**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice to promote healing and prevent infection, for 1 of 7 residents (CR #1) reviewed for wound care. The facility failed to follow wound care orders for CR#1's sacral wound on 11/07/24, 11/12/24, 11/16/24, 11/23/24, 11/24/24, and 11/27/24. CR#1 was transferred to the hospital after family intervention and was diagnosed with a stage 4 pressure injury (full-thickness skin and tissue loss, exposing muscle, tendon, or bone) with infection and severe sepsis. The noncompliance was identified as past non-compliance. The past non-compliance IJ began on 11/28/24 and ended on 2/20/25. The facility corrected the non-compliance before the survey began. This failure could place residents at risk of deterioration of wound, increased infection, decreased quality of life, and hospitalization. Findings included: 1.Record review of CR#1's Face Sheet (undated) revealed, a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses which included Non-ST elevation Myocardial infarction (heart attack that occurs when blood supply to the heart was reduced, causing damage), Acute respiratory failure with hypoxia (lungs failed to adequately oxygenate the blood), Chronic Obstructive Pulmonary Disease (airway obstruction and chronic inflammation of the lungs), Diabetes Mellitus (chronic metabolic disease characterized by high blood sugar levels), and End Stage Renal Disease (kidney failure). Record review of CR#1's admission MDS assessment dated [DATE] indicated a BIMS summary score of 05, which indicated severe cognitive impairment. The resident did not have pressure ulcers as a diagnosis on the entrance MDS. However, there was an indication for a pressure reducing device for her bed. Record review of CR#1's Comprehensive Care Plan, dated 10/03/24, indicated that CR#1 was at risk for pressure wounds related to alteration in skin integrity and pressure ulcer formation. The goal was to be free from alteration in skin integrity/formation of pressure wounds over the next 90 days. CR#1's interventions included assisting with toileting as indicated and performing weekly skin checks. Record review of CR #1 physician's orders on 11/05/24 indicated sacrum: cleanse site with normal saline, wound sacrum cleanser pat dry, skin prep, apply hydrocolloid sheet 3x weekly (Tuesday, Thursday, and Saturday) and prn. That order was discontinued, and a new sacrum wound care order was started on 11/21/24. The new order was for sacrum wound: cleanse site with Vashe pat dry, apply Santyl ointment (Nickel Thick) as topical, cover with calcium alginate as a primary dressing, and cover with bordered gauze daily and PRN every day. Record review of CR #1's treatment administration record for November 2024 revealed wound care was not performed as ordered on 11/07/24, 11/12/24, 11/16/24, 11/23/24, 11/24/24, and 11/27/24. Record review of CR #1's weekly wound evaluation summary dated 11/01/2024 revealed a new sacral opening. Record review of CR #1's weekly wound evaluation summary dated 11/05/2024 revealed wound to the sacrum which measured 3x2x0.1cm Record review of CR#1's wound care notes on 11/18/24 by NP F revealed that CR#1's chronic sacral wound was measured at 3.4x7x0 cm. Record review of CR#1's wound care notes on 11/25/24 by NP F revealed that CR#1's chronic sacral wound continued to be unstageable but deteriorating and measured at 5x5x0. Record review of nursing notes dated 11/28/24 revealed CR#1's family member notified EMS to have resident CR#1 transferred from the facility to the hospital due to the condition of CR#1's wound. Record review of local hospital's medical records revealed that CR #1 was brought to the ED on 11/28/24 at 8:34 AM from a nursing facility with a sacral wound. After assessment, the resident was admitted to the hospital with stage 4 pressure injury and severe sepsis (life threatening condition where one or more body's organ is damaged from the inflammatory response). Wound cultures were collected and revealed positive for Escherichia. Coli (bacteria found in the intestines). Attempted to interview with the previous wound care nurse on 03/19/25 at 1:39 PM, but she no longer worked for the facility. During an Interview on 03/20/25 at 12:51 PM with contracted Dialysis RN, she said CR #1 had fluid overload and was on dialysis Monday-Friday. She said CR #1 was alert and oriented with some confusion. She said the resident developed a sacral wound; therefore, they would turn her to her side so she would be off the wound while in dialysis. During an interview on 03/20/2025 at 1:00 PM with the ADON, (who started at the facility on 09/23/24), she said CR#1's family would come to the facility regularly. She said the staff would notify the family member of any changes. She said the resident was in the Geri-chair most of the day and out of the bed per the family's request. She said her expectation was for the staff to follow MD orders. She said the risk of not following MD orders was a concern and that staff should always follow the orders. She said the staff conducted in-services on following MD orders recently but could not to provide a date. The ADON said the risk of not following MD orders could worsen the condition/diagnoses or wound. During an interview on 03/20/2025 at 3:24 PM with the DON, she said CR#1 was admitted to the facility without pressure ulcers but developed a pressure wound while at the facility. She said the resident was being treated as ordered, but the staff did not document her treatment. The DON said she could not confirm wound care was perfomed due to insufficient documentation. She said the wound care nurse who performed the treatment was terminated and no longer work at the facility. The DON said there was a new wound care nurse. She said she expected the staff to follow MD orders and document all treatments . The DON said the risk of not performing wound care as ordered could lead to deterioration of the wound. Attempted to interview wound care Nurse Practitioner F on 03/20/25 at 3:51 PM, but she no longer worked for the wound care company. During an interview on 03/20/25 at 4:09 PM, the current wound care nurse, Nurse Practitioner L said Nurse Practitioner F assessed and provided treatment to CR#1, who no longer work for the company. Nurse Practitioner L said her expectation was that the nursing staff followed MD orders. She said some residents were placed on hydrocolloid, which can last up to 7 days; however, the staff should not deviate from the orders. She said if the order said to provide treatment every 3 days, the staff should follow that order. The Wound Care Nurse Practitioner L said the risk of not following the MD's orders was deterioration of the wound. During an interview on 03/20/25 at 5:13 PM with LVN T, wound care nurse, (who started at the facility on 2/24/25), she said her expectation was for staff to follow MD orders for wound care. She said the wound care doctor comes to the facility once a week, and if there were a change or deterioration to the wound, she would assess the wound to include measurements and notify the charge nurse and wound care MD. She said she conducted an in-service on skin assessments last week. She said she educated the CNAs on what to look for on the resident's skin. She said the risk of not following the physician's orders was the wound/ulcer could worsen. During an interview on 03/20/25 at 5:45 PM with the administrator, she said her expectation was the staff follow MD orders. She said she was unaware of what could happen if the staff did not cleanse the wound as ordered by the MD. During an interview on 04/07/25 at 2:12PM, CR#1's family member said she called EMS because CR#1's wound was large and had an odor. She said when she arrived at the local hospital the doctor admitted CR#1 her aunt because she was septic. She said she had E. Coli in her wound. She said after acquiring the wound and becoming septic, CR#1 was never the same. CR#1's family member said they had to perform colostomy (surgical procedure that creates an opening in the abdomen to allow stool to pass out the body) on 12/12/24, and she was discharged to another nursing facility on 12/14/24. During an interview on 04/07/25 at 4:48 PM, the Chief Medical Officer for the wound care company said NP F no longer worked there. She said, based on the photos, CR #1 had a chronic unstageable sacral wound. She said the wound had not significantly changed between the initial visit on 11/18/24, measuring 23.8 cm, and the 2nd visit on 11/25/24, measuring 25cm. She said the interventions, including the dressing that was ordered, were appropriate for wound care. She said the resident had significant comorbidities and was incontinent to bowel and bladder, which could also deteriorate the wound quickly. The chief medical officer said the resident was declining, and based on the appearance of the wound, this skin failure was a phenomenon that was recognized in residents with a terminal condition. During an interview on 04/07/25 at 5:01 PM, LVN M said nurses perform weekly skin assessment on the residents. She said the nurses were responsible for providing wound care if the wound care nurses were unavailable. She said the staff was in-serviced last week on wound care. She said the risk of not performing wound care could lead to further breakdown of the skin or worsen the wound. During an interview on 04/07/25 at 5:36 PM, RN O said nurses perform wound care when the wound care nurse was not available. She said they also have a wound care MD that comes once a week to provide care. RN O said they perform skin assessments on every new admission and conduct weekly skin assessments. She said a wound consult was requested for every resident with a wound, and the MD was contacted if there was a change in the wound. RN O said the last in-service on wound care was conducted last week. She said the risk of not providing wound care was infection. Attempted telephone interview with Dr. T on 04/08/25 at 12:54 PM, left a voicemail message. During an observation of Resident #2's wound care on 04/09/25 at 2:40 PM, the wound care nurse sanitized hands and applied PPE (personal protective equipment), including gown and gloves. She cleaned the bedside table and applied barrier to bedside table. She doffed gloves and washed her hands. She donned gloves, cleaned the unstageable sacral wound with wet gauze, and patted it dry. The wound care nurse doffed gloves, washed her hands, and donned new gloves. She applied Medihoney, calcium alginate, and dressing as ordered. She doffed her gown and gloves and washed her hands. She repositioned the resident to her right side and removed discarded items. During an interview on 04/09/25 at 2:51 PM, RN S said she does wound care as needed. She said she noticed an increase in training in January and February by the wound care nurse. She said she cannot remember the date of her last wound care training. She said in training, the staff was educated on change of condition (odor, increase drainage, increase pain, and increase temperature) and the notification process. She said when providing wound care, the staff should document changes in the wound and notify the MD, RP, and DON. She said staff should reposition residents every 2 hours and change wet and soiled briefs frequently to prevent skin breakdown. Review of the facility's policy titled Wound Evaluation, with a revision date of 06/ 2019, read in part . Procedures: 2. Document all treatments performed and resident response in Point Click Care. 6. Evaluation results are communicated to the members of the interdisciplinary care team through documentation, care plan meetings, and care planning . The noncompliance was identified as past non-compliance. The IJ began on 11/28/24 and ended on 02/20/25. The facility corrected the non-compliance and implemented the following interventions prior to the surveyors entering the facility on 03/18/25: -Record review of QA meetings, with facility clinical staff and regional nursing staff, regarding facility skin system and wound care on 12/06/24, 12/20/24, 01/10/25 and 02/07/25. -Record review of Wwound care nurses were terminated on 12/17/24 and 12/23/24. -Record review of skin sweeps conducted 12/23/24 through 12/31/24. Results indicated no other residents were found to have new or worsening wounds. -Record review of QA Nurse and DON followed-up on all wound care audits and skin assessments. -Outside Wound Care physician rounded on all residents on 02/06/25-02/07/25. -Interviews with staff they who stated they have been in-serviced to report any changes or anything different for the resident. - Record review of in-services and re-education provided to facility staff on 01/06/25, 01/14/25, 01/15/25, 02/05/25, and 02/14/25. Topics included: Wound care; change in conditioning; incontinent care and repositioning for residents with wounds. -Observations during annual recertification 03/18/25-03/20/25 revealed no concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 out of 2 residents (Resident #1 and CR #2) reviewed for adequate supervision. Facility failed to perform timely intervention after multiple reports of closet door malfunctioning. The closet door fell on Resident #1 on 07/22/23 resulting to hospitalization. The noncompliance was identified as Past Non Compliant. The IJ began on 7/22/23 and ended on 7/25/23. The facility corrected the non compliance by removing the doors prior to surveyor entrance. This deficiency exposed residents living in the facility to safety hazard. Findings included: Record review of Resident #1's face sheet revealed Resident #1 was a [AGE] year-old female. She was admitted to the facility on [DATE], her initial admission was 09/28/2017. She was diagnosed with osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases), pain, dementia, disorder of bladder, diarrhea, Major depressive disorder, abnormality of gait and mobility, fall, cataract, muscle weakness, and hypertension. Review of Resident #1's MDS (Minimum Data Set) dated July 31, 2023, section G0110 revealed resident required one-person physical assist with bed mobility, walk in room, walk in corridor, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. Section I0020 revealed Resident #1 had a medically complex condition Record review of Resident #1's care plan dated 07//12//2023 revealed: 1. Focus: Resident #1 has dementia Goal: Resident #1 will be safe in her environment . 2. Focus: ADL self-care Goal: Resident #1will have no further decline in ADL or injury . Intervention: anticipate needs and provide prompt assistance with the following - Walk in room [ROOM NUMBER]:1 - Walk in corridor 1:1 - Locomotion on unit 1:1 - Locomotion off unit 1:1 - Dressing 1:1 - Personal hygiene 1:1 3. Focus: Resident #1 is at risk for fall and injuries Goal: Resident #1 will be free from falls and injuries . Record review of progress note revealed the following: - On 07/22/2023 at 08:10pm At 7.50 pm Patient fall on the floor in her room attempting getting something in the closets , patient found on the floor face up and the closet door was on top of her, scream help me nurse rush into the room for help, 911 was called paramedics arrived at 08:00pm to access her Blood Pressure was elevated 179/91, Temperature 97.8 Pulse-90, SPO2 98 Pain scale 9 on the scale of 1-10 scale, patient was alert and oriented going to the ER was crying for pain. - On 07/23/2023 at 03:33am Patient returned from the ER at 0200 with the daughter accompany her in the room with 2 new prescription prn cyclobenzaprine 5mg PO and ondansetron 4mg PO prn, presently in her room sleeping vital signs stable daughter sitting by the side of her bed BP 124/70, T 97.2, P 74, R18, SPO2 98 ibuprofen 600mg ever 8 hours given for pain immediately she came back. presently in her bed sleeping. - On 07/23/2023 at 12:41pm Patient vital signs and neurological check completed. Upon check, patient vitals signs are low and neurological signs are abnormal. Daughter requested resident be sent back to the hospital for further evaluation. Pupils dilated, motor weakness noted, withdrawals to external stimulus, confused orientation, slurred speech. Body aches and weakness. Symptoms in relation to fall last evening on night shift. Record review of hospital record revealed Resident #1 was diagnosed with Nausea and Vomiting. Diagnostic CT (Computerized Tomography) scan revealed No CT evidence of acute intracranial abnormality. Physician note revealed Resident #1 likely had concussion, On 08/23/2023 at 2:23pm in an observation of Resident #1 in her room, resident was in bed and sleeping. Family Member 1 was at the bedside, she stated after her mom was back from the hospital on the next day (07/24/2023), the resident (CR#2) across her mom's (Resident #1) room stated that he (CR#2) had complained about the closet door to the therapist (Occupational Therapist A) few days before her mom had the accident, but they (facility) did not do anything about it. Resident's Family member 1 stated CR #2 told her that the Occupational Therapist A took pictures of the closet door of his room when he (CR#2) told him (Occupational Therapist A). Resident Family member 1 stated when she made attempt to get the pictures, Occupational Therapist A stated he did not have picture. On 08/23/2023 at 3:11pm in an interview with CR #2 (Former resident of the facility) via phone, he said about more than a month ago when he first noticed the closet door of his room came off, he stated his family member (Family Member 2) moved the closet door couple of times to one side so he (CR#2) won't have to move them when he needed to use the closet, he said Family Member 3 also helped to move the door too. CR #2 said the Occupational Therapist A who was helping him with therapy saw the closet door at that time and took picture of the closet door, CR #2 stated the Occupational Therapist A stated he was going to show the picture to the management. CR #2 stated but it seemed like the Occupational Therapist A was scared because he later denied that he did not have any picture again. CR #2 stated there was nothing done to address the issue. He stated he first experienced the issue of closet door malfunctioning in his room before the incident of Resident #1 happened (he could not recall exact date). He stated his closet door did not completely come off, but it was disconnected from the frame on one side. On 08/23/2023 at 4:07pm in an interview with Occupational Therapy A, he stated he had been working at the facility for about 4 years. He said CR #2 told him around July that the closet door was faulty. Occupational Therapist A stated he could not recall specific date, but he said it was few days after CR #2 came back from the hospital, he said resident (CR#2) was hospitalized on [DATE] and came back about 3 days after. He said he did not see the closet door, neither did he take any picture. He stated he told the former Administrator, he stated he did not recall the exact date when CR #2 told him, but he told the Administrator (the former Administrator) about it. He stated right now the maintenance had removed all the barn-style doors from the closet. On 08/23/2023 at 4:47pm in an interview with the DON who had been working at the facility for two months, she said she did not know what happened to Resident #1's door, and she (DON) was not in the building at the time of the incident. She stated that immediately the incident happened, all the closet doors were removed for safety reason. She stated prior to that incident, she did not hear of any closet door coming off or having fault. On 08/23/2023 at 5:15pm in an interview with the New Administrator, She Said she was not there in the facility when the Resident #1 fell with the closet door on top of her. She said she did hear about it at the time she started working at the facility about 4 weeks ago. The New Administrator said the closet doors were removed ever before she started working at the facility. On 08/23/2023 at 5:42pm in an interview over the phone with Former Administrator, she said she did not hear about any incident about closet door faulty before the Resident #1's incident happened. She said she was the interim Administrator, and she was only at the facility for a month (the end of June to the end of July). She said they took off the barn door of all the closets for safety. She said she knew that the organization was in the process of remodeling of some of the rooms and that will be up to them to decide what to do with the closets. On 08/23/2023 at 6:03pm in an interview via the phone with the Former Maintenance Staff, he said before the incident of Resident #1's closet door fell off on her, he said a resident and another family member told him that the door fell down and hit the family member's foot. He stated the room was in the new hallway that was just built. He stated he did not recall the name of the resident and the exact date, but he heard a complaint about the closet doors in the past which he told the Administrator (former Administrator), the general contractor and the Regional Staff. On 08/23/2023 at 6:55pm in a phone interview with the Regional Staff, he said he did not remember any maintenance staff telling him about closet door malfunctioning. He said he was notified after the Resident #1 fell and the closet doors were removed. He stated he had no idea who notified him at that time, he said he got notified about it anyway. On 08/30/2023 at 4:02pm in an interview with Nurse A who was the nurse taking care of Resident #1 the day Resident #1 fell. She said the resident screamed for help and they all rushed to the room. Nurse A reported that the resident stated she was trying to pick something in the closet and when she was losing her balance, she grabbed the closet door then the closet door came off and she fell with the closet door. Nurse said resident was crying in pain and pain medication was administered. Nurse A stated Resident #1 was sent to the hospital immediately, but she was back from the hospital within 24-hours in the morning - she stated the incident occurred during the night shift and she was sent to hospital that night, but resident came back in the morning. Nurse said the resident was sent back to hospital the same day she came back because she was having abnormal vital sign, altered mental status and nausea/ vomiting as a result of the fall. On 09/05/2023 at 6:28pm in an interview with Former medication Aide, she stated the closet doors of the new hallway appeared fragile, she said it was not firm like the closet door of other old rooms. She stated she did not hear complaints from any residents but with the look of the closet door hanging on a rail, she said it appeared fragile. On 09/05/2023 at 6:38pm in an interview with family member 2, he stated he came to the facility up to three times a week to visit CR #2, and he was in the building about three to four weeks while the CR #2 was admitted there. He stated they got a lot of things going on at one time there at the facility, he said there was no hot water for almost a month, he said but they got the hot water fixed. He stated every time he came to the facility, he had seen the closet door of CR#2's room in a pretty bad condition. He said it was loose on the top part. He stated complaint was made to the staffs there, but nothing was done for a very long time. On 09/05/2023 at 6:43pm in an interview with the Family member 3, the son of CR #2, he stated the closet door of his father's room was coming off track multiple times. He said the closet door came off track many times and he put it back couple of times too, he said there were multiple times the door was off track He stated every time he would point out the closet door to the staffs - he said he did not know their names, he said I point it out to whoever comes in there, but they said it was the maintenance job. Facility did not have policy on Physical Environment. The noncompliance was identified as Past Non Compliant. The IJ began on 7/22/23 and ended on 7/25/23. The facility corrected the non compliance by removing the doors prior to surveyor entrance. On 9/13/23 at 1:14 p.m., facility administrator was notified of past non compliance IJ. A plaln of removal was not requested. An IJ template was provided to the administrator via email.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from neglect for 2 of 13 residents (Resident #1 and Resident #2) reviewed for neglect. -The facility failed to provide adequate supervision for Resident #1 to prevent harm from suicidal ideations and self-injurious behaviors that resulted in him swallowing a battery, having a plan to swallow razors, and being hospitalized . -The facility failed to adequately educate staff on caring for residents with diagnosis of suicidal ideations and self-harming behaviors. -The facility failed to care plan and put additional services in place for Resident #1 when he admitted to the facility with suicidal ideations and having multiple suicide attempts on 2/6/23 and re-admitted on [DATE] after swallowing another battery. -The facility failed to initiate safety interventions when Resident #1 expressed suicidal ideations, requested to go to the hospital and was found with scissors and razors after he continuously requested medicine for his chronic pain and leaking ileostomy bag and resulted in an actual suicide attempt on 06/17/2023. -The facility failed to notify the NP that Resident #1 had a diagnosis of suicidal ideations, and that Resident #1 was found with a box with scissors and razors inside. -The facility failed to consistently change Resident #1 and Resident #2's ileostomy bag resulting in leaking of stool, burning skin and hospitalization. An Immediate Jeopardy (IJ) was identified on 07/01/23. The IJ template was provided to the facility on 7/1/23 at 2:45 p.m. While the IJ was removed on 07/05/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been trained on caring for residents with suicidal ideations, neglect, ordering pain medications timely, changing ileostomy bags, and care planning for suicidal ideations. These failures placed residents who have a diagnosis of suicidal ideations at risk of not being properly monitored, not having their immediate needs being met and possibly resulting in hospitalization or death. Findings include: Resident #1 Record review of Resident #1's face sheet dated 6/28/23 revealed a [AGE] year-old male who initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of being initially admitting to the facility with suicidal ideations, systemic inflammatory response syndrome (SIRS) of Non-Infectious origin without acute organ dysfunction (exaggerated defense response of the body), cerebral palsy (disorder that affects a persons ability to maintain balance and posture), sepsis due to enterococcus, fistula of intestine (abnormal opening or intestine that allows the contents to leak to another part of the body), idiopathic peripheral autonomic neuropathy (damage of the peripheral [NAME] where cause can not be deermined), intervertebral disc degeneration, lumbar region, residual schizophrenia, scoliosis, bipolar disorder, colostomy status, major depressive disorder, and anxiety. Record review of Resident #1's Care Plan dated 6/26/23 revealed resident complains of increased pain/discomfort and is at risk for further episodes of increased pain/discomfort and injury. Goal: Resident will maintain current levels of ADLs and any pain/discomfort will be relieved within 1 hour of delivery of pain medication or other intervention over the next 90 days. Interventions: Allow to verbalize feelings of pain/discomfort . Resident #1 has a Colostomy due to Medical Condition. Goal: Resident #1 will have no complications from ostomy site over the next 90 days. Intervention: Monitor site for swelling, pain, redness, etc.Apply Nystatin powder to Colostomy Site. Resident #1 has a diagnosis of depression with Goal: have fewer or no episodes of depression and will voice feelings about self over the next 90 days. Interventions/Tasks: Allow [Resident #1] to verbalize feelings of depression. Give medications per order-monitor labs - report abnormalities to MD. Resident #1 has a behavior problem of not waiting on staff to change his colostomy will call the police 911. Intervention: Anticipate and meet [Resident #1's] needs. Resident #1 call 911 due to meds not here. Interventions/Tasks: If reasonable, discuss [Resident #1's] behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. Further Record review of Resident #1's Care Plan dated 6/26/23 revealed he was not care planned for suicidal ideations when he admitted to the facility with the diagnosis on 2/6/23. Record review of Resident #1's Quarterly MDS dated [DATE] revealed his BIMS Summary Score was 15 indicating he was cognitively intact. Resident #1's functional status revealed walking in room and corridor did not occur, supervision with set up help only for locomotion on and off the unit and eating. Resident #1 required limited assistance with one person assisting for transfer, toilet use, and personal hygiene and he needed extensive assistance with one person physically assisting him for dressing. Record review of Resident #1's Physician Orders dated 6/30/23 revealed: Discontinue Oxycontin 20 mg ER when 30 mg tablet has arrived. One time only for 3 days dated 6/28/23 and ended 7/1/23. Oxycodone HCL Oral tablet 10 mg give 1 tablet by mouth every 4 hours related to systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction dated 4/11/23. Oxycontin Oral tablet ER 12 Hour Abuse-Deterrent 30 mg give 1 tablet orally every 12 hours for chronic pain. Oxycontin Oral Tablet ER 12 Hour Abuse-Deterrent 20 mg Give 1 tablet orally every 12 hours for chronic pain. Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to colostomy topically three times a day for colostomy site irritated dated 04/04/23. Zinc Oxide External Ointment 20 % (Zinc Oxide (Topical)) Apply to colostomy site topically four times a day for colostomy site irritated dated 02/16/23. Record review of Resident #1's Medication Administration Record for 6/1-6/30/23 revealed: Colostomy Observation every shift Monitor Resident's colostomy. Ensure Colostomy is intact, free from s/s of infection and functioning properly. The box was blank on 6/6/23 at 6 p.m. Colostomy: Empty every shift Licensed Nurse will monitor colostomy and ensure it is emptied every shift and as needed. The box was blank on 6/6/23 at 6 p.m. Observation: Behaviors. Target Behaviors : withdrawn, crying, lack of appetite every shift Monitor Resident for Presence of Behaviors withdrawn, crying, lack of appetite. Document Yes or No to whether Behaviors were Observed. Notify MD as needed for Behaviors. The box was blank on 6/6/23 at 6 p.m. Observation: Pain - Observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the PNs. every shift for pain observation. The box was blank on 6/6/23 at 6 p.m. Skin: Protective skin barrier ointment after each incontinent episode and PRN every shift. The box was blank on 6/6/23 at 6 p.m. Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to colostomy topically three times a day for colostomy site irritated. The box was blank on 6/6/23 at 6 p.m. Zinc Oxide External Ointment 20 % (Zinc Oxide (Topical)) Apply to colostomy site topically four times a day for colostomy site irritated. The box was blank on 6/6/23 at 9 p.m. Oxycodone HCL Oral Tablet 10 mg. The box was blank on 6/6/23 at 6 p.m. Oxycontin Oral Tablet ER 12 Hour (Oxycodone HCl). The box was blank on 6/6/23, 6/10/23, and 6/11/23 at 9 p.m. Further review of the MAR revealed no documentation to indicate Resident #1 was out of the facility on the days the MAR was blank. Record review of Resident #1's Controlled Drug Administration Record Tablet for Oxycodone IR 10 mg oral date issued 5/3/23 revealed: 6/16/23 at 9 a.m. 6/16/23 at 1 p.m. 6/16/23 at 5 p.m. 6/16/23 at 8 p.m. 6/17/23 at 1 a.m. 6/17/23 at 5 a.m. 6/17/23 at 9 a.m. 6/17/23 at 1 p.m. 6/17/23 at 5 p.m. the last dose was administered and there were 0 tablets left. Record review of Resident #1's progress note dated 6/6/23 at 2:30 a.m. by LVN E revealed, Resident is currently stable .PRN Oxycodone HCl oral tablet 10 mg administered at 7:32 p.m. and 1:32 a.m. respectively due to burning pain on skin. Record review of Resident #1's progress note dated 6/8/23 at 4:06 p.m. by LVN D revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress note dated 6/9/23 at 4:56 a.m. by LVN A revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress notes dated 6/11/23 at 5:54 a.m. by LVN C revealed Resident #1 called 911 because his colostomy was not change prompt, at the time of his call the nurse/writer was on break, colostomy was changed .[Resident #1] alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's Progress note dated 6/13/23 at 11:07 p.m. by LVN A revealed Confirmed new order from [Doctor] to discontinue patient PRN oxycodone HCL Oral Tablet 10 mg (Oxycodone HCL) every 4 hours. [Resident #1] started on scheduled oxycodone HCl Oral tablet 10 mg (Oxycodone HCl) every 4 hours for his pain management. Resident #1 remains oxycodone HCl oral tablet ER 20 mg (Oxycodone HCl) twice daily. Resident #1 made aware of new changes with his pain medications. Record review of Resident #1's Follow up with Physician dated 6/13/23 at 12 a.m. revealed Past Medical History: Borderline personality disorder, cerebral palsy, depressive disorder, difficult intravenous access, PTSD, self-injury behavior, schizophrenia, chronic enterocutaneous fistula, right ureteropelvic junction renal stone with intermittent obstruction .Social History: .History of multiple suicide attempts via self-mutilating behavior and ingestion of various objects .History of Present Illness: This is a [AGE] year old while male with a past history of significant for PTSD/bipolar disorder with multiple suicide attempts with self-injurious behavior and ingestion of various objects, cerebral palsy, scoliosis, and a chronic enterocutaneous fistula 2/2 self-inflicted stab wound on his abdominal wall that required exploratory laparotomy x2 and excision of infected abdominal wall mesh (11/28/20), extensive adhesiolysis, and partial small bowel resection complicated by chronic draining wound .Patient states that his chronic abdominal pain is now becoming uncontrolled. He states that he is at his wits end and expressing a desire to go back to the hospital. His colostomy continues to leak stool creating a red rash around the site. He still refuses fentanyl patch saying that he doesn't like the way it makes him feel. He is requesting to have the oxy schedule and seeing if that helps. He has appt with surgery on 6/20/23. He also mentions that he is feeling more depressed but not suicidal. Record review of Resident #1's Progress note dated 6/17/23 at 10:15 p.m. by LVN A revealed NP notified that pharmacy only send patient Oxycontin 20 mg. [Resident #1] wasn't happy and was yelling that this can't be happening. NP stated that she did notified Doctor that pharmacy did not deliver [Resident #1] Oxycontin IR 10 mg. NP said she haven't gotten a response from the Doctor yet. [Resident #1] was made aware and did reassure him that we're working on it. Record review of Resident #1's SBAR (Change of Condition) dated 6/18/23 at 12:31 a.m. by LVN A revealed: [Resident #1] complaining of extreme pain to his stomach. [Resident #1] requested to be sent out to the hospital. NP notified .[Resident #1] requested to be sent out to the hospital because he can't take it anymore because of his pain. Nurse caught [Resident #1] holding some tools in his hand. Nurse took away from patient holding 4 disposable shaving razors, a small scissors and a plastic water cover from the kitchen while he was sitting up. NP notified and approved to send him out. Patient was yelling out loud, disturbing the peace of other residents'. Cursing out loud by using different offensive words that are derogatory. Unable to calm patient down. Patient went out via 911 at 11:47 p.m. Record review of Resident #1's Local Hospital Record dated 6/23/23 revealed Pouch was leaking on arrival. Pouch was last changed on 6/19/23 wound ostomy continence note. Changed pouch. Applied marathon liquid skin protectant to peristomal, raw, denuded openings. Applied 1 piece pouch with convex barrier ostomy ring. Good seal achieved. Record review of Resident #1's Progress notes dated 6/25/23 at 7:53 p.m. by LVN B revealed Received [AGE] year-old patient in the building via EMS Stretcher 2 men crew Awake Alert and Oriented x3, with medical history of cerebral palsy, depression, scoliosis, abdominal stab wound post colostomy that been leaking for the past 4 years and known history of drug seeking behavior just discharged from [local hospital]. Upon arrival patient continue to demand for the pain medication on the same spot and called another 911 that he is going back to hospital if nobody gave him immediate attention, medication confirm and verified with the doctor, presently eyes closed in the room continue to monitor throughout the night. Record review of Resident #1's Local Hospital Record Discharge summary dated [DATE] at 7:50 p.m. revealed, Reason for Visit: pain issues complained of abdomen pain from his colostomy, chronic. Takes oxycodone for pain. Nursing facility does not have his short acting oxycodone 10 mg which he gets every 4 hours only long acting 20 mg dose which he received at 9 p.m. tonight. States his colostomy bag is always leaking .His abdominal wall cellulitis may also be irritant dermatitis from the feces. He was started back on his chronic pain medications. Patient initially did not want to return to his facility. He then notified me that he swallowed a battery. Psychiatry was consulted and Cymbalta was increased to 80 mg daily. X-ray of the abdomen was completed that showed metallic cylindrical object in the left upper quadrant. Chest x-ray showed 2 cm focal opacity however he does have a skin tag in that region. GI was consulted and proceeded with EGD on 6/22 and was unable to retrieve foreign body. He was also noted to have elevated liver enzymes may be due to Cymbalta. He was continued on Cymbalta due to benefits of medication. Surgery was consulted. CT abdomen pelvis was completed that showed cylindrical metallic density within the small bowel loop in the lower mid abdomen with moderate stool burden. He was unable to pass battery. GI proceeded with colonoscopy and was able to retrieve the battery. He was restarted on regular diet which he tolerated well .Impression: Ingested foreign body-AAA battery battery-successfully removed by ileoscopy through ileostomy. Record review of Resident #1's Psychological Services Progress Note dated 6/27/23 revealed: Symptoms: (Symptoms that were focused on in this session) Psychological: depression, Physical: Physical decline, Functional/Behavioral challenges: Adjustment difficulty (illness/decline/Loss, Stressors/Changes in Mental Status: Declining health .Results of Psychotherapy: Functional improvement noted .Identified- external emotional triggers, Disposition/Rationale for continued treatment: Symptoms require more attention. In an observation and interview with Resident #1 at the facility on 6/28/23 at 1:20 p.m. revealed Resident #1 rolling around the hallway in his wheelchair. Resident #1 stated he ate a battery and he explained he had an ileostomy bag, and it was leaking. He stated it leaked all the time no matter what the facility did. Resident #1 stated he had it for 4 years and he had trouble with the facility getting ostomy bags all the time and he had trouble with them getting his PRN pain meds to him. Resident #1 stated he had several talks with Administration about these incidents asking them to tighten this up (his pain medication and ostomy bags). Resident #1 stated he spoke with Doctor's in the hospital to make things better and they said there was nothing they could do. He stated before he went to the hospital on 6/17/23, he found out his medicine (oxycodone 10 mg) had lapsed, and he told the nurse to send him to the hospital. He said he had discussions with them several times and LVN A said no they will just send him right back. Resident #1 stated with the state of mind he was in, he thought he would just do something that he had to go. He stated he was in a lot in pain with the ileostomy leaking and it burned his skin and he also had cerebral palsy and scoliosis. Resident #1 stated the state of mind he was in, he said to himself he would do what he had to do to get out of the facility. Resident #1 stated since this incident he spoke with the psych specialist at the facility and she was getting him medication for anxiety and she said if a scenario happened again and the facility ran out of meds then he (Resident #1) would tell the staff he wants to go to the hospital and he did not feel safe. Resident #1 stated since that issue happened the facility had a new unit manager and she stayed on top of the meds, and he stated he was staying on top of the meds also. Observation of Resident #1's ileostomy bag revealed it was leaking onto his brief and his skin. Resident #1 stated he felt that the facility neglected him, and he did not mean to snitch on anyone, but it is what it is. Resident #1 stated he could not remember the Nurses name. Resident #1 stated the staff said they could not make the ileostomy bag stop leaking. Resident #1 stated the ileostomy was not leaking as bad as it was yesterday. He said, the ileostomy bag leaked a lot and that was an understatement and it had burned him in the past where he had to go to the hospital. Resident #1 stated the last time he went to the hospital for the ileostomy burning his skin was a few months ago. In an interview and record review on 6/28/23 at 1:40 p.m. with Unit Manager A, she stated Resident #1 getsfrustrated about his pain meds when the facility does not get them right when they were due. Unit Manager A stated, Resident #1 was asking about his pain meds closer to 6 p.m. on 6/17/23 and he asked for the pain meds and the med aide was in another room and he got frustrated. Unit Manager A stated Oxycodone 10 mg was PRN, but they made it routine a few days before he went out. Unit Manager A stated Resident #1 went out on 6/17/23 and came back on 6/25/23. Record review of Resident #1's narcotic count sheet with Unit Manager A revealed Resident #1 did run out of Oxycontin ER 20 mg on 6/17/23 at 9 p.m. She stated he ran out of meds on 6/17/23 so no meds were given. Unit Manager A did call the local pharmacy on 6/28/23 at 2:13 p.m. and they stated Resident #1's Oxycontin ER 20 mg was delivered on 6/17/23 at 6:45 p.m. with 14 tablets. Unit Manager A stated Resident #1 ran out of Oxycodone 10mg. Record review of Resident #1's narcotic count sheet with Unit Manager A revealed the last Oxycodone 10 mg tablet was given on 6/17/23 and he had 0 pills left. Unit Manager A stated the local pharmacy stated oxycodone 10 mg was delivered on 6/18/23 at 6:32 p.m. Unit Manager A stated Resident #1 missed 1 dose of oxycodone 10 mg on 6/17/23 for 9 p.m. In an interview on 6/28/23 at 2:20 p.m. with the DON she stated thought Resident #1 called 911 on 6/17/23 and they showed up at the building. The DON stated he had not told them that he swallowed the battery. In an interview on 6/29/23 at 1:18 p.m. with LVN A she stated the Doctor messed up. She stated she got report from shift changeon 6/17/23 saying the Nurse got in touch with NP because Resident #1 ran out of meds, and they contacted the Doctor to call the medication in. LVN A stated she received report saying Unit Manager A took care of that, but the pharmacy only brought the oxycodone 20 mg and not the oxycodone 10 mg. LVN A stated the pharmacist said on 6/17/23 Resident #1 ran out of Oxycodone 10 mg and would need a new prescription. LVN A stated she got in touch with the NP and asked the NP to have the Doctor to contact LVN A. LVN A stated Resident #1 was suicidal and if he did not get his medicine, he would start doing things. She stated the Doctor did not respond back and he was supposed to call in those dosages. LVN A stated the meds came in the next day on 6/18/23. LVN A stated on 6/17/23 Resident #1 was screaming, and she realized Resident #1 was trying to cause harm to himself. She stated she told NP that Resident #1 said call 911 and the NP said call 911 . LVN A stated Resident #1 was holding some scissors and razors on 6/17/23 and she removed it from him and she continued to try to get the oxycodone 10 mg by contacting the NP. She stated she called 911 and said he was complaining of pain. LVN A stated Resident #1 was really angry and upset. He said it happened all the time that the facility ran out of his medication. LVN A stated Resident #1 was scheduled to get Oxycodone 20 mg twice a day and she went to his room saying it was his night meds 20mg for 10p.m. LVN A stated she told Resident #1 they did not have the 10 mg because they ran out of the 10 mg and was waiting for the pharmacy. She stated Resident #1 started yelling and raging screaming out of control. LVN A stated Resident #1 just got his oxycodone 20 mg long-acting meds at 9 p.m. and he started screaming and raging at 9p.m. She stated she had to leave Resident #1 to call the NP and he started yelling god dammit and saying things like he was going to harm himself. LVN A stated Resident #1 was mad the previous days because he was out of his medicine. LVN A stated Resident #1 was holding items in his hand, scissors and razors that could harm him. LVN A stated Resident #1 said he was going to harm himself. She stated Resident #1 was holding a pair of scissors, 4 disposable razors, a plastic lid from a plastic cup and he keep saying he was going to hurt himself. LVN A stated she was already aware of Resident #1's history and she took the items from him (Resident #1) and brought it to the Nurse station then she called 911 (Unknown time). LVN A stated 911 came and he told 911 he had a colostomy that was excoriated, and the stomach contents leaked out and he told 911 he was having stomach pain, the facility had been out of his meds for a few days, and he could not take it anymore and he did not want to be at the facility. She stated Resident #1 could not bear the pain and he was insisting to go to the hospital and NP said go ahead and send the resident. LVN A stated she did not know anything about a battery. She stated the only thing Resident #1 was holding in his hand were the scissors and razors and she took them away from him and called 911. LVN A stated she did not trust Resident #1. LVN A stated she did not call anyone to assist her with Resident #1 because the CNA was busy working and Resident #1 was sitting in the wheelchair crying, yelling and screaming god dammit LVN A stated the Doctor did not call in both dosages and they were supposed to call when they had 7 pills in the blister pack. LVN A stated Resident #1 had a history of trying to harm himself. LVN A stated the facility had an adequate supply for ileostomy bags and the only issue was about pain meds for Resident #1. In an interview on 6/29/23 at 1:53 p.m. with Resident #1, he stated prior to him swallowing the battery he had several conversations about having enough ostomy supplies because before the new Unit Manager got there, supplies was an issue. He stated he was having problems getting his prn pain meds when he needed, and he had several conversations with the previous Management (Administrator B). Resident #1 stated before he went to the hospital, he had gone days without his pain medication. He stated on 6/17/23, that evening he took his last prn dose of pain meds oxycodone 10 mg, and they said by the time it was time to get it again, the meds would be at the facility, and he said great. Resident #1 stated the medicine did not come in and they only brought the scheduled pain meds (oxycodone 20 mg) and he had asked for his pain meds (oxycodone 10 mg) and LVN A said the pharmacy only brought in the scheduled pain meds (oxycodone 20 mg). Resident #1 stated it was Saturday night and the next day was Sunday and if they run out on a Saturday you do not get meds until Monday. Resident #1 stated the med aide that day on 6/17/23 said it was his last dose at 5:30 to 6 p.m. and they said his meds should be in by the time the next dose was due. He stated he told the late-night nurse (LVN A) he was out of here (the facility) and that he was going to the hospital where they could take care of him. Resident #1 stated LVN A said let her give him (Resident #1) the scheduled dose and she said she would get a hold of the Doctor and he should let her see what she could do. Resident #1 stated the ostomy supply kept running out, there was the issue with getting prn meds and them running out of pain medication. He said, he had it and he blew up. Resident #1 stated he spoke with Unit Manager A before and he tried to solve the issue. Resident #1 stated it was a little after 9 p.m. on 6/17/23 when LVN A took the scissors from him at 9:45 to 10 p.m. when she saw them in his hand, and he said nothing nothing. Resident #1 stated in the box was razors, scissors and he had hidden batteries in his pocket. Resident #1 stated it was after 9 p.m. when she gave the scheduled meds, and she was having trouble getting hold of the Doctor. Resident #1 stated he told LVN A he wanted to get out of the facility, and she said if you just go for pain meds, they will give you one dose and send him right back. Resident #1 stated he had already told LVN A that he wanted to leave going to the hospital right after 9p.m. He stated LVN A took the scissors and razors, and after she (LVN A) left out of his room at around 9:45 to 10 p.m., Resident #1 shut his room door and swallowed the battery that he got from the TV remote. He stated he went out of his room after he swallowed the battery and continued to blow up and said he did not feel safe at the facility and wanted to go to the hospital, and he was leaving. Resident #1 said LVN A said let her call the Doctor and they sent him out to the hospital. Resident #1 stated LVN A allowed a couple of hours to go by and he was by himself in his room. He stated he stayed in the hallway for a while and LVN A told him to calm down and that he was waking people up, but by this time his ostomy bag was leaking, his skin was burning, and he was hurting. Resident #1 stated he was sent to the hospital in a mess with feces on him and his ostomy bag was still leaking. Resident #1 stated he never told LVN A he swallowed a battery; he told the hospital 24 to 48 hours after he had gotten to the hospital that he swallowed the battery, and they rushed him to emergency. Resident #1 stated when he went into the hallway he stayed until 911 got there. In an interview on 6/29/23 at 2:46 p.m. with the DON she stated if a resident was suicidal the facility would put them on one-on-one observation and call the doctor to let them know. The DON stated the facility would call the psychiatrist and let them know as well so they can come and evaluate the resident. The DON stated she was not sure how the pharmacy in the company operates because she just started working at the facility on 5/22/23 as interim. The DON stated the staff should not leave the resident who was trying to commit suicide by themselves, and she would stay there and get the Doctor on the phone. The DON stated that was why she said if someone was suicidal, they need to be one on one observation. The DON stated she did not know what to say about the battery because the facility did not know he swallowed a battery until he came back from the hospital. The DON stated she understood that you do not turn your back on someone who is suicidal, but where there is a will there is a way, they will swallow even in your presence. In an interview on 6/29/23 at 2:57 p.m. with the Administrator, she stated she did not know what to say about the battery. In an interview on 6/29/23 at 3:00 p.m. with Unit Manager A, she stated the residents were not allowed to have razors and that the residents do not have access to razors, and they were in the supply room. Unit Manager A stated Resident #1 asked for razors today, 6/29/23 to shave himself with and she told him no and the facility would shave him. In an interview on 6/30/23 at 12:54 p.m. with the Medical Director, he stated the nursing home staffhad been aware that Resident #1 was admitted with suicide ideations, and he had been followed by psychiatry and psychology in May 2023. The Medical Director stated Resident #1 denied that the resident made any outcries that he wanted to harm himself since being admitted at the facility. The Medical Director stated he did not know why Resident #1 had scissors or razors. The Medical Director stated he did not have his pain medicine because it was running low, and they were waiting for the attending physician to send in a refill. The Medical Director stated he was not aware the medication was completely out. The Medical Director stated an ileostomy bag was for hygiene and cleanliness, but sometimes due to the person's body or the way they were it may be difficult to keep the bag adhered. The Medical Director stated they want the bag to stay adhered for cleanliness, but if the stool leakage occurs and it was left unattended it could burn the skin. In an interview on 6/30/23 at 1:35 p.m. with the DON she stated she was told Resident #1 was sent to the hospital on 6/17/23. The DON stated if a patient needs to go to the hospital it needs to be from the Doctor or NP and If a resident said they wanted to go to the hospital they have to let the Dr know what's going on and they have to give the okay to send the resident out. The DON stated if the resident was admitted into the facility that means they were not on suicidal watch. She stated the moment the resident was admitted to the facility unless they voice out, they were suicidal they have to ask them what their plan was, then follow the steps of what they need to do. The DON stated it the resident had a diagnosis, there was nothing they would do if they were not voicing that they would hurt themselves. She stated although because the resident have the history of suicidal ideations, they would get psych services involved. The DON stated Resident #1 was not care planned for suicidal ideations and she stated she could not answer why, and she would have to get the MDS Coordinator to see why. The DON stated she did not know how Resident #1 got the scissors and razors. She stated when Resident #1 returned from the hospital on 6/25/23; they did a head-to-toe assessment and documented to make sure there were no new issues. The DON stated if the hospital deemed Resident #1 competent and okay to come back to the facility, then they go by the recommendations of what the hospital asked them to do. The DON stated if the hospital said they need psych services, the facility would follow the recommendations the hospital gave them. The DON stated she did not know why they were running out of medications. The DON stated the facility had a pharmacy and the Nurses have to call the pharmacy to replenish the medication. The DON stated every pharmacy was different, with this pharmacy they need to call them within 3 d[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement their written policies and procedures to prohibit neglect for 2 of 13 residents (Resident #1 and Resident #2) reviewed for neglect. - The facility failed to implement their policy on Neglect to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness for Resident #1 and Resident #2 and when Resident #1 was admitted to the facility with suicidal ideations and multiple suicide attempts on 2/6/23 and then re-admitted to the facility on [DATE] and did not receive comprehensive services to prevent further destructive behaviors. -The facility failed to care plan and put additional services in place for Resident #1 when he admitted to the facility with suicidal ideations and having multiple suicide attempts on 2/6/23 and re-admitted on [DATE] after swallowing another battery. -The facility failed to initiate safety interventions when Resident #1 expressed suicidal ideations, requested to go to the hospital and was found with scissors and razors after he continuously requested medicine for his chronic pain and leaking ileostomy bag and resulted in an actual suicide attempt on 06/17/2023. -The facility failed to notify the NP that Resident #1 had a diagnosis of suicidal ideations, and that Resident #1 was found with a box with scissors and razors inside. -The facility failed to consistently change Resident #1 and Resident #2's ileostomy bag resulting in leaking of stool, burning skin and hospitalization. An Immediate Jeopardy (IJ) was identified on 07/01/23. The IJ template was provided to the facility on 7/1/23 at 2:45 p.m. While the IJ was removed on 07/05/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been trained on caring for residents with suicidal ideations, neglect, ordering pain medications timely, changing ileostomy bags, and care planning for suicidal ideations. These failures placed residents who have a diagnosis of suicidal ideations at risk of not being properly monitored, not having their immediate needs being met and possibly resulting in hospitalization or death. Findings include: Record review of the Facility's Policy on Abuse, Neglect, & Exploitation Prevention Policy & Procedure revised 9/10/2020 revealed, Our facility prohibits the abuse, mistreatment, neglect, and/or exploitation of residents. We believe that all residents have the right to be free from such actions by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving our community .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Resident #1 Record review of Resident #1's face sheet dated 6/28/23 revealed a [AGE] year-old male who initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of being initially admitting to the facility with suicidal ideations, systemic inflammatory response syndrome (SIRS) of Non-Infectious origin without acute organ dysfunction (exaggerated defense response of the body), cerebral palsy (disorder that affects a persons ability to maintain balance and posture), sepsis due to enterococcus, fistula of intestine (abnormal opening or intestine that allows the contents to leak to another part of the body), idiopathic peripheral autonomic neuropathy (damage of the peripheral [NAME] where cause can not be deermined), intervertebral disc degeneration, lumbar region, residual schizophrenia, scoliosis, bipolar disorder, colostomy status, major depressive disorder, and anxiety. Record review of Resident #1's Care Plan dated 6/26/23 revealed resident complains of increased pain/discomfort and is at risk for further episodes of increased pain/discomfort and injury. Goal: Resident will maintain current levels of ADLs and any pain/discomfort will be relieved within 1 hour of delivery of pain medication or other intervention over the next 90 days. Interventions: Allow to verbalize feelings of pain/discomfort . Resident #1 has a Colostomy due to Medical Condition. Goal: Resident #1 will have no complications from ostomy site over the next 90 days. Intervention: Monitor site for swelling, pain, redness, etc.Apply Nystatin powder to Colostomy Site. Resident #1 has a diagnosis of depression with Goal: have fewer or no episodes of depression and will voice feelings about self over the next 90 days. Interventions/Tasks: Allow [Resident #1] to verbalize feelings of depression. Give medications per order-monitor labs - report abnormalities to MD. Resident #1 has a behavior problem of not waiting on staff to change his colostomy will call the police 911. Intervention: Anticipate and meet [Resident #1's] needs. Resident #1 call 911 due to meds not here. Interventions/Tasks: If reasonable, discuss [Resident #1's] behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. Further Record review of Resident #1's Care Plan dated 6/26/23 revealed he was not care planned for suicidal ideations when he admitted to the facility with the diagnosis on 2/6/23. Record review of Resident #1's Quarterly MDS dated [DATE] revealed his BIMS Summary Score was 15 indicating he was cognitively intact. Resident #1's functional status revealed walking in room and corridor did not occur, supervision with set up help only for locomotion on and off the unit and eating. Resident #1 required limited assistance with one person assisting for transfer, toilet use, and personal hygiene and he needed extensive assistance with one person physically assisting him for dressing. Record review of Resident #1's Physician Orders dated 6/30/23 revealed: Discontinue Oxycontin 20 mg ER when 30 mg tablet has arrived. One time only for 3 days dated 6/28/23 and ended 7/1/23. Oxycodone HCL Oral tablet 10 mg give 1 tablet by mouth every 4 hours related to systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction dated 4/11/23. Oxycontin Oral tablet ER 12 Hour Abuse-Deterrent 30 mg give 1 tablet orally every 12 hours for chronic pain. Oxycontin Oral Tablet ER 12 Hour Abuse-Deterrent 20 mg Give 1 tablet orally every 12 hours for chronic pain. Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to colostomy topically three times a day for colostomy site irritated dated 04/04/23. Zinc Oxide External Ointment 20 % (Zinc Oxide (Topical)) Apply to colostomy site topically four times a day for colostomy site irritated dated 02/16/23. Record review of Resident #1's Medication Administration Record for 6/1-6/30/23 revealed: Colostomy Observation every shift Monitor Resident's colostomy. Ensure Colostomy is intact, free from s/s of infection and functioning properly. The box was blank on 6/6/23 at 6 p.m. Colostomy: Empty every shift Licensed Nurse will monitor colostomy and ensure it is emptied every shift and as needed. The box was blank on 6/6/23 at 6 p.m. Observation: Behaviors. Target Behaviors : withdrawn, crying, lack of appetite every shift Monitor Resident for Presence of Behaviors withdrawn, crying, lack of appetite. Document Yes or No to whether Behaviors were Observed. Notify MD as needed for Behaviors. The box was blank on 6/6/23 at 6 p.m. Observation: Pain - Observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the PNs. every shift for pain observation. The box was blank on 6/6/23 at 6 p.m. Skin: Protective skin barrier ointment after each incontinent episode and PRN every shift. The box was blank on 6/6/23 at 6 p.m. Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to colostomy topically three times a day for colostomy site irritated. The box was blank on 6/6/23 at 6 p.m. Zinc Oxide External Ointment 20 % (Zinc Oxide (Topical)) Apply to colostomy site topically four times a day for colostomy site irritated. The box was blank on 6/6/23 at 9 p.m. Oxycodone HCL Oral Tablet 10 mg. The box was blank on 6/6/23 at 6 p.m. Oxycontin Oral Tablet ER 12 Hour (Oxycodone HCl). The box was blank on 6/6/23, 6/10/23, and 6/11/23 at 9 p.m. Further review of the MAR revealed no documentation to indicate Resident #1 was out of the facility on the days the MAR was blank. Record review of Resident #1's Controlled Drug Administration Record Tablet for Oxycodone IR 10 mg oral date issued 5/3/23 revealed: 6/16/23 at 9 a.m. 6/16/23 at 1 p.m. 6/16/23 at 5 p.m. 6/16/23 at 8 p.m. 6/17/23 at 1 a.m. 6/17/23 at 5 a.m. 6/17/23 at 9 a.m. 6/17/23 at 1 p.m. 6/17/23 at 5 p.m. the last dose was administered and there were 0 tablets left. Record review of Resident #1's progress note dated 6/6/23 at 2:30 a.m. by LVN E revealed, Resident is currently stable .PRN Oxycodone HCl oral tablet 10 mg administered at 7:32 p.m. and 1:32 a.m. respectively due to burning pain on skin. Record review of Resident #1's progress note dated 6/8/23 at 4:06 p.m. by LVN D revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress note dated 6/9/23 at 4:56 a.m. by LVN A revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress notes dated 6/11/23 at 5:54 a.m. by LVN C revealed Resident #1 called 911 because his colostomy was not change prompt, at the time of his call the nurse/writer was on break, colostomy was changed .[Resident #1] alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's Progress note dated 6/13/23 at 11:07 p.m. by LVN A revealed Confirmed new order from [Doctor] to discontinue patient PRN oxycodone HCL Oral Tablet 10 mg (Oxycodone HCL) every 4 hours. [Resident #1] started on scheduled oxycodone HCl Oral tablet 10 mg (Oxycodone HCl) every 4 hours for his pain management. Resident #1 remains oxycodone HCl oral tablet ER 20 mg (Oxycodone HCl) twice daily. Resident #1 made aware of new changes with his pain medications. Record review of Resident #1's Follow up with Physician dated 6/13/23 at 12 a.m. revealed Past Medical History: Borderline personality disorder, cerebral palsy, depressive disorder, difficult intravenous access, PTSD, self-injury behavior, schizophrenia, chronic enterocutaneous fistula, right ureteropelvic junction renal stone with intermittent obstruction .Social History: .History of multiple suicide attempts via self-mutilating behavior and ingestion of various objects .History of Present Illness: This is a [AGE] year old while male with a past history of significant for PTSD/bipolar disorder with multiple suicide attempts with self-injurious behavior and ingestion of various objects, cerebral palsy, scoliosis, and a chronic enterocutaneous fistula 2/2 self-inflicted stab wound on his abdominal wall that required exploratory laparotomy x2 and excision of infected abdominal wall mesh (11/28/20), extensive adhesiolysis, and partial small bowel resection complicated by chronic draining wound .Patient states that his chronic abdominal pain is now becoming uncontrolled. He states that he is at his wits end and expressing a desire to go back to the hospital. His colostomy continues to leak stool creating a red rash around the site. He still refuses fentanyl patch saying that he doesn't like the way it makes him feel. He is requesting to have the oxy schedule and seeing if that helps. He has appt with surgery on 6/20/23. He also mentions that he is feeling more depressed but not suicidal. Record review of Resident #1's Progress note dated 6/17/23 at 10:15 p.m. by LVN A revealed NP notified that pharmacy only send patient Oxycontin 20 mg. [Resident #1] wasn't happy and was yelling that this can't be happening. NP stated that she did notified Doctor that pharmacy did not deliver [Resident #1] Oxycontin IR 10 mg. NP said she haven't gotten a response from the Doctor yet. [Resident #1] was made aware and did reassure him that we're working on it. Record review of Resident #1's SBAR (Change of Condition) dated 6/18/23 at 12:31 a.m. by LVN A revealed: [Resident #1] complaining of extreme pain to his stomach. [Resident #1] requested to be sent out to the hospital. NP notified .[Resident #1] requested to be sent out to the hospital because he can't take it anymore because of his pain. Nurse caught [Resident #1] holding some tools in his hand. Nurse took away from patient holding 4 disposable shaving razors, a small scissors and a plastic water cover from the kitchen while he was sitting up. NP notified and approved to send him out. Patient was yelling out loud, disturbing the peace of other residents'. Cursing out loud by using different offensive words that are derogatory. Unable to calm patient down. Patient went out via 911 at 11:47 p.m. Record review of Resident #1's Local Hospital Record dated 6/23/23 revealed Pouch was leaking on arrival. Pouch was last changed on 6/19/23 wound ostomy continence note. Changed pouch. Applied marathon liquid skin protectant to peristomal, raw, denuded openings. Applied 1 piece pouch with convex barrier ostomy ring. Good seal achieved. Record review of Resident #1's Progress notes dated 6/25/23 at 7:53 p.m. by LVN B revealed Received [AGE] year-old patient in the building via EMS Stretcher 2 men crew Awake Alert and Oriented x3, with medical history of cerebral palsy, depression, scoliosis, abdominal stab wound post colostomy that been leaking for the past 4 years and known history of drug seeking behavior just discharged from [local hospital]. Upon arrival patient continue to demand for the pain medication on the same spot and called another 911 that he is going back to hospital if nobody gave him immediate attention, medication confirm and verified with the doctor, presently eyes closed in the room continue to monitor throughout the night. Record review of Resident #1's Local Hospital Record Discharge summary dated [DATE] at 7:50 p.m. revealed, Reason for Visit: pain issues complained of abdomen pain from his colostomy, chronic. Takes oxycodone for pain. Nursing facility does not have his short acting oxycodone 10 mg which he gets every 4 hours only long acting 20 mg dose which he received at 9 p.m. tonight. States his colostomy bag is always leaking .His abdominal wall cellulitis may also be irritant dermatitis from the feces. He was started back on his chronic pain medications. Patient initially did not want to return to his facility. He then notified me that he swallowed a battery. Psychiatry was consulted and Cymbalta was increased to 80 mg daily. X-ray of the abdomen was completed that showed metallic cylindrical object in the left upper quadrant. Chest x-ray showed 2 cm focal opacity however he does have a skin tag in that region. GI was consulted and proceeded with EGD on 6/22 and was unable to retrieve foreign body. He was also noted to have elevated liver enzymes may be due to Cymbalta. He was continued on Cymbalta due to benefits of medication. Surgery was consulted. CT abdomen pelvis was completed that showed cylindrical metallic density within the small bowel loop in the lower mid abdomen with moderate stool burden. He was unable to pass battery. GI proceeded with colonoscopy and was able to retrieve the battery. He was restarted on regular diet which he tolerated well .Impression: Ingested foreign body-AAA battery battery-successfully removed by ileoscopy through ileostomy. Record review of Resident #1's Psychological Services Progress Note dated 6/27/23 revealed: Symptoms: (Symptoms that were focused on in this session) Psychological: depression, Physical: Physical decline, Functional/Behavioral challenges: Adjustment difficulty (illness/decline/Loss, Stressors/Changes in Mental Status: Declining health .Results of Psychotherapy: Functional improvement noted .Identified- external emotional triggers, Disposition/Rationale for continued treatment: Symptoms require more attention. In an observation and interview with Resident #1 at the facility on 6/28/23 at 1:20 p.m. revealed Resident #1 rolling around the hallway in his wheelchair. Resident #1 stated he ate a battery and he explained he had an ileostomy bag, and it was leaking. He stated it leaked all the time no matter what the facility did. Resident #1 stated he had it for 4 years and he had trouble with the facility getting ostomy bags all the time and he had trouble with them getting his PRN pain meds to him. Resident #1 stated he had several talks with Administration about these incidents asking them to tighten this up (his pain medication and ostomy bags). Resident #1 stated he spoke with Doctor's in the hospital to make things better and they said there was nothing they could do. He stated before he went to the hospital on 6/17/23, he found out his medicine (oxycodone 10 mg) had lapsed, and he told the nurse to send him to the hospital. He said he had discussions with them several times and LVN A said no they will just send him right back. Resident #1 stated with the state of mind he was in, he thought he would just do something that he had to go. He stated he was in a lot in pain with the ileostomy leaking and it burned his skin and he also had cerebral palsy and scoliosis. Resident #1 stated the state of mind he was in, he said to himself he would do what he had to do to get out of the facility. Resident #1 stated since this incident he spoke with the psych specialist at the facility and she was getting him medication for anxiety and she said if a scenario happened again and the facility ran out of meds then he (Resident #1) would tell the staff he wants to go to the hospital and he did not feel safe. Resident #1 stated since that issue happened the facility had a new unit manager and she stayed on top of the meds, and he stated he was staying on top of the meds also. Observation of Resident #1's ileostomy bag revealed it was leaking onto his brief and his skin. Resident #1 stated he felt that the facility neglected him, and he did not mean to snitch on anyone, but it is what it is. Resident #1 stated he could not remember the Nurses name. Resident #1 stated the staff said they could not make the ileostomy bag stop leaking. Resident #1 stated the ileostomy was not leaking as bad as it was yesterday. He said, the ileostomy bag leaked a lot and that was an understatement and it had burned him in the past where he had to go to the hospital. Resident #1 stated the last time he went to the hospital for the ileostomy burning his skin was a few months ago. In an interview and record review on 6/28/23 at 1:40 p.m. with Unit Manager A, she stated Resident #1 getsfrustrated about his pain meds when the facility does not get them right when they were due. Unit Manager A stated, Resident #1 was asking about his pain meds closer to 6 p.m. on 6/17/23 and he asked for the pain meds and the med aide was in another room and he got frustrated. Unit Manager A stated Oxycodone 10 mg was PRN, but they made it routine a few days before he went out. Unit Manager A stated Resident #1 went out on 6/17/23 and came back on 6/25/23. Record review of Resident #1's narcotic count sheet with Unit Manager A revealed Resident #1 did run out of Oxycontin ER 20 mg on 6/17/23 at 9 p.m. She stated he ran out of meds on 6/17/23 so no meds were given. Unit Manager A did call the local pharmacy on 6/28/23 at 2:13 p.m. and they stated Resident #1's Oxycontin ER 20 mg was delivered on 6/17/23 at 6:45 p.m. with 14 tablets. Unit Manager A stated Resident #1 ran out of Oxycodone 10mg. Record review of Resident #1's narcotic count sheet with Unit Manager A revealed the last Oxycodone 10 mg tablet was given on 6/17/23 and he had 0 pills left. Unit Manager A stated the local pharmacy stated oxycodone 10 mg was delivered on 6/18/23 at 6:32 p.m. Unit Manager A stated Resident #1 missed 1 dose of oxycodone 10 mg on 6/17/23 for 9 p.m. In an interview on 6/28/23 at 2:20 p.m. with the DON she stated thought Resident #1 called 911 on 6/17/23 and they showed up at the building. The DON stated he had not told them that he swallowed the battery. In an interview on 6/29/23 at 1:18 p.m. with LVN A she stated the Doctor messed up. She stated she got report from shift changeon 6/17/23 saying the Nurse got in touch with NP because Resident #1 ran out of meds, and they contacted the Doctor to call the medication in. LVN A stated she received report saying Unit Manager A took care of that, but the pharmacy only brought the oxycodone 20 mg and not the oxycodone 10 mg. LVN A stated the pharmacist said on 6/17/23 Resident #1 ran out of Oxycodone 10 mg and would need a new prescription. LVN A stated she got in touch with the NP and asked the NP to have the Doctor to contact LVN A. LVN A stated Resident #1 was suicidal and if he did not get his medicine, he would start doing things. She stated the Doctor did not respond back and he was supposed to call in those dosages. LVN A stated the meds came in the next day on 6/18/23. LVN A stated on 6/17/23 Resident #1 was screaming, and she realized Resident #1 was trying to cause harm to himself. She stated she told NP that Resident #1 said call 911 and the NP said call 911 . LVN A stated Resident #1 was holding some scissors and razors on 6/17/23 and she removed it from him and she continued to try to get the oxycodone 10 mg by contacting the NP. She stated she called 911 and said he was complaining of pain. LVN A stated Resident #1 was really angry and upset. He said it happened all the time that the facility ran out of his medication. LVN A stated Resident #1 was scheduled to get Oxycodone 20 mg twice a day and she went to his room saying it was his night meds 20mg for 10p.m. LVN A stated she told Resident #1 they did not have the 10 mg because they ran out of the 10 mg and was waiting for the pharmacy. She stated Resident #1 started yelling and raging screaming out of control. LVN A stated Resident #1 just got his oxycodone 20 mg long-acting meds at 9 p.m. and he started screaming and raging at 9p.m. She stated she had to leave Resident #1 to call the NP and he started yelling god dammit and saying things like he was going to harm himself. LVN A stated Resident #1 was mad the previous days because he was out of his medicine. LVN A stated Resident #1 was holding items in his hand, scissors and razors that could harm him. LVN A stated Resident #1 said he was going to harm himself. She stated Resident #1 was holding a pair of scissors, 4 disposable razors, a plastic lid from a plastic cup and he keep saying he was going to hurt himself. LVN A stated she was already aware of Resident #1's history and she took the items from him (Resident #1) and brought it to the Nurse station then she called 911 (Unknown time). LVN A stated 911 came and he told 911 he had a colostomy that was excoriated, and the stomach contents leaked out and he told 911 he was having stomach pain, the facility had been out of his meds for a few days, and he could not take it anymore and he did not want to be at the facility. She stated Resident #1 could not bear the pain and he was insisting to go to the hospital and NP said go ahead and send the resident. LVN A stated she did not know anything about a battery. She stated the only thing Resident #1 was holding in his hand were the scissors and razors and she took them away from him and called 911. LVN A stated she did not trust Resident #1. LVN A stated she did not call anyone to assist her with Resident #1 because the CNA was busy working and Resident #1 was sitting in the wheelchair crying, yelling and screaming god dammit LVN A stated the Doctor did not call in both dosages and they were supposed to call when they had 7 pills in the blister pack. LVN A stated Resident #1 had a history of trying to harm himself. LVN A stated the facility had an adequate supply for ileostomy bags and the only issue was about pain meds for Resident #1. In an interview on 6/29/23 at 1:53 p.m. with Resident #1, he stated prior to him swallowing the battery he had several conversations about having enough ostomy supplies because before the new Unit Manager got there, supplies was an issue. He stated he was having problems getting his prn pain meds when he needed, and he had several conversations with the previous Management (Administrator B). Resident #1 stated before he went to the hospital, he had gone days without his pain medication. He stated on 6/17/23, that evening he took his last prn dose of pain meds oxycodone 10 mg, and they said by the time it was time to get it again, the meds would be at the facility, and he said great. Resident #1 stated the medicine did not come in and they only brought the scheduled pain meds (oxycodone 20 mg) and he had asked for his pain meds (oxycodone 10 mg) and LVN A said the pharmacy only brought in the scheduled pain meds (oxycodone 20 mg). Resident #1 stated it was Saturday night and the next day was Sunday and if they run out on a Saturday you do not get meds until Monday. Resident #1 stated the med aide that day on 6/17/23 said it was his last dose at 5:30 to 6 p.m. and they said his meds should be in by the time the next dose was due. He stated he told the late-night nurse (LVN A) he was out of here (the facility) and that he was going to the hospital where they could take care of him. Resident #1 stated LVN A said let her give him (Resident #1) the scheduled dose and she said she would get a hold of the Doctor and he should let her see what she could do. Resident #1 stated the ostomy supply kept running out, there was the issue with getting prn meds and them running out of pain medication. He said, he had it and he blew up. Resident #1 stated he spoke with Unit Manager A before and he tried to solve the issue. Resident #1 stated it was a little after 9 p.m. on 6/17/23 when LVN A took the scissors from him at 9:45 to 10 p.m. when she saw them in his hand, and he said nothing nothing. Resident #1 stated in the box was razors, scissors and he had hidden batteries in his pocket. Resident #1 stated it was after 9 p.m. when she gave the scheduled meds, and she was having trouble getting hold of the Doctor. Resident #1 stated he told LVN A he wanted to get out of the facility, and she said if you just go for pain meds, they will give you one dose and send him right back. Resident #1 stated he had already told LVN A that he wanted to leave going to the hospital right after 9p.m. He stated LVN A took the scissors and razors, and after she (LVN A) left out of his room at around 9:45 to 10 p.m., Resident #1 shut his room door and swallowed the battery that he got from the TV remote. He stated he went out of his room after he swallowed the battery and continued to blow up and said he did not feel safe at the facility and wanted to go to the hospital, and he was leaving. Resident #1 said LVN A said let her call the Doctor and they sent him out to the hospital. Resident #1 stated LVN A allowed a couple of hours to go by and he was by himself in his room. He stated he stayed in the hallway for a while and LVN A told him to calm down and that he was waking people up, but by this time his ostomy bag was leaking, his skin was burning, and he was hurting. Resident #1 stated he was sent to the hospital in a mess with feces on him and his ostomy bag was still leaking. Resident #1 stated he never told LVN A he swallowed a battery; he told the hospital 24 to 48 hours after he had gotten to the hospital that he swallowed the battery, and they rushed him to emergency. Resident #1 stated when he went into the hallway he stayed until 911 got there. In an interview on 6/29/23 at 2:46 p.m. with the DON she stated if a resident was suicidal the facility would put them on one-on-one observation and call the doctor to let them know. The DON stated the facility would call the psychiatrist and let them know as well so they can come and evaluate the resident. The DON stated she was not sure how the pharmacy in the company operates because she just started working at the facility on 5/22/23 as interim. The DON stated the staff should not leave the resident who was trying to commit suicide by themselves, and she would stay there and get the Doctor on the phone. The DON stated that was why she said if someone was suicidal, they need to be one on one observation. The DON stated she did not know what to say about the battery because the facility did not know he swallowed a battery until he came back from the hospital. The DON stated she understood that you do not turn your back on someone who is suicidal, but where there is a will there is a way, they will swallow even in your presence. In an interview on 6/29/23 at 2:57 p.m. with the Administrator, she stated she did not know what to say about the battery. In an interview on 6/29/23 at 3:00 p.m. with Unit Manager A, she stated the residents were not allowed to have razors and that the residents do not have access to razors, and they were in the supply room. Unit Manager A stated Resident #1 asked for razors today, 6/29/23 to shave himself with and she told him no and the facility would shave him. In an interview on 6/30/23 at 12:54 p.m. with the Medical Director, he stated the nursing home staffhad been aware that Resident #1 was admitted with suicide ideations, and he had been followed by psychiatry and psychology in May 2023. The Medical Director stated Resident #1 denied that the resident made any outcries that he wanted to harm himself since being admitted at the facility. The Medical Director stated he did not know why Resident #1 had scissors or razors. The Medical Director stated he did not have his pain medicine because it was running low, and they were waiting for the attending physician to send in a refill. The Medical Director stated he was not aware the medication was completely out. The Medical Director stated an ileostomy bag was for hygiene and cleanliness, but sometimes due to the person's body or the way they were it may be difficult to keep the bag adhered. The Medical Director stated they want the bag to stay adhered for cleanliness, but if the stool leakage occurs and it was left unattended it could burn the skin. In an interview on 6/30/23 at 1:35 p.m. with the DON she stated she was told Resident #1 was sent to the hospital on 6/17/23. The DON stated if a patient needs to go to the hospital it needs to be from the Doctor or NP and If a resident said they wanted to go to the hospital they have to let the Dr know what's going on and they have to give the okay to send the resident out. The DON stated if the resident was admitted into the facility that means they were not on suicidal watch. She stated the moment the resident was admitted to the facility unless they voice out, they were suicidal they have to ask them what their plan was, then follow the steps of what they need to do. The DON stated it the resident had a diagnosis, there was nothing they would do if they were not voicing that they would hurt themselves. She stated although because the resident have the history of suicidal ideations, they would get psych services involved. The DON stated Resident #1 was not care planned for suicidal ideations and she stated she could not answer why, and she would have to get the MDS Coordinator to see why. The DON stated she did not know how Resident #1 got the scissors and razors. She stated when Resident #1 returned from the hospital on 6/25/23; [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment plan of care for 1 of 13 residents (Resident #1) reviewed for comprehensive care plan in that The Facility failed to care plan for Resident #1 having suicidal ideations upon admission to the facility on 2/6/23 and again when he returned on 6/25/23 from the hospital after having swallowing a battery was not care planned or monitored for suicidal ideations. An Immediate Jeopardy (IJ) was identified on 07/01/23 at 2:45 p.m. While the IJ was lowered on 07/05/23, the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. This failure placed residents who have a diagnosis of suicidal ideations at risk of not being properly monitored, not having their immediate needs being met and possibly resulting in hospitalization or death. Findings include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old male who initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the diagnosis of systemic inflammatory response syndrome (SIRS) of Non-Infectious origin without acute organ dysfunction, cerebral palsy, sepsis due to enterococcus, fistula of intestine, idiopathic peripheral autonomic neuropathy, intervertebral disc degeneration, lumbar region, residual schizophrenia, scoliosis, bipolar disorder, colostomy status, major depressive disorder, anxiety, and initially admitted to the facility with suicidal ideations. Record review of Resident #1's Care Plan dated 6/26/23 revealed resident complains of increased pain/discomfort and is at risk for further episodes of increased pain/discomfort and injury. Goal: Resident will maintain current levels of ADLs and any pain/discomfort will be relieved within 1 hour of delivery of pain medication or other intervention over the next 90 days. Interventions: Allow to verbalize feelings of pain/discomfort . Resident #1 has a Colostomy due to Medical Condition. Goal: Resident #1 will have no complications from ostomy site over the next 90 days. Intervention: Monitor site for swelling, pain, redness, etc .Apply Nystatin powder to Colostomy Site. Resident #1 has a diagnosis of depression with Goal: have fewer or no episodes of depression and will voice feelings about self over the next 90 days. Interventions/Tasks: Allow [Resident #1] to verbalize feelings of depression. Give medications per order-monitor labs - report abnormalities to MD. Resident #1 has a behavior problem of not waiting on staff to change his colostomy will call the police 911. Intervention: Anticipate and meet [Resident #1's] needs. Resident #1 call 911 due to meds not here. Interventions/Tasks: If reasonable, discuss [Resident #1's] behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. Record review of Resident #1's Care Plan revealed he was not care planned for suicidal ideations when he admitted to the facility with the diagnosis on 2/6/23. Record review of Resident #1's Quarterly MDS dated [DATE] revealed Cognitive Pattern BIMS Summary Score was 15 indicating cognitively intact. Resident #1's functional status revealed walking in room and corridor did not occur, supervision with set up help only for locomotion on and off the unit, and eating. Resident #1 required limited assistance with one person assisting for transfer, toilet use, and personal hygiene and he needed extensive assistance with one person physically assisting him for dressing. Record review of Resident #1's Physician Orders dated 6/30/23 revealed: Discontinue Oxycontin 20 mg ER when 30 mg tablet has arrived. One time only for 3 days dated 6/28/23 and ended 7/1/23. Oxycodone HCL Oral tablet 10 mg give 1 tablet by mouth every 4 hours related to systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction dated 4/11/23. Oxycontin Oral tablet ER 12 Hour Abuse-Deterrent 30 mg give 1 tablet orally every 12 hours for chronic pain. Oxycontin Oral Tablet ER 12 Hour Abuse-Deterrent 20 mg Give 1 tablet orally every 12 hours for chronic pain. Record review of Resident #1's Controlled Drug Administration Record Tablet for Oxycodone IR 10 mg oral date issued 5/3/23 revealed: 6/16/23 at 9 a.m. 6/16/23 at 1 p.m. 6/16/23 at 5 p.m. 6/16/23 at 8 p.m. 6/17/23 at 1 a.m. 6/17/23 at 5 a.m. 6/17/23 at 9 a.m. 6/17/23 at 1 p.m. 6/17/23 at 5 p.m. the last dose was administered and there were 0 tablets left. Record review of Resident #1's SBAR (Change of Condition) dated 6/18/23 at 12:31 a.m. by LVN A revealed: [Resident #1] complaining of extreme pain to his stomach. [Resident #1] requested to be sent out to the hospital. NP notified .[Resident #1] requested to be sent out to the hospital because he can't take it anymore because of his pain. Nurse caught [Resident #1] holding some tools in his hand. Nurse took away from patient holding 4 disposable shaving razors, a small scissors and a plastic water cover from the kitchen while he was sitting up. NP notified and approved to send him out. Patient was yelling out loud, disturbing the peace of other residents'. Cursing out loud by using different offensive words that are derogatory. Unable to calm patient down. Patient went out via 911 at 11:47 p.m. Record review of Resident #1's Progress notes dated 6/25/23 at 7:53 p.m. by LVN B revealed Received [AGE] year-old patient in the building via EMS Stretcher 2 men crew Awake Alert and Oriented x3, with medical history of cerebral palsy, depression, scoliosis, abdominal stab wound post colostomy that been leaking for the past 4 years and known history of drug seeking behavior just discharged from [local hospital]. Upon arrival patient continue to demand for the pain medication on the same spot and called another 911 that he is going back to hospital if nobody gave him immediate attention, medication confirm and verified with the doctor, presently eyes closed in the room continue to monitor throughout the night. Record review of Resident #1's Progress note dated 6/17/23 at 10:15 p.m. by LVN A revealed NP notified that pharmacy only send patient Oxycontin 20 mg. [Resident #1] wasn't happy and was yelling that this can't be happening. NP stated that she did notified Doctor that pharmacy did not deliver [Resident #1] Oxycontin IR 10 mg. NP said she haven't gotten a response from the Doctor yet. [Resident #1] was made aware and did reassure him that we're working on it. Record review of Resident #1's Progress note dated 6/13/23 at 11:07 p.m. by LVN A revealed Confirmed new order from [Doctor] to discontinue patient PRN oxycodone HCL Oral Tablet 10 mg (Oxycodone HCL) every 4 hours. [Resident #1] started on scheduled oxycodone HCl Oral tablet 10 mg (Oxycodone HCl) every 4 hours for his pain management. Resident #1 remains oxycodone HCl oral tablet ER 20 mg (Oxycodone HCl) twice daily. Resident #1 made aware of new changes with his pain medications. Record review of Resident #1's Follow up with Physician dated 6/13/23 at 12 a.m. revealed Past Medical History: Borderline personality disorder, cerebral palsy, depressive disorder, difficult intravenous access, PTSD, self injury behavior, schizophrenia, chronic enterocutaneous fistula, right ureteropelvic junction renal stone with intermittent obstruction .Social History: .History of multiple suicide attempts via self-mutilating behavior and ingestion of various objects .History of Present Illness: This is a 43-yeaar old while male with a past history of significant for PTSD/bipolar disorder with multiple suicide attempts with self injurious behavior and ingestion of various objects, cerebral palsy, scoliosis, and a chronic enterocutaneous fistula 2/2 self-inflicted stab wound on his abdominal wall that required exploratory laparotomy x2 and excision of infected abdominal wall mesh (11/28/20), extensive adhesiolysis, and partial small bowel resection complicated by chronic draining wound .Patient states that his chronic abdominal pain is now becoming uncontrolled. He states that he is at his wits end and expressing a desire to go back to the hospital. His colostomy continues to leak stool creating a red rash around the site. He still refuses fentanyl patch saying that he doesn't like the way it makes him feel. He is requesting to have the oxy schedule and seeing if that helps. He has appt with surgery on 6/20/23. He also mentions that he is feeling more depressed but not suicidal. Record review of Resident #1's progress notes dated 6/11/23 at 5:54 a.m. by LVN C revealed Resident #1 called 911 because his colostomy was not change prompt, at the time of his call the nurse/writer was on break, colostomy was changed .[Resident #1] alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress note dated 6/9/23 at 4:56 a.m. by LVN A revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress note dated 6/8/23 at 4:06 p.m. by LVN D revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress note dated 6/6/23 at 2:30 a.m. by LVN E revealed, Resident is currently stable .PRN Oxycodone HCl oral tablet 10 mg administered at 7:32 p.m. and 1:32 a.m. respectively due to burning pain on skin. Record review of Resident #1's Local Hospital Record Discharge summary dated [DATE] at 7:50 p.m. revealed, Reason for Visit: pain issues complained of abdomen pain from his colostomy, chronic. Takes oxycodone for pain. Nursing facility does not have his short acting oxycodone 10 mg which he gets every 4 hours only long acting 20 mg dose which he received at 9 p.m. tonight. States his colostomy bag is always leaking .His abdominal wall cellulitis may also be irritant dermatitis from the feces. He was started back on his chronic pain medications. Patient initially did not want to return to his facility. He then notified me that he swallowed a battery. Psychiatry was consulted and Cymbalta was increased to 80 mg daily. X-ray of the abdomen was completed that showed metallic cylindrical object in the left upper quadrant. Chest x-ray showed 2 cm focal opacity however he does have a skin tag in that region. GI was consulted and proceeded with EGD on 6/22 and was unable to retrieve foreign body. He was also noted to have elevated liver enzymes may be due to Cymbalta. He was continued on Cymbalta due to benefits of medication. Surgery was consulted. CT abdomen pelvis was completed that showed cylindrical metallic density within the small bowel loop in the lower mid abdomen with moderate stool burden. He was unable to pass battery. GI proceeded with colonoscopy and was able to retrieve the battery. He was restarted on regular diet which he tolerated well .Impression: Ingested foreign body-AAA battery battery-successfully removed by ileoscopy through ileostomy. Record review of Resident #1's Local Hospital Record dated 6/23/23 revealed Pouch was leaking on arrival. Pouch was last changed on 6/19/23 wound ostomy continence note. Changed pouch. Applied marathon liquid skin protectant to peristomal, raw, denuded openings. Applied 1 piece pouch with convex barrier ostomy ring. Good seal achieved. Record review of Resident #1's Psychological Services Progress Note dated 6/27/23 revealed: Symptoms: (Symptoms that were focused on in this session) Psychological: depression, Physical: Physical decline, Functional/Behavioral challenges: Adjustment difficulty (illness/decline/Loss, Stressors/Changes in Mental Status: Declining health .Results of Psychotherapy: Functional improvement noted .Identified- external emotional triggers, Disposition/Rationale for continued treatment: Symptoms require more attention. In an observation and interview with Resident #1 on 6/28/23 at 1:20 p.m. revealed Resident #1 rolling around the hallway. Resident #1 stated he ate a battery and he explained he had an ileostomy bag and it was leaking and it leaked all the time no matter what the facility did. Resident #1 stated he had it for 4 years and he had trouble with the facility getting ostomy bags all the time and he had trouble with them getting his PRN pain meds to him. Resident #1 stated he had swallowed a battery before. Resident #1 stated he had several talks with Administration about these incidents asking them to tighten this up (his pain medication and ostomy bags). Resident #1 stated he spoke with Doctor's in the hospital to make things better and they said it was nothing they could do. He stated before he went to the hospital on 6/17/23, he found out his medicine (oxycodone 10 mg) had lapsed and he told the nurse to send him to the hospital and that he had discussions with them several times and she said no they will just send him right back. Resident #1 stated with the state of mind he was in, he thought he would just do something that he had to go. He stated he was in a lot in pain with the ileostomy leaking and it burned his skin and he also had cerebral palsy and scoliosis. Resident #1 stated the state of mind he was in, he said to himself he would do what he had to do what to get out of the facility. Resident #1 stated since this incident he spoke with the psych specialist at the facility and she was getting him medication for anxiety and she said if a scenario happened again and the facility ran out of meds then he (Resident #1) would tell the staff he wants to go to the hospital and he did not feel safe so he can get what he needed done. Resident #1 stated since that issue happened the facility had a new unit manager and she stayed on top of the meds and he stated he was staying on top of the meds also. Observation of Resident #1's ileostomy bag revealed it was leaking onto his brief and his skin. Resident #1 stated he felt that the facility neglected him and he did not mean to snitch on anyone but it is what it is. Resident #1 stated he could not remember the Nurses name. Resident #1 stated the staff say they could not make the ileostomy bag stop leaking. Resident #1 stated the ileostomy was not leaking as bad as it was yesterday. He said the ileostomy bag leaked a lot and that was an understatement and it had burned him in the past where he had to go to the hospital. Resident #1 stated the last time he went to the hospital for the ileostomy burning his skin was a few months ago. In an interview and record review on 6/28/23 at 1:40 p.m. with Unit Manager A she stated Resident #1 was frustrated about his pain meds when they do not get them right when they are due. Unit Manager A stated Resident #1 was asking about his pain meds closer to 6p.m. and he asked for the pain meds and the med aide was in another room and he got frustrated. One med was PRN, but they made it routine a few days before he went out. Unit Manager A stated Resident #1 went out on 6/17/23 and came back on 6/25/23. Record review of Resident #1's narcotic count sheet with Unit Manager A revealed Resident #1 did run out of Oxycontin ER 20 mg on 6/17/23 at 9 p.m. She stated he ran out of meds on 6/17/23 so no meds were given. Unit Manager A did call the local pharmacy at 2:13 p.m. and they stated Resident #1's Oxycontin ER 20 mg was delivered on 6/17/23 at 6:45 p.m. with 14 tablets. Unit Manager A stated Resident #1 ran out of Oxycodone 10mg. Observation of Resident #1's narcotic count sheet revealed the last tablet was given on 6/17/23 and he had 0 pills left. Unit Manager A stated the local pharmacy stated oxycodone 10 mg was delivered on 6/18/23 at 6:32 p.m. Unit Manager A stated Resident #1 missed 1 dose of oxycodone 10 mg on 6/17/23 for 9 p.m. In an interview on 6/28/23 at 2:20 p.m. with the DON she stated Resident #1 called 911 and they showed up at the building. The DON stated he had not told them that he swallowed the battery. In an interview on 6/29/23 at 1:18 p.m. with LVN A she stated the Doctor messed up. She stated she got report from shift change saying the Nurse got in touch with NP because Resident #1 ran out of meds and they contacted the Doctor to call the medication in. LVN A stated she received report saying Unit Manager A took care of that, but the pharmacy only brought the oxycodone 20 mg and not the oxycodone 10 mg. LVN A stated the pharmacist said Resident #1 ran out of Oxycodone 10 mg and would need a new prescription. LVN A stated she got in touch with the NP and asked the NP to have the Doctor to contact LVN A. LVN A stated Resident #1 was suicidal and if he did not get his medicine he would start doing things. She stated the Doctor did not respond back and he was supposed to call in those dosages. LVN A stated the meds came in the next day on 6/18/23. LVN A stated Resident #1 was screaming, and she realized Resident #1 was trying to cause harm to himself. She stated she told NP and said Resident #1 said call 911 and the NP said call 911 . LVN A stated Resident #1 was holding some scissors and razors and she removed it from him. She stated she called 911 and said he was complaining of pain. LVN A stated Resident #1 was really angry and upset and he said it happened all the time that the facility ran out of his medication. LVN A stated Resident #1 was scheduled to get 20 mg twice a day and she went to his room saying it was his night meds 20mg for 10p.m. LVN A stated she told Resident #1 the did not have the 10 mg because they ran out of the 10 mg and was waiting for the pharmacy. She stated Resident #1 started yelling and raging screaming out of control. LVN A stated Resident #1 just got his oxycodone 20 mg long acting meds at 9 p.m. and he started screaming and raging at 9p.m. She stated she had to leave Resident #1 to call the NP and he started yelling god dam it and saying things like he was going to harm himself. LVN A stated Resident #1 was mad the previous days because he was out of his medicine. LVN A stated Resident #1 was holding items in his hand, scissors and razors that could harm him. LVN A stated Resident #1 said he was going to harm himself. She stated Resident #1 was holding a pair of scissors, 4 disposable razors, a plastic lid from a plastic cup and he keep saying he was going to hurt himself. LVN A stated she was already aware of Resident #1's history and she took the items from him (Resident #1) and brought it to the Nurse station then she called 911 (Unknown time). LVN A stated 911 came and he told 911 he had a colostomy that was excoriated, and the stomach contents leaked out and he told 911 he was having stomach pain, the facility had been out of his meds for a few days and he could not take it anymore and he did not want to be at the facility. She stated Resident #1 could not bear the pain and he was insisting to go to the hospital and NP said go ahead and send the resident. LVN A stated she did not know anything about a battery. She stated the only thing Resident #1 was holding in his hand were the scissors and razors and she took them away from him and called 911. LVN A stated she did not trust Resident #1. LVN A stated she did not call anyone to assist her with Resident #1 because the CNA was busy working and Resident #1 was sitting in the wheelchair crying, yelling and screaming god dam it, god dam it, god dam it. LVN A stated Resident #1 had not received oxycontin for 2 days and he told the previous shift and Unit Manager tried to take care of the meds. LVN A stated she called the pharmacy and they said they need a new prescription, so she called the NP. LVN A stated the Doctor did not call in both dosages and they were supposed to call when they have 7 pills in the blister pack. LVN A stated Resident #1 had a history of trying to harm himself. LVN A stated the facility had an adequate supply for ileostomy bags and the only issue was about pain meds for Resident #1. In an interview on 6/29/23 at 1:53 p.m. with Resident #1 he stated prior to this happening he had several conversations about having enough ostomy supplies because before the new Unit Manager got here supplies was an issue. He stated he was having problems getting his prn pain meds when he needed and he had several conversations with the previous Management (Administrator B). Resident #1 stated before he went to the hospital he has gone days without his pain medication. He stated on 6/17/23, that evening he took his last prn dose of pain meds oxycodone 10 mg and they said by the time it was time to get it again, the meds would be at the facility and he said great. Resident #1 stated the medicine did not come in and they only brought the scheduled pain meds (oxycodone 20 mg) and he had asked for his pain meds (oxycodone 10 mg) and LVN A said the pharmacy only brought in the scheduled pain meds (oxycodone 20 mg). Resident #1 stated it was Saturday night and the next day was Sunday and if they run out on a Saturday you do not get meds until Monday. Resident #1 stated the med aide that day said it was his last dose at 5:30 to 6 p.m. and they said his meds should be in by the time the next dose is due. He stated he told the late night nurse (LVN A) he was out of here (the facility) and that he was going to the hospital where they could take care of him. Resident #1 stated LVN A said let her give him (Resident #1) the scheduled dose and she said she would get a hold of the Doctor and he should let her see what she could do. Resident #1 stated the ostomy supply kept running out, there was the issue with getting prn meds and them running out of pain medication. He said he had it and he blew up. Resident #1 stated he spoke with Unit Manager A before and he tried to solve the issue. It was a little after 9 p.m. He stated LVN A took the scissors from him at 9:45 to 10 p.m. when she saw them in his hand and he said nothing nothing. Resident #1 stated in the box was razors and scissors and he had hidden batteries in his pocket. Resident #1 stated it was after 9 p.m. when she gave the scheduled meds and she was having trouble getting hold of the Doctor. Resident #1 stated he told LVN A he wanted to get out of the facility and she said if you just go for pain meds they will give you one dose and send him right back. Resident #1 stated he had already told LVN A that he wanted to leave going to the hospital right after 9p.m. He stated LVN A took the scissors and razors, and after she (LVN A) left out of his room at around 9:45 to 10 p.m., Resident #1 shut his room door and swallowed the battery. He stated he went out of his room after he swallowed the battery and continued to blow up and said he did not feel safe at the facility and wanted to go to the hospital and he was leaving. Resident #1 said that's fine, let her call the Doctor and they sent him out to the hospital. Resident #1 stated LVN A allowed a couple of hours to go by and he was by himself in his room. He stated he stayed in the hallway for a while and LVN A told him to calm down and that he was waking people up, but by this time his ostomy bag was leaking, his skin was burning and he was hurting. Resident #1 stated he was sent to the hospital in a mess with feces on him and his ostomy bag was still leaking. Resident #1 stated he never told LVN A he swallowed a battery, he told the hospital 24 to 48 hours after he had gotten to the hospital that he swallowed the battery and they rushed him to emergency. Resident #1 stated when he went into the hallway he stayed until 911 got there. In an interview on 6/29/23 at 3 p.m. with Unit Manager A she stated the residents were not allowed to have razors and that the residents do not have access to razors and they are in the supply room. Unit Manager A stated Resident #1 asked for razors today, 6/29/23 to shave himself with and she told him no and the facility would shave him. In an interview on 6/30/23 at 12:54 p.m. with the Medical Director he stated the team had been aware that Resident #1 was admitted with suicide ideations and he had been followed by psychiatry and psychology in May 2023. The Medical Director stated Resident #1 denied that the resident made any outcries that he wanted to harm himself since being admitted at the facility. The Medical Director stated he did not know why Resident #1 had scissors or razors. The Medical Director stated he did not have his pain medicine because it was running low and they were waiting for the attending physician to send in a refill. The Medical Director stated he was not aware the medication was completely out. The Medical Director stated an ileostomy bag is for hygiene and cleanliness, but sometimes due to the persons body or the way they are it may be difficult to keep the bag adhered. The Medical Director stated they want the bag to stay adhered for cleanliness, but if the stool leakage occurs and its left unattended it could burn the skin. In an interview on 6/30/23 at 1:35 p.m. with the DON she stated she was told Resident #1 was sent to the hospital. The DON stated if a patient needs to go to the hospital it needs to be from the Doctor or NP and If a resident said they wanted to go to the hospital they have to let the Dr know what's going on and they have to give the okay to send the resident out. The DON stated if the resident was admitted into the facility that means they are not on suicidal watch. She stated the moment the resident was admitted to the facility unless they voice out they are suicidal they have to ask them what their plan is then follow the steps of what they need to do. The DON stated it the resident had a diagnosis, there was nothing they would do if they were not voicing that they would hurt themselves. She stated although because they have the history of, they would get psych services involved. The DON stated Resident #1 was not care planned for suicidal ideations and she stated she could not answer why and she would have to get the MDS Coordinator to see why. The DON stated she did not know how Resident #1 got the scissors and razors. She stated when Resident #1 returned from the hospital; they did a head to toe assessment and documented to make sure there were no new issues. The DON stated if the hospital deemed Resident #1 competent and okay to come back to the facility, then they go by the recommendations of what the hospital asked them to do. The DON stated if the hospital said they need psych services, the facility would follow the recommendations the hospital gave them. The DON stated she did not know why they were running out of medications. The DON stated the facility had a pharmacy and the Nurses now to call the pharmacy to replenish the medication. The DON stated every pharmacy was different, with this pharmacy they need to call them within 3 days if the resident was running out of medications unless the PRN medication had a 14 day stop date. In an interview on 6/30/23 at 1:50 p.m. with the NP she stated Resident #1 was mentally competent but was in a lot of general pain. She stated Resident #1 was on oxycodone ER release every 12 hours (long acting) and oxycodone 10 mg (a short acting one). The NP stated when she saw Resident #1 he sat in the wheelchair and he looked like he was in a lot of pain. She stated she thought he was used to getting a lot of narcotic meds. The NP stated Resident #1 recently requested to go to the hospital because he ran out of oxycodone. The NP stated the hospital found Resident #1 with a UTI and they treated him with antibiotics. The NP stated when she saw Resident #1, he said he did not want to deal with the pain and he did not want to deal with this kind of life. The NP stated Resident #1 requested to be on hospice, but she was not sure if hospice would accept him. The NP stated Resident #1 did not mention to her that he wanted to harm himself. She stated Resident #1 said he did not want to deal with this kind of pain in his life. The NP stated she spoke with Resident #1 and he was calm and smiling. The NP stated the day he was sent out to the hospital the nurse (LVN A) told her Resident #1 was screaming and threw stuff at her (LVN A) and asked to go to the hospital. The NP stated it was 2 weeks ago on Saturday, 6/17/23 and Resident #1 said he was in a lot of pain. The NP stated he received the pain medication every 4 hours and every 12 hrs. The NP stated she did not know Resident #1 was diagnosed with suicidal ideations. She stated she just started seeing Resident #1 and she just started working at the facility about 3 weeks ago. The NP stated she did not see any documents of suicidal ideations. The NP stated if she was aware she would have put in an order for transfer to psychiatric hospital because Resident #1 needed inpatient psych and therapy. She stated if she saw that she would have asked the nurse to send him to behavioral hospital. The NP stated on 6/17/23, LVN A said Resident #1 was agitated and aggressive. She stated the nurses should document it and give it to the hospital and the hospital should put a psychiatric consult for an inpatient unit. The NP stated Resident #1 was not safe to stay and he needed really close monitoring with that kind of behavior, but at the facility no one can sit with him 24/7. She stated if Resident #1 had that kind of intention it's really hard to prevent it. In an interview on 6/30/23 at 2:07 p.m. with CNA A she stated the facility did not make any changes for Resident #1 when he returned from the hospital. CNA A stated the staff were told to make sure they do not go in the room alone because he can get a little cranky. CNA A stated when Resident #1 did not have his medicine he starts worrying. In an interview on 6/30/23 at 2:20 p.m. with LVN F she stated Resident #1 when he did not have his meds he was in so much pain because of leakage from his ostomy bag. She stated on 6/17/23, she was working and his pain meds were not in the building and he stated he was suicidal. LVN F stated when Resident #1 came back from the hospital she did see him and they made sure that he had his meds in stock and they checked his colostomy. LVN F stated when everything was in place and Resident #1 was assured he had his pain meds he is okay and now they got his pain medication scheduled instead of I being PRN. She stated they scheduled meds so it gives him ease so he knows he has his meds with no additional worry. When he does not have his meds he is not calm and in pain and it gives him a lack of hope. LVN F stated she was leaving the facility late that day and she heard Resident #1 was attempting to hurt himself. LVN F stated she never left the facility at 630 p.m. when her shift ended, but she normally left at 7 p.m. or 7:30 p.m. In an interview on 6/30/23 at 2:29 p.m. with CNA B she stated when Resident #1 did not get his pain meds he was upset and wants to go to the hospital. CNA B stated she heard Resident #1 say he did not want to be at the facility and that he was not happy. CNA B stated the facility never gave her special instructions for Resident #1. In an interview on 6/30/23 at 2:36 p.m. with the MDS Coordinator she stated when Resident #1 was admitted to the facility there were 2 MDS Nurses, one does skilled and the other does long term. The MDS Coordinator stated they just got a violation from the State for care plans. The MDS Coordinator stated they were updating all the previous care plans and she did not know how Resident #1 was over looked and why he was not care planned for suicidal ideations. She stated if Resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 13 residents reviewed for accidents, hazards, and supervision. -The facility failed to provide adequate supervision for Resident #1 to prevent harm from suicidal ideations and self-injurious behaviors that resulted in him swallowing a battery, having a plan to swallow razors, and being hospitalized . -The facility failed to adequately educate staff on caring for residents with diagnosis of suicidal ideations and self-harming behaviors. -The facility failed to care plan and put additional services in place for Resident #1 when he admitted to the facility with suicidal ideations and having multiple suicide attempts on 2/6/23 and re-admitted on [DATE] after swallowing another battery. An Immediate Jeopardy (IJ) was identified on 06/30/23. The IJ template was provided to the facility on 6/30/23 at 2:59 p.m. While the IJ was removed on 07/05/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been trained on accidents and supervision, caring for residents with suicidal ideations, neglect, ordering pain medications timely, changing ileostomy bags, and care planning for suicidal ideations. These failures placed residents who have a diagnosis of suicidal ideations at risk of not being properly monitored, not having their immediate needs being met and possibly resulting in hospitalization or death. Findings include: Record review of Resident #1's face sheet dated 6/28/23 revealed a [AGE] year-old male who initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of being initially admitting to the facility with suicidal ideations, systemic inflammatory response syndrome (SIRS) of Non-Infectious origin without acute organ dysfunction (exaggerated defense response of the body), cerebral palsy (disorder that affects a persons ability to maintain balance and posture), sepsis due to enterococcus, fistula of intestine (abnormal opening or intestine that allows the contents to leak to another part of the body), idiopathic peripheral autonomic neuropathy (damage of the peripheral nerves where cause can not be deermined), intervertebral disc degeneration, lumbar region, residual schizophrenia, scoliosis, bipolar disorder, colostomy status, major depressive disorder, and anxiety. Record review of Resident #1's Care Plan dated 6/26/23 revealed resident complains of increased pain/discomfort and is at risk for further episodes of increased pain/discomfort and injury. Goal: Resident will maintain current levels of ADLs and any pain/discomfort will be relieved within 1 hour of delivery of pain medication or other intervention over the next 90 days. Interventions: Allow to verbalize feelings of pain/discomfort . Resident #1 has a Colostomy due to Medical Condition. Goal: Resident #1 will have no complications from ostomy site over the next 90 days. Intervention: Monitor site for swelling, pain, redness, etc.Apply Nystatin powder to Colostomy Site. Resident #1 has a diagnosis of depression with Goal: have fewer or no episodes of depression and will voice feelings about self over the next 90 days. Interventions/Tasks: Allow [Resident #1] to verbalize feelings of depression. Give medications per order-monitor labs - report abnormalities to MD. Resident #1 has a behavior problem of not waiting on staff to change his colostomy will call the police 911. Intervention: Anticipate and meet [Resident #1's] needs. Resident #1 call 911 due to meds not here. Interventions/Tasks: If reasonable, discuss [Resident #1's] behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. Further Record review of Resident #1's Care Plan dated 6/26/23 revealed he was not care planned for suicidal ideations when he admitted to the facility with the diagnosis on 2/6/23. Record review of Resident #1's Quarterly MDS dated [DATE] revealed his BIMS Summary Score was 15 indicating he was cognitively intact. Resident #1's functional status revealed walking in room and corridor did not occur, supervision with set up help only for locomotion on and off the unit and eating. Resident #1 required limited assistance with one person assisting for transfer, toilet use, and personal hygiene and he needed extensive assistance with one person physically assisting him for dressing. Record review of Resident #1's Physician Orders dated 6/30/23 revealed: Discontinue Oxycontin 20 mg ER when 30 mg tablet has arrived. One time only for 3 days dated 6/28/23 and ended 7/1/23. Oxycodone HCL Oral tablet 10 mg give 1 tablet by mouth every 4 hours related to systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction dated 4/11/23. Oxycontin Oral tablet ER 12 Hour Abuse-Deterrent 30 mg give 1 tablet orally every 12 hours for chronic pain. Oxycontin Oral Tablet ER 12 Hour Abuse-Deterrent 20 mg Give 1 tablet orally every 12 hours for chronic pain. Record review of Resident #1's Medication Administration Record for 6/1-6/30/23 revealed: Observation: Behaviors. Target Behaviors : withdrawn, crying, lack of appetite every shift Monitor Resident for Presence of Behaviors withdrawn, crying, lack of appetite. Document Yes or No to whether Behaviors were Observed. Notify MD as needed for Behaviors. The box was blank on 6/6/23 at 6 p.m. Observation: Pain - Observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the PNs. every shift for pain observation. The box was blank on 6/6/23 at 6 p.m. Oxycodone HCL Oral Tablet 10 mg. The box was blank on 6/6/23 at 6 p.m. Oxycontin Oral Tablet ER 12 Hour (Oxycodone HCl). The box was blank on 6/6/23, 6/10/23, and 6/11/23 at 9 p.m. Further review of the MAR revealed no documentation to indicate Resident #1 was out of the facility on the days the MAR was blank. Record review of Resident #1's Controlled Drug Administration Record Tablet for Oxycodone IR 10 mg oral date issued 5/3/23 revealed: 6/16/23 at 9 a.m. 6/16/23 at 1 p.m. 6/16/23 at 5 p.m. 6/16/23 at 8 p.m. 6/17/23 at 1 a.m. 6/17/23 at 5 a.m. 6/17/23 at 9 a.m. 6/17/23 at 1 p.m. 6/17/23 at 5 p.m. the last dose was administered and there were 0 tablets left. Record review of Resident #1's SBAR (Change of Condition) dated 6/18/23 at 12:31 a.m. by LVN A revealed: [Resident #1] complaining of extreme pain to his stomach. [Resident #1] requested to be sent out to the hospital. NP notified .[Resident #1] requested to be sent out to the hospital because he can't take it anymore because of his pain. Nurse caught [Resident #1] holding some tools in his hand. Nurse took away from patient holding 4 disposable shaving razors, a small scissors and a plastic water cover from the kitchen while he was sitting up. NP notified and approved to send him out. Patient was yelling out loud, disturbing the peace of other residents'. Cursing out loud by using different offensive words that are derogatory. Unable to calm patient down. Patient went out via 911 at 11:47 p.m. Record review of Resident #1's progress note dated 6/6/23 at 2:30 a.m. by LVN E revealed, Resident is currently stable .PRN Oxycodone HCl oral tablet 10 mg administered at 7:32 p.m. and 1:32 a.m. respectively due to burning pain on skin. Record review of Resident #1's progress note dated 6/8/23 at 4:06 p.m. by LVN D revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress note dated 6/9/23 at 4:56 a.m. by LVN A revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress notes dated 6/11/23 at 5:54 a.m. by LVN C revealed Resident #1 called 911 because his colostomy was not change prompt, at the time of his call the nurse/writer was on break, colostomy was changed .[Resident #1] alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's Progress note dated 6/13/23 at 11:07 p.m. by LVN A revealed Confirmed new order from [Doctor] to discontinue patient PRN oxycodone HCL Oral Tablet 10 mg (Oxycodone HCL) every 4 hours. [Resident #1] started on scheduled oxycodone HCl Oral tablet 10 mg (Oxycodone HCl) every 4 hours for his pain management. Resident #1 remains oxycodone HCl oral tablet ER 20 mg (Oxycodone HCl) twice daily. Resident #1 made aware of new changes with his pain medications. Record review of Resident #1's Follow up with Physician dated 6/13/23 at 12 a.m. revealed Past Medical History: Borderline personality disorder, cerebral palsy, depressive disorder, difficult intravenous access, PTSD, self-injury behavior, schizophrenia, chronic enterocutaneous fistula, right ureteropelvic junction renal stone with intermittent obstruction .Social History: .History of multiple suicide attempts via self-mutilating behavior and ingestion of various objects .History of Present Illness: This is a 43-yeaar old while male with a past history of significant for PTSD/bipolar disorder with multiple suicide attempts with self-injurious behavior and ingestion of various objects, cerebral palsy, scoliosis, and a chronic enterocutaneous fistula 2/2 self-inflicted stab wound on his abdominal wall that required exploratory laparotomy x2 and excision of infected abdominal wall mesh (11/28/20), extensive adhesiolysis, and partial small bowel resection complicated by chronic draining wound .Patient states that his chronic abdominal pain is now becoming uncontrolled. He states that he is at his wits end and expressing a desire to go back to the hospital. His colostomy continues to leak stool creating a red rash around the site. He still refuses fentanyl patch saying that he doesn't like the way it makes him feel. He is requesting to have the oxy schedule and seeing if that helps. He has appt with surgery on 6/20/23. He also mentions that he is feeling more depressed but not suicidal. Record review of Resident #1's Nurse notes dated 6/17/23 at 6:57 p.m. by LVN A revealed Only Oxycontin ER 20 mg came in at this time from pharmacy. Nurse spoke with pharmacy on call. He stated Doctor only called in the 20 mg and they still need new prescription for Oxycontin 10 mg. Nurse sent message to the NP request new prescription to be sent to the pharmacy. Record review of Resident #1's Nurse notes dated 6/17/23 at 9:01 p.m. by LVN A revealed oxycodone HCl oral tablet 10 mg. Give 1 tablet orally every 4 hours for chronic pain was pending pharmacy delivery. Record review of Resident #1's Progress note dated 6/17/23 at 10:15 p.m. by LVN A revealed NP notified that pharmacy only send patient Oxycontin 20 mg. [Resident #1] wasn't happy and was yelling that this can't be happening. NP stated that she did notified Doctor that pharmacy did not deliver [Resident #1] Oxycontin IR 10 mg. NP said she haven't gotten a response from the Doctor yet. [Resident #1] was made aware and did reassure him that we're working on it. Record review of Resident #1's Progress notes dated 6/25/23 at 7:53 p.m. by LVN B revealed Received [AGE] year-old patient in the building via EMS Stretcher 2 men crew Awake Alert and Oriented x3, with medical history of cerebral palsy, depression, scoliosis, abdominal stab wound post colostomy that been leaking for the past 4 years and known history of drug seeking behavior just discharged from [local hospital]. Upon arrival patient continue to demand for the pain medication on the same spot and called another 911 that he is going back to hospital if nobody gave him immediate attention, medication confirm and verified with the doctor, presently eyes closed in the room continue to monitor throughout the night. Record review of Resident #1's Local Hospital Record Discharge summary dated [DATE] at 7:50 p.m. revealed, Reason for Visit: pain issues complained of abdomen pain from his colostomy, chronic. Takes oxycodone for pain. Nursing facility does not have his short acting oxycodone 10 mg which he gets every 4 hours only long acting 20 mg dose which he received at 9 p.m. tonight. States his colostomy bag is always leaking .His abdominal wall cellulitis may also be irritant dermatitis from the feces. He was started back on his chronic pain medications. Patient initially did not want to return to his facility. He then notified me that he swallowed a battery. Psychiatry was consulted and Cymbalta was increased to 80 mg daily. X-ray of the abdomen was completed that showed metallic cylindrical object in the left upper quadrant. Chest x-ray showed 2 cm focal opacity however he does have a skin tag in that region. GI was consulted and proceeded with EGD on 6/22 and was unable to retrieve foreign body. He was also noted to have elevated liver enzymes may be due to Cymbalta. He was continued on Cymbalta due to benefits of medication. Surgery was consulted. CT abdomen pelvis was completed that showed cylindrical metallic density within the small bowel loop in the lower mid abdomen with moderate stool burden. He was unable to pass battery. GI proceeded with colonoscopy and was able to retrieve the battery. He was restarted on regular diet which he tolerated well .Impression: Ingested foreign body-AAA battery battery-successfully removed by ileoscopy through ileostomy. Record review of Resident #1's Psychological Services Progress Note dated 6/27/23 revealed: Symptoms: (Symptoms that were focused on in this session) Psychological: depression, Physical: Physical decline, Functional/Behavioral challenges: Adjustment difficulty (illness/decline/Loss, Stressors/Changes in Mental Status: Declining health .Results of Psychotherapy: Functional improvement noted .Identified- external emotional triggers, Disposition/Rationale for continued treatment: Symptoms require more attention. In an observation and interview with Resident #1 on 6/28/23 at 1:20 p.m. revealed Resident #1 rolling around the hallway. Resident #1 stated he ate a battery and he explained he had an ileostomy bag, and it was leaking, and it leaked all the time no matter what the facility did. Resident #1 stated he had it for 4 years and he had trouble with the facility getting ostomy bags all the time and he had trouble with them getting his PRN pain meds to him. Resident #1 stated he had swallowed a battery before. Resident #1 stated he had several talks with Administration about these incidents asking them to tighten this up (his pain medication and ostomy bags). Resident #1 stated he spoke with Doctor's in the hospital to make things better and they said it was nothing they could do. He stated before he went to the hospital on 6/17/23, he found out his medicine (oxycodone 10 mg) had lapsed, and he told the nurse to send him to the hospital and that he had discussions with them several times and she said no they will just send him right back. Resident #1 stated with the state of mind he was in, he thought he would just do something that he had to go. He stated he was in a lot in pain with the ileostomy leaking and it burned his skin and he also had cerebral palsy and scoliosis. Resident #1 stated the state of mind he was in, he said to himself he would do what he had to do what to get out of the facility. Resident #1 stated since this incident he spoke with the psych specialist at the facility and she was getting him medication for anxiety and she said if a scenario happened again and the facility ran out of meds then he (Resident #1) would tell the staff he wants to go to the hospital and he did not feel safe so he can get what he needed done. Resident #1 stated since that issue happened the facility had a new unit manager and she stayed on top of the meds, and he stated he was staying on top of the meds also. Observation of Resident #1's ileostomy bag revealed it was leaking onto his brief and his skin. Resident #1 stated he felt that the facility neglected him, and he did not mean to snitch on anyone, but it is what it is. Resident #1 stated he could not remember the Nurses name. In an interview and record review on 6/28/23 at 1:40 p.m. with Unit Manager A she stated Resident #1 was frustrated about his pain meds when they do not get them right when they are due. Unit Manager A stated Resident #1 was asking about his pain meds closer to 6p.m. and he asked for the pain meds and the med aide was in another room and he got frustrated. One med was PRN, but they made it routine a few days before he went out. Unit Manager A stated Resident #1 went out on 6/17/23 and came back on 6/25/23. Record review of Resident #1's narcotic count sheet with Unit Manager A revealed Resident #1 did run out of Oxycontin ER 20 mg on 6/17/23 at 9 p.m. She stated he ran out of meds on 6/17/23 so no meds were given. Unit Manager A did call the local pharmacy at 2:13 p.m. and they stated Resident #1's Oxycontin ER 20 mg was delivered on 6/17/23 at 6:45 p.m. with 14 tablets. Unit Manager A stated Resident #1 ran out of Oxycodone 10mg. Observation of Resident #1's narcotic count sheet revealed the last tablet was given on 6/17/23 and he had 0 pills left. Unit Manager A stated the local pharmacy stated oxycodone 10 mg was delivered on 6/18/23 at 6:32 p.m. Unit Manager A stated Resident #1 missed 1 dose of oxycodone 10 mg on 6/17/23 for 9 p.m. In an interview on 6/28/23 at 2:20 p.m. with the DON she stated Resident #1 called 911 and they showed up at the building. The DON stated he had not told them that he swallowed the battery. In an interview on 6/29/23 at 1:18 p.m. with LVN A she stated the Doctor messed up. She stated she got report from shift change on 6/17/23 saying the Nurse got in touch with NP because Resident #1 ran out of meds, and they contacted the Doctor to call the medication in. LVN A stated she received report saying Unit Manager A took care of that, but the pharmacy only brought the oxycodone 20 mg and not the oxycodone 10 mg. LVN A stated the pharmacist said on 6/17/23 Resident #1 ran out of Oxycodone 10 mg and would need a new prescription. LVN A stated she got in touch with the NP and asked the NP to have the Doctor to contact LVN A. LVN A stated Resident #1 was suicidal and if he did not get his medicine, he would start doing things. She stated the Doctor did not respond back and he was supposed to call in those dosages. LVN A stated the meds came in the next day on 6/18/23. LVN A stated on 6/17/23 Resident #1 was screaming, and she realized Resident #1 was trying to cause harm to himself. She stated she told NP that Resident #1 said call 911 and the NP said call 911 . LVN A stated Resident #1 was holding some scissors and razors on 6/17/23 and she removed it from him and she continued to try to get the oxycodone 10 mg by contacting the NP. She stated she called 911 and said he was complaining of pain. LVN A stated Resident #1 was really angry and upset. He said it happened all the time that the facility ran out of his medication. LVN A stated Resident #1 was scheduled to get Oxycodone 20 mg twice a day and she went to his room saying it was his night meds 20mg for 10p.m. LVN A stated she told Resident #1 they did not have the 10 mg because they ran out of the 10 mg and was waiting for the pharmacy. She stated Resident #1 started yelling and raging screaming out of control. LVN A stated Resident #1 just got his oxycodone 20 mg long-acting meds at 9 p.m. and he started screaming and raging at 9p.m. She stated she had to leave Resident #1 to call the NP and he started yelling god dammit and saying things like he was going to harm himself. LVN A stated Resident #1 was mad the previous days because he was out of his medicine. LVN A stated Resident #1 was holding items in his hand, scissors and razors that could harm him. LVN A stated Resident #1 said he was going to harm himself. She stated Resident #1 was holding a pair of scissors, 4 disposable razors, a plastic lid from a plastic cup and he keep saying he was going to hurt himself. LVN A stated she was already aware of Resident #1's history and she took the items from him (Resident #1) and brought it to the Nurse station then she called 911 (Unknown time). LVN A stated 911 came and he told 911 he had a colostomy that was excoriated, and the stomach contents leaked out and he told 911 he was having stomach pain, the facility had been out of his meds for a few days, and he could not take it anymore and he did not want to be at the facility. She stated Resident #1 could not bear the pain and he was insisting to go to the hospital and NP said go ahead and send the resident. LVN A stated she did not know anything about a battery. She stated the only thing Resident #1 was holding in his hand were the scissors and razors and she took them away from him and called 911. LVN A stated she did not trust Resident #1. LVN A stated she did not call anyone to assist her with Resident #1 because the CNA was busy working and Resident #1 was sitting in the wheelchair crying, yelling and screaming god dammit LVN A stated the Doctor did not call in both dosages and they were supposed to call when they had 7 pills in the blister pack. LVN A stated Resident #1 had a history of trying to harm himself. LVN A stated the facility had an adequate supply for ileostomy bags and the only issue was about pain meds for Resident #1. In an interview on 6/29/23 at 1:53 p.m. with Resident #1 he stated prior to this happening he had several conversations about having enough ostomy supplies because before the new Unit Manager got here supplies was an issue. He stated he was having problems getting his prn pain meds when he needed, and he had several conversations with the previous Management (Administrator B). Resident #1 stated before he went to the hospital, he has gone days without his pain medication. He stated on 6/17/23, that evening he took his last prn dose of pain meds oxycodone 10 mg, and they said by the time it was time to get it again, the meds would be at the facility, and he said great. Resident #1 stated the medicine did not come in and they only brought the scheduled pain meds (oxycodone 20 mg) and he had asked for his pain meds (oxycodone 10 mg) and LVN A said the pharmacy only brought in the scheduled pain meds (oxycodone 20 mg). Resident #1 stated it was Saturday night and the next day was Sunday and if they run out on a Saturday you do not get meds until Monday. Resident #1 stated the med aide that day said it was his last dose at 5:30 to 6 p.m. and they said his meds should be in by the time the next dose is due. He stated he told the late-night nurse (LVN A) he was out of here (the facility) and that he was going to the hospital where they could take care of him. Resident #1 stated LVN A said let her give him (Resident #1) the scheduled dose and she said she would get a hold of the Doctor and he should let her see what she could do. Resident #1 stated the ostomy supply kept running out, there was the issue with getting prn meds and them running out of pain medication. He said, he had it and he blew up. Resident #1 stated he spoke with Unit Manager A before and he tried to solve the issue. It was a little after 9 p.m. He stated LVN A took the scissors from him at 9:45 to 10 p.m. when she saw them in his hand, and he said nothing nothing. Resident #1 stated in the box was razors and scissors and he had hidden batteries in his pocket. Resident #1 stated it was after 9 p.m. when she gave the scheduled meds, and she was having trouble getting hold of the Doctor. Resident #1 stated he told LVN A he wanted to get out of the facility, and she said if you just go for pain meds, they will give you one dose and send him right back. Resident #1 stated he had already told LVN A that he wanted to leave going to the hospital right after 9p.m. He stated LVN A took the scissors and razors, and after she (LVN A) left out of his room at around 9:45 to 10 p.m., Resident #1 shut his room door and swallowed the battery. He stated he went out of his room after he swallowed the battery and continued to blow up and said he did not feel safe at the facility and wanted to go to the hospital, and he was leaving. Resident #1 said that's fine, let her call the Doctor and they sent him out to the hospital. Resident #1 stated LVN A allowed a couple of hours to go by and he was by himself in his room. He stated he stayed in the hallway for a while and LVN A told him to calm down and that he was waking people up, but by this time his ostomy bag was leaking, his skin was burning, and he was hurting. Resident #1 stated he was sent to the hospital in a mess with feces on him and his ostomy bag was still leaking. Resident #1 stated he never told LVN A he swallowed a battery; he told the hospital 24 to 48 hours after he had gotten to the hospital that he swallowed the battery, and they rushed him to emergency. Resident #1 stated when he went into the hallway he stayed until 911 got there. In an interview on 6/29/23 at 2:46 p.m. with the DON she stated if a resident is suicidal the facility would put them on one-on-one observation and call the doctor to let them know. The DON stated the facility would call the psychiatrist and let them know as well so they can come and evaluate the resident. The DON stated she was not sure how the pharmacy in the company operates because she just started working at the facility on 5/22/23 as interim. The DON stated the staff should not leave the resident who was trying to commit suicide by themselves, and she would stay there and get the Doctor on the phone. The DON stated that was why she said if someone was suicidal, they need to be one on one observation. The DON stated she did not know what to say about the battery because the facility did not know he swallowed a battery until he came back from the hospital. The DON stated she understood that you do not turn your back on someone who is suicidal, but where there is a will there is a way, they will swallow even in your presence. In an interview on 6/29/23 at 2:57 p.m. with the Administrator she stated she did not know what to say about the battery. In an interview on 6/29/23 at 3 p.m. with Unit Manager A she stated the residents were not allowed to have razors and that the residents do not have access to razors, and they are in the supply room. Unit Manager A stated Resident #1 asked for razors today, 6/29/23 to shave himself with and she told him no and the facility would shave him. In an interview on 6/30/23 at 12:54 p.m. with the Medical Director he stated the nursing home staff had been aware that Resident #1 was admitted with suicide ideations, and he had been followed by psychiatry and psychology in May 2023. The Medical Director stated Resident #1 denied that the resident made any outcries that he wanted to harm himself since being admitted at the facility. The Medical Director stated he did not know why Resident #1 had scissors or razors. The Medical Director stated he did not have his pain medicine because it was running low, and they were waiting for the attending physician to send in a refill. The Medical Director stated he was not aware the medication was completely out. The Medical Director stated an ileostomy bag is for hygiene and cleanliness, but sometimes due to the person's body or the way they are it may be difficult to keep the bag adhered. The Medical Director stated they want the bag to stay adhered for cleanliness, but if the stool leakage occurs and its left unattended it could burn the skin. In an interview on 6/30/23 at 1:35 p.m. with the DON she stated she was told Resident #1 was sent to the hospital. The DON stated if a patient needs to go to the hospital it needs to be from the Doctor or NP and If a resident said they wanted to go to the hospital they have to let the Dr know what's going on and they have to give the okay to send the resident out. The DON stated if the resident was admitted into the facility that means they are not on suicidal watch. She stated the moment the resident was admitted to the facility unless they voice out, they are suicidal they have to ask them what their plan is then follow the steps of what they need to do. The DON stated it the resident had a diagnosis, there was nothing they would do if they were not voicing that they would hurt themselves. She stated although because they have the history of, they would get psych services involved. The DON stated Resident #1 was not care planned for suicidal ideations and she stated she could not answer why, and she would have to get the MDS Coordinator to see why. The DON stated she did not know how Resident #1 got the scissors and razors. She stated when Resident #1 returned from the hospital; they did a head-to-toe assessment and documented to make sure there were no new issues. The DON stated if the hospital deemed Resident #1 competent and okay to come back to the facility, then they go by the recommendations of what the hospital asked them to do. The DON stated if the hospital said they need psych services, the facility would follow the recommendations the hospital gave them. The DON stated she did not know why they were running out of medications. The DON stated the facility had a pharmacy and the Nurses now to call the pharmacy to replenish the medication. The DON stated every pharmacy was different, with this pharmacy they need to call them within 3 days if the resident was running out of medications unless the PRN medication had a 14 day stop date. In an interview on 6/30/23 at 1:50 p.m. with the NP she stated Resident #1 was mentally competent but was in a lot of general pain. She stated Resident #1 was on oxycodone ER release every 12 hours (long acting) and oxycodone 10 mg (a short acting one). The NP stated when she saw Resident #1, he sat in the wheelchair, and he looked like he was in a lot of pain. She stated she thought he was used to getting a lot of narcotic meds. The NP stated Resident #1 recently requested to go to the hospital because he ran out of oxycodone. The NP stated the hospital found Resident #1 with a UTI and they treated him with antibiotics. The NP stated when she saw Resident #1, he said he did not want to deal with the pain, and he did not want to deal with this kind of life. The NP stated Resident #1 requested to be on hospice, but she was not sure if hospice would accept him. The NP stated Resident #1 did not mention to her that he wanted to harm himself. She stated Resident #1 said he did not want to deal with this kind of pain in his life. The NP stated she spoke with Resident #1, and he was calm and smiling. The NP stated the day he was sent out to the hospital the nurse (LVN A) told her Resident #1 was screaming and threw stuff at her (LVN A) and asked to go to the hospital. The NP stated it was 2 weeks ago on Saturday, 6/17/23 and Resident #1 said he was in a lot of pain. The NP stated he received the pain medication every 4 hours and every 12 hrs. The NP stated she did not know Resident #1 was diagnosed with suicidal ideations. She stated she just started seeing Resident #1 and she just started working at the facility about 3 weeks ago. The NP stated she did not see any documents of suicidal ideations. The NP stated if she was aware she would have put in an order for transfer to psychiatric hospital because Resident #1 needed inpatient psych and therapy. She stated if she saw that she would have asked the nurse to send him to behavioral hospital. The NP stated on 6/17/23, LVN A said Resident #1 was [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for Administration. -The administration failed to complete a comprehensive review of Resident #1's medical records which detailed his prior and current destructive behaviors including swallowing batteries and stabbing himself and was unaware until this surveyor informed them. -The administration failed to ensure interventions were in place to protect Resident #1 after readmission to the facility. -The administration failed to care plan, implement, and provide care and services to Resident #1 in accordance with facility policies and procedures for suicidal ideations. An Immediate Jeopardy (IJ) was identified on 06/30/23 at 2:59 p.m. The IJ template was provided to the facility on 6/30/23 at 2:59 p.m. While the IJ was removed on 07/05/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been trained on caring for residents with suicidal ideations, neglect, ordering pain medications timely, changing ileostomy bags, and care planning for suicidal ideations. These failures could affect all residents placing them at risk of the facility not being administered in a way to assist with physical, mental, and psychosocial needs. Findings include: Record review of Resident #1's face sheet dated 6/28/23 revealed a [AGE] year-old male who initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of being initially admitting to the facility with suicidal ideations, systemic inflammatory response syndrome (SIRS) of Non-Infectious origin without acute organ dysfunction (exaggerated defense response of the body), cerebral palsy (disorder that affects a person's ability to maintain balance and posture), sepsis due to enterococcus, fistula of intestine (abnormal opening or intestine that allows the contents to leak to another part of the body), idiopathic peripheral autonomic neuropathy (damage of the peripheral nerves where cause cannot be determined), intervertebral disc degeneration, lumbar region, residual schizophrenia, scoliosis, bipolar disorder, colostomy status, major depressive disorder, and anxiety. Record review of Resident #1's Care Plan dated 6/26/23 revealed resident complains of increased pain/discomfort and is at risk for further episodes of increased pain/discomfort and injury. Goal: Resident will maintain current levels of ADLs and any pain/discomfort will be relieved within 1 hour of delivery of pain medication or other intervention over the next 90 days. Interventions: Allow to verbalize feelings of pain/discomfort . Resident #1 has a Colostomy due to Medical Condition. Goal: Resident #1 will have no complications from ostomy site over the next 90 days. Intervention: Monitor site for swelling, pain, redness, etc.Apply Nystatin powder to Colostomy Site. Resident #1 has a diagnosis of depression with Goal: have fewer or no episodes of depression and will voice feelings about self over the next 90 days. Interventions/Tasks: Allow [Resident #1] to verbalize feelings of depression. Give medications per order-monitor labs - report abnormalities to MD. Resident #1 has a behavior problem of not waiting on staff to change his colostomy will call the police 911. Intervention: Anticipate and meet [Resident #1's] needs. Resident #1 call 911 due to meds not here. Interventions/Tasks: If reasonable, discuss [Resident #1's] behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. Further Record review of Resident #1's Care Plan dated 6/26/23 revealed he was not care planned for suicidal ideations when he admitted to the facility with the diagnosis on 2/6/23. Record review of Resident #1's Quarterly MDS dated [DATE] revealed his BIMS Summary Score was 15 indicating he was cognitively intact. Resident #1's functional status revealed walking in room and corridor did not occur, supervision with set up help only for locomotion on and off the unit and eating. Resident #1 required limited assistance with one person assisting for transfer, toilet use, and personal hygiene and he needed extensive assistance with one person physically assisting him for dressing. Record review of Resident #1's Physician Orders dated 6/30/23 revealed: Discontinue Oxycontin 20 mg ER when 30 mg tablet has arrived. One time only for 3 days dated 6/28/23 and ended 7/1/23. Oxycodone HCL Oral tablet 10 mg give 1 tablet by mouth every 4 hours related to systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction dated 4/11/23. Oxycontin Oral tablet ER 12 Hour Abuse-Deterrent 30 mg give 1 tablet orally every 12 hours for chronic pain. Oxycontin Oral Tablet ER 12 Hour Abuse-Deterrent 20 mg Give 1 tablet orally every 12 hours for chronic pain. Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to colostomy topically three times a day for colostomy site irritated dated 04/04/23. Zinc Oxide External Ointment 20 % (Zinc Oxide (Topical)) Apply to colostomy site topically four times a day for colostomy site irritated dated 02/16/23. Record review of Resident #1's Medication Administration Record for 6/1-6/30/23 revealed: Colostomy Observation every shift Monitor Resident's colostomy. Ensure Colostomy is intact, free from s/s of infection and functioning properly. The box was blank on 6/6/23 at 6 p.m. Colostomy: Empty every shift Licensed Nurse will monitor colostomy and ensure it is emptied every shift and as needed. The box was blank on 6/6/23 at 6 p.m. Observation: Behaviors. Target Behaviors : withdrawn, crying, lack of appetite every shift Monitor Resident for Presence of Behaviors withdrawn, crying, lack of appetite. Document Yes or No to whether Behaviors were Observed. Notify MD as needed for Behaviors. The box was blank on 6/6/23 at 6 p.m. Observation: Pain - Observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the PNs. every shift for pain observation. The box was blank on 6/6/23 at 6 p.m. Skin: Protective skin barrier ointment after each incontinent episode and PRN every shift. The box was blank on 6/6/23 at 6 p.m. Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to colostomy topically three times a day for colostomy site irritated. The box was blank on 6/6/23 at 6 p.m. Zinc Oxide External Ointment 20 % (Zinc Oxide (Topical)) Apply to colostomy site topically four times a day for colostomy site irritated. The box was blank on 6/6/23 at 9 p.m. Oxycodone HCL Oral Tablet 10 mg. The box was blank on 6/6/23 at 6 p.m. Oxycontin Oral Tablet ER 12 Hour (Oxycodone HCl). The box was blank on 6/6/23, 6/10/23, and 6/11/23 at 9 p.m. Further review of the MAR revealed no documentation to indicate Resident #1 was out of the facility on the days the MAR was blank. Record review of Resident #1's Controlled Drug Administration Record Tablet for Oxycodone IR 10 mg oral date issued 5/3/23 revealed: 6/16/23 at 9 a.m. 6/16/23 at 1 p.m. 6/16/23 at 5 p.m. 6/16/23 at 8 p.m. 6/17/23 at 1 a.m. 6/17/23 at 5 a.m. 6/17/23 at 9 a.m. 6/17/23 at 1 p.m. 6/17/23 at 5 p.m. the last dose was administered and there were 0 tablets left. Record review of Resident #1's progress note dated 6/6/23 at 2:30 a.m. by LVN E revealed, Resident is currently stable .PRN Oxycodone HCl oral tablet 10 mg administered at 7:32 p.m. and 1:32 a.m. respectively due to burning pain on skin. Record review of Resident #1's progress note dated 6/8/23 at 4:06 p.m. by LVN D revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress note dated 6/9/23 at 4:56 a.m. by LVN A revealed Resident #1 alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's progress notes dated 6/11/23 at 5:54 a.m. by LVN C revealed Resident #1 called 911 because his colostomy was not change prompt, at the time of his call the nurse/writer was on break, colostomy was changed .[Resident #1] alert and without. Remains on pain management. Denies of shortness of breath. No fever noted. Around stoma site area with redness and irritated. Routine Colostomy care provided . Record review of Resident #1's Progress note dated 6/13/23 at 11:07 p.m. by LVN A revealed Confirmed new order from [Doctor] to discontinue patient PRN oxycodone HCL Oral Tablet 10 mg (Oxycodone HCL) every 4 hours. [Resident #1] started on scheduled oxycodone HCl Oral tablet 10 mg (Oxycodone HCl) every 4 hours for his pain management. Resident #1 remains oxycodone HCl oral tablet ER 20 mg (Oxycodone HCl) twice daily. Resident #1 made aware of new changes with his pain medications. Record review of Resident #1's Follow up with Physician dated 6/13/23 at 12 a.m. revealed Past Medical History: Borderline personality disorder, cerebral palsy, depressive disorder, difficult intravenous access, PTSD, self-injury behavior, schizophrenia, chronic enterocutaneous fistula, right ureteropelvic junction renal stone with intermittent obstruction .Social History: .History of multiple suicide attempts via self-mutilating behavior and ingestion of various objects .History of Present Illness: This is a [AGE] year old while male with a past history of significant for PTSD/bipolar disorder with multiple suicide attempts with self-injurious behavior and ingestion of various objects, cerebral palsy, scoliosis, and a chronic enterocutaneous fistula 2/2 self-inflicted stab wound on his abdominal wall that required exploratory laparotomy x2 and excision of infected abdominal wall mesh (11/28/20), extensive adhesiolysis, and partial small bowel resection complicated by chronic draining wound .Patient states that his chronic abdominal pain is now becoming uncontrolled. He states that he is at his wits end and expressing a desire to go back to the hospital. His colostomy continues to leak stool creating a red rash around the site. He still refuses fentanyl patch saying that he doesn't like the way it makes him feel. He is requesting to have the oxy schedule and seeing if that helps. He has appt with surgery on 6/20/23. He also mentions that he is feeling more depressed but not suicidal. Record review of Resident #1's Progress note dated 6/17/23 at 10:15 p.m. by LVN A revealed NP notified that pharmacy only send patient Oxycontin 20 mg. [Resident #1] wasn't happy and was yelling that this can't be happening. NP stated that she did notified Doctor that pharmacy did not deliver [Resident #1] Oxycontin IR 10 mg. NP said she haven't gotten a response from the Doctor yet. [Resident #1] was made aware and did reassure him that we're working on it. Record review of Resident #1's SBAR (Change of Condition) dated 6/18/23 at 12:31 a.m. by LVN A revealed: [Resident #1] complaining of extreme pain to his stomach. [Resident #1] requested to be sent out to the hospital. NP notified .[Resident #1] requested to be sent out to the hospital because he can't take it anymore because of his pain. Nurse caught [Resident #1] holding some tools in his hand. Nurse took away from patient holding 4 disposable shaving razors, a small scissors and a plastic water cover from the kitchen while he was sitting up. NP notified and approved to send him out. Patient was yelling out loud, disturbing the peace of other residents'. Cursing out loud by using different offensive words that are derogatory. Unable to calm patient down. Patient went out via 911 at 11:47 p.m. Record review of Resident #1's Local Hospital Record dated 6/23/23 revealed Pouch was leaking on arrival. Pouch was last changed on 6/19/23 wound ostomy continence note. Changed pouch. Applied marathon liquid skin protectant to peristomal, raw, denuded openings. Applied 1 piece pouch with convex barrier ostomy ring. Good seal achieved. Record review of Resident #1's Progress notes dated 6/25/23 at 7:53 p.m. by LVN B revealed Received [AGE] year-old patient in the building via EMS Stretcher 2 men crew Awake Alert and Oriented x3, with medical history of cerebral palsy, depression, scoliosis, abdominal stab wound post colostomy that been leaking for the past 4 years and known history of drug seeking behavior just discharged from [local hospital]. Upon arrival patient continue to demand for the pain medication on the same spot and called another 911 that he is going back to hospital if nobody gave him immediate attention, medication confirm and verified with the doctor, presently eyes closed in the room continue to monitor throughout the night. Record review of Resident #1's Local Hospital Record Discharge summary dated [DATE] at 7:50 p.m. revealed, Reason for Visit: pain issues complained of abdomen pain from his colostomy, chronic. Takes oxycodone for pain. Nursing facility does not have his short acting oxycodone 10 mg which he gets every 4 hours only long acting 20 mg dose which he received at 9 p.m. tonight. States his colostomy bag is always leaking .His abdominal wall cellulitis may also be irritant dermatitis from the feces. He was started back on his chronic pain medications. Patient initially did not want to return to his facility. He then notified me that he swallowed a battery. Psychiatry was consulted and Cymbalta was increased to 80 mg daily. X-ray of the abdomen was completed that showed metallic cylindrical object in the left upper quadrant. Chest x-ray showed 2 cm focal opacity however he does have a skin tag in that region. GI was consulted and proceeded with EGD on 6/22 and was unable to retrieve foreign body. He was also noted to have elevated liver enzymes may be due to Cymbalta. He was continued on Cymbalta due to benefits of medication. Surgery was consulted. CT abdomen pelvis was completed that showed cylindrical metallic density within the small bowel loop in the lower mid abdomen with moderate stool burden. He was unable to pass battery. GI proceeded with colonoscopy and was able to retrieve the battery. He was restarted on regular diet which he tolerated well .Impression: Ingested foreign body-AAA battery battery-successfully removed by ileoscopy through ileostomy. Record review of Resident #1's Psychological Services Progress Note dated 6/27/23 revealed: Symptoms: (Symptoms that were focused on in this session) Psychological: depression, Physical: Physical decline, Functional/Behavioral challenges: Adjustment difficulty (illness/decline/Loss, Stressors/Changes in Mental Status: Declining health .Results of Psychotherapy: Functional improvement noted .Identified- external emotional triggers, Disposition/Rationale for continued treatment: Symptoms require more attention. In an observation and interview with Resident #1 at the facility on 6/28/23 at 1:20 p.m. revealed Resident #1 rolling around the hallway in his wheelchair. Resident #1 stated he ate a battery and he explained he had an ileostomy bag, and it was leaking and it burned his skin. He stated it leaked all the time no matter what the facility did. Resident #1 stated he had it for 4 years and he had trouble with the facility getting ostomy bags all the time and he had trouble with them getting his PRN pain meds to him. Resident #1 stated he had several talks with Administration about these incidents asking them to tighten this up (his pain medication and ostomy bags). Resident #1 stated he spoke with Doctor's in the hospital to make things better and they said there was nothing they could do. He stated before he went to the hospital on 6/17/23, he found out his medicine (oxycodone 10 mg) had lapsed, and he told the nurse to send him to the hospital at 9 p.m. He said he had discussions with them several times and LVN A said no they will just send him right back. Resident #1 stated with the state of mind he was in, he thought he would just do something that he had to go. He stated he was in a lot in pain with the ileostomy leaking and it burned his skin and he also had cerebral palsy and scoliosis. Resident #1 stated the state of mind he was in, he said to himself he would do what he had to do to get out of the facility. Resident #1 stated since this incident he spoke with the psych specialist at the facility and she was getting him medication for anxiety and she said if a scenario happened again and the facility ran out of meds then he (Resident #1) would tell the staff he wants to go to the hospital and he did not feel safe. Resident #1 stated since that issue happened the facility had a new unit manager and she stayed on top of the meds, and he stated he was staying on top of the meds also. Observation of Resident #1's ileostomy bag revealed it was leaking onto his brief and his skin. Resident #1 stated he felt that the facility neglected him, and he did not mean to snitch on anyone, but it is what it is. Resident #1 stated he could not remember the Nurses name. Resident #1 stated the staff said they could not make the ileostomy bag stop leaking. Resident #1 stated the ileostomy was not leaking as bad as it was yesterday. He said, the ileostomy bag leaked a lot and that was an understatement and it had burned him in the past where he had to go to the hospital. Resident #1 stated the last time he went to the hospital for the ileostomy burning his skin was a few months ago. In an interview and record review on 6/28/23 at 1:40 p.m. with Unit Manager A, she stated Resident #1 getsfrustrated about his pain meds when the facility does not get them right when they were due. Unit Manager A stated, Resident #1 was asking about his pain meds closer to 6 p.m. on 6/17/23 and he asked for the pain meds and the med aide was in another room and he got frustrated. Unit Manager A stated Oxycodone 10 mg was PRN, but they made it routine a few days before he went out. Unit Manager A stated Resident #1 went out on 6/17/23 and came back on 6/25/23. Record review of Resident #1's narcotic count sheet with Unit Manager A revealed Resident #1 did run out of Oxycontin ER 20 mg on 6/17/23 at 9 p.m. She stated he ran out of meds on 6/17/23 so no meds were given. Unit Manager A did call the local pharmacy on 6/28/23 at 2:13 p.m. and they stated Resident #1's Oxycontin ER 20 mg was delivered on 6/17/23 at 6:45 p.m. with 14 tablets. Unit Manager A stated Resident #1 ran out of Oxycodone 10mg. Record review of Resident #1's narcotic count sheet with Unit Manager A revealed the last Oxycodone 10 mg tablet was given on 6/17/23 and he had 0 pills left. Unit Manager A stated the local pharmacy stated oxycodone 10 mg was delivered on 6/18/23 at 6:32 p.m. Unit Manager A stated Resident #1 missed 1 dose of oxycodone 10 mg on 6/17/23 for 9 p.m. In an interview on 6/28/23 at 2:20 p.m. with the DON she stated thought Resident #1 called 911 on 6/17/23 and they showed up at the building. The DON stated he had not told them that he swallowed the battery. In an interview on 6/29/23 at 1:18 p.m. with LVN A she stated the Doctor messed up. She stated she got report from shift change on 6/17/23 saying the Nurse got in touch with NP because Resident #1 ran out of meds, and they contacted the Doctor to call the medication in. LVN A stated she received report saying Unit Manager A took care of that, but the pharmacy only brought the oxycodone 20 mg and not the oxycodone 10 mg. LVN A stated the pharmacist said on 6/17/23 Resident #1 ran out of Oxycodone 10 mg and would need a new prescription. LVN A stated she got in touch with the NP and asked the NP to have the Doctor to contact LVN A. LVN A stated Resident #1 was suicidal and if he did not get his medicine, he would start doing things. She stated the Doctor did not respond back and he was supposed to call in those dosages. LVN A stated the meds came in the next day on 6/18/23. LVN A stated on 6/17/23 Resident #1 was screaming, and she realized Resident #1 was trying to cause harm to himself. She stated she told NP that Resident #1 said call 911 and the NP said call 911 . LVN A stated Resident #1 was holding some scissors and razors on 6/17/23 and she removed it from him and she continued to try to get the oxycodone 10 mg by contacting the NP. She stated she called 911 and said he was complaining of pain. LVN A stated Resident #1 was really angry and upset. He said it happened all the time that the facility ran out of his medication. LVN A stated Resident #1 was scheduled to get Oxycodone 20 mg twice a day and she went to his room saying it was his night meds 20mg for 10p.m. LVN A stated she told Resident #1 they did not have the 10 mg because they ran out of the 10 mg and was waiting for the pharmacy. She stated Resident #1 started yelling and raging screaming out of control. LVN A stated Resident #1 just got his oxycodone 20 mg long-acting meds at 9 p.m. and he started screaming and raging at 9p.m. She stated she had to leave Resident #1 to call the NP and he started yelling god dammit and saying things like he was going to harm himself. LVN A stated Resident #1 was mad the previous days because he was out of his medicine. LVN A stated Resident #1 was holding items in his hand, scissors and razors that could harm him. LVN A stated Resident #1 said he was going to harm himself. She stated Resident #1 was holding a pair of scissors, 4 disposable razors, a plastic lid from a plastic cup and he keep saying he was going to hurt himself. LVN A stated she was already aware of Resident #1's history and she took the items from him (Resident #1) and brought it to the Nurse station then she called 911 (Unknown time). LVN A stated 911 came and he told 911 he had a colostomy that was excoriated, and the stomach contents leaked out and he told 911 he was having stomach pain, the facility had been out of his meds for a few days, and he could not take it anymore and he did not want to be at the facility. She stated Resident #1 could not bear the pain and he was insisting to go to the hospital and NP said go ahead and send the resident. LVN A stated she did not know anything about a battery. She stated the only thing Resident #1 was holding in his hand were the scissors and razors and she took them away from him and called 911. LVN A stated she did not trust Resident #1. LVN A stated she did not call anyone to assist her with Resident #1 because the CNA was busy working and Resident #1 was sitting in the wheelchair crying, yelling and screaming god dammit LVN A stated the Doctor did not call in both dosages and they were supposed to call when they had 7 pills in the blister pack. LVN A stated Resident #1 had a history of trying to harm himself. LVN A stated the facility had an adequate supply for ileostomy bags and the only issue was about pain meds for Resident #1. In an interview on 6/29/23 at 1:53 p.m. with Resident #1, he stated prior to him swallowing the battery he had several conversations about having enough ostomy supplies because before the new Unit Manager got there, supplies was an issue. He stated he was having problems getting his prn pain meds when he needed, and he had several conversations with the previous Management (Administrator B). Resident #1 stated before he went to the hospital, he had gone days without his pain medication. He stated on 6/17/23, that evening he took his last prn dose of pain meds oxycodone 10 mg, and they said by the time it was time to get it again, the meds would be at the facility, and he said great. Resident #1 stated the medicine did not come in and they only brought the scheduled pain meds (oxycodone 20 mg) and he had asked for his pain meds (oxycodone 10 mg) and LVN A said the pharmacy only brought in the scheduled pain meds (oxycodone 20 mg). Resident #1 stated it was Saturday night and the next day was Sunday and if they run out on a Saturday you do not get meds until Monday. Resident #1 stated the med aide that day on 6/17/23 said it was his last dose at 5:30 to 6 p.m. and they said his meds should be in by the time the next dose was due. He stated he told the late-night nurse (LVN A) he was out of here (the facility) and that he was going to the hospital where they could take care of him. Resident #1 stated LVN A said let her give him (Resident #1) the scheduled dose and she said she would get a hold of the Doctor and he should let her see what she could do. Resident #1 stated the ostomy supply kept running out, there was the issue with getting prn meds and them running out of pain medication. He said, he had it and he blew up. Resident #1 stated he spoke with Unit Manager A before and he tried to solve the issue. Resident #1 stated it was a little after 9 p.m. on 6/17/23 when LVN A took the scissors from him at 9:45 to 10 p.m. when she saw them in his hand, and he said nothing nothing. Resident #1 stated in the box was razors, scissors and he had hidden batteries in his pocket. Resident #1 stated it was after 9 p.m. when she gave the scheduled meds, and she was having trouble getting hold of the Doctor. Resident #1 stated he told LVN A he wanted to get out of the facility, and she said if you just go for pain meds, they will give you one dose and send him right back. Resident #1 stated he had already told LVN A that he wanted to leave going to the hospital right after 9p.m. He stated LVN A took the scissors and razors, and after she (LVN A) left out of his room at around 9:45 to 10 p.m., Resident #1 shut his room door and swallowed the battery that he got from the TV remote. He stated he went out of his room after he swallowed the battery and continued to blow up and said he did not feel safe at the facility and wanted to go to the hospital, and he was leaving. Resident #1 said LVN A said let her call the Doctor and they sent him out to the hospital. Resident #1 stated LVN A allowed a couple of hours to go by and he was by himself in his room. He stated he stayed in the hallway for a while and LVN A told him to calm down and that he was waking people up, but by this time his ostomy bag was leaking, his skin was burning, and he was hurting. Resident #1 stated he was sent to the hospital in a mess with feces on him and his ostomy bag was still leaking. Resident #1 stated he never told LVN A he swallowed a battery; he told the hospital 24 to 48 hours after he had gotten to the hospital that he swallowed the battery, and they rushed him to emergency. Resident #1 stated when he went into the hallway he stayed until 911 got there. In an interview and Record review on 6/29/23 at 2:30 p.m. with Administrator she stated she was not aware that Resident #1 swallowed a battery and she stated she thought the battery was from Resident #1's previous hospitalization when he swallowed the battery. The Administrator stated she was not aware until the State Surveyor informed her that Resident #1 swallowed the battery. The Administrator did review with this Surveyor Resident #1's hospital records where Resident #1 swallowed a battery prior to being admitted to their facility on 2/6/23. When asked why the Administrator was not aware of the battery, she stated she was newly hired and had only been at the facility a few days. In an interview with the Assistant Administrator on 6/29/23 at 2:35 p.m. he stated he was not aware Resident #1 swallowed a battery. In an interview on 6/29/23 at 2:46 p.m. with the DON she stated if a resident was suicidal the facility would put them on one-on-one observation and call the doctor to let them know. The DON stated the facility would call the psychiatrist and let them know as well so they can come and evaluate the resident. The DON stated she was not sure how the pharmacy in the company operates because she just started working at the facility on 5/22/23 as interim. The DON stated the staff should not leave the resident who was trying to commit suicide by themselves, and she would stay there and get the Doctor on the phone. The DON stated that was why she said if someone was suicidal, they need to be one on one observation. The DON stated she did not know what to say about the battery because the facility did not know he swallowed a battery until he came back from the hospital. The DON stated she understood that you do not turn your back on someone who is suicidal, but where there is a will there is a way, they will swallow even in your presence. In an interview on 6/29/23 at 2:57 p.m. with the Administrator, she stated she did not know what to say about the battery. In an interview on 6/29/23 at 3:00 p.m. with Unit Manager A, she stated the residents were not allowed to have razors and that the residents do not have access to razors, and they were in the supply room. Unit Manager A stated Resident #1 asked for razors today, 6/29/23 to shave himself with and she told him no and the facility would shave him. In an interview on 6/30/23 at 12:54 p.m. with the Medical Director, he stated the nursing home staff had been aware that Resident #1 was admitted with suicide ideations, and he had been followed by psychiatry and psychology in May 2023. The Medical Director stated Resident #1 denied that the resident made any outcries that he wanted to harm himself since being admitted at the facility. The Medical Director stated he did not know why Resident #1 had scissors or razors. The Medical Director stated he did not have his pain medicine because it was running low, and they were waiting for the attending physician to send in a refill. The Medical Director stated he was not aware the medication was completely out. The Medical Director stated an ileostomy bag was for hygiene and cleanliness, but sometimes due to the person's body or the way they were it may be difficult to keep the bag adhered. The Medical Director stated they want the bag to stay adhered for cleanliness, but if the stool leakage occurs and it was left unattended it could burn the skin. In an interview on 6/30/23 at 1:35 p.m. with the DON she stated she was told Resident #1 was sent to the hospital on 6/17/23. The DON stated if a patient needs to go to the hospital it needs to be from the Doctor or NP and If a resident said they wanted to go to the hospital they have to let the Dr know what's going on and they have to give the okay to send the resident out. The DON stated if the resident was admitted into the facility that means they were not on suicidal watch. She stated the moment the resident was admitted to the facility unless they voice out, they were suicidal they have to ask them what their plan was, then follow the steps of what they need to do. The DON stated it the resident had a diagnosis, there was nothing they would do if they were not voicing that they would hurt themselves. She stated although because the resident have the history of suicidal ideations, they would get psych services involved. The DON stated Resident #1 was not care planned for suicidal ideations and she stated she could not answer why, and she would have to get the MDS Coordinator to see why. The DON stated she did not know how Resident #1 got the scissors and razors. She stated when Resident #1 returned from the hospital on 6/25/23; they did a head-to-toe assessment and documented to make sure there were no new issues. The DON stated if the hospital deemed Resident #1 competent and okay to come back to the facility, then they go by the recommendations of what the hospital asked them to do. The DON stated if the hospital said they need psych services, the facility would follow the recommendations the hospital gave them. The DON stated she did not know why [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident was free from abuse for 6 of 25 residents ( Resident #2, Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10) reviewed for abuse. - The facility failed to ensure Resident #2, a resident with severe IDD and behaviors, was free from physical abuse on 03/31/23 from Resident #6 by placing them in the same room resulting in bleeding from the mouth and lacerations to the lip. - The facility failed to ensure Resident #8 was free from repeated physical abuse from Resident #7, resulting in Resident #8 suffering from a busted lip and a cigarette burn over multiple altercations. - The facility failed to ensure Resident #9, and Resident #10 were free from physical abuse from Resident #2, a resident with severe IDD and behaviors by placing them in the same room. On 05/22/23 at 03:21 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 05/29/23 at 07:10 PM, the facility remained out of compliance at an H (severity level of actual harm that is not immediate and a scope of pattern) due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk of increased abuse, major injury and a decreased quality of life Findings included: Resident #2 Record review of Resident #2's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: unspecified dementia, depression, difficulty swallowing, G-tube (a tube that goes into the stomach to provide food and medications), anxiety disorders, left hand contractures, right hand contractures and sever intellectual disabilities. Record review of Resident #2's Quarterly MDS dated [DATE] revealed, unclear speech, s rarely understood, sometimes understands, severely impaired cognition as indicated by a BIMS score of 00 out of 15, no response to resident mood interview questions, no documented behavioral symptoms (physical behaviors directed towards others, verbal behavioral symptoms directed to others or other behavioral symptoms not directed towards others), no rejection of care, no wandering, total dependence on all ADLs, use of a wheelchair, always incontinent of both bladder and bowel, non-traumatic brain dysfunction and left and right hand contractures. Record review of Resident #2's undated Care Plan printed 05/16/23 revealed, focus-IDD Resident #2 has been identified as PASRR positive related to intellectual disability; intervention- provide recommended services (habilitation coordination, independent living skills training and OT). Focus- nonverbal for communication needs/wants; potential for unmet needs/social isolation/boredom, escalating anxiety and agitation; intervention- provide emotional support to resident, refer resident for additional support relative to potential for escalating behaviors, referrals to psychiatric services for medication management and stabilization of behaviors. Focus- 2/09/23 Resident #2 was not hitting his roommate; intervention- resident was moved to another room. No incidents of physical aggression were documented on the Resident #2's care plan. No documentation of the type of Resident #2's behaviors. Record review of Resident #2's Census List starting at admission [DATE] to 05/18/23 revealed, since 01/2023 Resident #2 has had 3 room changes. Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: anxiety, irritability, anger, non-verbal with a history of resistance and combative behaviors. Collateral information: aggression on and off. Record review of Resident #2's Nursing Note dated 02/10/23 at 01:34 PM and signed by LVN B revealed, Resident #2 initiated physical aggression against his roommate (Resident #9) on 02/09/23 LVN B was notified by the housekeeper that she saw Resident #2 hit his roommate while in bed. The roommate was moved out from room immediately. Record review of Resident #2's Nursing Note dated 02/22/23 at 05:46 PM signed by LVN B revealed, Patient is combative , hitting other patients. Patient was seen on his roommate's (Resident #10) body. Roommate (Resident #10) stated take this man out of here, I want peace. Resident #2 was taken to another room. Resident #2 was seen hitting other patients on the hallway, refused to stay in room. Record review of Resident #2's Psychiatric Provider note dated 02/22/23 revealed, Resident #2 was awake and agitated, monitored for behaviors and staff reported Resident #2 has been increasingly agitated and aggressive. He has been attempting to hit staff Orders to send to behavior hospital will be provided. Record review of Resident #2's Nursing Note dated 02/23/23 at 09:15 AM signed by LVN B revealed, Patient is becoming a threat to other patients and staff. He refused to stay in room Patient in hallway hitting everyone passing by. Patient needs to be moved to a psych hospital ASAP . Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: aggression, hitting staff, hitting other residents, safety to self. Collateral Information: Staff reports patient has intermittent aggression towards others and fluctuating mood. Assessment/Plan: increased Risperdal (an antipsychotic) due to physical aggression, reported paranoia and negative symptoms. Severe IDD- is not treated with medications . There was no reference of the resident's appropriateness to have a roommate. Record review of Resident #2's Psychiatric Provider note dated 02/24/23 revealed, behavioral hospital admission denied. Record review of Resident #2's Nursing Note dated 03/31/23 at 11:55 AM signed by LVN C revealed, at about 09:35 AM write noted Resident #2 roommate (Resident #6) standing over residents' wheelchair pushing wheelchair over resident. Resident #2 was noted to be lying on the floor between bed and wheelchair with blood coming from his mouth. LVN C separated the residents and Resident #6 got into bed and stated, somebody better get him before I kill him. Laceration noted to upper lip area, Resident #2 was brought to the nurse's station in a wheelchair at which he was observed to hit another resident while sitting at the nursing station. At this time facility is working on room changes for resident and possible admit to psych facility. Record review of Resident #2's Nursing Note dated 03/31/23 at 01:12 PM signed by LVN B revealed, LVN B was told by staff that at 08:00 AM Resident #2 was hit by his roommate (Resident #6) because he was close to his bed, so the patient was taken out of the room. At 09:00 AM, Resident #2 was returned to his bed because he was throwing himself off the wheelchair at which point another staff saw Resident #6 hitting Resident #2 using a wheelchair. At 11:02, LVN B observed Resident #6 hitting Resident #2 with a shoe. Record review of Resident #2's Social Worker Notes dated 03/31/23 signed by Social Worker A revealed, referral made for inpatient psych evaluation and stay for Resident #2, but admission was denied to resident being unable to advocate for himself. Resident sent out for acute medical ER for evaluation. PLEASE NOTE when resident returns to facility, he will need to go to a different room from previous room with roommate. Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: aggression, hitting staff, hitting other residents, safety to self. Collateral Information: staff reports patient can be irritable and restless. An observation on 05/17/23 at 08:13 AM revealed, Resident #2 sleeping in bed in no immediate distress with contracted left and right hands wearing hand rolls with fingernails approximately ¼ inch long. An observation on 05/17/23 at 11:55 AM revealed, Resident #2 on knees on the floor playing with his gown on the side of his fall mat. Resident #6 Record review of Resident #6's Face Sheet dated 05/17/23 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, bipolar disorder, delusional disorders, unspecified psychosis, and hypertension. Record review of Resident #6's undated Care Plan printed 05/17/23 revealed, focus- PASRR positive related to severe mental illness; intervention- continue psychiatrist services at the facility. Focus- diagnosis of bipolar disorder with risk for inappropriate behaviors; Goal- Resident #6 will not harm himself or others; intervention- psych consult, monitor behaviors ever shift. Focus- Resident #6 has displayed frequent episodes of refusal of medications and ADL cares and was at risk for injury; Interventions- keep MD/NP informed of resident's refusal of medications and/or ADL care. Focus initiated on 10/28/21 and revised on 04/20/22- diagnoses of schizophrenia, bipolar disorder, psychosis, delusional disorder. sometimes become aggressive with facility properties and staff. Focus- ADL self-care deficits and is at risk for further decline in ADL functioning and injury; intervention- Resident #6 will be well dressed, groomed and clean; intervention- 1on1 for personal hygiene. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 03 out of 15, no signs of delirium, no rejection of care, supervision with most ADLs, use of a wheelchair and occasionally incontinent of both bladder and bowel. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Mental Status Examination- risk of aggression none. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Mental Status Examination- risk of aggression none. Record review of Resident #6's Incident and Accident Report dated 03/31/23 signed by LVN B revealed, LVN B was informed by staff that at 08:00 AM Resident #6 was seen hitting his roommate (Resident #2) because he was close to his bed. Another staff also saw roommate Resident #6 hitting Resident #2 with a wheelchair. At 11:02 AM, LVN B also saw Resident #6 hitting Resident #2 with a shoe. Record review of Resident #6's Psychological Services Supportive Care Progress Note from 03/29/23 to 04/19/23 revealed, no reference to Resident #6 assaulting Resident #2 on 3 different occasions on 03/31/23. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Collateral Information: staff reports Resident #6 has been refusing his medication for weeks and had behavioral physical incident with his roommate. Mental Status Examination- risk of aggression none. An observation and interview on 05/18/23 at 12:00 PM revealed, Resident #6 lying in bed in no immediate distress. Resident #6 said he did not remember any incidents of physical aggression with Resident #2. In an interview of 05/17/23 at 11:22 AM, LVN B said Resident #6 was usually verbally and physically aggressive and did not want to be disturbed. She said on 03/31/23 Resident #6 attacked Resident #2 on three different occasions of which she witnessed the third. LVN B said she was informed that Resident #6 had hit Resident #2 once in the morning and later- on, in the morning Resident #6 pushed a wheelchair over Resident #2 as he laid on the floor causing Resident #2 to bleed from the mouth. She said Resident #2 was initially removed from the room, but he was later returned to the same room as Resident #6 because there was no other room to place him, and Resident #2 kept throwing himself on the floor and it was at that point that she witnessed Resident #6 hit Resident #2 with a shoe. LVN B said she immediately separated the two residents and placed Resident #2 at the nursing station until he was sent out of evaluation. She said the expectation for resident-to-resident altercations was that the resident's be immediately separated to prevent further abuse and Resident #2 should not have been returned to the same room as Resident #6. In an interview on 05/18/23 at 11:43 AM, the Administrator said she failed to identify that Resident #6 was the perpetrator of abuse against Resident #2 on 03/31/23. She said she believed Resident #1 assaulted Resident #2 and completed her investigation based on that. She could not explain why she believed the assailant was Resident #1 and not Resident #6. The Administrator said she did not look into Resident #6 at all, she did not notify the provider about Resident #6's aggression and no corrective action was taken about Resident #6's assault of Resident #2. She said since she did not investigate Resident #6, she did not know staff identified him as being physically aggressive or that the NP would be removing Resident #6's psych meds due to the resident refusing. The Administrator said based on the information she learned about Resident #6, it was not appropriate for the resident to have a roommate due to him being a danger to others. She said failure to investigate the correct resident could place residents at risk of injury. In an interview on 05/18/23 at 12:56, the Psychiatric NP said Resident #6 had history of aggression and she was never informed of the incidents of abuse between Resident #6 and Resident #2 that occurred on 03/31/23. She said Resident #6 had been refusing all his medications including his psych medications, so her plan was to GDR to discontinue all his medications. The Psychiatric NP said the facility was expected to notify her of any cases of physical aggression in any residents but it would not have mattered in this case because Resident #6 had refused all his medication so she could not make any pharmaceutical interventions and therapist handles non-pharmaceutical interventions. When asked how Resident #6's behaviors would be controlled and if his lack of medication would place others in danger, the Psychiatric NP said if Resident #6 was deemed to be a risk to himself or other then he would have to be sent out to a behavioral hospital Resident #9 Record review of Resident #9's face sheet dated 05/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: dementia and bipolar disorder with psychotic features. Record review of Resident #9's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, total dependence on most ADLs and always incontinent of both bladder and bowel. Record review of Resident #9's undated Care Plan dated 05/25/23 revealed Focus- Resident #6 has potential to be verbally/physically aggressive behaviors related bipolar disorder; interventions- analyze key times, places, circumstances, triggers and what de-escalates behaviors and document. Record review of Resident #9's Psychiatric Subsequent Assessment dated 12/16/22 signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Record review of Resident #9's Psychiatric Subsequent Assessment dated 01/12/23 signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Record review of Resident #9's Progress Notes dated 02/10/23 and signed by LVN B revealed, housekeeper stated she saw Resident #9 being hit by his roommate (Resident #2). Resident #9 was moved out from the room immediately, a head-to-toe assessment was performed and no bruising or bleeding was noted. Record review of Resident #9's Psychiatric Subsequent Assessment dated 03/13/23 signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Collateral Information: no mood or behavior changes reported by staff. Resident #10 Record review of Resident #10's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, partial traumatic amputation level between knee and ankle and chronic pain syndrome. Record review of Resident #10's quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, no behaviors, total dependence on most ADLs. Record review of Resident #10's undated Care Plan printed 05/25/23 revealed, focus- below the right knee amputation. Record review of Resident #10's 02/2023 Progress Notes revealed, no documentation of Resident #10 being hit by Resident #2. Record review of Resident #10's Census List printed 05/18/23 revealed, Resident #10 was in room [ROOM NUMBER]-A from 02/11/23 to 02/23/23. In an interview of 05/17/23 at 11:22 AM, LVN B said Resident #2's behaviors involve throwing himself on the floor, throwing himself on roommates, hitting residents and staff. She said Resident #2 will always instigate altercations with his roommates and she feels like Resident #2 should be in a room by himself because of his behaviors. She said Resident #2 was a fall risk so the idea from administration was to place him with a roommate that could watch him and report any falls or injuries Resident #2 may suffer. LVN B said Resident #2 has had multiple altercations with different roommates like Resident #6, Resident #9 and Resident #10. LVN B said Resident #2 had a severe intellectual disability and could not control his behaviors, his behaviors were not intentional and he did not understand what he was doing to others. In an interview on 05/18/23 at 12:43 PM, Resident #31 said his roommate Resident #2 has a history of hitting other residents. He said prior to rooming with Resident #2 the resident had hit him in the hallway so he was concerned about rooming with him in case he hit him, but he guessed that the facility put them together so he could look out for Resident #2 since he falls. Resident #31 said so far, he had not had any issues with Resident #2 because the resident was sick and had not been active. He said Resident #2's behaviors included getting on the floor to just stare at him (Resident #31) and rolling off his own bed blocking the door . Resident #31 said he has not had any issues with Resident #2 so far but if he did, he would hurt Resident #2. In an interview on 05/18/23 at 12:56, the Psychiatric NP said Resident #2 admitted to the facility with a diagnosis of severe IDD. She said his behaviors include jumping off the bed, hitting and touching others and she can see him instigating altercations with other residents. She said that these behaviors are his baseline, and his behaviors c could be troublesome to his roommates. When asked if Resident #2 was appropriate for a roommate, the Psychiatric NP would not answer. Resident #7 Record review of Resident #7's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: dementia without behavioral disturbance, psychotic disturbance, depression, and anxiety. Record review of Resident #7's quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, no potential indicators of psychosis such as hallucinations and delusions. No behavioral symptoms directed towards others, no verbal behavioral symptoms directed towards others, no behavioral symptoms not directed towards others, supervision needed for locomotion on the unit, supervision needed for location off the unit and use of a manual wheelchair. Record review of Resident #7's undated Care Plan revealed, focus- have verbal aggressive behavior (cussing staff) related to dementia. Focus- Resident #7 has been physically aggressive; goal- Resident #7 will demonstrate effective coping skills through the review date. Record review of Resident #7's Incident by Incident Type Report from 11/01/22 to 05/23/23 revealed, Resident #7 initiated 3 separate incidents of physical aggression on 11/19/22, 05/03/23 and 05/17/23. Record review of Resident #7's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, reason for referral: verbal aggression and resistance to care. Collateral information: staff reports patient behaviors have not worsened, patient calmer since medication changes. Mental Status Examination- risk of aggression: none. Record review of Resident #7's Progress Notes dated 11/19/22 at 9:56 PM revealed, Resident #7 assaulted another resident (Resident #8) outside in the smoking area. He punched him on the mouth resulting in a laceration on the lip, the residents were separated and the provider, DON and Administrator were notified. Record review of Resident #7's Progress Notes dated 11/21/22 at 11:16 AM and signed by DON C revealed, Resident #7 had a history of assaulting people and due to his institutionalized mentality, he will continue to strike out physically and he is not appropriate for the facility. Resident #7 as unapologetic about his behavior and has repeatedly stated if he says anything to me, I will hit him again. Staff continued to make frequent rounds monitoring Resident #7's interactions with others. Record review of Resident #7's Progress Notes dated 11/21/22 at 02:09 PM and signed by the Social Worker B, RP notified Resident #7 was not appropriate for continued stay in the interest of safety for others. During past months since admission Resident #7 has had significant physically aggressive behaviors towards other residents. Record review of Resident #7's 'Psychiatric Subsequent Assessment' dated 12/03/22 revealed, patient admits that he recently had an altercation with another resident and stated that it wasn't his fault. Collateral Information: staff reports patient recently punched another resident (Resident #8) in the face . Reports there was an altercation in the smoking area. Record review of Resident #7's Fair Hearing Medicaid Nursing Facility Discharge' letter dated 01/12/23 revealed, the facility could not discharge Resident #7 based on events that occurred on or prior to a discharge letter issued on 11/29/22 because, the hearing officer did not receive evidence from the facility prior to the hearing and a representative from the facility was not present at the hearing on 12/28/22 to explain or support the facility's actions to discharge Resident 7 so the Hearings Officer closed the record without a response from the facility. Record review of Resident #7's Progress Notes dated 05/03/23 at 05:15 AM revealed, Resident #7 struck another resident in dining area, resident was escorted back to room and both parties were divided. Record review of Resident #7's Physician's Notes dated 05/15/23 revealed, Resident #7 continues to be receptive to supportive care and there have been no changes in moods or behaviors. There are no complaints at this time. Record review of Resident #7's Progress Notes dated 05/17/23 at 10:36 PM revealed, at 07:30 AM Resident #8 was brought to the nursing station and told the nurse that Resident #7 hit him in the face and the chest. Resident #7 said Resident #8 called him a derogatory term and that was the reason he punched him in the face. Record review of Resident #7's Social Worker A dated 05/18/23 at 10:44 AM revealed, Resident #7 hit another resident (Resident #8) late in the evening yesterday Resident would benefit from emergency psych evaluation as he was a current threat to other residents due to his disorientation and confusion. An observation and Interview on 05/17/23 at 09:55 AM revealed, Resident #7 lying in bed well-groomed and in no immediate distress. He said a white man in a wheelchair hit him in the back so he came back and hit him back. He said Resident #8 talked about his mother and that was why he hit Resident #8, he said he had not had any other issues with any other residents and no other issues with Resident #7. In an interview on 05/24/23 at 01:16 PM, the Assistant Administrator said there was no incident report on record for the incident involving Resident #7 and #8 on 11/19/22. Resident #8 Record review of Resident #8's Face Sheet printed 06/15/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: paraplegia (paralysis of the legs and lower body), history of traumatic brain injury, type 2 diabetes, mood disorder, assault by unspecified firearm. Record review of Resident #8's quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, no signs of delirium or hallucinations, no physical behavioral symptoms directed toward others, no verbal behavioral symptoms directed towards others, no other behavioral symptoms not directed toward others, no rejection of care, total dependence on most ADLs and use of a wheelchair. Record review of Resident #8's undated Care Plan revealed, focus- Resident #8 was a smoker with potential for injury. Record review of Resident #8's Incident/Accident Report dated 11/18/22 at 07:30 PM revealed, Resident #7 punched Resident #8 in the mouth at 07:00 PM resulting in a laceration to the lip while outside in the smoke area. Record review of Resident #8's Progress Notes dated 11/19/22 at 07:03 AM revealed, Resident #7 punched Resident #8 on 11/18/22 at 07:00 PM in the mouth when both of them were in the smoking area and Resident #8 had a deep laceration to his lip. Resident #8 stated Resident #7 punched him because he told him to stop assaulting staff because of cigarettes . Resident #8 was assessed, and MD was notified about laceration who gave orders for the resident to be sent out to the hospital for sutures. Resident #8 was sent to the hospital on [DATE] at 07:00 PM. Record review of Resident #8's Progress Notes dated 11/19/22 at 07:33 AM revealed, Resident #8 returned from the hospital on [DATE] at 04:00 AM and did not appear to have stitches. Record review of Resident #8's Progress Notes dated 11/19/22 at 11:31 AM revealed, Resident #8 said Resident #7 threw finger at him and was yelling at him. Resident #8 was escorted out of the dining room to go out during smoke time. Record review of Resident #8's Physician Note dated 11/22/22 revealed, Resident #8 was reportedly punched in the face by another resident (Resident #7). Resident #8 sustained a laceration to the lip; he was sent to the ER however he did not have any sutures placed. Record review of Resident #8's Progress Note dated 05/03/22 revealed, Resident #8 got hit by another resident (Resident #7) on his chest in the dining room. Resident #8 said he was yelling for someone to adjust him properly in his chair and the Resident #7 got irritated wheeled close to him and hit him in the chest. Head to toe assessment completed and Resident #8 had no bruising or swelling noted. Record review of Resident #8's Progress Notes dated 05/17/23 at 07:30 PM revealed, Resident #8 got into a fight with Resident #7 on the smoking patio but the incident was not witnessed. Resident #7 hit Resident #8 on the lips chest and ne ck. Resident #8 was observed to have bruised lips, a purple bruise on the neck/throat area from trauma and Resident #8 reported Resident #7 burned him with a cigarette to which a blister was observed . Record review of Resident #8's Physician Note dated 05/23/23 signed by MD A revealed, chief complaint: follow up for coffee burn, cigarette burn, sunburn and trauma to neck. MD A was notified by staff on 05/23/23 that Resident #8 was in a fight with another resident in which he was punched in the jaw/neck and sustained a cigarette burn to his right arm. Resident #8 still has a bruise to his neck, but the cigarette burn was almost healed. An observation and Interview on 05/21/23 at 06:27 PM revealed, Resident #8 sitting in his wheelchair in his room, well-groomed and in no immediate distress. Resident #8 said he has had multiple altercations with Resident #7 and he didn't feel safe in the facility when Resident #7 was there. He said Resident #7 always curses at him in the hallways, the dining room and in the smoking area every day. Resident #8 said the facility has made no efforts to move Resident #7 so they don't meet in the hallway, change their dinning or smoking breaks and did not ensure they were separated or supervised during meals in the dining room or smoke breaks in the courtyard even though he had made multiple complaints. Resident #8 said Resident #7 has punched him in the chest and lip on multiple occasions causing him to bleed and get stitches. He said in the last incident Resident #7 burned him on his arm with a cigarette. He said the facility have taken no action to ensure he was safe from Resident #7. In an interview on 05/17/23 at 09:00 AM, the Administrator said she was the abuse coordinator and she was responsible for reporting and investigating all allegations of abuse and neglect. She said when there was a resident to resident altercation nursing staff are expected to separate the resident's immediately to ensure their safety, complete head to toe assessments and then notify the family, the MD and then facility administration. She said if residents have a history of physical aggression they should be supervised or separated from others to ensure they are not a danger. The Administrator said failure to take appropriate action following an allegation/incident of abuse places residents at risk of further abuse and injury. In an interview on 05/17/23 at 09:05 AM, DON A said following a resident-to-resident altercation residents must be immediately separated immediately for safety, a head to toe assessment must be completed and documented. She said at no point in time should a resident be returned to the same room as the assailant and in the long term the residents should not be left alone unsupervised in the same area for safety. In an interview on 05/17/23 at 08:45 AM, the Assistant Administrator said on 05/03/23 he heard Resident #8 screaming and observed Resident #7 pushing back. He said the nurses reported that Resident #7 hit Resident #8 twice in the chest because Resident #8 was screaming which agitated Resident #7 and caused him to hit Resident #8 in response. The Assistant Administrator said the residents were separated and there have been no incidents since then. He said there had been previous incidents between Resident #7 and Resident #8 in the smoking area, when Resident #8 took up for the staff so Resident #7 hit him in the face. The Administrator said he believed Resident #8 was triggered by loud noises. In an interview on 05/18/23 at 10:30 AM, the Administrator said she was the facility abuse coordinator and was responsible for investigating all allegations of abuse. She said once an allegation of abuse was made or abuse was observed nursing staff are required to stop the abuse, ensure the resident was safe, the nurse performs a head-to-toe assessment checking for injuries and then report the incident to her. The Administrator said she or the designees are responsible to complete a thorough investigation completing witness statements from staff, any alert residents and any staff or residents who have interactions with the perpetrator. She said the facility staff must perform follow up assessments with residents for a week following the alleged incident of abuse. She said failure to complete detailed investigations and implement facility policies on abuse places residents at risk for further abuse. The Administrator was unable to describe what action was taken to prevent abuse with Resident #2, Resident 5, Resident #6, Resident #7. Resident #8, Resident #9 and Resident #10. In an interview on 05/22/23 at 04:00 PM, the Assistant Administrator said following the incident on 05/18/23 Resident #7 was sent out to a behavioral hospital and he will not be returning. He said Resident #7 and Resident #8 have had multiple altercations in the smoking area and the dining ar[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 7 of 22 Residents (Resident #2, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10) reviewed for abuse. 1. The facility failed to ensure Resident #2, a resident with severe IDD and behaviors, was free from abuse on 03/31/23 from Resident #6 by placing them in the same room resulting in bleeding and injuries. 2. The facility failed to ensure Resident #8 was free from repeated abuse from Resident #7, resulting in Resident #8 suffering from a busted lip and a cigarette burn over multiple altercations. 3. The facility failed to ensure Resident #9 and Resident #10 were free from abuse from Resident #2, a resident with severe IDD and behaviors by placing them in the same room. 4. The facility failed to perform a detailed investigation and follow her documented provider action taken post investigation for an allegation of abuse regarding Resident #5 by allowing CNA X to return to work with residents who could not speak for themselves in the secure unit. On 05/22/23 at 03:21 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 05/29/23 at 07:10 PM, the facility remained out of compliance at an H (severity level of actual harm that is not immediate and a scope of pattern) due to the facility continuing to monitor the implementation and effectiveness of their plan of removal These failures could place residents at risk of increased abuse, major injury, and decreased quality of life. Findings Included Resident #2 Record review of Resident #2's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: unspecified dementia, depression, difficulty swallowing, G-tube (a tube that goes into the stomach to provide food and medications), anxiety disorders, left hand contractures, right hand contractures and sever intellectual disabilities. Record review of Resident #2's Quarterly MDS dated [DATE] revealed, unclear speech, s rarely understood, sometimes understands, severely impaired cognition as indicated by a BIMS score of 00 out of 15, no response to resident mood interview questions, no documented behavioral symptoms (physical behaviors directed towards others, verbal behavioral symptoms directed to others or other behavioral symptoms not directed towards others), no rejection of care, no wandering, total dependence on all ADLs, use of a wheelchair, always incontinent of both bladder and bowel, non-traumatic brain dysfunction and left and right hand contractures. Record review of Resident #2's undated Care Plan printed 05/16/23 revealed, focus-IDD Resident #2 has been identified as PASRR positive related to intellectual disability; intervention- provide recommended services (habilitation coordination, independent living skills training and OT). Focus- nonverbal for communication needs/wants; potential for unmet needs/social isolation/boredom, escalating anxiety and agitation; intervention- provide emotional support to resident, refer resident for additional support relative to potential for escalating behaviors, referrals to psychiatric services for medication management and stabilization of behaviors. Focus- 2/09/23 Resident #2 was not hitting his roommate; intervention- resident was moved to another room. No incidents of physical aggression were documented on the Resident #2's care plan. No documentation of the type of Resident #2's behaviors. Record review of Resident #2's Census List starting at admission [DATE] to 05/18/23 revealed, since 01/2023 Resident #2 has had 3 room changes. Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: anxiety, irritability, anger, non-verbal with a history of resistance and combative behaviors. Collateral information: aggression on and off. Record review of Resident #2's Nursing Note dated 02/10/23 at 01:34 PM and signed by LVN B revealed, Resident #2 initiated physical aggression against his roommate (Resident #9) on 02/09/23 LVN B was notified by the housekeeper that she saw Resident #2 hit his roommate while in bed. The roommate was moved out from room immediately. Record review of Resident #2's Nursing Note dated 02/22/23 at 05:46 PM signed by LVN B revealed, Patient is combative, hitting other patients. Patient was seen on his roommate's (Resident #10) body. Roommate (Resident #10) stated take this man out of here, I want peace. Resident #2 was taken to another room. Resident #2 was seen hitting other patients on the hallway, refused to stay in room. Record review of Resident #2's Psychiatric Provider note dated 02/22/23 revealed, Resident #2 was awake and agitated, monitored for behaviors and staff reported Resident #2 has been increasingly agitated and aggressive. He has been attempting to hit staff Orders to send to behavior hospital will be provided. Record review of Resident #2's Nursing Note dated 02/23/23 at 09:15 AM signed by LVN B revealed, Patient is becoming a threat to other patients and staff. He refused to stay in room. Patient in hallway hitting everyone passing by. Patient needs to be moved to a psych hospital ASAP. Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: aggression, hitting staff, hitting other residents, safety to self. Collateral Information: Staff reports patient has intermittent aggression towards others and fluctuating mood. Assessment/Plan: increased Risperdal (an antipsychotic) due to physical aggression, reported paranoia and negative symptoms. Severe IDD- is not treated with medications. There was no reference of the resident's appropriateness to have a roommate. Record review of Resident #2's Psychiatric Provider note dated 02/24/23 revealed, behavioral hospital admission denied. Record review of Resident #2's Nursing Note dated 03/31/23 at 11:55 AM signed by LVN C revealed, at about 09:35 AM writer noted Resident #2's roommate (Resident #6) standing over residents' wheelchair pushing wheelchair over resident. Resident #2 was noted to be lying on the floor between bed and wheelchair with blood coming from his mouth. LVN C separated the residents and Resident #6 got into bed and stated, somebody better get him before I kill him. Laceration noted to upper lip area, Resident #2 was brought to the nurse's station in a wheelchair at which he was observed to hit another resident while sitting at the nursing station. At this time facility is working on room changes for resident and possible admit to psych facility. Record review of Resident #2's Nursing Note dated 03/31/23 at 01:12 PM signed by LVN B revealed, LVN B was told by staff that at 08:00 AM Resident #2 was hit by his roommate (Resident #6) because he was close to his bed, so the patient was taken out of the room. At 09:00 AM, Resident #2 was returned to his bed because he was throwing himself off the wheelchair at which point another staff saw Resident #6 hitting Resident #2 using a wheelchair. At 11:02, LVN B observed Resident #6 hitting Resident #2 with a shoe. Record review of Resident #2's Social Worker Notes dated 03/31/23 signed by Social Worker A revealed, referral made for inpatient psych evaluation and stay for Resident #2, but admission was denied to resident being unable to advocate for himself. Resident sent out for acute medical ER for evaluation. PLEASE NOTE when resident returns to facility, he will need to go to a different room from previous room with roommate. Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: aggression, hitting staff, hitting other residents, safety to self. Collateral Information: staff reports patient can be irritable and restless. An observation on 05/17/23 at 11:55 AM revealed, Resident #2 on needs on the floor playing with his gown on the side of his fall mat. Resident #6 Record review of Resident #6's Face Sheet dated 05/17/23 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, bipolar disorder, delusional disorders, unspecified psychosis, and hypertension. Resident #6 did not have a diagnosis of contractures. Record review of Resident #6's undated Care Plan printed 05/17/23 revealed, focus- PASRR positive related to severe mental illness; intervention- continue psychiatrist services at the facility. Focus- diagnosis of bipolar disorder with risk for inappropriate behaviors; Goal- Resident #6 will not harm himself or others; intervention- psych consult, monitor behaviors ever shift. Focus- Resident #6 has displayed frequent episodes of refusal of medications and ADL cares and was at risk for injury; Interventions- keep MD/NP informed of resident's refusal of medications and/or ADL care. Focus initiated on 10/28/21 and revised on 04/20/22- diagnoses of schizophrenia, bipolar disorder, psychosis, delusional disorder. sometimes become aggressive with facility properties and staff. Focus- ADL self-care deficits and is at risk for further decline in ADL functioning and injury; intervention- Resident #6 will be well dressed, groomed and clean; intervention- 1on1 for personal hygiene. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 03 out of 15, no signs of delirium, no rejection of care, supervision with most ADLs, use of a wheelchair and occasionally incontinent of both bladder and bowel. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Mental Status Examination- risk of aggression none. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Mental Status Examination- risk of aggression none. Record review of Resident #6's Incident and Accident Report dated 03/31/23 signed by LVN B revealed, LVN B was informed by staff that at 08:00 AM Resident #6 was seen hitting his roommate (Resident #2) because he was close to his bed. Another staff also saw roommate Resident #6 hitting Resident #2 with a wheelchair. At 11:02 AM, LVN B also saw Resident #6 hitting Resident #2 with a shoe. Record review of Resident #6's Psychological Services Supportive Care Progress Note from 03/29/23 to 04/19/23 revealed, no reference to Resident #6 assaulting Resident #2 on 3 different occasions on 03/31/23. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Collateral Information: staff reports Resident #6 has been refusing his medication for weeks and had behavioral physical incident with his roommate. Mental Status Examination- risk of aggression none. An observation and interview on 05/18/23 at 12:00 PM revealed, Resident #6 lying in bed in no immediate distress. Resident #6 said he did not remember any incidents of physical aggression with Resident #2. In an interview of 05/17/23 at 11:22 AM, LVN B said Resident #6 was usually verbally and physically aggressive and did not want to be disturbed. She said on 03/31/23 Resident #6 attacked Resident #2 on three different occasions of which she witnessed the third. LVN B said she was informed that Resident #6 had hit Resident #2 once in the morning and later-on, in the morning Resident #6 pushed a wheelchair over Resident #2 as he laid on the floor causing Resident #2 to bleed from the mouth. She said Resident #2 was initially removed from the room, but he was later returned to the same room as Resident #6 because there was no other room to place him, and Resident #2 kept throwing himself on the floor and it was at that point that she witnessed Resident #6 hit Resident #2 with a shoe. LVN B said she immediately separated the two residents and placed Resident #2 at the nursing station until he was sent out of evaluation. She said the expectation for resident-to-resident altercations was that the resident's be immediately separated to prevent further abuse and Resident #2 should not have been returned to the same room as Resident #6. In an interview on 05/18/23 at 11:43 AM, the Administrator said she failed to identify that Resident #6 was the perpetrator of abuse against Resident #2 on 03/31/23. She said she believed Resident #1 assaulted Resident #2 and completed her investigation based on that. She could not explain why she believed the assailant was Resident #1 and not Resident #6. The Administrator said she did not look into Resident #6 at all, she did not notify the provider about Resident #6's aggression and no corrective action was taken about Resident #6's assault of Resident #2. She said since she did not investigate Resident #6, she did not know staff identified him as being physically aggressive or that the NP would be removing Resident #6's psych meds due to the resident refusing. The Administrator said based on the information she learned about Resident #6, it was not appropriate for the resident to have a roommate due to him being a danger to others. She said failure to investigate the correct resident could place residents at risk of injury. In an interview on 05/18/23 at 12:56, the Psychiatric NP said Resident #6 had history of aggression and she was never informed of the incidents of abuse between Resident #6 and Resident #2 that occurred on 03/31/23. She said Resident #6 had been refusing all his medications including his psych medications, so her plan was to GDR to discontinue all his medications. The Psychiatric NP said the facility was expected to notify her of any cases of physical aggression in any residents but it would not have mattered in this case because Resident #6 had refused all his medication so she could not make any pharmaceutical interventions and therapist handles non-pharmaceutical interventions. When asked how Resident #6's behaviors would be controlled and if his lack of medication would place others in danger, the Psychiatric NP said if Resident #6 was deemed to be a risk to himself or other then he would have to be sent out to a behavioral hospital Resident #9 Record review of Resident #9's face sheet dated 05/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: dementia and bipolar disorder with psychotic features. Record review of Resident #9's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, total dependence on most ADLs and always incontinent of both bladder and bowel. Record review of Resident #9's undated Care Plan dated 05/25/23 revealed Focus- Resident #6 has potential to be verbally/physically aggressive behaviors related bipolar disorder; interventions- analyze key times, places, circumstances, triggers and what de-escalates behaviors and document. Record review of Resident #9's Psychiatric Subsequent Assessment dated 12/16/22 signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Record review of Resident #9's Psychiatric Subsequent Assessment dated 01/12/23 signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Record review of Resident #9's Progress Notes dated 02/10/23 and signed by LVN B revealed, housekeeper stated she saw Resident #9 being hit by his roommate (Resident #2). Resident #9 was moved out from the room immediately, a head-to-toe assessment was performed and no bruising or bleeding was noted. Record review of Resident #9's Psychiatric Subsequent Assessment dated 03/13/23 signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Collateral Information: no mood or behavior changes reported by staff. Resident #10 Record review of Resident #10's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, partial traumatic amputation level between knee and ankle and chronic pain syndrome. Record review of Resident #10's quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, no behaviors, total dependence on most ADLs. Record review of Resident #10's undated Care Plan printed 05/25/23 revealed, focus- below the right knee amputation. Record review of Resident #10's 02/2023 Progress Notes revealed, no documentation of Resident #10 being hit by Resident #2. Record review of Resident #10's Census List printed 05/18/23 revealed, Resident #10 was in room [ROOM NUMBER]-A from 02/11/23 to 02/23/23. In an interview of 05/17/23 at 11:22 AM, LVN B said Resident #2's behaviors involve throwing himself on the floor, throwing himself on roommates, hitting residents and staff. She said Resident #2 will always instigate altercations with his roommates and she feels like Resident #2 should be in a room by himself because of his behaviors. She said Resident #2 was a fall risk so the idea from administration was to place him with a roommate that could watch him and report any falls or injuries Resident #2 may suffer. LVN B said Resident #2 has had multiple altercations with different roommates like Resident #6, Resident #9 and Resident #10. LVN B said Resident #2 had a severe intellectual disability and could not control his behaviors, his behaviors were not intentional and he did not understand what he was doing to others. In an interview on 05/18/23 at 12:43 PM, Resident #31 said his roommate Resident #2 has a history of hitting other residents. He said prior to rooming with Resident #2 the resident had hit him in the hallway so he was concerned about rooming with him in case he hit him, but he guessed that the facility put them together so he could look out for Resident #2 since he falls. Resident #31 said so far, he had not had any issues with Resident #2 because the resident was sick and had not been active. He said Resident #2's behaviors included getting on the floor to just stare at him (Resident #31) and rolling off his own bed blocking the door. Resident #31 said he has not had any issues with Resident #2 so far but if he did, he would hurt Resident #2. In an interview on 05/18/23 at 12:56, the Psychiatric NP said Resident #2 admitted to the facility with a diagnosis of severe IDD. She said his behaviors include jumping off the bed, hitting and touching others and she can see him instigating altercations with other residents. She said that these behaviors are his baseline, and his behaviors could be troublesome to his roommates. When asked if Resident #2 was appropriate for a roommate, the Psychiatric NP would not answer. Resident #7 Record review of Resident #7's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: dementia without behavioral disturbance, psychotic disturbance, depression, and anxiety. Record review of Resident #7's quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, no potential indicators of psychosis such as hallucinations and delusions. No behavioral symptoms directed towards others, no verbal behavioral symptoms directed towards others, no behavioral symptoms not directed towards others, supervision needed for locomotion on the unit, supervision needed for location off the unit and use of a manual wheelchair. Record review of Resident #7's undated Care Plan revealed, focus- have verbal aggressive behavior (cussing staff) related to dementia. Focus- Resident #7 has been physically aggressive; goal- Resident #7 will demonstrate effective coping skills through the review date. Record review of Resident #7's Incident by Incident Type Report from 11/01/22 to 05/23/23 revealed, Resident #7 initiated 3 separate incidents of physical aggression on 11/19/22, 05/03/23 and 05/17/23. Record review of Resident #7's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, reason for referral: verbal aggression and resistance to care. Collateral information: staff reports patient behaviors have not worsened, patient calmer since medication changes. Mental Status Examination- risk of aggression: none. Record review of Resident #7's Progress Notes dated 11/19/22 at 9:56 PM revealed, Resident #7 assaulted another resident (Resident #8) outside in the smoking area. He punched him on the mouth resulting in a laceration on the lip, the residents were separated and the provider, DON and Administrator were notified. Record review of Resident #7's Progress Notes dated 11/21/22 at 11:16 AM and signed by DON C revealed, Resident #7 had a history of assaulting people and due to his institutionalized mentality, he will continue to strike out physically and he is not appropriate for the facility. Resident #7 as unapologetic about his behavior and has repeatedly stated if he says anything to me, I will hit him again. Staff continued to make frequent rounds monitoring Resident #7's interactions with others. Record review of Resident #7's Progress Notes dated 11/21/22 at 02:09 PM and signed by the Social Worker B, RP notified Resident #7 was not appropriate for continued stay in the interest of safety for others. During past months since admission Resident #7 has had significant physically aggressive behaviors towards other residents. Record review of Resident #7's 'Psychiatric Subsequent Assessment' dated 12/03/22 revealed, patient admits that he recently had an altercation with another resident and stated that it wasn't his fault. Collateral Information: staff reports patient recently punched another resident (Resident #8) in the face. Reports there was an altercation in the smoking area. Record review of Resident #7's Fair Hearing Medicaid Nursing Facility Discharge' letter dated 01/12/23 revealed, the facility could not discharge Resident #7 based on events that occurred on or prior to a discharge letter issued on 11/29/22 because, the hearing officer did not receive evidence from the facility prior to the hearing and a representative from the facility was not present at the hearing on 12/28/22 to explain or support the facility's actions to discharge Resident 7 so the Hearings Officer closed the record without a response from the facility. Record review of Resident #7's Progress Notes dated 05/03/23 at 05:15 AM revealed, Resident #7 struck another resident in dining area, resident was escorted back to room and both parties were divided. Record review of Resident #7's Physician's Notes dated 05/15/23 revealed, Resident #7 continues to be receptive to supportive care and there have been no changes in moods or behaviors. There are no complaints at this time. Record review of Resident #7's Progress Notes dated 05/17/23 at 10:36 PM revealed, at 07:30 AM Resident #8 was brought to the nursing station and told the nurse that Resident #7 hit him in the face and the chest. Resident #7 said Resident #8 called him a derogatory term and that was the reason he punched him in the face. Record review of Resident #7's Social Worker A dated 05/18/23 at 10:44 AM revealed, Resident #7 hit another resident (Resident #8) late in the evening yesterday Resident would benefit from emergency psych evaluation as he was a current threat to other residents due to his disorientation and confusion. An observation and Interview on 05/17/23 at 09:55 AM revealed, Resident #7 lying in bed well-groomed and in no immediate distress. He said a white man in a wheelchair hit him in the back so he came back and hit him back. He said Resident #8 talked about his mother and that was why he hit Resident #8, he said he had not had any other issues with any other residents and no other issues with Resident #7. In an interview on 05/24/23 at 01:16 PM, the Assistant Administrator said there was no incident report on record for the incident involving Resident #7 and #8 on 11/19/22. Resident #8 Record review of Resident #8's Face Sheet printed 06/15/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: paraplegia (paralysis of the legs and lower body), history of traumatic brain injury, type 2 diabetes, mood disorder, assault by unspecified firearm. Record review of Resident #8's quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, no signs of delirium or hallucinations, no physical behavioral symptoms directed toward others, no verbal behavioral symptoms directed towards others, no other behavioral symptoms not directed toward others, no rejection of care, total dependence on most ADLs and use of a wheelchair. Record review of Resident #8's undated Care Plan revealed, focus- Resident #8 was a smoker with potential for injury. Record review of Resident #8's Incident/Accident Report dated 11/18/22 at 07:30 PM revealed, Resident #7 punched Resident #8 in the mouth at 07:00 PM resulting in a laceration to the lip while outside in the smoke area. Record review of Resident #8's Progress Notes dated 11/19/22 at 07:03 AM revealed, Resident #7 punched Resident #8 on 11/18/22 at 07:00 PM in the mouth when both of them were in the smoking area and Resident #8 had a deep laceration to his lip. Resident #8 stated Resident #7 punched him because he told him to stop assaulting staff because of cigarettes. Resident #8 was assessed, and MD was notified about laceration who gave orders for the resident to be sent out to the hospital for sutures. Resident #8 was sent to the hospital on [DATE] at 07:00 PM. Record review of Resident #8's Progress Notes dated 11/19/22 at 07:33 AM revealed, Resident #8 returned from the hospital on [DATE] at 04:00 AM and did not appear to have stitches. Record review of Resident #8's Progress Notes dated 11/19/22 at 11:31 AM revealed, Resident #8 said Resident #7 threw finger at him and was yelling at him. Resident #8 was escorted out of the dining room to go out during smoke time. Record review of Resident #8's Physician Note dated 11/22/22 revealed, Resident #8 was reportedly punched in the face by another resident (Resident #7). Resident #8 sustained a laceration to the lip; he was sent to the ER however he did not have any sutures placed. Record review of Resident #8's Progress Note dated 05/03/22 revealed, Resident #8 got hit by another resident (Resident #7) on his chest in the dining room. Resident #8 said he was yelling for someone to adjust him properly in his chair and the Resident #7 got irritated wheeled close to him and hit him in the chest. Head to toe assessment completed and Resident #8 had no bruising or swelling noted. Record review of Resident #8's Progress Notes dated 05/17/23 at 07:30 PM revealed, Resident #8 got into a fight with Resident #7 on the smoking patio but the incident was not witnessed. Resident #7 hit Resident #8 on the lips chest and neck. Resident #8 was observed to have bruised lips, a purple bruise on the neck/throat area from trauma and Resident #8 reported Resident #7 burned him with a cigarette to which a blister was observed. Record review of Resident #8's Physician Note dated 05/23/23 signed by MD A revealed, chief complaint: follow up for coffee burn, cigarette burn, sunburn and trauma to neck. MD A was notified by staff on 05/23/23 that Resident #8 was in a fight with another resident in which he was punched in the jaw/neck and sustained a cigarette burn to his right arm. Resident #8 still has a bruise to his neck, but the cigarette burn was almost healed. An observation and Interview on 05/21/23 at 06:27 PM revealed, Resident #8 sitting in his wheelchair in his room, well-groomed and in no immediate distress. Resident #8 said he has had multiple altercations with Resident #7 and he didn't feel safe in the facility when Resident #7 was there. He said Resident #7 always curses at him in the hallways, the dining room and in the smoking area every day. Resident #8 said the facility has made no efforts to move Resident #7 so they don't meet in the hallway, change their dinning or smoking breaks and did not ensure they were separated or supervised during meals in the dining room or smoke breaks in the courtyard even though he had made multiple complaints. Resident #8 said Resident #7 has punched him in the chest and lip on multiple occasions causing him to bleed and get stitches. He said in the last incident Resident #7 burned him on his arm with a cigarette. He said the facility have taken no action to ensure he was safe from Resident #7. In an interview on 05/17/23 at 08:45 AM, the Assistant Administrator said on 05/03/23 he heard Resident #8 screaming and observed Resident #7 pushing back in his wheelchair. He said the nurses reported that Resident #7 hit Resident #8 twice in the chest because Resident #8 was screaming which agitated Resident #7 and caused him to hit him in response. The Assistant Administrator said the residents were separated and there have been no incidents since then. He said there had been previous incidents between Resident #7 and Resident #8 in the smoking area, when Resident #8 took up for the staff so Resident #7 hit him in the face. The Assistant Administrator said he believed Resident #8 was triggered by loud noises. In an interview on 05/22/23 at 04:00 PM, the Assistant Administrator said following the incident on 05/18/23 Resident #7 was sent out to a behavioral hospital and he would not be returning to the facility. He said Resident #7 and Resident #8 have had multiple altercations in the smoking area and the dining area. He said Resident #7 and Resident #8 normally take their smoking break or are sitting in the dining area together and to his knowledge there have never been measures in place to ensure that these two residents were separated. Resident #5 Record review of Resident #5's face sheet, dated 5/18/2023, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Hemiplegia (paralysis of one side of the body), Cognitive Communication Deficit, Unspecified Lack of coordination. Record review of Resident #5's Annual MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, limited to extensive assistance for most ADLs, and personal hygiene and always incontinent of both bladder and bowel. Record review of Resident #5's Care Plan dated 03/16/23 revealed, focus- at risk for confusion, aggression and decline in ADL related to dementia; goal- be able to function in the environment safely; intervention- administer medication as ordered by MD, assist resident with ADL's. Record review of the facility submitted FORM 3613-A Provider 5 day Report signed 04/06/23 by the administrator revealed, CNA X was re-assigned to work with residents to work with residents who could speak up for themselves In an interview on 05/16/23 at 09:00 AM, the Administrator said she was the abuse coordinator and she was responsible for reporting and investigating all allegations of abuse and neglect. She said when there is a resident to resident altercation nursing staff are expected to separate the resident's immediately to ensure their safety, complete head to toe assessments and then notify the family, the MD and then facility administration. She said if residents have a history of physical aggression they should be supervised or separated from others to ensure they are not a danger. The Administrator said failure to take appropriate action following an allegation/incident of abuse places residents at risk of further abuse and inj[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to thoroughly investigated and take measures to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in process, and failed to ensure corrective action must be taken for 12 of 22 Residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10, Resident #20, Resident #21 and Resident #22) reviewed for abuse. 1. The facility failed to thoroughly invesitage allegations of abuse and ensure corrective actions were in place to ensure Resident #2, a resident with severe IDD, history behaviors and history of resident to resident altercations, was free from abuse on 03/31/23 from Resident #6 resulting in bleeding and injuries. 2. The facility failed to investigate Resident #6's allegation of abuse of Resident #2 by failing to identify the correct resident involved in the incident. 3. The facility failed to thoroughly investiage allegations of abuse and ensure corrective actions were in place to ensure Resident #8 was free from repeated abuse from Resident #7, resulting in Resident #8 suffering from a busted lip and a cigarette burn over multiple altercations. 4. The facility failed to thoroughly investigated allegations of abuse ensure corrective actions were in place to ensure Resident #9 and Resident #10 were free from abuse from Resident #2, a resident with severe IDD, history of behaviors and history of resident to resident altercations by placing them in the same room. 5. The facility failed to thoroughly investigate allegations of abuse of Resident #3, Resident #4, Resident #5, Resident #20. Resident #21 and Resident #22. On 05/22/23 at 03:21 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 05/29/23 at 07:10 PM, the facility remained out of compliance at an H (severity level of actual harm that is not immediate and a scope of pattern) due to the facility continuing to monitor the implementation and effectiveness of their plan of removal These failures could place residents at risk of increased abuse, major injury and decreased quality of life. Resident #2 Record review of Resident #2's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: unspecified dementia, depression, difficulty swallowing, G-tube (a tube that goes into the stomach to provide food and medications), anxiety disorders, left hand contractures, right hand contractures and sever intellectual disabilities. Record review of Resident #2's Quarterly MDS dated [DATE] revealed, unclear speech, s rarely understood, sometimes understands, severely impaired cognition as indicated by a BIMS score of 00 out of 15, no response to resident mood interview questions, no documented behavioral symptoms (physical behaviors directed towards others, verbal behavioral symptoms directed to others or other behavioral symptoms not directed towards others), no rejection of care, no wandering, total dependence on all ADLs, use of a wheelchair, always incontinent of both bladder and bowel, non-traumatic brain dysfunction and left and right hand contractures. Record review of Resident #2's undated Care Plan printed 05/16/23 revealed, focus-IDD Resident #2 has been identified as PASRR positive related to intellectual disability; intervention- provide recommended services (habilitation coordination, independent living skills training and OT). Focus- nonverbal for communication needs/wants; potential for unmet needs/social isolation/boredom, escalating anxiety and agitation; intervention- provide emotional support to resident, refer resident for additional support relative to potential for escalating behaviors, referrals to psychiatric services for medication management and stabilization of behaviors. Focus- 2/09/23 Resident #2 was not hitting his roommate; intervention- resident was moved to another room. No incidents of physical aggression were documented on the Resident #2's care plan. No documentation of the type of Resident #2's behaviors. Record review of Resident #2's Census List starting at admission [DATE] to 05/18/23 revealed, since 01/2023 Resident #2 has had 3 room changes. Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: anxiety, irritability, anger, non-verbal with a history of resistance and combative behaviors. Collateral information: aggression on and off. Record review of Resident #2's Nursing Note dated 02/10/23 at 01:34 PM and signed by LVN B revealed, Resident #2 initiated physical aggression against his roommate (Resident #9) on 02/09/23 LVN B was notified by the housekeeper that she saw Resident #2 hit his roommate while in bed. The roommate was moved out from room immediately. Record review of Resident #2's Nursing Note dated 02/22/23 at 05:46 PM signed by LVN B revealed, Patient is combative, hitting other patients. Patient was seen on his roommate's (Resident #10) body. Roommate (Resident #10) stated take this man out of here, I want peace. Resident #2 was taken to another room. Resident #2 was seen hitting other patients on the hallway, refused to stay in room. Record review of Resident #2's Psychiatric Provider note dated 02/22/23 revealed, Resident #2 was awake and agitated, monitored for behaviors and staff reported Resident #2 has been increasingly agitated and aggressive. He has been attempting to hit staff Orders to send to behavior hospital will be provided. Record review of Resident #2's Nursing Note dated 02/23/23 at 09:15 AM signed by LVN B revealed, Patient is becoming a threat to other patients and staff. He refused to stay in room Patient in hallway hitting everyone passing by. Patient needs to be moved to a psych hospital ASAP. Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: aggression, hitting staff, hitting other residents, safety to self. Collateral Information: Staff reports patient has intermittent aggression towards others and fluctuating mood. Assessment/Plan: increased Risperdal (an antipsychotic) due to physical aggression, reported paranoia and negative symptoms. Severe IDD- is not treated with medications. There was no reference of the resident's appropriateness to have a roommate. Record review of Resident #2's Psychiatric Provider note dated 02/24/23 revealed, behavioral hospital admission denied. Record review of Resident #2's Nursing Note dated 03/31/23 at 11:55 AM signed by LVN C revealed, at about 09:35 AM write noted Resident #2 roommate (Resident #6) standing over residents' wheelchair pushing wheelchair over resident. Resident #2 was noted to be lying on the floor between bed and wheelchair with blood coming from his mouth. LVN C separated the residents and Resident #6 got into bed and stated, somebody better get him before I kill him. Laceration noted to upper lip area, Resident #2 was brought to the nurse's station in a wheelchair at which he was observed to hit another resident while sitting at the nursing station. At this time facility is working on room changes for resident and possible admit to psych facility. Record review of Resident #2's Nursing Note dated 03/31/23 at 01:12 PM signed by LVN B revealed, LVN B was told by staff that at 08:00 AM Resident #2 was hit by his roommate (Resident #6) because he was close to his bed, so the patient was taken out of the room. At 09:00 AM, Resident #2 was returned to his bed because he was throwing himself off the wheelchair at which point another staff saw Resident #6 hitting Resident #2 using a wheelchair. At 11:02, LVN B observed Resident #6 hitting Resident #2 with a shoe. Record review of Resident #2's Social Worker Notes dated 03/31/23 signed by Social Worker A revealed, referral made for inpatient psych evaluation and stay for Resident #2, but admission was denied to resident being unable to advocate for himself. Resident sent out for acute medical ER for evaluation. PLEASE NOTE when resident returns to facility, he will need to go to a different room from previous room with roommate. Record review of Resident #2's Psychiatric assessment dated [DATE] signed by the Psychiatric NP revealed, reason for referral: aggression, hitting staff, hitting other residents, safety to self. Collateral Information: staff reports patient can be irritable and restless. An observation on 05/17/23 at 11:55 AM revealed, Resident #2 on needs on the floor playing with his gown on the side of his fall mat. Blood was observed on the floor by the resident. Resident #6 Record review of Resident #6's Face Sheet dated 05/17/23 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, bipolar disorder, delusional disorders, unspecified psychosis, and hypertension. Record review of Resident #6's undated Care Plan printed 05/17/23 revealed, focus- PASRR positive related to severe mental illness; intervention- continue psychiatrist services at the facility. Focus- diagnosis of bipolar disorder with risk for inappropriate behaviors; Goal- Resident #6 will not harm himself or others; intervention- psych consult, monitor behaviors ever shift. Focus- Resident #6 has displayed frequent episodes of refusal of medications and ADL cares and was at risk for injury; Interventions- keep MD/NP informed of resident's refusal of medications and/or ADL care. Focus initiated on 10/28/21 and revised on 04/20/22- diagnoses of schizophrenia, bipolar disorder, psychosis, delusional disorder. sometimes become aggressive with facility properties and staff. Focus- ADL self-care deficits and is at risk for further decline in ADL functioning and injury; intervention- Resident #6 will be well dressed, groomed and clean; intervention- 1on1 for personal hygiene. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 03 out of 15, no signs of delirium, no rejection of care, supervision with most ADLs, use of a wheelchair and occasionally incontinent of both bladder and bowel. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Mental Status Examination- risk of aggression none. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Mental Status Examination- risk of aggression none. Record review of Resident #6's Incident and Accident Report dated 03/31/23 signed by LVN B revealed, LVN B was informed by staff that at 08:00 AM Resident #6 was seen hitting his roommate (Resident #2) because he was close to his bed. Another staff also saw roommate Resident #6 hitting Resident #2 with a wheelchair. At 11:02 AM, LVN B also saw Resident #6 hitting Resident #2 with a shoe. Record review of Resident #6's Psychological Services Supportive Care Progress Note from 03/29/23 to 04/19/23 revealed, no reference to Resident #6 assaulting Resident #2 on 3 different occasions on 03/31/23. Record review of the facility Form 3613-A: Provider Investigation Report signed 04/07/23 revealed, Resident #1 was identified as assaulting Resident #2 with a wheelchair on 03/31/23 instead of Resident #6. There was no mention of Resident #6 in the investigation report. Record review of Resident #6's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, Collateral Information: staff reports Resident #6 has been refusion his medication for weeks and had behavioral physical incident with his roommate. Mental Status Examination- risk of aggression none. An observation and interview on 05/18/23 at 12:00 PM revealed, Resident #6 lying in bed in no immediate distress. Resident #6 said he did not remember any incidents of physical aggression with Resident #2. In an interview of 05/17/23 at 11:22 AM, LVN B said Resident #6 was usually verbally and physically aggressive and did not want to be disturbed. She said on 03/31/23 Resident #6 attacked Resident #2 on three different occasions of which she witnessed the third. LVN B said she was informed that Resident #6 had hit Resident #2 once in the morning and later on in the morning Resident #6 pushed a wheelchair over Resident #2 as he laid on the floor causing Resident #2 to bleed from the mouth. She said Resident #2 was initially removed from the room but he was later returned to the same room as Resident #6 because there was no other room to place him and Resident #2 kept throwing himself on the floor and it was at that point that she witnessed Resident #6 hit Resident #2 with a shoe. LVN B said she immediately separated the two residents and placed Resident #2 at the nursing station until he was sent out of evaluation. She said the expectation for resident to resident altercations is that the resident's be immediately separated to prevent further abuse and Resident #2 should not have been returned to the same room as Resident #6. In an interview on 05/18/23 at 11:43 AM, the Administrator said she failed to identify that Resident #6 was the perpetrator of abuse against Resident #2 on 03/31/23. She said she believed Resident #1 assaulted Resident #2 and completed her investigation based on that. She could not explain why she believed the assailant was Resident #1 and not Resident #6. The Administrator said she did not look into Resident #6 at all, she did not notify the provider about Resident #6's aggression and no corrective action was taken about Resident #6's assault of Resident #2. She said since she did not investigate Resident #6, she did not know staff identified him as being physically aggressive or that the NP would be removing Resident #6's psych meds due to the resident refusing. The Administrator said based on the information she learned about Resident #6, it was not appropriate for the resident to have a roommate due to him being a danger to others. She said failure to investigate the correct resident could place residents at risk of injury. In an interview on 05/18/23 at 12:56, the Psychiatric NP said Resident #6 had history of aggression and she was never informed of the incidents of abuse between Resident #6 and Resident #2 that occurred on 03/31/23. She said Resident #6 had been refusing all his medications including his psych medications so her plan was to GDR to discontinue all his medications. The Psychiatric NP said the facility is expected to notify her of any cases of physical aggression in any residents being followed but it would not have mattered in this case because Resident #6 had refused all his medication so she could not make any pharmaceutical interventions and therapist handles non-pharmaceutical interventions. When asked how Resident #6's behaviors would be controlled and if his lack of medication would place others in danger the Psychiatric NP said if Resident #6 is deemed to be a risk to himself or other then he would have to be sent out to a behavioral hospital Resident #9 Record review of Resident #9's face sheet dated 05/23/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: dementia and bipolar disorder with psychotic features. Record review of Resident #9's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, total dependence on most ADLs and always incontinent of both bladder and bowel. Record review of Resident #9's undated Care Plan dated 05/25/23 revealed Focus- Resident #6 has potential to be verbally/physically aggressive behaviors related bipolar disorder; interventions- analyze key times, places, circumstances, triggers and what de-escalates behaviors and document. Record review of Resident #9's Psychiatric Subsequent Assessment dated 12/16/22 signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Record review of Resident #9's Psychiatric Subsequent Assessment dated 01/12/23 signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Record review of Resident #9's Progress Notes dated 02/10/23 and signed by LVN B revealed, housekeeper stated she saw Resident #6 being hit by his roommate (Resident #2). Resident #6 was moved out from the room immediately, a head to toe assessment was performed and no bruising or bleeding was noted. Record review of Resident #9's Psychiatric Subsequent Assessment dated 03/13/23 signed by the Psychiatric NP revealed, mental status examination- risk of aggression: physical. Collateral Information: no mood or behavior changes reported by staff. There is no documentation Resident #10 Record review of Resident #10's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, partial traumatic amputation level between knee and ankle and chronic pain syndrome. Record review of Resident #10's quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, no behaviors, total dependence on most ADLs. Record review of Resident #10's undated Care Plan printed 05/25/23 revealed, focus- below the right knee amputation. Record review of Resident #10's 02/2023 Progress Notes revealed, no documentation of Resident #10 being hit by Resident #2. Record review of Resident #10's Census List printed 05/18/23 revealed, Resident #10 was in room [ROOM NUMBER]-A from 02/11/23 to 02/23/23. In an interview of 05/17/23 at 11:22 AM, LVN B said Resident #2's behaviors involve throwing himself on the floor, throwing himself on roommates, hitting residents and staff. She said Resident #2 will always instigate altercations with his roommates and she feels like Resident #2 should be in a room by himself because of his behaviors. She said Resident #2 was a fall risk so the idea from administration was to place him with a roommate that could watch him and report any falls or injuries Resident #2 may suffer. LVN B said Resident #2 has had multiple altercations with different roommates like Resident #6, Resident #9 and Resident #10. LVN B said Resident #2 had a severe intellectual disability and could not control his behaviors, his behaviors were not intentional and he did not understand what he was doing to others. In an interview on 05/18/23 at 12:43 PM, Resident #31 said his roommate Resident #2 has a history of hitting other residents. He said prior to rooming with Resident #2 the resident had hit him in the hallway so he was concerned about rooming with him in case he hit him, but he guessed that the facility put them together so he could look out for Resident #2 since he falls. Resident #31 said so far, he had not had any issues with Resident #2 because the resident was sick and had not been active. He said Resident #2's behaviors included getting on the floor to just stare at him (Resident #31) and rolling off his own bed blocking the door. Resident #31 said he has not had any issues with Resident #2 so far but if he did, he would hurt Resident #2. In an interview on 05/18/23 at 12:56, the Psychiatric NP said Resident #2 admitted to the facility with a diagnosis of severe IDD. She said his behaviors include jumping off the bed, hitting and touching others and she can see him instigating altercations with other residents. She said that these behaviors are his baseline, and his behaviors could be troublesome to his roommates. When asked if Resident #2 was appropriate for a roommate, the Psychiatric NP would not answer. Resident #7 Record review of Resident #7's Face Sheet dated 05/23/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: dementia without behavioral disturbance, psychotic disturbance, depression and anxiety. Record review of Resident #7's quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, no potential indicators of psychosis such as hallucinations and delusions. No behavioral symptoms directed towards others, no verbal behavioral symptoms directed towards others, no behavioral symptoms not directed towards others, supervision needed for locomotion on the unit, supervision needed for location off the unit and use of a manual wheelchair. Record review of Resident #7's undated Care Plan revealed, focus- have verbal aggressive behavior (cussing staff) related to dementia. Focus- Resident #7 has been physically aggressive; goal- Resident #6 will demonstrate effective coping skills through the review date. Record review of Resident #7's Incident by Incident Type Report from 11/01/22 to 05/23/23 revealed, Resident #7 initiated 3 separate incidents of physical aggression on 11/19/22, 05/03/23 and 05/17/23. Record review of Resident #7's Psychiatric Subsequent assessment dated [DATE] and signed by the Psychiatric NP revealed, reason for referral: verbal aggression and resistance to care. Collateral information: staff reports patient behaviors have not worsened, patent calmer since medication changes. Mental Status Examination- risk of aggression: none. Record review of Resident #7's Progress Notes dated 11/19/22 at 9:56 PM revealed, Resident #7 assaulted another resident (Resident #8) outside in the smoking area. He punched him on the mouth resulting in a laceration on the lip, the residents were separated and the provider, DON and Administrator were notified. Record review of Resident #7's Progress Notes dated 11/21/22 at 11:16 AM and signed by DON C revealed, Resident #6 had a history of assaulting people and due to his institutionalized mentality he will continue to strike out physically and he is not appropriate for the facility. Resident #6 was unapologetic about his behavior and has repeatedly stated if he says anything to me I will hit him again. Staff continued to make frequent rounds monitoring Resident #6's interactions with others. Record review of Resident #7's Progress Notes dated 11/21/22 at 02:09 PM and signed by the Social Worker B, RP notified Resident #7 is not appropriate for continued stay in the interest of safety for others. During past months since admission Resident #7 has had significant physically aggressive behaviors towards other residents. Record review of Resident #7's 'Psychiatric Subsequent Assessment' dated 12/03/22 revealed, patient admits that he recently had an altercation with another resident and states that it wasn't his fault. Collateral Information: staff reports patient recently punched another resident in the face. Reports there was an altercation in the smoking area. Record review of Resident #7's Fair Hearing Medicaid Nursing Facility Discharge' letter dated 01/12/23 revealed, the facility could not discharge Resident #7 based on events that occurred on or prior to a discharge letter issued on 11/29/22 because, the hearing officer did not receive evidence from the facility prior to the hearing and a representative from the facility was not present at the hearing on 12/28/22 to explain or support the facility's actions to discharge Resident 7 so the Hearings Officer closed the record without a response from the facility. Record review of Resident #7's Progress Notes dated 05/03/23 at 05:15 AM revealed, Resident #7 struck another resident in dining area, resident was escorted back to room and both parties were divided. Record review of Resident #7's Physician's Notes dated 05/15/23 revealed, Resident #7 continues to be receptive to supportive care and there have been no changes in moods or behaviors. There are no complaints at this time. Record review of Resident #7's Progress Notes dated 05/17/23 at 10:36 PM revealed, at 07:30 AM Resident #8 was brought to the nursing station and told the nurse that Resident #7 hit him in the face and the chest. Resident #7 said Resident #8 called him a derogatory term and that was the reason he punched him in the face. Record review of Resident #7's Social Worker A dated 05/18/23 at 10:44 AM revealed, Resident #7 hit another resident (Resident #8) late in the evening yesterday Resident would benefit from emergency psych evaluation as he is a current threat to other residents due to his disorientation and confusion. An observation and Interview on 05/17/23 at 09:55 AM revealed, Resident #7 lying in bed well-groomed and in no immediate distress. He said a white man in a wheelchair hit him in the back so he came back and hit him back. He said Resident #8 talked about his mother and that is why he hit him, he said he had not had any other issues with any other residents and no other issues with Resident #7. In an interview on 05/24/23 at 01:16 PM, the Assistant Administrator said there was no incident report on record for the incident involving Resident #7 and #8 on 11/19/22. Resident #8 Record review of Resident #8's Face Sheet printed 06/15/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: paraplegia (paralysis of the legs and lower body), history of traumatic brain injury, type 2 diabetes, mood disorder, assault by unspecified firearm. Record review of Resident #8's quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, no signs of delirium or hallucinations, no physical behavioral symptoms directed toward others, no verbal behavioral symptoms directed towards others, no other behavioral symptoms not directed toward others, no rejection of care, total dependence on most ADLs and use of a wheelchair. Record review of Resident #8's undated Care Plan revealed, focus- Resident #8 was a smoker with potential for injury. Record review of Resident #8's Incident/Accident Report dated 11/18/22 at 07:30 PM revealed, Resident #7 punched Resident #8 in the mouth at 07:00 PM resulting in a laceration to the lip while outside in the smoke area. Record review of Resident #8's Progress Notes dated 11/19/22 at 07:03 AM revealed, Resident #7 punched Resident #8 on 11/18/22 at 07:00 PM in the mouth when both of them were in the smoking area and Resident #8 had a deep laceration to his lip. Resident #8 stated Resident #7 punched him because he told him to stop assaulting staff because of cigarettes. Resident #8 was assessed, and MD was notified about laceration who gave orders for the resident to be sent out to the hospital for sutures. Resident #8 was sent to the hospital on [DATE] at 07:00 PM. Record review of Resident #8's Progress Notes dated 11/19/22 at 07:33 AM revealed, Resident #8 returned from the hospital on [DATE] at 04:00 AM and did not appear to have stitches. Record review of Resident #8's Progress Notes dated 11/19/22 at 11:31 AM revealed, Resident #8 said Resident #7 threw finger at him and was yelling at him. Resident #8 was escorted out of the dining room to go out during smoke time. Record review of Resident #8's Physician Note dated 11/22/22 revealed, Resident #8 was reportedly punched in the face by another resident (Resident #7). Resident #8 sustained a laceration to the lip; he was sent to the ER however he did not have any sutures placed. Record review of Resident #8's Progress Note dated 05/03/22 revealed, Resident #8 got hit by another resident (Resident #7) on his chest in the dining room. Resident #8 said he was yelling for someone to adjust him properly in his chair and the Resident #7 got irritated wheeled close to him and hit him in the chest. Head to toe assessment completed and Resident #8 had no bruising or swelling noted. Record review of Resident #8's Progress Notes dated 05/17/23 at 07:30 PM revealed, Resident #8 got into a fight with Resident #7 on the smoking patio but the incident was not witnessed. Resident #7 hit Resident #8 on the lips chest and neck. Resident #8 was observed to have bruised lips, a purple bruise on the neck/throat area from trauma and Resident #8 reported Resident #7 burned him with a cigarette to which a blister was observed. Record review of Resident #8's Physician Note dated 05/23/23 signed by MD A revealed, chief complaint: follow up for coffee burn, cigarette burn, sunburn and trauma to neck. MD A was notified by staff on 05/23/23 that Resident #8 was in a fight with another resident in which he was punched in the jaw/neck and sustained a cigarette burn to his right arm. Resident #8 still has a bruise to his neck, but the cigarette burn was almost healed. An observation and Interview on 05/21/23 at 06:27 PM revealed, Resident #8 sitting in his wheelchair in his room, well-groomed and in no immediate distress. Resident #8 said he has had multiple altercations with Resident #7 and he didn't feel safe in the facility when Resident #7 was there. He said Resident #7 always curses at him in the hallways, the dining room and in the smoking area every day. Resident #8 said the facility has made no efforts to move Resident #7 so they don't meet in the hallway, change their dinning or smoking breaks and did not ensure they were separated or supervised during meals in the dining room or smoke breaks in the courtyard even though he had made multiple complaints. Resident #8 said Resident #7 has punched him in the chest and lip on multiple occasions causing him to bleed and get stitches. He said in the last incident Resident #7 burned him on his arm with a cigarette. He said the facility have taken no action to ensure he was safe from Resident #7. In an interview on 05/17/23 at 08:45 AM, the Assistant Administrator said on 05/03/23 he heard Resident #8 screaming and observed Resident #7 pushing back in his wheelchair. He said the nurses reported that Resident #7 hit Resident #8 twice in the chest because Resident #8 was screaming which agitated Resident #7 and caused him to hit him in response. The Assistant Administrator said the residents were separated and there have been no incidents since then. He said there had been previous incidents between Resident #7 and Resident #8 in the smoking area, when Resident #8 took up for the staff so Resident #7 hit him in the face. The Assistant Administrator said he believed Resident #8 was triggered by loud noises. In an interview on 05/22/23 at 04:00 PM, the Assistant Administrator said following the incident on 05/18/23 Resident #7 was sent out to a behavioral hospital and he would not be returning to the facility. He said Resident #7 and Resident #8 have had multiple altercations in the smoking area and the dining area. He said Resident #7 and Resident #8 normally take their smoking break or are sitting in the dining area together and to his knowledge there have never been measures in place to ensure that these two residents were separated. Resident #5 Record review of Resident #5's face sheet, dated 5/18/2023, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Hemiplegia (paralysis of one side of the body), Cognitive Communication Deficit, Unspecified Lack of coordination. Record review of Resident #5's Annual MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, limited to extensive assistance for most ADLs, and personal hygiene and always incontinent of both bladder and bowel. Record review of Resident #5's Care Plan dated 03/16/23 revealed, focus- at risk for confusion, aggression and decline in ADL related to dementia; goal- be able to function in the environment safely; intervention- administer medication as ordered by MD, assist resident with ADL's. Record review

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 7 of 12 residents (Resident #2, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10 and Resident #13) reviewed for supervision. 1. The facility failed to provide adequate supervision for Resident #2, a resident with severe IDD and behaviors, by placing him in the same room as Resident #6 which resulted in Resident #2 suffering from multiple occasions of abuse on 03/31/23. 2. The facility failed to provide adequate supervision for Resident #8 and Resident #7 which resulted in Resident #8 suffering from multiple incidents of abuse by Resident #7 which included a busted lip and a cigarette burn. 3. The facility failed to provide adequate supervision to prevent Resident #9 and Resident #10 from suffering from abuse from Resident #2, a resident with severe IDD and behaviors by placing them in the same room. 4. The facility failed to provide adequate supervision to Resident #13 (identified outside of the IJ), to prevent an injury of unknown origin which resulted in hospitalization with bilateral (both sides) hip fractures which required surgical repair. An Immediate Jeopardy (IJ) situation was identified on 05/22/23 at 03:21 PM. While the IJ was removed on 05/29/23 at 07:10 PM, the facility remained out of compliance at an H (severity level of actual harm that is not immediate and a scope of pattern)due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of increased abuse, major injury, and a decreased quality of life. Findings include: Resident #2 Record review of Resident #2's face sheet, dated 05/23/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: unspecified dementia, depression, difficulty swallowing, G-tube (a tube that goes into the stomach to provide food and medications), anxiety disorders, left hand contractures, right hand contractures and sever intellectual disabilities. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed unclear speech, the resident was rarely understood, sometimes understands, had severely impaired cognition as indicated by a BIMS score of 00 out of 15, no response to resident mood interview questions, no documented behavioral symptoms (physical behaviors directed towards others, verbal behavioral symptoms directed to others or other behavioral symptoms not directed towards others), no rejection of care, no wandering, total dependence on all ADLs, use of a wheelchair, always incontinent of both bladder and bowel, non-traumatic brain dysfunction and left and right hand contractures. Record review of Resident #2's, undated, Care Plan, printed 05/16/23, revealed a focus-IDD Resident #2 was identified as PASRR positive related to intellectual disability; intervention- provide recommended services (habilitation coordination, independent living skills training and OT). Focus- nonverbal for communication needs/wants; potential for unmet needs/social isolation/boredom, escalating anxiety and agitation; intervention- provide emotional support to resident, refer resident for additional support relative to potential for escalating behaviors, referrals to psychiatric services for medication management and stabilization of behaviors. Focus- 2/09/23 Resident #2 was not hitting his roommate; intervention- resident was moved to another room. No incidents of physical aggression were documented on the Resident #2's care plan. There was no documentation of Resident #2's type of behaviors. Record review of Resident #2's Census List starting at admission [DATE] to 05/18/23 revealed, since 01/2023 Resident #2 has had 3 room changes. Record review of Resident #2's Psychiatric Assessment, dated 09/16/22, signed by the Psychiatric NP revealed, reason for referral: anxiety, irritability, anger, non-verbal with a history of resistance and combative behaviors. Collateral information: aggression on and off. Record review of Resident #2's Nursing Note, dated 02/10/23 at 01:34 PM, and signed by LVN B revealed, Resident #2 initiated physical aggression against his roommate (Resident #9) on 02/09/23 LVN B was notified by the housekeeper that she saw Resident #2 hit his roommate while in bed. The roommate was moved out from room immediately. Record review of Resident #2's Nursing Note, dated 02/22/23 at 05:46 PM, signed by LVN B, revealed Patient is combative , hitting other patients. Patient was seen on his roommate's (Resident #10) body. Roommate (Resident #10) stated take this man out of here, I want peace. Resident #2 was taken to another room. Resident #2 was seen hitting other patients on the hallway, refused to stay in room. Record review of Resident #2's Psychiatric Provider note, dated 02/22/23, revealed Resident #2 was awake and agitated, monitored for behaviors and staff reported Resident #2 was increasingly agitated and aggressive. He was attempting to hit staff. Orders to send to behavior hospital will be provided. Record review of Resident #2's Nursing Note, dated 02/23/23 at 09:15 AM, signed by LVN B revealed Patient is becoming a threat to other patients and staff. He refused to stay in room . Patient in hallway hitting everyone passing by. Patient needs to be moved to a psych hospital ASAP. Record review of Resident #2's Psychiatric Assessment, dated 02/24/23, signed by the Psychiatric NP, revealed reason for referral: aggression, hitting staff, hitting other residents, safety to self. Collateral Information: Staff reports patient has intermittent aggression towards others and fluctuating mood. Assessment/Plan: increased Risperdal (an antipsychotic) due to physical aggression, reported paranoia and negative symptoms. Severe IDD- is not treated with medications. There was no reference of the resident's appropriateness to have a roommate. Record review of Resident #2's Psychiatric Provider Note, dated 02/24/23, revealed behavioral hospital admission denied. The note did not include the reason Resident #2's behavioral hospital admission was denied. Record review of Resident #2's Nursing Note, dated 03/31/23 at 11:55 AM, signed by LVN C, revealed at about 09:35 AM Resident #2's roommate (Resident #6) was standing over residents' wheelchair pushing wheelchair over resident. Resident #2 was noted to be lying on the floor between bed and wheelchair with blood coming from his mouth. LVN C separated the residents and Resident #6 got into bed and stated somebody better get him before I kill him. Laceration noted to upper lip area, Resident #2 was brought to the nurses station in a wheelchair at which he was observed to hit another resident while sitting at the nursing station. At this time facility is working on room changes for resident and possible admit to psych facility. Record review of Resident #2's Nursing Note, dated 03/31/23 at 01:12 PM, signed by LVN B, revealed LVN B was told by staff that at 08:00 AM Resident #2 was hit by his roommate (Resident #6) because he was close to his bed so the patient was taken out of the room. At 09:00 AM, Resident #2 was returned to his bed because he was throwing himself off the wheelchair at which point another staff saw Resident #6 hitting Resident #2 using a wheelchair. At 11:02 AM, LVN B observed Resident #6 hitting Resident #2 with a shoe. Record review of Resident #2's Social Worker Notes, dated 03/31/23, signed by Social Worker A revealed, referral made for inpatient psych evaluation and stay for Resident #2 but admission was denied due to resident being unable to advocate for himself. Resident sent out for acute medical ER for evaluation. Please Note when resident returns to facility, he will need to go to a different room from previous room with roommate. Record review of Resident #2's Psychiatric Assessment, dated 04/06/23, signed by the Psychiatric NP, revealed reason for referral: aggression, hitting staff, hitting other residents, safety to self. Collateral Information: staff reports patient can be irritable and restless. An observation on 05/17/23 at 11:55 AM revealed, Resident #2 on his knees on the floor playing with his gown on the side of his fall mat. Resident #6 Record review of Resident #6's face sheet, dated 05/17/23, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, bipolar disorder, delusional disorders, unspecified psychosis and hypertension. Record review of Resident #6's Quarterly MDS, dated [DATE], revealed the resident had severely impaired cognition as indicated by a BIMS score of 03 out of 15, no signs of delirium, no rejection of care, supervision with most ADLs, use of a wheelchair and was occasionally incontinent of both bladder and bowel. Record review of Resident #6's, undated, Care Plan, printed 05/17/23, revealed, focus- PASRR positive related to severe mental illness; intervention- continue psychiatrist services at the facility. Focus- diagnosis of bipolar disorder with risk for inappropriate behaviors; Goal- Resident #6 will not harm himself or others; intervention- psych consult, monitor behaviors every shift. Focus- Resident #6 has displayed frequent episodes of refusal of medications and ADL care and is at risk for injury; Interventions- keep MD/NP informed of resident's refusal of medications and/or ADL care. Focus initiated on 10/28/21 and revised on 04/20/22- diagnoses of schizophrenia, bipolar disorder, psychosis, delusional disorder. Sometimes became aggressive with facility properties and staff. Focus- ADL self-care deficits and was at risk for further decline in ADL functioning and injury; intervention- Resident #6 will be well dressed, groomed and clean; intervention- 1on1 for personal hygiene. Record review of Resident #6's Psychiatric Subsequent Assessment, dated 03/03/23, and signed by the Psychiatric NP, revealed Mental Status Examination- risk of aggression none. Record review of Resident #6's Psychiatric Subsequent Assessment, dated 03/22/23, and signed by the Psychiatric NP, revealed Mental Status Examination- risk of aggression none. Record review of Resident #6's Incident and Accident Report, dated 03/31/23, signed by LVN B revealed LVN B was informed by staff that at 08:00 AM Resident #6 was seen hitting his roommate (Resident #2) because he was close to his bed. Another staff also saw roommate Resident #6 hitting Resident #2 with a wheelchair. At 11:02 AM, LVN B also saw Resident #6 hitting Resident #2 with a shoe. Record review of Resident #6's Psychological Services Supportive Care Progress Note from 03/29/23 to 04/19/23, revealed no reference to Resident #6 assaulting Resident #2 on 3 different occasions on 03/31/23. Record review of Resident #6's Psychiatric Subsequent Assessment, dated 04/14/23, and signed by the Psychiatric NP, revealed Collateral Information: staff reports Resident #6 has been refusing his medication for weeks and had behavioral physical incident with his roommate. Mental Status Examination- risk of aggression none. An observation and interview on 05/18/23 at 12:00 PM revealed, Resident #6 lying in bed in no immediate distress. Resident #6 said he did not remember any incidents of physical aggression with Resident #2. In an interview of 05/17/23 at 11:22 AM, LVN B said Resident #6 was usually verbally and physically aggressive and did not want to be disturbed. She said on 03/31/23 Resident #6 attacked Resident #2 on three different occasions of which she witnessed the third. LVN B said she was informed Resident #6 had hit Resident #2 once in the morning and later on in the morning Resident #6 pushed a wheelchair over Resident #2 as he laid on the floor causing Resident #2 to bleed from the mouth. She said Resident #2 was initially removed from the room but he was later returned to the same room as Resident #6 because there was no other room to place him and Resident #2 kept throwing himself on the floor and it was at that point she witnessed Resident #6 hit Resident #2 with a shoe. LVN B said she immediately separated the two residents and placed Resident #2 at the nursing station until he was sent out for an evaluation. She said the expectation for resident to resident altercations was the resident's be immediately separated to prevent further abuse and Resident #2 should not have been returned to the same room as Resident #6. In an interview on 05/18/23 at 11:43 AM, the Administrator said she failed to identify Resident #6 was the perpetrator of abuse against Resident #2 on 03/31/23. She said she believed Resident #1 assaulted Resident #2 and completed her investigation based on her. The Administrator said she did not look into Resident #6 at all because she had not identified him as the assailant, she did not notify the provider about Resident #6's aggression and no corrective action was taken about Resident #6's assault of Resident #2. She said since she did not investigate Resident #6 she did not know staff identified him as being physically aggressive or that the NP would be removing Resident #6's psych meds due to the resident refusing. The Administrator said based on the information she learned about Resident #6, it was not appropriate for the resident to have a roommate due to him being a danger to others. She said failure to investigate the correct resident could place residents at risk of injury. In an interview on 05/18/23 at 12:56, the Psychiatric NP said Resident #6 had history of aggression and she was never informed of the incidents of abuse between Resident #6 and Resident #2 that occurred on 03/31/23. She said Resident #6 had been refusing all his medications including his psych medications so her plan was to GDR to discontinue all his medications. The Psychiatric NP said the facility was expected to notify her of any cases of physical aggression in any residents being followed but it would not have mattered in this case because Resident #6 had refused all his medication so she could not make any pharmaceutical interventions and the therapist handled non-pharmaceutical interventions. When asked how Resident #6's behaviors would be controlled and if his lack of medication would place others in danger the Psychiatric NP said if Resident #6 was deemed to be a risk to himself or others then he would have to be sent out to a behavioral hospital. Resident #9 Record review of Resident #9's face sheet, dated 05/23/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: dementia and bipolar disorder with psychotic features. Record review of Resident #9's Quarterly MDS, dated [DATE], revealed severely impaired cognition as indicated by a BIMS score of 00 out of 15, total dependence on most ADLs and always incontinent of both bladder and bowel. Record review of Resident #9's Care Plan, dated 05/25/23, revealed Focus- Resident #9 had a potential to be verbally/physically aggressive behaviors related bipolar disorder; interventions- analyze key times, places, circumstances, triggers and what de-escalates behaviors and document. Record review of Resident #9's Psychiatric Subsequent Assessment, dated 12/16/22, signed by the Psychiatric NP, revealed, mental status examination- risk of aggression: physical. Record review of Resident #9's Psychiatric Subsequent Assessment, dated 01/12/23, signed by the Psychiatric NP, revealed, mental status examination- risk of aggression: physical. Record review of Resident #9's Progress Notes, dated 02/10/23, and signed by LVN B, revealed the housekeeper stated she saw Resident #9 being hit by his roommate (Resident #2). Resident #6 was moved out from the room immediately, a head to toe assessment was performed and no bruising or bleeding was noted. Record review of Resident #9's Psychiatric Subsequent Assessment, dated 03/13/23, signed by the Psychiatric NP, revealed mental status examination- risk of aggression: physical. Collateral Information: no mood or behavior changes reported by staff. Resident #10 Record review of Resident #10's face sheet, dated 05/23/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, partial traumatic amputation level between knee and ankle and chronic pain syndrome. Record review of Resident #10's quarterly MDS, dated [DATE], revealed severely impaired cognition as indicated by a BIMS score of 00 out of 15, no behaviors, total dependence on most ADLs. Record review of Resident #10's, undated, Care Plan, printed 05/25/23, revealed, focus- below the right knee amputation. There was no documentation of any behaviors or aggression in Resident #10's care plan. Record review of Resident #10's 02/2023 Progress Notes revealed, no documentation of Resident #10 being hit by Resident #2. Record review of Resident #10's Census List, printed 05/18/23, revealed Resident #10 was in room [ROOM NUMBER]-A from 02/11/23 to 02/23/23. In an interview on 05/17/23 at 11:22 AM, LVN B said Resident #2's behaviors involved throwing himself on the floor, throwing himself on roommates, hitting residents and staff. She said Resident #2 would always instigate altercations with his roommates and she felt like Resident #2 should be in a room by himself because of his behaviors. She said Resident #2 was a fall risk and the idea from administration was to place him with a roommate that could watch him and report any falls or injuries Resident #2 may suffer. LVN B said Resident #2 had multiple altercations with different roommates like Resident #6, Resident #9 and Resident #10. LVN B said Resident #2 had a severe intellectual disability and could not control his behaviors, and he did not do it intentionally and did not understand what he was doing to others. In an interview on 05/18/23 at 12:43 PM, Resident #31 said his roommate Resident #2 had a history of hitting other residents. He said prior to rooming with Resident #2 the resident had hit him in the hallway so he was concerned about rooming with him in case he hit him, but he guessed the facility put them together so he could look out for Resident #2 since he falls. Resident #31 said so far he had not had any issues with Resident #2 because the resident was sick. He said Resident #2 would get on the floor and just stare at him, roll off his bed blocking the door. Resident #31 said he had not had any issues with Resident #2 so far but if he did he would hurt Resident #2. In an interview on 05/18/23 at 12:56, the Psychiatric NP said Resident #2 admitted to the facility with a diagnosis of severe IDD. She said his behaviors included jumping off the bed, hitting and touching others and she could see him instigating altercations with other residents. She said these behaviors were his baseline and it could be troublesome to his roommates. When asked if Resident #2 was appropriate for a roommate, the Psychiatric NP would not answer. Resident #7 Record review of Resident #7's face sheet, dated 05/23/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: dementia without behavioral disturbance, psychotic disturbance, depression and anxiety. Record review of Resident #7's quarterly MDS, dated [DATE], revealed moderately impaired cognition as indicated by a BIMS score of 10 out of 15, no potential indicators of psychosis such as hallucinations and delusions. No behavioral symptoms directed towards others, no verbal behavioral symptoms directed towards others, no behavioral symptoms not directed towards others, supervision needed for locomotion on the unit, supervision needed for location off the unit and use of a manual wheelchair. Record review of Resident #7's, undated, Care Plan revealed, focus- have verbal aggressive behavior (cussing staff) related to dementia. Focus- Resident #7 has been physically aggressive; goal- Resident #7 would demonstrate effective coping skills through the review date. Record review of Resident #7's Incident by Incident Type Report from 11/01/22 to 05/23/23, revealed Resident #7 initiated 3 separate incidents of physical aggression on 11/19/22, 05/03/23 and 05/17/23. Record review of Resident #7's Psychiatric Subsequent Assessment, dated 11/18/22, and signed by the Psychiatric NP, revealed reason for referral: verbal aggression and resistance to care. Collateral information: staff reports patient behaviors have not worsened, patent calmer since medication changes. Mental Status Examination- risk of aggression: none. Record review of Resident #7's Progress Notes, dated 11/19/22 at 9:56 PM, revealed Resident #7 assaulted another resident (Resident #8) outside in the smoking area. He punched him on the mouth which resulted in a laceration on the lip, the residents were separated and the provider, DON and Administrator were notified. Record review of Resident #7's Progress Notes, dated 11/21/22 at 11:16 AM, and signed by DON C revealed Resident #6 had a history of assaulting people and due to his institutionalized mentality he would continue to strike out physically and he was not appropriate for the facility. Resident #6 was unapologetic about his behavior and repeatedly stated if he says anything to me I will hit him again. Staff continued to make frequent rounds monitoring Resident #6's interactions with others. Record review of Resident #7's Progress Notes, dated 11/21/22 at 02:09 PM, and signed by the Social Worker B, RP notified Resident #7 was not appropriate for continued stay in the interest of safety for others. During past months since admission Resident #7 had significant physically aggressive behaviors towards other residents. Record review of Resident #7's 'Psychiatric Subsequent Assessment, dated 12/03/22, revealed patient admits he recently had an altercation with another resident and stated it wasn't his fault. Collateral Information: staff reports patient recently punched another resident in the face. Reports there was an altercation in the smoking area. Record review of Resident #7's Fair Hearing Medicaid Nursing Facility Discharge letter, dated 01/12/23, revealed the facility could not discharge Resident #7 based on events that occurred on or prior to a discharge letter issued on 11/29/22 because, the hearing officer did not receive evidence from the facility prior to the hearing and a representative from the facility was not present at the hearing on 12/28/22 to explain or support the facility's actions to discharge Resident #7 so the Hearings Officer closed the record without a response from the facility. Record review of Resident #7's Progress Notes, dated 05/03/23 at 05:15 AM, revealed Resident #7 struck another resident in the dining area, the resident was escorted back to his room and both parties were divided. Record review of Resident #7's Physician's Notes, dated 05/15/23, revealed Resident #7 continued to be receptive to supportive care and there were no changes in moods or behaviors. There were no complaints at this time. Record review of Resident #7's Progress Notes, dated 05/17/23 at 10:36 PM, revealed at 07:30 AM Resident #8 was brought to the nursing station and told the nurse Resident #7 hit him in the face and the chest. Resident #7 said Resident #8 called him a derogatory term and that was the reason he punched him in the face. Record review of Resident #7's Social Worker A, dated 05/18/23 at 10:44 AM, revealed Resident #7 hit another resident (Resident #8) late in the evening yesterday. Resident would benefit from emergency psych evaluation as he was a current threat to other residents due to his disorientation and confusion. An observation and interview on 05/17/23 at 09:55 AM revealed Resident #7 lying in bed well-groomed and in no immediate distress. He said a white man in a wheelchair hit him in the back so he came back and hit him back. He said Resident #8 talked about his mother and that was why he hit him. He said he had not had any other issues with any other residents and no other issues with Resident #7. In an interview on 05/24/23 at 01:16 PM, the Assistant Administrator said there was no incident report on record for the incident involving Residents #7 and #8 on 11/19/22. He said following any accident/incidents which include resident to resident altercations, an accident/incident report must be completed to detail the event but he did not know why the incident had not been document Resident #8 Record review of Resident #8's face sheet, printed 06/15/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: paraplegia (paralysis of the legs and lower body), history of traumatic brain injury, type 2 diabetes, mood disorder, assault by unspecified firearm. Record review of Resident #8's quarterly MDS, dated [DATE], revealed intact cognition as indicated by a BIMS score of 15 out of 15, no signs of delirium or hallucinations, no physical behavioral symptoms directed toward others, no verbal behavioral symptoms directed towards others, no other behavioral symptoms not directed toward others, no rejection of care, total dependence on most ADLs and use of a wheelchair. Record review of Resident #8's, undated, Care Plan revealed, focus- Resident #8 was a smoker with potential for injury. Record review of Resident #8's Incident/Accident Report, dated 11/18/22 at 07:30 PM, revealed Resident #8 punched Resident #7 in the mouth at 07:00 PM which resulted in a laceration to the lip while outside in the smoke area. Record review of Resident #8's Progress Notes, dated 11/19/22 at 07:03 AM, revealed Resident #7 punched Resident #8 on 11/18/22 at 07:00 PM in the mouth when both of them were in the smoking area and Resident #8 had a deep laceration to his lip. Resident #8 stated Resident #7 punched him because he told him to stop assaulting staff because of cigarettes. Resident #8 was assessed and MD was notified about the laceration and gave orders for the resident to be sent out to the hospital for sutures. Resident #8 was sent to the hospital on [DATE] at 07:00 PM. Record review of Resident #8's Progress Notes, dated 11/19/22 at 07:33 AM, revealed Resident #8 returned from the hospital on [DATE] at 04:00 AM. Record review of Resident #8's Progress Notes, dated 11/19/22 at 11:31 AM, revealed Resident #8 said Resident #7 pointed a finger at him and was yelling at him. Resident #8 was escorted out of the dining room to go out during smoke time. Record review of Resident #8's Physician Note dated 11/22/22 revealed, Resident #8 was reportedly punched in the face by another resident (Resident #7). Resident #8 sustained a laceration to the lip, he was sent to the ER however he did not have any sutures placed. Record review of Resident #8's Progress Note, dated 05/03/22, revealed Resident #8 got hit by another resident (Resident #7) on his chest in the dining room. Resident #8 said he was yelling for someone to adjust him properly in his chair and Resident #7 got irritated, wheeled close to him and hit him in the chest. Head to toe assessment completed and Resident #8 had no bruising or swelling noted. Record review of Resident #8's Progress Notes, dated 05/17/23 at 07:30 PM, revealed Resident #8 got into a fight with Resident #7 on the smoking patio but the incident was not witnessed. Resident #7 hit Resident #7 on the lips, check and neck. Resident #8 was observed to have bruised lips, a purple bruise on the neck/throat area from trauma and Resident #8 reported Resident #7 burned him with a cigarette to which a blister was observed. Record review of Resident #8's Physician Note, dated 05/23/23, signed by MD A revealed chief complaint: follow up for coffee burn, cigarette burn, sunburn and trauma to neck. MD A was notified by staff on 05/23/23 that Resident #8 was in a fight with another resident in which he was punched in the jaw/neck and sustained a cigarette burn to his right arm. Resident #8 still had a bruise to his neck but the cigarette burn was almost healed. An observation and interview on 05/21/23 at 06:27 PM revealed, Resident #8 sitting in his wheelchair in his room, well-groomed and in no immediate distress. Resident #8 said he had multiple altercations with Resident #7 and he didn't feel safe in the facility when Resident #7 was there. He said Resident #7 always cursed at him in the hallways , the dining room and in the smoking area every day. Resident #8 said the facility made no efforts to move Resident #7 so they don't meet in the hallway, change their dinning or smoking breaks and did not ensure they were separated or supervised during meals in the dining room or smoke breaks in the courtyard even though he had made multiple complaints. Resident #8 said Resident #7 punched him in the chest and lip on multiple occasions causing him to bleed and get stitches. He said in the last incident Resident #7 burned him on his arm with a cigarette. He said the facility have taken no action to ensure he was safe from Resident #7. In an interview on 05/17/23 at 08:45 AM, the Assistant Administrator said on 05/03/23 he heard Resident #8 screaming and observed Resident #7 pushing back. He said the nurses reported Resident #7 hit Resident #8 twice in the chest because Resident #8 was screaming which agitated Resident #7 and caused him to hit him in response. The Assistant Administrator said the residents were separated and there were no incidents since then. He said there had been previous incidents between Resident #7 and Resident #8 in the smoking area, when Resident #8 took up for the staff so Resident #7 hit him in the face. The Administrator said he believed Resident #8 was triggered by loud noises. In an interview on 05/22/23 at 04:00 PM, the Assistant Administrator said following the incident on 05/18/23 Resident #7 was sent out to a behavioral hospital and he would not be returning. He said Resident #7 and Resident #8 had multiple altercations in the smoking area and the dining area. He said Resident #7 and Resident #8 normally took their smoking break or dining area together and to his knowledge there had never been measures in place to ensure these two residents were separated. He could not provide a reason why interventions were not put into place or why additional supervision was not provided to Resident #7 or Resident #8 to prevent further altercations. In an interview on 05/16/23 at 09:00 AM, the Administrator said she was the abuse coordinator and she was responsible for reporting and investigating all allegations of abuse and neglect. She said when there was a resident to resident altercation nursing staff were expected to separate the resident's immediately to ensure their safety, complete head to toe assessments and then notify the family, the MD and then the facility administration. She said if residents had a history of physical aggression they should be supervised or separated from others to ensure they were not a danger to others. The Administrator said failure to provide adequate supervision following an allegation/incident of abuse placed residents at risk of further abuse and injury. In an interview on 05/16/23 at 09:05 AM, DON A said following a resident to resident altercation residents must be immediately separated for safety, a head to toe assessment must be completed and documented. She said at no point in time should a resident be returned to the same room as the assailant and in the long term the residents should not be left alone unsupervised in the same area for safety. In an interview on 05/18/23 at 10:30 AM, the Administrator said she was the facility abuse coordinator and was responsible for investigating all allegations of abuse. The Administrator was unable to describe what action or supervision was provided to prevent abuse with Resident #2, Resident #6, Resident #7, Resident #8, Resident #9 and Reside[TRUNCATED]