Every finding on record at Alpine Care of Zion

Based on interview, and record review the facility failed to make a referral for R1 due to R1's payment source for 1 of 7 residents reviewed for administration in the sample of 7. The findings include: On 08/24/2026 at 9:15AM, R1 said, I gave [V8 Social Worker] the name and phone number of a facility I wanted to transfer to. On 08/24/2026 at 12:23PM, V8 (Social Services) said, I did not send out the referral for [R1]. No facility will accept [R1]. [R1] has no payor source. R1's Progress Notes dated 07/01/2026 to 08/24/2026 show no referrals for transfer to other facilities. The facility's Social Services policy dated 02/2026 shows the Social Service Representative will continue to obtain information, obtain resident preferences and communicate with the Interdisciplinary Team on the discharge plan and timeline.

Based on observations, interview, and record review, the facility failed to ensure a known elopement risk resident that was showing exit seeking behaviors did not leave the facility for 1 (R3) of 8 residents reviewed for accidents in the sample of 8. The finding include: R3's Medical Record on 08/24/2026 shows, R1 has multiple diagnoses including, dementia, psychosis, lack of coordination, ataxia, and reduced mobility. On 08/24/2026 at 10:00AM, R3 was ambulating in the hall. R3 stood looking out the window by the fire exit stairwell.On 08/24/2026 at 1:00PM, V5 (Maintenance) showed R3's path out the fire exit stairwell, down four flights of stairs and out of the building to a sidewalk on the south side of the build. On 08/24/2026 at 11:17AM, V1 (Administrator) said, R3 went out the front door and walked about 1 block.On 08/24/2026 at 12:17PM, V8 (Social Worker) said, [R3] was admitted as an elopement risk. [R3] has delusions. Prior to this incident we found a map [R3] had drawn of the facility. [R3] had labeling for the stairs, the nurse's station, and other details of the unit. The staff viewed the map as an escape plan. The facility placed a bracelet that alerts the staff when [R3] leaves the unit. [R3] went out the fire exit. Staff followed [R3] for two blocks before bringing back to the facility. On 08/24/2026 at 1:00PM, V5 (Maintenance) said, [R3] left out the fire exit stairwell. The staff started towards [R3]. The staff did not follow [R3] into the stairwell. I watched the video. [R3] exited out the 4th floor stairwell, outside the building to the sidewalk. On 08/24/2026 at 2:23PM, R3 said, I do not remember leaving. I do not why I would leave.R3's Incident Report dated 08/16/2026 at 1:00PM, shows, resident was agitated and displayed exit seeking behaviors needing continuous redirection. Resident then left the 4th floor unit via elevator, went past reception, desk then out of the door.The facility Elopement policy revised 02/2026 shows, all residents are afforded adequate supervision to provide the safest environment possible.

Based on observation, interview, and record review the facility failed to ensure a resident's call light was within reach and able to be used while she was in bed. This applies to 1 (R2) of 3 residents reviewed for accommodations of needs in the sample of 7. The findings include: On 7/28/26 at 9:47AM R2 was in bed with her bed in the low position and mats on both sides of the bed. R2's right hand was contracted in a closed position, and she was unable to move it on her own. R2's call light was clipped to the right 1/4 side rail of the bed. On 7/28/26 at 10:40AM R2 was repositioned by staff in the bed but the call light remained attached to the right 1/4 side rail of the bed. R2's current Physician's Order Sheet shows that R2 has a diagnosis of Right-sided Hemiplegia and Hemiparesis (weakness and paralysis).On 7/28/26 at 10:43AM V11 (Certified Nursing Assistant) while looking at R2's call light stated, (R2) is total care. Once in a while she will use her call light. It's a far reach to the other side (left side). I can ask maintenance if they have a longer cord. V11 then moved R2's bed to make the call light reach to the other side of R2's bed so R2 could reach the call light with her left hand. R2's Current Care Plan states, CALL LIGHT: Encourage (R2) to use call light for assistance.

Based on interview and record review the facility failed to ensure a resident's hair was cleaned regularly and brushed daily to prevent matting. This applies to 1 of 3 residents (R1) reviewed for Activities of Daily Living (ADLs) in the sample of 7. The findings include: A facility Concern/Response Form dated 7/23/26 states, Family member (daughter) followed up regarding previously reported concerns, expressed concerns about the resident's hair care and requested further discussion with facility leadership regarding resident's care. Social Services acknowledged the family's concerns and will meet with family to discuss resident's care and appropriate interventions. Social Services will follow up with interdisciplinary team. Social Services coordinated with the clinical team to address the resident's hair concerns. Two CNAs [Certified Nursing Assistants] completed hair detangling interventions, which required approximately 1-2 hours. The resident's care plan was updated to include ongoing hair care interventions to promote consistent grooming and prevent future matting. On 7/28/26 at 12:55PM V6 (Social Services) stated, From my understanding (V10 R1's daughter) said that we neglected (R1) by not detangling her hair. The care team has tried to braid her hair and then (R1) messes with her hair and it gets matted. They had not been getting (R1) up, and she was sleeping on it, pulling the braid out and twirling her hair. I was part of the team that helped to get the matting out and it took an hour and 45 minutes and 3 staff to get the matting out of her hair. Now they are getting her up after breakfast and she stays up until dinner. They are also putting bibs on her to keep her clothes clean with meals. She has been moved from room to room, and the clothes were still in a bag. I took all the clothes out of the bag and labeled the drawers and got everything organized. I started the 15th of June so I don't know what happened before that, but I can assure what is happening now. They have not had a social worker since May. So, it is not an excuse, but certain things were not done. I think her clothes were hung up at first and then they were put in a bag. When I was hanging them up, I noticed they were all labeled with her name. I don't know how long she has been in that room. Her hair was detangled twice before. I think they cut her hair once before too. She yells and screams and is difficult to works with.On 7/28/26 at 1:30PM V2 (Director of Nursing) stated, We facilitated to make sure her hair was getting combed (after it was found to be matted). We had a couple CNAs try to braid it. She plays with it when she is in bed. On 7/28/26 at 2:05PM V10 (R1's daughter) stated, (R1) got there on April 24th. I had a care conference with them on 6/19/26 and went over all these issues and her hair was good for like 3 days. On 7/22 her hair was so matted it was all the way across the back of her head and like a kitchen sponge. It took them 2 hours to detangle it. She has such poor hygiene. When I come in, she has food all over her clothes. It is ridiculous that they can't get her up and get her dressed and brush her hair every day. That is just basic care. After that meeting on the 19th, they never updated her care plan, it was just a progress note, and they told me her care plan is updated as needed. I don't understand why they didn't feel these things should be updated on her care plan. R1's Care plan dated 7/23/26 states, Resident prefers assistance with maintaining hair care and grooming. Resident's hair will remain clean, detangled, and groomed according to her personal preferences to promote comfort, dignity, and self-esteem. Encourage staff to provide hair care, including gentle detangling, as part of the resident's routine personal care. Respect the resident's preferences regarding hairstyle and grooming whenever possible.The facility policy titled Maintaining ADLs dated 3/2021 states, The facility provides the necessary care and services to attain or maintain the highest practical, physical, mental and psychological wellbeing of the resident in accordance to the comprehensive assessment and plan of care.

Based on observation, interview, and record review the facility failed to put fall interventions in place for a resident at risk for falls and with a history of a fall in another facility. This applies to 1 of 3 residents (R1) reviewed for fall interventions in the sample of 7. The findings include: On 7/28/26 at 2:05PM V10 (R1's daughter) stated, They say she is not a fall risk. I asked them to put her in a low bed because she had a fall at the other facility, and it was traumatic for her. She fell out of bed and had a huge bump on the back of her head. They say she is not a fall risk because she has not had a fall at this facility. I asked for mats on the floor, but they won't do that because 'she is not a fall risk'. Me and the Ombudsman can't understand why you wouldn't want to just put the precautions in place. On 7/28/26 at 1:30PM V2 (Director of Nursing) stated, Family wanted a low bed (on 7/22/26) with 1/4 rails- helps her reposition too. She hasn't tried to get out of bed. She was really scared to get out of bed. Per the family she has anxiety and does not want to get out of bed. We have been getting her up. She had a fall at the other facility; I guess it was a traumatic fall. She doesn't have mats. She is not a fall risk. She has not had a fall here. She has been doing much better now. On 7/28/26 at 4:00PM R1 was in her wheelchair seated next to her bed. As the surveyor approached, R1 stated, I can lift this right leg if someone can just help me lift this left leg and get it into the bed. R1's admission assessment dated [DATE] shows that R1 is a High Risk for Falls. R1's Minimum Data Set assessment dated [DATE] shows that R1 had a fall at some time in the last month prior to admission to the facility. R1's Nurse Practitioner Progress Note dated 6/8/26 states, High Fall Risk: Follow all facility precautions. R1's current fall care plan is dated 4/24/26 and does not address R1's High Fall Risk. The facility policy titled Fall Program dated 3/2021 states, All residents will be evaluated for falls. Upon completion of the fall evaluation: if a resident is identified at risk for falls; the following may occur: A care plan is developed or updated, New fall interventions are reviewed with the resident and or responsible party and applicable staff .

Based on observation, interview and record review, the facility failed to ensure multi-use insulin pens and vials were labeled with the dates they were opened and the dates they expired. This applies to 5 of 5 residents (R4, R5, R6, R7 and R8) reviewed for medication labeling and storage in the sample of 8. The findings include: On [DATE] at 9:50 AM in the medication cart on the second-floor west wing there was an undated open vial of Humalog Insulin for R4, 2 undated Lispro Insulin pens, 1 undated Lantus Insulin pen and 1 undated Lantus Insulin Vial for R5 and 1 undated Humalog Insulin vial and 1 undated Lantus Insulin vial for R6. Also, in the medication bag of Insulin labeled with R6's name there was an undated Lantus Insulin vial with R4's name on it. On [DATE] at 10:10 AM V3 (RN-Registered Nurse) stated, We are supposed to date them when opened, then they are good for 30 days out of the refrigerator.On [DATE] at 10:25AM in the medication cart on the second-floor east wing there was an undated open vial of Humalog Insulin and undated open vial of Lantus Insulin for R7 and an Undated open vial of Lispro Insulin for R8. On [DATE] at 10:38 AM V4 (LPN-Licensed Practical Nurse) stated, They should be dated as soon as they are opened, and they are good for 30 days.The facility policy titled Insulin Pens dated 3/2021 states, Insulin pens can be stored at room temperature, once in use for up to 28 days. The date the pen was initiated should be recorded on the label.

Based on interview and record review the facility failed to ensure that residents were free from physical abuse, including residents who have a history of resident-to-resident physical altercations. This applies to 2 of 4 residents (R1 & R2) reviewed for physical abuse in the sample of 4. The findings include:R1's face sheet lists her diagnoses to include: schizoaffective disorder, bipolar type, major depressive disorder, anxiety disorder and post-traumatic stress disorder. R2's face sheet lists his diagnoses to include: alcohol abuse, cocaine abuse and generalized anxiety disorder. On 4/13/26 at 9:58 AM, R2 stated, (on 3/31/26) he was on the elevator trying to go to the 4th floor when R1 tried to get on the elevator with him. He told her there wasn't enough room for her on the elevator. She got mad and forced her way onto the elevator running over his foot with her wheelchair. He couldn't get out and had to call for help. V5 Activity Aide heard him calling for help and came over to help. She was able to move R1 out of the way so R2 could get out. They both went on with their day. Later that same day, R1 called the police and stated, R2 hit her and broke her arm. He stated, he never hit her, she ran over his foot and wouldn't let him leave the elevator. His foot was sore for a few days and they did an x-ray to make sure everything was ok. The x-ray was negative. This is also not the first time they had gotten into it and R1 accused him of hitting her. The facility found that was not true.On 4/13/26 at 3:05 PM, R1 stated, (on 3/31/26) she was trying to get on the elevator with R2 when he started yelling at her and hit her with his walker. He hit her on top of her shoulder. She called the police but they sided with him. She did go to the hospital and had a bruise. This is not the first time they have gotten into it. He ran over her foot one time. The facility's final incident investigation form dated 4/8/26 shows, resident to resident altercation. Circumstances of the alleged incident: R1 reported to V3 Social Services, that R2 while on the elevator hit her in the arm and ran over her foot with his rollator/walker. R2 stated, that R1 backed up into the elevator with her wheelchair and ran over his foot and then would not let him exit the elevator. V5 Activity Aide came to the elevator and helped to separate them. R1 called the police herself. R1 demanded to go to the hospital and was sent out to local hospital. All x-rays were negative. R2 refused to go to the hospital. The facility's employee/resident statement/interview form dated 3/31/26 written by V8 Licensed Practical Nurse (LPN) shows, Statement: Around 12:30 (PM) this afternoon, resident (R2) was on the elevator going from floor 1 to the penthouse. Elevator stopped on the third floor and a female resident (R1) attempted to enter the elevator. Upon entrance of the elevator, female resident (R1) (accompanied with wheelchair) rolled into the residents (R2) foot and walker, cornering him. Elevator closed and went to penthouse. Female resident (R1) noted to yell at resident A (R2), verbalizing she can be on the elevator with him. Once elevator reached penthouse, resident A (R2) expressed to female resident (R1) that he would like to exit, in which the female resident (R1) refused access to resident A (R2) to exit. Resident A (R2) called out for help, when a staff member (V5 activity aide) came and requested the female resident (R1) to allow resident A to exit elevator in which she refused. Staff member assisted female resident (R1) out of elevator, allowing resident A (R2) to exit on the penthouse floor. Female resident (R1) re-entered elevator going down. On 4/13/26 at 11:37 AM, V5 Activity Aide stated, she was on her way to the bathroom when she heard R2 calling for help to get off the elevator. She asked R1 to move out of the way and she refused to move. She ended up helping R1 move so R2 could get off the elevator. R1 was being a little difficult and was upset. R1's behavior progress notes dated 3/31/26 shows, Behavior: Resident called the police on another resident (R2) today, which is an identified characteristic noted on her care plan. Seeking out, bullying, and fabricating information about another resident, stating they displayed negative towards her. Non-Pharmacological Interventions: Resident requested to be sent to hospital complaining of pain her arm and foot. Resident transported via ambulance to local hospital for further evaluation.R1's local hospital discharge instruction dated 3/31/26 shows, Diagnosis: 1: contusion of right shoulder; 2: contusion of left foot. Education: Contusion: A contusion is a deep bruise. Contusions are the result of a blunt injury to tissues and muscle fibers under the skin. R2's change of condition progress note dated 3/31/26 shows, At around 1730 (5:30 PM) resident reported to writer that his r (right) foot was ran over with a wheelchair and he is experiencing soreness, writer assessed residents' foot no signs of swelling or redness at this time. Recommendations of Primary Clinicians: NP (nurse practitioner) instructed writer to place order for x-ray of the R foot. R2's x-ray of the right foot results dated 4/1/26 shows, There is no acute fracture, dislocation. R1's Minimum Data Set, dated [DATE] shows, she is cognitively intact. R2's Minimum Data Set, dated [DATE] shows, he is cognitively intact. On 4/13/26 at 11:00 AM, V3 Social Services stated, R1 and R2 have issues with each other. More R1 than R2. No one understands why she has it out for him or why she keeps trying to get him in trouble. There have been two incidents between the two now. The first one R1 said R2 rolled over foot. They were able to check the cameras and found that was not true. The facility's concern/response form dated 3/9/26 from R1 about R2 shows, a concern with a resident behavior/interaction/roommates. Resident (R1) reports that she was involved in a verbal disagreement with another resident (R2). Follow up action taken: Based on staff observation and assessment no physical altercation or contact was observed on camera footage. Situation appeared to be a verbal disagreement between residents that escalated due to misunderstanding.Follow up Action Taken: Staff reinforced maintaining respectful interactions. Staff will monitor interactions to prevent further escalation On 4/13/26 at 2:30 PM, V2 Director of Nursing stated, she knows R1 and R2 have personality conflicts and don't like each other. They don't get along. The facility's abuse and retaliation policy dated 1/29/26 shows, Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free form any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and seven (7) federal components of prevention and investigation. Definitions of abuse, neglect, exploitation & abuse coordinator: Abuse: Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. Types of abuse: 1. Physical, 2. Verbal, 3. Mental, 4. Sexual, 5. Neglect, 6. Theft/Misappropriation of property/financial abuse, 7. Involuntary seclusion, 8. Exploitation, 9. Injury of Unknown Origin, 10, Retaliation. Types of abuse and examples: 1. Physical: Physical abuse includes but is not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling. Any person in a position of power or authority may potentially cause harm to a resident. Potential aggressors include but are not limited to, facility staff, other residents, state employers, family members, volunteers, students in an affiliated Nurse-training program, students in affiliated institutions including therapy, social, and activity programs, guardian and other visitors.

Based on observation, interview, and record review, the facility failed to ensure residents were changed in a timely manner for two of three residents (R1 and R2) reviewed for activities of daily living (ADLs) in the sample of 5.The findings include:On 3/26/26 at 9:25 AM, R1 was lying in bed on a low air loss mattress. R1 said he is incontinent and is wet now. R1 said he doesn't know when he was last changed; maybe around 7:00 AM, but staff have not been back around to check on him.On 3/26/26 at 9:39 AM, V4, Certified Nursing Assistant (CNA), brought her supplies and began to change R1. V4 took the front of R1's incontinence brief and it was completely saturated with urine and had a foul smell. V4 said she does not know the last time R1 was changed. R1 then said V7, CNA, changed him last. V4 said it V7 last changed him, then it was probably around 6:00 AM because V7 is the night shift CNA. As V4 continued to change and provide incontinence care to V4, deep grooves/indentations from his brief were noted in his thighs/groin area, especially to his left thigh which was red and inflamed. After V4 cleaned up R1's backside, she said she needed to do a full linen change and pointed out a dried ring of urine on R1's fitted sheet. V4 said residents should be changed every two hours. V4 said day shift is from 7:00 AM to 3:00 PM.On 3/26/26 at 10:15 AM, R2 was lying in bed on a low air loss mattress. V5, CNA, came in to change R2. V5 said she does not know the last time R2 was changed; she has not changed him yet today. V5 said when she starts her shift, she has to get the residents ready for breakfast and she had to feed R2. V5 began to change R2 and pulled down the front of his incontinence brief which was saturated with foul smelling urine. As R2 was turned with no assistance from R2 to remove the soiled brief the back of the brief was saturated with urine too. V5 said residents are supposed to be changed every two hours.On 3/26/26 at 11:28 AM, V2, Director of Nursing (DON), said residents should be changed every two hours, and as needed.R1's Restorative Section GG effective 1/28/26 shows R1 is dependent on staff for personal hygiene and requires substantial/maximal assistance to roll left and right, move from sitting to lying or from lying to sitting, and is dependent on staff to move from sitting to standing or to move from bed to a chair or from a chair to bed, and the ability to get on/off a commode. R1's current care plan provided by the facility (undated) shows R1 requires assistance with ADLs (bed mobility, personal hygiene, toileting) and will be assisted with ADLs as needed.R2's current care plan provided by the facility (undated) shows R2 has bowel and bladder incontinence and an ADL self-care performance and impaired mobility deficit related to limited range of motion (ROM). R2 has frequent bladder incontinence and staff are to check and change him including washing, rinsing, and drying his perineum every two hours and as needed. R2 requires total staff assistance for toilet use.The facility's Incontinent and Perineal Care Policy (reviewed/revised 6/6/24) shows it is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. Rounds will be done at least every two hours to check for incontinence during each shift.

Based on observation, interview, and record review, the facility failed to ensure staff changed gloves and completed hand hygiene during and after incontinence care for 1 of 3 residents (R2) reviewed for incontinence care in the sample of 5.The findings include:On 3/26/26 at 10:15 AM, V5, Certified Nursing Assistant (CNA), was changing and providing incontinence care to R2. Wearing gloves, V5 pulled R2's urine saturated brief down and used peri wash and disposable wipes to cleanse his front peri area. V5 retracted R2's foreskin and cleaned his glans, wiped his groin, then turned R2 and removed the soiled brief and linens. Using the same gloves and without hand hygiene, V5 arranged and rolled a clean fitted sheet, pad and brief under R2. V5 positioned R2 on his back and fastened his brief. V5 went to the door and obtained assistance. V5 and V6, CNA, boosted R2 up in bed. V5 put a clean gown on R2 and then covered him with a clean top sheet and his own personal blanket. RV5 proceeded to adjust R2's pillows, tidy up the items on R2's overbed table, and remove the garbage. V5 left the room with a bag of soiled linens wearing the same gloves she had on throughout the entire task.On 3/26/26 at 11:28 AM, V2, Director of Nursing (DON), said during incontinence care, gloves need to be changed after removing dirty briefs and dirty linens and anytime they are visibly soiled. After wiping the dirty, soiled areas, the gloves should be changed and hands sanitized.The facility's Incontinent and Perineal Care Policy (reviewed/revised 6/6/24) shows it is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. Put on gloves, wash and dry the perineal area and discard disposable items, remove gloves and put on a new set of clean gloves to put on clean briefs/incontinent pads. Complete hand washing after the procedure.

Based on observation, interview and record review the facility failed to identify, assess, and implement treatment orders for a resident who had facility acquired pressure ulcer. This applies to 1 of 3 residents (R3) reviewed for pressure ulcers in the sample of 6. The findings include: On 12/5/25 at 10:05 AM, R3 was in his wheelchair self propelling down the hallway. R3 said he has pain to his bottom that started about two weeks ago. R3 said it's a sore on his right buttock, he does not have a dressing or cream being applied. R3 said he reported this to the staff, but nothing was done. On 12/5/25 at 10:07 AM, V9 (Licensed Practical Nurse-LPN) said R3 reported pain to his bottom about two weeks ago. He was referred to wound care and it was checked out and she was told it was not pressure. V9 said it was a dime size area to his right buttock that looked like a healed wound. R3 is not getting any treatment to his backside. On 12/5/25 at 10:48 AM, V14 (Wound Nurse), V9 (LPN) were in R3's room for a skin check. R3 was lying in his bed, he pulled down his pants and a dime size open area to his right buttock was present with no treatment in place. V14 said there was an area on his bottom a few weeks ago they were monitoring and now it's an open. She said at that time barrier cream was ordered. V14 said she was not aware of R3's open area until today. Staff should be monitoring skin daily, report new skin alterations and should be applying the barrier cream. This surveyor informed V14 the barrier cream was not found in his room. V14 went back in R3's room to find the cream, R3 was upset and irritated, and said to V14 what are you looking for, I don't have cream, where would I get it. V14 could not locate the barrier cream in R3's room and said he should have had the cream for protection. V14 said R3's right buttock area is a new pressure injury. On 12/5/25 at 1:00 PM, V14 (Wound Nurse) said she could not locate wound notes for the skin alteration that was identified a few weeks ago. V14 said she will assess the wound and obtain treatment orders. R3's Physician Order Sheets dated December 2025 shows orders on 11/7/25 to apply house stock incontinence barrier cream to buttock and moisturizer .may keep at bedside as needed daily and every shift. R3's Skin and Wound Note dated 11/10/25 shows new admission to the facility skin/wound assessment shows no history of chronic wounds and no wounds on current exam (R3) has risk factors that may contribute to wound formation, impaired functional mobility, bowel incontinence, and peripheral vascular disease. R3's Electronic Health Record (EHR) does not show documentation of R3's skin's alteration to his right buttock. R3's current care plan shows he has the potential for pressure ulcer development, Braden score of 19 with interventions including to administer treatments as ordered, apply house stock moisturizer daily and as needed, assess for pain, monitor/document/report to MD as needed changes in [NAME] status .weekly monitoring of wounds, assessments, recommendations, measurements. The facility's Skin Regimen and Treatment Formulary Policy revised July 2025 states, It is the policy of this facility to ensure prompt, identification, documentation and to obtain appropriate treatment for residents with skin breakdown .charge nurses must document in the EHR any skin breakdown upon assessment and identification. Furthermore, treatment must be obtained form the patient's physician .prevention a) topical moisturizer applied .b) incontinent moisturizer barrier cream

Based on observation, interview and record review the facility failed to ensure resident's bathrooms had an antiseptic handwash for 4 of 8 residents (R5, R6, R7 and R8) reviewed for infection control in the sample of 8.The findings include:1.On 11/14/25 at 9:40 AM, R5's bathroom had no hand soap. R5 said there has been no hand soap in the bathroom for a while, I have asked for hand soap repeatedly from staff, but I am ignored. I feed myself, I do things for myself, I have nothing to wash my hands, only plain water, no soap. R5's facility assessment dated [DATE] show a BIMS of 13- no cognitive impairment.2. On 11/14/25 at 9:55 AM, R6's bathroom had no hand soap. R6 said there has been no soap for a long time now, staff should know we have no soap to use to wash our hands.R6's facility assessment dated [DATE] show a BIMS of 13- no cognitive impairment.3. On 11/14/25 at 12:45 PM, R7 was eating his lunch in his room. His bathroom had no hand soap. R7 stated It's been months that there has been no hand soap, they took everything out because they said there was a recall of the hand soap and gave us hand sanitizer but never filled the hand soap. There was nothing to use to remove germs after using the bathroom, we were all taught that we are supposed to wash our hands, right? R7's facility assessment dated [DATE] show a BIMS of 15- no cognitive impairment.4. On 11/14/25 at 1pm. R8 said staff removed the hand soap because they were talking about a recall. R8 said after using the bathroom, after meals, or after going out to smoke, there is no soap to wash his hands. R8 said staff just replaced the hand soap just now, actually just a moment ago.R8's facility assessment dated [DATE] show a BIMS of 15- no cognitive impairment.Both V5 (Certified Nursing Assistant) and V6 Social Services confirmed with this Surveyor that there was no hand soap in R4-R8's bathrooms. On 11/14/25 at 1:00 PM, V2 (Director of Nursing) said there was a hand soap recall but that was way back in August 2025. All residents should have access to hand soap in their bathrooms for handwashing to prevent infection.On 11/14/25 at 1:30 PM, V7 (Maintenance Director) said he had informed his housekeeping staff to make sure all bathrooms have soap to prevent infection.The facility policy entitled hand hygiene dated 6/30/25 show, hand hygiene is important in controlling infections. the facility will comply with the CDC guidelines in regard to hand hygiene. Hand washing with soap and water for at least 20 seconds is recommended: d- before eating and after personally using the toilet.

Based on interview and record review the facility failed to initiate discharge upon a resident's request for one (R1) of three residents reviewed for discharge planning in the sample of 3.The findings include:R1's facility assessment dated [DATE] show, R1 has no cognitive impairment with a BIMS of 15.On 9/22/25 at 9:45 AM R1 was in bed alert, R1 said he was here for therapy. R1 had been wanting to either go home or transfer to another facility in Kenosha Wisconsin near his family. R1 said he has spoken to different lady Social Workers. All I got as a response was we will look into it or will let you know or will get back to you. R1 said up to now, no one had gotten back to him or let him know of what was going on with his request to go home or to transfer to another facility. R1 said he can afford to pay a 24-hour nursing care at home (R1 was private pay). R1 said his home has a ramp and walk in shower. If he cannot go home yet and need to transfer to another facility, no one had updated him with what facilities he can go to in Wisconsin. A Social Service document dated 9/8/25 by V6 (Social Worker) show: On 9/6/25, this writer met with the resident (R1) after he requested to speak with Social Services.the resident requested information regarding transferring to a different facility in Wisconsin. This writer provided supportive listening and informed the resident that follow-up will be arranged to address his concerns and discuss available options.On 9/22/25 at 11:46 AM, V6 (Social Service) said she was at the facility last Saturday 9/6/25. V6 said she was informed that R1 requested to talk to a Social Worker, so she went to spoke to R1. R1 verbalized to her that R1 wanted to transfer to another facility, however R1 felt no one was assisting him to do this. V6 said she documented their conversation in R1's progress notes but did not do anything further. V6 said she did not do any follow up regarding R1's wish to discharge to another facility, also she did not do any referrals to other facilities in Wisconsin. V6 said one of the Social Workers at the facility but mainly assigned to 4th floor residents. V6 said she can also work with residents from another floor. R1 was on 2nd floor so she relayed R1's desire to discharge to V7. (Social Service Director)On 9/22/25 at 10 AM, V7 said she was the Social Service Director but took over as the Social Worker on 2nd floor beginning of August 2025 after the previous 2nd floor Social Worker left the facility. V7 said there has been no referrals for R1 made up to now to other facilities (approximately 2 weeks) after R1 had verbalized his desire to transfer to another facility or discharged . V7 said V6 (Social Worker on 4th floor) could have started referrals. All the Social Workers work together in this facility. V7 said as of today, (9/22/25) referrals will be sent and R1's family will be called to discuss R1's plan of discharge. Discharge planning should start on the day of admit.The facility policy on Discharge planning and instructions dated 6/30/25 show, facility to conduct proper discharge planning for all residents. Discharge planning shall be initiated by the facility and resident's admission and reevaluated quarterly. Social services shall evaluate its residents discharge planning potential in collaboration with facilities interdisciplinary team. Social services shall facilitate referrals to appropriate community agencies.

Based on observation, interview and record review the facility failed to ensure a medication refrigerator was maintained in the acceptable temperature range for 4 of 4 residents (R18, R73, R34 and R143) reviewed for medication storage in the sample of 33.The findings include:On 8/12/25 at 9:10 AM, the surveyor and V16 (Licensed Practical Nurse) checked the 3rd floor medication refrigerator. The medication refrigerator felt warm. The thermometer inside the medication refrigerator showed a temperature of 54 degrees Fahrenheit (F). V16 closed the refrigerator and waited for approximately 25 minutes. The medication refrigerator was again checked, the thermometer inside now showed a temperature of 60 degrees F. V16 said the medication refrigerator should be in the 40's degrees (F) to maintain effectiveness of the medications. Inside the medication refrigerator was R18's unopened Humalog Lispro quick pen, (insulin pen), R73's unopened Humalog quick pen (insulin pen), R34's eye drops of Latanoprost Ophthalmic Solution 0.005 %, and R143's Dulaglutide Subcutaneous Solution Auto-injector 1.5 MG/0.5ML (Trulicity.)On 8/12/25 at 9:35 AM V12 (3rd floor Supervisor) said unopened insulin pen should be stored at a temperature of 36 to 46 degrees (F). V12 also said the eye drops and the Trulicity should also be within that range 36-46 degree F. V12 said we will replace the refrigerator as soon as possible. V12 said she will also check the medications inside the medication refrigerator affected. On 8/12/25 at 10:15 am, V17 (Maintenance) said he had to replace the medication refrigerator; the refrigerator was not functioning (not cooling) due to too much ice buildup. V17 said he had provided a new refrigerator now for the medication room.A document entitled Temperature log provided by V2 (DON), showed the Refrigerator Medication temperature must be kept on 36-46 digress F.The Facility Policy on Medication Storage dated 7/2/25 show It is the facility's policy to comply with Federal Regulations in storage labeling and disposal of medications.

Based on observation, interview, and record review the facility failed to provide an on going assessment for R149's restraint use for 1 of 1 residents (R149) reviewed for physical restraints in the sample of 33.Findings include:On 08/11/2025 at 10:11AM, R149 was sitting in a wheelchair in the hallway by the nurse's station. R149 was wearing a waist restraint that was attached to the wheelchair. On 08/13/2025 at 10:02AM, V13 Restorative Nurse said, the lap restraint is under restorative. An assessment should be completed annually and quarterly. If the restraint is used for trunk support, the restorative nurse performs the restraint assessment on the resident. If the restraint is for behaviors or falls, the assessment is performed by the falls/psychotropic nurse. The 08/22/2024 restraint assessment is the only assessment I have for the restraint.On 08/13/2025 at 10:33AM, V12 Falls/Psychotropic Nurse said, R149 is a fall risk. The restraint is used due to his poor trunk support. I do not have a restraint assessment for R149 or a restraint reduction assessment.R149's Physical Restraints Informed Consent dated 08/22/2024 shows, Method of Physical Restraint Used: Lap Restraint. The reason the physical restraint is needed: Dementia, non-compliant with transfer status, impulsive behavior, poor trunk control.R149's Restraint assessment dated [DATE] shows, Other devices: Does this device prevent resident from standing, transferring, or walking? Yes. Does this device meet the definition of restraint? Yes. Purpose of Restraint: .leaning forward due to poor trunk control, observed with impulsive behavior, and non-compliant with transfer status. This device is considered a restraint, resident is unable to remove per self and staff to remove during activities of daily living.R1's Medication Administration Record dated 08/2025 shows, waist restraint applied to wheelchair. Check every 2 hours for skin integrity and circulation. Start date 08/22/2024 at 7:00AM. Marked as completed on Night, Day, and Evening shift August 1 through August 11, 2025. R149's MDS-Minimum Data Set, dated 07/2025 shows, Physical Restraints: NOT USED.The facility Restraints policy revised 07/03/25 shows, the use of the restraining device may be assessed and reduced at least quarterly.

Based on observation, interview and record review the facility failed to ensure residents who require staff assist were provided incontinence care and facial grooming in a timely manner. This applies to 3 of 33 residents (R9, R90 & R85) reviewed for activities of daily living (ADLs) in the sample of 33. The findings include: 1. On 8/11/25 at 9:48 AM, R9 was lying in bed. She was partially covered with a sheet. Her bed pad was under her feet instead of her buttocks. The bed pad had a wet, yellow circle where her feet were resting. The bottom sheet also had a wet, yellow circle under her buttocks. At 11:26 AM, R9 was still resting in the same position in her bed. She was still laying in a wet, yellow circle. There was a strong urine odor. At 12:14 PM, V9 4th floor nursing supervisor was feeding R9 in bed. She remained in the same position in bed. V9 4th floor nursing supervisor covered R9 with a blanket and fed her lunch. R9 was still lying in a urine saturated bed. At 12:32 PM, V10 and V11 Certified Nursing Assistants (CNA) changed R9. R9 had wet through her disposable brief, the bed pad and onto the bottom sheet. V10 CNA stated, she was taking care of R9 as her CNA. When asked, if R9 was changed this AM, she stated, it's hard, she be fighting. R9 did not fight the CNAs when they changed her at 12:32 PM. On 8/13/25 at 11:26 AM, V2 Director of Nursing stated, R9 can not verbalize her needs so she is a check and change. She should be checked and changed every 2 hours and as needed. R9's urinary continence task did not show she was changed at all on 8/11/25. The task list shows, she was last changed on 8/10/25 at 8:03 PM. R9's restorative section GG dated 2/19/25 shows, she requires partial/moderate assistance with toileting hygiene. The assessment has not been updated since. R9's electronic medical record shows, she was re-admitted to hospice on 6/9/25. 2. R85's facility assessment dated [DATE] documents R85 has no cognitive impairment (BIMS of 15.) The same assessment show R85 is dependent on staff for toileting, R85 is always incontinent of bladder and bowel functions and R85 has no behaviors of rejection of care. On 8/11/25 at 10:45 AM, R85 said she has MS (multiple sclerosis) and she need two (2) staff to toilet her. R85 said she wears two incontinent pads because no one changes her after she gets up in the morning. Once I'm up at around 10: 30 AM, I am up until 7:30pm, trying to find someone to change me is hard, they say they are busy or they have no one to help them to change me, so I just decided to have 2 pads, a pad beneath me on chair in case my urine leaks due to not being changed. R85 said she would like to be changed at least once after she gets up. On 8/12/25 at 1PM V18 (Certified Nursing Assistant-CNA) said R85 wears 2 pads or double briefs. R85 also seats with a pad under her because she does not want to be wet in her chair. V18 (CNA) said she toilets R85 when she was working but she cannot speak for other staff or on PM shift. On 8/13/25 at 10am, V12 (3rd floor Nurse Supervisor) and V2 (Director of Nursing) said they spoke to R85 yesterday and R85 said the same thing, that R85 was not toileted when she ask staff to toilet her. V12 and V2 both said that starting today, they made a schedule with the agreement of R85. After R85 gets up, staff has to toilet R85 at around 1:30 PM and between 8-9:30 PM. R85's careplan dated 7/1/25 show, R85 has ADL Self Care Performance Deficit and Impaired Mobility r/t MS,. morbid severe obesity, slurred speech, diplopia, contracture- left knee, pain in left knee,. peripheral autonomic neuropathy, neuromuscular dysfunction of bladder, vitamin D deficiency, DVT with intervention of assist resident as needed : I am Dependent with staff with Toilet Hygiene. The facility Policy on incontinence care dated 6/30/25 show it is the policy to provide perineal care to ensure cleanliness and comfort for the resident to prevent infection and skin irritations and to observe the resident skin condition 3. R90's Face Sheet printed on 8/11/25 showed she admitted to the facility on [DATE]. The same document showed she was a [AGE] year-old female and diagnosed with severe intellectual disabilities, tracheostomy, and dependent on a ventilator. On 08/11/2025 at 10:08 AM, R90 was in bed. R90 had facial hair. The facial hair was located on R90's top lip area and continued around to her chin. The facial hair was about 1/8 to 1/4 inch long and could be visible half way across the room. On 08/11/2025 at 1:42 PM, V7 (R90's Family Member/Guardian) said R90 was nonverbal and dependent on staff for activities of daily living (ADL). V7 said R90 had long facial hair and needed to be shaved. On 08/11/2025 at 12:54 PM, V8 (Certified Nursing Assistant) said she was familiar with R90. V8 said R90 was nonverbal, dependent on staff for ADL, and did not refuse care. A facility assessment done on 07/31/2025 showed R90 was dependent on staff for shaving and did not reject care. R90's Behavior Task documentation from admission [DATE]) to present (8/12/25) did not indicate R90 refused care. R90's Care Plan with an initiated date of 7/28/25 showed she required assistance with ADLs. The facility's General Care policy with a revised date of 6/30/25 showed it is the facility's policy to care for every resident to meet their needs.

Based on observation, interview, and record review the facility failed to serve a resident their preferred meal portion/size for 1 of 33 residents (R10) reviewed for food preferences in the sample of 33.The findings include:On 08/11/2025 at 10:26 AM, R10 said he was always hungry after meals. R10 said he was to receive double portions of food, however he was not getting double portions of food. R10's Order Summary Report dated 08/11/25 showed R10 was to get double portions of food.On 08/11/2025 at 12:02 PM, R10 was in his room eating. The serving size of his meal appeared to be the same size as a regular meal. The meal ticket on R10's tray did not indicate R10 was to get double portions. On 08/11/2015 at 12:30 PM, V3 (Food Service Manager) said if a resident was to get double portions it would be listed on the meal ticket and that is how the kitchen would know to serve double portions of food. On 08/12/2025 at 10:33 AM, V4 (Dietitian) said R10 was to receive double portions as it was R10's preference. V4 stated R10 reported he was hungry after meals so double portions were ordered. V4 said the double portions were not added as a weight management intervention.

Based on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) when entering a COVID-19 isolation room for 1 of 1 residents (R21) reviewed for infection control in the sample of 33. The findings include:On 08/11/2025 at 10:30 AM, there was a sign on R21's door. The sign indicated R21 was on isolation. The sign indicated everyone that entered the room was to wear the following PPE: a N-95 mask, gloves, isolation gown, and eye protection. On 08/11/2025 at 10:35 AM, R21 was in her room and V5 (Certified Nursing Assistant) entered R21's room with linens. V5 had on PPE however she did not have on any eye protection.On 08/11/2025 at 10:45 AM, V5 exited R21's room with a clear bag of what appeared to be dirty linens. On 08/12/2025 at 10:58 AM, V6 (Infection Control Nurse) said R21 was on isolation for COVID-19. V6 said staff should wear a N-95 mask, gloves, isolation gown, and eye protection when entering R21's room. R21's Order Summary Report dated 8/12/25 showed an order to maintain at all times strict contact and droplet isolation due to active COVID-19 infection.R21's Care Plan with an initiated date of 08/05/25 showed R21 required isolation for COVID-19. Listed under interventions was to use appropriate PPE. The facility's Preventing and Controlling Acute Respiratory Illness Outbreaks in Skilled Nursing Facilities and Other Facilities Providing Skilled Care policy with a revised date of 07/16/25 showed required PPE for COVID-19 isolation included eye protection.

Based on interview and record review the facility failed to assess a surgical wound and change the dressing as ordered for13 days. This failure resulted in R2 developing an infection in the left knee surgical wound requiring hospitalization and surgery on 6/3/25. This applies to 1 of 3 residents (R2) reviewed for surgical wounds in the sample of 5.The findings include: R2's Physician's Order Sheet dated August 8, 2025 shows that she was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Dementia and History of Falling. This document also shows orders for: Left Leg non-removeable dressing every day shift for wound care and an appointment scheduled with V6 (Orthopedic Physician) on 6/18/25. R2's admission assessment dated [DATE] states, left lower leg- cast.R2's Hospital Discharge Instructions dated 5/20/25 show an order for Dressing change every 3-5 days and as needed. Instructions: Place sheet of Xerofoam, 4x4s then Kerlix. Ace wrap from ankle to thigh. Then place splint to maintain leg extension. Then wrap from ankle to thigh again with another ace wrap to hold the splint.On 8/8/25 at 10:30AM V5 (LPN- Wound Care) stated, She came in with a few wounds on the legs and then the surgical on the (Left) knee.When she came here she had a hard cast on and as far as I know it was not removeable It was wrapped with an Ace wrap but it was a hard cast At least I thought it was a hard cast. I was not here the day they removed it. I may have overlooked the order for the wound care when she came in. We get a lot of (V6's- Orthopedic Physician) patients and their orders say 1-2 weeks but then we call to make an appointment and we can't get in for about a month. I have talked to him a few times since the wound infection but I don't think I talked to him before. He used to be very hard to get a hold of but now I have his direct number so I can reach him a lot easier. When (R2) came in I'm sure I talked to the primary care physician and told him she had a non removeable cast and he just said ok. On 8/8/25 at 12:06PM V4 (Registered Nurse) stated, I did the admission assessment for her. I checked the cast and I notified wound care. I don't remember seeing an order for wound care. I report to wound care and then they take over the orders from there. I don't recall her having any specific problems with the cast. She kept asking for Norco - very regularly. She did not complain of specific pain from the cast, just pain in general.On 8/8/25 at 3:00PM V10 (Wound Nurse Practitioner) stated, That info came from the patient. She was alert and oriented so I listened to what she said. (To not remove the dressing until she sees the ortho). At the time I saw her I did not have access to the orders and that is what the patient verbalized to me. I looked through the hospital record later before I finalized my note but I must have overlooked the order for treatment. In my experience I have seen physician's leave the dressing in place until the patient is seen in the office. Hers was a splint with batting, it was able to be removed but we had orders to leave it in place. 1 month would be a long time to leave the dressing in place but I go by what the surgeon says.R2's Progress Notes dated 6/3/25 state, During wound care around 10:50 AM, a putrid odor was noted coming from the residents non-removable cast. Wound care nurse opened the cast and noted bluish black tissue with increased drainage. The writer was requested to visualize the surgical site who also noted the same. The writer immediately contacted the surgeons office and was able to speak to a nurse who stated surgeon is only in office on Wednesday and nurse will reach out to the surgical doctor who may request a call back. Following that call, the writer contacted the resident's Primary Care Physician who said a surgeon needs to see and assess her wound immediately. This is a 100% surgical issue and no one else should touch the site besides a surgeon, preferably (V6) who is the surgeon for the resident. Follow up with the surgical office in 2 hours, if no update, send the resident to (Local Hospital) non-emergency.On 8/8/25 at 11:15AM V3 (Licensed Practical Nurse) stated, She had a cast on her leg and there was a smell coming from the room. I can't recall for how long we noticed the odor. I spoke with the wound care team and then I called the MD and told him about the symptoms we were seeing. (V7- LPN Wound Care) removed the cast- I was not in the room when she did. There was this bluish, blackish greenish drainage and the wound was open. The smell got stronger when she opened the splint. She took the whole splint with her, I never saw it. Usually I am in the room but I think it was just her. On 8/8/25 at 12:40 PM V7 stated, She did not have a cast. She had a posterior mold with undercast padding and an ace bandage over the top. I had noticed some breakthrough drainage in the early morning so I put an ABD pad over it then that bled through. I removed the ABD and trimmed back the padding so I could see the knee and I could see redness around the knee. We didn't do dressing changes on her- the order was for non-removeable dressing. We would check for circulation but there was no dressing change. It was written in the treatment orders. The ABD did not have like bright red blood on it but more like old brownish drainage. I had the nurse call the MD and we sent her to the ER. Unless I am doing the admission I do not go back and look at the admission orders. I just use the orders in the treatment record. R2's Hospital Wound Care Progress Note dated 6/4/25 states, Wound culture sample taken from ED, patient admitted for further evaluation and treatment for wound infection requiring IV antibiotics, with infectious disease and orthopedic consult.R2's Hospital Consultation Note dated 6/5/25 and written by V6 (Orthopedic Physician) states, Patient presents to the ED from (Nursing Home). Patient with resent surgery 2 weeks ago on the left knee following a fall. Per staff bandage has not been removed since surgery and they noticed a foul smell, removed bandage and noticed necrotic tissue and inflammation. [AGE] year old female well known to service. Recent admission with large transverse laceration across leg/knee that required I&D (Incision and Drainage) with woundvac treatment. Was doing well post op and transferred to SNF. For reasons unknown, woundvac was not continued at SNF. Large Eschar and poor wound healing ensured. Patient was brought to (Hospital) and decision made to admit for more comprehensive wound care than was being offered at the SNF. Planning to repeat I &D in the OR (Operating Room). Assessment/Plan: 1. Wound Dehiscence; 2. Wound infection.

Based on observation, interview, and record review the facility failed to notify a resident's representative of a significant change of condition. This applies to 1 of 3 (R1) residents reviewed for notification in the sample of 3. The findings include: R1's face sheet shows she is a [AGE] year old female with diagnoses including chronic respiratory failure with hypercapnia, candidiasis, congestive heart failure, type 2 diabetes, pulmonary hypertension, chronic kidney disease stage 3, lymphedema and tracheostomy status. R1's face sheet shows V11 is listed as responsible party/emergency contact #1 V12 (R1's daughter) is listed as emergency contact #2. On 12/17/24 at 9:29 AM, R1 was observed lying in bed with a tracheostomy in place. R1 said she came back from the hospital recently and does not recall being on a ventilator while at the facility before going to the hospital. R1 said her family was upset the staff did not notify them of her condition change. On 12/17/24 at 12:30 PM, V4 (Registered Nurse-RN) said on 12/4/24, V8 (Respiratory Therapist-RT) notified him her oxygen levels were low. He notified the nurse practitioner and orders were received for a breathing treatment and if not resolved place R1 on a mechanical ventilator to help her breathe. R1 was placed on a mechanical ventilator to help her breathe and maintain her oxygen levels. The family was upset and worried the next day when they saw R1 on the mechanical ventilator and were not notified. V4 said he did not notify the emergency contact because, R1 is alert and oriented and there was no change in her cognition. On 12/17/24 at 1:00 PM, V11 (R1's spouse) said he was not notified R1 was placed on a mechanical ventilator until the next day when he came to visit and saw her on the ventilator. V12 (R1's daughter) said she too was not notified of R1 being placed on the ventilator to help her breathe. On 12/17/24 at 2:18 PM, V8 (RT) said on 12/4/24, R1 was very lethargic she checked her oxygen levels, and they were in the 70's. She provided respiratory treatment and interventions to relieve her respiratory distress but could not maintain R1's oxygen saturation above 90%. R1 was then placed on a mechanical ventilator. When a resident is placed on a mechanical ventilator it is an emergent situation, nursing should notify the family and the physician of the residents change in condition. On 12/17/24 at 12:08 PM, V2 (DON) said V12 (R1's daughter) was asking why R1 was placed on the ventilator and why no one was notified about her being placed on the ventilator. At the time R1 was agreeable to be placed on the ventilator. It's up to R1 if she wanted her emergency contact notified of her condition change. R1's nurse note dated 12/5/24 documents Change of Condition, (R1's) oxygen saturation was dropping to 77%, as per RT. Breathing treatment and ambu bag with 40% concentration initiated. RT suctioned copious amounts of thick secretions .NP (Nurse Practitioner) was notified and orders received to connect (R1) onto a mechanical ventilator. The facility's Notification for Change of Condition Policy revised 2024 states, The facility will provide care to residents and provide notification of resident change in status. The facility must immediately inform the resident; consult with the resident's physical; and if known, notify the resident's legal representative or an interested family member when there is .a significant change in the resident's physical, mental or psychosocial status (i.e. deterioration in health .), a need to alter treatment significantly .

Based on interview and record review the facility failed to follow the physician's order to send R1, who was hypoxic, and having difficulty breathing to the hospital. This failure resulted in R1's deterioration towards the end of the evening shift, on [DATE] to needing cardiopulmonary resuscitation (CPR) on [DATE] at 2:25AM, to R1's death at the facility in her room at 3:10AM, for 1 of 5 residents reviewed for quality of nursing care in the sample of 5. The Immediate Jeopardy began on [DATE], towards the end of the 3:00PM to 11:00PM shift, when V6 (RN-Registered Nurse) provided R1 with a 100% non-rebreather due to R1 having difficulty breathing and becoming hypoxic with blood oxygen levels dropping below 90%. V6 (RN) failed to follow R1's Physician Order provided on [DATE] at 1:13PM, showing to send R1 to hospital with difficulty breathing/SOB (shortness of breath). The findings include: V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 5:28PM. The Immediate Jeopardy was removed on [DATE] at 2:30PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. On [DATE] at 10:13AM, V4 (RT-Respiratory Therapist) said, when using an oxygen NRB (Non-rebreather Mask) with an oxygen tank, the flow should be 15 liters (L) or higher to ensure the patient receives 100% oxygen. The NRB has a bag attached. The bag must be filled with oxygen to ensure the exhaled carbon dioxide is released and does not collect inside the mask. If less than 15L oxygen flow rate is maintained the resident will get less oxygen intake and their blood carbon dioxide levels will increase. A concentrator has a maximum output of 50% oxygen; a NRB cannot be used with an oxygen concentrator. Respiratory Therapists manage residents on ventilators. We do not manage oxygen administrator for non-ventilator patients. On [DATE] at 11:55AM, V3 (Licensed Practical Nurse/LPN) (11:00PM to 7:00AM, shift) said, R1 was on a non-rebreather. The respiratory therapist (V5 RT) was the one that switched her over. We had her on a nasal cannula, RT (Respiratory Therapy) changed her over to the non-rebreather, I did not perform intervention, I documented. We thought the concentrator may not be working so we switched her over to the tank. On [DATE] at 12:32PM, V5 (RT) said, I did not place the NRB on R1. I arrived for the Code Blue (cardiopulmonary resuscitation) and began using a bag valve mask. R1's Progress Notes by V5 (RT) dated [DATE] at 2:35AM, shows Respiratory Note, Note Text: Code blue called to resident's room. RT arrived immediately to room and began to bag resident on flush oxygen. EMT (Emergency Medical Technician) arrived and took over bagging (providing oxygen (O2) via Bag Valve mask). On [DATE] at 1:03PM, V6 (Registered Nurse/RN) said, I put the NRB mask on R1 towards the end of my shift [sic] (3:00PM to 11:00PM). Her oxygen level was going down below 90%. I put her on the NRB and it increased her blood oxygen level to ,d+[DATE]%. R1 is not normally on oxygen. I did not obtain an order for the use of a NRB mask. On [DATE] at 11:51AM, V2 (Director of Nursing/DON) said, NRB are for emergency use. There is no standing order for NRB mask use. When a non-rebreather is used, it is an emergency. The nurse would not stop to get an order. On [DATE] at 2:06PM, V7 (Physician Extender) said, when I was called ([DATE] at 1:13PM), R1 had SOB (shortness of breath) and a blood oxygen level of 90%. I think the patient had just come back from dialysis. R1 had a plural effusion prior and episodes of SOB with activity and change in position. If there are changes in R1's condition the staff did not mention any other indicator to send resident to hospital. I was not informed about the results of the stat (immediate) chest x-ray. If I had received the results of the chest x-ray, I would have provided orders; a finding of atelectasis and pneumonia are not normal. If notified, I could compare x-rays, if a worse problem is identified, we could have sent the patient out to the hospital. I cannot tell you what I would have done, I am not certain. I did not have a chance to make a comparison. The information was not relayed to me. I was not informed about the non-rebreather mask. Everything depends on the condition of the patient. If the resident's breathing is abnormal and blood oxygen levels are going down, they need to send the patient to the hospital. The nurse should follow my instructions as well. When the indications are present to send the resident to the hospital .the nurse is aware of the protocol. After using up all the measures, and the condition of the patient is declining with hypoxia (low oxygen level) and SOB we need to send the resident to hospital right away. R1's Progress Notes dated [DATE] at 12:30AM, shows, V3 (LPN) Note Text: Approx 12:30am resident was assessed by 2 nurses. SPO2 (blood oxygen level) ,d+[DATE]% via O2L (liters) non-rebreather mask. 12:47am po (by mouth) med (medication) was administered. Resident monitored and checked periodically. Approx (approximately) 1:30am VS (vital signs) obtained. T (temperature) 97.1 P (pulse) 65 R (reparations)16 SPO2 (peripheral oxygen saturation) 97% via non-rebreather mask with O2@ 2L . 1:55am Resident has order to send her out to ER, but if condition worsens, send out 911. Call placed to transport ambulance for ETA (estimated time of arrival) update. Approx 2:10 Resident reassessed by 2 nurses. Approx 2:15am resident reassessed and noted resident with faint pulse and respiration, minimal response to verbal and physical stimuli. O2 increased to 10L per non-rebreather mask due to hypoxia. Approx 2:20am Resident reassessed again and unable to obtain pulse/respiration. Code blue and 911 called. CPR-Cardio Pulmonary Resuscitation initiated. Crash cart obtained and AED (Automatic External Defibrillator) applied. No shock advised. Ambu bag (bag valve mask) applied. IV NS (intravenous-normal saline) fluids administered to PICC (peripherally inserted central catheter) line in L (left) upper arm. CPR continued. Approx 2:25am RT arrived to room and took over ambu bag. CPR continued. No pulse. Staff continued CPR until paramedics arrived at approx 2:34. EMT took over code upon arrival to room. Paramedics started 2 more IV lines with fluids, to both legs. CPR continued. Approx 3:10am resident pronounced dead. MD (physician) notified of resident status. Administrator and DON (director of nursing) notified of resident status. Family notified and updated of resident status. Approx 4am coroner was notified of death and he released the body for funeral home pick up. R1's Physician Order [DATE] at 1:13PM, shows, send to hospital with difficulty breathing/SOB. R1's Physician Order [DATE] at 1:13PM, shows, stat chest x-ray. R1's Chest X-Ray, reported date [DATE] at 8:16PM, shows, suboptimal pulmonary expansion. Near complete opacification right hemithorax. Patchy perihilar and lower lobe opacities left lung. The findings may reflect atelectasis and pneumonia. Follow-up as clinically indicated. R1's Abdomen, 2 View X-ray reported date [DATE] at 11:38AM, shows, Lung Bases are clear. Review of R1's Physician's Orders dated [DATE] to [DATE] shows, R1 did not have an oxygen order for the use of a 100% non-rebreather mask. R1's oxygen order dated [DATE] shows, oxygen continuous 2 liters per minute via nasal cannula. The facility's Physician Orders policy dated [DATE] shows, it is the policy of this facility to ensure that all resident .plan of care must be in accordance to the licensed physician's order. The facility shall ensure to follow physician orders as it is written Physician orders will be carried out at a reasonable time. Provision of care, treatment and services administered must be approved by the attending physician The facility's Oxygen Therapy and Administration policy dated [DATE] defines, Hypoxia as oxygen saturation levels of less than 92%. R1's Physician Order dated [DATE] at 3:56PM, shows, FULL CODE. R1's Death Certification dated, [DATE] shows, Cause of death: Cardiopulmonary Arrest, End Stage Renal Failure. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1. On [DATE] [Name of Director of Nursing] DON, initiated in-services for Nurses, CNAS, and Respiratory Therapists on change of condition policy, including recognizing change of conditions, and ensure resident's experiencing a change in condition requiring emergency lifesaving interventions are sent to the hospital in a timely manner. The facility will ensure that new hires, staff on leave, and agency staff will be in-serviced prior to their first shift regarding this topic. 2. On [DATE] [Name of Director of Nursing] DON, initiated in-services for Nurses, CNAS, and Respiratory Therapists on reviewing the resident's stat diagnostic tests and report abnormal findings to the physician for all residents in the facility, and to ensure physician orders are carried out for resident's experiencing a change in condition. The facility will ensure that new hires, staff on leave, and agency staff will be in-serviced prior to their first shift regarding this topic. 3. QA tool titled F684 QA Tool was initiated on [DATE]. This audit tool will be utilized to monitor education regarding change of condition, ensuring emergency life-saving interventions in timely manner, reviewing residents stat diagnostic tests and reporting abnormal findings to the physician for all residents in the facility, ensure physician orders are carried out for all resident's experiencing a change in condition. This will be carried out by [Name of Administrator] administrator, for 5 residents, twice a week for 8 weeks.

Based on observation, interview and record review the facility failed to identify or assess an unstageable deep tissue sacral pressure injury. This failure resulted in R108's sacral pressure injury being infected upon identification/evaluation, requiring intravenous antibiotic therapy. The facility also failed to identify a left heel pressure injury and failed to ensure treatments were in place per physician orders. This applies to 2 of 5 residents (R108 & R131) reviewed for pressure injuries in the sample of 29. The findings include: 1. R108's face sheet lists her diagnoses to include: adult failure to thrive, local infection of the skin and subcutaneous tissue, pressure ulcer of sacral region, stage 4, diabetes mellitus and spondylosis without myelopathy or radiculopathy, cervical region. The facility's wound report provided on September 26, 2023 shows, R108 has a facility acquired stage 4 ulceration to her sacrum identified on June 6, 2023. R108's progress notes dated June 6, 2023 shows, Writer called and left message twice in regards to new wound found to sacrum and attempt to get verbal consent for wound physician to see Resident. R108's EMR (electronic medical record) does not show any assessments of her new wound on June 6, 2023. The first assessment of R108's sacral wound is on June 14, 2023. R108's initial wound evaluation and management summary dated June 14, 2023 by the wound physician shows, History: Chief complaint: Patient present with a wound on her sacrum and a rash Focused Wound Exam (Site 1): Unstageable (due to necrosis) sacrum full thickness, Etiology: pressure, MDS (minimum data set) 3.0 stage: unstageable necrosis, duration: greater than 3 days, Wound Size (L x W x D (length x width x depth)): 4.0 x 7.0 x 0.2 cm (centimeters), Surface Area: 28.00 cm, Exudate: moderate serous, Thick adherent devitalized necrotic tissue: 70%, Granulation tissue: 30%. Additional wound detail: Pt (patient) arrived to facility with the wound; it was NOT acquired in-house; .This pt was originally admitted to the current facility from the hospital for a L (left) ankle fx (fracture) following a fall in 2022; She has continued to progressively decline, and has become a long term resident; She has had numerous hospitalization s across the year for issues such as AMS (altered mental status), TIA (transient ischemic attack), PE (pulmonary embolism) and UTI (urinary tract infection) with sepsis most recently; She was recently readmitted , and had been stable for a time, but was found on routine skin exam to have developed a wound on her sacrum, prompting consultation . The wound was heavily necrotic and so was debrided; We will begin santyl/foam Q (every) daily at this time; Based on the speed at which this wound developed and became necrotic, infection is a very real contributor to the wound's acceleration, so Deep Tissue Cx (culture) was taken at the bedside, and we will begin empiric doxycycline (antibiotic) at this time; . R108's EMR shows, she was discharged to the hospital March 23-27, 2023 (3 months prior to wound development) with no other hospitalization s. The facility did not provide any documentation to show R108 had a wound on her sacrum prior to June 6, 2023 and no assessments were done from June 6-14, 2023 (8 days later). R108's lab results for her sacral wound culture reported on June 20, 2023 shows, positive for ESBL (extended spectrum beta lactamase). R108's Medication Administration Record (MAR) for the month of June 2023 shows, she was treated with 3 different antibiotics for a wound infection. Gentamicin Sulfate Ointment 0.1%, apply to sacrum topically every day shift for wound care infection Q daily. Doxycycline Hyclate Tablet 100 mg (milligram), give 1 tablet by mouth two times a day for infection for 14 days. Zosyn Intravenous Solution Reconstituted 3.375 (3-0.375) GM (gram) (piperacillin sodium-tazobactam sodium), Use 3.375 gram intravenously four times a day for wound care infection for 2 weeks. On September 26, 2023 at 9:07 AM, R108 had a large baseball size open wound on her sacrum. The wound was slightly red around the open area. The open area was red with some white tissue inside. V4 WCN stated, it was an in house acquired sacral wound. On September 26, 2023 at 1:54 PM, V4 Wound Care Nurse (WCN) stated, she first saw R108's sacral wound on June 6, 2023 it was a DTI (deep tissue injury). She doesn't know why she doesn't have an assessment done. She didn't have measurements, a picture or any other information about the wound. She confirmed the first wound assessment was done on June 14, 2023 with the wound care doctor. I honestly don't know why it is not in there (assessment done on June 6, 2023). She also stated, R108 is dependent on staff for turning, repositioning and changing. R108's Minimum Data Set, dated dated dated [DATE] shows, she is not cognitively intact and requires extensive assist of two people for bed mobility, toilet use ad personal hygiene. R108's care plan (not date) shows, R108 At risk for skin breakdown d/t (due to): DM (Diabetes Mellitus), HTN (hypertension), Impaired mobility, Incontinent, Use of anticoagulant, Braden score of 13, Actual skin alteration, Sacrum: pressure injury stage 4. The facility's Skin Care Treatment Regimen last revised July 28, 2023 shows, Policy Statement: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for residents with skin breakdown. 2. On September 26, 2023 at 9:42 AM, V4 WCN was changing R131's sacral wound dressing with V9 Wound Care Physician and V29 Certified Nursing Assistant (CNA). R131 did not have a dressing on his sacral wound. There was a small open area to his sacrum. R131 was observed with a large blackish, red skin discoloration on R131's left heel as he was rolled over on his side. R131 had a pressure relieving boot on the windowsill and nothing was offloading his heels. V9 Wound Care doctor continued to assess R131's sacral wound and then left the room. V4 WCN continued with R131's wound care to his sacrum. Once she was done with R131's sacrum she positioned him back on his back. When asked what the discoloration was on R131's heel, V3 WCN looked at it and stated, Oh well that's new and walked out to get V9 Wound Care Doctor to come back in the room and look at the wound. V9 Wound Care Doctor stated, he needed to offload his heels because it was putting direct pressure on them. When R131 was asked why R131 didn't have his pressure relieving boot on R131 stated, I wear my boot most everyday, I don't know why it is not on. He also stated, someone must of taken his dressing off his sacrum when he was being changed, he didn't know. V29 CNA stated, he always wears his boots and if he doesn't it's only for a bit usually. The facility's wound report provided on September 26, 2023 shows, he was admitted with a stage 4 sacral pressure ulceration. The same report does not show, a wound on his left heel. R131's wound evaluation and management summary dated September 26, 2023 shows, History: Chief Complaint: Patient has wounds on his left heel; sacrum . Focused Wound Exam (Site 1): Stage 4 pressure wound sacrum full thickness: .Wound Size: 0.7 x 0.4 x 0.2 cm . Focused Wound Exam (Site 8): Unstageable DTI to the left heel partial thickness: Etiology: Pressure, MDS 3.0 Stage: Unstageable DTI with intact skin, Wound Size (L x W x D): 0.8 x 0.7 x not measurable cm . R131's progress notes dated September 26, 2023 shows, During rounds with V9 Wound Care Doctor new DTI noted to left heel. R131's order review report shows, Left heel: cleanse site, apply betadine and leave open to air. every day shift for wound care. Sacrum: cleanse site, apply collagen and cover with foam border dressing every day shift every 3 days for wound care. R131's Minimum Data Set, dated dated dated [DATE] shows, he is cognitively intact. The same assessment shows, he requires total dependence for bed mobility, transfer and toilet use. He requires total dependence of one person for dressing and extensive assist of one person for personal hygiene. R131's care plan (no date) shows, Focus: R131 has potential for pressure ulcer development related to COPD (Chronic Obstructive Pulmonary Disease), PVD (Peripheral Vascular Disease), HTN (hypertension), Impaired mobility, incontinent, Braden score of 16, actual skin alteration, sacrum: pressure stage 4. Interventions: Administer treatments as ordered and monitor for effectiveness. Apply heel protector as indicated. Notify nurse immediately of any new areas of skin breakdown, such as redness, blisters, bruises, discoloration noted during bath or daily care. Turning and repositioning every 2 hours and as needed. The facility's Skin Care Treatment Regimen last revised July 28, 2023 shows, Policy Statement: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for residents with skin breakdown.

Based on interview and record review, the facility failed to protect a female resident from being sexually abused by a male resident. This failure resulted in R187 sexually assaulting R116 on 10/12/22. This applies to 1 of 27 residents (R116) reviewed for abuse in a sample of 27. The findings include: The facility Abuse Report Final Form dated 10/18/22 states, On October 12, 2022 at 9:30 AM, V16 (Certified Nursing Assistant/CNA) went into R116's room and observed R187 standing at (R116's) bedside. R116 was noted lying in bed with her gown on and with incontinent brief open . R116's Progress Notes dated 10/12/22 state, Sexual assault detected on the patient with another male resident by a CNA around 8:45 AM today. Management was informed and the POAs of the resident were duly informed of the incident. The resident was taken to the hospital by ER team at 9:20 AM and returned to the facility at exactly 9:15 PM. The patient was treated at the hospital with antibiotic [MEDICATION(S)] (Antibiotic) and discharged to the facility with no new order. Laboratory test was also carried out at the hospital (Chlamydia, CMP, Urine Culture, [CONDITION(S)] Ag). The resident was also discharged with information sheet for the family which consist of: 1. Sexually transmitted disease and sexual assault sheet 2. Prophylaxis information sheet 3. Emergency contraception and medication information sheet 4. Checkpoint instruction kit The general condition of the resident was stable on receiving from the hospital team with the following vital signs: Temperature: 98.2, BP: 118/72, Pulse: 72, Respiration: 20, Spo2: 95 at room temperature. Evening medication passed. Continue monitoring. On 10/17/22 at 1:45 PM, V1 (Administrator) stated, The man is a [AGE] year old man with a BIMS of 1. He was admitted on [DATE]. His daughter wanted to bring him here from home, but she didn't know anything about him- medications, etc. I told her she had to take him to the hospital first, and then he came here. He had no history of anything like this. The CNA walked in and he was standing at the bedside wearing only a t-shirt. R116 was lying down in bed and had a gown on and a brief but the brief was open and pulled down. The CNA acted immediately and put him on one on one, and the police came. They were not able to interview him- he has dementia. We really don't know if he did anything or not. We sent her out and they did a rape kit and a STD screen. We won't get the results back for 4-6 weeks and those results will go to her daughter. He was sent to (another local) hospital and he won't be coming back here. On 10/18/22 at 3:30 PM, V1 (Administrator) stated, The CNA (V16) allegedly walked in the room bringing a tray for one of the residents and he was standing at the bed with his back to the door wearing just a t-shirt. Originally, she said she saw he had his hands near her private area. She called for help and V17 (Licensed Practical Nurse/LPN) came down, and then V17 got (another male CNA) and put both residents on one to one. Then Social Services went in to talk to R116. I then asked V19 (Nurse Practitioner/NP) and V20 (Wound Care MD) to look at her and do an exam on her private areas to look for trauma. I called the police and V21 (Local Police Officer) came down and tried to interview R187. He came downstairs and said, V1- 'the light is not on for him.' He also interviewed R116 and (R116) said she didn't know who it was, but she felt someone's finger in her. She didn't know if it was a nurse or a CNA or who it was. We sent her to (Local Hospital) and they did a rape kit and a STD screen. I tried to look it up today and it says it could take up to 6 months to get the results- due to staffing. Social Services also went in and talked to (R116's roommate) and she said she saw him standing there but that is all she saw. Never saw his feet leave the floor. I sent him to (another local hospital) and he is not coming back here. Then today (V16's) story was, 'I came in the room, and I didn't know who he was, and I saw his hand moving in and out and touching her clitoris.' V16 (CNA) said she did not see any of his clothes on the floor. R187 came here on September 30. There is no sexual anything in his history. He wanders, yes, and we had him on 1-1 for about 2-3 days when he first came in. We never had any problems with his behavior, and he was easily redirectable. On 10/19/22 at 9:21 AM, V16 (CNA) stated, I was going in her room and there was someone standing there over her bed- I didn't know who he was. I saw her blanket was pulled back and her brief was open, and his hand was touching her private area. I grabbed him and gently started trying to walk him away, but he was resisting me. I got him as close to the door as I could, and then I screamed for the nurse. V17 (LPN) came in and helped me get him away from her. He was definitely touching her in her private area. R116 is confused too. She didn't seem upset; she was just lying there. The nurse completely took over from there and I didn't talk to R116 about it. On 10/18/22 at 2:33 PM, V17 (LPN) stated, V16 (CNA) called me, and I went to R116's room. I saw R187 standing by R116's bed and R116 was laying in the bed and her diaper was off and her gown was up, and his hands were beside him. This was about 8:30 AM. I took R187 away and put him in his room. I asked V16 to stay with R116. We had a monitor in the hallway, and I asked him to stay with R187 and I immediately called V1 (Administrator). Immediately, V1 wanted R116 to be examined and then she called the police. She wanted me to get everything off of R116 and the bed, including her gown, sheets, diaper, etc., and put them in a bag. R116 did not seem upset. When V16 called me, she yelled really loud and so I ran down the hall. My first instinct was to move R187 away from R116. (R187) wanders a lot. He uses everyone's bathroom. I suspect when he got off the toilet, he went into the room instead of the hallway. Now that I think of it, I think his pants were in the bathroom. He had no pants on- he walked away with me just fine. If his pants were around his ankles, then he would not have been able to walk. The one thing I have noticed about resident's up here is when they are wet, they will take their diapers off. They don't want to be wet. Some will put them on the floor, but they want them off. When R116 is uncomfortable with the urine, she might just take off the diaper. I can't say she has a tendency to do that, but I think she would. R187 didn't seem to understand that anything was wrong. I called someone to be in the room with him and closed the door. All the excitement was making him more nervous. He is very confused. On 10/18/22 at 2:45 PM, V18 (Social Worker) stated, R187's BIMS (Basic Interview for Mental Status) was a 1(Severe cognitive impairment) and he can't have a conversation. He does not know what is going on. My Social Service Director had a conversation with R116. She asked her if she felt safe and any issues with R187 and she told her no. The Local Police Department Offence Report dated 10/12/22 at 8:59 AM states, V1 advised that she reviewed surveillance camera footage in the hallway of the 4th floor and observed R187 enter R116's room at 8:11 AM, then was escorted out of the room at 8:30 AM by a staff member . This same report also states, I identified myself as a Local Police Officer due to R116 not being able to see. The following is a summary of my conversation with R116, not verbatim. I asked R116 if she was okay, then R116 proceeded to tell me about the incident that took place. (R116) said she was lying in bed when a subject (unknown male or female) came into her room for 15-30 minutes and placed their finger in her vagina. R116 thought it was a nurse that was doing it and asked them to remove their finger from her vagina. R116 advised that the unknown subject didn't say anything and left the room. R116 was unable to provide any additional information at this time. R116's Wound Evaluation and Management Summary written by V19 (Wound Care Physician) dated 10/12/22 states, Due to recent events, complete skin exam completed at facility request. Overall, there were no ecchymoses, lacerations, contusions, handprints or injuries noted whatsoever. Particularly, there was no battle damage noted over wrists, scalp, chest/breasts, thighs. Oropharyngeal cavity WNL, nails are [NAME] with no debris under nails at all. Peri-area is clear and healthy and there is no external damage to anal or vaginal introitus. Patient is in high spirits and although demented, her mental status appears to be at her baseline and uninterrupted. R187's Admission Record shows that he is a [AGE] year old male resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R187's Care plan dated 10/5/22 states, R187 is at risk for elopement. He has poor cognition and exhibits disorientation. He needs frequent reminders as to the location of his room and to not enter other resident's rooms. He will frequently touch and grab items that are not his and when staff redirect, he will say, mine. R187's Care Plan also states, R187 is functioning at cognitively impaired level related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R187 is extremely confused and disoriented. R116's Admission Record shows that she is a [AGE] year old female resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R116's Care Plan dated 1/10/22 states, R116 is functioning as a cognitively impaired level related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R116's care plan dated 7/14/21 states, R116 displays socially inappropriate and manipulative behavior. The facility policy entitled Abuse and Neglect dated 1/17/22 states, It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse . This policy also states, Sexual abuse includes but is not limited to harassment, coercion, disparaging remarks or sexual assault.

Based on observation, interview, and record review the facility failed to transfer a resident from recliner chair to bed using a mechanical lift in a safe manner. This failure resulted in R1 falling out of the mechanical lift sling onto the floor where she sustained a fractured ankle, a laceration to her head and elbow, an [CONDITION(S)], and pulled out her [CONDITION(S)] catheter on 3/14/22. This applies to 1 of 3 residents (R1) reviewed for safety in a sample of 3. The findings include: The Facility Incident Report dated 3/18/22 states, On 3/14/22 at around 9:00 PM, assigned V4 (CNA) was transferring resident to the bed and resident fell on to the floor on her right side. Immediately V4 notified V3 (RN) nurse on duty that resident fell during transfer and was on the floor. V3 nurse on duty immediately went to resident's room and noted resident lying on the floor on her right side and right side of her bed. The floor was dry and clean, no clutter is noted at this time. On 3/22/22 at 10:15AM, R1 was lying in bed in her room. R1 had multiple bruises to her face, a goose egg to her right forehead, and bandage on her right temple. R1 also had a large, bruised area to her left lower neck extending onto her left chest. R1 had a splint with an ace wrap to her right ankle extending up to her knee, and a gauze wrapped dressing on her right elbow. R1 stated, I'm in pain, the whole right side of my body hurts. My hip is badly bruised and my elbow. I think the (mechanical lift sling) strap was not on properly. It couldn't have been. They are not supposed to transfer me with one person but it doesn't do any good to tell them that. They just say, 'Oh no, I am strong enough, I can do it.' But then why am I lying on the floor and you are standing up there! Many times they have transferred me with just one person. They just won't listen to me. I had to have a new [CONDITION(S)] port put in in the hospital (explaining the bruising to her neck). I fell between the bed and the wall (half wall in center of the room). I think I hit the base of the (mechanical lift), I don't really know. I had to have hit something to break my ankle. I have 2 broken bones in my ankle. On 3/22/22 at 9:50AM, V5 (Restorative Nurse) stated, I wasn't here when it happened but it was an agency CNA- (V4). One of the loops on the (Mechanical Lift) sling snapped and R1 fell out. She called the nurse right away and the nurse called 911. They tried to clean the wound on her head before EMS arrived. I don't know what happened to that sling but we replaced it. They may have discarded it. I didn't want it back on the floor. She said she inspected the sling before she used it. I am not sure if there was just one CNA. I haven't actually talked to her but she wrote a statement. On 3/22/22 at 12:15 PM, V4 stated, I was lifting R1 with the sling and one of the sling loops popped. It was just me. There were only 2 CNAs on the floor that night and the other CNA was busy. I have transferred her by myself many times. The loop snapped and she fell on the floor onto her right side. I put a pillow under her head and ran and got the nurse. On 3/22/22 at 11:30 AM, V1 (Administrator) stated, The top green loop on the right side of the sling just snapped- like it was cut with scissors. I think it was a freak accident. I showed it to our medical director (R1's Primary Physician) and he told me I should contact the manufacturer- so we sent something off to them. At 2:30 PM, V1 stated, I tell them all the time, if the other CNAs are busy then go get the nurse to help you with the transfer. V4's undated written statement shows, I went into R1's room at about 9:00 PM to put her in bed. I hooked the sling up to the (Mechanical) lift and proceeded to lift her up out of her chair. That's when one of the loops on the sling broke and R1 fell out of the sling and hit the right side of her face and right arm on the (Mechanical) lift. I immediately got the nurse and stayed with her until the ambulance came. R1's Hospital Consult Note dated 3/15/22 states, Patient is [AGE] year old very nice lady well known to me from follow-up on her [CONDITION(S)] at the group nursing home. Patient had a fall from the (Mechanical) lift at the nursing home transfer to the ER with head trauma and pain to right elbow and right ankle. Work-up showed patient has intracranial bleeding and she had a scalp hematoma on the right side. Right elbow laceration which was sutured in the emergency room , fractured right ankle which was diagnosed with fibula and tibia distal impacted fracture. Patient's permacath was pulled out accidentally during the fall . R1's Minimum Data Set (MDS) dated [DATE] shows that R1 has no cognitive impairment and requires total assist of 2 staff for transfers. R1's Care Plan initiated on 2/14/22 states, I require cueing, encouragement, total x2 person assistance with transferring with (Mechanical) lift. The facility policy entitled Mechanical Lift Transfers, Revised on 7/28/21 states, There will always be 2 staff to assist resident. 1 staff will control the lift as the other will guide resident and support back and neck to transfer surface.

Based on interview and record review, the facility failed to assess and document a newly admitted resident's condition and failed to provide enteral nutrition and medication for that resident in a timely manner. This failure resulted in R8 not receiving any of his scheduled medications or feedings for 23 hours. This applies to 1 of 3 residents(R8) reviewed for necessary care and services in a sample of 10. The findings include: R8's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's Progress Notes dated [DATE] state, Resident arrived at the facility via stretcher from hospital approximately 6:15PM. Resident was accompanied by family, his wife, and daughter. Resident is receiving oxygen via [CONDITION(S)]. Resident is NPO (Nothing by mouth) and gets nutritional via peg-tube. Both [CONDITION(S)], and peg tube are new to resident. Both were placed on approximately [DATE]. This writer went to do a head to toe assessment, this writer was informed by family that patient is non-verbal and can nod to hearing Spanish speaking verbal cues . On [DATE] at 3:15PM V9 (Registered Nurse) stated, His daughter and his wife were with him when he was admitted . I went in with the CNA and greeted them and got him settled. I spoke with the daughter. The wife and the patient did not speak English. We get ,d+[DATE] admissions a night on that hall so it is not uncommon for ,d+[DATE] nurses to be working on the admission. One will do the assessment, and one will do the orders. I did not give him any medication that night. I did not discuss his medications with the daughter. A STAT KUB (Kidneys, Ureter, Bladder X-ray) had to be done before we could give him anything. The KUB is called into (X-Ray Company). I talked to his daughter about the G-tube and the [CONDITION(S)] and she told me they were both new for him. Usually when we call for a KUB they tell us it is a ,d+[DATE] hours wait. Then we get the results pretty much right away. We can go into the system and look them up or the fax them over. We can't give any meds or start the tube feeding until the KUB is done. On [DATE] at 9:30AM, V12 (Licensed Practical Nurse) stated, I had called them (X-ray company) but I don't remember what time I called. They usually give us a time and then they will call us ½ hour before they come. They are supposed to come within 4 hours but we have been having a problem with them not always coming within that 4 hours. Any new admission with a G-Tube we have to call and order a stat KUB. We have no control how long it takes them to come or when we get the results. That is our only option to call. No other companies available to us. On [DATE] at 1:00PM V14(RN) stated, I just helped the other nurse with the orders on the night he came in. I didn't see him- he wasn't my patient. The next day, he was my patient. We couldn't give nay meds until the G-Tube was checked. I checked his blood sugar because he wasn't getting any feeding and it was low. I don't remember what it was. I talked to the Nurse Practitioner that was there and she gave the order for the Glucogon if is blood sugar was below a certain number. We were going to start and IV line since we couldn't give him any food. The nurses were trying to start the IV but I don't remember if they ever got it started. (X-Ray Company) was called and they said they would come as soon as they could. The X-Ray tech came towards the end of my shift. I never started the feeding either, I couldn't give him anything. I don't remember my head to toe assessment for him. I remember he had family at the bedside and his daughter was very concerned about his medications and his feedings. I tried to explain to them about our protocol to do the X-Ray first. R8's Progress Notes dated [DATE] at 2:02 PM state, Resident did not get a KUB to confirm PEG placement. Will wait for confirmation after KUB is done to administer mediations and tube feeding. R8's Progress Notes dated [DATE] at 3:00PM state, Resident's KUB result came back for the peg-tube placement. Peg-tube is in place . On [DATE] at 3:30PM V10 (Registered Nurse) stated, He was brand new to me- I'm not sure how long he had been there but he was new to me. I asked for a very thorough report- I like to get as much information as I can. I knew he had a G-Tube and I was told they were coming to do the KUB that day. I went in to assess him and saw he was sleeping. His daughter told me he was non-verbal most of the time but could respond at times. His daughter said he had just been sleeping. I did his vitals and they were ok. I tried to arouse him and I spoke to him in Spanish and he nodded his head. His daughter asked if we were going to start the tube feeding. I did his blood sugar and it was low- I don't remember what the number was but it was low. He was off of his G-Tube feeding for a while. I hooked up his food and I checked his blood sugar about an hour later and it was in the low 90's. I checked on him frequently. I was wondering why it took so long to get the Stat KUB for G-Tube confirmation. I was thinking to myself, Why do I have to make sure things are done? R8's Progress Notes dated [DATE] at 5:27PM state, Blood Sugar (BS) is low. R8's Progress Note dated [DATE] at 11:00PM states, At approximately 8:00 PM, prior to the incident, resident observed sleeping, no signs and symptoms of distress noted. V/S within normal limits, B/P: ,d+[DATE], P: 92, R: 18, T: 98.0, O2: 98 via [CONDITION(S)]. This writer rounded on resident at approximately 9:00PM and resident was observed sleeping. Chest was rising up and down with regular breathing. Wife at bedside sleeping on the bedcott. Bedtime medications were given at that time via PEG tube. Assigned CNA rounded on resident at approximately 10:14PM to change resident's brief with another CNA. Afterwards, assigned CNA notified Respiratory Therapy (RT) regarding suctioning the resident due to resident noted with gargling sound and RT immediately went to the resident's room and suctioned the resident. RT was calling for help, heard by the other nurse and notified this writer that resident was unresponsive at approximately 10:17PM. This writer noted RT in the room and the resident unresponsive. All pulses were checked and resident noted with no breathing and no pulse. 10:18 PM, Code Blue was called and CPR was started immediately and oxygen was increased to 6L via [CONDITION(S)] and ambu bag was initiated by RT. AED was used on the resident and no shock was advised by machine. [DATE] was called at approximately 10:19PM by another nurse. EMTs arrived at approximately 10:25PM and took over and started doing CPR to the resident. EMTs left with the resident at 10:35PM with EMTs still performing CPR. Wife and daughter aware of clinical situation, wife was present while performing the code. At approximately 10:36PM, (R8's physician) was notified of resident's current health status. R8's Progress Notes dated [DATE] at 10:50PM state, Called Hospital ER and obtained information on cause of death. Cause of death was [CONDITION(S)]. Notified Director of Nursing. On [DATE] at 3:50PM, V13 (CNA) stated, (R8) wasn't really responsive when I went in there but he didn't really look any different than when I had seen him the night before. After we changed him we noticed he was producing some more secretions from lying on his back maybe. So I went and got (V11 Respiratory Therapist). I saw her in passing so it was maybe ,d+[DATE] seconds after I left the room. I told (V11) that (R8) needed to be suctioned. (V11) said (R8) wasn't responsive so I ran to get the crash cart and I notified reception to call a code blue. I just helped to gather supplies and was on stand-by to assist if needed. The paramedics came and then they left with hi while doing CPR. On [DATE] at 9:45AM, V11 stated, (R8) had been given care by the CNA. They came and told me that he needed to be suctioned. When I got there he was unresponsive and had no pulse. So I called a code and started CPR. After I got help with the CPR I suctioned him but didn't get much out. I had seen him a few hours before that and didn't really notice anything unusual. His wife was at the bedside and they were both sleeping. On [DATE] at 11:10AM V15 (Nurse Practitioner) stated, I never saw this patient but I gave orders for the tube feeding. I think the nurse was just preparing for when we got the X-Ray so she could start the tube feeding. We have to have clearance for the PEG Tube and the facility has to rely on outside sources/agencies to do that. This guy if I remember correctly had a hemorrhagic stroke and that makes him very high risk for another one. Especially within the first 30 days after the first one. His medications are important ones and it is very unfortunate that he had to wait to get his medications and I am very sorry that happened. However he was also very high risk. R8's Death Certificate dated [DATE] shows his cause of death as Pontine [CONDITION(S)] with Locked-in Syndrome and Hypertension. R8's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications R8 should have received on [DATE] at 9:00PM include [MEDICATION(S)] 500mg (Anticonvulsant), [MEDICATION(S)] 25mg (Antihypertensive) and [MEDICATION(S)] 0.5mg (Immunosuppressant). Medications R8 should have received on [DATE] at 9:00AM include [MEDICATION(S)] 10mg (Antihypertensive), [MEDICATION(S)] 75mg (Immunosuppressant), [MEDICATION(S)] 40mg (Diuretic), [MEDICATION(S)] 5mg (Immunosuppressant), [MEDICATION(S)] 500mg (Anticonvulsant), [MEDICATION(S)] 50mg (Antihypertensive), [MEDICATION(S)] 25mg (Antihypertensive), [MEDICATION(S)] 0.5mg (Immunosuppressant) and [MEDICATION(S)] 50mg (Antihypertensive 3 doses missed at 12:00AM, 6:00AM and 12:00PM). R8's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This feeding was not started until approximately 5:30PM on [DATE]. (23 hours after his admission to the facility). R8's EMR (Electronic Medical Record) accessed on [DATE] shows no documented Blood Sugars at 6:00AM or 12:00PM as ordered. There are no documented orders to start an IV and there is no documentation related to concerns of R8's low blood sugar. There is also no documented nursing assessment of R8's condition between the admission assessment on [DATE] at 6:15PM and the final assessment on [DATE] at 8:00PM. The KUB X-Ray results show the test was performed on [DATE] at 1:12PM. The results show the G-tube is placed properly. On [DATE] at 10:50AM V2 (Director of Nursing) stated, We called the (X-ray company) and they told us that whoever took the order on their end did not write it down as a Stat order. They just wrote it down as a regular order. This has happened before. The facility Protocol entitled, Regulatory Project to Mark Enteral Feeding Tubes and Validate Placement with an X-Ray dated [DATE] states, Use a Sharpie to mark around the actual G-Tube at the insertion site. Get an X-Ray of the abdomen immediately to show whether the marked G-Tube is in the stomach.

Based on observation, interview and record review the facility failed to provide supervision during a meal to a resident (R136) with a history of choking. The facility failed to safely transfer a resident (R82). This resulted in R136 choking during a meal, requiring CPR (cardiopulmonary resuscitation), and subsequent hospitalization with [MEDICAL CONDITION] (trach) and gastrostomy tube ([DEVICE]) placement. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on (MONTH) 23, (YEAR) at 5:39 PM when R136 choked during the evening meal. On (MONTH) 17, (YEAR) at 9:00 AM, V1 Administrator was informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on (MONTH) 17, (YEAR) at 2:15 PM While the immediacy was removed the facility remains out of compliance at a level two. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This applies to 2 of 19 residents (R136, R82) reviewed for supervision during meals and safe transfers in the sample of 33 and one resident (R143) outside the sample. The findings include: 1. R136's Care Plan dated (MONTH) 30, (YEAR) and revised (MONTH) 2, (YEAR) showed, SWALLOWING PROBLEMS The resident demonstrates some risk to potentially choke or aspirate food or liquids. This problem is related to [DIAGNOSES REDACTED]. R136's Progress Note dated (MONTH) 15, (YEAR) at 6:08 PM, showed R136 choked on a hot dog while in the dining room, requiring the [MEDICATION NAME] maneuver. R136 was sent to the hospital for an evaluation. R136's Progress Note dated (MONTH) 23, (YEAR) at 12:41 PM, showed R136 had a second choking episode in the dining room requiring the [MEDICATION NAME] maneuver. A facility Incident Report dated (MONTH) 23, (YEAR) at 6:00 PM showed R136 had a third choking episode. The report showed V18 Certified Nursing Assistant (CNA) notified V12 Licensed Practical Nurse (LPN) that R136 was having difficulty breathing while in the third floor dining room. V12 LPN observed food in 136's mouth and attempted to remove the food. R136 became unresponsive as the [MEDICATION NAME] maneuver was being done. A Code Blue was called and CPR was started on R136. R136 was taken by ambulance to a local hospital. R136's hospital History and Physical Report dated (MONTH) 26, (YEAR) showed, It appears (R136) aspirated at the nursing home and had a respiratory arrest . The report showed that R136 had a [MEDICATION NAME] while hospitalized which showed food particles were extracted from the bronchi . R136 had a [MEDICAL CONDITION] surgically placed on (MONTH) 6, (YEAR) due to worsening respiratory status. R136's Order Summary Report dated (MONTH) 10, (YEAR) showed physician orders [REDACTED]. On (MONTH) 9, (YEAR) at 10:18 AM, R136 was lying in bed, watching television. R136 had a [MEDICAL CONDITION] in place connected to humidified oxygen via [MEDICAL CONDITION]. An enteral feeding pump was noted next to R136's bed. The facility's nursing schedules dated (MONTH) 23, (YEAR), showed V12 LPN, V16 LPN, V13 CNA, V14 CNA, V15 CNA, and V18 CNA were the staff working the evening shift on the third floor when R136 choked in the dining room. On (MONTH) 12, (YEAR) at 9:30 AM, V1 Administrator stated V12 and V16 LPN, V13-V15 CNA, and V18 CNA were the only staff working on the third floor on (MONTH) 23, (YEAR) when R136 had a choking episode. Based on interviews of all staff working on the third floor on the evening of (MONTH) 23, (YEAR), no staff member stated they were the actual person to find R136 choking. On (MONTH) 10, (YEAR) at 1:45 PM, V12 LPN stated that on (MONTH) 23, (YEAR), during dinner time, she and V16 LPN were seated at the third floor nurses station when a CNA wheeled (R136) to me in a wheelchair, saying she was having trouble breathing. I can't remember who the CNA was. (R136) was pale, not talking. I could tell she was choking on something. We wheeled (R136) down to her room and put her on the bed. I looked in her mouth and saw food. I did a finger sweep and pulled out pieces of meat. I checked for a pulse, she did not have one and was not breathing so I started CPR right away .I am not sure if (R136) was at risk for choking or had choked before . V12 LPN stated neither her nor V16 LPN were in the dining room when R136 was choking. On (MONTH) 11, (YEAR) at 10:00 AM, V18 CNA stated that she was not the staff member that found R136 choking in the dining room on the evening of (MONTH) 23, (YEAR). V18 stated she was not even in the dining room. V18 stated, I was passing meal trays in the hall. I saw a female CNA wheeling (R136) to the nurse's station, stating she (R136) couldn't breathe. I don't know who the female CNA was . I helped take (R136) to her room and get her into bed I was not aware that (R136) was at risk for choking. On (MONTH) 11, (YEAR) at 11:06 AM, V13 CNA stated on the evening of (MONTH) 23, (YEAR), I was passing trays in the hallway so I was not in the dining room when (R136) choked. On (MONTH) 11, (YEAR) at 11:31 AM, V14 CNA stated he was not in the dining room on the evening of (MONTH) 23, (YEAR) when R136 choked. V14 CNA also stated he was not sure if R136 was at risk for choking prior to the incident. On (MONTH) 12, (YEAR) at 9:25 AM, V15 CNA stated on the evening of (MONTH) 23, (YEAR), I was not in the dining room when (R136) choked. I was out in the hallway. On (MONTH) 12, (YEAR) at 9:15 AM, V17 (Physician) stated, Any resident with a history of choking or dysphagia should be under direct supervision of staff when eating. I feel that any residents with a history of choking or aspiration precautions should be seated at a table together with at least ,[DATE] aides seated with them while they are eating. 2. R143's Care Plan dated (MONTH) 1, (YEAR) showed R143 had a [DIAGNOSES REDACTED]. One of R143's Care Plan Goals showed R143 will not have any episode of choking or aspiration through next review . Provide/serve the resident's nutritional diet as ordered. Prescribe diet is renal, puree, nectar . R143's Order Summary Report dated (MONTH) 11, (YEAR) showed an order for [REDACTED].>R143's Minimum Data Set, dated dated dated (MONTH) 6, (YEAR) showed R143 required extensive assistance of one person for eating. On (MONTH) 11, (YEAR) at 11:55 AM, R143 was seated in the second floor dining room, feeding herself a mechanical soft diet of beef, rice, and pineapple. The dietary card on R143's tray showed R143 was served a mechanical soft diet. Three CNA's were passing lunch trays to residents. No staff were sitting next to or assisting R143 with eating. At 12:15 PM, R143 remained at the dining room table, feeding herself pineapple with no assistance. One CNA remained in the dining room, as she was picking up lunch trays with her back turned to R143. On (MONTH) 11, (YEAR) at 12:15 PM, V29 CNA/Guest Relations stated, (R143) feeds herself. Residents are served diets based on what diet is listed on their dietary card. On (MONTH) 16, (YEAR) at 11:36 AM, V1 Administrator stated the facility does not have a policy on monitoring residents at risk for choking or with aspiration precautions during meals. Through observation, interview and record review on (MONTH) 17, (YEAR), the surveyor confirmed the facility took the following steps to remove the immediacy: 1. Resident (R136) was sent to a local hospital on (MONTH) 23, (YEAR). 2. A schedule has been implemented (MONTH) 17, (YEAR) to indicate a Dining Monitor in every dining room for every meal. The Dining Monitor is in addition to any nursing staff passing trays or assisting with feeding. The Dining Monitor will include but not limited to any members of the IDT (interdisciplinary team) and department managers. Schedule will be provided to Dining Monitor on a weekly basis and as needed. The Administrator will maintain sign off sheets for the Dining Monitor. 3. The facility conducted an audit on (MONTH) 13, (YEAR) of all diet orders to ensure that correct diets are being served to all residents per physician's orders [REDACTED]. 4. An audit was done on (MONTH) 13, (YEAR) on all resident's in the facility to determine who are at risk for aspiration. There were 22 residents identified as at risk for aspiration. 5. All residents denitrified to be at risk for aspirations have recent swallow evaluation and/or screen in the last 30 days. All residents that have been identified to be at risk for aspirations and have no recent evaluation or screen in the last 30 days will be evaluated by the Speech Therapist starting today, (MONTH) 17, (YEAR). 6. The facility implemented a formal procedure on (MONTH) 13, (YEAR) regarding upgrading and downgrading diets. All staff were in-serviced on (MONTH) 17, (YEAR) on these procedures. 7. The facility completed an audit on (MONTH) 13, (YEAR) of all residents that require 1:1 supervision and assistance during meal times related to their risk of aspiration. 8. A binder was created on each unit with the list of residents and the assistance needed during meal times on (MONTH) 13, (YEAR). These lists will be updated daily, and as needed, by the Dietician and Restorative Nurse to ensure accuracy of information. 9. Inservices initiated on (MONTH) 17, (YEAR) regarding immediate referral to Speech and Language Pathologist (SLP) for any change in status in swallowing including upgrades of diets. 10. Inservices with all nursing staff, dietary staff and SLP regarding the new procedure on Upgrading Diets has been initiated on (MONTH) 17, (YEAR) and will be ongoing until all staff of above departments will be educated. 11. An inservice of nursing and CNA staff as to the names of residents who are at risk for aspiration and the availability of the binder on each unit indicating the names of those at risk for aspiration was done on (MONTH) 13, (YEAR). 12. Inservices regarding Choking and Aspiration were completed on (MONTH) 24, (YEAR), (MONTH) 25, (YEAR), and (MONTH) 26, (YEAR), and repeated on (MONTH) 17, (YEAR) and is ongoing. 13. An audit has been conducted by the Social Service Department on (MONTH) 13, (YEAR) regarding, but not limited to, those with DNR's/POLST and Advanced Directives. Care plans were updated (MONTH) 13, (YEAR). 14. The facility IDT team will conduct daily dietary meetings that will include but not limited to resident diet orders and or changes and or eating/feeding ability effective (MONTH) 17, (YEAR). 15. The facility established a formal policy on Dysphagia and Aspiration on (MONTH) 17, (YEAR). 16. In-services were conducted with all employees between (MONTH) 13, (YEAR) and (MONTH) 17, (YEAR), on but not limited to, Aspiration Precautions, Dysphagia, Supervision in dining room, Choking, [MEDICATION NAME] Maneuver, CPR, Upgrading and Downgrading Diets, Dining Room Monitor Position, Assistance with Feeding, Communication with diet orders and changes, and Identification of residents with aspiration precautions. 17. An audit was conducted by Nursing Management and Human Resources on all Employee CPR certifications on (MONTH) 17, (YEAR). 18. The Nursing Administration initiated a QA process on (MONTH) 17, (YEAR) with all residents that are identified to be at risk for aspiration and all residents needing supervision and/or assistance to ensure that their plan of care related to meals is implemented at all times. This QA process will be ongoing daily for 30 days and random checks will be done. 19. All employees actively engaged in employment, will be in-serviced by (MONTH) 19, (YEAR) on the following topics, Aspiration Precautions, Dysphagia, Supervision in dining rooms, Choking, [MEDICATION NAME] Maneuver, CPR, Upgrading and Downgrading Diets, Dining Room Monitor Position, Assistance with Feeding, Communication with diet orders and changes, and Identification of residents with aspiration precautions. Any other employee not actively engaged in employment, will not be permitted to actively engage in employment until they are in-serviced on these topics. 3. On (MONTH) 9, (YEAR) at 10:50 AM, R82 entered his room in his wheelchair. V9 & V10 (Both Certified Nursing Assistant's) were providing care to R82's roommate. R82 told V9and V10 he needed to use the bathroom. V10 and V11 told R82 to wait and come back. R82 left the room and came back. R82 told V9 and V10 he needed to to use the bathroom again. V27 (Registered Nurse) entered R82's room, R82 told V27 he needed to use the bathroom. V27 stated I guess R82 can use the bathroom. R82 took himself to the bathroom and staff did not offer to assist him to the bathroom. V9 entered the bathroom after R82 left the bathroom and stated, R82 just peed over the floor. On (MONTH) 12, (YEAR) at 9:48 AM, V3 (DON) said residents who are at risk for falls should have staff assist them during transfers using a gait belt. The Fall Risk assessment dated (MONTH) 14, (YEAR) shows R82 is at risk for falls and requires one person assist with transfers. The Minimum Data Set assessment dated (MONTH) 17, (YEAR) shows R82 requires extensive one person assist with to

Based on observation, interview and record review the facility failed to identify, plan, educate, evaluate, and make arrangements for a residents needs before discharging to the community. This failure of ineffective transition to post discharge care contributed to the resident experiencing feelings of worthlessness, recurrent thoughts of suicidal ideation, and admission to a psychiatric hospital. This applies to 1of 5 residents (R1) reviewed for discharge in the sample of 8. The findings include: R1's Minimum Data Set, dated dated dated (MONTH) 8, (YEAR) shows R1 is cognitively intact, with no noted behaviors or rejection of care and has [DIAGNOSES REDACTED]. R1's (MONTH) (YEAR) Physician order [REDACTED].-vitamin, Vitamin D, [MEDICATION NAME], and [MEDICATION NAME] daily. R1's Care Plan dated (MONTH) 14, (YEAR) shows R1 had anxiety with symptoms manifesting by mood distress, depression, and cyclic mood swings. R1's interventions shows R1 meets with the licensed clinical social worker on a weekly basis for talk therapy. R1's Nurses Notes from (MONTH) 6 to (MONTH) 7, (YEAR) shows that R1 was seen five times by V4 Medical Nurse Practitioner and seven times by V14 Psychiatric Nurse Practitioner. R1's (MONTH) 3, (YEAR) Psychiatric Progress Note shows R1 is calm and cooperative with care, mood stable, not depressed, anxious or irritable. On (MONTH) 23, (YEAR) at 10:51 AM, R1 stated that the Friday of Mothers Day weekend he was kicked out of the facility by V3 Social Services Director without medications or paperwork. R1 had no place to go and had to sleep in the car wash. R1 voiced feelings of psychosocial harm by stating he felt lost, like a piece of garbage, and just kicked out with no reason why. R1 stated he developed [MEDICAL CONDITION] with a plan to wrap himself in a tarp and lay in the middle of a busy road. R1 stated he called the police and was taken to the local emergency room and then transported to a behavioral health hospital. On (MONTH) 23, (YEAR) at 2:15 PM, V3 Social Service Director said she had a meeting around noon time on (MONTH) 11, (YEAR) with R1 and V6 Social Services. R1 was very upset when V3 informed him that his out on pass privileges may be taken away by the doctor (due to a positive alcohol urine test after returning from a previous day out on pass). V3 said R1 wanted to be discharged and was going to go to his brother's house. V3 said she informed R1 that she needed to know R1's pickup time, address, and doctor and to let her know when he had this information. R1's General Progress Note dated (MONTH) 11, (YEAR) at 3:36 PM, shows R1's positive urine alcohol test was relayed to physician and order to discharge to community was obtained. On (MONTH) 24, (YEAR) at 12:25 PM, V11 Licensed Practical Nurse (LPN) said she was told in report R1 may be discharging with his son but was not sure of who, when and where. V11 said this is normally all set up by social services. V11 said she received a call from the receptionist around 7:30 PM on (MONTH) 11, (YEAR), that R1 had been picked up by someone. On (MONTH) 24, (YEAR) at 1:11 PM, V15 Receptionist said she saw R1 leave on (MONTH) 11, (YEAR) around 7:00 PM with no belongings. V15 said she did not observe anyone picking him up. V15 said she then called R1's nurse and informed her that R1 left. On (MONTH) 29, (YEAR) at 12:15 PM, V11 stated when I found out R1 left without discharge paperwork and medications I informed housekeeping to the clean room, pack up his belongings, and then I charted. V11 said she did not call R1, V13 (R1's brother), the doctor, or the supervisor. On (MONTH) 24, (YEAR) at 1:45 PM, V7 Behavioral Health Program Therapist at a local behavioral health Hospital said R1was admitted to the local behavioral health Hospital from a local emergency room for [MEDICAL CONDITION]. V7 said R1 reported to her he was told to get out of the facility he was at with no discharge plan. V7 said R1 was extremely depressed, suicidal, expressed feelings of hopelessness, worthlessness, and felt he had been tossed out on the streets like garbage. V7 said she called V1 administrator and V1 could not provide any information of R1's discharge plans. R1's Pyschiatric Evaluation dated (MONTH) 13, (YEAR) from the local behavioral health Hospital shows R1's chief complaint: suicidal and depressed .patient reports severe anxiety with panic attacks and feelings of hopelessness, helplessness, and worthlessness. R1 Discharge Summary Note dated (MONTH) 12, (YEAR) at 1:29 PM (day after discharge) by V12 Social Services, shows per resident request, resident was D/C (discharged ) on (MONTH) 11, (YEAR) to his brothers house. Nurse was able to call his doctor to obtain the discharge order, medications were packed. On (MONTH) 24, (YEAR) at 11:35 AM, V12 Social Services said (in regards to her Discharge Summary Note) she just assumed that R1 went to his brother's house because that was reported by V3 Social Service Director. V12 said meds packed meant that he could take his meds home with him and she was unaware if R1 took his meds with him at discharge. On (MONTH) 23, (YEAR) at 10:24 AM, V13 (R1's brother) said he was unaware that R1 was leaving the facility and R1 was never with him. R1's Transfer/Discharge Report dated (MONTH) 11, (YEAR) shows R1's current medications but no documentation of last dose, when to take the next dose, or how many tablets were given at discharge. This same form shows R1 was discharge home with family. On (MONTH) 23, (YEAR) at 2:50 PM, in the third floor medication room, R1's medication punch cards containing tablets [MEDICATION NAME], Trazadone, [MEDICATION NAME], Folic acid, [MEDICATION NAME], Tamsulosin, and [MEDICATION NAME] were found in a return to pharmacy bin. On (MONTH) 24, (YEAR) at 1:00 PM, V2 Director of Nursing (DON) said the discharge papers and the medication list form for R1was not filled out. V2 said both forms are to be filled out for residents discharged from the facility. On (MONTH) 24, (YEAR) at 11:30 AM V2 said the discharge nurse should give the resident a list of medication that include the name of the medication, the last dose, and how many pills were dispensed as part of the education upon discharge. This form should be signed by the resident and the nurse. V2 stated the residents medications are given to the resident at discharge. R1's Medical Record does not contain any social service notes regarding conversation with R1 about discharge and follow up needs. R1's unsigned Instruction for Discharge Form dated (MONTH) 12, (YEAR) (the day after R1 was discharged ) is incomplete and only shows the resident's responsible party as himself, his cell phone number, and a comment that says per residents requested stated that he wanted to be discharged to his brothers house. The sections of this from that were blank include: physician in community, housing arrangements, pharmacy, follow up appointments, medication education, prevention and disease management, medications and treatments. On (MONTH) 29, (YEAR) at 11:00 AM V3 Social Service Director said at discharge, social services should assess the residents needs, fill out the appropriate sections of the discharge form, and chart a progress note. V3 said for a resident who needs psychiatric services, a follow up appointments would be set up with the local health department and a primary care physician. V3 said she did not do this for R1. V3 said she did not contact the local health department or V13 (R1's brother). On (MONTH) 29, (YEAR) at 11:55 AM, V14 Psychiatric Nurse Practitioner said she saw R1 every three weeks and as needed. V14 stated R1 was mentally stable on his medications and she would have recommended a follow up psychiatric appointment in one month and weekly psychotherapy had she known R1 was being discharged . V14 said before a discharge she would see the resident, made sure they had a follow up appointment set up, and had enough medication to last until the appointment. V14 said she was not aware that R1 left without his medications. V14 said R1's medication should not be abruptly stopped. There could be adverse reactions if stopped abruptly including: suicidal thoughts, tremors, increased anxiety, and irritability. On (MONTH) 30, (YEAR) at 12:10 PM, V3 stated I dropped the ball, I told V6 Social Service to hold off on filling out R1's discharge form. V3 said for R1's psychiatric services she would have touched base with V14 Psychiatric Nurse Practitioner and set up an appointment with the local county behavioral health department. The facility's Transfer and Discharge Policy dated (MONTH) 20, (YEAR) shows to notify the resident .of transfer or discharge and the reason for the move in writing and in the language and manner they understand Make referral to the community services to ensure continuity of services to the resident. Ensure safe transportation to the destination. The facility's Discharge Planning and Instructions Policy dated (MONTH) 20, (YEAR) shows it is the policy of the facility to conduct proper discharge planning for all residents and provide appropriate discharge instructions in preparation for discharge once a discharge order is obtained from the resident's attending physician discharge instructions shall be provided by pertinent disciplines consistent to the residents special needs during discharge social services shall facilitate referrals to appropriate community agencies medications will be sent with the resident being discharged to the community.

Based on interview, and record review the facility failed to ensure a resident with a [DIAGNOSES REDACTED]. This failure resulted in R1 being verbally abused by a staff member on on June 25, 2017. This applies to 1 of 8 residents (R1) reviewed for abuse in a sample of 8. On July 6, 2017 at 9:50AM, the sign posted on the resident's outdoor roof top access door shows, Penthouse Deck Hours 9:00AM to Noon, 1:00PM to 9:00PM. On July 6, 2017 at 9:30AM, R3 said, E5-Activity Aide started yelling and screaming at R1 and his family. I was here when it started. R1 tried to leave the area but E5 kept following him while calling his mom a prostitute. On July 6, 2017 at 10:00AM, R2 said, if you are done smoking you can stay on the deck. You can't smoke, but you can stay out there. On July 6, 2017 at 1:15 PM, R7 said, I was in tears on June 25, 2017, it was too much, I was in tears. E5 provoked the incident. E5 picked up a cue stick. R1 was sitting over there, and E5 wanted R1 to go inside. R1 was not smoking. The language was horrible. E5 picked up a pool cue and threw a phone at R1. Everyone was sitting out here. Why she decided to go off on R1 is unknown. On July 6, 2017 at 1:20PM, R8 said, we didn't know what was going on here. E5 picked up the phone receiver and threatened to hit him, then E5 picked up a pool cue. R1's Minimum Data Set, dated dated dated [DATE] shows, R1's Brief Interview for Mental Status 15 (Cognitively Intact). R1 was no longer residing in the facility during this investigation. Several attempts to contact R1 by telephone were made. Messages were left twice on July 6, 2017 and again on July 10, 2017. R1 did not return any of the calls. Under the same circumstances a resonable person would have felt insulted, angry, and intiminated when the staff member began yelling at them, calling their mother names, and threatening to harm them. R1's General Progress Note dated June 25, 2017 at 7:13 PM, shows, a nurse and two Certified Nursing Assistants (CNA) responded to a request for assistance from an Activity Aide. A resident and activity aide were found yelling and screaming at each other. Both the resident and the activity aide began to get very aggressive towards each other and towards staff members involved in trying to stop the feud. The activity aide was holding the telephone, standing far away from the resident, yelling and screaming at the resident. The arguing escalated and continued for about 15-20 minutes before writer could get resident on the elevator safely. R1's undated, written statement shows, at the facility on June 25, 2017 R1 requested to continue to sit outside on the deck without smoking and visit with his mother. E5 demanded R1 leave the deck. E5 then called R1's mother a [***] . R1 admits to becoming angry and exchanging words with E5. E5 then called R1's mother a crack-head prostitute. R1 alleges E5 grabbed a pool stick and threatened to kill him. R1 alleges E5 hit him in the head and hand with a telephone. The facility's abuse investigation report dated June 29, 2017 for the June 25, 2017 incident between R1 and E5 shows, Abuse Substantiated. The facility's Abuse and Neglect and Procedure policy dated November 28, 2016 shows, verbal abuse includes but not limited to the use of oral, written, or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. Example: name calling, swearing, yelling, threatening harm, trying to frighten the resident.

Based on interview and record review the facility failed to protect a resident (R2) from sustaining a blister during transportation with liquid oxygen. The facility also failed to provide supervision and application of preventative devices to prevent injury from fall for R1 and R4. This applies to three of three residents reviewed for falls and incidents (R1, R2, and R4) from a total sample of four. As a result, R2 sustained two blisters (left interior thigh and right interior thigh) that became infected and required intravenous antibiotic therapy. The findings include: 1. R2 has multiple medical [DIAGNOSES REDACTED]. R2 also has a trachestomy and is non verbal and not able to make her needs known, as per section B of the November 5th 2014 Minimum Data Set (MDS) Assessment. On 01/02/15 at 10:15 AM, Z1 (former CNA) stated he took R2 to the shower on 12/20/14 at approximately 9:00 AM and the portable oxygen tank R2 was using was on the side of R2's recliner chair. Z1 stated he put the portable liquid oxygen tank on the ground and then transferred R2 to the shower chair. Z1 stated he did a skin check at that time and found no issues, transferred back to the recliner chair after drying R2 off and placing her in a hospital type gown. Z1 stated he then placed the portable liquid oxygen tank on R2's lap, laying down flat. R2 was taken to her room and transferred to her bed. Z1 stated he noticed blistering on R2's left thigh at approximately 12:45 PM and notified E10 (Staff Nurse). E10 stated she examined the blisters at that time on R2's bilateral anterior thighs and notified Z5 (R1's spouse) and Z2 (Physician Assistant for R2's medical doctor). Z2 was in the facility at the time and wrote orders for treatment of [REDACTED]. On 01/02/14 at 11:50 AM, Z2 stated she was at the facility at the time of the incident. Z2 stated she was sitting at the nurses station when she noticed R2 being taken out of the shower room backwards in a recliner type chair and the portable liquid oxygen tank was on R1's lap. Z2 stated, "I saw steam rising from the tank and thought it was strange. Z2 stated, " I was notified by E10 approximately 2 hours later that R2 had a blister on each thigh but they didn't say I need to see it at that time so I wrote orders for cleaning the area and applying a tegaderm to keep the blister intact until seen by the wound nurse." Z2 stated she did not see the blister until 12/26/14 and stated she was "alarmed" by the look of the blisters and immediately thought it was from the oxygen "condenser". Z2 stated when the nurse initially mentioned that R2 had bullae she didn't think it was from her being immunocmpromised. Z2 stated, "There is nothing wrong with R2's immune system, bullae is just a fancy name for a large blister." On 12/26/14 at 2:00 PM, E3 (Assistant Director of Nursing, ADON) stated E10 had told her about the blisters on the anterior aspect of both R2's thighs. E3 stated E10 (staff nurse) did not know how it happened. E3 stated she checked the video camera recording and saw that Z1 had placed the liquid oxygen tank on R2's lap and E3 stated she figured it was from friction from the oxygen tank. E3 stated she did an investigation of the incident and the analysis and cause of the incident at that time was determined to be liquid oxygen was placed on R2's lap after the shower. On 01/02/15 at 9:55 AM, Z6 (Illinois Representative for Helgat Gas Product, sticker on facility portable oxygen tank), stated the liquid oxygen is 100 degrees below zero and if skin came in contact with the liquid oxygen it could cause second or third degree burns. Z6 also stated the portable oxygen tank should always be kept upright. On 12/31/14 at 2:00 PM, E9 (central supply / maintenance), stated he fills the portable liquid oxygen tanks daily and transports them to the nursing units. E9 stated he was trained by the supplier on how to fill the tanks and safety measures needed when handling. E9 stated the portable liquid oxygen tanks should be kept upright, not turned upside down or put on the side because they could leak. On 01/02/15 at 9:00 AM, Z5 (R2's spouse) stated he was notified by E10 (Staff Nurse) of the blisters on R2's thighs but was told it was unknown how it happened. Z5 stated E2 (Director of Nursing ) notified him by telephone to let him know that the CNA involved had laid the portable liquid oxygen tank across R2's legs and was told the person involved was terminated. On 12/31/14 at 12:05 PM, E12 (Wound Nurse), stated she was notified to see R2's blisters on 12/22/14. E12 stated her and Z3 (Wound Doctor) both examined the blisters. E12 stated she did not know what they were from and no one had told her the resident had an oxygen tank on her legs during a shower transport two days earlier. On 12/31/14 at 12:45 PM, Z3 (Wound Doctor), stated she examined R2's blisters on 12/22/14 and was not aware how she obtained them. Z3 stated, no one ever told her that R2 was transported with a portable liquid oxygen tank on her lap two days earlier. Z3 Stated, "it would be unusual to just come out of a shower with blisters on her thighs." The temporary care plan dated 12/20/14 tilted, "Potential for altered skin integrity" documents R2 to have a blister on the right anterior thigh that measured 4.5 cm x 1.3 cm and a blister on her left anterior thigh that measured 12.9 cm x 11 cm. On 12/22/14, Z3 (Wound Doctor) documented the right anterior thigh measured 6 cm x 2 cm and the left anterior thigh measured 13 cm x 11 cm. The left blister is documented to be full-thickness with moderate exudate, serous fluid, mild odor, 26-50% slough, 1-25% granulation tissue. The right anterior thigh blister is documented to be intact, no drainage. On 12/29/14, Z3 documented the left blister to measure 13 cm x 11 cm, all other assessments are the same. The note documents the left blister has denuded margins covered by slough. The fluid is becoming thickened, has an odor and surrounding redness. Cultures were done at that time and R2 was placed on oral antibiotics. On 01/02/15 the left anterior thigh blister cultures were completed and shown to have E-Coli with ESBL (Extended Spectrum of Beta Lactamase) a bacteria that is resistant to many antibiotics. R2 needed to be placed on intravenous antibiotics. The Facility's undated Policy and Procedure titled "Liquid Oxygen Policy and Procedure" documents "It is the facilities policy to ensure that liquid oxygen is stored and utilized appropriately." The procedure portion of the document states the supplier will remove all empty big liquid oxygen tankard replace with full tanks. The big and portable tanks are stores in the oxygen room and lastly, the filling of portable tanks will be done in the facility in the oxygen room by trained staff. On 12/31/14 at approximately 1:00 PM, E1 (Administrator), stated this was the only policy on liquid oxygen they facility has. This policy does not cover any safety issues or hazards for staff that handles the portable oxygen tanks on the nursing units. There is no policy for transferring residents with portable liquid oxygen or how the tanks should be handled by staff. R2 is unable to voice pain or move an object away if pain is felt due to upper extremity contractures in both arms and hands. 2. R1 ' s admission record shows she is an [AGE] year old female original admitted was 8/6/14, readmitted on [DATE]. R1's most recent MDS (minimum data set) dated 11/20/14 shows cognitive status BIMS (brief interview for mental status) score as 3 which indicates severe cognitive impairment. In addition, the MDS codes R1 as needing one person physical assistance with ambulation. The section for balance during transitions and walking shows that R1 is not steady, only able to stabilize with staff assistance when walking (with assistive device if used ), and when turning around and facing the opposite direction while walking. The functional limitations in range of motion are coded for limitations that interfered with daily functions or placed resident at risk of injury. The Upper extremities (shoulders, elbow, wrist, hand), and the lower extremities (hip, knee, ankle, foot) are impaired on both sides for R1. R1 ' s care plan dated 9/1/14 and revised on 10/26/14 focus for activities of daily living self care performance deficit related to dementia and shortness of breath, with a goal to remain free of fall related injury through 2/15/15. The interventions include for walking R1 used assistive device walker for ambulation, and R1 is able to walk with one person assistance. The focus area for osteoporosis has a goal that R1 will remain free of injuries or complications related to osteoporosis through 2/15/15. Interventions include wear padded hip protectors to prevent hip fractures. Incident report dated 12/22/14 at 3:00 PM documenets that R1 was observed walking in the hallway with a walker and an unsteady gait when she lost her balance and fell with right side of the head hitting the wall. R1 complained of pain and numbness on right leg after the incident. R1' s Doctor and family were notified. R1 was admitted to the hospital with [REDACTED]. During an interview on 12/31/14 at 1:35 PM with E14 LPN said that she was the only witness. E14 said she was at the nursing station towards the end of her shift when she saw R1 walking by herself with a walker when she lost her balance and fell down and grazed her head and landed on the floor. During a telephone interview on 1/2/15 Z4 who was R1's physician said R1 was evaluated at the hospital for orthopedic surgery, however due to extensive lung disease and brain lesions it was determined that it would be too high risk of a procedure. Z4 said he never saw R1 have padded hip protectors. On 12/30/14 at 1:23 PM E3 the assistant director of nursing said she completed the incident report involving R1 on 12/22/14 that was reported to the department and the post incident investigation dated 12/23/14. E3 said that R1 did walk by herself, she was not aware of care plan for hip protectors and never saw them. E3 said R1 was at high risk for falls and had previous fractures according to family. The facility fall risk assessment dated [DATE] indicate R1 is at high risk for falls. The nursing monthly summary for November 2014 shows R1 needs 1 person assist with ambulation. Physical therapy progress notes dated 12/6/14 indicate start of care was 11/7/14, treatment for [REDACTED]. The current level of function for gait tasks with assistive devices shows R1 requires rolling walker and stand by assistance (close enough to reach patient if assist needed) for safe ambulation 3. On 11/15/2014 R4 experienced an unwitnessed fall with injury and a subsequent hospital admission resulting in a [DIAGNOSES REDACTED]. R4 was readmitted to the nursing facility 11/19/13. On 12/8/2014, R4 ' s nursing notes show R4 " was found lying half and half out of bed, top half was lying on floor mat .... " Comprehensive Nursing and Rehabilitation assessment dated [DATE] shows R4 requires extensive assist for bed mobility, total assist for transfers, and total assist/non-ambulator for ambulation. On 11/19/2014 and 11/26/2014 facility Falls Assessment Tool shows R4 is assessed to be at high risk for falls. R4 's Fall prevention care plan interventions (updated 2/21/2014) include " Be sure the resident ' s call light is within reach and encourage the resident to use it for assistance as needed. " On 1/7/2015 at 2:30PM, when asked if R4 knew how to utilize the call light for assistance, R4 stated " Nobody ever showed me or told me. " The call light was observed to be clipped to the bed linen lying to the right side of R4 ' s head and the button of the call light rested approximately six inches to the right of R4 ' s right ear. When asked to demonstrate her ability to push the button R4 was unable to locate her call button. When the location of the call light was pointed out to R4, R4 attempted to reach for the call light by reaching across her body with her left hand, however was unable to reach her call light. At 2:40PM, E17 stated the resident is able to use the call light independently and " the call light must be within reach " which she stated would be " at the side of her arms clipped to the bed " . E17 stated resident will use call light when resident wants to get up or when she needs anything. When E17 was shown the call light was clipped out of R4 ' s reach, E17 repositioned the call light across R4 ' s torso toward R4 ' s left hand with the call light button resting on R4 ' s torso. After the call light was repositioned, R4 demonstrated she was able to locate and grab the call light.

1. Based on observation,interview and record review the facility failed to provide a safe environment from residents identified with aggressive behaviors. This failure resulted in R30's unprovoked physical attack on 8/12/2013 to R34 and R18. And the 5/10/13 altercation when R22 choked R38 and held a knife to R38's neck. These failures resulted in an Immediate Jeopardy This applies to two of five sampled residents R18 and R22 reviewed for resident to resident altercations and four residents R30,R34,R38 and R90 in the supplemental sample. The Immediate Jeopardy was identified on 9/5/2013 at 7:15 PM. The Immediate Jeopardy was determined to have begun on 8/12/2013 when the facility failed to implement interventions to protect other residents from R30's unprovoked physical attacks to R34 and R18. And the facility staff could not provide any evidence that a monitoring system was in place for R30 who remained in the facility in a three bed occupied room until 8/13/2013 evening. (E3) Assistant Director of Nursing was informed of the Immediate Jeopardy on 9/5/2013 at 7:15 PM The Immediate Jeopardy was removed on 9/6/2013 at 7:00 AM. While the immediacy was removed on 9/6/2013, the facility remained out of compliance at a Severity Level 3. The facility has ongoing staff training and evaluation of this training and monitoring of residents identified to be at risk for physical aggression The finding include: The facility's security footage viewed on 8/20/2013 at 2:00 p.m. shows on 8/12/2013 at 6:30 p.m., four residents R9,R34,R114 and R66 were seated at a table on the facility's penthouse patio smoking. R30 was seen coming through the patio door at a purposeful pace. R30 headed straight for R34 who has a right below the knee amputation and uses a wheelchair. R30 began to repeatedly hit R34 with closed fists to R34's upper body and head. One of R30's punches knocked R34 out of the wheelchair to the ground. R30 continued to repeatedly punch R34. No staff were seen on the patio while this attack is taking place. (E14) Activity Staff came through the patio doors about 2 minutes after the attack. E14 removed R30 from the patio and left R34 on the ground. R34 was seen crawling on the ground trying to get his wheelchair that was three to five feet away. As the tape continue to run, no one was seen to come and evaluate R34. On 8/13/2013 at 12:30 PM, R18 said her jaw hurts and her lip was busted. R18 said she was hit by R30 during a fight that happen on Monday 8/12/2013 with R30. R30 was admitted to the facility 6/4/2010 with a [DIAGNOSES REDACTED]. R30 was observed in his room lying across the bed on 8/13/2013 at 11:45 am. R30 appeared disheveled and unshaven. R30 was asked if he wanted lunch he stated he was not hungry. On 8/13/2013 at 1:00 PM, (E1) Administrator / Abuse coordinator said there was an altercation with R30 that happened on 8/12/2013 and the facility was still investigating the incident. The facility's incident reports from January 2013 until August 2013 show R30 is identified to have had five other resident to resident altercations with R34 and R90. The Incident / Occurrence Report dated 5/17/2013 at 12:30 PM states: R30 and R90 were observed standing waiting for the elevator on the third floor. R30 started yelling at R90 for no apparent reason. R90 attempted to walk away from R30 but R30 kept yelling and swinging to hit R90 punching R90 in the arm. (E1) administrator witnessed the altercation and separated the residents. E1 documented on 5/17, E1 pulled R30 over privately and explained to him (we) can not hit another resident. R30 understood and would not try to do it again. We will continue to monitor and watch closely for R30's behaviors. The facility did not provide a plan of how the facility will monitor R30's behaviors. The nursing notation of 5/17/2013 at 1:30pm, states the Nurse Practitioner was notified and ordered R30 to be sent to the hospital for a psych evaluation. R30 was returned to the facility at 10:10 PM on 5/17/2013 with no new orders. On 5/29/2013, R30 was moved to the 4 th floor where the facility's Alzheimer's and Dementia residents live, as a preventive measure to help reduce any future issues with R90. This intervention is not addressed on the plan of care. The incident /occurrence report dated 4/24/2013 records the incident of 4/23/2013 at 9:00pm. The report describes: R34 had been yelling in the hallway about not being able to take a shower. R30 told R34 to shut up or he would hit him. R34 told R30 to go ahead. R30 shoved R34 a couple of times before he struck R34 in the upper left chest. When R30 realized R92 was in the shower he reportedly hit R34. This incident was unwitnessed by staff. R34 called the police. This report is not documented in the clinical record. The report lists resident R17 as the only witness. The report states the (CNA's) Certified Nursing Assistants did not see anything ( R30 hitting R34). The facility interviewed R30 about the incident on 4/24/2013. R30 stated " There is no solution coming." R30 said he recalled punching R34 four or five times in the arm. R30 added " it may have been uncalled for." The nursing notation dated 3/1/2013 at 9:45 am states: R30 came out of the shower room. R90 was by the elevator. Words were exchanged and R30 pushed R90. On 3/3/2013 at 9:30 p.m. the nursing documentation reads: R30 had an altercation with R90. R30 came up to R90 and started punching him in the face. R90 fell to the floor with his face down. R90 received a slight skin abrasion to his lip. The residents were separated and R30 was sent to his room to be monitored. At 11:30 p.m., R30 was sent to the hospital for a psych evaluation and was returned back to the facility at 1:25 am. The staff monitoring of R30 is not documented. On 3/8/2013 at 6:50 am nursing documents: R30 had altercation with R90. The reason for the incident was unclear. The incident report dated 3/13/2013 describes R30 sat with his back to the entrance of the dining room. R90 came into the dining room cursing. R30 believed the cursing was directed toward him. R 30 got up from the chair and struck R90 in the face, slight redness was noted to the left jaw. The only witness to this incident were residents R83 and R23 On 8/15/2013 at 10:30 am, R23 stated that there were no staff present in the dining area on third floor during the 3/8/2013 incident. R30's plan of care dated 3/2013 does not address the incidents of 3/1, 3/3, 3/8, 4/23, 5/17 and 8/12/2013. The care plan does not identify R30's preoccupation with R34 and R90 and females in the facility. The interventions on the care plan remain the same. On the next review date of 6/19/13, the goal remains the same even though the goal is not met. R30's plan of care for his verbally/physically abusive behavior dated 3/2013 states: R30 demonstrates behavioral distress related to: being challenged by mental illness and R30 appears confused and disoriented at times. R30's problems are manifested by : (These items are checked on a pre printed form) Verbally abusive behavior when agitated Use of profanity,demeaning statements ,verbal threats and yelling at others Physically abusive behavior when agitated Attempting to push,shove,scratch,hit,slap,kick,grab,or otherwise harm another person comment written: Behavior has increased recently and may be related to psychological and cognitive problems. The goal / objectives for R30 is : R30 will no longer exhibit physical aggression toward peers the date is stated as ongoing The approaches/interventions are not individualized and the following areas are checked off: If the resident becomes verbally or physically abusive attempt to calm the resident by explaining that "ladies and gentlemen "do not talk/behave this way."we do not touch other people." If talking to the resident is not successful in stopping the behavior ,try to walk with the resident to a quiet area, away from other residents. Intervene by speaking calmly and professionally in a soft tone of voice . Staff should avoid raising own voice, since this tends to make the resident more upset. This may cause the situation to escalate. Ask the resident to calmly explain what is causing this upsetting behavior. Praise the resident for speaking calmly and appropriately. Compliment the resident on successfully completing meals and group activities without inappropriate behavior. The incident /occurrence Certified Nursing Assistant statement form dated 05-10-13 at 5:00 PM, shows a written statement from the staff: "we were all passing dinner trays when we turned around, we saw R 22 standing over R 38 while he ((R38) was sitting choking and holding a knife to his(R38) neck saying in Spanish " his (he is) messing with me " R 22 jumped up and with both arms around R 38"s neck squeezing hard while having a knife in his hand ...". An undated statement from E19 reads: " I heard some residents shouting " no! no! no! and as (I) turned around I saw R 22 standing at the back of another resident (R 38)and was holding him in his head on a " head lock" with his(R22's) left hand, and his right hand holding a table knife poked on R 38 neck.." Another undated statement from E30 (Certified Nursing Assistant) documented: "R22 jumped up and put both arms around R38 neck squeezing it hard while having a knife in his (R22's) hand yelling stop messing with me ... ". R22 ' s Minimum Data Set of 05-09-13 showed R 22 ' s cognitive score was 14 (cognitively intact), with behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually). Behaviors of this type occurred 1 to 3 days. Puts others at significant risk for physical injury and significantly disrupts care and living environment. On 08-15-13 at 1:55 PM, E17 stated, " As I remember, it happened during dinner. R 38 was sitting down when R 22 approached him (from) behind and he grabbed him and head locked R 38. R 22 was delusional. I was not here at the time. It was Friday and I was not informed until Monday. I just coordinate the staff interviews. I do not recall doing any changes, updating or creating a care plan. There was no plan of care and interventions developed to address R 22 ' s identified behavior. . The surveyor confirmed through interview and observation that the facility took the following action to remove the Immediate Jeopardy: R30 was discharged to another facility on 8/13/2013 29 residents have been assessed with [REDACTED]. The facility has developed and implemented a policy specific to the supervision and monitoring of residents with potential for aggressive behaviors. The facility has reviewed and revised its policy regarding responding to statements and gestures potentially indicative of verbal and/or physical aggression The facility's 3p-11p and 11p-7a staff have been inserviced on prevention and recognition of early signs of aggression and effective interventions The 7 A-3p staff training will be completed before staff report on duty 9/6/2013 until all staff have received inservicing. The facility will evaluate the effectiveness of the actions through weekly evaluation of data and the Quality Assurance process. 2. Based on observation, interview and record review the facility failed to provide a safe environment for residents who wander, who smoke and who are at risk for falls. This applies to oe of 20 sampled residents (R26) reviewed for safety and supervision in the sample of 29 and five residents (R32, R39, R42, R43, R44) in the supplemental sample. The findings include: R32 was admitted to the special care Alzheimer's unit on 06/10/2013 with [DIAGNOSES REDACTED]. R32 had bruises on the left side of the back and the left thigh as written in the nurses notes on 06/11/13 at 0630. The facility identified these as risk factors for abuse and neglect on 06/12/13. The minimum Data set ((MDS) dated [DATE] shows R32 is cognitively impaired, has poor memory, disorganized thinking, difficulty focusing attention and is a wanderer. R32 requires the physical assistance of one person in transferring and ambulating. R32's brief interview of Mental Status shows a score of 5. R32 is not interviewable. The Care Area Assesment Worksheet dated 6/18/13 for communication shows, R32 may miss some part of the message, speaks limited English, and needs an interpreter. E13 (unit manager) said on 08/15/13 at 11:30 a.m., R32 did not require assistance with transfer or ambulation. The MDS dated [DATE] showed B32 requires the asistance of one staff to transfer and ambulate. The assessment shows R32 os at risk for falls and is unable to stabilize without staff assistance. The elopement risk assessment dated [DATE] shows R32 is at risk for unauthorized departure (elopement risk), wears an electronic device, and is at low risk for abuse/neglect. The abuse/neglect screening assessment score was inaccurate on 6/12/13 and did not include the unexplained bruising found on admission and the depression and anxiety behaviors from R32's history. R32's nurses notes and the Incident tracking record of behaviors describe the following 11 incidents from 6/1/13 through 7/13/13: 1. 6/11/12 at 2 p.m., ambulating, agitated, prn. (whenever necessary) medication was given for aggressive and uncooperative behavior. 2. 6/12/13, left hip bruise, unable to say how occured. 3. 7/2/13, R32 was found in the room of R44, exposing her breasts, R44 was touching the resident. 4. 7/5/13 holding onto another residents hand... separated by staff... continued trying to follow. 5. 7/10/13, wandering in other's rooms, hitting walls taunting peers. 6. 7/12/13 at 10:30 p.m. Physically aggressive with another resident, trying to kick other residents, pulling shirts and collars (of both residents) some redness on skin of R32, staff intervened and separated. 7. 7/13/13 at 9 p.m. fighting (with) another resident, both residents's slapped each other. Both residents fighting over male resident. 8. 8/5/13 at 12 noon, fell and hit head, bump on right occipital area. 9. 8/12/13 at 2 p.m. bleeding from mouth, minimal small cut on upper and lower gums. 10. 7 a.m. Aggressive with staff (fighting) right eye discoloration darker, eloped via exit door, found on teh third floor. 11. 8/13/13 9 a.m. discoloration under right chin, swollen tongue and open areas in mouth, palpable mass left side of face. Order to send to hospital emergency room for evaluation. diagnosed with [REDACTED]. R32 has a care plan goal, to refrain from verbally and/or physically abusive behavior following staff interventions. The interventions in place dated 6/12/13 for R32's care plan are not specific for R32, such as explaining rules of conduct and each person's obligations to treat one with dignity and respect, attempt to calm resident by explaining that, "ladies and gentlemen do not talk/behave this way," ask the resident to calmly explain what is causing the upsetting behavior, educate resident when displaying inappropriate behavior." R32 had a consultation with Z6 (psychiatrist) on 5/21/13, before admission to the facility for the treatment of [REDACTED]." On 6/14/13, R32 received a psychiatric consultation with Z5 (psychiatrist). The consultation report showed R32 to have a history of memory problems, emotionally escalates and became very volatile 6 months ago, a notable elopement risk and potentially combative and unable to be redirected, not safe to remain at home, has sadness, began having memory problems, notabley emotionally escalates" On 6/23/13 Z7 psychiatric report wrote, R32, "Notable cognitive challenges and is not capable of engaging in and benefitting from psychotherapy at this time." On 8/21/13, E13 and E37 (activity director) and residents on the special care unti at all times. When asked what specific plan teh facility developed to monitor to ensure resident safety, the facility did not have a specific plan in place for the residents on the special care unti. R26's Preliminary 24 Hour Incident Investigation Report dated 5/17/13 showed the following: "R26 stated a peer approached, and told her she could not have bed pads. The peer attempted to take bed pads and then allegedly hit R26 in the face." R26 was interviewed in her room on 8/15/13 at 3:29 p.m. R26 stated that R39 got mad at her (R26) for no reason and slapped her face. Since the incident of 5/16/2013, R26 said she sees R39 all the time. R26 expressed concerned she needed to be careful around R39. On 8/15/13 at 3:29 p.m., E12 (nurse) said R39 had a [DIAGNOSES REDACTED]. E12 stated that R39 was usually mad because she wanted to be with her family, and often tried to elope. E12 stated she was working when the incident occurred between R26 and R39. E12 said she did not witness the alleged abuse. After the incident, E12 said that R26 and R39 remained living on the same unit, but were on opposite hallways. E12 did not explain how R26 and R39 were being monitored to ensure they remained separated. E12 just stated we monitored the residents. On 8/13/13, 8/14/13 and 8/17/13, R43 was observed using an ambulating device to wander between the Alzheimer Unit and teh other areas of teh 4th floor. R43 was observed not being redirected to the Alzheimer side of the unti by staff. On 08/14/2013 at 1:30 p.m., E15 (nurse) stated he worked full time on the Alzheimer Unit. E15 said that the Alzheimer residents wandered between the hallways of the 4th floor. E15 said staff try to monitor them. While E15 was being interviewed, R43 walked past the nursing station frm the Alzheimers side of the unit. The other nursing staff present in the hallway and nursing station did not redirect R43 back to the Alzheimer side of the unit. E15 was asked if the Alzheimer residents were allowed to wander from their side of teh unit, like R43 going down the hallway? E15 replied, "No." Then, E15 ran to the other side of the unit and escorted R43 back to the Alzheimer side. On 8/20/2013 at 3:45 p.m. E12 (day shift nurse) explained that it was difficult to manage the Alzheimer residents who have behaviors, while working with only two CNA's. On 08/20/2013, E40 said she usually worked the evening shift with the Alzheimer residents. E40 stated it's hard to monitor and supervise the residents on the evening shift because they have "sun-downing," behaviors and act out. E40 stated that nursing staff cannot always stay with them because they have to provide care to other residents. E40 said we still have to take residents to the bathroom, feed them and pass medications. On 8/20/13 at 12:15 p.m. R42 was observed sitting in a chair smoking on the 5th floor patio. There was no ashtray or receptacle near for R42 to use. E10(Social Services) was the only staff person present monitoring residents smoking on the patio. As E10 walked away from R42, towards the other side of the patio, the resident dropped lit cigarette ashes down the front of his sweater. R42 brushed the ashes off his sweater and laid the lit cigarette butt onto the seat of his chair. On 8/23/13 at 10:10 a.m., E1(Administrator) stated that typically there is one to two staff on the patio to monitor smoking. The number of staff assigned will depend on the time of day. Often one person is assigned to the patio and it will also depend on the number of residents who are smoking. There are 15-20 residents who smoke on the patio and they are the residents who are assessed to be independent smokers and are not a smoking risk. E1 provided a copy of the smoking policy which states that smoking is allowed at designated times in designated smoking locations, that residents are not to give away, sell, share, trade or light another resident's cigarettes and lists the circumstances under which a resident can lose smoking privileges. R42's Smoking Safety Risk assessment dated [DATE] showed that the resident was allowed to participate in the smoking program even though he had a history of [REDACTED]. The care plan showed proper use of ashtrays as on approach to be reviewed with the resident and instructed that he was to be monitored during smoking times. R42 signed a copy of teh smoking policy on 8/1/12. Surveyor: Babatunde, Michelle

Based on interview and record review the facility failed to prevent multiple incidents of unprovoked resident to resident physical abuse by R30 between March 1, 2013 to August 12, 2013. This failure resulted in R18 sustaining facial injuries and R34 being knocked out of his wheelchair and beaten with closed fists unable to protect himself. This applies to two of 20 residents (R9,R18) reviewed for abuse in the sample of 29 and five residents R30, R34,R66,R90,R114 in the supplemental sample. The findings include: On 8/20/2013 at 2:00 p.m, E1 showed the facility's security footage taken on 8/12/2013 at 6:30 p.m. The video showed four residents R9,R34,R114 and R66 who were smoking and seated at a table on the facility's penthouse patio. R30 was seen coming through the patio door at a purposeful pace. R30 headed straight for R34 who has a right [MEDICAL CONDITION] and was seated in a wheelchair. Without provocation, R30 began to repeatedly hit R34's upper body and head with closed fists. One of the punches knocked R34 out of the wheelchair to the ground. R30 continued to punch R34. No staff were seen on the patio while this attack took place. (E14) Activity Staff came through the patio doors about 2 minutes after the attack. R30 continued to hit R34. E14 forcibly removed R30 from the patio and left R34 on the ground. R34 was seen crawling on the ground trying to get to his wheelchair that was three to five feet away. As the tape ran no one came to evaluate R34. On 8/13/2013 at 12:30 PM, R18 said her jaw hurts and her lip was busted. R18 said she was hit by R30 during a fight that happened on Monday 8/12/2013,at night in the penthouse, with R30. R18 said R30 was fighting with another resident on the patio. R30 was in line waiting for cigarettes with R18 and R92. R18 was the last resident in line. R18 said R30 left the line and went to the patio and began to beat up R34. R30 was brought back into the activity area by (E14) activity staff. R18 said she was standing behind R30 who was seated in a chair. R30 all of a sudden threw his arm up and hit R18 in the face knocking her down and split her lip and repeatedly hit her in the chest and her stomach. R18 showed the gastrostomy tube in her stomach stating it is very painful. R18 stated that the tube got pulled by R30 while he was hitting her. R18 said her mouth was sore [MEDICAL CONDITION] she eats with the split lip. R18 said she hurt all over from the attack. R18 stated she thinks she should have been sent to the hospital but she was not. R18 said she has not been seen by the doctor or examined by any one. R18 said she was only given some pain medication and told to " suck it up." by the nurses. R18 said she wishes the facility would do something with R30. He hits other residents for no reasons just like he did me. The staff do not seem to care. They did nothing to him. R30 was admitted to the facility 6/4/2010 with a [DIAGNOSES REDACTED]. On 8/13/2013 at 11:45 am, R30 was in his room lying across the bed. R30 appeared disheveled and unshaven. R30 was asked if he wanted lunch. He stated he was not hungry. On 8/13/2013 at 1:00 PM, (E1) Administrator / Abuse coordinator said there was an altercation with R30 that happened on 8/12/2013 and the facility is still investigating the incident. On 8/13/2013 at 2:00 PM, E1 stated that he was not sure if R30 is still in the facility. E1 said the facility was having a problem with the previous hospital they sent R30 to. They keep sending him back to the facility. E1 was asked how the facility was monitoring R30 after this incident. E1 said he told R30 that the next incident he would be sending him out. E1 stated he was not sure how many altercations R30 was involved in. R30's clinical record from January 2013 to August 2013 shows that R30 has been involved in unprovoked resident to resident altercations on five previous occasions: 5/17/2013 with R90 4/23/2013 with R34 3/3/2013 with R90 3/8/2013 with R90 3/1/2013 with R90 E1 stated nothing happened to R18 she was not hit by R30. E1's investigation dated 8/14/2013, shows "Being that I know R18 rather well at this point, I know she seeks attention and has constantly lied in the past, and made attempts for attention" .... " At the end of the investigation, to the best of my abilities I have determined that no abuse occurred to R18 in this matter" ( regarding the altercation of 8/12/13 between R30 hitting R18). However , there is a signed statement by E14 who stated she witnessed the altercation between R18 and R30 on 8/12/2013. On 8/13/2013 at 2:40 PM, social service interviewed (Z4) nurse practitioner. Z4 stated she was not made aware that there were two incidents of resident to resident altercation involving R30. Z4 said she was called on the morning of 8/13/13 by (E3) Assistant Director of Nursing and told the details of the 8/12/2013 incident and the involvement of two residents. Z4 stated she told E3 to "send him out." The nursing notes dated 7/15/2013 is the last notation for R30 until 8/12/ 2013 at 7:45 PM which documented the incident. There is no description of how the facility planned to monitor R30 after the altercations. On 8/13/2013 at 7:00 PM, the facility placed a call to another hospital for possible admission. R30 was sent out at 7:30 PM on 8/13/2013 for the two resident to resident altercations. The nursing note of 8/12/2013 shows at 8:10 PM Z4 was called and asked for a psychiatry evaluation for R30. Z4 said no to the request. On 8/15/2013 at 12:30 PM, the facility's Medical Director (Z1) stated the facility dropped the ball in the management of R30. The facility is looking at their admission process for evaluating residents like R30.

Based on observation, interview and record review the facility neglected to follow its policies for abuse prevention and Investigation of occurrences by not ensuring residents are protected from further abuse, not providing medical attention after a resident injury and after a change in condition. The facility neglected to have a policy and procedure to follow for incontinence care. These failures contributed to R32 presented with bleeding in the mouth and bruising and was not sent for evaluation for over 24 hours. R32 needed surgical repair of the left jaw bone. R18 sustaining facial injuries and being sent to the hospital for evaluation of abdominal pain 3 days after being hit by R30. R133 developed a stage II pressure sore after being incontinent for 5 hours. R34 was knocked out of his wheel chair and was beaten by R30. This applies to 1 of 12 residents (R18) reviewed for incidents in the sample of 29 and 4 residents (R30, R32, R34 and R133) in the supplemental sample. The findings include: 1. On 8/12/13 at 2 p.m. R32 ' s (nursing) notes completed by E16 (nurse), resident noted " with bleeding coming from mouth, minimal, noted a small amount on upper and lower gum/mucous area, pressure gauze applied, to monitor " . No evaluation, assessment or monitoring was found for R32 ' s condition. The progress note written by E13 on 8/13/13, shows Z4 (nurse practitioner) was not notified about R32 ' s bleeding on (8/12/13). R32's nurse's note dated 8/13/13 at 7:30 a.m. reads, resident. " noted with swelling of the left jaw at the base of the mandible, movable, palpable mass noted around 2.5 cm X 1.5 cm in size, but noted with redness and swelling of the tongue ...Z4 notified and orders to send resident to emergency room for further evaluation. " On 8/22/13 at 1:30 p.m., E16 stated, she did not receive a report about the change in R32's condition or about the swelling of the left side of the face from the 11 p.m. to 7a.m. shift nurse (E33) at the change of shift (7:30 a.m.). E13 (unit manager) stated she interviewed E33, on 8/15/13 about the occurrences on the morning of 8/13/13. E33's written description was: " I did not notice any bruise on the left jaw, before R32 went to the hospital, Last 8/13/13, R32 attempted to exit on South door at around 0645 writer got her up from the third floor and brought her back on fourth floor South unit, resident was agitated and gave her [MEDICATION NAME] ...calmer after 30 minutes " . The description of The Incident/ Occurrences Form for R32 dated 08/13/13 written by E13 (nurse/investigator), shows at 7:30 a.m.: " resident walking in the hallway going to dining room for breakfast noted with right eye bruise, reddish to bluish discoloration ...upon further assessment, resident noted with swelling at the base of the left mandibular area visible palpable mass ...tongue noted with redness and swelling." On 08-15-13 at 1:30 PM, E 13 stated R32 was transferred to the hospital and was found to have a left fractured jaw. E13 stated E33 gave medication to R32 on the morning of 8/13/13 at 7 a.m. and did not notice the bruise on R32's left chin. E13 stated it depends on the angle you ' re looking at. E16 stated she had no idea of what happened to R32. The operative report dated 8/14/13 dictated by Z2 (surgeon) shows: R23 had an , " open reduction with rigid internal fixation of the left body [MEDICAL CONDITION] as well as extraction of her remaining teeth numbers 26, 27, and 32. Z2 informed Z3 that R32 will probably have complete parathesia( tingling) of the left inferior alveolar nerve distribution surgery due to the placement of the fixation screws and not being able to avoid the inferior nerve in such a small mandible. " 2. On 8/13/2013 at 12:30 PM, R18 said her jaw hurts and her lip was busted. R18 said she was hit by R30 during a fight that happened on Monday 8/12/2013,at night in the penthouse, with R30. R18 said R30 was fighting with another resident on the patio. R30 was in line waiting for cigarettes with R18 and R92. R18 was the last resident in line. R18 said R30 left the line and went to the patio and began to beat up R34. R30 was brought back into the activity area by (E14) activity staff. R18 said she was standing behind R30 who was seated in a chair. R30 all of a sudden threw his arm up and hit R18 in the face knocking her down and split her lip and repeatedly hit her in the chest and her stomach. R18 showed the gastrostomy tube in her stomach stating it is very painful. R18 stated that the tube got pulled by R30 while he was hitting her. R18 said her mouth was sore [MEDICAL CONDITION] she eats with the split lip. R18 said she hurt all over from the attack. R18 stated she thinks she should have been sent to the hospital but she was not. R18 said she has not been seen by the doctor or examined by any one. R18 said she was only given some pain medication and told to " suck it up." by the nurses. The nursing documentation for 8/12/ 2013, at 7 PM shows staff was informed that R18 had an incident with another resident. R18's abdomen was assessed. No drainage noted. R18 was given an as needed medication for pain and anxiety. The record does not show that the physician was notified of the incident. On 8/13/2013 at 8 AM, R18 complained of abdominal pain. The nursing note on 8/14/2013 at 3:30 AM, shows R18 complained of abdominal pain. At 1 PM, Z4 was notified and a [MEDICATION NAME] consultation was ordered. The 8/15/2013 nursing note(no time given) shows R18 was sent to the hospital for pain in the abdomen. The facility's surveillance video from 8/12/13, shows R30 came though the patio door at a purposeful pace. R30 headed straight for R34 who has a right [MEDICAL CONDITION] and uses a wheel chair. R30 repeatedly hit R34 with his closed fist to his upper body and head. One of R30's punches knocked R34 out of his wheel chair to the ground. R30 continued to punch R34 while he was on the ground. No staff was seen on the patio while this attack was taking place. E14 (activity staff) was seen coming through the patio doors 2 minutes after the attack. E14 removed R30 from the patio and left R34 on the ground. R34 was seen crawling on the ground trying to get his wheel chair that was 3 to 5 feet away. As the tape continued to play no one came to evaluate R34. R30 was placed in the activity room after the altercation with R34. R30 then repeatedly hit R18. After the altercation on 8/12/2013 R30 was kept in the facility until 8/13/2013 in a 3 bed room with other residents. The facility did not monitor R30 and did not protect other residents. On 8/13/2013 at 2 PM, E1 stated that he was not sure if R30 was still in the facility. E1 said the facility was having a problem with the hospital they send R30 to. They keep returning R30 to the facility. E1 was asked how the facility monitored R30 after this incident. E1 said he told R30 that at the next incident he would be sending him out. The nursing notes dated 7/15/2013 is the last until the 8/12/2013 7:45 PM incident. The nurses note does not describe how the facility monitored R30 after the altercations. On 8/13/2013 at 7 PM, a call was placed to another hospital for possible admission for R30. R30 was sent out at 7:30 PM on 8/13/2013 for the two resident to resident altercations. ON 8/14/2013 at 10:30 AM though 12 PM, R133 was in the dining room sitting in a wheel chair during activities, sleeping. R133 had a very strong urine odor. At 12:05 PM, R133 was taken to and left in her room. R133 was not repositioned by the staff. At 12:45 PM, E11 (Certified Nursing Assistant - CNA) transferred R133 from the wheel chair to the bed. R133's shirt and pants were soaked from mid back down to her lower thighs. R133 was dripping wet when the disposable incontinence brief was removed. A new stage II pressure ulcer was observed on the left buttocks. At 12:47 PM, E11 explained "she (R133) does not move by herself, she does not talk at all and she is totally dependent on staff for everything (ADL's). The night shift got her up this morning, my shift starts at 7 AM. She (R133) was already up. I had not checked on her or toileted her until now (more than 5 hours). The facility's undated policy for Investigation of Occurrences Report: All incidents/accidents/occurrences report will be discussed and assessed to ensure all occurrences are investigated properly. The Procedure under number 3, Medical attention shows the nurse shall: Examine the patient, Notify the attending physician of the occurrence and document notification, notify the family member of the occurrence and document the notification. If necessary transfer the injured resident to the hospital (or preferred hospital) or call 911 if immediate help is needed. The facility's undated abuse procedure/abuse prevention program lists under item 6: protection of residents- The facility will take steps to prevent mistreatment while the investigation is underway. Residents who allegedly mistreated another resident will be removed from contact with other residents during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents and employees of the facility. E1 was asked for a policy on incontinence care and replied they didn't have one.

Based on interview and record review, the facility failed to provide nursing services by not assessing and evaluating the cause of R32's bleeding from the mouth on 8/12/13. The facility failed to monitor R32 for a change in condition. These failures resulted in R32 having a delay in surgery for [REDACTED]. This applies to one of one resident (R32) reviewed for injuries of unknown origin in the supplemental sample. The findings include 1. On 8/12/13 at 2 p.m. R32 's (nursing) notes completed by E16 (nurse), reports resident noted " with bleeding coming from mouth, minimal, noted a small amount on upper and lower gum/mucous area, pressure gauze applied, to monitor " . No evaluation, assessment or monitoring was found for R32 ' s condition. The progress note written by E13 on 8/13/13, shows Z4 (nurse practitioner) was not notified about R32 ' s bleeding on (8/12/13). R32's nurse's note dated 8/13/13 at 7:30 a.m. reads, resident. " noted with swelling of the left jaw at the base of the mandible, movable, palpable mass noted around 2.5 cm X 1.5 cm in size, but noted with redness and swelling of the tongue ...Z4 notified and orders to send resident to emergency room for further evaluation. " On 8/22/13 at 1:30 p.m., E16 stated, she did not receive a report about the change in R32's condition or about the swelling of the left side of the face from the 11 p.m. to 7a.m. shift nurse (E33) at the change of shift (7:30 a.m.). E13 (unit manager) stated she interviewed E33, on 8/15/13 about the occurrences on the morning of 8/13/13. E33's written description was: " I did not notice any bruise on the left jaw, before R32 went to the hospital, Last 8/13/13, R32 attempted to exit on South door at around 0645 writer got her up from the third floor and brought her back on fourth floor South unit, resident was agitated and gave her [MEDICATION NAME] ...calmer after 30 minutes " . The description of The Incident/ Occurrences Form for R32 dated 08/13/13 written by E13 (nurse/investigator), shows at 7:30 a.m.: " resident walking in the hallway going to dining room for breakfast noted with right eye bruise, reddish to bluish discoloration ...upon further assessment, resident noted with swelling at the base of the left mandibular area visible palpable mass ...tongue noted with redness and swelling." On 08-15-13 at 1:30 PM, E 13 stated R32 was transferred to the hospital and was found to have a left fractured jaw. E13 stated E33 gave medication to R32 on the morning of 8/13/13 at 7 a.m. and did not notice the bruise on R32's left chin. E13 stated it depends on the angle you ' re looking at. E16 stated she had no idea of what happened to R32. The operative report dated 8/14/13 dictated by Z2 (surgeon) shows: R23 had an , "open reduction with rigid internal fixation of the left body [MEDICAL CONDITION] as well as extraction of her remaining teeth numbers 26, 27, and 32. Z2 informed Z3 that R32 will probably have complete parathesia( tingling) of the left inferior alveolar nerve distribution surgery due to the placement of the fixation screws and not being able to avoid the inferior nerve in such a small mandible. "

Based on observation, interview and record review, the facility failed to provide R14 with treatment/services to prevent a decline in the range of motion (ROM) for his left wrist. This failure contributed to R14 developing contractures of the elbow, bilateral hands and left wrist between January and August 2013. This applies to one of nine residents (R14) reviewed for services to maintain their range of motion, in the sample of 29. The findings include: On 8/13/13 at 12 PM, during the initial tour and on 8/14/13 at 10 AM, R14 was sitting in bed. R14's left wrist was dropped downward. R14 had a soft wrist splint lying on his bed. R14 said he would sometimes wear this soft wrist splint. On 8/20/2013 at 3 PM, E13 (restorative nurse) was interviewed. After reviewing R14's contractures assessment, dated 1/27/13, 4/22/13 and 7/15/13, E13 said R14 had no limitation in function of his joints. E13 stated R14 was receiving restorative care for grooming issues and ROM (range of motion). Then, E13 went to R14's bedside and observed that R14's left wrist dropped downward at the wrist. E13 was not able to fully extend R14's left wrist. E13 stated that R14 had experienced a decrease in the range of motion to his wrist. E6 (restorative nurse) was not aware that R14's left wrist had a decline in function. E6 stated that no one told her that R14 had a problem with his left wrist and needed services. R14's August 2013 Physician order [REDACTED]. R14's 1/12/13 Initial and 7/04/13 Quarterly MDS (Minimum Data Set) assessments show no functional limitation in ROM for his upper extremities (including the elbow, wrist and hand). R14's care plan, dated 5/09/13, shows he was at risk for the development of contractures. This care plan also states that R14 had contractures of the elbow, bilateral hands, but not the wrist. R14's care plan did not show nursing approaches and treatments for R14's wrist joint. On 8/21/2013, the facility presented another Contractures Assessment for R14. This new assessment showed R14's left wrist had limited function with pain. This Contractures Assessment had a date of 8/19/13, but was not on the assessment flow sheet on 8/20/13. On 8/13/13 and on 8/14/2013, R14 was observed with a dropped left wrist and not wearing any positioning device.

Based on interview and record review, the facility failed to provide specific mental health rehabilitation services and a suicide risk assessment for 1 of 6 residents (R17) with a primary [DIAGNOSES REDACTED]. This failure resulted in the facility failing to identify R17 as being at risk for suicide from 1/13/11 until March 24, 2011 when R17 attempted to take her life by wrapping a nurse call cord around her neck. Findings include: A review of the facility's face sheet noted R17 a [AGE] year old female was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Psychiatry progress notes dated 1/13/11, 2/10/11, 3/10/11, 4/14/11, 5/19/11 and 06/09/11 contain the statement "The patient (R17) is encouraged to report SI or VI or any side effect of the RX immediately. R2 (DON) explained that SI stands for [MEDICAL CONDITION]. The readmission assessment did not contain documentation that a suicide risk assessment had been done. E1 (Administrator) was asked to provide this information if it existed. E1 acknowledged that this assessment was not done. R17's medical record contained documentation that on March 27, 2011, R17 tried to take her life by wrapping the nurse call cord around her neck. The care plans of 3/17/11, 6/9/11 and 8/24/11 document the approach to meeting R17's psychosocial needs was to "meet with res 1:1 as necessary and discuss any concerns or problems res may have... " E5's documentation of R17's 1:1 meetings showed that between 3/11/11 and 4/25/11, R17 refused 7 of 8 meetings. There were no adjustments to R17's plan of care, nor was there any investigation as to why R17 was refusing the 1:1 meetings. On 9/20/11, E1 stated R17 has a history of acting out with respect to her wallet and over money issues. There is no mention about the behaviors with respect to her wallet or money in any of R17's care plans. . .

1) Based on interview and record review, the facility failed to; assess, care plan, and make adjustments to the plan of care when indicated, and provide specific mental health rehabilitation services. ensure residents received necessary specialized rehabilitative services that include measurable goals, and time frames, identifying and monitoring targeted behaviors for 4 of 7 residents with a primary [DIAGNOSES REDACTED]. In addition, specialized rehabilitative services were provided by one of four staff members, (E5), that did not have the state required credentials. This is for 5 of 6 residents (R17, R2, R4, R6, and R14) in the sample identified with a primary [DIAGNOSES REDACTED]. This failure resulted in the facility failing to identify R17 as being at risk for suicide and on March 24, 2011 R17 attempted to take her life by wrapping a nurse call cord around her neck. Findings include: 1) R17 a [AGE] year old female was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The psychiatry progress notes dated 1/13/11, 2/10/11, 3/10/11, 4/14/11, 5/19/11 and 06/09/11 contain the sentence "The patient is encouraged to report SI or VI or any side effect of the RX immediately. E2 (DON) elaborated that SI stands for [MEDICAL CONDITION]. . The facility staff did not do a suicide risk assessment of R17. The care plans of 3/17/11, 6/9/11 and 8/24/11 document the approach to meeting R17's psychosocial needs was to "meet with res 1:1 as necessary and discuss any concerns or problems res may have... " There is no mention about the behaviors with her wallet or money. E5's documentation of R17's 1:1 meetings showed that between 3/11/11 and 4/25/11, R17 refused 7 of 8 meetings. There were no adjustments to R17's plan of care, nor was there any investigation as to why R17 was refusing the 1:1 meetings. On 9/19/11 at approximately 10:00 am E1 (Administrator) provided a list of residents having Serious Mental Illness that contained documentation that R17's primary [DIAGNOSES REDACTED]. R17's medical record contained documentation that on March 27, 2011, R17 tried to take her life by wrapping the nurse call cord around her neck. In a Social Service note of 3/27/11, E9 (PRSC) documents that "A female CNA was unwrapping a cord from around female resident's neck. CNA stated she came into the room and she saw resident sitting up with call light cord around neck and her face had already turned purple. Staff inquired why she would do that and she (R17) said that she wanted her wallet and no one liked her...Writer asked R17 again and she said she had no reason to live.... Resident's doctor was called by nurse and also put on 15 min checks." Review of the Nurse's note dated 3/27/11 19:30 documented "Resident has no behavior problems this PM shift, Resident was crying and saying she was sorry for pulling the cord and would we replace them. Resident was told not sat this time - will continue @ Q 15 min bed checks." E1 (Administrator) was unable to provide any addition documentation in the nurse's notes." R17's medical record contained a document labeled Incident Report Statement of Witness Report prepared by E8 (LPN). This report documents "...CNA doing 14:30 rounds before end of shift and noted resident had wrapped around he neck the call light cord stating "I don't want to live anymore, nobody loves me here." The annual psychiatric evaluation of 7/7/11 does not address the incident of March 27,2011. Additionally, the psychiatric report of 4/14/11 did not address the behavior of wrapping cord around her neck and potential of great bodily harm. All of these progress notes and annual evaluation were performed by Z2 (Psychiatrist) A suicide risk assessment was not done prior to the incident on March 27, 2011, yet staff acknowledged the statement in the psychiatrist's progress notes. A suicide risk assessment was done on 3/28/11 (the day after the incident), in which R17 was identified as a moderate risk for suicide. Another note on the back of the suicide risk assessment form, written by E (PRSD) documented that "Resident is not a threat to herself. Conducted follow-up to 3/27 incident. This writer interviewed resident and she (R17) stated that she had no intention on harming herself because she was upset about her wallet. Resident has no plan to harm herself". On 9/20/11, E1 stated the R17 has a history of acting out with respect to her wallet and over money issues. R17's care plans did not address the risk for suicidal behaviors or the acing out due to her wallet or money. 2) E1, (Administrator) on 9-19-2011 at approximately 10:00am. provided a list of 48 residents identified with SMI as their primary diagnosis. E1 affirmed the facility has a licensed SMI unit. E4, (PRSD/Psychiatric Rehabilitation Services Director) on 9-19-2011 at approximately 11:10am. provided the facility Social Services Group Schedule which is, "Monday, Wednesday, and Friday: 9:00am. Symptom Management. 10:00am. Anger and Impulse Control Coping Skills. 10:30am. Social Skills. 6:30pm. Community Integration and Life Skills. 7:00pm. Social Skills. Wednesday and Friday: 3:30pm. Cooking and Domestic Living, Group Living. 8:00pm. Chemical Dependency and Relapse Prevention. Tuesday and Thursday: 9:00am. Money Management. 10:00am. Medication Management. 7:00pm. Relaxation and Meditation. Saturday and Sunday: 2:00 Expression Group. R2, R6, and R14,refuse to attend group. E5, (PRSC) on 9-20-2011 at 10:35am. stated, "I don't think I document (R2, R6, and R14,) refusal every week. I do 1:1 counseling with them." R2, R6, and R14's 1:1 Weekly Notes contain documentation of goals to "discuss any concerns or problems they may have." On 9-22-2011 at 10:30am. E1, (Administrator) stated, "We do not have Behavior Logs. Last night I spoke with our Pharmacy Consultant and she said we only have to chart the behaviors in the Nursing Notes, not complete Behavior Logs. No one reviews the Nursing Notes to see frequency and patterns. The Nursing Notes would need to be reviewed. We do not review the Nursing Notes." Additionally, E2, (DON) and E1, (Administrator) and E4, (PRSD/Psychiatric Rehabilitation Services Director) affirmed individual resident target behaviors had not been identified for (R2, R6, and R14). Additionally, R2, R6, and R14, Comprehensive Physical and Psychosocial Care Plans do not document time and frequency or identified measurable goals. On 9-19-2011 at 3:40pm. E4, (PRSD/Psychiatric Rehabilitation Services Director) provided a list 4 of PRSC, (Psychiatric Rehabilitation Services Coordinator)s working with the SMI population of the facility. E4 provided supporting documentation of the 4 PRSC's credentials. E5, (PRSC) has a bachelor of science in commerce. E5, (PRSC) on 9-20-2011 at 10:35am. stated, "I have a bachelor degree in business administration. I have not received acceptance from Public Health to act as PRSC. I have worked at the facility for ten years, eight of those on the SMI unit as a PRSC." E5 affirmed that she independently assesses the residents on her caseload, creates their individualized care plan, as well as assessing, implementing, and monitoring treatment plans. On 9-20-2011 at 11:00am, E5, (PRSC), provided a list of 52 active SMI residents on her caseload, including R2 and R14. 3) R4's current POS for the month of 9/2011 contains documentation that R4 is a [AGE] year old with [DIAGNOSES REDACTED]. R4's clinical record including nurse's notes and progress notes showed that there was no documentation for R4's specific targeted behavior and how is the behavior being addressed. E5, (PRSC) on 9-20-2011 at 10:35am. stated, "I don't think I document specific concerns or problems and goals with regards to (R4) 1:1 counseling." R4 1:1 Weekly Notes contain documentation of goals to "discuss any concerns or problems ." R4 was observed lying in bed on 9/19/2011 around 10:45 A.M. R4 was quiet and non verbal .