavioral issues/hallucinations R7 was experiencing before R7 jumped out of the window on the 3rd floor. V29 said even after R7 jumped out of the window, the facility never notified V29 of the incident, and V29 just recently learned (after Christmas) R7 had jumped out of the window. V29 said it is documented on several occasions R7 was preoccupied with going out of the facility see his(R7) mother, and R7 should have been moved to the 1st floor for supervision and monitoring incase R7 tried to leave the facility. V29 said, If the facility staff had called me to let me know (R7) wanted to leave the facility to visit his mother, I would have instructed them to move him to the first floor since he has cognitive deficits. V29 commented having R7 on the first floor could have prevented R7 sustaining serious injuries from falling out of the 3rd floor window. V29 further commented R7 is on psychotropic medications, which were started while R7 was admitted to hospital for treatments for injuries sustained during the fall on 11/29/2022. On 1/18/2023 at 1:15pm, R7 was observed to be on 1:1 with a sitter due to R7 exhibiting elopement behavior. Facility policy titled Psycho-social Programming Protocol (corresponds with Policy), no date, documents: Psycho-social programming should be offered to anyone who expresses during our assessment process or is observed with maladaptive behaviors, mental health issues, and any cognitive issues resulting in behavioral issues. Facility policy titled: Psychotropic Medications-Use Of, dated 09/2020, documents: A psychotropic medication will be defined as any medication that is prescribed for the purpose modifying mood and/or behavior.

Based upon observation, interview, and record review, the facility failed to follow the fall management program/policy, and failed to implement fall prevention interventions (R1, R12), failed to conduct a thorough investigation to determine root cause (R1), and failed to conduct a timely investigation (R12) for 2 of 3 residents reviewed for falls. These failures resulted in R1's (10/4/22) fall with right foot soft tissue swelling. Findings include: 1. R1's diagnoses include bilateral paralytic syndrome following cerebral infarction, paraplegia, right/left foot drop. R1's (9/21/22) BIMS determined a score of 15 (cognitively intact). R1's (9/21/22) functional assessment affirms 2 person physical assist is required for transfers and 1 person physical assist is required for locomotion. R1's (9/27/22) fall risk assessment determined a score of 4 (at risk). R1's care plan includes (2/12/22) resident is at risk for falls secondary to paraplegia, wheelchair bound, functional deficits, and muscle weakness. Intervention: encourage appropriate use of wheelchair. (4/20/22) Resident is noted to have limitation in range of motion secondary to foot drop. Intervention: assist as needed. R1's (10/4/22) initial report states resident left facility with an escort for scheduled appointment at the hospital, resident was noted slightly slid off her wheelchair while taking her off the vehicle lift at the destination. According to her assigned escort, resident legs touched the floor, and she was immediately readjusted back on the wheelchair. R1's final report excludes a root cause analysis. R1's (10/4/22) history & physical includes chief complaint: fall. Stated complaint: foot pain status post fall. Patient accidentally slipped partially out of the wheelchair prior to arrival when she hit a bump and complains of some right foot discomfort. Patient states that after she had a stroke 6 months ago, she's been lying contracted in a crooked position on her right hip. R1's (10/4/22) x-rays include posterior dislocation of the right hip and soft tissue swelling along the dorsum of the (right) foot. On 11/28/22 at 11:02am, V3 (RN/Registered Nurse) was observed exiting R1's room. Surveyor inquired about R1 functional status V3 stated, She's not able to walk. On 11/28/22 at 11:05am, R1 was lying in bed on her left side. R1's right leg was severely contracted and right foot drop was noted. Surveyor inquired about R1's contractures, R1 replied, I had a stroke my whole body is contracted. I have a contracted hip. R1's bed was in high position and side rails and/or floor mats were not in use. Surveyor inquired about the (10/4/22) incident. R1 stated, I fell out the wheelchair. I had to go to another facility to see the pain doctor. The gentleman was pushing me into the facility as we got to the doors, he hit a little crinch in the sidewalk and I slid out the wheelchair onto my bad leg because I was in a regular wheelchair not with a seatbelt. R1 affirmed her specialty wheelchair (which has a seatbelt) is too small, therefore, a regular wheelchair was in use at the time of the incident. Surveyor inquired about R1's (10/4/22) injuries. R1 responded, My butt hit the ground and the back of my knee was bruised. My hip was already dislocated. On 11/28/22 at 11:12am, V3 (RN) entered R1's room. Surveyor inquired about the height of R1's bed, V3 stated, Right now, it's a bit high. It's supposed to be low. Surveyor inquired why side rails were not in use, V3 responded, We need the rails. On 11/28/22 at 3:37pm, surveyor inquired about R1's (10/4/22) incident, V15 (Bus Driver) stated, I was unloading the passenger (R1) and she kinda slipped down. She ended up, I think, barely touching the floor. Surveyor inquired if V15 was pushing R1's wheelchair when the incident occurred. V15 responded, I was assisting to bring it out to the ramp to go inside the hospital. If you don't push her out, she just stays there, so you gotta assist her to come out, and affirmed he (V15) was pushing R1's wheelchair towards the ramp. Surveyor inquired what R1's facility escort was doing. V15 replied, Waiting for me (V15) to take her (R1) on the ramp so she (Escort) could take her (R1) inside. Surveyor inquired if V15 received training for transferring residents to and from the bus. V15 stated, Yes, to work the lifter up and down. Surveyor inquired if V15 is a CNA (Certified Nursing Assistant), V15 responded No. On 11/29/22 at 9:23am, surveyor inquired about the root cause of R1's (10/4/22) incident. V2 (Director of Nursing) stated, She (R1) was out on an appointment at the hospital, as they were letting the lift down, the wheel went on some uneven pavement and she slid out of the chair. To prevent it from happening again, we reassessed her (R1) for wheelchair, and spoke with her (R1) in regards to safety and sitting up in the chair, and spoke to staff regarding safety during transport. Surveyor inquired about the facility failures which likely caused R1's (10/4/22) incident. V2 responded, I believe we didn't fail at all. Surveyor inquired why R1 was transported in a regular wheelchair (without a seat belt). V2 replied, Because at that time she was using a regular wheelchair and was sitting comfortably in the wheelchair. Surveyor inquired if V15 received any training for transporting and/or assisting residents prior 10/4/22. V2 stated, That's information that I would have to find out, however, no additional information and/or documentation was provided. On 11/30/22 at 10:44am, surveyor inquired about R1's functional status, V31 (Restorative Nurse) responded, Her functioning is bad she's pretty much total care. She can't do anything really, the way her body is crooked. I did a geri assessment on her when she's in the bed she can come up just a little bit, not a whole lot. She couldn't really lift up. Surveyor inquired if a regular wheelchair is appropriate for R1, V31 responded, No, never. Surveyor inquired about an appropriate mode of transportation for R1's appointments, V31 stated, If she has to go somewhere she has to go via stretcher. 2. R12's diagnoses include dementia and acquired absence of right leg (above knee). R12's (10/14/22) BIMS (Brief Interview Mental Status) determined a score of 1 (severely impaired). R12's (10/14/22) functional assessment affirms (1 person) physical assist is required for transfers. R12's (10/14/22) fall risk assessment determined a score of 7 (at risk). R12's (7/15/22) care plan states resident is at risk for falls secondary to history of falls, right AKA (Above Knee Amputation), dementia, and seizure disorder. Intervention: promote placement of call light within reach. R12's (11/15/22) incident report states the nurse went to resident's room and observed resident on the floor with linen wrapped around his body having a seizure. R12's (11/16/22) head CT (Computed Tomography) includes deformity of the nasal bones with associated soft tissue swelling and could reflect fractures of indeterminate age. On 11/28/22 at 10:50am, R12 was sitting in a wheelchair (adjacent the bed) however a call light was not within reach. Surveyor inquired about the (11/15/22) incident, R12 stated, I just fell out standing up or something. On 11/28/22 at 10:56am, V3 (Registered Nurse) entered R12's room surveyor inquired if R12 requires transfer assistance, V3 stated, He needs help. We always tell him to wait for the CNA (Certified Nursing Assistant) to help him. Surveyor inquired about R12's fall prevention interventions. V3 responded, We have a CNA to meet up with his needs if he goes back to the bed. He uses the call light to get the attention of the CNA or the Nurses. The call light is functioning. Surveyor inquired about the location of R12's call light. V3 moved R12's bed, lifted R12's mattress and stated Where is the call light? It fell on the floor. It's supposed to be on the bed all the time. On 11/29/22 surveyor requested R12's (11/15/22) fall investigation, however, the investigation was not received. On 11/29/22 at 2:42pm, surveyor inquired about R12's (11/15/22) incident/injury, V2 (Director of Nursing) responded, He was sent out to the ER (Emergency Room) to be evaluated. I know there was no injuries. Surveyor inquired if an investigation was conducted for R12's (11/15/22) incident. V2 responded Yes. Surveyor inquired why the investigation was not received. V2 affirmed she provided surveyor staff statements. On 11/30/22 at 9:36am, surveyor requested R12's (11/15/22) alleged investigation. V2 stated, I did report that deformity yesterday (14 days after the incident). V2 subsequently presented R12's preliminary incident investigation report which includes date of alleged incident: 11/16/22 (the incident occurred on 11/15/22). Any obvious injuries: no (R12 sustained nasal injuries). The facility will continue to conduct a complete and thorough investigation until a conclusion is reached. R12's 11/15/22 final investigation was not received during this survey. On 11/30/22 at 1:36pm, surveyor inquired about potential harm to a resident that sustains a fall. V29 (Medical Director) stated, Usually with a fall that's unwitnessed let's say that the patient hits the head, there could be injury to the scalp or bleed to the brain that could lead to death. Another one would be fractures. The (8/2020) fall management program states it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment. Educate staff members to check during room rounds the 4 P's (pain, positioning placement of personal items, personal needs). The nurse call device will be placed within the resident's reach. The bed will be maintained in a position appropriate for resident transfers. Use standard fall/safety precautions for all residents. The (8/2020) management of falls policy states provide assistive devices for mobility, hearing and vision as appropriate for the resident. Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards.