Every finding on record at Briar Place Nursing

Based on observation, interview, and record review, the facility failed to follow policy procedures, failed to ensure that staff report/document maintenance concerns, failed to ensure that date resolved were documented on the maintenance work log, failed to replace blinds/screens in disrepair, failed to maintain essential equipment, and/or failed to identify safety hazards for 8 of 11 residents (R3, R4, R5, R6, R8, R9, R10, R11) in the sample reviewed for physical environment. Findings include: 1.) R10's (7/23/26) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 8/10/26 at 2:09pm, surveyor inquired about concerns with facility blinds and/or paint. R10 proceeded to enter the (1st floor) dining room and stated Let me show you something, the screens in the dining room have holes in them and the bugs can come in. The dining room screens were torn with large holes and one of the dining room blinds was notably bent. The dining room A/C (air conditioning) unit was leaking profusely; there were 2 saturated bath blankets and a saturated sheet on the floor (next to the AC unit) however a large puddle of water was also on the floor (near the patio doors) creating potential safety hazard. Surveyor inquired about concerns with the leaking A/C unit R10 responded That's been leaking for quite some time, it's by the patio door so we (residents) have to be careful walking here. We don't want to slip and fall. Surveyor inquired how long the dining room A/C unit has been leaking, R10 replied Probably a month or more. On 8/10/26 at 2:40pm, surveyor inspected R10's bathroom. R10 stated This paper towel holder fell off the wall 2 months ago and I told them about it, but they (maintenance) haven't fixed it. R10's bathroom wall (near the sink) had a large hole and several small holes (likely where the paper towel holder was previously hung) and the paper towel holder was on the toilet tank cover. Surveyor inquired about concerns with R10's notably dusty vent (above the sink) R10 responded That's been there for a while. On 8/10/26 at 3:39pm, the saturated linens and large puddle of water remained on the floor near the (1st floor) A/C unit and patio doors. V17 (Activities Aide) was observed walking from the dining room onto the patio, however failed to address the water hazard near the door. Surveyor also observed several residents on the patio with V16 (Activities Aide) at this time. Surveyor inquired about concerns with the A/C unit leaking water near the patio doors V17 stated I (V17) guess that the towels are there for the water, looks like its sheets. Surveyor inquired how long the A/C unit has been leaking water V17 responded It happens all the time. On 8/10/26 at 3:41pm, surveyor inquired about concerns with the leaking A/C unit near the (1st floor) patio doors V16 (Activities Aide) stated They (staff) have towels on the floor or will wipe up the floor with the towels. Surveyor inquired if the patio door near the A/C unit is the only entrance to the patio V16 responded There are doors over there, but we (staff) use this one (referring to the door near the A/C unit). On 8/11/26 at approximately 10:15am, wet sheets were observed on the floor in the (1st floor) dining room near the A/C unit and patio doors. On 8/11/26 at 10:22am, surveyor inspected room YYY with V22 (Social Service) and observed a sheet covering the right window and the blinds on the left window were broken. Surveyor inquired about sheet covering the window, V22 stated I'm gonna have to speak with the maintenance about that. Surveyor inquired about concerns with the blinds. V22 responded There's one broken section right here. Holes were observed on the screens, and the right screen was not secured to the window. Surveyor inquired about concerns with the screens V22 replied It's broken, I see a hole here, on the base section and I (V22) see a gap (referring to the right screen). I see a screen on the left it seems to have a vertical tear. One of four screens was missing. Surveyor inquired if all 4 windows have a screen. V22 stated I don't see a screen there referring to the 2nd screen from the left side. On 8/11/26 at 2:24pm, surveyor inquired when facility maintenance inspections are conducted. V5 (Maintenance Director) stated Daily and throughout the day. We also have maintenance logs. Surveyor inquired if staff document maintenance concerns on the log. V5 responded Yeah, even the residents if they want to. Surveyor requested a copy of the current (1st floor) Maintenance Log. V5 presented the (7/17/26-8/11/26) Maintenance Work Log and affirmed all the documented problems were addressed; however the dates resolved were NOT documented. Surveyor inquired about concerns with the window treatments in room YYY. V5 (Maintenance Director) responded They put a sheet up there. I could replace the blind (referring to the right window). Surveyor inquired about the appearance of the blinds (on the left window) which were broken (part of the slat was missing). V5 replied It's functional. Surveyor inquired why water was on the floor next to the A/C unit (in room [ROOM NUMBER]) V5 stated It's condensation from the air conditioning pan, it's not draining properly. The pan catches the water, and it drains out the building. We're (facility) getting a quote to replace or repair the pipe that actually catches the water. Last week there were some guys (technicians) out checking the drains and scoping out the work. We're looking for one more company before they (facility) make the decision who we're gonna go with. On 8/11/26 at 2:33pm, surveyor inquired about concerns with the blinds in room ZZZ (the blinds were dusty and several slats were broken). V5 replied I'll get it replaced. Surveyor inquired if the broken blinds in room ZZZ were reported or documented on the maintenance log. V5 stated No. Surveyor inquired if screens were on the windows in room ZZZ. V5 responded Not on this side referring to the left window (without a screen). On 8/11/26 at 2:41pm, surveyor inquired about concerns in R10's bathroom. V5 stated The paper towel dispenser is off the wall. Surveyor inquired who should be reporting maintenance concerns. V5 stated When Nursing or Housekeeping comes in here they should let me know that the paper towel dispenser is off the wall, or the CNAS (Certified Nursing Assistants) and affirmed he (V5) was unaware. The (7/17/26-8/11/26) facility maintenance work log excludes R10's paper towel dispenser. On 8/11/26 at 2:43pm, surveyor inquired about the leaking A/C unit in the 1st floor dining room. V5 responded It's connected to the same issue (referring to observation/interview in room YYY). It's condensation from the air conditioning pan, it's not draining properly. Surveyor inquired how long the dining room A/C unit has been leaking V5 replied About a week or so. 2.) On 8/10/26 at 2:23pm, V15 (Housekeeping) cleaned and mopped in R11's room then entered the hallway. Surveyor subsequently entered R11's room and inspected the blinds which were notably dusty. Surveyor exited the room and inquired if R11's blinds were dusted today. V15 responded No clean today then re-entered R11's room and proceeded to dust to the blinds. R11's (8/11/26) BIMS determined a score of 15 (cognition intact). On 8/10/26 at 2:25pm, surveyor inquired about concerns with the facility blinds and/or paint R11 stated They don't dust the blinds like they should, it's very seldom. They put a fire sprinkler in my (R11) bathroom, and they didn't paint or patch it up, it's finished halfway. On 8/10/26 at 2:38pm, surveyor inspected R11's bathroom, a 1 x 4 inch (upright) board was screwed to the floor (under the sink) and appeared to be holding/securing the floating sink. The board also impeded access for wheelchair bound residents. The ceiling drywall appeared to be repaired and painted white, however most of the bathroom is painted blue. The wall tiles behind R11's sink were removed and not replaced. The floor tiles around R11's toilet were also missing. On 8/11/26 at 2:35pm, surveyor inquired why R11's bathroom sink has an upright board (screwed to the floor) which appeared to be securing the sink to the wall. V5 (Maintenance Director) responded I added this for a safety precaution. It's a floating sink they (residents) lean on this instead of grabbing the handrail. Surveyor inquired how R11 can reach the sink while in while in a wheelchair (due to board impeding access). R11 replied I stubbed my toe on that board one time and had to get x-rays. Surveyor inquired about the missing ceramic tiles on R11's bathroom wall. V5 stated We just had to open this wall because a pipe broke everything had to be replaced in here about a week ago. Surveyor inquired about the missing floor tiles around the toilet. V5 responded It's missing but they (prior maintenance staff) grouted it, whoever was here before me, they just didn't replace it and affirmed he's (V5) been employed by the facility for 1 year. Surveyor inquired about the appearance of R11's bathroom vent. V5 stated It's dusty I definitely see that. During inspection of R11's bathroom R11 stated The paper towels thing is broke, it's not working. Surveyor inquired if R11's paper towel dispenser was working. V5 pressed the handle on the dispenser several times to no avail and affirmed that it was not working. The facility maintenance work log includes (7/27/26) paper towel dispenser in R11's room and (8/4/26) paper towel broken in R11's room (documented twice) which remains broken. 3.) R3 was admitted to the facility 2/1/2024. On 7/17/2026 R3 had a Brief Interview of Mental Status (BIMS) of ten indicating moderate cognitive impairment. Minimum Data Set (MDS) Section GG Functional Abilities had R3 at supervision or touching assistance with toileting hygiene. On 8/10/2026 at 9:41 AM R3 stated the sink and toilet in the bathroom in R3's room have been backed up for a couple of days now. R3 stated the sink and toilet overflowed a few days ago and staff came and cleaned it up, but the sink and toilet were never fixed. The sink in R3's bathroom observed to have brown-tinged standing/non-draining water in the bathroom sink. Toilet in R3's bathroom has brown-tinged water and toilet paper observed in the toilet. Surveyor attempted to flush toilet, and toilet could not be flushed. On 8/10/2026 at 9:50 AM V10 (Registered Nurse) observed the bathroom sink and toilet in R3's room. V10 stated the sink is stopped up and the toilet won't flush. V10 stated R3's bathroom flooded last week, but V10 did not know how long the bathroom was unusable. R3 stated to V10 it has been a couple of days that it has been like that. It hasn't been fixed in a few days. R3 stated maintenance knows about it but hasn't fixed it. On 8/10/2026 at 9:55 AM V5 (Maintenance Director) stated V5 was unaware of any issue with R3's bathroom. V5 was unaware the bathroom flooded a few days ago and V5 was unaware bathroom was not working. R3 stated to V5 that the bathroom has been like that for a few days. 4.) R4 was readmitted to the facility on [DATE]. BIMS and MDS Section GG had not been completed as of 8/12/2026. R4 was observed ambulating independently in the hallway without mechanical or staff assistance. On 8/10/2026 at 9:43 R4 stated through the closed bathroom door in R4's room Come back, our bathroom is not working. The sink is clogged. On 8/10/2026 at 9:50 AM V10 (Registered Nurse) was asked about the clogged bathroom sink in R4's room. V10 stated the Certified Nursing Assistants (CNAs) should have said something about the fact it is not working. V10 and surveyor observed standing water with no movement and no drainage in the bathroom sink in R4's room. On 8/10/2026 at 9:55 AM V5 stated V5 was unaware of any issue with R4's bathroom sink not draining. 5.) R6 was admitted to the facility on [DATE]. On 7/2/2026 R6 had a BIMS of fifteen indicating R6 is cognitively intact. MDS Section GG Functional Abilities had R6 at supervision or touching assistance with toileting hygiene. On 8/10/2026 at 10:06 AM R6 stated the call lights do not work in the room. R6 stated we've told the staff many times and no one fixes them. R6 described that the call light between bed one and bed two did not work. R6 described that the call light between bed two and bed three did not work. Surveyor pulled the call light between bed one and two, and between two and three. Call light could not be activated. No light illuminated above the hallway door when either of the two call lights were pulled. On 8/11/2026 at 9:31 AM V18 (CNA) activated the two bedside call lights in R6's room. Neither of the two call lights illuminated the outside door light. V18 stated the risk if call lights do not work is that residents will not get the help they need. 6.) R9 was admitted to the facility on [DATE]. On 6/26/2026 R9 had a BIMS of fifteen indicating R9 is cognitively intact. MDS Section GG Functional Abilities had R9 as dependent with toileting hygiene. On 8/10/2026 at 9:44 AM R9 stated, My call light does not work. It has not worked for a couple of days. It has probably been four days or more. My roommate and I don't get along so she won't call for help if I ask. I cannot get out of bed. I can't get help any other way, so I have to have a working call light to get help if I need it. R9 pulled the call light and surveyor observed that no over the door light illuminated. On 8/10/2026 at 10:31 AM V11 (CNA) stated some call lights do not work on this floor. V11 was unsure about how long the call lights have not been working. V11 stated We have told maintenance about it. On 8/11/2026 at 9:24 AM V18 (CNA) pulled R9's call light. It did not illuminate over the outside door. R9 stated it has not been working. R9 stated I've been asking everyone to ask maintenance to fix it. R9 stated everyone is the nurses and CNAs on the unit. On 8/11/2026 at 9:26 AM V19 (CNA) stated I know R9's call light is not working. I don't know how long it hasn't worked. On 8/11/2026 at 9:48 AM V2 (Director of Nursing/DON) asked R9 if R9 told anyone about the call light not working. R9 told V2 that R9 has been waiting a long time to have R9's call light fixed. It stopped working last Thursday. R9 stated I've been telling the CNAs and nurses every day and asking them to call maintenance. They told me maintenance was off on Friday so no one could fix my call light. 7.) On 8/10/2026 at 10:34 AM R8 was not in R8's room. The call light was observed to have no pull code attached to the call light from the wall. On 8/10/2026 at 1:49 PM V2 (DON) stated nurses and CNAs round every 2 hours on residents alternating between nurses and CNAs. Someone sees each resident at least hourly. If a resident has a concern that is not nursing specific, the nurse or CNA will relay the concern to the appropriate department or tell social service who can identify the appropriate department. On 8/11/2026 at 9:41 AM V2 and surveyor observed R8's call light without a pull string. V2 stated there should be a sting to activate the call light. 8.) On 8/11/2026 at 9:30 AM R5 stated the call lights do not work. V18 (CNA) tested the two bedside call lights in R5's room. Neither of the two call lights illuminated the outside door light. On 8/11/2026 at 9:35 AM V2 (DON) was observed checking call lights and distributing red bells to residents with non-working call lights. V2 stated V2 was unaware call lights were not working. The process if a call light is not working is that staff notify maintenance. Part of rounding by staff is to make sure call lights are not malfunctioning. V2 stated we also have the Guardian Angel Program where leaders visit each resident daily. V2 stated residents' call lights are checked daily as part of that program. V2 stated the risk if a call light checked and is not working is that resident care will be delayed. On 8/11/2026 at 9:42 AM V5 (Maintenance Director) stated V5 was unaware call lights in residents' rooms were not illuminating the overdoor light. V5 explained if nursing does not reset the bathroom call light, the bedside call lights in the room will not work. On 8/11/2026 at 2:20 PM V5 (Maintenance Director) stated there are four separate call lights in each room. All of the call lights in each room are connected to make a continuous loop. If you don't activate or turn off the call light fully, it is left in the middle and disturbs the circuit. That is a mistake staff make. If staff are moving fast, they don't fully turn the call light off and the resident can't use the call light because the call light doesn't work and staff are unaware that the resident is calling for help. For R9's nonfunctioning call light, V5 stated that V5 unscrewed the call light and had to straighten the call light behind the wall. The box behind the wall shifted so the call light did not work. On 8/12/2026 at 10:43 AM V2 (DON) stated expectation is that call lights are working at all times. If call lights are not working, it is reported immediately to maintenance, V2, and any ancillary departments that can assist in resolving the issue. V2 stated I am not sure why that did not happen on the second floor. When stated when V2 became aware of the issue with call lights not working, V2 reacted by checking on the residents, providing a bell to residents to call for assistance and V2 notified maintenance. V2's concern if call lights are not working is that care may not be adequately provided. Expectation is that rounding should have identified the concern. Bathroom sink issues should be reported on the maintenance log. V2 stated the Guardian Angels is a program within the facility in which a leader is assigned a group of residents and that leader rounds daily on each resident. V2 stated Guardian Angels should also have identified any issue with bathroom sinks and toilets not working and with call lights not working. V2 stated if residents' bathroom sinks or toilets are not working in their bedroom and the sink or toilet cannot be readily and quickly fixed; the resident should have been removed from that room to a room with a working sink and toilet. Had V2 been aware of sinks and toilets not working, V2 stated we would have involved maintenance and changed the resident's room. If call lights are not working and toilets or sinks are not working, V2 stated there is concern about the comfort and safety of the residents. If sinks are not working, handwashing and infection prevention is at risk. V2 stated education was initiated yesterday to instruct staff to report concerns and also how to reset the bathroom call lights so that the beside call lights work. Facility's undated policy titled Residents' Rights for People in Long-Term Care Facilities includes residents have the right to safe and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction. Facility's policy titled Housekeeping Guidelines dated 7/2014 stated the purpose is to provide guidelines to maintain a safe and sanitary environment for residents, facility staff and visitors. The housekeeping policy states housekeeping personnel shall adhere to daily cleaning assignments developed so to maintain the facility in a clean and orderly manner. Cleaning of curtains, walls, blinds, etc. will be cleaned when dust or soiling is visible. Facility's policy title Policy and Procedure Call Light dated 1/2025 stated all call lights will be answered by staff within a reasonable time, depending on the task required. The purpose of the policy is to respond to resident's requests and needs in a timely and courteous manner. All residents shall have the nurse call light system available and within easy accessibility to the resident at the bedside or other reasonable accessible location. Call light/bell system defects will be reported promptly to the Maintenance Department for servicing. The preventative maintenance policy (revised 5/2026) states the facility is committed to maintaining a safe, functional, and comfortable environment for residents, staff, and visitors. A comprehensive Preventative maintenance Program will be implemented to ensure that building systems, equipment, and environmental conditions are routinely inspected, maintained and repaired. Procedure: Random environmental rounds and safety audits shall be conducted by the Maintenance Director and/or Housekeeping Director. Maintenance concerns may be reported by any staff member. Resident equipment is in safe working order. Facility areas are clean and safe. Call light systems are operational. Electrical equipment is inspected and safe for use. Wall coverings are secure and undamaged. Issues that are identified shall be logged and prioritized for repair within established timeframes. Immediate risks to safety must be corrected at once or the area taken out of service.

Based on interview and record review, the facility failed to ensure notification of room and roommate changes were documented, failed to ensure family was notified of the room change, and failed to ensure residents received written notice including the reason for the change before the room or roommate change. These failures affected four (R1, R5, R6, and R7) residents reviewed for residents' rights in the total sample of 7 residents. Findings include:R1's admission Record documented that R1's diagnoses include but are not limited to Type 2 Diabetes Mellitus, major depressive disorder, and delusional disorder, and COPD (Chronic Obstructive Pulmonary Disease). R1's contact includes V9 (Resident Family member # 1). Contact Type: POA (power of attorney). R1's census list documented that R1 had a room change on 03/28/2026. R1's (02/25/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating R1's mental status as cognitively intact. R1's (Effective Date Range: 03/20/2026 to 03/28/2026) progress notes were reviewed with no notes documented for notification of R1's POA of R1's room change. R5's admission Record documented that R5's diagnoses include but are not limited to schizophrenia, low back pain, and myalgia. Contact: Self as responsible party. R5's census list documented that she has been in her current room since 10/07/2022. R5'S (01/27/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating the resident's mental status as cognitively intact. R5's (Effective Date Range: 03/20/2026 to 03/28/2026) progress notes were reviewed with no notes documented for notification of R5's family regarding a new roommate.R6's admission Record documented that R6's diagnoses include but are not limited to COPD (Chronic Obstructive Pulmonary Disease), asthma, and hypertension. Contact: Self as responsible party.R6's census list documented that R6's has been in her current room since 12/31/2023. R6's (03/05/2026) Minimum Data Set documented, in part Section C. - Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 13. Indicating the resident's mental status as cognitively intact.R6's (Effective Date Range: 03/20/2026 to 03/28/2026) progress notes were reviewed with no notes documented for notification of R6's family regarding a new roommate.R7's admission Record documented that R7's diagnoses include but are not limited to hypertension, low back pain, and obesity. Contact: Self as responsible party. R7's census list documented that R7 has been in her current room since 08/22/2023. R7's (04/14/2026) Minimum Data Set documented, in part Section C. - Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating the resident's mental status as cognitively intact. R7's (Effective Date Range: 03/20/2026 to 03/28/2026) progress notes were reviewed with no notes documented for notification of R7's family regarding new roommate.On 04/24/2026 at 10:08am, knocked and entered R1's room; R6 was lying on bed watching a show on her Television. R7 pointed on the drawn curtain next to R6's bed and stated her (R1) bed was next to (R6)'s bed. On 04/24/2026 at 10:09am, R1 stated she had a room change a couple of weeks ago, she is sure her POA is (V9 - Resident Family Member #1) and she did not know if the facility talked to her (V9) about the room change. R1 stated she did not sign any document regarding a room change.On 04/24/2026 at 1:58pm, R5 stated she could not remember the name of staff member who showed her (R1) the room, but she did observe staff showing her the room. R6 stated she was not presented with a written notification of roommate change. On 04/24/2026 at 3:17pm, R7 stated she could not recall if she was introduced to her new roommate prior to moving her in the room. R7 stated she could not recall if she was presented with a written notification of roommate change. On 04/24/2026 at 3:18pm, R6 stated she did not recall if staff introduced her (R1) to all the residents in the room and she could not recall if she was presented with written notification of a roommate change. On 04/24/2026 at 1:23pm, V1 (Assistant Administrator) stated she leaves it to Social Services Department to contact Power of Attorney regarding the room change. On 04/24/2026 at 1:36pm, V5 (Psychiatric Rehabilitation Services Director) and V8 (Psychiatric Rehabilitation Services Assistant Director) both stated they did not notify (V12) of R1's room change. On 04/24/2026 at 3:45pm, V5 stated she did not notify (R5, R6, and R7)'s family members of a roommate change and did not document any notification. On 04/24/2026 at 3:46pm, V8 stated she did not notify (R5, R6, and R7)'s family members of a roommate change and did not document any notification because she was not at the facility when she (R1) moved to their room. On 04/24/2026 at 3:15pm, V1 (Assistant Administrator) stated she brought (R1) in the room and all three (R5, R6, and R7) were in the room. V1 stated they were all notified they would have a new roommate, but the notifications were not documented. On 04/24/2026 at 4:00pm, V1 (Assistant Administrator) stated there was no written notice provided to the residents or POA regarding the room and roommate change prior to (R1) moving to her new room. V1 stated the facility should have provided written notification of a room and roommate change. The purpose of having written notification is for documentation purposes, so the facility has a receipt of notification of the room and roommate change; that the residents were informed of the reasons behind the change. V1 stated there was also no documentation that the residents and family were notified of room and roommate change. The expectation is for the staff, who notified the residents and family of the room and roommate change, to document in the progress note about the notification. V1 stated if it is not documented then it never happened. The (5/19) Facility provided 'Room Changes' Policy and Procedure documented, in part A. Policy: Room changes will be assigned based on the resident's needs and nursing care required. 3. Residents are informed of room changes prior to its occurrence. B. Procedure: 1. admission Directors or Social Services notifies the resident and family of room changes and documents. If unable to reach family, a voicemail is left for family to contact the Social Services Director. 2. If the resident is being transferred to a new room which already has a resident residing in it, the resident will be notified prior to transfer. Notification is documented in the progress notes. The (undated) Facility provided 'Statement of Resident Rights' documented, in part No resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the constitution of the State, or the constitution of the United States on account of his or her status as a resident of the community, nor shall a resident forfeit any of the following rights: (e) Right and dignity. The resident has a right to be treated with respect and dignity, including (6) the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.

Based on interview and record review, the facility failed to follow physician orders and failed to follow the facility community pass policy after no credible evidence of contraband was found for one (R72) resident. This failure affected one resident (R72) in a sample of 72 residents. Findings include:R72 is [AGE] years of age with diagnoses include not limited to: Alcohol Abuse, Anxiety Disorder, Unspecified, Major Depressive Disorder, Recurrent, Unspecified, Post- Traumatic Stress Disorder, Chronic, Suicidal ideations, Anemia, Unspecified, Insomnia, Unspecified, Other Psychoactive Substance Abuse, Uncomplicated, Schizophrenia, UnspecifiedSection C - Cognitive Patterns (7/6/2025) documented BIMS 15 (cognitively intact)R72's physician orders document an active physician order for independent community pass.R72's Community Survival Skills Assessment documents (in part) Effective 9/9/2025 at 08:51 9. Documents 2. Cannot Determine B. Recommendations and Outcomes 1. Recommendations 2. The resident does not appear to be capable of unsupervised outside pass privileges at this time. (9/9/2025) Residents independent community access restricted for 30 daysR72's progress notes (9/10/25) authored by V33 (Psychosocial Rehabilitation Services Coordinator) documents in part that V33 had suspicion that R72 had contraband and staff searched R72's room. Nothing was found. Staff attempted to receive a urine sample and R72 refused and got agitated, ultimately requesting a transfer in nursing home. There is no documentation with R72's medical record that indicates that R72 had any symptoms of being under the influence of any illicit substance or other indications that R72 was in possession of any illicit substance.On 9/11/2025 at 11:12 AM, R72 was visibly upset and explained that R72's community pass was restricted a couple days ago after another resident made up a story about R72 bringing a marijuana pen into the facility. R72 stated, I didn't do anything wrong, I went out for a couple hours and came back. (R17) was jealous or something that I went out on pass and told them I had a weed pen to get back at me. I don't have a weed pen, I don't smoke. They (facility staff) came in and searched my room and didn't find anything but (V33) still took my pass away. It's not fair they have no reason to take away my pass!On 9/11/2025 at 1:29 PM, V33 (Psychosocial Rehabilitation Services Coordinator) affirmed that V33 is the social worker assigned to R72 and was the staff member that restricted R72's community pass. R72 explained that another resident had said R72 had a weed (marijuana) pen. R72 searched the room and there was no weed (marijuana) pen found. R72 was agitated after the staff searched R72's room and wouldn't give a urine sample so the V33 restricted R72's community pass. V33 affirmed that there were no other indications that R72 may have been under a controlled substance other than agitation. V33 was unsure if there was anything that R72 signed that consented for forced drug testing or if it was part of the community pass program.On 9/11/2025 at 2:58 PM, V34 (Psychiatrist) affirmed that V34 is a psychiatrist for the facility. V34 explained that residents under the effects of marijuana present differently, but marijuana typically produces a calming effect (not agitation). In some cases, marijuana can cause hallucinations and psychosis.Review of the community pass program policy that were signed by R72 documents in part that pass privileges will be taken away for a minimum of 30 days if R72 comes back from pass intoxicated or under the influence of drugs and that drug testing can be completed if the resident comes back from an overnight community pass and is suspected to be under the influence (R72 was not out of the facility overnight).

Based on observation, interview, and record review, the facility failed to follow its abuse prevention policy by not protecting a resident from financial exploitation. This failure resulted in mental anguish and helplessness among 1 of 4 residents (R2) reviewed for theft and abuse in a sample of 4.The findings include:R2 is a [AGE] year-old female who was admitted on [DATE], and is independent in cognitive skills for daily decision-making, as per the Minimum Data Set (MDS) dated [DATE].On 9/2/25 at 12:05 PM, R2 stated, I originally had $1200 in my account, and I ran out $800 out of $1,200. I didn't give my bank card to anyone. Someone stole my card. The facility received my card through the mail, and I don't know why they left my mail under my pillow while I was admitted to the hospital. Somebody stole my card and used it in the neighborhood store. I am worried about my financial security here, and I don't know what to do. I didn't authorize anybody to buy stuff for me. When I returned from the hospital, I noticed charges on my card that I did not recognize. I called my bank, and they assisted me in making a report on these fraudulent charges. It was so stressful for me to call the bank and file a police report.A review of the facility's reportable incident dated August 15, 2025, showed that on August 22, 2025, police brought a picture of a person leaving a store where R2's card was used. The person in the picture appeared to be V5 (Certified Nursing Assistant/CNA), an employee of the facility. The police and facility administrator questioned V5 about taking the card, which V5 denied having done. As a result, V5 was immediately suspended pending the outcome of the investigation.A review of the police report with status date 8/20/25 documents that the police contacted the bank, and the bank confirmed multiple unauthorized transactions and withdrawals on R2's bank card by V5.On 9/2/25 at 11:45 AM, V6 (Social Service Director) stated, Our investigation found a significant amount of money missing from R2's credit card. We interviewed V5 (CNA), who claimed that R2 had requested him to purchase items at the store, but R2 reported unrecognized charges. Even if a resident request such purchases, staff are not authorized to make them. Based on this, V5 was suspended, though I am not certain about his current termination status.On 9/2/25 at 11:50 AM, V7 (Human Resource Director) stated, V5 was previously reprimanded for violating the uniform code. In this incident, V5 purchased items at a store using R2's card, allegedly at R2's request, but this was outside his job duties. As a result, we decided to terminate V5. I have been trying to reach him by phone to complete the termination, but he has not responded. Originally, he was suspended, and we are now moving to terminate him.On9/3/25 at 12:20 PM, V9 (Activity Director) stated, Honestly, I don't remember the date I delivered R2's mail under her pillow. We usually deliver mail to residents' hands. In this specific scenario, I didn't know that R2 was out of the facility, and that's why I left it under the pillow. If the resident is not there, I should have given it to social services to securely store.On 9/3/25 at 11:25 AM, V1 (Administrator/Abuse Coordinator) stated, We provide abuse in-service on a quarterly and as needed. The residents have the right to be free from abuse.A review of the facility presented an abuse prevention policy dated 01/24 document: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property, or mistreatment.

Based on the interview and record review, the facility failed to comply with privacy and confidentiality requirements when delivering mail to residents. This applies to 1 of 4 residents (R2) reviewed for privacy and confidentiality with mail delivery in a sample of 4.The findings include:On 9/2/25 at 12:05 PM, R2 stated, The facility received my card through the mail, and I don't know why they left my mail under my pillow while I was admitted to the hospital. Somebody stole my card and used it in the neighborhood store.On 9/3/25 at 9:10 am, V6 (Social Service Director) stated, Activity staff are usually responsible for delivering the mail to residents. If a resident is not present, they are required to give the mail to social services for secure storage. I cannot explain why, in this instance, the activity staff left the mail under R1's pillow when she was not present. The correct procedure is to return the mail to me for safekeeping, not to leave it in the resident's room.On 9/3/25 at 12:20 PM, V9 (Activity Director) stated, I honestly do not remember the date I delivered R2's mail by placing it under her pillow. Typically, we hand mail directly to residents. In this case, I was unaware that R2 was out of the facility, which is why I left the mail under her pillow instead of giving it to social services for secure storage, as is required when a resident is unavailable.The facility presented undated mail delivery policy document: The facility supports each resident's right to send mail and to receive mail in a timely manner in accordance with applicable state and federal regulations.

Based upon record review and interview the facility failed to follow policy procedures, failed to ensure that comprehensive care plans are reviewed quarterly, failed to ensure that the goal target date is within 90 days, and failed to revise an advance directive care plan (as directed) for one of four residents (R4) reviewed for change in condition.Findings include:R4's ([DATE]) POLST (Practitioner Orders for Life-Sustaining Treatment) Form states No CPR (Cardiopulmonary Resuscitation): Do Not Attempt Resuscitation. R4's ([DATE]) POS (Physician Order Sheet) includes Do Not Resuscitate.R4's ([DATE]) care plan states Advance Directive - Full Code however R4's POLST and POS affirm DNR status. R4's Advance Directive care plan was revised on [DATE] (over 3 months ago) with Target Date: [DATE] (roughly 6 months later). On [DATE] at 2:33pm, surveyor inquired about required care plan review and/or revision V6 (Director of Nursing) stated They're quarterly and or if it's a significant change. Surveyor inquired if care plan goals should be 6 months past the review date V6 responded Oh no, we should be checking that more often. Surveyor inquired about R4's current code status V6 replied He's a DNR (Do Not Resuscitate). Surveyor inquired if R4's ([DATE]) advance directive care plan states DNR V6 reviewed the care plan and stated He (R4) has full code, it was revised but it's not accurate. It looks like the information that we (facility) have on advance directive code status is not accurate, he's technically a DNR this needs revised. The (6/14) care plan policy states care conferences for review and revision of resident's care plan are scheduled at a conducive time for residents and their families. Skilled and intermediate residents every 90 days and PRN (as needed). The interdisciplinary team is responsible for the implementation of resident care management.

Based upon record review and interview the facility failed to follow policy procedures and failed to ensure that the advance directives care plan was correct for one of four residents (R4) reviewed for change in condition.Findings include:R4's ([DATE]) POLST (Practitioner Orders for Life-Sustaining Treatment) Form states No CPR (Cardiopulmonary): Do Not Attempt Resuscitation. R4's ([DATE]) POS (Physician Order Sheet) includes Do Not Resuscitate. R4's care plan (revised [DATE]) states Advance Directive - Full Code [which is incongruent with R4's POLST & POS]. On [DATE] at 2:33pm, surveyor inquired about R4's current code status V6 (Director of Nursing) stated He's a DNR (Do Not Resuscitate). Surveyor inquired if R4's ([DATE]) advance directive care plan states DNR V6 reviewed the care plan and responded He (R4) has full code, it was revised but it's not accurate. It looks like the information that we (facility) have on advance directive code status is not accurate, he's technically a DNR this needs revised. The (9/24) advance directives policy states for the purposes of this policy and procedure Advanced Directives means a written instrument, such as a living will or life prolonging procedure declaration, appointment of health care representative and power of attorney for health care purposes. Advanced Directives shall be addressed on the resident's plan of care.

Based on interview and record review, the facility failed to secure the physical environment (window) in R1's room and implement appropriate precautions for a resident with a history of elopement risk, high suicidal risk, high risk per criminal background/ behavioral history, and assessed as being unsafe in the community unsupervised for one resident (R1) of three residents reviewed for elopement. This failure resulted in R1 removing the stationary window brackets that prevent the window from opening in his room, jumping out of the window, and eloping through the open back gate of the facility undetected by staff.The immediate jeopardy began on 7/3/25 at 10:28 PM, when R1 removed the stationary window brackets that prevent the window from opening in his room, jumped out of the window, and eloped through the open back gate of the facility undetected by staff. V3 DON Director of Nursing and V27 Regional Director of Operations were notified of the immediate jeopardy on 7/17/25 at 2:42 PM. The surveyor confirmed by interview and record review that the immediate jeopardy was removed on 7/24/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include:R1 is a [AGE] year old resident with diagnoses that include Bipolar Disorder Severe with Psychotic Features, Delusional Disorder, Suicidal Ideation, Suicide Attempt, Major Depressive Disorder, Psychosis, Schizoaffective Disorder, Violent Behavior, and Attention Deficit Hyperactivity Disorder.On 7/9/25 at 9:49 AM, V5 Family Member was inquired of R1. V5 said, I was told R1 unscrewed the window screws with a fork and jumped out the window of his room on 7/3/25 during the night. I was notified later that night. R1 hasn't been found. R1 sent a text message to his father and I from different phones saying he wants to die. He won't go to the hospital or tell us his location. He wants to care for himself. He has Bipolar with Schizoaffective Disorder. He tried to commit suicide before in jail, he jumped headfirst from the balcony.On 7/9/25 at 10:45 AM, upon observation R1's room is locked when attempting to enter. V6 Maintenance Director arrived to open the room for this surveyor. V6 said, It's a one person room so since R1's things are here I just locked it. R1 has a private room three doors from the nurse's station. Upon entrance to the room, it appears to be organized, there are food items, R1's identification card, and phone charger are on the bed. There are 2-3 bags of clothing stacked up in the left corner in a laundry basket. There is one large window with 3 windowpanes facing the back of the facility. V6 moved the center windowpane into the open position it was in when he arrived in the room after R1's elopement. V6 said, I came in on the of July 4th day shift. His room was a wreck. His clothes and food were all over the floor. The middle window was open and slide to the right. This part of the window isn't supposed to open, it's stationary. R1 broke the stoppers off the window.Upon observation, the window screws at the top are bent and V6 opened the middle windowpane and slide it over to the right as it was when he found it. The middle windowpane appears to have been dislodged from the window frame from the top allowing it to become unsecured and opened. On 7/9/25 at 11:08 AM, V6 escorted this surveyor to the backyard area of the facility. Upon entrance to the backyard there is a wooden fence that is secured by a lock that was opened by V6. There are 2 cameras on the back of the building facing the yard area. Under R1's window are pieces of a broken fence on the ground. There is a basement level window beneath R1's first floor window. V6 measured the space from R1's window to the ground which measured a 9-10 foot drop from the 1st story window. The wooden fence was observed to be intact. There is another gate entrance on the east side that is not secured. V6 said, R1 must have jumped the fence.On 7/9/25 at 11:24 AM, V7 RN Registered Nurse was inquired of R1. V7 said, R1 always isolates himself. If I ask how he is, he can't answer correctly. He'll say something off the topic. R1 did get out the building before. I had an instance when a CNA (Certified Nurse Assistant) opened the ramp door for a family member, and he ran in front of them into the parking lot. We got him back in. He only had a day pass if the family requested, and they had to pick him up here. I came in on July 4th 7AM to 3PM shift. I was told in report R1 eloped on 3PM to 11PM shift, they looked for him and called the police.On 7/9/25 at 11:50 AM, V9 Restorative CNA said, I was here on July 3rd, on 3PM to 11PM shift. I came by to get the linen bin by his room and his door and window was open. I checked the bathroom, and he was gone. I ran to the nurse's station and called a code pink. Staff went outside and police were called. I didn't see anything on the windowsill. I saw him last around 10:15 PM just in his room.On 7/9/25 at 12:22 PM, V11 CNA was inquired of R1. V11 said, I worked 3PM to 11PM. R1 is quiet and stays to himself. I checked on him during rounds and mealtimes. He ate his own food in his room. Closer to the end of the shift V9 CNA and I peeked in his room, and he was gone. We checked his bathroom. The middle part of the window was open. I didn't notice anything else. We called a code pink. The nurse called 911, staff searched and drove around to see if he was in the area. It was close to 11PM when police came.On 7/9/25 at 12:45 PM, V3 DON Director of Nursing was inquired of R1's elopement being notified to Illinois Department of Public Health. V3 said, We didn't report it because he's been in contact with his family via phone and we don't have knowledge of him being injured or hurt.On 7/9/25 at 12:55 PM, V12 RN Registered Nurse said, I was the nurse on first floor on July 3rd 3PM to 11PM shift. R1 hangs out in his room. He's a smoker. That night I did my rounds. He took his medication. I saw him last around 10 PM. He was in his room sitting on the bed. V9 CNA came to me at the nurse's station around 10:30 PM. She said she was doing her rounds and didn't see R1 in his room. I got up, went to his room, looked, and called his name. I checked the bathroom and the room and saw the middle of the window was open. I called a code pink. Staff came down and went outside the building. I called 911, the administrator, director of nursing, and the family. I went back into the room; I didn't see anything on the windowsill. I looked out the window and saw a part of a fence on the ground. I didn't hear anything.On 7/9/2025 at 1:30 PM, V13 PRSC Psychiatric Rehab Services Coordinator was inquired of R1. V13 said, I was R1's social worker. I worked July 3rd till 4:30 PM. R1 is very anxious, and he paces. It's his baseline behavior. He was quieter that day, he didn't come into my office. He usually comes in every day. His diagnoses are Bipolar Schizoaffective Disorder, Schizophrenia, Delusional Disorder, Hallucinations, Anxiety, and Depression. He only has community access with family if he's compliant with medication. He's never had an independent pass. His last community survival assessment was on 5/1/25, it says he has behavioral concerns and elopement. I spoke with him on July 2nd, he came to my office with some books and talked about things that didn't make sense. His delusions were mixing with reality. But it was getting harder for me to understand what he was talking about. This week I was trying really hard to understand. He was someone we'd keep an eye on more and look through his things. We'd take things so he's safe. He's an identified offender because of his charge of aggravated battery and bodily harm. He was sent out on petition on June 10th to the hospital because of his behavior, but I wasn't aware he got out the building. I feel his behaviors built up.On 7/9/25 at 2:15 PM, R5 was inquired of R1. R5 said, R1 was very anxious. He was just talking to himself before he left and was pacing. It startled me. A couple of days before we were in the basement, and he took a fork and showed me how to pry open the door and escape. He asked me if I wanted to escape, and I said I wasn't going to do it. I saw him last at smoke break around 6PM. He must have got out before 11PM because he usually meets me by the vending machine at night to get snacks. He texted me the night after he escaped. I tried to call him back, but his phone was off.On 7/14/25 at 12:29 PM, V3 DON Director of Nursing was inquired of R1's elopement. V3 said, I got a call from the assistant director of nursing maybe 10:45 PM on July 3rd. Assistant Director of Nursing called me, and V12 RN notified me and said R1 was missing. V9 CNA checked his room and noticed the window was out. They initiated a code pink; they did a facility search and checked all exit door which were secured. Staff went out on the grounds to look for him. The police were called, they arrived at the facility before midnight. They took a report and gave the report number to the ADON. The doctor, family and administrator were notified. Change of shift was reported that R1 was missing, and I asked them to call local hospitals and be on standby if he comes back. He has gotten out before. He pushed out the front door and staff was behind him. He walked down the road, and we called the police to redirect him back to the facility. He was petitioned back to the hospital for a psychiatric evaluation. The psychiatrist did a medication adjustment for him. Elopement risk assessment done, he got out, but staff was behind him. He was placed on a one to one supervision until he was transferred to the hospital. We sent him out for another hospital psychiatric evaluation. He has a history of suicidal ideation. Prior to coming to this facility, he had a suicidal attempt in the hospital. When he initially came, he was identified as an extreme offender on his background check. It was recommended from his criminal background to be placed in a private room due to his history of suicidal attempt with jumping out of a third story window prior to his admission. Our administration decided it would be safer for him to be on the 1st floor opposed to the higher floor being more potentially dangerous. He is just supervised and encouraged about medication compliance. During the investigation, we didn't find any utensils, a room search was done, and nothing was found. R1 was found in a hospital in Wisconsin on yesterday and was checked medically and deemed safe with no medical issues. Due to their state regulations, they were unable to admit him to inpatient psychiatric care. R1 was transferred back to this facility via ambulance yesterday evening and staff notified his physician. He was transferred to the hospital for psychiatric evaluation.On 7/14/2025 at 1:05 PM, V1 Administrator was inquired of R1's elopement. V1 said, V28 ADON called me during the night around 10:30 PM. They said the window was out in his room. The staff called a code pink that went and searched the building and outside in the back and around the area. They went to 7-11 store but didn't see him. Police were called. Police did a missing person report for all the surrounding cities. We started calling local hospitals, but he didn't show up. We called the doctor and family. His mom or dad said he uploaded an Instagram picture, but we couldn't locate him. He got out before but didn't make it far. In June got out the front door behind a visitor, but staff went out behind him. He hasn't gotten aggressive since being here. His criminal history showed he has aggression and needed a private room. We did have to call the police and they brought him back and we petitioned him out the hospital for psych evaluation. He's not exit seeking usually, it just happened. His room is by the nurse's station. We didn't put him on 3rd floor, but due to his history we put him on 1st floor due to him jumping from windows. We didn't find anything. We have cameras and saw him tumble out the window, he got up and walked away fast. He walked toward the 7-11 store. The staff went over there but didn't find him. We checked the camera and it showed R1's legs and he rolled out the window, got up and walked fast to the other side of the yard and went out the gate.On 7/14/25 at 1:42 PM, V3 DON was inquired of security and cameras. V3 said, The last smoke break time is between 6-7PM. Residents with an independent pass have to be back in the building by 7:30 PM. They can go in and out of the back gate, it's not locked. We have staff monitor it. The security cameras are in V1's (Administrator) office and she's the only person with access. We don't have security.On 7/15/25 at 2:26 PM, V14 PRSC Psychiatric Rehab Services Coordinator was inquired of R1's 6/18/25 elopement risk review decision score. V14 said, The elopement risk is triggered within the first 24hrs when a resident comes in. Sometimes nurses will complete it. It's a part of the admission documents. Social Service staff should review the elopement risk and correct it if it's not right. It's especially important for R1 because he is high risk for elopement. We know he's not a low risk elopement taking account his history.On 7/16/25 at 10:40 AM, V6 Maintenance Director was inquired of R1's window in the room. This surveyor and two other survey staff reviewed R1's room window with V6 Maintenance Director. V6 said, I don't know how he would have gotten the window open with his hands. He must have used something to get it open because the brackets to keep the window from opening were broken. I added bolts to reinforce the window and L bracket to prevent it from being pulled back.On 7/14/25 at 9:50 AM, V3 DON was inquired of R1's status. V3 said, R1 was found in a hospital in Wisconsin diagnosed with altered mental status then transferred back to the facility. R1 was evaluated and ordered to be sent out for psychiatric evaluation at the local hospital.On 7/14/25 at 1:30 PM, V1 Administrator and this surveyor viewed the security camera footage from July 3, 2025, at 10:28 PM. The camera showed R1 jump from his window to the ground, rolled once and stood up. R1 walked quickly toward the east side of the back yard on the sidewalk through the open gate. V1 Administrator was inquired of the east gate being left open. V1 said, The gate is usually left open for the residents that have an independent pass. The residents come and go from that gate and sit in the yard area.On 7/24/25 at 9:53 AM, V3 DON Director of Nursing was inquired of R1's involuntary discharge. V3 said, Due to his high elopement risk he was deemed not fit for the facility. He may need a different environment. He was bored here. He's younger. The population wasn't conducive for him along with his diagnosis and extreme exiting desire. We provided all the services he needed, but he spoke with his mom and said he was bored here. He wants to be free and work. He just wanted to be outside. It was an interdisciplinary decision with his physician and R1. His family lives out of state and the facilities there are not up to their standards so R1 was accepted into a facility in Waukegan. He agreed to go. R1 could potentially lure or coax other residents to elope or help them elope. He wasn't appropriate for this facility; he was a safety risk. R1 was hand delivered a petition at the hospital with a stamped envelope. He was explained the appeal process, and his family was notified. We'll coordinate with the other facility to transfer his belongings. The facility will have to do a medical request for pertinent information, and it will be sent from medical records.R1's records were reviewed as follows.R1's progress notes from 6/10/25 at 11:30 AM document being discharged to the hospital. R1 is delusional, hallucinating and paranoid. Unable to take vital signs, patient is refusing. 911 called. R1's physician ordered him to be sent to the hospital for a psychiatric evaluation. On 6/10/25 V14 PSRAD Psychiatric Rehab Services Assistant Director completed a petition for R1 to be hospitalized . R1 eloped out of the front door of the facility pushing past visitors leaving the grounds. The facility required police intervention to transfer R1 to the hospital for psychiatric evaluation. R1 was hospitalized for six days. R1 returned to the facility 6/16/25.On 6/16/25 V20 NP Nurse Practitioner documented R1 was hospitalized for Psychosis. Hospital reports states patient presented to the hospital via EMS (Emergency Medical Services) after eloping from a nursing home and being found trespassing behind a dumpster smoking marijuana.On 6/18/25 at 20:53 (8:53 PM) R1 was evaluated by V21 Nurse Practitioner Psychiatrist following his hospitalization. Assessment- this patient has multiple psychiatric complexities and would benefit from continued management with monitoring of mood and behavior. Will titrate medications based on current symptom progression.The 6/18/25 elopement risk review documents: 2. elopement history/community risk- reported/documented episodes of elopement and/or attempts to elope: 2. no. Total score: 23 low risk.On 7/15/25 at 2:26 PM, V14 PRSAD Psychiatric Rehab Services Assistant Director was inquired of R1's 6/18/25 elopement risk review decision score. V14 said, The elopement risk is triggered within the first 24hrs when a resident comes in. Sometimes nurses will complete it. It's a part of the admission documents. Social Service staff should review the elopement risk and correct it if it's not right. It's especially important for R1 because he is high risk for elopement. We know he's not a low risk elopement taking account his history.R1's June 2025 and July 2025 behavior monitoring from his 6/16/25 readmission to 7/3/25 does not document any identified behaviors.R1's July 2025 MAR (Medication Administration Record) documents he received Depakote ER (extended release) oral tablet 250mg (milligrams) give 3 tablets by mouth at bedtime for Schizoaffective Disorder on 7/3/25 at 2100.R1's progress note states: 7/3/25 at 23:20 (11:20 PM), V12 RN Registered Nurse documented at 10:30PM, CNA Certified Nurse Assistant observed resident sitting in his room. At approximately 10:35 PM, CNA walked past resident's room and noted his window was open and he was no longer present. Upon further inspection, it was discovered that part of the window had been removed. A code pink was immediately called. All exit doors were secured, and staff completed a search of the facility and grounds The Administrator, DON, Social Services, MD, and resident's mother was notified. Monitoring and communication with local hospitals, police, and emergency services are ongoing.On 7/4/25 at 12:26 AM, the police department official report documents the police response to the facility for a missing person R1.R1's 5/1/25 community survival skills assessment recommendations indicate resident has supervised community access due to behavioral concerns as well as history of elopement. The care plan documents an updated 6/18/25 assessment but is not found in R1 records upon his readmission to the facility. R1's 2/20/24 criminal history record indicates aggravated battery and bodily harm.R1's care plan documents the following: Elopement Risk I, R1, am challenged by mental illness and poor insight. I have a history of leaving my former facility without notifying staff and having a responsible escort (elopement). I also have a history of wandering into restricted and/or dangerous places. I will respond to staff direction to redirect his attention away from a potentially problematic situation (i.e. trying to exit the facility without supervision) when this behavior occurs.Interventions: Elopement Risk assessment completed per policy. Implement preventive intervention strategies that include: Assess me for potential elopement/unauthorized departure risk. Make rounds/room checks per facility protocol to minimize chance of unauthorized leave. Implement Elopement Risk Protocol Redirect resident to room/unit Use distraction to try to distract resident away from the current situation.Suicidal Risk: I, R1, have a history of suicidal ideations and attempts related to mental illness. I deny current S/I or intent. My self-identified triggers include medication noncompliance and using illicit substances. Interventions: As warranted conduct/carry out: Daily monitoring & supervision of the resident.SMI Severe Mental Illness: The resident has a diagnosis & history of severe mental illness (SMI) of Bipolar, Schizoaffective & Depression. The resident will: take medication as prescribed. Interventions: Explain facility rules, resident behavioral expectations & resident rights. R1 requires psychotropic medication to help manage and alleviate: Bipolar, SA Schizoaffective Disorder, SI Suicidal Ideation, AH Auditory Hallucination, Psychosis, Delusions, Agitation and Aggressive Behavior, ADHD Attention Deficit Hyperactivity Disorder, Depression, Behavior with Depressive Features, Anxiety, Neurosis.Aggression Risk: I, R1, am challenged by mental illness, mania, and psychosis. I am noted to respond/react to internal stimuli. Symptoms are manifested by aggression when agitated. Behavior: The resident expresses maladaptive behavioral symptoms related to: A diagnosis of chronic mental illness, a substance abuse disorder.R1 has presented with using the utensils that are provided at mealtime, to barricade himself in his room. Due to R1's h/o suicidal ideation this behavior poses a risk to his safety. R1 is to be provided with plastic silverware only. R1 is given plastic silverware to prevent him from barricading himself in the room.Isolating: The resident expresses maladaptive behavioral symptoms related to isolating himself in his room. Intervention: Involve the resident to supportive incidental, group or 1:1 counseling, as appropriate. Indicate treatment modality.Community Access: I, R1, do not appear to be capable of unsupervised outside pass privileges at this time. I require support and supervision in order to safely access the community independently rt: mental health needs. Intervention: Conduct a community survival skills assessment or similar community safety evaluation to reasonably the person's ability to safely determine and respectfully negotiate within the outside community. Initiated 6/18/25. No assessment dated [DATE] found in R1's documents.R1's comprehensive assessment section C cognitive patterns dated 5/7/2025 documents a brief interview for mental status score of 14. R1 is cognitively intact.R1's comprehensive assessment section E behavior dated 5/7/25 does not document any behaviors despite V13 PRSC's concern of R1's delusions prior to his elopement during interview on 7/9/25. R1's comprehensive assessment section GG functional abilities dated 5/7/25 documents he required supervision or touching assistance (helper provides verbal cues and/or touching/steading and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. The following activities are documented: toileting hygiene, shower/bathing, personal hygiene, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, walking 10 feet, 50 feet with two turns, and 150 feet.R1's 7/13/25 hospital records document a referring diagnosis of Schizoaffective disorder (a mental illness characterized by psychotic symptoms of hallucinations and delusions plus significant mood disturbances (mania or depression)). R1 presented to the emergency department for increased mania and eloping from a nursing facility to Wisconsin. R1 stated, I just wanted to leave for a while. He is internally preoccupied. Patient is in need of inpatient psychiatric hospitalization for mood stabilization and safety.Visit diagnoses include Compulsive behavior, Bipolar affective disorder, current episode manic (a period of abnormally elevated or irritable mood, increased energy, and activity levels, often associated with bipolar disorder. Schizoaffective disorder.R1's mental status exam documents: patient's grooming and hygiene is poor. Thought content: Auditory hallucinations are present. Delusions and paranoia are present. Insight/Judgment: poor.This patient is admitted to the hospital for stabilization of acute psychiatric issues. Will titrate medications and provide psychotherapeutic services on the unit and within the milieu in order to improve decompensated symptoms.R1 received prescribed medications for stabilization and remained hospitalized .On 7/15/25 at 3:59 PM, V21 NP Nurse Practitioner documented on R1 during his hospitalization: Late Entry: Facility cannot meet the resident's requirements due to extreme psychiatric needs. He is an elopement risk. Presently patient is a threat to himself and others and is not appropriate to remain at Briar Place. Involuntary discharge requested.On 7/17/25 at 11:35 AM, V14 Psychiatric Rehab Services Assistant Director documented on R1 during his hospitalization: Social Service Note: On this date, [NAME] was reserved with IVD due to error on previous form. Attached with IVD was bed hold policy and stamped and addressed envelope. Social worker [NAME] present at the time of drop off. [NAME] was told how to appeal and the process. [NAME] expressed his understanding had no concerns.The revised 1/25 Policy and Procedure Missing Resident states in part: It is the policy of this facility to report and investigate all reports of missing residents.Procedure: 1. All personnel are responsible for reporting a resident attempting to leave the premises, or suspected of missing, to the charge nurse as soon as practical. This includes any resident that did not sign out on pass and/or did not notify a staff member of his or her leaving.3. Should an employee discover that a resident is missing from the facility, he or she should: f. The Administrator and Director of Nursing will evaluate the situation and develop a plan of action based on the individual resident. The following steps should occur: 11. The decision to notify the Illinois Department of Public Health is made by the Administrator.a. The Illinois Department of Public Health is notified after the confused/disoriented resident is missing for 24 hours and all attempts to locate the resident have been exhausted.- This notification does not include the resident who is alert/oriented and has made a decision to leave the facility and not return. The Immediate Jeopardy that began on 7/3/2025 was removed on 7/24/2025 when the facility took the following actions to remove the immediacy. R1's window and facility exit doors were immediately secured to prevent further risk of elopement. A full facility search was initiated, including resident rooms, common areas, stairwells, and secured outdoor spaces. A search of the surrounding community, including the parking lot, adjacent properties, and nearby streets was conducted. The local police department was notified, and a formal missing person's report was filed. R1's family/ responsible party was notified of the incident and ongoing search efforts. Staff contacted area hospitals and local shelters to inquire whether R1 had been admitted or presented for care.The Administrator and Assistant Director of Social Services remained in contact with law enforcement, family members, local hospitals, and shelters every four hours until R1 was located and transported to a hospital on 7/13/25. R1 is not returning to the facility.The facility Maintenance Director replaced the stationary window bracket in R1's room. The repair was verified by the Administrator to ensure the window was no longer able to be manipulated.The facility has implemented a system to ensure that residents who require supervision due to elopement risk and/or recent elopement attempts receive adequate supervision and do not leave unsupervised. The Administrator educated all staff including the Activity Director, Activity Aides, admission Director, Assistant Director of Nursing, Business Office Manager, Certified Drug and Alcohol Counselor, Certified Nursing Assistants, Cooks, Dietary Manager, Dietary Aides, Director of Nursing, Housekeeping Director, Housekeepers, Human Resources Director, Infection Preventionist, Licensed Practical Nurses, Maintenance Director, Maintenance Tech, MDS Nurse, Medical Records Director, Receptionists, Registered Nurses, Restorative Aides, Social Workers, Social Service Aides, Staffing Coordinator, and Wound Care Nurse on the facility's elopement policy and how to identify and respond to elopement risk in residents with psychiatric disorders. The education reviewed the facility's policy for identifying residents at risk for elopement through completion of the Elopement Risk Review assessment in the resident's chart on admission/re-admission (completed by admitting nurse) and quarterly and with changes in condition (completed by the social worker). Staff were educated that the results of these assessments are used to develop an individualized care plan to reduce the risk of resident elopement and that residents identified as high-risk for elopement have their pictures at the nurse's stations and the front desk. The education reviewed that staff are required to provide supervision for elopement risk residents as outlined in the resident care plan. No new policies, procedures, or protocols have been implemented. The facility reinforced the existing elopement prevention policy and procedure through comprehensive staff education. This education ensures that all team members understand the facility's current elopement prevention system, including how residents are assessed for risk, how care plans are developed and updated, and how supervision expectations are communicated and maintained.Additionally, staff were educated how to identify and manage behaviors associated with increased elopement risk in residents with psychiatric disorders. The staff were educated that residents with psychiatric disorders may attempt to leave due to delusional beliefs, paranoia or hallucinations, manic impulsivity, agitation, suicidal ideations, history of trauma, substance cravings, and lack of insight into care needs. The warning signs of elopement risk were indicated including verbalizing distress, pacing, agitation, or trying to avoid staff, expressing paranoid thoughts, asking where exits are, loitering near doors/windows, packing bags or hiding items, refusing care, sudden isolation, or mood change. Situational triggers were also identified including new admission or recent hospitalization, medication changes, increased psychotic symptoms, conflict with peers or staff, and significant life events or trauma.Staff were educated to respond by not escalating the situation, remaining calm, validating the resident's feelings, not challenging hallucinations or delusions and instead validating feelings, ensuring safety by staying nearby and alerting the nurse immediately, not leaving the resident unsupervised, and reporting/documenting the behavior. Prevention strategies were discussed including knowing who is high-risk, reviewing care plans and supervision requirements, removing potentially harmful objects from the environment, securing rooms with compromised windows, and reporting any change in behavior immediately to the nurse. Evidence that education took place was documented by staff signing an in-service attendance sheet at the time education was provided in person. For staff who received education via phone, the Administrator documented educated via phone next to the staff member's name on the same in-service sheet, with a witness signature included. Staff who are on vacation or leave of absence will receive this education upon their return, prior to their next scheduled shift. This education will also be provided to all new hire staff during orientation. The facility does not employ agency staff. This education began on 7/9/25 and was completed on 7/17/25. The facility has implemented a comprehensive plan to ensure that all 3-piece windows in resident-accessible areas are secure and cannot be manipulated for elopement. A facility-wide inspection was completed by the Maintenance Director to verify that windows are secured and cannot be manipulated for elopement. Any windows identified as not secure or able to be manipulated for elopement

Based on interview and record review, the facility failed to follow their abuse policy by failing to investigate an allegation of misappropriation of resident's fund by another resident. This failure affected two of three (R4 and R6) residents reviewed for investigating residents' allegations of misappropriation of funds.Findings include:R4 is [AGE] years old admitted to the facility on [DATE], past medical history includes, but not limited to Osteomyelitis, other acute osteomyelitis left ankle and foot, acquired absence of other left toes, iron deficiency anemia, paranoid schizophrenia, moderate protein calorie malnutrition, unspecified open wound left lower leg, prediabetes, delusional disorders, chest pain, etc.On 7/14/2025 at 11:30AM, R4 was observed in her room, alert and oriented and said that she was sent to the hospital because she had an argument with another resident (R6), R4 stated that R6 stole from her, she used R6's phone to order food one time and R6 ended up making numerous charges to R4's credit card. R4 added that her POA has the bank statement that shows all the charges. The staff did not want to get her money from R6, but the nurse was trying to give her a shot. R4 said that she refused, but the staff was still coming to her with the needle, so she spat on his face, that's the only way she can get him off her, and they sent her to the hospital. R6 is [AGE] years old and have resided at the facility since 3/15/2025, past medical history includes Pathological fracture, hip, unspecified, encounter for fracture with routine healing unspecified fracture of right calcaneus, Benign prostatic hyperplasia without lower urinary tract symptoms, cocaine dependence with withdrawal, major depressive disorder, essential primary hypertension, paroxysmal atrial fibrillation, etc.On 7/14/2025 at 12:05PM, R6 said that he used to be on the third floor, he moved to the first floor a couple of days ago after he had an argument with a lady on the third floor (R4). R6 denied physically assaulting R4 but had a verbal altercation with her. One day, R4 asked to use R6's cell phone, R6 informed R4 that she can only send text, she cannot make a call because his phone bill has not been paid. R4 went out and later came back to his room and offered to pay his phone bill, R4 gave R6 her credit card and he paid $300.00 to the phone company. Later R4 told him that the phone company charged her $500.00, R6 is not sure maybe $300.00 was the amount due and $500.00 was the total bill. R6 stated that since R4 paid for his phone, she always takes the phone and keeps it with her most of the time and uses it to make calls. R6 admitted that R4 has used his phone to order food and he did not realize that her card information was saved on his phone. He added that there were 2 additional charges, one for $199.00 that R6 said he is not sure who made it, when he went home for the 4th of July, his family may have used his phone, he did not realize that R6's credit card number was saved on his phone. There was a $100.00 charge from the phone company but R4 cancelled that one. Surveyor asked R6 if he reported this to any staff and he said, everyone is aware, including the social worker.On 7/15/2025 at 1:40PM, R6 said that his cell phone was broken by R4 the day they were involved in an altercation, he filled a grievance for his phone, but the social worker said that his phone will not be replaced by the facility. R6 had the phone with him and showed his phone to the surveyor, and it was noted that the screen was all shattered. R6 added that he cannot make calls with the phone due to the damage.Review of medical record did not show any documentation of the incident in either resident's record, or the reason R6 was moved to the first floor. Facility did not initiate any investigation of the allegation of misappropriation of resident's fund until the complaint investigation was initiated, though both residents stated that everyone one was aware that R4 accused R6 of stealing her money.On 7/14/2025 at 1:31PM, V14 (PSRAD) said that R6 was moved to the first floor because him and his girlfriend were not seeing eye to eye, they had a back-and-forth argument, but V14 is not sure what it was all about. R14 said that she was on the floor to see another resident when she heard R4 and R6 arguing, she tried to find out what was going on but R4 told her to mind her business, that the argument is between her and her boyfriend. R4 got aggressive with all the staff, code yellow was called and R4 was sent out to the hospital on 7/7/2025 due to aggression towards staff. V14 was asked if she spoke to R6 to find out what the argument was about, and she said no.Care plan initiated on 7/9/2025 for R4 by V14 states the following: Resident has a history of problems with money management, related to: Compromised decision making., Compromised judgment., This money management problem is manifested by getting into altercations with peers concerning borrowing, lending money. R4 presents with poor money management as evident by her offering money and to pay for/ buy things for staff and peers and later accuse them of stealing her money.On 7/15/2025 at 11:59AM, V14 was presented with the above care plan that she initiated for R4 two days after the altercation between R4 and R6 and was asked who R4 accused of stealing her money and she said, I don't recall, I am not sure why I put that in the care plan.Grievance form dated 7/8/2025, filed by R6 stated that his phone was broken by R4 and R6 wanted the facility to replace his phone. V14 who completed the action taken by facility section of the documented in part that the facility will not replace the phone, staff did not intend to upset R4 but due to the nature of their conversation, staff had to intervene.On 7/15/2025 at 2:32PM, V14 was presented with the concern /grievance form for R6, and she said that her understanding is that the phone belonged to both R4 and R6, the facility will not replace the phone if R4 broke her own phone. V14 added the altercation between the two residents should have been documented and investigated even from the time R4 started becoming agitated to the time the code red was called.Abuse policy dated 01/2024 states in part: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Purpose states to describe the procedure of identification, assessment, and protection of residents from abuse, neglect, misappropriation of property and exploitation. This will be accomplished by orienting and training staff on how to deal with stress and difficult situations and how to recognize and report occurrences of abuse, neglect exploitation and misappropriation of property.Under investigation, the policy states in part that incidents will be reviewed, investigated, and documented whether abuse, neglect, mistreatment, or misappropriation of resident property occurred, was alleged or suspected. Incidents or allegations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will be reviewed by the administration and shall be investigated, as indicated and appropriate.

Based on observation, interview and record review, the facility failed to keep the facility temperature below 81 degrees Fahrenheit and failed to ensure the temperature was comfortable for one resident (R3) out of 6 residents reviewed for safe, comfortable environment. These failures have the potential to affect all 202 residents residing in the facility. Findings include: Facility census, dated 6/22/2025, documents 202 residents residing at the facility. On 6/22/2025, resident room temperature checks were performed with V3 (Assistant Administrator). On the first, second, and third floors, three rooms on each floor had adequate temperatures ranging from 76.2 degrees Fahrenheit to 80.0 degrees Fahrenheit. On 6/22/2025, facility halls/hallways temperature checks were performed with V3 (Assistant Administrator) for inadequate cooling and the following concerns were identified: First floor low side hall/hallway: 88 degrees Fahrenheit First floor high side hall/hallway: 85.6 degrees Fahrenheit Third floor low side hall/hallway: 87.2 degrees Fahrenheit Third floor high side hall/hallway: 89.1 degrees Fahrenheit Second floor low side hall/hallway: 84.1 degrees Fahrenheit Second floor high side hall/hallway: 87.1 degrees Fahrenheit Temperatures of the facility's halls/hallways are not withing adequate temperature between 71 degrees Fahrenheit and 81 degrees Fahrenheit. On 6/22/2025 at 10:12am, V3 (Assistant Administrator) said, The air went down on Friday (6/20/25). HVAC (heating, ventilation, and air conditioning) company was contacted. The air conditioning that supplies the resident rooms was repaired. There is a separate system for the halls which is still not working. Portable air conditioners were ordered on Friday (6/20/25) for the halls, but they seem to still not be giving keeping the halls cool enough. I (V3) don't think the halls are a bad temp (temperature). On 6/22/2025 at 10:15am, R3 said, It's (temperature) awful outside of my (R3) room. You can feel the hotness once you step out of your room. The air conditioning is working in my (R3) room. The moment you step out of your is not comfortable. The nurses be giving us (residents) water and ice. Supposedly, They're (facility staff) working on fixing it (air conditioning) in the halls. Hopefully these new things (pointed to portable air conditioning units) start to work right. They (portable air conditioning units) ain't doing sh** right now. [NAME], staff be telling us (residents) to stay in our rooms or wherever the temp (temperature) is comfortable for us (residents). R3's face sheet documents medical diagnoses that include but are not limited to type 2 Diabetes Mellitus, morbid obesity, and hemiplegia. R3's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates that R3 is cognitively intact. On 6/22/2025 at 10:25am, V6 (Certified Nursing Assistant/CNA) said, I (V6) usually work the first and third floors. All the halls on all the floors are too hot. Actually, the third floor is the worst. Yes, the air conditioning in the residents' rooms are working. We (staff) are giving the residents cold water, ice, and popsicles around the clock. On 6/22/2025 at 10:55am, V7 (Maintenance Director) said, There are 2 separate systems that operate the air for the hallways and the resident rooms. The resident rooms AC (air conditioning) uses multi-stack chillers with 6 compression stacks. The hallways use 2 (name of AC units/system) air blower units. The hallway AC went out 2 weeks ago and has been going off and on since. They continue to lock out and overheat. We've (facility staff) have been in contact with (name of AC units/system) technicians and they have come here 4 to 5 times to fix the issues, but they are currently still working on it. It's an old building. When one thing is fixed, up pop another problem. The technicians did fix one unit and then the other one (unit) went (broke). They (facility staff) ordered portable AC units, which is a temporary fix. The portable AC units came yesterday (6/22/25), but they (portable AC units) are not keeping up to provide cool temperatures. The tech (technician) is currently here, moving the units around to fix the issue. All the AC in the residents'' rooms are working now. We (facility staff) had to replace some motors. The facility halls are definitely too hot and not comfortable. Yes, the whole facility, all the floors are not receiving adequate cooling. On 6/24/25 at 9:53am, V1 (Administrator) provided a timeline for the air conditioning issues that documents, in part, 6/19/25 at 9:00am: maintenance identified that AC unit was malfunctioning. (Name of AC Company) tech contacted for assessment and repair. Ongoing extra fluids, ice water provided, popsicles distributed, fans operating. Cooling centers established in dining rooms with portable AC units. Fans placed throughout the facility. 6/19/25 at 10:00am: Contacted (Name of portable air conditioning company) for information regarding AC rental units. (Portable Airconditioning Company) has units on hand and is available 24/7. Delivery time estimated 2 hours if needed. 6/19/25 at 11:00am: (Company for air conditioning units for facility hallways) technician in facility for evaluation and repair of AC unit. Ongoing: Extra fluids, ice water provided, popsicles distributed, fans operating. 6/19/25 at 11:00am: (Company for air conditioning units for facility hallways) technician corrected issues with blower and referred facility to (Name of different HVAC company) HVAC to address potential issues with unit on the roof. Ongoing: Extra fluids, ice water provided, popsicles distributed, fans operating. 6/19/25 at 12:00pm: (Name of different HVAC company) HVAC to address potential issues with unit on the roof contacted to schedule service. On 6/19/25 at 4:00pm: Received return call from (Name of different HVAC company) HVAC to address potential issues with unit on the roof HVAC. Two technicians scheduled to be at the facility 6/20/25. On 6/20/25 at 7:00am: Technicians from (Name of different HVAC company) HVAC to address potential issues with unit on the roof HVAC in facility for servicing cooling units on roof. Maintenance initiated on units. On 6/20/25 at 5:00pm: Additional fans ordered to facility to have on hand and confirmed availability of rental units with (Name of portable air conditioning company) if needed in preparation for upcoming heat advisory forecast. On 6/20/25 at 5:00pm: (Name of different HVAC company) HVAC to address potential issues with unit on the roof HVAC technicians completed maintenance on rooftop AC units. Ongoing extra fluids, ice water provided, popsicles distributed, fans operating during this time. E-mails between V2 (Director of Nursing/DON) and V11 (employee from portable air conditioner company for the hallways of the facility), dated 6/22/2025, documents, in part, . Scheduled Date: 6/22/2025; Order Type: Pickup; Description: 2025-06-22 service call ac (air conditioners) need to move to a new location on site - circuit issues. E-mails show portable air conditioner units were not functioning properly. Facility policy titled, Preventative Maintenance Program, reviewed date 11/2023, documents, in part, Purpose: To conduct regular environmental tours/safety audits to identify areas of concern within the facility . The environmental temperature is pleasant . Facility policy titled, Resident Rights, undated, documents, in part, . Right to a Dignified Existence: . A homelike environment . Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike .

Based on observation, interview and record review, the facility failed to ensure the chillers (air conditioner units) were in operating condition and functioning properly. These failure have the potential to affect all 202 residents residing at the facility. Findings include: Facility census, dated 6/22/2025, documents 202 residents residing at the facility. On 6/22/2025, resident room temperature checks were performed with V3 (Assistant Administrator). On the first, second, and third floors, three rooms on each floor had adequate temperatures ranging from 76.2 degrees Fahrenheit to 80.0 degrees Fahrenheit. On 6/22/2025, facility halls/hallways temperature checks were performed with V3 (Assistant Administrator) for inadequate cooling and the following concerns were identified: First floor low side hall/hallway: 88 degrees Fahrenheit First floor high side hall/hallway: 85.6 degrees Fahrenheit Third floor low side hall/hallway: 87.2 degrees Fahrenheit Third floor high side hall/hallway: 89.1 degrees Fahrenheit Second floor low side hall/hallway: 84.1 degrees Fahrenheit Second floor high side hall/hallway: 87.1 degrees Fahrenheit Temperatures of the facility's halls/hallways are not withing adequate temperature between 71 degrees Fahrenheit and 81 degrees Fahrenheit. On 6/22/2025 at 10:12am, V3 (Assistant Administrator) said, The air went down on Friday (6/20/25). HVAC (heating, ventilation, and air conditioning) company was contacted. The air conditioning that supplies the resident rooms was repaired. There is a separate system for the halls which is still not working. Portable air conditioners were ordered on Friday (6/20/25) for the halls, but they seem to still not be giving keeping the halls cool enough. I (V3) don't think the halls are a bad temp (temperature). On 6/22/2025 at 10:15am, R3 said, It's (temperature) awful outside of my (R3) room. You can feel the hotness once you step out of your room. The air conditioning is working in my (R3) room. The moment you step out of your is not comfortable. The nurses be giving us (residents) water and ice. Supposedly, They're (facility staff) working on fixing it (air conditioning) in the halls. Hopefully these new things (pointed to portable air conditioning units) start to work right. They (portable air conditioning units) ain't doing sh** right now. [NAME], staff be telling us (residents) to stay in our rooms or wherever the temp (temperature) is comfortable for us (residents). R3's face sheet documents medical diagnoses that include but are not limited to type 2 Diabetes Mellitus, morbid obesity, and hemiplegia. R3's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates that R3 is cognitively intact. On 6/22/2025 at 10:25am, V6 (Certified Nursing Assistant/CNA) said, I (V6) usually work the first and third floors. All the halls on all the floors are too hot. Actually, the third floor is the worst. Yes, the air conditioning in the residents' rooms are working. We (staff) are giving the residents cold water, ice, and popsicles around the clock. On 6/22/2025 at 10:55am, V7 (Maintenance Director) said, There are 2 separate systems that operate the air for the hallways and the resident rooms. The resident rooms AC (air conditioning) uses multi-stack chillers with 6 compression stacks. The hallways use 2 (name of AC units/system) air blower units. The hallway AC went out 2 weeks ago and has been going off and on since. They continue to lock out and overheat. We've (facility staff) have been in contact with (name of AC units/system) technicians and they have come here 4 to 5 times to fix the issues, but they are currently still working on it. It's an old building. When one thing is fixed, up pop another problem. The technicians did fix one unit and then the other one (unit) went (broke). They (facility staff) ordered portable AC units, which is a temporary fix. The portable AC units came yesterday (6/22/25), but they (portable AC units) are not keeping up to provide cool temperatures. The tech (technician) is currently here, moving the units around to fix the issue. All the AC in the residents'' rooms are working now. We (facility staff) had to replace some motors. The facility halls are definitely too hot and not comfortable. Yes, the whole facility, all the floors are not receiving adequate cooling. On 6/24/25 at 9:53am, V1 (Administrator) provided a timeline for the air conditioning issues that documents, in part, 6/19/25 at 9:00am: maintenance identified that AC unit was malfunctioning. (Name of AC Company) tech contacted for assessment and repair. Ongoing extra fluids, ice water provided, popsicles distributed, fans operating. Cooling centers established in dining rooms with portable AC units. Fans placed throughout the facility. 6/19/25 at 10:00am: Contacted (Name of portable air conditioning company) for information regarding AC rental units. (Portable Airconditioning Company) has units on hand and is available 24/7. Delivery time estimated 2 hours if needed. 6/19/25 at 11:00am: (Company for air conditioning units for facility hallways) technician in facility for evaluation and repair of AC unit. Ongoing: Extra fluids, ice water provided, popsicles distributed, fans operating. 6/19/25 at 11:00am: (Company for air conditioning units for facility hallways) technician corrected issues with blower and referred facility to (Name of different HVAC company) HVAC to address potential issues with unit on the roof. Ongoing: Extra fluids, ice water provided, popsicles distributed, fans operating. 6/19/25 at 12:00pm: (Name of different HVAC company) HVAC to address potential issues with unit on the roof contacted to schedule service. On 6/19/25 at 4:00pm: Received return call from (Name of different HVAC company) HVAC to address potential issues with unit on the roof HVAC. Two technicians scheduled to be at the facility 6/20/25. On 6/20/25 at 7:00am: Technicians from (Name of different HVAC company) HVAC to address potential issues with unit on the roof HVAC in facility for servicing cooling units on roof. Maintenance initiated on units. On 6/20/25 at 5:00pm: Additional fans ordered to facility to have on hand and confirmed availability of rental units with (Name of portable air conditioning company) if needed in preparation for upcoming heat advisory forecast. On 6/20/25 at 5:00pm: (Name of different HVAC company) HVAC to address potential issues with unit on the roof HVAC technicians completed maintenance on rooftop AC units. Ongoing extra fluids, ice water provided, popsicles distributed, fans operating during this time. E-mails between V2 (Director of Nursing/DON) and V11 (employee from portable air conditioner company for the hallways of the facility), dated 6/22/2025, documents, in part, . Scheduled Date: 6/22/2025; Order Type: Pickup; Description: 2025-06-22 service call ac (air conditioners) need to move to a new location on site - circuit issues. E-mails show portable air conditioner units were not functioning properly. Facility policy titled, Preventative Maintenance Program, reviewed date 11/2023, documents, in part, Purpose: To conduct regular environmental tours/safety audits to identify areas of concern within the facility . The environmental temperature is pleasant . Facility policy titled, Resident Rights, undated, documents, in part, . Right to a Dignified Existence: . A homelike environment . Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike .

Based on interview and record review, the facility failed to document providing the bed hold policy to the resident or representative upon transfer to a local hospital, for one (R2) of three residents reviewed for bed hold policy. Findings include: R2 is a [AGE] year old male originally admitted on : 8-5-2024 with medical diagnosis that include ans are not limited to: Bipolar disorder and suicidal ideation. On 4-11-2025 R2 was transfer via 911 to a local emergency room with involuntary petition. On 5-18-2025 at 12:50pm V1 said, the bed hold policy should be given with explanation when a resident is sent out to the hospital, my expectation is that the staff will document it in the electronic medical record, we do not have any documentation that indicate that R2 received the bed hold notification. R1 is a [AGE] year old male originally admitted on [DATE] with medical diagnosis that include and are not limited to: Bipolar disorder, diabetes type 2, alcohol dependent and hypertension. R1 was transfer to a local hospital for emergency services on 4-18-2025 with involuntary petition. On 5-17-2025 at 9:40 am R1 said, I was a resident at the facility for 15 months. On April 18, 2025, I was transferred to the hospital. The involuntary discharge paperwork was given to the paramedics at that time. I did not receive a copy of the bed hold policy when I was sent to the hospital, and I was not informed about the 10-day bed hold policy. On 5-19-2025 at 1:00pm V2 (director of Nursing) said, we have a 10 days bed hold policy, we hold a bed for the resident, when any resident is sent out to the hospital receives a copy of the bed hold policy, and my expectation is for the nursing staff to document in the residents record. I think we forgot to put a note in R2's record, we missed to document that the bed hold policy was given. On 5-19-2025 at 1:30pm V14 (Assistant Director of Nursing) said, when we transfer a resident to hospital, we will give a copy of the 10 days bed hold policy. My expectation is for the nurse to document in the patients record some nurses forget to document and is not acceptable. On 5-18-2025 V1 (administrator) presented policy tiled: Bed hold policy dated: July-2024 reads: to ensure the residents are informed of the bed hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility. On 5-19-2025 at 3:30pm V1 presented undated resident handbook, reads: bed hold policy explains your rights under the Federal and state law and is provided to you at the time of transfer to the hospital.

Based on observation, interview, and record review the facility failed to provide one resident (R85) with adequate supervision during a shower. This resulted in R85 experiencing a seizure which led to her arm getting stuck in the handrail causing her to fracture her humerus. Findings Include: R85 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R85 has multiple diagnoses including but not limited to the following: Epilepsy, right humerus fracture, bipolar disorder, paranoid schizophrenia, mood disorder, anxiety, pain, and depression. Facility Reported Incident with date of 10/9/24 states in part but not limited to the following: R85 noted in shower room with right arm between shower rail and wall, R85 noted with pain, shortening, and abnormal rotation to right arm. R85 transferred to hospital for further evaluation and treatment. Hospital records dated 10/10/24 shows R85 arrived at the hospital from facility after an unwitnessed seizure in the shower. R85 complaining of pain after she fell to the right shoulder that showed deformity and fracture. On 11/18/2024 at 10:40AM, R85 was interviewed regarding incident on 10/9/24. It is to be noted that R85 was noted to be in bathroom by herself. R85 stated, On 10/9/24, I was taking a shower independently in the shower room when I had a seizure. R85 said I felt the seizure coming on but I could not get to the call light as it was across the shower. I could not sit down because the shower chair was broken and not safe to sit on. I always take showers independently with no supervision. My arm got caught in the handrail while I was seizing. I had to be there seizing for at least 20 minutes before V11 (Registered Nurse) came to check on me. My entire body was bruised and black and blue. V32 (Maintenance Director) had to come and take the handrail off the wall because my arm was so wedged into the rail. I had fractured my right upper arm and must wear an immobilizer. It is to be noted that R85 was alone in her room and dressed herself independently after this interview. At 10:55AM, V11 was interviewed regarding R85's incident on 10/9/24. V11 said the shower rooms are always locked. The staff must let the residents into the shower room to ensure they are aware of who is in there. V11 said I was at the nurses' station talking to a family member when I heard crying and whimpering coming from the shower room. R85 was in the shower room for about 20 minutes before I heard R85 crying. R85 always showers independently. When I entered the shower room, I saw R85 in the shower closest to the door on the left. Her arm was wedged in between the handrail. We had to call maintenance to take the side rail out to get her arm out. We immobilized her arm and sent her to the hospital. Progress notes written by V11 on 10/9/2024 were reviewed and correlates to what V11 said in interview. Per Minimum Data Set, dated dated dated [DATE] shows R85 required supervision/touching assistance while showering. R85 care plan states in part but not limited to the following: R85 has a self-care deficit in ADLs/mobility related to epilepsy, seizures, etc. Interventions include supervise in shower for safety, dated 3/20/2024. On 11/20/24 V35 (Medical Director/Attending Physician) was interviewed. V35 said a resident with a diagnosis of epilepsy and uncontrolled seizures, meaning the resident has had seizures within the last six months, should be supervised in the shower for safety. Prior to incident on 10/9/2024, it is to be noted that per progress notes, R85 has had seizures on 9/20/2024, 9/9/2024, 8/1/2024, 7/13/2024, 6/28/2024, 6/27/2024, 6/3/2024, and 5/2/2024. Facility Policy titled Resident Supervision dated 01/2024 states in part but not limited to the following: Supervision is followed per the plan of care in accordance with individualized resident focused approach.

Based on observation, interviews, and record review the facility failed to follow their pain management program when they failed to accurately assess R182's pain level and to ensure R182's pain was managed in a timely manner, four days after neck surgery to repair herniated discs. This failure resulted in R182 not receiving effective pain medication while experiencing severe and unbearable pain for an extended period of time, 9/10 on a pain scale of 0-10, in addition to suffering through periods of uncontrolled anxiety as a result of the prolonged severe pain. Findings include: R182 is a [AGE] year-old resident of the facility with medical diagnosis listed in part, but not limited to idiopathic peripheral autonomic neuropathy, hypertension, type 2 diabetes, hyperglycemia, and bipolar disorder. Per a progress note dated 10/21/2024 at 7:36 PM by V25 (Nurse Practitioner), R182 was hospitalized from 10/15/2024 to 10/19/2024 for a C3-C7 decompressive laminectomy and posterior cervical fusion to repair herniated discs. On 11/19/2024 at 12:57 PM, R182 said when he returned from the hospital on Saturday, 10/19/2024 at around 6:30 PM following neck surgery, he was in excruciating pain, 9/10 on a scale of 0-10. R182 said V23 (Licensed Practical Nurse) told him she could not find a prescription for his pain medicine, Oxycodone, in his paperwork from the hospital. R182 said V23 gave him acetaminophen at around 7:30 PM for his excessive pain and he tried his best to fall asleep but was not able to because the pain medication was not effective. R182 said the night shift nurse told him they could not do anything as far as a prescription for the stronger pain medication, Oxycodone, was concerned, and he would need to wait until Sunday morning when they would try to get a hold of a physician or practitioner to get his order. R182 said on Sunday, 10/20/2024, he was still getting only acetaminophen for pain relief. R182 said he asked the morning nurse for an update, and the nurse said they were still trying to get a hold of either the surgeon's team or the facility doctor. R182 said he felt like everything kept getting passed over to the next shift. R182 said by Monday, 10/21/2024, the facility nurses had still not contacted any physician that could fill out his Oxycodone prescription, so he asked a nurse for help in getting an ambulance to take him back to the hospital due to his unbearable pain, but his request was not given. R182 also said after three straight days without pain relief, he became very anxious and was worried his high blood pressure and high blood sugar would also be affected. R182 said his Oxycodone order finally arrived in the early hours of 10/22/2024. Lastly, R182 said after his original prescription of Oxycodone ran out on 10/28/2024, the facility did not re-fill his prescription until 10/31/2024, forcing him to suffer through three additional days of severe pain. On 11/18/2024 at 1:45 PM, V25 (Nurse Practitioner) said she filled a prescription on Monday, 10/21/2024 for Oxycodone 5 mg, 30 tablets, every four hours, as needed, for pain, which was enough medication to last five days. V25 said she gave him another 30 tablets of Oxycodone on 10/30/2024 for delivery on 10/31/2024, with the intent to begin weaning him off the medication. Per a progress note dated 10/22/2024 at 1:40 AM by V22 (Licensed Practical Nurse), R182's order for Oxycodone HCl Oral Tablet 5 MG for pain, arrived 10/22/2024, three days after R182 had returned to the facility from neck surgery. On 11/20/2024 at 10:20 AM, V21 (Licensed Practical Nurse) said when a resident returns to the facility with a narcotics order, they usually come back with a prescription, and if not, the facility nurses have to follow up with the facility primary care physician or nurse practitioner in order to get the medication. V21 said R182 shouldn't have waited that long for his Oxycodone pain medication because he was suffering, and the facility should not have waited more than eight hours before filling the prescription order. V21 said she was not aware R182 was in so much pain, but if she would have been, she probably would have sent him back to the hospital. On 11/20/2024 at 11:00 AM, V2 (Director of Nursing) said the facility protocol was for the nursing staff to exhaust all possibilities to reach the hospital physician in order to obtain a pain medication prescription for a resident. V2 said if the nurses were unable to reach the hospital physician, they were to call the facility physician and explain the situation, who would, then, decide what form of medication they would provide until they personally assessed the resident. V2 said she could not recall if she was made aware that R182 was in excessive pain, but the facility nurse should have sent R182 back to the hospital if he was in any excruciating pain because that is what she would have recommended. On 11/20/2024 at 1:47 PM, V35 (Medical Director) said if a resident would need medication for severe pain following cervical fusion surgery, and returned to the facility without a prescription for pain medication from the hospital, the facility would need to check for any medications in stock, and if there was nothing that would alleviate the pain, then the staff should call the attending facility physician or the pharmacy the next morning. On 11/19/2024 at 12:57 PM, R182 said the weekend of 10/19/2024, was the worst for him because his pain level was 9/10 when he returned from the hospital. However, R182's pain assessment in his October 2024 medication administration record (MAR) showed no pain scores recorded for the evening and night shifts of 10/19/2024. R182's MAR pain scores for the date of 10/20/2024 were 0/10 for the day shift, 0/10 for the evening shift, and 0/10 for the night shift. In a progress note dated 10/21/2024 at 7:36 PM, V25 stated R182 reported 10/10 pain. However, R182's MAR pain scores for the date of 10/21/2024 were 0/10 for the day shift, NA for the evening shift, and 0/10 for the night shift. R182 said he began taking Oxycodone on 10/22/2024, but after his Oxycodone ran out on 10/28/2024, he had to endure another three days of severe pain and anxiety until his next order arrived on 10/31/2024. Yet, R182's MAR pain scores for 10/29/2024 were 0/10 for the day shift, 0/10 for the evening shift, and 0/10 for the night shift, and for 10/30/2024 they were 0/10 for the day shift, 0/10 for the evening shift, and 0/10 for the night shift. Per the facility's Pain Management Program, dated November 2014, the program's purpose is to establish a program that can effectively manage pain in order to remove adverse physiologic and psychologic effects of unrelieved pain. The program also states, The resident's descriptive words regarding the quality, duration, and location of pain will be used to evaluate the pain and to identify changes in pain. The program lists as one of its components, Accurate and complete documentation of pain assessment and monitoring. Lastly, the program states, The resident's physician will be notified of the resident's complaints of pain which are not relieved by comfort measures, including pain medication.

Based on observations, interview, and record review the facility failed to follow the hand hygiene policy. This failure has a potential to affect all 216 residents currently residing in the facility. Findings include: On 11/17/24 at 11:10 AM, Surveyors were provided the facility census that listed 216 residents currently residing in the facility. On 11/18/24 at 10:34 AM, Surveyor observed, third floor unit, V20 (Certified Nurse Assistant) walking out of a resident's room the third floor unit without performing hand hygiene. Surveyor interviewed V20 (CNA) who said in the summary, there are no hand sanitizers in the hallways or residents' rooms due to residents' cognitive condition, resident use to try to drink hand sanitizer. We are supposed to always have personalized hand sanitizers in our pockets. I don't have a hand sanitizer with me right now. Surveyor further inquired how did V20 (CNA) sanitize hands upon exiting resident's room, V20 (CNA) said, I have no way to sanitize my hands right now. On 11/18/24 at 11:13 AM, surveyor observed V5 (Wound Care Nurse) perform wound care for R270. V5 (Wound Care Nurse) removed large dressing with copious amount of foul smelling drainage. V5 did not remove soiled gloves after cleaning wound, applied treatment and then removed soiled gloves and donned a clean glove without performing hand hygiene. Further, V5 cleaned bowel movement from R270's buttocks, removed glove from the right hand and then donned a new glove without performing any hand hygiene. On 11/18/24 at 11:40 AM, surveyor inquired V5 (Wound Care Nurse) about hand hygiene related to the sacral wound dressing change. V5 said, I should have sanitized my hands. On 11/19/24 at 10:43 AM, Surveyor interviewed, second floor unit, V17 (Certified Nurse Assistant) who said in the summary, we usually carry personalized hand sanitizer in our scrub's pocket to maintain hand hygiene. I don't have personalized hand sanitizer with me right now. On 11/19/24 at 11:18 AM, Surveyor observed V17 (Certified Nurse Assistant) going in and out of two residents' rooms the second floor unit without performing hand hygiene. On 11/19/24 at 10:49 AM, Surveyor interviewed, first floor unit, V18 (Certified Nurse Assistant) who said in the summary, there are no sanitizers in the common unit areas and residents' rooms, we are supposed to have a bottle of personalized hand sanitizer. V18 (CNA) grabbed a bottle of a personalized hand sanitizer from the nursing station desk and slipped it into her scrub's pocket while talking to the surveyor. On 11/19/24 at 12:03 PM, Surveyor interviewed V6 (Infection Preventionist) who said in the summary, I talk to staff about hand hygiene, I tell them when the hand hygiene should be done and how long should it take to wash and/or sanitize hands. Last hand hygiene in-service was done in October 2024. We don't have hand sanitizers in the hallways and residents' rooms. There are residents who will attempt to drink it due to their cognitive limitations or mental diagnosis. Staff should always carry their own hand sanitizers. I stack personalized hand sanitizers in nursing station on each unit on all three floors to make sure hand sanitizers are readily available. Staff should sanitize their hands to prevent spread of infections. Staff should always sanitize their hands upon entering and exiting residents' rooms, unless their hands are visibly dirty, then staff should wash their hands with soap and water. Additionally, staff should perform hand hygiene before and after providing resident care, before and after passing, meal trays, etc. The facility Hand Hygiene policy dated 01/01/2020 reads in part, The use of gloves does not replace hand hygiene. Hand hygiene is always the final step after removing and disposing of personal protective equipment (PPE). Using alcohol-based hand gel; If hands are not visibly soiled, use an alcohol based hand rub for all the following situations: Before applying gloves and after removing gloves or other PPE; After providing direct patient care; before handling clean or soiled dressing, gauze pads, etc; After contact with inanimate objects (e.g., medical equipment) in the immediate vicinity of the resident.

Based on observations, interview, and record review the facility failed to provide a clean and sanitary home-like environment for 143 residents currently residing on the facility's first and second floor units. Findings include: On 11/17/24 at 11:10 AM, Surveyors were provided the facility census that listed 216 residents currently residing in the facility, whereas 143 residing on the first and second floor units. On 11/17/24 at 09:15 AM, Surveyor sensed strong odor upon entrance to the first floor unit common area. On 11/17/24 at 11:11 AM, Surveyor observed an empty medicine cup and empty milk cartoon on the elevator's floor. Surveyor observed wet, yellow, puddle, smelling like urine in the common area upon exit from the elevator on the second floor. Surveyor sensed strong urine odor on the second floor. Low side of the second floor unit floors noticed to be sticky. On 11/17/24 at 02:38 PM, Surveyor interviewed V36 (Housekeeper) who said in the summary, I am assigned to the second floor. We always have two housekeepers on the second floor unit except today, the other housekeeper was off today. My assignment consists of removing the trash, moping nursing station, hallways, and then I move on to the common area bathroom, and then residents individual rooms. The stench is from the residents who don't shower, my assigned area is clean. Cleaning elevators falls under 1st floor housekeeper. As a rule of thumb, if it's urine, feces, or blood, I am not to clean it, it is certified nurse assistant's responsibility. I cleaned the urine puddle today with bleached towel, but I really don't know how to do it, nobody told me how to clean body fluids. On 11/18/24 at 11:26 AM, Surveyor interviewed V14 (Housekeeping Director) who said in the summary, the facility seems cleaner and smells better today because there are more housekeepers in the facility. Generally, there are more housekeepers scheduled to work from Monday through Friday. There are five housekeepers from Monday through Friday, from 7:00 AM to 3:00 PM: two housekeepers on the 3rd floor, two housekeepers on the 2nd floor, and one housekeeper on the 1st floor. Then there are two to three housekeepers from 3:00 PM to 8:00 PM. On Saturdays and Sundays there are three to four housekeepers from 7:00 AM to 3:00 PM and two housekeepers between 3:00 PM to 8:00 PM. As far as cleaning urine and feces, certified nurse assistants should pick up the bulk of it and then the housekeepers supposed to sanitize the floor. I know we have special kits to clean blood. But you know, urine puddles happen all the time in the facility, residents pee on the floor all the time, so we (housekeepers) just clean it up. On 11/20/2024 at 1:56 PM, Surveyor interviewed V1 (Administrator) who said in the summary, cleaning body fluids is mutual responsibility of housekeepers and nursing staff. Nursing staff should pick up the bulk of soil, for example urine or feces, and then call housekeeping to disinfect. The facility Blood and Body Fluid Spills Clean Up Procedure (no date) reads in part In the event of a spill of blood, body fluid or tissues occurring on any environmental surface (Bed, floor, table, etc.) the employee will secure a Blood and Body Fluid Clean Up Kit.

Based on observation, interview, and record review, the facility failed to follow their own pharmacy's policy on expiration dating for medications in vials by failing to date two opened vials of insulin found inside the facility's second floor storage room refrigerator, potentially affecting two residents (R51 and R130) reviewed for drug storage. Findings include: On [DATE] at 10:55 AM, accompanied by V16 (Agency Licensed Practical Nurse), one opened vial of insulin Glargine belonging to R51 and one opened vial of insulin Lispro belonging to R130 were found inside the facility's second floor storage room refrigerator, and neither vial was dated. On [DATE] at 10:56 AM, V16 said insulin had to be dated upon opening to know when it expired because insulin had a shortened expiration time and only stayed potent and worked for 28 days after opening the vial. On [DATE] at 11:06 AM, V2 (Director of Nursing) said medications were dated based on the recommendation of the medication. V2 also said if a medication had a recommended usage time of 28 days, they would need to know the open date to determine the proper expiration date in order to know when to discard the medication because the medication was only effective during that time, otherwise it would lose its effectiveness. Per R51's medication administration record, (MAR) for the month of [DATE], insulin Glargine solution, 100 unit/mL, had been administered one time per day, for diabetes, at 25 units, subcutaneously, from [DATE] to [DATE]. Per R130's medication administration record, (MAR) for the month of [DATE], insulin Lispro solution, 100 unit/mL, had been administered before meals at 11:00 AM, for diabetes, at 10 units, subcutaneously, and per sliding scale before meals and at bedtime, subcutaneously, from [DATE] to [DATE]. The facility's Pharmacy Policies and Procedures Manual, last revised [DATE], stated, When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The same policy also read, The nurse shall place a 'date opened' sticker on the medication and enter the date opened and the new date of expiration, and, The expiration date of the vial or container will be 30 days. Lastly, the policy stated, Certain medications or package types, such as multiple dose injectable vials, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency.

Based on observation, interview, and record review, the facility failed to ensure a vulnerable resident (R6) was free of physical abuse inflicted by staff. This failure resulted in R6 sustaining multiple injuries including a closed head injury and contusions (bruising) of the right thumb and forearm. Findings include: R6 is [AGE] years old and admitted to the facility 1/19/24 with diagnoses that include schizoaffective disorder, bipolar disorder, and other mental health disorders. According to the minimum data set, R6 is alert, however, is assessed to have mild cognitive dysfunction. Facility reported incident of 8/21/24 described an altercation with R6 and V15 a Certified Nursing Assistant (CNA) during the evening (3pm-11pm) shift. According to nursing progress notes, V16 LPN witnessed V15 CNA hitting R6 while in bed. V16 immediately intervened by removing V15 from the room and assessed R6 for injuries. R6 was transferred to the hospital and returned in the early morning with diagnoses of a closed head injury, and contusions (bruising) of the right thumb and forearm. R6 was observed 8/29/24 at 11:16am alert and oriented to person and place. R6 was walking with a moderately steady gait and was appropriately dressed and groomed. During this interview, R6 was exhibiting some flight of ideas when conversing. Regarding the incident that occurred 8/21/24, R6 said 'someone came in and put the tray down on the bedside table. Somehow, I got hit in the head with the table. The nurses and everybody came in and I was bleeding he couldn't remember the details, but there was something about the table.' R6 didn't remember going to the hospital, but said, he was picked up in an ambulance, and they took some X-rays before bringing him back to the facility. R6 said again that he didn't remember exactly what happened, but said his head hurt and has been hurting a lot. R6 was noted to be grimacing and pointing to the front left side of his brow and forehead. The right hand was observed to be significantly swollen compared to the left hand and arm which appeared normal. R6 flexed the right hand and said it still hurts to close the hand. R6 said that he can't think of any time an incident has happened that anyone in the facility hurt him and said that he has not been hurt by anyone before. R6 said that he has not seen the person (CNA) since that evening. Progress note written by nurse on duty V16 LPN (Licensed Practical Nurse) states: While the writer was passing meds [medications], she observed a CNA leaning towards the resident and hitting him, the writer then observed the resident stand up and throw his bedside table at the CNA. The CNA begin to state that she was placing the resident's snacks on his nightstand and the resident begin to holler at her and throw a cup of water at her. The writer separated the CNA from the resident and told her to leave. A head to toe assessment was completed and the writer observed redness and swelling to the left side of the forehead and redness to the left jaw and an abrasion to the right hand (vitals) 129/87 74 18 97.4 98% on RA. The resident was sent out via 911 for further evaluation, the local police was made aware .the writer also spoke with the resident's father, the administrator and the DON, the writer also left a voicemail with the NP for a return call. The resident was transferred to hospital. V16 LPN was interviewed on 8/29/24 at 12pm. V16 said while getting ready to pass medication, V16 was outside of R6's room, and V15 CNA didn't realize V16 was standing there. V16 witnessed V15 hit R6 and R6 got up off the bed to defend themselves. V16 instructed V15 to clock out and leave the building, and then assessed R6. R6 was holding their head, and V16 called 911 for transport to the hospital and to make a police report and then called the administrator and Director of Nursing. On 8/29/24 at 12:26pm, V15 CNA said that they went to respond to an activated call light from R6 and found that it had been tangled. According to V15, R6 became suspicious that V15 was taking their belongings and began to yell and threw a cup of water at V15. V15 said that R6 kept attacking V15 by throwing cups, and the bedside table. V15 tried to block R6's attempts of attacking but would not specify in what manner. V15 said when R6 threw a cup of water V15 slipped, fell on to R6 and R6 kicked V15 in the abdomen while R6 was lying in the bed. V15 said they started yelling and when the nurse came, yelled at the nurse the resident attacked me- Do Something! V15 said that working with R6 before, R6 isn't known to be aggressive nor does R6 display agitation. V15 denied having any training regarding abuse or being provided with the abuse policy at the time of hire (July 2024). However, based on review of the personnel file, V15 completed a post-test for abuse and resident's rights and provided signatures indicating completion. During the interview, V15 shared that they haven't been back to the facility since the night of the incident and 10 minutes prior to this interview, said that the Administrator V1 terminated employment over the phone. V15 said that if they could have done anything differently, they would have stepped away from R6 when they became agitated and went to get the nurse. Police report dated 8/21/24 includes an interview with the responding officer and V15 CNA who said that R6 threw water and a cup at V15's face. V15 said that they got on top of R6 to stop R6 from throwing anything else and then R6 kicked V15 in the stomach. V15 goes on to say they 'pushed the side of R6's face while getting up.' On 8/29/24 at 2:36PM, V1 Administrator said, when V15 CNA was interviewed the night of the incident, V1 asked if V15 hit or striked R6 and V15 kept saying I defended myself however would not directly answer or offer any elaboration. R6 sustained injuries and V15 wasn't able to give a definitive answer regarding exactly what they did to defend themselves. V1 said as of today, V15 has been terminated for gross negligence and failure to follow protocol with regard to residents who display aggression. Care plan reviewed for R6 does not indicate any agitation, violent, or aggressive behaviors prior or current. Witness statements from staff members on duty at the time of the incident also denied R6 having any such behaviors. The facility Abuse Policy and Procedure revised 1/18 states in part; This facility desires to prevent abuse, neglect exploitation, mistreatment, and misappropriation of resident property by establishing a resident sensitive and resident secure environment.

Based on interview and record review, the facility failed to provide detailed written notice 30 days prior to the discharge for one resident (R1) by failing to allow R1 to return to the facility while being accounted for on a facility issued community pass. This failure resulted in R1 not being properly discharged and being without medical care and medications for a month before getting a new primary care physician. Findings include: R1 is a [AGE] year old male and admitted to the facility 12/22/23 with diagnoses that included cerebral infarction, diabetes, asthma, hypertension, and substance abuse. On 8/20/24 at 4:09PM, R1 was interviewed over the phone and said that they were discharged from the facility on 7/27/24 without written notice. R1 explained that they were given a white pass which gives permission to leave the facility supervised overnight from 7/27/24 to 7/29/24. R1 said that his sister came to the facility to sign R1 out on 7/27/24, and R1 was allowed to leave. Shortly after leaving, the manager on duty (V13) called R1 over the phone and R1 was instructed to return to the facility, or he would be considered discharged against medical advice (AMA). V1 Administrator was added to the call and told R1 and R1's sister that R1 should not have been allowed to leave the building, was considered discharged AMA and could not return. R1 said when he returned to the facility on [DATE], R1 was not allowed access into his room and his belongings were brought to him via the side door. On 8/26/24 at 12:21PM, V1 Administrator said, R1 did not express wanting to leave AMA, but we told him that he would be considered AMA if he left because at the time he went on pass, he was supposed to be going to the hospital for a psych evaluation. V1 said on 7/26/24 in the evening, a staff member accused R1 of drinking alcohol outside, away from facility property. When R1 returned, we requested he go to the hospital for evaluation, and he refused. The paramedics came to take him to the emergency room , and when they spoke with the emergency room physician, the physician refused to receive him so they left and R1 remained in the facility. After he refused, staff filled out an involuntary petition for inpatient hospitalization due to belligerent and verbally aggressive behaviors that occurred 7/26/24 in the evening. V1 said they were told that R1 was presented with an AMA form, however R1 didn't sign it. V1 denied giving R1 any written notice of discharge. R1's progress notes were reviewed for 7/26/24 and details of R1 being verbally aggressive were not available to review. V3 Assistant Director of Nursing was also interviewed on 8/21/24 at 3:08pm. V3 said they called V4 Psychiatrist to get an order for involuntary psychiatric admission, however, was unable to define or elaborate how R1 displayed verbal aggression. V3 also said that R1 eventually calmed down after staff spoke with him and notified him about the petition. During his interview, R1 said that when he returned to the facility from being out on an independent pass 7/26/24, he participated in a blood alcohol test using a breathalyzer. According to R1 and R1's progress notes, when V7 Substance Abuse Program Coordinator tested R1, with a result of 0.02. R1 said that he refused going to the hospital because he was not intoxicated, he was cooperating with the staff, and he got angry because a staff member took a photo of him while off the facility premises. When R1 refused to go to the hospital, the staff suddenly accused R1 of being aggressive in order to force him to go to the hospital. According to listed medical diagnoses, and care plan, R1 was not being treated for any psychiatric diagnoses and did not have a history of aggression while residing in the facility. On 8/22/24 at approximately 3:00pm, V4 Psychiatrist said that he evaluated R1 while he was in the facility and said R1 did not have any psychiatric difficulties and did not require management of any psychiatric medications. V4 said typically a resident who requires emergent inpatient psych evaluation will be admitted within a few hours, and if there was an emergency where the resident was displaying violent behavior, the facility would call 911 to immediately remove the resident. V4 said that alcohol levels decrease 30 points per hour after the person stops drinking and the legal limit is 0.08. V4 said a level of 0.02 is really low and would not demonstrate an intoxicated person and after about an hour the level would likely be zero. The facility presented the white pass form for overnight visits dated 7/27/24 to 7/29/24. The form was signed by R1's social worker, the nurse on duty, the receptionist and R1's sister. When this survey began on 8/20/24, the lobby was observed to have double locked doors entering the lobby and entering the resident care area. Access to both doors is only permitted by the receptionist. On 8/27/24 at 12:26pm, V14 Receptionist said they were on duty at the time R1 left the building. V14 signed the white pass and copied R1's sisters' identification. V14 said that no person is able to enter or leave the facility without the receptionist giving access. On 8/21/24 at 1:28PM, V9 Receptionist explained that the white pass is provided to the resident by the nurse and requires a nurse's signature and permission to leave the facility. V9 said, the resident initially asks for the pass and then different departments have to fill it out before coming to the front desk. Once it has been filled out, the receptionist will have the family member or whoever is picking up the resident fill out the information on the sheet and we take their identification to upload in the system. V11 Social Worker said, that in order for residents to leave the facility overnight, they initiate a request from social services who will fill out the top portion of the form indicating when the resident is leaving and returning to the facility, the reason for the visit and with whom they will be visiting. Social Services is responsible for applying this information and then signing the form. After that, the nurse will review and sign the form indicating whether medications are required for the visit. Lastly, the resident takes the form to the front desk, the receptionist reviews it before allowing the resident to leave. On 8/27/24 at 10:35AM, R1 said when he returned to the facility from overnight pass on 7/29/24, R1 was restricted access into the building and not allowed to his room. R1 said his belongings were brought to him via the side door and he was refused medications. Physician order sheet active at the time of discharge included medications for asthma, high blood pressure and diabetes. R1 said it took approximately four weeks to get an appointment with a new primary physician out in the community. R1 reported having some medications left over at his family's home, but was completely out for about a week, while waiting for his appointment. During that time, R1 frequently experienced cramps and pain in his extremities, requiring him to limit activities which negatively impacted his ability to work. Additionally, R1 was working with an agency to find housing in the community, and R1 was planning to move out of the facility within a few weeks. However, when the facility discharged R1, the agency was unable to help him any longer. The facility presented the white Pass Request Form for R1 dated 7/27/24. The form was signed by V11 Social Worker, V10 Registered Nurse. Discharge report summary as of 8/20/24 listed R1 discharging from the facility against medical advice (AMA) on 7/27/24 at 9:33AM. The active discharge care plan for R1 was last revised 4/22/24 and stated Resident wishes to be long term and has no plans on discharging at this time. The facility's policy and procedure tilted Discharge Against Medical Advice revised 7/24 states: Policy: It is the policy of this organization to provide medical and psychosocial care to residents of the facility. In the majority of situations, it is not in the resident's best interest to leave Against Medical Advice (AMA). Staff are to: (1) utilize good public relations skills to try to talk the person who wants to leave AMA out of leaving and (2) contact the attending physician (and notify the psychiatrist) and an administrative representative prior to allowing the individual to leave the premises. Purpose: To define the facility's responsibility when a resident discharge him/herself from the facility without the consent of or an order from the attending physician. Procedure: 1. Staff shall provide appropriate attention and make a reasonable effort to prevent a resident from leaving AMA (Against Medical Advice). 3. Assess the resident's competence to make the AMA decision (vital signs, mental status-including the presence or absence of hallucinations and delusions, judgment, reasoning, awareness, and insight). If there are questions about the individual's ability to provide informed consent, there should be no consideration for an AMA discharge. If the person is insistent on leaving, his/her only option will be hospitalization , and this includes involuntary psychiatric hospitalization . 4. Explain and document a discussion of the reasons to remain in the facility and all of the potential serious risks associated with leaving. 5. Explain and document efforts to persuade the resident to remain in the facility. 6. Explain and document your ongoing concern for the resident and his/her well-being (and in some cases, the well-being of his/her family members). 7. Use all available resources to prevent a resident from leaving AMA. This may include the social worker, nurses, nursing assistants, activity staff, a family member, or even a friend. 8. If available, involve the resident's responsible party (e.g., family). They may be able to talk the resident out of leaving. Also, if the resident does leave and an untoward event occurs, the responsible party would have been appropriately informed about the AMA discharge. Use your best judgment as to what must remain confidential. Confidentiality should take second priority to your efforts to assure the resident's continued health and safety. 9. Negotiate and compromise with the resident. Assess what is bothering/upsetting the individual and attempt to find an equitable solution (e.g., if the person doesn't have independent outside privileges, perhaps he/she can enjoy a cigarette on the patio). Try to find a resident buddy to help the person adjust and offer support. 10. If the person is still insisting that he/she is going to leave, follow instructions from the attending physician (e.g., if the person is not competent, hospital transfer may need to occur).

Based on interview and record review, the facility failed to restrict independent community access to a resident (R3) who was known to be refusing psychiatric/medically necessary medication and exhibiting active delusions and hallucinations. This failure resulted with R3 going out for a walk unsupervised and not returning to the facility. R3 was found three days later by local law enforcement, lying on the ground in the community, and taken to the emergency room where R3 was assessed with active psychosis. Findings include: R3 is a [AGE] year old female who originally admitted to the facility 4/30/2019 and has diagnoses that include schizoaffective disorder-bipolar type, generalized anxiety disorder, hypertension, and diabetes. The list of medical problems also includes a history of experiencing hallucinations and suicidal ideations. R3 is a ward of the state and has been appointed with having a state guardian since 9/26/1988. Progress notes were reviewed and indicated R3 has demonstrated a history of delusional behaviors and refusing medications. R3 has also left the faciity on [DATE] while using independent pass privileges and failed to return at the specified time. On 2/14/24 Social Services wrote [R3] has been presenting with increased delusions. On 2/22/24, Social Services notes Resident has been presenting with refusal of medications. On 2/24/24, Social Services and nursing wrote that R3 went out with a community pass in the morning, and called the facility to say she would not be returning. The facility filed a police report with the local department. Nursing note written 2/25/24 said that R3 returned to the facility in the morning and appeared to be having paranoid thoughts and delusions which prompted nursing staff to seek involuntary hospitalization for a psychiatric evaluation. R3 was hospitalized and returned to the facility 3/1/24. When R3 returned to the facility, the Social Service Director assessed R3 to be appropriate for independent community access and reinstated the green pass on 3/29/24 according to the Community Survival Skills Assessment. On 3/30/24, Social services notes in the monthly summary that R3 continues with experiencing hallucinations and delusional behaviors. On 7/26/24, R3 left the facility with a green pass and did not return. R3's Community Pass Program sheet for July 2024 showed that R3 signed out of the facility 7/26/24 at 2:50pm to go on a walk and was signed by the receptionist on duty. According to the Medication Administration Record of July 2024, R3 refused medications 23 times, including those prescribed for schizophrenia, hypertension, and diabetes prior to being granted access to leave the facility. No interventions were documented to address these concerns. When entering the facility at the start of the survey on 8/20/24, the facility was observed to have a double locked door system in place that prevents independent entry and exit in the lobby and then in the direct resident care areas. On 8/22/24 at 2:05PM, V6 LPN (Licensed Practical Nurse) said they worked the morning and evening shift (7am- 11pm) of 7/26/24 and recalled last seeing R3 in the early afternoon. V6 said that they had not administered medications in the morning to R3 because she had been refusing medications for days and weeks leading up to that day. V6 said R3's refusals were known to staff and providers. V6 said that they were not aware that R3 had not returned to the facility before ending their shift at 11pm and confirmed they did not administer medications to R3 in the evening, despite signing them as given, because R3 was not in the building. V6 said, according to facility policy, if the residents don't return to the facility while having a green pass, the resident is considered to be discharged against medical advice (AMA). The facility presented a Community Pass Agreement that states in part, Failure to adhere to any of the policies and procedures of the community pass agreement may result in notification of the physician and constitutes discharge against medical advice. On 8/26/24 at 11:46PM, V13 Business Office Manager said they were the manager on duty Saturday morning 7/27/26. V13 said while rounding, they received report from the morning nurse that R3 had gone out on pass the previous day and did not return to the facility during the evening. V13 called the local police department and when they arrived at the facility a missing person's report was filed. The police report of 7/27/24 noted that an officer reported to the facility for a complaint of missing person. The report indicates that the responding officer collected personal information from the medical record about R3 and reported that information to a statewide data system. The responding officer includes following-up on the entry submitted into the database and noted that R3 had been located on 7/30/24 by a police department in a town approximately 14 miles from the facility and subsequently taken to the hospital. The reporting officer called the hospital and learned that R3 was admitted as an inpatient. Hospital emergency room notes indicated that R3 was brought to the hospital 7/30/24 at approximately 11:00AM. R3 was thought to be homeless, and was reported lying outside in a residential area, when the police were contacted and brought R3 to the emergency department. R3 was complaining of low back pain, and intermittent difficulty with walking on assessment. R3 also appeared psychotic, and exhibited flight of ideas, and required frequent redirection. Psychiatry was consulted in the emergency room and R3 was admitted to the inpatient behavioral health unit. On 8/26/24 at 12:21PM, V1 Administrator said that R3 had a history of going out with a green pass and not returning to the facility earlier this year. V1 was unsure of when R3 was assessed to have independent pass privileges reinstated after the incident, but said, at some point social services assessed her to be appropriate for independent pass. V1 said, the front desk staff should have noticed that R3 didn't come back and was missing from the facility prior to leaving off duty at 8pm and notified the nurse on duty. V1 would have expected the nurse on duty to notice as well after 8pm. V1 was not made aware that R3 was missing from the facility until the following day on 7/28/24 when the nurse noted that R3 was missing. V1 said the police were called to the facility to file a missing persons report. V1 said a few days later, R3 was found in the community by law enforcement and taken to the hospital. V1 stated R3 lied to the police and said she was homeless. She is manipulative and voiced that she didn't want to return (to the facility). V1 said, that they were not aware that R3 was refusing medications at the time R3 was allowed to leave the facility independently because they were not notified by nursing staff. A Care Plan for Community Access was initiated 5/7/19. At the time of initiation, R3 was granted an independent community (green) pass with the permission of the Guardian. The last revision in the Goal section is dated 11/22/23 and states Resident will remain in the facility and request staff to accompany her when wanting to go outside. The care plan focus was updated on 2/24/24 to note that R3's green pass was restricted for 30 days due to failure to return at agreed upon time. Facility Policy titled: Community Pass Policy revised 7/1/24 states in part; Purpose- to define the facility's and the resident's responsibilities when a resident leaves the facility with community pass. Procedure: 1. A Community Survival Skills Assessment will be completed by Social Services upon resident admission, quarterly, and when there is a significant change in condition. 2. Decisions regarding pass privileges, including independent privileges or being accompanied by a responsible individual, are determined by physician's orders and social services assessments. Residents who demonstrate consistent maladaptive ad problematic behaviors may not be candidates for independent privileges. 4. The facility reserves the right to restrict/revoke the community pass privilege of a person assessed by the IDT (Interdisciplinary team) or physician or Social Services as a threat to him/herself or others to assure the safety of the individual resident and the neighboring community. V1 said the facility implements the policy that residents who have an independent pass are considered discharged AMA if they don't return from pass, as a way of the facility releasing liability because it is unknown what the resident is doing while outside of the facility.

Based on interview and record review, the facility failed to effectively supervise a resident with history of drug abuse. This deficient practice affects one resident of three residents reviewed for change in condition. R28 had multiple incidents of noncompliance for bringing in contraband and R28 tested positive for cocaine once during R28's stay in the facility. R28 expired on [DATE] in the facility with cause of death as combined drug toxicity: Drug fentanyl Acetyl despropionyl fentanyl raised to the level of an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when R28 was found to be unresponsive at the bedside without breath. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 10:18am. The surveyor confirmed by onsite observation, interview and record review that the immediacy was removed on [DATE], but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: R28 was admitted in the facility on [DATE] and expired on [DATE]. R28 is a [AGE] year old female resident. R28 has diagnoses but not limited to: post traumatic stress disorder, psychoactive substance abuse, anxiety disorder, major depressive disorder, attention-deficit hyperactivity disorder and suicidal ideation. R28's notes for Initial Meeting for [NAME]/Alcohol and Substance Abuse program/Introduction dated [DATE], reads in part: R28 noted using heroin and cocaine. R28 also reported that she was prescribed Vicodin (controlled substance pain medication) after car accident which caused R28 to start using again. R28 further reported using heroin for 5 or 6 years. Per medical records, R28 was noncompliant with her psychotropic medications. R28 was told that R28 will be referred to the [NAME] program for poly0substance abuse. R28 was made aware that this facility has zero tolerance for using alcohol, THC (Tetrahydrocannabinol-found in cannabis) or any mood-altering substances while in treatment inside and outside the facility and random UDS (Urine Drug Screening) and BAC (Blood Alcohol Concentration) will be administered and for suspicion of using. Social Service Note dated [DATE], reads in part: writer met with R28 due to R28 being on 72-hour smoking restriction as there was contraband found in her room. Writer re-educated R28 on the smoking policy and encouraged R28 to refrain from bringing contraband into the facility. Social Service Note dated [DATE], reads in part: Staff reported that R28 was seen with contraband in R28's room on [DATE]. Writer approached R28 about the situation. R28 was calm when talking to the writer. Writer reminded R28 about the house rules. After releasing R28's frustration, R28 began to understand what writer explained to R28. Care plan will be updated as needed. Staff will continue to monitor accordingly. Social Service Note dated [DATE], reads in part: Writer spoke to R28 after witnessing R28 smoking in the hallway. Writer confiscated R28's vape and re-directed R28 to social service office. R28 stated to have gotten them when R28 went out and forgot to turn it over. Writer educated R28 on the house rules regarding smoking materials outside of designated area and encouraged R28 to turn in material at the front desk upon re-entry. Due to multiple violations, R28 smoking privileges will be taken for 30 days. Social Service Note dated [DATE] reads in part: Writer notified that on [DATE] R28 had contraband. Upon entering the room bathroom was not smoky as R28 exiting the bathroom. An unlit cigarette was located in R28's bedroom. R28 was educated about the hazards/safety risks of smoking inside the facility. R28 is restricted from smoking for 30 days. Social Service Note dated [DATE] at 12:30PM, reads in part: Conducted a random UDS (Urine Drug Screening) and results were positive for THC and opioids. It is apparent that R28 currently uses THC and R28 takes pain pill under doctor's and facility's supervision. R28 stated I smoked a joint at the reunion but did not do other drug or alcohol. CADC (Certified Alcohol and Drug Counselor) commended R28 not using other mood-altering substances. Furthermore, CADC told R28 that R28 cannot use marijuana while in treatment. Offered another level of treatment but R28 refused, stating it's only marijuana. Will continue [NAME] (mental illness and substance abuse) programming. Social Service Note dated [DATE] at 12:36PM, reads in part: Writer met with R28 due to having contraband. Upon entering room, bathroom was not smoky as R28 was exiting the bathroom. A vape was located in R28's bedroom. R28 is restricted from smoking for 60 days. Social Service Note dated [DATE], reads in part: R28 mother called and spoke to writer, when she was out of town, R28 was caught using cocaine with first cousin and lying about her drug use. Will follow up. Social Service Note dated [DATE], reads in part: CADC and R28's mom met briefly yesterday impromptu as she was coming to visit R28. R28's current drug use activity and last positive UDS (THC and Cocaine) were discussed in the meeting. Both agreed that inpatient or residential treatment for R28 is recommended, will continue to follow up. Contract for Refusing Inpatient Residential Treatment dated [DATE], reads in part: R28 has been observed on several occasions with positive UDS with THC and opiates which she is currently taking while under supervision of doctors and other IDT members. The latest UDS was positive for cocaine. Her Drug and Alcohol Therapist has offered R28 an opportunity to attend an inpatient or residential Treatment for her substance abuse issues but R28 adamantly refused to do so. On [DATE] at 11:15AM, V17 (Substance Abuse Coordinator) stated in regards to [DATE] contract positive result of cocaine: It was false positive, I should have documented false positive and not positive for cocaine. We asked R28 and R28 denied it, and there could be over the counter medication that can give false positive result. Based on my clinical observation and assessment that day, the result was false positive, but I did not document because I did not see it would be important to document my clinical observation and assessment at the time. Social Service Note dated [DATE], reads in part: Writer was informed that resident was caught in possession of contraband. Social service staff confiscated the items (Vape and THC pens) and performed consensual room search. R28 placed on 90-day smoking restriction. On [DATE] at 1PM, V4 (Social Service Director) regarding delivered items, reception will check and if the social services are available they will also check. Unfortunately we are not able to do search for visitors. We check the package once the package is left by the visitor to any residents. Regarding [DATE] we confiscated contraband, vape /THC pen was found. We checked and searched the whole room and nothing else was found. R28 was placed on smoking restriction. V4 cannot recall how R28 got the vape. R28 was already on red pass. R28 can go out to community with family members and friends but not unsupervised. Someone has to sign R28 out before R28 can go out on pass. On [DATE] at 1:15PM, V4 stated that for dropped off essential items and groceries, social service brings it to the residents. Reception will call the nurse to come and get the food delivered and the receptionist should have checked it prior to calling and giving it to the nurse. Unless the resident is waiting down in the unit by the reception area, the receptionist will check the bag before giving it to the resident. Also, front desk will inform the social service that a family member/ other visitors coming in with bag of items. If dropping it off, then social service will come down and search and if visitor is staying and coming in with bag of items then the reception will check the bag. On [DATE] at 10AM, V24 (Receptionist) stated that V4 will notify the nurse that a family member will bring a bag of snacks for the nurse to check in the nurses station. Because I do not know the residents diet. I will call the nurse and let them know that a family member is on their way with a bag of snacks. Outside deliveries, they come in they show us their phone and show us they are here to deliver something. Sometimes residents will come down and wait for the delivery person and wait for them on the other side of the door (receptionist area to facility floor unit). In regards to groceries, Social service will check. I will inform social service that a grocery is delivered or dropped off. Social service need to be present when handing the bag to the resident. Food delivery service, it has to be given unopened to the resident. We don't check if with the receipt and the bag is closed. On [DATE] at 3:30 PM, V17 (Substance Abuse Coordinator), stated that due to history of drug use while in the facility, R28 was counseled not to do drugs anymore. In general, a resident that tested positive for illegal drugs we will try to find out where they got the drugs from. We notify the MD. If they have a guardian we will notify the guardian. High level treatment which is inpatient was offered to R28. R28 refused. Our intervention was to continue with the current intervention in the care plan. No new specific intervention added at the time she tested positive for cocaine. Staff to encourage R28 to attend group meeting such as AA meeting. Increase one to one meeting. Nurses Notes dated [DATE] 05:45, reads in part: Upon rounds at this time, observed R28 in bed lying on Left side. Called her name, not easily aroused. Unresponsive verbally and tactile. Upon further assessment she appeared not to be breathing. Code blue immediately called, CPR Initiated. All staff Nurses responded. 911 Emergency was called and they arrived immediately. CPR (Cardio Pulmonary Resuscitation) continuous EMS (Emergency Medical Services) resumed CPR. Police present. Patient's mother already notified and in the facility as well as the Director of Nursing. EMS Continued CPR then called the Time of Death 6:18AM. Fire Department Runsheet dated [DATE], reads in part: Unit notified [DATE] at 5:56AM, Unit arrived at scene at 6:03AM, and patient contact at 6:04AM. Called for Cardiac Arrest. Found nursing home staff attempting CPR on [AGE] year old resident. Unknown PMH. Unknown last time patient was seen normal. Unknown what time patient was found not breathing. Exam, patient cyanotic from the neck up. Patient with full rigor throughout body. 4 lead applied confirmed asystole. Local ER call for medical control. Medical control confirmed DOA (Dead on Arrival) at 6:11AM. On [DATE] at 10AM, V60 (R28's complainant) Reported that after R28's death, they checked R28's text messages on her cellphone and R28 was in communication with somewhat an Uber driver stating that the drugs will be placed inside the hair coloring box. Was not specific what kind of drugs it was and was not able to give the date of this transaction conversation through text messages. V60 reported that R28 died of drug overdose. On [DATE] at 11:25AM, V61 (Coroner's office personnel) confirmed cause of death for R28 as written in R28's Death Certificate as combined drug toxicity: Drug fentanyl Acetyl despropionyl fentanyl. Physician Order sheet reviewed and there is no order for Fentanyl medication. Resident Handbook revision date [DATE], reads in part: Room, Personal and Body Searches. Staff members perform room checks every day. Staff will check each resident room to ensure a clean and safe environment. You may be present at the times of these room checks. Please be aware that staff will be checking all closets, dressers, suitcases and shelving. Certain items are not permitted in your room for your safety and safety of others. Some items not allowed in the facility, include but not limited to: Firecrackers or any kind of chemicals or flammable materials. Any poisonous materials. Guidelines for Community Access Determination dated [DATE], reads in part: Resident personal belongings will be searched upon entry and re-entry to the facility. [DATE] Alcohol/Substance Use/Abuse policy reads in part: Substance Use/Abuse Policy objective It is the policy of the nursing facility to provide a safe and healthy living environment. The facility recognizes that persons requiring long-term care present with significant physical and mental health problems. In some situations, the person may have a history of substance abuse. The facility recognizes that substance use/abuse disorders result in substantial physical and mental impairment disability and recognize the personal responsibility of the individual to seek and remain engaged in treatment. The facility shall work with the individual to provide appropriate treatment referrals to enable the individual to work on abstinence, sobriety, personal improvement and reducing chances of recidivism. Appropriate interventions are strongly recommended to persons with substance abuse problems. Each resident (and/or representative) is informed that facility policy prohibits the use of alcohol without a doctor's order. Facility policy prohibits use of illicit drugs. As a condition of residence, each person living in the facility acknowledges that he/she will not use alcohol or illicit drugs during residence in this building. Persons returning from the community who present with signs and symptoms of intoxication will be evaluated by the nurse on duty or charge nurse. The nurse is responsible for taking vital signs and assessing the person's present behavior. The nurse will be responsible for contacting the attending physician (A.P.) if the resident is determined to be in need of medical attention and/or a decision is required regarding withholding prescribed medications. Documentation will be placed in the chart regarding signs/symptoms of intoxication/inebriation. Documentation should include the resident's own admission of alcohol/drug use. The facility reserves the right to have the person submit to blood/urine testing at any time if policy violation is suspected. Follow-up interventions and treatment recommendations will be communicated to the resident/representative and documented in the medical record. Outside treatment sources will be utilized as appropriate. Residents with substance abuse disorders are expected to participate in acute/active treatment, sobriety counseling, or aftercare Persons who continually jeopardize their health and the health and safety of others will be evaluated for involuntary discharge. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1. A system to ensure contraband does not enter the facility and is removed from the resident will be achieved through staff education. Education will be provided by the Administrator, to registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager. This education will review the facility's contraband policy updated on [DATE] and will include that residents may be asked to voluntarily empty and show the contents of their pockets at any time if reasonable suspicion exists. Reasonable suspicion includes frequent leaves of absence with or without facility knowledge, odors, new needle marks, and changes in resident behavior such as unexplained drowsiness, slurred speech, lack of coordination, mood changes, particularly after interaction with visitors or absences from the facility. Residents may be asked to voluntarily reach into concealed clothing areas and remove any items and place these items on a horizontal surface. Staff are instructed to have the resident hand items to the staff members or place the items on the horizontal surface. It is the objective of this policy that the above steps occur in plain sight of multiple witnesses (if possible) to afford appropriate protection to both the resident and the involved staff member(s). These steps are necessary to assure that the resident is treated with respect and dignity throughout the procedure. It is appropriate to ask the resident to empty his/her pockets and display their contents or roll down his/her socks. It is not appropriate to bring a resident into a room for a more specific search unless there is strong suspicion that the individual is attempting to bring in objects/items that may cause serious harm. If a more specific search is required the staff are to follow guidelines as set forth by the administrator or the administrative representative. This may even involve requesting professional assistance from the local police. Only outerwear articles of clothing including, but not limited to, jackets, coats, scarves, hats, gloves, and vests, shall be removed in plain site of staff. This policy recognizes that residents have attempted to hide/conceal contraband articles in undergarments in the past. If this appears to be the case and staff assess and suspect that these items may cause harm, staff are directed to contact the administrator or the administrative representative for instructions on how to proceed. The facility emphasizes treatment with dignity at all times. The facility reserves the right to remove locks from drawers, cabinets, closets, lockers, or any other object if there is reason to suspect that the resident possesses any item or items that may potentially harm other persons. The facility may choose, at its discretion, to involve drug-sniffing dogs (e.g., from a K9 company) if residents are suspected to be trafficking drugs inside the facility. A root cause analysis will be completed upon identification of contraband. This education began on [DATE] and will be completed by [DATE]. Upon completion of the training, staff will sign an will contact agency staff before their scheduled shift to review staff education regarding the prevention of contraband from entering the facility and the removal of contraband from resident possession. A binder with staff education will be kept at the front desk and agency staff will be required to read and sign to validate their understanding of the information presented in the binder. If agency nurses have any questions regarding the information presented in the staff education binder, they will be instructed to contact the Director of Nursing for clarification prior to signing the record of education. In the absence of the Director of Nursing, the Assistant Director of Nursing will review the education requirements and answer any questions for agency nurses. The facility has identified five staff members who are on a leave of absence/vacation. These staff members will be contacted by the Administrator to review staff education regarding the prevention of contraband from entering the facility and the removal of contraband from resident possession. The staff education will be placed in a binder at the front desk and must be reviewed and signed by the staff member before returning to work. The staff member will sign a record of education to validate their understanding of the information presented in the binder. If the staff have any questions regarding the education, they will be instructed to contact the Administrator before signing the record of education. In the Administrator's absence, the Director of Nursing will answer questions regarding the education. Additionally, this education will be provided to new staff upon hire during orientation training and will be repeated to all staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager annually. Record of continuing education sheet to confirm their knowledge and understanding of the topic presented. The Director of Nursing will contact agency staff before their scheduled shift to review staff education regarding the prevention of contraband from entering the facility and the removal of contraband from resident possession. A binder with staff education will be kept at the front desk and agency staff will be required to read and sign to validate their understanding of the information presented in the binder. If agency nurses have any questions regarding the information presented in the staff education biner, they will be instructed to contact the Director of Nursing for clarification prior to signing the record of education. In the absence of the Director of Nursing, the Assistant Director of Nursing will review the education requirements and answer any questions for agency nurses. The facility has identified five staff members who are on a leave of absence/vacation. These staff members will be contacted by the Administrator to review staff education regarding the prevention of contraband from entering the facility and the removal of contraband from resident possession. The staff education will be placed in a binder at the front desk and must be reviewed and signed by the staff member before returning to work. The staff member will sign a record of education to validate their understanding of the information presented in the binder. If the staff have any questions regarding the education, they will be instructed to contact the Administrator before signing the record of education. In the Administrator's absence, the Director of Nursing will answer questions regarding the education. Additionally, this education will be provided to new staff upon hire during orientation training and will be repeated to all staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager annually. 2. A system to prevent residents with a history of substance abuse from introducing contraband into the facility or obtaining contraband in the facility will be achieved through staff education. Education will be provided by the Administrator to registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager. This education will review the facility's policy on Alcohol/Substance Use/Abuse updated on [DATE]. The education will review that Each resident (and/or representative) is informed that facility policy prohibits the use of alcohol without a doctor's order. Facility policy prohibits the use of illicit drugs. As a condition of residence, each person living in the facility acknowledges that he/she will not use alcohol or illicit drugs during residence in this building. Persons assessed with an active substance abuse problem are offered appropriate treatment and rehabilitative services. While this policy addresses illicit drugs and alcohol, the same standards and expectations are in place for persons with a prescription narcotic addiction. These individuals are also responsible for engaging in appropriate treatment to reduce/eliminate dependency on opioids. Persons returning from the community who present with signs and symptoms of intoxication will be evaluated by the nurse on duty or charge nurse. The nurse is responsible for assessing the person's physical condition and present behavior. The nurse will be responsible for contacting the attending physician (A.P.) if the resident is determined to be in need of medical attention and/or a decision is required regarding withholding prescribed medications. Documentation will be placed in the chart emphasizing signs/symptoms of intoxication/inebriation (such as smell of alcohol, behavior changes, balance/gait problems, appearance of the eyes, and change in speech pattern). Documentation should include the resident's own admission of alcohol/drug use. The facility reserves the right to have the person submit to blood/urine testing at any time if policy violation is suspected. Persons who are evaluated as medically unstable will be transferred for appropriate medical care. Follow-up interventions and treatment recommendations will be communicated to the resident/representative and documented in the medical record. Outside treatment sources will be utilized as appropriate. Residents with substance abuse disorders are expected to participate in acute/active treatment, sobriety counseling, or aftercare interventions, as appropriate to their personal situation. The facility has the right to implement money management interventions pursuant to federal law if substance abuse continues. Persons who continually jeopardize their health and the health and safety of others will be evaluated for involuntary discharge. Education will include instruction on how to identify which residents have a substance abuse disorder and how to locate resident-specific interventions to prevent them from obtaining contraband while in the facility. This information will be kept in binders at the nurse's stations. The binders will include a list of residents with substance abuse disorders and information on resident-centered interventions to prevent them from obtaining contraband while in the facility. These binders will be updated by social services weekly and with resident changes in condition. This education began on [DATE] and will be completed [DATE]. Upon completion of this education, staff will sign a record of continuing education to confirm their knowledge and understanding of the information presented. This education will be provided to new staff upon hire during orientation training and will be repeated to all staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager annually. The Director of Nursing will contact agency staff before their scheduled shift to review staff education regarding the prevention of residents with substance abuse disorders from introducing contraband into the facility or obtaining contraband in the facility. A binder with staff education will be kept at the front desk and agency staff will be required to read and sign to validate their understanding of the information presented in the binder. If agency nurses have any questions regarding the information presented in the staff education biner, they will be instructed to contact the Director of Nursing for clarification prior to signing the record of education. In the absence of the Director of Nursing, the Assistant Director of Nursing will review the education requirements and answer any questions for agency nurses. The facility has identified five staff members who are on a leave of absence/vacation. These staff members will be contacted by the Administrator to review staff education regarding the prevention of residents with substance abuse disorders from introducing contraband into the facility or obtaining contraband in the facility. The staff education will be placed in a binder at the front desk and must be reviewed and signed by the staff member before returning to work. The staff member will sign a record of education to validate their understanding of the information presented in the binder. If the staff have any questions regarding the education, they will be instructed to contact the Administrator before signing the record of education. In the Administrator's absence, the Director of Nursing will answer questions regarding the education. The procedure for developing resident-centered care plans to provide guidance to staff to prevent residents with a history of substance abuse from introducing contraband into the facility or obtaining contraband in the facility will be achieved through education provided by the Administrator to the Social Services department staff on the importance of identifying residents with substance abuse disorders and assessing their risk of introducing drugs/contraband and obtaining drugs/contraband while in the facility. This risk assessment is documented in the resident chart in the Social Service Initial Interview for SMI/Substance Abuse Disorder (SS) assessment. This risk assessment must be used by the social services staff to develop a resident-centered care plan to address the potential risks of the resident introducing drugs/contraband into the facility and obtaining contraband/drugs while in the facility. Care plan interventions will be based on the resident's personal risk factors and coping mechanisms and may include but are not limited to efforts outlined in the facility policy for Alcohol/Substance Use/Abuse such as outside treatment services, acute/active treatment, sobriety counseling, or aftercare interventions. The effectiveness of the care plan must be reviewed quarterly and with changes in condition and updated as indicated. A binder will be placed at each nurse's station with a list of residents with substance abuse disorders as well as information on the resident-centered interventions for preventing them from obtaining contraband while in the facility. These binders will be updated by the social services department weekly and with resident changes in condition. This education will begin on [DATE] and will be completed [DATE]. Upon completion of this education, social services staff will sign a record of continuing education to confirm their understanding and knowledge of the topics presented. This education will be presented to new hire social services staff upon hire and will be reviewed with all social services staff annually. Agency staff is not utilized in the social services department. There are currently no social services staff on leave of absence or vacation. There have been no updates to facility policies. 3. A system to supervise residents from obtaining contraband and from having or obtaining illicit drugs in the facility will be achieved through staff education. The Administrator will educate staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and business office manager on the facility standard for providing adequate supervision for residents with substance abuse disorders to prevent them from obtaining contraband/ drugs. This education includes a review of the facility policy for safety and supervision which focuses on ensuring a facility-oriented approach to safety to address risks for groups of residents including residents with substance abuse disorders/history. Education will discuss the importance of identifying safety risks and environmental hazards on an ongoing basis. Staff will be educated that resident supervision is a core component of resident safety and that the type and frequency of supervision are determined by the individual resident's needs. Staff must intervene immediately whenever an unfavorable event between residents, staff, or visitors is noticed. Staff must decrease safety hazards as much as possible and provide redirection when necessary. The education will review the facility's procedure for staff to

Based on interview and record review, the facility failed to prevent a resident from being physically abused by another resident. This failure affected one of three (R2) residents reviewed for abuse and resulted in R2 being transferred to local hospital and requiring treatment for 3cm long laceration under the left eye. Findings include: R2 is [AGE] years old and has resided at the facility since 2022, with past medical history of Flaccid hemiplegia affecting left nondominant side, calculus of gallbladder without cholecystitis without obstruction, gastritis unspecified without bleeding, hematemesis, essential primary hypertension, major depressive disorder, hypokalemia, unspecified convulsions, etc. 2/7/2024 at 1:50PM, R2 was observed in is room, awake and alert with some confusion, an old scar noted to the left side of head, but no discoloration noted on resident's face. At 2:30PM, surveyor approached the assigned nurse for the resident V4 (LPN), who stated that resident came back from the hospital about two weeks ago with sutures, but she is not sure if it has been removed. V4 and surveyor went to examine resident again and he stated, I don't have anything on my face now, but I now remember that I was hit in the face by another resident that lives across the hall, it happened in the dining room and no staff was around at the time, he hit me with an object that he tied around his hand and gave me a black eye. V4 stated that the other resident is R7, and is currently at the hospital. R7 is [AGE] years old with a known history of aggression and violet behavior. Review of medical record showed that R7 was sent to the hospital for evaluation 1/20/2024 for physical aggression towards another resident (R2), and there are several documentations of aggression towards staff and residents, and R7 not being able to be redirected by staff. R7 was given an involuntary discharge from the facility due to aggression and agitation towards staff and other residents. Facility reportable dated 1/26/2024 documented an alleged resident to resident altercation between R2 and R7 that occurred on 1/20/2024 at 4:30PM, the report concluded that abuse could not be substantiated due to lack of credible evidence. 2/8/2024 at 1:17PM, V1 (Administrator) said that she conducted the abuse investigation for R2 and R7, she did not interview either of the residents, she attempted to talk to R2, but he refused to talk to her. R7 was sent to the hospital and would not cooperate with interviews. V1 added that both residents did not have any physical contact and R2 did not have any injuries according to her investigation. Hospital record for R2 dated 1/20/2024 document the reason for visit / chief complaint as battery, patient presents to emergency room from nursing home after being attacked by another resident. Patient states he was hit all over his body, complains of headache but denies loss of consciousness. Under history and physical note, the same document states in part: patient is a [AGE] year-old man who lives in a nursing home, had an altercation with another resident, patient did not provoke the altercation . Patient had minor bruises and a cut that was sutured in the emergency room . Physical exam documented multiple bruises on the forehead and maxillary areas, patient had a laceration that is 3cm long under his left eye. Review of medical record showed the following documented in R2's nursing progress notes: 1/21/2024, V10 (RN) documented: patient noted to have discoloration to left eye with noted steri-strips patient states he can see out of his eye. 1/22/2024, V11 (LPN) documented: resident (R2) has 4 steri strips on laceration below his left eye and skin discoloration around his left eye, resident also has small discoloration to his forehead. 2/9/2024 at 10:11AM, V8 (Hospital Staff) said that she saw the resident when he was at the hospital, resident had some injuries but nothing life threatening, he was treated for minor injuries and admitted for observation. 2/9/2024 at 1:49PM, V10 (RN) said that she recalls resident, he was in the hospital about 3 weeks ago, V10 was told that another resident punched him or hit him in the face, resident had steri strip and discoloration to his left eye, V10 said that she does not know the name of the other resident, she was not present when it happened , it was reported to her by another nurse. 2/9/2024 at 1:55PM, V11 (LPN) said that she has worked at the facility for 7 years as a full-time staff, she is familiar with R2, he is alert and oriented, requires assist with transfers but a very nice person. V11 said that R2 was involved in an altercation with another resident, he was already in bed when she came to work on night shift, but she noted some steri strip and discoloration on resident's left eye. V11 said she believes the altercation was with R7 who was sent to the hospital and never came back as far as she knows. V11 said that R2 has never been aggressive with a staff or another resident. Abuse policy and procedure revised 1/4/2028 states in part, abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. IV Establishing a resident sensitive environment, this facility desires to prevent abuse, neglect, exploitation, mistreatment, and misappropriation of resident property by establishing a resident sensitive and resident secure environment.

Based on interview and record review facility failed to conduct skin assessments for a high risk alteration in skin integrity resident for 1 (R7) of 3 residents reviewed for quality of care in the sample of 9. This failure resulted in R7 sustaining a gangrenous toe requiring amputation and potential amputation of his entire leg. Finding include: R7 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Schizophrenia; Peripheral Vascular Disease; History of Falling; and Type 2 Diabetes Mellitus. According to R7's MDS (Minimum Data Set) assessment dated [DATE] under section C, R7 has BIMS (Brief Interview of Mental Status) score of 13 indicating intact cognition. R7's skin integrity care plan dated 08/10/2020 reads in part, (R7) has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to type 2 diabetes; Interventions: Skin will be checked during routine care on a daily basis and during the weekly/Bi-weekly bath or shower schedule; Any skin integrity issues/concerns will be conveyed to the Charge Nurse for further evaluation and/or treatment changes/new interventions and the MD will be called PRN; Monitor for S/S and/or complaints of pain. Provide medication as indicated. Complete Pain review as indicated. Wound and Skin Alteration Review dated 06/23/2023 reads in part, L (left) digit 1 Trauma; Nonstagable; wound size 05(cm)x0.5(cm)x0(cm). Wound and Skin Alteration Review dated 06/30/2023 does not address left digit wound. Admission/Readmission Skin Integrity Review dated 09/07/2023 reads in part, LT (Left) Great Toe; Black Scab/Swollen. On 01/17/2024 at 3:00 PM, Surveyor requested from V1 (Administrator) and V3 (Assistant Director of Nursing) all R7's skin assessments between 07/2023 - 09/08/2023, no other skin assessments available upon request. On 01/18/2024 at 11:45 AM, Surveyor requested from V2 (Director of Nursing) all R7's bath and shower sheets between 07/2023 - 09/08/2023, bath and shower sheets incomplete or indicating R7 refused. Progress note dated 09/02/2023 at 1:01 PM written by V10 (Registered Nurse) reads in part,(R7) extremely lethargic BS (blood sugar) 31 BP (blood pressure) 89/51, R7 with slurred speech, sugar water given, repeat blood sugar 51 repeat BP 90/50, R7 with slurred speech, 911. (R7) being transported to (the local) hospital. On 01/17/2024 at 11:57 AM, Surveyor interviewed V10 (RN) who related the following in summary: On 09/02/2024 around 1:00 PM, I noticed R7 behaving a little odd. I lifted the covers, thinking maybe he was incontinent and that's when I noticed that R7's big toe was discolored. I wasn't sure if it was from wound care treatment, the skin was just discolored, or it was from infection. I checked R7's blood sugar, it was 31. When I checked it around 11:35 AM, it was 95 and I held his insulin at that time. I gave sugar water right away, notified physician, and sent him to the emergency room via 911. This blood sugar drop was somewhat unusual for R7, it's never happened before. R7's cognitive state was enough to express his needs or concerns. On 01/17/2024 at 3:12 PM, Surveyor interviewed V13 (Certified Nursing Assistant) who related the following in summary: R7 complained of his toe pain. I did see bandage around one of his toes after he returned from the hospital in June 2023, but I don't remember which toe. R7's pain assessment for July 2023 and August 2023 read pain to be at 0. Pain assessment dated [DATE] and 09/03/2023 read pain to be at 6. On 01/18/2024 at 10:46 AM, Surveyor interviewed V14 (Wound Coordinator for corporation) who related the following in summary: I'm familiar with R7, I worked with him back in 2021/2022. R7 had a wound on his left great toe. It was very small, superficial skin graft was done, and the toe healed back at that time. R7 had diabetes, diabetic residents are under increased risk for wound development due to decreased circulation. Gangrene is black, necrotic tissue, it can also appear discolored or green. Gangrenous toe may develop in 24-48 hours, depending on resident's comorbidities. Blood sugar drop in a diabetic resident can be related to gangrenous toe. Developing gangrenous toe is a severe complication. On 01/18/2024 at 11:10 AM, Surveyor interviewed V15 (Wound Doctor for corporation) who related the following in summary: I took care of R7 until 06/30/2023. R7 had a wound on his left great toe that was resolved on 06/30/2023, and there was no need to see him after that. The facility didn't report any new wounds for R7 until he was discharged from the facility (09/08/2023). It doesn't take a lot of time to develop a gangrenous toe. I cannot tell if R7's blood sugar drop to 31 was directly connected to the gangrenous toe unless there was an infection. The stage of R7's toe was emergent. On 01/18/2024 at 11:30 AM, Surveyor interviewed V11 (Registered Nurse) who related the following in summary: I am a regular nurse on the second floor, where R7 resided, for the past 3 years. R7 had reoccurring wound on his left great toe, but I haven't noticed any wounds on R7's left toe between July 2023 - 09/08/2023 (until R7's discharge). Skin assessment should be done by treatment/wound care nurse. Also, skin is checked with showers. Floor nurses do skin assessment upon admission. I don't know who should do weekly skin assessment when it's indicated in residents' care plan. I think nurses do assessment only when there are concerns expressed by the resident or when CNA notices something. Floor nurses do rounds upon the beginning of the shift but residents are dressed, so assessment is limited and we don't see everything. I think there should be someone in charge of thorough daily skin assessments. On 01/18/2024 at 11:47 AM, Surveyor interviewed V2 (Director of Nursing) who related the following in summary: During daily assessments, nurses should be checking vital signs, pain, any new changes of condition upon beginning of their shift. Head to toe assessment is done with any change of condition, but it's not done regularly. The skin assessment should be completed on residents' shower days and at the time of any change of condition, or upon resident or CNA reporting concerns. Wound care nurse should be doing daily skin assessment with treatment and routine weekly skin assessment. Hospital record dated 09/02/2023 reads in part, Reason for visit: Foot Ulcer; ER Chief Complaint: (blood) glucose 31; big toe black and painful for 1 month per (R7); Consult physician: Black toe/poss osteomyelitis. Hospital record dated 09/08/2023 reads in part, (R7) presented for an elective left common femoral endarterectomy, left profundoplasty, and left external iliac stenting, secondary to dry gangrene of the left great toe with SFA (superficial femoral artery) occlusion and peripheral arterial disease. (R7) has left great toe that is gangrenous. When asked how long it was present, he says he doesn't remember. When pressed, he thinks it might have been present for the last couple of months. Plan to attempt hallux amputation for salvage of LLE (left lower extremity). Still may require BKA (below knee amputation) if slow heeling, infection, progressive gangrene noted LLE (left lower extremity). Wound policy dated 07/2022 reads in part, Purpose: To promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. Residents should be examined thoroughly at least weekly by a licensed nurse to identify existing pressure ulcers. Nurse Aids should complete a shower sheet on all residents when they are bathed or showered and given to the charge nurse.

Based on observation, interview, and record review the facility failed to identify pressure injuries prior to wounds becoming unstageable and failed to ensure residents with unstageable wounds received wound assessments, monitoring, and treatments for 2 of 3 residents (R6, R14) reviewed for pressure injuries in the sample of 14. These failures resulted in R6 developing 6 new pressure injuries, and two existing unstageable pressure injuries with worsening and decline of the wounds. These failures also resulted in R14 developing one new pressure injury. The findings include: 1. On 1/6/23 at 9:35 AM, R6 was in bed flat on his back with his heels resting on the mattress. R6 was alert and oriented and said he was admitted to the facility in October due to a car accident. R6 said he is unable to walk and is bedridden due the car accident and history of back surgeries. R6 said due to pain he is unable to turn himself in bed and requires assistance from staff to turn. R6 said he has bed sores on his bottom that he didn't come into the facility with. R6 said he has nerve like pain in his feet, and pain in his back/bottom area. R6 said he had a dressing on his bottom, but he was not sure how long ago it was changed. R6 said the wound doctor comes in but has not for a month or so. R6 said he has gone a week or so without a dressing change and thinks the last dressing change was around mid-December. R6 said he can't recall anyone measuring his wounds. R6's Initial Skin Alteration Review dated 10/18/22 shows R6 was admitted on [DATE] and has one partial thickness wound classified as a skin tear/abrasion on his right trochanter. R6's Wound and Skin Alteration Review dated 12/8/22 shows R6 has a new wound, right lower back, unstageable pressure injury measuring 3 x 3.5 x 0 cm, with 100% black eschar wound bed with no drainage. R6's Wound and Skin Alteration Review dated 12/8/22 shows R6 has a new wound, sacrum, unstageable pressure injury measuring 8 x 6 x 0 cm, 50 % black eschar wound bed with regular edges and scant drainage with no odor. R6's Wound Physician Notes dated 12/8/22 shows R6 has unstageable pressure wound to right lower back, measures 3 x 3.5 x 0 cm. Wound is 100% necrotic tissue with mild serous exudate; unstageable pressure wound to sacrum, measures 8 x 6 x 0 cm. Wound is 50% necrotic with mild serous exudate .recommend silvadene and dry dressing daily and as needed .Due to patient's multiple comorbidities he is at high risk for developing new and worsening wounds. R6's Wound and Skin Alteration Review dated 12/15/22 (one week later) shows R6's right lower back unstageable pressure wound measures 3 x 3.1 x 0 cm, with 100% black eschar wound bed and scant serosanguinous (clear bloody) drainage. R6's Wound and Skin Alteration Review dated 12/15/22 (one week later) shows R6's sacral unstageable pressure wound measures 8 x 6 x 0 cm, with 60% black eschar wound bed with irregular edges and moderate (25%-75%) serosanguinous (clear bloody) and sanguineous (bloody) drainage. R6's Wound Physician Notes dated 12/15/22 shows R6 has unstageable pressure wound to right lower back, measures 3 x 3.1 x 0 cm. Wound is 100% necrotic tissue with mild serous exudate; unstageable pressure wound to sacrum, measures 8 x 6 x 0 cm. Wound is 60% necrotic with mild serous exudate .recommend silvadene and dry dressing daily and as needed .Due to patient's multiple comorbidities he is at high risk for developing new and worsening wounds. R6's wound assessments showed there were no assessments performed after 12/15/22 (22 days ago). On 1/6/23 at 10:34 AM, V8 (Licensed Practical Nurse/LPN) said she was the nurse assigned for R6 and was not sure of who had wounds on the floor, who does dressings changes, or if the facility had a wound nurse. On 1/6/23 at 10:51 AM, V14 (Registered Nurse/RN) said there is no wound nurse currently, the wound nurse left about a month ago. V14 said the floor nurses should be doing the dressing changes and wound assessments. V14 said she hasn't seen the wound doctor since the wound nurse left. On 1/6/23 at 11:10 AM, V3 (Assistant Administrator) said there is no wound nurse since the last one left. V3 said V16 (Corporate RN) was handling treatments but she is not in the facility now. V3 said there were no other skin assessments for R6 after 12/15/22 (22 days ago). V3 said she was not sure when the wound doctor came to the facility and there were no other wound doctor notes. On 1/6/23 at 12:02 PM, V7 and V10 (Certified Nursing Assistants/CNA) lowered R6's brief and assisted R6 to roll to his left side in the bed. R6 had a gauze type dressing saturated with purulent drainage on his bottom which began to drain in a stream down R6's back, a blood saturated gauze type dressing to R6's right lower back, and a gauze type dressing on R6's lower left leg that was saturated with blood which had saturated the sheet on the bed and formed a pool of blood on the mattress. R6's right and left heel contained large dark purple areas, and R6 had a round red open area over a vertebra on the middle of his back. V2 (Director of Nursing/DON) stated These dressings have not been changed in a while; that looks like pus running out of the sacral wound. I only saw treatments for 3 wounds for R6. I'm not aware of any new wounds. V2 removed the dressings on R6's lower back and sacral area. The sacral area had 4 separate wounds, two larger areas and two smaller round areas. The wound on the top right of the sacral area was filled with yellow/brown colored slough and continued to drain purulent pus like fluid. The wound on the top left area and the two smaller round areas on the bottom left and bottom right side had exposed white areas (resembling tendon) in the wound beds. The wound on R6's right lower back was red, deep, and appeared to have undermining and tunneling. V2 stated Yes I see that white area. I'm not sure if that's tendon or bone. V2 said she had not measured wounds in a while and began to measure R6's wounds: right lower back 2 cm x 2.5 cm, deep, red, with undermining and possible tunneling right upper sacral wound 3.5 x 2.5 cm, filled with slough and draining purulent pus left upper sacral wound 5 x 2.5 cm, white tendon like area left lower sacral wound .5 x .75 cm, white tendon like area right lower sacral wound .5 x .5 cm, white tendon like area low middle back wound .8 x 5 cm, open pink area left heel 2.5 x 1.5 cm, dark purple, irregular edges right heel 4 x 6 cm, dark purple, irregular edges V2 did not measure depth of any of the wounds. V2 cleansed the wounds and applied a dressing to all the wounds. V2 stated I had no idea about these wounds. We don't have a wound nurse and we need one. I will have to call the doctor and get an antibiotic. The one wound looks infected. On 1/6/23 at 1:21 PM, V15 (Nurse Practitioner/NP) said she was aware that R6 had some wounds and was referred to the wound doctor. V15 said she had never spoke to the wound doctor and was not aware of any new wounds for R6. V15 stated I would expect them (facility staff) to contact the wound doctor for any new wounds. I don't get involved with wounds. R6's Treatment Administration Record (TAR) for December of 2022 shows treatment orders to cleanse with normal saline and apply silvadene and cover with dry dressing daily and as needed for R6's sacrum and right lower back. The last treatment for R6's sacral and right lower back wounds was signed off as completed on 12/23/22, and no treatments have been signed off for January of 2023 (14 days no dressing changes). On 1/6/23 at 1:24 PM, V16 (Corporate Nurse) said she had been assisting with wounds since the wound nurse left, but she has been gone for two weeks. V16 said she left on 12/22/22. V16 said she was assessing wounds weekly (Thursdays) including measuring and changing treatment orders as needed. V16 said she would round with the wound NP weekly. V16 said wounds should be assessed weekly in order to determine if the wound is healing or declining, and the assessments include measuring the wounds. V16 said residents' skin and wounds should be assessed daily and at any interaction with the resident during care. V16 said any skin alterations should be reported to the nurse. V16 said treatments should be provided as ordered to keep the wound clean, prevent infection, and to promote a healing environment. V16 said she was aware of R6's unstageable pressure to the sacrum and the right back. V16 said skin assessments are done by staff during bed baths or showers, and there is an assigned skin assessment task for the RN to do. V16 said if the wound nurse is not in the facility the floor nurses are supposed to do the treatments as ordered and weekly skin assessments. V16 said she told V18 (Wound NP) that she was going to be out of the facility but was not sure why V18 was not coming to the facility while she (V16) was gone. On 1/6/23 at 2:23 PM, V6 (Assistant Administrator) said she was not aware that no one was monitoring and assessing wounds since V16 has been gone, and she (V6) was not aware that the wound doctor was not coming to the facility. R6's Care Plan dated 10/17/22 shows R6 is at increased risk for alteration in skin integrity related to diagnosis of fracture of the left acetabulum, vertebrogenic low back pain, pain in left hip .R6 has shearing to the right hip, old surgical scar to the lower back .feet and heels are intact. Interventions: any new skin integrity issues/concerns will be conveyed to charge nurse, weekly measurements and documentation, administer wound care (treatments) per physician orders. The same care plan shows initiated on 12/8/22 resident with unstageable wound to right lower back and sacrum with interventions: consult wound physician, weekly wound measurements, skin will be checked during routine care, provide treatment as per physician order. The facility's undated Pressure Ulcer Prevention Policy shows Purpose: to prevent and treat pressure sores .inspect the skin several times daily during bathing, hygiene, and repositioning measures. New or worsened skin concerns should be reported immediately to the nurse for follow up treatment .NOTE: Daily skin checks will be done by CNAs during routine care. 2. On 1/6/23 at 11:15 AM, R14 was in bed with the left side of the bed against the wall. R14's left leg was slightly bent at the knee touching the wall. There were no pillows or padding between the wall and R14's knee. R14 stated I have a pressure sore of my left knee. I got it from my left knee being scrunched and against the wall. I'm paralyzed and don't realize it. They just changed the dressing now. It's supposed to be every night. Lately it's been more like every other night. The wound doctor came once, and the wound NP would come weekly but I haven't seen her in a while. I'm not sure if they measure it; I've just seen them look at it. R14's Treatment Nurse Initial Skin Alteration Review dated 11/18/22 shows R14 has a new facility acquired unstageable pressure injury to her left knee. The wound measures 1.5 x 1.8 x 0 cm and is 100% necrotic. On 1/6/23 at 1:32 PM, V16 (Corporate RN) said R14 was found to have a pressure to her left knee caused by her knee being against the wall. V16 said Treatment orders are in place, and we moved her bed slightly away from the wall so there is space between her knee and the wall. V16 said R14 should have weekly skin assessments for the wound. R14's most recent Wound and Skin Alteration Review of the left knee pressure injury is dated 12/15/22 (22 days ago). On 1/6/23 at 2:23 PM, V6 (Assistant Administrator) said there were no more skin assessments for R14's left knee; the 12/15/22 was the most recent assessment. R14's Care Plan dated 10/18/22 shows skin will be checked during routine care.

Based on interview and record review the facility neglected to follow their policy and procedure by not providing wound care for R6's unstageable pressure injuries to his sacrum and right lower back. This resulted in R6 not receiving wound care for 14 days and subsequently developing 6 new pressure injuries and 2 existing unstageable pressure injuries with worsening and decline of the wounds. This applies to 1 of 3 residents (R6) reviewed for neglect in the sample of 14. The findings include The facility's Abuse Prevention Program Facility Policy and Procedure dated 11/28/17 shows Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents cause physical harm, pain, or mental anguish. The facility's undated Pressure Ulcer Prevention Policy shows Purpose: to prevent and treat pressure sores. R6's Treatment Administration Record (TAR) for December of 2022 shows treatment orders to cleanse with normal saline and apply silvadene and cover with dry dressing daily and as needed for R6's sacrum and right lower back. The last treatment for R6's sacral and right lower back wounds was signed off as completed on 12/23/22 and no treatments have been signed off for January of 2023 (14 days no dressing changes). On 1/6/23 at 12:02 PM, V7 and V10 (Certified Nursing Assistants/CNA) lowered R6's brief and assisted R6 to roll to his left side in the bed. R6 had a gauze type dressing saturated with purulent drainage on his bottom which began to drain in a stream down R6's back, a blood saturated gauze type dressing to R6's right lower back, and a gauze type dressing on R6's lower left leg that was saturated with blood which had saturated the sheet on the bed and formed a pool of blood on the mattress. R6's right and left heel contained large dark purple areas and R6 had a round red open area over a vertebra on the middle of his back. V2 (Director of Nursing) stated These dressings have not been changed in a while; that looks like pus running out of the sacral wound. I only saw treatments for 3 wounds for R6. I'm not aware of any new wounds. V2 removed the dressings on R6's lower back and sacral area. The sacral area had 4 separate wounds, two larger areas and two smaller round areas. The wound on the top right of the sacral area was filled with yellow/brown colored slough and continued to drain purulent pus like fluid. The wound on the top left area and the two smaller round areas on the bottom left and bottom right side had exposed white areas (resembling tendon) in the wound beds. The wound on R6's right lower back was red, deep, and appeared to have undermining and tunneling. V2 stated Yes I see that white area. I'm not sure if that's tendon or bone. V2 said she had not measured wounds in a while and began to measure R6's wounds: right lower back 2 cm x 2.5 cm, deep, red, with undermining and possible tunneling right upper sacral wound 3.5 x 2.5 cm, filled with slough and draining purulent pus left upper sacral wound 5 x 2.5 cm, white tendon like area left lower sacral wound .5 x .75 cm, white tendon like area right lower sacral wound .5 x .5 cm, white tendon like area low middle back wound .8 x 5 cm, open pink area left heel 2.5 x 1.5 cm, dark purple, irregular edges right heel 4 x 6 cm, dark purple, irregular edges V2 did not measure depth of any of the wounds. V2 cleansed the wounds and applied a dressing to all the wounds. V2 stated I had no idea about these wounds. We don't have a wound nurse and we need one. I will have to call the doctor and get an antibiotic; the one wound looks infected. On 1/6/23 at 11:10 AM, V3 (Assistant Administrator) said there is no wound nurse since the last one left. V3 said V16 (Corporate RN) was handling treatments but she was not here (in the facility) now. On 1/6/23 at 1:24 PM, V16 (Corporate Nurse) said she had been assisting with wounds since the wound nurse left, but she has been gone for two weeks. V16 said she left on 12/22/22. V16 said treatments should be provided as ordered to keep the wound clean, prevent infection, and to promote a healing environment. V16 said if the wound nurse is not in the facility the floor nurses are supposed to do the treatments as ordered and weekly skin assessments. V16 said she told V18 (Wound Nurse Practitioner/NP) that she was going to be out of the facility but was not sure why she was not coming to the facility while she was gone. On 1/6/23 at 2:23 PM, V6 (Assistant Administrator) said she was not aware that no one was monitoring and assessing R6's wounds or providing treatment since V16 had been gone and she was not aware that the wound doctor was not coming to the facility. V6 said that Abuse Policy provided was the most current and there were no additional pages.

Based on interviews and record reviews, the facility failed to have adequate supervision and interventions in place to keep residents assessed to be at risk for falls, free from injury. These failures applied to two (R133 and R302) of two residents reviewed for accidents and supervision and resulted in (R133) having a fall with head injury that required three sutures and resulted in R302 having an accident which resulted in a mid collar bone fracture. Findings include: R133 is a [AGE] year old male who was admitted to the facility 1/27/22 with diagnoses that include Dementia, cognitive communication deficit, lack of coordination and anxiety disorder. According to Minimum Data Set assessment dated [DATE], R133 has a BIMS of 03 indicating significant cognitive dysfunction. R133 also has a functional status requiring supervision by staff for walking. Fall incident report dated 9/23/22 indicated that R133 lost his balance and fell on his left side while trying to walk the hallway. R133 sustained a bleeding injury to the back of the head, was in visible pain and was sent to the local hospital for evaluation. R133 returned to the facility with 3 staples to the back of the scalp. On 09/27/22 at 11:25 AM R133 was observed in a reclining chair in front of the nurses station. R133 moved legs over the arm of the chair and got out of the chair standing. Two staff rushed to put R133 back in the chair. At 12:15 PM V7 (LPN) said, R133 is a fall risk and he keeps getting up. He recently had a fall I believe Friday or Saturday. He had to go to the hospital and came back with three staples to the back of his head from a laceration. He is able to walk and he sometimes goes into other rooms to walk because he has bad dementia. 09/29/22 11:11 AM V3 DON (Director of Nursing) said, I'm not sure if R133 has fallen in the past. I would not have expected the nursing staff to leave him unsupervised. Usually on the second floor the CNAs are doing a lot, so sometimes they put residents at the nursing station for close supervision. I would expect for the staff to always watch the residents while sitting at the nurse's station. On 9/29/22 at 10:11 AM V1 Administrator said, I am still investigating the incident. What I understand is that he slept most of the day, woke up sometime in the evening went out into the hallway and ended up falling. He came out of his room and was walking with socks on and no shoes. On 09/29/22 at 10:52 AM V33 Assistant Director of Social Services said, at the time R133 fell , R133 was moved to a different room because we were rearranging for isolation. While the CNAs were preparing his room and bed, he was in a chair outside of the room. I was pushing a resident in the wheelchair in the hallway when I saw him fall. It was noticed that R133 was weaker than normal because he was having trouble walking and not at baseline. He also has dementia and doesn't know what's going on most of the time. I and saw him falling slow motion and was pushing another resident so I couldn't get to him fast enough to prevent him from falling. We were just walking by and staff were busy doing other things. There was no other staff in the immediate area to assist and prevent him from falling. He fell and hit the back of his head with some bleeding. The CNAs helped him back to the chair and called the nurse. Care plan for falls initiated 5/17/22 and updated 9/26/22 states in part that R133 is at risk for falls related to comorbidities including antianxiety, dementia and lack of coordination. Interventions reviewed. Facility Fall policy reviewed which states in part, Foot wear will be monitored to ensure the resident has proper fitting shoes or footwear is non-skid. R302 is a [AGE] year old female with a diagnoses history upon admission 05/23/3033 of Dementia with Behavioral Disturbance, Multiple Fractures, History of Falling, and [CONDITION(S)]. R302's admission fall assessment dated [DATE] documents she was at low risk for falls with a score of 1.0. R302's admission referral packet dated 05/12/2022 documents she had a history of falls and fractures, fell in the bathroom while at home, exhibited increased restlessness and agitation. R302's most current care plan for falls initiated 05/24/2022 documents she is at risk for falls related to Poly-pharmacy, History of Falls, Cognitive Impairments, Communication Impairment, Decreased Safety Awareness, Impulsiveness with attempts to stand or self-transfer without assistance from staff despite repeated direction/education, Use of [CONDITION(S)] Medications, Behavioral Problems, [CONDITION(S)] diagnosis with interventions including: Anticipate and meet individual needs of the resident, complete the Fall Risk Review per the facility protocol. R302's admission Minimum Data Set, dated dated dated [DATE] documents that she required supervision and one person physical assistance with transfers, movements inside and outside the room, toilet use and requires limited one person physical assistance with walking in room, walking on and off unit, dressing, personal hygiene, and walking in corridors; was always incontinent of bowel and bladder. R302's initial incident investigation report dated 09/12/2022 documents R302 experienced an injury as a result of stumbling while on her way to the washroom in her room and bumping her arm on the door. R302 and her roommate denied that she had fallen. R302 had reported to the nurse that she was having right shoulder pain, a body assessment was conducted and she was noted with bruising to her right collar bone. An x-ray was completed and revealed R302 with a fracture to the mid collar bone and noted she had a history of a fracture to the right collar bone with hardware in place. R302 was sent to the hospital and upon her return care plans and assessments will be updated. The root cause is an accident caused by stumbling into the door frame and there was no credible evidence of abuse; V40 (Licensed Practical Nurse) was interviewed and stated she went to R302's room after receiving a report from V41 (Certified Nursing Assistant) that R302 had a bruise on her shoulder and observed R302 with a bruise. V40 reported R302 told her she bumped her arm on the door when she got up from bed and transferred herself into the wheelchair and she rolled toward the door; once at the door she stood up and showed how R302 hit the door and the bruise matched up with the edge of the door. R302's progress note created by V40 (Licensed Practical Nurse) dated 9/11/2022 18:38 documents CNA reported to writer that resident has a bruise to right shoulder. Writer asked what happened and she stated that she bumped her shoulder on the bathroom door handle while ambulating. Writer measured resident up to the door handle. The door handle is the approximate height to resident shoulder. Resident complained of pain rating at a 5. Writer received a telephone order for a stat X-Ray of the right shoulder. On 09/29/22 at 9:51 AM V1 (Administrator/RN) stated the facility initiates a fall assessment during the admission process, a referral packet is reviewed for history of falls and care plan is updated with interventions. V1 stated R302's current care plan does not reflect a root cause analysis or personalized interventions based on past falls. V1 stated although R302's incident was not a fall it was an accident. V1 stated stumbling from one plane to the next such as what occurred during R302's incident is an example of a risk factor for falling. V1 stated staff reported R302 walked independently and would need some redirection but she was alert and could answer and voice her needs. V1 stated based on R302's current care plan she was at risk for the incident she experienced. V1 stated there should have been more interventions in place for R302. V1 stated care plans should be personalized. 09/29/22 at 4:15 PM V1 (Administrator) stated R302's fall risk interventions could have included 15-30 minute checks and being placed closer to the nurses station for closer supervision. The facility's Care Plan Policy reviewed 09/29/2022 states: All residents will have comprehensive assessments and an individualized plan of care developed to assist them in achieving and maintaining their optimal status. The interdisciplinary team develops a comprehensive, individualized care plan based on interdisciplinary team assessments and comprehensive assessment of the resident prior to the care conference within 21 days of admission. Concerns, problems, needs, and/or strengths are listed based on resident's individual needs. Physician's orders and personal care and nursing needs are also listed based upon comprehensive assessments. The facility's Fall Prevention Program Policy reviewed 09/29/2022 states: It is the policy of this facility to have a fall prevention program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The Fall Prevention Program includes the following components: Use and implementation of professional standards of practice Care plan incorporates: Preventative measures. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Residents at risk of falling will be assisted with toileting needs in accordance with voiding patterns identified during the assessment process and as addressed on the plan of care.

Based on interview and record review, the facility neglected to provide services for the appropriate discharge of a dementia resident in accordance to their discharge policy, neglected to ensure the receiving facility could meet the medical and psychosocial needs of the resident, neglected to adequately communicate with the receiving facility, about a resident's pending discharge to confirm the residents acceptance to that facility and failed to complete discharge and transfer documentation for the receiving facility to determine residents acceptance prior to discharge, This applies to 1 of 3 residents (R1) reviewed for discharge and transfer. As a result of the facility's lack to provide adequate services for discharging a resident, R1 arrived to veteran's acute care facility without a bed available and ultimately was discharged to a veteran's homeless shelter which could not meet R1's physical, mental and psychological needs. This put R1 at an immediate risk for abuse, physical and/or psychosocial harm. This was identified as an Immediate Jeopardy situation that began on 11/16/21 and was removed on 12/15/21. V1 (Administrator) was informed of the Immediate Jeopardy on 12/10/21 at 1:05PM. However, the deficiency remains at a level 2 harm until the facility can evaluate the effectiveness of the implementation of their removal plan. Findings include: According to a face sheet, R1 was admitted to the facility on [DATE]. R1 is a [AGE] year-old resident with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Care Plan dated 8/19/21 documents R1 is at risk for increasing confusion secondary to dementia. R1 also has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An intervention is documented as reality orientation as needed. The Care Plan dated 8/23/21 documents R1 is at risk for abuse due to medical and psychological diagnosis. The Care Plan dated 8/23/21 documents R1 is unable to access community independently due to medical issues and ambulation. The Care Plan dated 8/23/21 documents R1 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan dated 8/24/21 documents R1 expressed a desire to be discharged to the community. R1 was given a reality orientation regarding R1 needing assistance and R1 agreed to be discharged to another nursing facility or back to the VA. An intervention is documented as review the resident's medical record including medications and treatment recommendations. Discuss the resident's abilities and needs to the nurse and attending physician to determine what services the resident will need in the community. R1's Minimum Data Set (MDS) assessment dated [DATE] Section C documents: R1 does have a behavior of disorganized thinking where the severity comes and goes. The MDS Section E documents: R1 does have a behavior of delusions. The MDS Section G: documents R1 needs a two-person physical assist with bed mobility, transfer, walk in room, walk in corridor, locomotion on unit, local motion off unit, dressing, toilet use, and personal hygiene. R1 uses a wheelchair. The MDS Section I documents: R1 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Elopement Risk Review dated 10/6/21 documents R1 is not at risk for elopement at this time however R1 does have a history of wandering outside of previous nursing facility. There are signs of compromised delusional capacity and substantially impaired judgment and/or physical status limitations that would place the resident at risk in the community. The Community Survival Skills assessment dated [DATE] documents R1 does not appear to be capable of unsupervised outside past privilege at this time due to R1 not being able to move/navigate/negotiate safely on community streets and R1 does not know the facility address, location, and how to contact the facility in an emergency. 2. In determining what services were documented regarding R1's discharge the following records were reviewed: R1's Social Service note dated 11/9/21 documents R1 requested to be discharged to a VA (Veteran Affairs) facility but contact was not able to be made with anyone at the facility. A Social Service note dated 11/12/21 documents social services contacted the admission department at the VA facility and was informed the VA facility is a hospital not a Skilled Nursing facility. R1 is currently not seeking admission to a hospital. A Discharge note dated 11/16/21 at 9:31AM documents R1 will be discharged to the VA facility in the northern part of the city. R1 was registered into the facility/hospital by the admissions department and will be discharged with services in place. The admissions department took R1's information and found R1 in the system from a previous residency. R1 was made aware of the discharge and the interdisciplinary team was made aware of the discharge plan as well. A Discharge Summary Progress note at 11:03 AM dated 11/16/21 documents R1 was discharged to the VA facility as anticipated. R1 denied needing any services in place due to the VA facility having services available. A Discharge Summary progress note dated 11/16/21 at 3:56 PM documents the transportation company contacted social services upon arrival to the VA facility. The transportation company informed social services that there had been no bed available for a R1 and was not able to find R1 in their computer. Social services then contacted the VA facility and was told there was a conversation with staff from the VA facility but no other information is provided. R1 refused to return to the facility and an employee informed social services R1 would be taken over to the walk-in homeless center to which R1 agreed. A Social Service note dated 11/17/21 documents R1 was discharged to VA housing placement. Staff spoke with several representatives from the VA facility regarding this discharge and R1 being accepted as an appropriate placement. Social services explained to staff at the VA facility that there must have been a miscommunication on their part because R1 was provided a discharge date . The Discharge Instructions dated 11/12/21 document R1 will discharge with no services or referrals necessary. R1 is documented as being independent for dressing/grooming, transfer, and ambulation/mobility. 3. In determining what communication the facility's staff had with the receiving facility in which R1 was to be discharged to the following record review and interviews were conducted: The VA Facility Hospital Records dated 11/16/21 documented: R1 was brought to the emergency room from a nursing home where R1 has been discharged . R1 does not want to go back to this nursing home and does not want to go to any nursing home but does not have any other plan and is homeless at this point. When asked why he came to the VA facility today R1 responded I told them to bring me here because I wanted to check the place out. It has been a while. R1 is alert and oriented to place in time but does not make safe and logical decisions when it comes to discussing R1's current situation and medical issues. R1 is noted with sort of flight of ideas and refers to seeing things with you not correlate. R1 says R1 wants to go get a car which is parked somewhere for past many months and then R1 says R1 does not have a key or a driver's license. There is no specific complaint at this point. The admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Social services came to evaluate R1 and are working on various options but currently recommend to admit to the medical floor in the hospital until further arrangements are made. R1 states he is taking blood pressure medication but cannot recall what it is or when it was taken. A review of previous records document R1 is on and antihypertensive medication from a note in 02/2021. No other paperwork was noted with R1. A medication reconciliation was not able to be completed. On 11/30/21 at 1:11PM, V17 (VA facility Admissions) stated, When people call here, I get them registered for care. There are registered for primary care appointments. We do have like a long-term area here and a homeless area but I don't register anyone for that. If they were trying to get over there, I would transfer them to that department. You have to be eligible for those areas though. I don't remember anyone by that name (R1) but if I did register them it wasn't for long term care. I don't remember talking to anyone from that facility. On 12/1/21 at 11:49AM, V13 (Patient Advocate) stated, On November 16th, R1 showed up with a transporter at the main entrance and asked where to go. The transporter told me the facility told the transporter to just drop R1 off here. I called V12 (PRSC/ psychiatric rehabilitative service coordinator) and V12 had no idea where R1 was supposed to go. V12 told me R1 facilitated the discharge by himself. V12 was basically blaming R1 for not knowing where R1 should be. V12 told me R1 called registration and they registered R1. I explained to V12 that was only for primary care and to find a doctor not for any admission here. No one over there confirmed where R1 was going. They just sent R1 here. R1 then refused to go back so I sent them over to the emergency room to get a place to stay. On 12/1/21 at 3:40PM, V15 (VA facility Social Worker) stated, R1 called me at the end of October, November 3rd, and November 5th. I spoke with R1 on the 5th and R1 reported wanting new placement. I suggested to R1 to go through the facility he was at currently and we couldn't help R1 because R1 is not currently homeless. I spoke with V5 (Social Services Director) also that day. I told V5 R1 was interested in finding new placement but there was no mention of R1 coming here. V5 described R1 as having dementia and Alzheimer's, and R1 thought he could physically do more than he was capable. I explained to V5 due to R1's war wounds not being severe enough, R1 could not qualify for our long-term program here. I also explained for the homeless shelter R1 was not capable to be admitted because R1 was in a wheelchair. We do more assisted living placements. We don't have an actual shelter here. There are no nurses or other staff to care for people here. It's just an office. I wrote all this in my note on the 5th when I spoke with V5. I know R1 registered with V17 from admissions. V17 told R1, he was all set to come and R1 was set to come for primary care. R1 has a dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. In determining what assessment and services were provided to assist R1 with a desired discharge the following interviews were conducted with the facility's staff members: On 11/30/21 at 1:31PM, V12 (PRSC) stated, The resident came up to me and told me he wanted to be discharged to that (VA) facility. R1 called on his own phone and I listened in and I was asking questions too. They told us ok that R1 was registered and R1 could come anytime. I never seen a discharge like that before. R1 set up his own transportation and left that same day. When R1 got there, they acted like they didn't know who R1 was. R1 refused to come back then and R1 was taken to the homeless shelter, I think. Normally, we send over paperwork they need to the facility and someone comes out to assess them or talk to them. They are accepted and then they give us a room where they are going and then they transfer over. We didn't fax anything over because they said they had R1 in the system already. R1 had been there before so I thought R1 knew where R1 was going. They acted like they didn't need anything. We send what they ask for over to make sure their level of care is accepted. On 12/1/21 at 12:51PM, V5 (Social Services Director) stated, V12 was overseeing the discharge but I know V12 spoke with two representatives from the VA, and they cleared R1 to come back over. Then when R1 got there they said they weren't aware R1 was coming. I know R1 was taken to the homeless shelter from what they told me on the phone. For discharges, we confirm the location, date, and time when they are getting ready to go. We set up any follow up appointments if needed. We normally talk with the admission coordinator. We send over paperwork depending on what they request. They didn't request anything. R1 didn't want to come back then and they ended up telling me they found a place for R1 to go. I think the homeless shelter has nurses and aides there at the homeless shelter to help the people. R1 didn't have community access when R1 was here. R1 wouldn't be able to get around out there alone. I was told the homeless shelter was going to assist with placement after R1 got there. That wasn't a permanent place for R1 to stay. R1 does have a past history of homelessness. On 12/2/21 at 12:46PM, V16 (Psychiatrist) stated, R1 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I do not remember being notified about R1's discharge but another doctor could have been. R1 was a poor historian and was not being forthcoming during my questioning. R1 was minimizing the severity of R1's own mental illness. I used to work at the VA, so I know you have to submit a stupid amount of paperwork to get in there. I also know someone from there comes out to evaluate the residents. I would hope R1 would be placed in the long term or mental illness area of the facility versus the homeless shelter. There are going to be more services at the long-term area. Their intention was good, but someone screwed up paperwork somewhere. The civilian world doesn't understand you just can't walk in there. On 12/3/21 at 2:19PM, V9 (Nurse) stated, Social Services mainly does the discharge. Nursing just fills out the paperwork, prints out the medication sheet and face sheet, get all their belongings and medications together, and we document how they left. I know R1 was going to the VA facility, but I don't know where. I didn't know what was going on because R1 was being discharged that day as soon as I heard about it. I didn't call to give nurse to nurse report. I always have with all other discharges. Social Services told me everything was done already so I didn't call. They usually give me a number and name to call report. On 12/7/21 at 9:45AM, V18 (Nurse Practitioner) stated, I remember being called to discharge R1. I knew R1 was going to the VA, but I didn't know where in the VA. The facility does the discharge and then will call us when they are ready to discharge. I would just expect them to follow whatever their policy says on discharging. I didn't know R1 went to a homeless shelter. I was told that is where R1 wanted to go and R1 worked with social services to plan the discharge. On 12/7/21 at 1:15PM, V19 (Primary Physician) stated, All discharges are mainly done by social work. They just call us when the resident is ready to go. I don't remember them telling me R1 was going to the homeless shelter but if that is where R1 wanted to go and R1 was persistent enough then R1 will go. 90% of the people that discharge to homeless shelters leave against medical advice (AMA). They aren't a safe place for anyone. It has to be a safe discharge, or they need to sign out AMA. As demonstrated by the evidence above, the facility neglected to implement the following policy regarding discharging a resident from the facility: The policy titled, Discharge/Transfer of Resident, that is not dated documents, 1. Review and adhere to current federal regulations as found in Resident Rights and Transfer and Discharge Policies. 6. Complete Transfer Form accurately and completely including vital signs. Ensure that resident's current physical and psycho/social assessments, medications, and current treatment is completely described and available to the receiving facility upon transfer. 9. Notify family and receiving facility when being transferred to acute care facility. The surveyor confirmed via record review and interview facility did the following to remove the immediacy: Re-education on Systems: Education initiated and completed on 12.10.2021 by the Administrator, DON, and Social Services Director. -All staff including those off duty was re-educated on providing residents with a safe discharge, taking into consideration skilled nursing care needs, following the facility discharge policy, sending the appropriate transfer paperwork: including medications and transfer paperwork. The facility discharge policy and abuse policy covered. -All staff including those off duty, which includes admissions, activities, dietary, nursing, social service, maintenance, housekeeping and the therapy department was educated via phone were educated with the same training as the staff educated in person, however, the staff who received training over the phone were notified that they will also be required to attend an in-person training prior to the beginning of the next shift worked additionally. -Ongoing education will be provided to facility staff and new hires will be educated during orientation by the Social Service Director, Assistant Social Service Director, Substance Abuse Coordinator or Director of Nursing. On the spot training will be completed for those staff who needs more education on safe discharge by the Social Service Director, Assistant Social Service Director, Substance Abuse Coordinator or Director of Nursing. A baseline house audit was conducted and completed by Social Services/Assistant Social service Director on 12.10.2021 of current planned discharges in process to ensure that planned discharges are safe and following the facility discharge and abuse policy. -A QA tool was developed and 5 audits a week will be completed by the Director of Nursing or Social Service Director to ensure residents are provided a safe planned discharge, taking into consideration skilled nursing care needs, following the facility discharge policy, sending the appropriate transfer paperwork; including medications and transfer paperwork. The facility will ensure to the best of its ability that a resident's planned discharge takes into account medical and psychological needs. In addition to the above actions, the facility put into place the following steps to ensure its residents are discharged into a safe environment: 1. Upon resident's desire to discharge, the PRSC will inquire the location and type of facility the resident would like to transfer to. 2. The PRSC will contact the receiving facility to identify the level of care provided at their location. 3. The PRSC will then inform resident or resident's representative if the receiving facility could meet the resident's physical and psychosocial needs. This information will be charted in the resident's medical record. 4. A care plan meeting with the resident and his/her representative will be held to discuss resident's discharge and its appropriateness. 5. All communication from the care plan meeting will be documented in the resident's medical record. The Director of Nursing or the charge nurse will update the primary care physician and the psychiatrist on the information received from the care plan meeting. 6. The charge nurse will contact the resident's primary care physician and psychiatrist of the discharge and will obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 7. A discharge assessment will be completed by all disciplines and will accompany the residents at the time of discharge. 8. Social Service Director, Assistant Social Service Director, PRSC, or Director of Nursing will arrange for in durable medical equipment as needed. 9. Social Service Director, Assistant Social Service Director, PRSC, or Director of Nursing will print all discharge papers to accompany the resident to the receiving facility. 10. Social Service Director, Assistant Social Service Director, PRSC, or Director of Nursing will be responsible for reviewing all discharges/transfer papers and to ensure the facility followed its policy. 11. An audit tool will be completed by Social Service Director, Assistant Social Service Director, or Director of Nursing within the social service department to identify if all necessary steps were completed. 12. During the morning meeting and stand down meeting the IDT: Administrator, Social Service Director, MDS coordinator, Assistant Director of Nursing, Assistant Director of Nursing, Infection control nurse, Treatment Nurse, Restorative Nurse, Dietary Manager, Maintenance director, Activity Director, and Housekeeping Director will review the documentation for the discharge to ensure those responsible for assisting with the discharge are completing the discharge appropriately.

Based on interview and record review, the facility failed to vaccinate a resident during two vaccine clinics and failed to allow family to take this resident out of the building to be vaccinated for 1 of 3 (R8) residents reviewed for immunizations in a total sample of 16. This failure resulted in R8 developing severe symptoms, and was transported to the local hospital, where R8 was admitted to the hospital for Covid 19 complications. Findings Include: R8 is a [AGE] year with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 admitted to the facility on [DATE]. A Nursing note dated 11/9/21 documents the administrator called R8's power of attorney to discuss concerns. The power of attorney wanted to know why family is not allowed in the facility and why R8 has not been COVID-19 vaccinated yet. The administrator educated the power of attorney that during an outbreak no one is able to come into the facility and all outdoor and indoor visits are canceled. The power of attorney was also informed visits will return when the facility is no longer in outbreak status. A Nursing note dated 11/20/21 documents R8 was noted to be positive for COVID-19 and isolation protocol was initiated. The family for R8 was notified around 11 PM of R8's status. A Nursing note dated 11/21/21 at 6:08PM documents R8's power of attorney was called and informed that R8's wound to the sacrum was getting worse. The power of attorney was also notified that the wound physician changed treatments and R8 is refusing to eat much. A Nursing note dated 11/21/21 at 6:40PM documents R8's face is flushed. R8 is warm to touch and congested. R8 is febrile with a temperature of 102, a heart rate of 138, and a low oxygen level at 80%. R8 was started on 4L of oxygen per nasal cannula and 911 was called. R8 was transferred to the hospital for evaluation. On 11/23/21 at 9:55AM, V29 (Family Member) stated, R8 was sent there in September and we wanted R8 to have the vaccine in a place like that around everyone. We would constantly call and check to see why she wasn't vaccinated yet, but no one could give us an answer. I know my wife got the consent signed in October. I don't remember the date but R8 never ended up getting vaccinated. They called us and told us R8 had COVID on November 20th. A couple days after that R8 was being sent to the hospital for trouble breathing from COVID. R8 is on a COVID unit right now and has to have oxygen on all the time. The one time when we called, we were told that they only have the booster shots available right now. I offered to come get R8 to take R8 to a (local pharmacy) or someplace I could find the vaccine since they couldn't give it, but they kept telling us we couldn't take R8 out because there was an outbreak. I even asked if I could have someone from R8's doctor office or anyone I could find come in to give the vaccine and they said no again. On 12/14/21 at 11:56AM, V1 (Administrator) stated, All residents are screened on admission to see if they are vaccinated or not. If they aren't, we ask them if they want the vaccine or not. If they do then they get put on the list to get the vaccine when we have another clinic come by or another pharmacy. Right now, we just had a Grocery Chain Store come out yesterday and vaccinate people. We usually have people come out about once a month. We have them sign a consent or their POA before to make sure it's ready. I remember getting a call from the family asking about it and we had just gone into lockdown then. We don't have someone come out just to vaccinate one person. I was having staff walk people over to (large department store) right before the lockdown happened to get their shot if they wanted one. We couldn't get R8 over to (large department store) before the outbreak started here and then I couldn't let R8 go out or let anyone else come in. I don't remember the dates the clinics were held before that. The pharmacist schedules them. Then she ended up getting COVID and being sent out, so we never got the chance, but she was scheduled to get it when they were here yesterday. She was admitted in September. On 12/14/21 at 2:51PM, V20 (Pharmacist) stated, I work with places to schedule vaccines for the residents. We either have the vaccines delivered here and run the clinic through (name of Provider) or we source through another pharmacy that will come out. We have been in the facility about once or twice a month doing them. We do the first round and then follow up with the second dose about 21 days later. We held vaccines through Grocery Chain Store yesterday. The Chain Store was also scheduled on 10/19. The last clinic day through (name of Provider) was on 10/7. If R8 was admitted in September, I was there twice in October so R8 should have been seen if R8 was on the list. I can't tell you how they get the people on the list. I just know to bring a certain amount of vaccines for the number that is needed. I don't know why R8 wasn't vaccinated if R8 wanted to be. We try to educate as best as possible for people to get vaccinated especially living in areas where there are a lot of people. Being vaccinated in a facility has shown us that the number of hospitalization s for COVID complications have decreased if there is an outbreak. The Care Plan dated 9/16/21 documents R8 is at risk for potential exposure to COVID-19 and/or potential risk to spread to others. The COVID-19 Vaccine Consent Form dated 10/27/21 documents R8 has not been vaccinated and R8's power of attorney has given permission for R8 to be vaccinated. The laboratory report dated 11/20/21 documents R8 was positive for COVID-19. COVID-19 monitoring form dated 11/2021 and 11/21/21 documents R8 was monitored every four hours for a change in symptoms and vital signs. R8's vital signs for 11/21/21 are as follows: heart rate at this time is documented as 138 beats per minute (normal is 60-100 beats per minute), the respiratory rate is documented as 22 breaths per minute (normal is 12-16 breaths per minute), the temperature is documented as 102 degrees Fahrenheit (normal is 97-99 degrees Fahrenheit), and the oxygen level is documented as 80% on room air (normal is greater than 95%). The Hospital Records dated 11/22/21 document R8 arrived at the emergency room via ambulance for shortness of breath and fever. In the ambulance ride over, R8 needed to wear 6L of oxygen via nasal cannula. R8 is currently at 89% on room air. R8 admitted to the medical floor with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review the facility failed to develop an effective plan to modify the behavior of drinking alcohol, being intoxicated and displaying inappropriate behavior in the facility this affected 1 of 3 residents (R1) reviewed for behavior modification. This failure resulted in (R1) having multiple incidents of being intoxicated on the nursing unit and having peer to peer altercations. Subsequently leading to R1 falling while under the influence of alcohol and cannabis requiring treatment at the local hospital for a frontal traumatic subarachnoid hemorrhage. Findings include. R1's progress notes document the resident was found to be intoxicated on 5 occasions. The progress notes document the following: 6/30/2021, R1 had red eye, slurring words and unsteady gait. 7/31/2021, This writer called 911 regarding resident being intoxicated and belligerent. 8/5/2021, This writer heard the CNA say that she thinks the resident is under the influence. Resident observed talking under his breath, pacing the hallway. This writer told the nurse to call 911 if resident becomes belligerent. 8/17/2021, Resident seems to be drunk, he is staggering and his breathe smells like alcohol And, 8/23/2021, Resident is noted under the influence of alcohol. Resident is noted smelling of alcohol and slurring of speech. Resident gait is unsteady. Resident refused breathalyzer test. Review of R2's care plan noted was not updated after each occurrence of intoxication at the facility. The following are R2's substance abuse care plan interventions: *Meet with the IDT (interdisciplinary team) to discuss the extent of the Resident's Illness. The physician may consider a referral to the psychiatrist and/or write an order restrict pass privileges Date initiated 9/19/202 * Provide leisure counseling to the resident to help him use free time in productive, not destructive ways. Date initiated 9/19/2020. Daily room search upon return from the hospital. Date initiated 8/30/2021. *Staff encouraged resident to attend programming to address substance abuse concerns. Date initiated 8/17/2021. *Staff offered resident option for programming outside in the community to address substance abuse concerns. Date initiated 8/6/2021. *Staff will provide resident breathalyzer to assess whether he is under the influence. Date initiated 8/23/2021. *This resident will be placed on 15 checks to ensure safety. Date initiated 8/07/2021. *Work with the resident to establish a verbal or written contract specifying use of alcohol, illicit substances and intoxication. Date initiated 8/30/2021. On 9/2/21 at 12:12 PM, V12 (Assistant Director of Social Services) stated when a resident is found intoxicated, we will pull their community passes and notify the doctor and monitor them. If too intoxicated we will send them to the hospital. On 6/30/2021, 7/23/2021, 8/6/2021, 8/17/2021, and 8/23/2021 the resident was found to be intoxicated, I wasn't here for the other ones but it was reported to me that he came into the facility intoxicated. R1 denied that it happened. They reported to me that R1 was stumbling and belligerent and appeared intoxicated. When I met with him I could smell alcohol on his breath. We placed him on one on one monitoring and he can't go anywhere without supervision. Then we sent him to the hospital because he was screaming and aggressive and threatening staff. On the 7/23/2021 incident. V20 (PRSD, Psychiatric Recreational Social Director) stated R1 had an intoxicated incident with a peer, in the hallways screaming and yelling. R1 made a comment to a peer and peer struck him. At that time, we took away community access for 30 days. We referred R1 to an alcohol help group and he declined and R1 requested discharge planning then declined once the process started. We educated him to reframe and placed him on one on one monitor. On 8/6/2021 V20 stated R1 was intoxicated in his room. He was already not going outside of the facility. We conducted a room sweep on the 3rd floor to see any other residents were bringing in alcohol. He got into a fight with a peer. We took resident to the hospital and placed him on one-on-one monitoring before the ambulance came. We asked him how the alcohol is getting in and he would not tell us. We are not sure how he is getting alcohol. On 8/17/2021 V20 stated the incident happened on night shift. R1 was pacing and aggressive and was petitioned to be admitted to the hospital. We had a care plan meeting and talked about his expectations. We referred him to a substance abuse program. R1 initially agreed to go to a substance abuse program and then declined. Currently not in a substance abuse problem. V12 (Assistant Director of Social Services) stated R1 has never taken a breathalyzer test. He refuses to take them. On 9/7/2021 at 2:40 PM, V21 (PRSC) - stated that after 7/30/21 incident R1 denied drinking. I followed his progress regarding intoxication. I referred him to an comunity addiction group that was offered on zoom, but he refused to attend. I encouraged him to talk to psychologist, but he refused to because of trust issues. He was sent to the hospital after this (there is no documentation). I talked to him one on one and he was reading pamphlets so I thought he would go to a group. I was told the alcohol came from a peer. Alcohol was found, I think it was on the last incident. R1 is in denial still. We looked for a new facility for him in July and he was denied. I told him if he keeps doing that that no one will take him. I'm not aware of him ever taking a breathalyzer test. Normally R1 is well mannered, but when he is intoxicated, he is falling, slurs speech, aggressive towards people, and gets flirtative with women. I was told they found liquor in his cup on the 8/24/21 incident. When asked if finding any of the interventions effective? V21 stated talking to him would be the most effective. R1 is very stand-offish. It is difficult to find out what will make him stop. R1 has to want to stop with an addiction. I don't know if any of the interventions have been effective. I don't know. He seems good. Time will tell. On 9/7/2021 at 3:22 PM, V20 (PRSD) Surveyor asked: What are the consequences or alternatives for R1 not going to meetings. V20 states, There are no consequences. He has a right to refuse. Surveyor asked if the behavior modification is not working, how are you meeting his needs. V20 states, He is making the decision not to engage and not participate in treatment. He understands what he is doing. When he drinks, he becomes an angry drunk. On 9/1/2021 at 1:34 PM, observed R1 with a left black eye, blood shot sclera of the left eye, and a lump the size of a small grape on the left side of R1's left eye. R1 states he fell last week. Progress notes for R1 documents the following: Note by V20 (PRSD) 8/23/2021 at 13:08 (1:08PM), Resident is noted under the influence of alcohol. Resident is noted smelling of alcohol and slurring of speech. Resident gait is unsteady. Resident refused the breathalyzer test. Resident refused to tell Administrator, APRSD, MDS team, and writer the whereabouts of where he is keeping the alcohol and who is purchasing the alcohol.

Based on observation, interview, and record review the facility failed to monitor/supervise and provide a safe environment for a resident that was assessed to be intoxicated this affected 1 of 3 residents (R1) reviewed for monitoring/supervision. These failures resulted in R1 falling to the floor after being assessed to be intoxicated resulting in R1 being sent to the local hospital and diagnosed with a frontal traumatic subarachnoid hemorrhage. The facility also failed to implement their care plan and ensure that fall prevention interventions were in place to include call lights within reach and bed bolsters applied to prevent or reduce the risk of falling for 2 of 3 residents (R2, R7) reviewed for falls. These failure resulted in R2 falling on the floor next to the bed while attempting to reach for the call light to ask for assistance. Findings include: Record review for R1 documents a [AGE] year old male admitted to the facility on [DATE]. R1diagnosis includes [CONDITION(S)], long term use of Anticoagulants (blood thinner), [CONDITION(S)] affecting right dominant side, Hypertension (high blood pressure), Anxiety Disorder, Cannabis Use. Current medications include: [MEDICATION(S)] (blood thinner) 10 mg daily, [MEDICATION(S)] (blood thinner) 0.7ml inject daily. On 9/1/2021 at 1:34 PM, observed R1 with a left black eye, blood shot sclera of the left eye, and a lump the size of a small grape on the left side of the left eye. R1 stated he fell last week. Progress notes for R1 documents the following: Note by V20 (PRSD, Psychiatric Recreational Social Director) : 8/23/2021 at 1:08 pm, Resident is noted under the influence of alcohol. Resident is noted smelling of alcohol and slurring of speech. Resident gait is unsteady. Resident refused the breathalyzer test. Resident refused to tell Administrator, APRSD (Assistant Psychiatric Recreational Social Director), MDS team, and writer the whereabouts of where he is keeping the alcohol and who is purchasing the alcohol. Note by V12 (APRSD): 8/23/2021 at 2:58 PM. This resident was placed on 1:1 due to exhibiting signs of intoxication. This resident was placed on 1:1 until ambulance arrived. This resident presented with belligerent behaviors, using socially inappropriate language, making threats to staff, attempting to antagonize staff by attempting to hit staff, then drawing his arm back. Note by V19 (LPN): 8/23/2021 at 8:52 PM. Resident returned back to the facility on gurney accompanied by two attendants. Resident escorted back to room and laid down for about two hours. Resident came out of room and began to curse at peers and staff. Resident threw a cup of water at this writer and then threw another plastic cup at this writer and stated that he would kill me when redirection was attempted. Resident attempted to enter peers rooms without permission and was redirected several times with resident cursing and threatening staff several times. Resident balled up his fist and attempted to hit this writer in the face. 911 was called and resident calmed down and went back to room. Wil continue to monitor resident. Note by V19 (LPN): 8/24/2021 at 8:03 PM. Resident fell in bed room hitting head and began to bleed with noted laceration above left eye. Pressure applied to laceration and steri-strips applied. 911 called to transfer resident to the nearest ER for evaluation. Resident left facility on gurney with eyes open talking to first responders in route to hospital. On 9/8/2021 at 9:02 AM, V19 (LPN) Stated she remembers the situation with R1 that occurred on 8/23/21 and 8/24/2021. V19 stated that R1 appeared intoxicated while we were waiting for hospital intake to accept him. R1 was on close monitoring by a CNA and myself. We redirected R1. R1 kept getting up out of bed, staggering and attempting to go into peer's rooms. He became verbally aggressive. R1 was threatening and threw cups of water at me and verbally threatened me. R1 was very verbally aggressive and approaching me in an aggressive manner. He kept stepping into my space. I was trying to keep a safe distance and he tried to hit me. He threaten me several times. Police was called. We monitored him throughout the night after he came back from the hospital. I was doing rounds in the morning on 8/24/21 and noticed the curtain pulled. R1 had fallen and he was still intoxicated, but verbally responsive. He had a laceration above his eye. His speech still slurred and still aggressive. I applied pressure to the laceration. Steri-strips and taped it. V19 stated she called the physician, and received orders to send R1 out and we placed R1 on neuro-checks. On 9/9/2021 at 11:26 AM, V21 (Primary Care Physician) stated that if the R1 was aggressive he believes R1 should have had 1:1 monitoring to avoid injury. R1's Hospital discharge instructions from 8/23/2021 21:04 (9:04PM) ER visit documents the following: Diagnosis: Alcohol intoxication R1 Hospital records document the following: 8/23/2021 at 16:30 (4:30pm); urine drug screen is positive for Cannabis 8/23/201 at 16:26 (4:36pm); Alcohol Level is 217H (217 High). {ClinlabNavigator.com document blood alcohol concentration of 150-300 mg/dl: Clinical signs & Symptoms = confusion, disorientation, impaired balance, slurred speech.} R1 Hospital records from 8/24/2021 visit document the following: Clinical Diagnoses: Fall; Hemorrhage of the Brain, traumatic; Acute Alcohol intoxication CT Scan dated 8/24/21 documents the following: Opinion: small acute subarachnoid hemorrhage within a left frontal sulcus. Doctors History and Physical dated 8/24/21 documents the following: R1 fell while intoxicated now has a SAH (subarachnoid hemorrhage.) R2's fall risk care plan documents the following: 1) Be sure call light is within reach and encourage the resident to use for assistance as needed. Staff to respond promptly to all requests for assistance. Call light within reach among other interventions. 2) Staff to ensure the bed bolsters are securely fastened while in bed. 3) Sign put on wall to pull call light for assistance. 4) Sign put on wall to keep call light attached to shirt or pillow. 5) He has floor mats on both sides. On 9/2/2021 at 10:20 AM, Surveyor walked to R2's room which is next to the nurse's station. R2's call light is on. R2's door is wide open and he is on the floor screaming for help. Writer requested assistance from staff. V9 (RN) responded to call for help. R2 is observed next to the wall that runs parallel to his bed. R2 is wearing a ripped diaper, a shirt and no pants and black socks and shoes on. Surveyor asked R2 what happened. R2 states I was trying to get the call light. I'm wet. R2's call light is located on the wall and connected to light switch and is not within reach of the resident. The call light is behind and stuck under the bedside table. V9 was shown where the call light was located. V9 confirmed the call light placement, then with some difficultly he released the call light that was stuck under the bedside table. There were no bolsters or pads anywhere around the bed. There were no floor mats on the floor. V9 stated he is the nurse caring for R2 today. Asked what kind of fall precautions are in place R2. V8 stated, Just bed in low position. Some residents have pads on the floor. I don't recall him ever having any. On 9/2/2021 at 10:37 AM, V10 (CNA) stated he saw R2 about an hour ago and R2 gets in and out of the bed a lot. It was pointed out that there were no bed bolsters near the bed and requested to look in closet with V10. Bed bolsters were observed in R2's closet. V10 stated it is the CNA's responsibility to put the bed bolsters on the bed when resident is in bed. V10 states, When I came this morning he was in bed and no bolsters were on the bed. I came in around 7:00 am. He had no bolster the whole morning. Post fall incident report for R2 by V19 (LPN) dated 9/2/2021 documents the following: Resident Description: Resident stated he was attempting to turn on his call light by getting out of bed when he lost his balance resulting in a fall to the floor. On 9/7/21 at 9:05 AM with V18 (LPN). R2 is sleeping, No floor mats were noted on the floor. R7's Fall Risk care plan documents the following interventions: 1) Bed Low 2) Be sure call light is within reach and encourage the resident to use for assistance as needed. Staff to respond promptly to all requests for assistance. Call light within reach among other interventions. On 9/1/2021 at 12:50 PM, R7 observed sitting up in the bed and states she is not able to walk. Bed not in low position. Observed call light was not within reach. Call light is 3-4 feet away from R7 hanging on a string that is not on the residents bed or close enough to reach. V4 (CNA) was asked if R7's call light is accessible. V4 stated that R7 moves her bed up and down frequently. R7 denies. Surveyor asked V4 how R7 reached her call light whether the bed is up or down. R7 started to roll her bed down and the call light was still too far away. V4 stated R7 can't reach it and attached call light on R7. On 9/7/21 at 9:09 AM, observed R7's bed is not in a low position. R7 is sitting up in her bed with R7's call light located to her right and behind R7 hanging from the wall. V18 (LPN) was asked how R7 can reach the call light. V18 stated it is usually on her. V18 pulled call light to the resident within reach. On 9/7/2021 at 12:23 PM with V18 (LPN) observed R7's bed to be in a very high position. Surveyor asked V18 about bed height. V18 stated she does not know why R7's bed is up so high. Facility's Fall Prevention Program document the following: Policy: It is the policy of this facility to have a fall prevention program to assure the safety of all resident in the facility, when possible. Standard Fall/Safety Precautions for All Residents: 8. Call lights are kept within reach and answered promptly.

Based on interview and record review, the facility failed to follow their notification of change in policy and procedure to include notification to the attending physician of skin excoriation around an ostomy site, and failed to notify the legal guardian of a transfer to the local hospital for 1 (R1) of 3 residents reviewed for notification of change. This failure resulted in R1's initial excoriated site going untreated and increasing in size to 14cm x 14cm before the physician was notified and then required hospitalization R1 was admitted with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's brief interview for mental status dated 5/17/21 document a score of twelve which indicates moderate impairment. R1 was assessed to be alert and oriented to person, place and time. R1's minimal data set section H (Bladder and Bowel) dated 5/22/21 documents: Ostomy R1 was observed with redness and excoriation to the left lower quadrant measuring at 14cm x 14cm, 5/7/21 by V30 (Nurse). Brown dried substance on pants and bed pad similar to stool. Progress note dated 5/7/21 documents: R1 was noted to have large (below breasts to pelvic area) excoriated, draining area. Doctor called, R1 will be transferred to the hospital for evaluation. R1 is her own guardian. On 6/2/21 at 10:36am, V20 (R1's guardian) said the facility explained it was a misunderstanding that she was not contacted when R1 went to hospital (on 5/7/21). The nurse V30 (Nurse) was under the impression that R1 was responsible for herself . V20 said she would expect to be notified of any changes in condition. On 6/2/21 at 2:04pm, V3 (ADON) said, V30 (Nurse) discharged R1 to the hospital (on 5/7/21) and failed to call the guardian. V30 made a mistake. On 6/3/21 at 2:01pm, V30 (Nurse) said, I did not call the guardian because R1's face sheet documents guardian/self. R1's face sheet did not include a power of attorney. R1's Letter of Office -Temporary Guardian dated 3/8/21 documents: R1 has been appointed a temporary guardian of the person and estate by an order of the court. R1's nursing progress notes dated 5/12/21 document Resident was re admitted to facility from Hospital. Resident's [CONDITION(S)] bag is intact, abdomen is free from excoriation. On 6/3/21 at 9:31AM, V25 (NP) said R1's assessment 5/27/21 there was about one inch of redness around stoma site. V25 was unaware of any further changes surrounding R1's skin or ostomy site. On 6/10/21 at 10:19 AM, V25 (NP) said on 6/3/21 she changed the treatment plan to R1's skin around ostomy site. V25 said area had worsened from previous assessment (5/27/21). V25 said she is unable to determine how long it would take for excoriation to develop on R1. V25 said if she had been notified of change in condition she would have seen R1 and performed an assessment and determine if a change would be needed. On 6/4/21 at 10:44 AM, V26 (NP) said she was not notified of any changes to R1. V26 said she would have changed R1's plan of care or initiated treatment after an assessment to prevent area from getting worse. V26 said it would take one to two days for excoriation to appear on the skin. V26 said she would have increased supervision and monitoring of ostomy site. Facility policy titled Change in Condition Physician Notification Policy dated 4/20 documents: All significant changes in the resident status are thoroughly assessed and physician notification is based on assessment finding and is to be documented in the medical record. Medical care non-emergency problems are communicated to the attending physician and family in a timely, concise and thorough manner generally within twenty-four hours or sooner. Responsible party is to be notified of change in condition.

Based on interview and record review, the facility failed to follow their abused policy by 1) not preventing sexual abuse for 2 of 3 (R21 and R24) from R16 and also failed 2) to prevent resident to resident physical attack affecting 3 of 3 (R3, R12, and R13) all reviewed for abuse. This failure resulted in R16 inappropriately exposing himself to R21. R21 said she felt angry and scared of R16, this failure also resulted in R16 grabbing and forcefuly tongue kissing R24 in her mouth. R24 said she felt violated by R16's actions. Findings include: 1) R21 was admitted with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/4/21 at 2:28pm, R21 who was assessed to be alert to person, place and time, said, R16 was sitting in a chair in my room talking, R16 unzipped his pants, took his penis out and started playing with it. I observed R16 playing with his hands and penis in his lap with white liquid on top his penis. I felt angry, scared and was preparing to defend myself. On 6/9/2021 at 10:14am, V5 (Asst. PRSD) said, R16 exposed himself to R21. R16 pulled out his penis. On 6/10/21 at 1:07pm, V29 (PRSC) said, R16 has had sexually inappropriate behaviors that was slowly progressing until R16 was discharge to the hospital for exposing self to R21. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Social service note dated 6/2/21 documents: R16 presented with socially inappropriate behavior as evidenced by R16 walking into R21's room and exposing himself. R16 said, that he walked into peer room and begin to expose himself to resident saying he overheard that resident can have sex for fifteen minutes. Police report dated 6/2/21 documents: R21 was identified as the victim. R21 said R16 exposed himself in her room. Abuse Prevention Program dated 12/19: Resident have a right to be free from abuse. Abuse means any sexual assault inflicted upon a resident other than by accidental means. Sexual Abuse is sexual contact of any type with a resident. R24 was admitted with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R24 brief interview for mental status dated 6/2/21 score of twelve which indicated moderate impairment. On 6/10/21 at 2:42pm, R24 who was assessed to be alert to person, place and time, said, I was assaulted on the elevator in May. I was getting on the elevator, R16 lean out and hugged and kissed me on the cheek. R16 put his tongue on my cheek and dragged it across my face towards my mouth. I pushed R16 off me before his tongue entered my mouth. I felt violated. On 6/9/21 at 4:45pm and 5:09pm, V1 (administrator) said, R24 was the peer on the elevator with R16. R24 reported that R16 kissed her. R24 said, she felt R16's tongue on her cheek. On 6/11/21 at 12:30pm, V1 (administrator) said, sexual abuse is any unwanted touching, kissing, licking, sexual penetration or sexual advancement. If my staff writes a progress note with the word attempted it means my staff saw a resident trying to do something. Physician note date 5/17/21 documents: R24 is orient to person, place and time. Social service note date 6/9/21 documents: R24 alleged that peer attempted to kiss her in the elevator. Staff was informed R24 received physical aggression while in the elevator. Abuse Prevention Program dated 12/19: Resident have a right to be free from abuse. Abuse means any sexual assault inflicted upon a resident other than by accidental means. Sexual Abuse is sexual contact of any type with a resident. R16 was admitted on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Brief interview for mental status documents a score of ten which indicated moderate impairment. On 6/8/21 at 5:32pm, R16 who was assessed to be alert to person, place and thing said, I showed my penis to R21. I wanted R21 to suck it. I touched a resident with the dark hair and glasses on the breast. On 6/9/2021 at 10:14am, V5 (Asst. PRSD) said, R16 exposed himself to R21. R16 pulled out his penis. On 6/10/21 at 1:07pm, V29 (PRSC) said, R16 has had sexually inappropriate behaviors that was slowly progressing until R16 was discharge to the hospital for exposing his self to R21. R16 made sexually inappropriate gestures towards staff. On 6/11/21 at 12:30pm, V1 (administrator) said, the word noted is used interchangeable with what the staff observed. Physician note dated 4/29/21 documents: R16 is oriented to person, place and time. R16 is able to state first and last name, current state located in, as well as what year it is. Progress note dated 5/18/21 documents: R16 was sexually inappropriate towards a peer in the elevator. Social service note dated 5/19/21 documents: R16 was noted being sexually inappropriate towards staff while on the elevator. Care plan dated 5/19/21 documents: R16 has been sexually inappropriate towards both staff and resident. Police report dated 5/27/21 documents: R16 said, he touched a female breast over clothing at the nursing home. Social service note dated 6/2/21 documents: R16 presented with socially inappropriate behavior as evidenced by R16 walking into R21's room and exposing himself. Petition for involuntary/ judicial admitted [DATE] documents: R16 had behavioral concerns as evident by exposing self to peer. Abuse Prevention Program dated 12/19: Resident have a right to be free from abuse. Abuse means any sexual assault inflicted upon a resident other than by accidental means. Sexual Abuse is sexual contact of any type with a resident. 2) R4 admitted to facility on 1/25/21 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Minimum Data Set, dated dated dated [DATE] documents a brief interview for mental status score of 0 which indicates cognitively impaired. R4's referral packet contains a social service note dated 1/18/21 documents R4 was sent to hospital on 1/3/21 due to physical altercation with a resident. R4 is at risk for elopement due to wandering and confusion related to dementia. R4's progress note dated 2/4/21 documents: It was reported to the writer that this resident initiated physical aggression on the second floor in their room. It was reported this resident pushed peer out of wheelchair onto the floor. Residents were separated. Writer immediately investigated event. Upon investigation, resident stated I did not push anybody, not that I know of. Writer conducted 1:1 counseling with resident to vent feelings and concerns. Writer encouraged resident to maintain boundaries with peers. Writer encouraged resident to seek staff assistance when situations arise. Resident will be placed on a 72 hour checks. R4's progress note dated 2/11/21 documents: It was reported to the writer from the 2nd floor nurse that this resident initiated physical aggression on peer on the 2nd floor in the room. Resident were immediately separated. Writer investigated immediately. Upon investigation, it was reported that resident was sitting on peers bed. Peer asked resident to leave because she was still trying to sleep. Resident then became agitated and grabbed the toilet seat and attempted to strike peer. Writer attempted to conduct 1:1 counseling with resident. Resident was calm due to not remembering. Resident stated I did not fight with anyone, I have been eating breakfast all morning. Writer encouraged resident to refrain from all forms of aggression. Writer encouraged resident to seek staff assistance as needed. Resident will be petitioned out to local hospital. R4's note do not indicate any hospitalization . Facility unable to provide petition when requested. R4's progress note dated 4/5/21 documents: It was reported to the writer that this resident initiated physical aggression on the second floor in their room. It was reported this resident pushed peer out of wheelchair onto the floor. The residents were separated. A resident claimed her peer came into her room and started touching her tray. Then she grabbed her fruit cocktail and throws it at her. The peer also slapped her hand away. After that, she started messing with her other roommates and sat in her (roomate's) wheelchair. She told her other roommate to pull the call light. She then left out the room and told a nurse. The resident stated that she was trying to find her bed. She also said that she did not throw or hit anybody. The writer conducted 1:1 counseling with the resident to vent feelings and concerns. The writer encouraged the resident to maintain boundaries with peers. The writer encouraged the resident to seek staff assistance when situations arise. The resident will be placed on 72-hour checks. The writer will follow up accordingly. R4's progress note dated 4/25/21 documents: It was reported to the writer that the resident was in a physical altercation with her roommate. The peer stated the resident had poop in her hands. The peer asked her if she could wash. The resident grabbed the tray and hit her with it four times until she stopped. The writer conducted 1:1 counseling with the resident to vent feelings and concerns. The writer encouraged the resident to maintain boundaries with peers. The writer encouraged the resident to seek staff assistance when situations arise. R4's progress note dated 5/5/21 documents: Writer was informed that resident was involved in physical altercation. Resident and peer were immediately separated. Resident was placed on 72-Hour Behavior Monitoring, emotional support and PRN was given. Resident was placed on 1:1 and encouraged to respect peers. Resident was also given time to express concerns in regards to peer and encouraged not to be aggressive towards staff. Resident's peer was also placed on 72-Hour monitoring. Resident was ensured she lives in a safe place. Resident was encouraged to follow-up with staff immediately when a problem arises. R4's screening for indicators of aggressive and/or harmful behaviors dated 1/25/21 documents under risk assessment a score of 4, which indicates potentially able to integrate into the peer community, minimal risk for aggression. Dementia related interventions include re-orientation, re-assurance, and emphasis on safety/security. SMI related interventions include stress management/stress relief, improving communication skills, harm reduction (Score < or = 4). R4's care plan Date Initiated: 02/05/2021 documents Aggression: Resident presents with aggressive behavior due to confusion and disorientation related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was counseled by this writer an encouraged to refrain from aggressive behavior(s) during this time. Date Initiated: 05/11/2021; Staff will assess resident for underlying medical issues to relate to behavioral outburst. Date Initiated: 05/08/2021; Staff will place resident in less stimulating activities to manage heightened anxiety. Date Initiated: 04/05/2021. Staff will reassure resident she lives in a safe environment. Date Initiated: 04/25/2021. Staff will utilize pharmacological interventions to manage heightened behaviors. Date Initiated: 05/05/2021. Writer encouraged resident to maintain boundaries with peers. Date Initiated: 02/05/2021. Writer encouraged resident to refrain from all forms of aggression. Date Initiated: 02/11/2021. Writer encouraged resident to seek staff before situations arise. Date Initiated: 02/05/2021. Writer encouraged resident to use deep breathing techniques when feeling agitated. Date Initiated: 02/05/2021. Writer encouraged the resident to talk to peers instead of being violent. Date Initiated: 04/28/2021. Writer will attempt to conduct 1:1 counseling for resident to vent feelings and concerns. Date Initiated: 02/05/2021. On 6/3/21 at 1105Am, V4 (PRSD) said R4 could not understand redirection. R4 has history of confusion and wanders. R4 becomes easily startled and will act out in a defensive manner. R4 will rummage through roommate's belongings. Upon review of R4's care plan interventions, V4 said interventions were not effective. Facility policy titled Behavior management for agitated behavior dated 4/20 documents under preventive measures; If not in quiet area consider relocation to appropriate space, own room or other space; when voice is loud, offer drink, food toileting, take for a walk or redirect to activity, observe for behavior escalation of anxiety, aggression, swearing and other irritability. R3 was admitted to facility on 7/4/2018 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 brief interview for mental status dated 5/18/21 document a score of 14 which indicates cognitively intact. On 5/28/21 at 1:00pm, R3 was alert and oriented at time of interview said that R4 was grabbing things in her room and she asked her to stop. R3 said R4 then smacked her across the face but not hard. R4 reported incident and R3 was moved to different room. R3 said she did not hit R4 back because she is an older lady and has dementia. R3 said R4 has history /behavior of wandering and going through peoples things. Facility abuse reportable dated 5/5/21 documents R3 got upset with R4 because R4 was going through R3's personal belongings. R3 asked R4 to stop, and R4 became physically aggressive towards R3 and struck her with an open hand. After a thorough investigation, there is no credible evidence that abuse occurred based on R4's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's progress notes dated 5/5/21 documents Resident is a [AGE] year old female. Resident diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident stated peer was upset because resident asked peer to stop going through her personal items. Upon doing this peer then became physically aggressive with resident. Resident and peer were immediately separated. Resident was encouraged to seek staff assistance or you call light before interacting with peers. Resident were immediately separated and a room change was done. R4's progress note dated 5/5/21 documents: Writer was informed that resident was involved in physical altercation. Resident and peer were immediately separated. Resident was placed on 72-Hour Behavior Monitoring, emotional support and PRN was given. Resident was placed on 1:1 and encouraged to respect peers. Resident was also given time to express concerns in regards to peer and encouraged not to be aggressive towards staff. Resident's peer was also placed on 72-Hour monitoring. Resident was ensured she lives in a safe place. Resident was encouraged to follow-up with staff immediately when a problem arises. Facility abuse prevention program reviewed 1/4/19 documents abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse for all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal, sexual, physical and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual intended to inflict harm or injury. R12 was admitted to facility on 5/28/19 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's brief interview for mental status dated 4/5/21 document a score of 14 which indicates cognitively intact. On 6/2/21 at 1019AM, R12 who was alert and oriented at time of interview, said R4 hit her in the head with top of food covering from the tray 4 times. R12 said she had a little mark but was ok. Facility reportable dated 4/25/21 documents: R12 reported that R4 threw a breakfast tray towards her and food got on R12, but the tray did not touch her. After a thorough investigation, there is no credible evidence that abuse occurred based on R4 being confused related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's progress notes dated 4/25/21 document: During medication pass writer heard yelling coming resident room. Resident informed writer that her roommate threw her breakfast tray on her. Writer asked what happen? Resident stated she threw her breakfast tray on me for no reason. Resident was immediately separated. Head to toe assessment done. No c/o pain/discomfort noted. R4's progress note dated 4/25/21 documents: It was reported to the writer that the resident was in a physical altercation with her roommate. The peer stated the resident had poop in her hands. The peer asked her if she can wash. The resident grabbed the tray and hit her with it four times until she stopped. The writer conducted 1:1 counseling with the resident to vent feelings and concerns. The writer encouraged the resident to maintain boundaries with peers. The writer encouraged the resident to seek staff assistance when situations arise. Facility abuse prevention program reviewed 1/4/19 documents abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse for all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal, sexual, physical and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual intended to inflict harm or injury. R13 was admitted to facility on 5/22/2018 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's brief interview for mental status dated 5/12/21 document a score of 12 which indicates moderately impaired. Facility abuse reportable dated 2/11/21 documents: R4 was sitting on R13's bed while R13 was sleeping. R4 was confused and thought that R13 was in R4's bed. R13 told R4 to get off her bed. R4 became upset and hit R13. After a thorough investigation, there is no credible evidence that abuse occurred due to R4 low BIMS (brief interview for mental status) score of 0 and confusion which is related to Alzheimer's disease. On 6/2/21 at 1215PM, R13 who was alert and oriented at time of interview, said R4 attacked her with the top of the toilet lid. R4 was holding toilet lid cover over her face and hit her with it. Staff came and were able to remove R4. R4 changed rooms. R13's social service progress note documents dated 2/11/21: Resident is a [AGE] year old female who is alert and oriented X3. Resident is able to communicate wants and needs with clear speech. Resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident ambulates independently and is able to perform ADL's independently. Resident is compliant with meals, medications, and ADL's. It was reported to the writer by nurse that this resident received physical aggression from peer while in her room. Writer immediately investigated event. Upon investigation, resident stated that peer hit her with toilet lid then choked her by grabbing her jacket hood. Writer immediately did 1:1 counseling with resident to vent feelings and concerns. Writer did breathing techniques with the resident. Writer also gave resident a leisure packet to help calm and redirect her. Writer encouraged resident to maintain boundaries with peer. Writer re-educated resident on COVID-19 policy. Writer encouraged resident to seek staff before situations arise. R4's progress note dated 2/11/21 documents: It was reported to the writer from the 2nd floor nurse that this resident initiated physical aggression on peer on the 2nd floor in the room. Resident were immediately separated. Writer investigated immediately. Upon investigation, it was reported that resident was sitting on peer's bed. Peer asked resident to leave because she was still trying to sleep. Resident then became agitated and grabbed the toilet seat and attempted to strike peer. Writer attempted to conduct 1:1 counseling with resident. Resident was calm due to not remembering. Resident stated I did not fight with anyone, I have been eating breakfast all morning. Writer encouraged resident to refrain from all forms of aggression. Writer encouraged resident to seek staff assistance as needed. Resident will be petitioned out to local hospital. Facility abuse prevention program reviewed 1/4/19 documents abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse for all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal, sexual, physical and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual intended to inflict harm or injury.

Based on interview and record review, the facility failed to implement effective interventions of wearing a helmet to reduce the injury during potential fall incidents for a resident with a diagnosis of [CONDITION(S)] this affects 1 of 1 residents (R2) reviewed for fall risk interventions The facility also failed to supervise a resident with a history of wandering and having peer to peer altercations for 1 of 3 (R4) residents reviewed for supervision. The facility's failure resulted in R2 having multiple falls and being transported to the local hospital and treated for head injuries to include lacerations requiring sutures. Findings include: R2 admitted to the facility on [DATE] with a diagnosis of [CONDITION(S)]'s disease, [CONDITION(S)], [CONDITION(S)] and dysphagia. R2 minimum data set (MDS) dated [DATE] documents a brief interview for mental status score of 0 which indicates cognitively impaired. Under section G documents one person physical assist with transfers, walk in room, walk in corridor, locomotion on and off unit. During the survey, R2 was observed wearing a black helmet. The helmet was noted to cover her entire head and forehead. R2's fall report dated 4/4/21 documents R2 fell backwards to the floor near her wheelchair. Abrasion on the back of her head. Under injury documents abrasion on top of scalp R2's fall risk review dated 4/4/21 documents a score of 12 high fall risk due to balance problem when walking; Exhibits loss of balance while standing; Changes gait pattern when walking through doorways; Exhibits jerking or instability when making turns; Uses an assistive device, e.g. cane, walker, wheelchair, etc; Decrease in muscle coordination. R2's progress note dated 4/6/21 documents: writer was called by the CNA. R2 was sitting on the floor with blood on the floor. Writer cleaned the wound on top of the resident's head with saline. Packed it with gauze and placed a bandage. On 6/2/21 at 3:52PM, V23 (Nurse) said she asked V8 (CNA) to help R2 back to her wheelchair because she was ambulating in front of nursing station. V8 assisted R2 back to her wheelchair and assisted her back to her room. V8 reported that he was leaving the room to get supplies when R2 stood up from wheelchair and then went to sit back down. When R2 went to sit back down, the wheelchair moved back and R2 hit her head on the arm of wheelchair and sat on her buttocks. V23 said the wheelchair was not locked for it to move back and reported R2 was not wearing her helmet. V23 did not receive any report of R2 refusing to wear helmet. On 6/1/21 at 10:00PM, V8 (CNA) said he did not see R2 fall on 4/6/21. V8 said he was assisting R2 with care and left the room to get supplies and when he re-entered the room, R2 was sitting on the floor and the wheelchair was behind her. V8 said the wheelchair was not locked and R2 was not wearing a helmet at time of incident. V8 was unaware that R2 had a helmet. R2's facility reportable dated 4/6/21 documents: Resident was observed siting on the floor. Noted with laceration on top of her head. R2 was observed with wheelchair at her back. R2 sent to local hospital and returned with 2 staples to head. R2 tends to be impulsive and became agitated with redirection attempts. R2 will [NAME] herself into her wheelchair. It was concluded that the root cause of the fall is that she missed her wheelchair when attempting to sit and fell . Interventions facility will conduct medication review. Care plan and assessments updated as indicated. Incident report on 4/6/21 at 18:50 (6:50pm) that R2 was sitting on the floor and there was blood on the floor. R2's hospital record dated 4/6/21 documents R2 was found on the floor by her wheelchair. Staff believes R2 possibly fell back out of her wheelchair and hit her head. R2 sustained small laceration to her posterior scalp. Two staples were placed. R2's progress note dated 4/10/21 documents: Peer informed writer that resident was ambulating without assistance, and fell face forward in the hallway. Head to toe assessment done. Writer observed resident has a laceration on the left side of the forehead, and a laceration on the back of head. Administrator made aware. R2's facility reportable dated 4/10/21 documents: R2 suddenly stood up, lost her balance and fell forward. R2 sent to local emergency room and came back same day with sutures to her forehead. It was concluded the root cause of her losing her balance is due to her involuntary movement secondary to her [CONDITION(S)]'s disease. Interventions resident directed to get up slowly from the wheelchair. Incident report dated 4/10/21 documents: Peer informed writer that resident was ambulating without assistance and fell face forward in the hallway. Laceration on the left side of forehead and laceration on the back of head On 6/1/21 at 1:46pm, V9 (nurse) said staff reported R2 was walking down hallway unassisted, before staff could intervene R2 fell face forward and hit her head on floor. R2 did not have a helmet on at time of incident. R2 sustained injury to forehead. V9 unable to explain how R2 sustained injury to back of head or if R2 fell again same day prior to transfer to hospital. R2's hospital record dated 4/10/21 documents R2 from facility for witnessed fall. R2 hit wall and fell backwards. R2 has wound to her forehead and previous staples to back of her head now bleeding. There is a 3cm laceration extending from the previous 3 cm laceration that is stapled on the septal area. There is a 3cm wide laceration on her left mid forehead. Three sutures were placed on forehead and 3 staples were placed on scalp. Computerized tomography of the head dated 4/10/21 documents small scalp hematoma and laceration with skin staples overlying high left parietal calvarium (side of skull). Scalp laceration with small hematoma overlying the left frontal calvarium (front of skull). On 6/11/21 at 10:05 am, V38( Former DON) said she thought R2 was wearing her helmet at the time of the falls but was unable to explain why that intervention was not documented in any of the reports or investigations. When asked how R2 sustained injuries to her head if a helmet was on, V38 responded that maybe the helmet fell off when she fell or was not secured properly. On 6/10/21 at 10:39AM, V1 (Administrator) said R2 will refuse to wear her helmet. The helmet is used to protect her head from injury. V1 said she would expect staff to continue to offer R2 helmet, inform social services of refusal and staff should document all attempts or refusal. V1 said she did not assist with fall reportables on 4/6/21 and 4/10/21. V1 said unsure if R2 was wearing helmet at time of fall from reports. R2's April progress notes do not document any refusals of the helmet. R2's fall report dated 3/15/21 documents: R2 fell on the floor trying to transfer to weight scale. R2's fall report dated 3/23/21 documents: R2 was observed on the floor in common washroom. No witnesses found. And checked not using wheelchair. R2's fall report dated 4/12/21 document R2 was sitting in front of nursing station and tried to stand up and lost her balance and fell to floor. No witness found. R2's progress note dated 5/19/21 documents; R2 sitting in the hallway outside the dining room. R2 with superficial cut on inside lower lip. R2's care plan documents: R2 is at risk for falls related to [CONDITION(S)]'s disease, [CONDITION(S)], [CONDITION(S)], feeding difficulties, dysphagia R2 was offered a helmet for her head and she refused to wear it. She was educated on the importance of wearing the helmet. R2 will sit in the chair with legs crossed and was educated not to sit that way due to fall risk. R2 has impulsive behaviors and gets out her chair. Date Initiated: 11/18/2019 with revision on: 02/22/2021. Following interventions were documented: Psychiatrist- MD consult for medication review. Date Initiated: 04/06/2021; chair needs to be placed against the wall for stability and resident's name placed on it. Date Initiated: 01/29/2020 and revision on: 01/20/2021; CNAs/Nurses to provide contact guard when transferring from one surface to another and during weighing on standing scale. Date Initiated: 03/17/2021 with revision on: 04/08/2021; Commode placed over toilet/grab bars on toilet to make standing up easier. Date Initiated: 08/19/2019; Non-slip pad placed in seat of Resident's wheelchair, to prevent sliding. Date Initiated: 08/19/2019; R2 has impulse behavior; Nurses utilize PRN [CONDITION(S)] per MD order. Date Initiated: 11/05/2020 and revision on: 03/24/2021; Low bed. Date Initiated: 11/18/2019 and revision on: 01/20/2021; MD notified new order for UA C&S (urine specimen). R2 to be encouraged to sit in wheelchair. Date Initiated: 04/05/2021; medication review and neuro checks. Date Initiated: 02/27/2021; monitor for [CONDITION(S)]. Date Initiated: 08/19/2019; Neurology consult to be scheduled. Date Initiated: 04/12/2021; New wheelchair cushion and antilock brakes to wheelchair. Date Initiated: 01/19/2021 Revision on: 04/08/2021; new shoes provided. Date Initiated: 08/23/2020; new shoes without laces provided. Date Initiated: 09/03/2020; noncompliant with staying in wheelchair. Date Initiated: 11/05/2020; observe frequently and place in supervised area when out of bed. Date Initiated: 08/19/2019; Offered helmet for head, R2 refused. Date Initiated: 09/27/2019; Physical Therapy to evaluate and treat for strengthening and balance. Date Initiated: 08/19/2019. Proper fitting pants provided. Date Initiated: 12/01/2020. Revision on: 04/08/2021. Re-educated resident on fall precautions, need for safety helmet to be worn while out of bed. Date Initiated: 12/04/2019; Resident encouraged to walk with assistance however declines. Date Initiated: 02/10/2020. Resident provided helmet and refused to use it. Date Initiated: 02/10/2020. Resident to be in close area for monitoring to prevent falls. Date Initiated: 11/04/2020. Resident to keep proper footwear on at all times. Date Initiated: 02/10/2020. Resident to wear appropriate footwear. Date Initiated: 02/17/2020. Resident to wear helmet & hip protectors. Date Initiated: 02/17/2020. Revision on: 01/20/2021. Staff educated on fall prevention efforts and strategies. Date Initiated: 08/19/2019. Staff to assist resident by holding chair to prevent tipping when she is attempting to sit. Date Initiated: 09/28/2019. Staff to monitor assist as needed when attempting to sit in chair. Date Initiated: 09/20/2019. Staff to remind resident to not sit in chair with legs crossed. Date Initiated: 11/22/2019. Stationary chair removed from bedside. Date Initiated: 03/21/2020. Revision on: 01/20/2021. Therapy to screen. Date Initiated: 02/17/2020. Toilet program. Date Initiated: 03/25/2021. R2 encouraged to wait for staff prompts while toileting. Date Initiated: 09/04/2020. R2 provided proper fitting pants to prevent pant leg from sagging under her feet causing her to fall. Date Initiated: 08/23/2020; R2 was sent to ER for further evaluation due to laceration to the back of her head after first aid provided. Date Initiated: 04/06/2021. Transferred to hospital. Date Initiated: 12/30/2019; Wheelchair provided for locomotion. Date Initiated: 09/28/2020. Gather information on past falls and attempt to determine the root cause of the fall(s). Anticipate and intervene to prevent recurrence. Date Initiated: 08/19/2019. Be sure call light is within reach and encourage the resident to use it for assistance as needed. Staff to respond promptly to all requests for assistance. Date Initiated: 08/19/2019. Anticipate and meet individual needs of the resident. Date Initiated: 08/19/2019. Complete the Fall Risk Review per the facility protocol. Date Initiated: 08/19/2019. Facility provided brand of helmet R2's wears which is a soft padded helmet which protects against cuts and abrasions. R4 admitted to facility on 1/25/21 with diagnosis of major depressive disorder, hypertension, [CONDITION(S)], acute kidney failure, Alzheimer's disease, and dementia without behavioral disturbances. R4's Minimum Data Set, dated dated dated [DATE] documents a brief interview for mental status score of 0 which indicates cognitively impaired. R4's referral packet contains a social service note dated 1/18/21 documents R2 was sent to hospital on 1/3/21 due to physical altercation with a resident. R2 is at risk for elopement due to wandering and confusion related to dementia. R4's progress note dated 2/4/21 documents: It was reported to the writer that this resident initiated physical aggression on the second floor in their room. It was reported this resident pushed peer out of wheelchair onto the floor. Residents were separated. Writer immediately investigated event. Upon investigation, resident stated I did not push anybody, not that I know of. Writer conducted 1:1 counseling with resident to vent feelings and concerns. Writer encouraged resident to maintain boundaries with peers. Writer encouraged resident to seek staff assistance when situations arise. Resident will be placed on a 72 hour checks. R4's progress note dated 2/11/21 documents: It was reported to the writer from the 2nd floor nurse that this resident initiated physical aggression on peer on the 2nd floor in the room. Resident were immediately separated. Writer investigated immediately. Upon investigation, it was reported that resident was sitting on peers bed. Peer asked resident to leave because she was still trying to sleep. Resident then became agitated and grabbed the toilet seat and attempted to strike peer. Writer attempted to conduct 1:1 counseling with resident. Resident was calm due to not remembering. Resident stated I did not fight with anyone, I have been eating breakfast all morning. Writer encouraged resident to refrain from all forms of aggression. Writer encouraged resident to seek staff assistance as needed. Resident will be petitioned out to local hospital. R4's note do not indicate any hospitalization . Facility unable to provide petition when requested. R4's progress note dated 4/5/21 documents: It was reported to the writer that this resident initiated physical aggression on the second floor in their room. It was reported this resident pushed peer out of wheelchair onto the floor. The residents were separated. A resident claimed her peer came into her room and started touching her tray. Then she grabbed her fruit cocktail and throws it at her. The peer also slapped her hand away. After that, she started messing with her other roommates and sat in her (roomate's) wheelchair. She told her other roommate to pull the call light. She then left out the room and told a nurse. The resident stated that she was trying to find her bed. She also said that she did not throw or hit anybody. The writer conducted 1:1 counseling with the resident to vent feelings and concerns. The writer encouraged the resident to maintain boundaries with peers. The writer encouraged the resident to seek staff assistance when situations arise. The resident will be placed on 72-hour checks. The writer will follow up accordingly. R4's progress note dated 4/25/21 documents: It was reported to the writer that the resident was in a physical altercation with her roommate. The peer stated the resident had poop in her hands. The peer asked her if she could wash. The resident grabbed the tray and hit her with it four times until she stopped. The writer conducted 1:1 counseling with the resident to vent feelings and concerns. The writer encouraged the resident to maintain boundaries with peers. The writer encouraged the resident to seek staff assistance when situations arise. R4's progress note dated 5/5/21 documents: Writer was informed that resident was involved in physical altercation. Resident and peer were immediately separated. Resident was placed on 72-Hour Behavior Monitoring, emotional support and PRN was given. Resident was placed on 1:1 and encouraged to respect peers. Resident was also given time to express concerns in regards to peer and encouraged not to be aggressive towards staff. Resident's peer was also placed on 72-Hour monitoring. Resident was ensured she lives in a safe place. Resident was encouraged to follow-up with staff immediately when a problem arises. R4's screening for indicators of aggressive and/or harmful behaviors dated 1/25/21 documents under risk assessment a score of 4, which indicates potentially able to integrate into the peer community, minimal risk for aggression. Dementia related interventions include re-orientation, re-assurance, and emphasis on safety/security. SMI related interventions include stress management/stress relief, improving communication skills, harm reduction (Score < or = 4). R4's care plan Date Initiated: 02/05/2021 documents Aggression: Resident presents with aggressive behavior due to confusion and disorientation related to diagnosis of Alzheimer. Interventions 5/08-Resident was place on an 1.1 observed due to aggressive behavior. Resident was counseled by this writer an encouraged to refrain from aggressive behavior(s) during this time. Date Initiated: 05/11/2021; Staff will assess resident for underlying medical issues to relate to behavioral outburst. Date Initiated: 05/08/2021; Staff will place resident in less stimulating activities to manage heightened anxiety. Date Initiated: 04/05/2021. Staff will reassure resident she lives in a safe environment. Date Initiated: 04/25/2021. Staff will utilize pharmacological interventions to manage heightened behaviors. Date Initiated: 05/05/2021. Writer encouraged resident to maintain boundaries with peers. Date Initiated: 02/05/2021. Writer encouraged resident to refrain from all forms of aggression. Date Initiated: 02/11/2021. Writer encouraged resident to seek staff before situations arise. Date Initiated: 02/05/2021. Writer encouraged resident to use deep breathing techniques when feeling agitated. Date Initiated: 02/05/2021. Writer encouraged the resident to talk to peers instead of being violent. Date Initiated: 04/28/2021. Writer will attempt to conduct 1:1 counseling for resident to vent feelings and concerns. Date Initiated: 02/05/2021. On 6/3/21 at 1105Am, V4 (PRSD) said R4 could not understand redirection. R4 has history of confusion and wanders. R4 becomes easily startled and will act out in a defensive manner. R4 will rummage through roommate's belongings. Upon review of R4's care plan interventions, V4 said interventions were not effective. Facility policy titled Behavior management for agitated behavior dated 4/20 documents under preventive measures; If not in quiet area consider relocation to appropriate space, own room or other space; when voice is loud, offer drink, food toileting, take for a walk or redirect to activity, observe for behavior escalation of anxiety, aggression, swearing and other irritability.

Based on observation, interview and record review the facility failed to follow their [CONDITION(S)] policy by not ensuring the ostomy device was well fitting to prevent excoriation around ostomy site and failure of obsevation of Ostomy care for 1 of 2 (R1) residents reviewed for ostomy care. This failure resulted in R1 developing an excoriated skin area due to leaking ostomy device/bag, this initial excoriated area went untreated and developed into a large area of excoriation of 14cm x 14cm, which required hospitalization . Findings include: R1 was admitted with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 brief interview for mental status dated 5/17/21 document a score of twelve which indicates moderate impairment. R1 was assessed to be alert and oriented to person, place and time. R1's minimal data set section H (Bladder and Bowel) dated 5/22/21 documents: Ostomy R1's nursing progress notes dated 5/7/21 document: Resident was noted to have large (below breasts to pelvic area) excoriated, draining area. R1 will be transferred to local hospital. On 6/1/21 at 12:05pm, R1 said the redness went away after she was at the hospital but the redness is starting to come back again. R1 said she was using different bags at the hospital and they helped with the ostomy leaking. R1 said she requested the facility to order those bags but has yet to receive them. R1 said she is using previous ostomy supplies provided by facility and she is responsible for all of the care. R1 said the facility only provides supplies and does not change or empty the bag. On 6/1/21 at 12:20pm, R1 was observed with redness and excoriation to the left lower quadrant measuring at 14cm x 14cm by V7 (nurse). Brown dried substance on pants and bed pad similar to stool. On 6/3/21 at 9:31AM, V25 (NP) said R1 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Ostomy leaking could be from not having a good seal around ostomy. On V25's assessment dated [DATE], there was about one inch of redness around stoma site. V25 said she was unaware of any further changes surrounding R1's skin or ostomy site. On 6/10/21 at 10:19 AM, V25 (NP) said on 6/3/21 she changed the treatment plan to R1's skin around ostomy site. V25 said area had worsened from previous assessment (5/27/21). V25 said she is unable to determine how long it would take for excoriation to develop on R1. On 6/4/21 at 10:44 AM, V26 (NP) said R1 was sent to hospital in May after being treated in-house for possible [CONDITION(S)] to abdomen. V26 (nurse practitioner) stated if the ostomy bags (#8578) from the hospital were working and did not cause skin irritation or leakage, the facility should have coverted to those supplies/bags that work. V26 said, R1 is not capable of changing her own ostomy bag. R1's ostomy care must be supervised. V26 said it would take one to two days for excoriation to appear on the skin. On 6/3/21 at 9:38am, V2 (DON) said, the treatment nurse and floor nurse should be looking at R1's ostomy site. R1 is competent to complete her own ostomy care, but it needs to be supervised to make sure R1 is doing it right. The leakage could be contribute to R1 doing her own ostomy care. R1 did not have any new treatment put in place since surveyor requested the measurement of R1's excoriation. R1's medication and treatment record dated May 2021 did not document any assessment or monitoring of ostomy site. R1's nursing progress notes dated 5/12/21 document Resident re admit from Hospital. Resident's [CONDITION(S)] bag is intact, abdomen is free from excoriation. R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Despite improvement in treatment continued issues with bag caused symptoms to worsen, Treated with antibiotics and seen by [CONDITION(S)] RN. Skin improving, slight [CONDITION(S)] no tenderness, otherwise no other concerns reported, [CONDITION(S)] intact and with belt in place. Chronic leaking bag-resolved, continue to use belt, and eliminate use of [NAME] only used as filler, and ensure proper cutting of bag. R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 often does not get a good seal on the ostomy pouch which causes skin irritation when there is leakage. Nursing to follow up with R1 regarding her [CONDITION(S)] self-care. [MEDICATION(S)] 0.1% cream to any irritated skin around the site BID until further notice. R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The [CONDITION(S)] of the abdomen has increased to a larger area again. Per nursing, the bag is frequently leaking due to R1 picking at it. Nurses are changing the bag at least once per day related to poor seal between the skin and the bag. R1 states the area is painful and it is tender to touch. Rash Present, [CONDITION(S)] of the abdomen 5-6 inches square around the stoma area and extending outward with tenderness. R1's Care plan dated 3/13/21 documents: R1 is at risk alteration in skin integrity. Intervention: any skin integrity issues/concerns will be conveyed to the Charge Nurse for further evaluation and treatment changes/new interventions and the doctor will be called as needed. Administer wound care treatment per doctor orders. R1 has incontinence of bowel. Intervention: observed for signs of skin irritation and or breakdown. Report irritation/breakdown to the physician. Facility policy titled [CONDITION(S)] care dated 4/20 documents: Residents with [CONDITION(S)] will receive [CONDITION(S)] care as needed. [CONDITION(S)] care will be done to keep stoma and surrounding skin area clean, to remove and dispose of secretions, to prevent excoriation and eliminate odors. Any significant observations or changes in appearance are supposed to be recorded in the nurse's notes and the physician notified. [CONDITION(S)] care will be done in the same manner as [CONDITION(S)] care.

Based on observation, interview, and record review, the facility failed to ensure that staff protected a confused and dependent resident who was assessed as high risk for physical abuse from another resident with a history of aggression and with criminal felony background; they failed to ensure that resident (R1) was closely monitored after a previous history of threats of violence towards a former roommate; and they failed to ensure that staff provided supervision per facility policy for two of four residents (R1, R2) reviewed for abuse. These failures resulted in R1's physical assault on R2 which required an emergent transfer to the hospital with the following injuries: facial trauma and head trauma, contusions to the face and head, lacerations to his head, face, and arms, eye socket fracture, and nose fracture. Findings include: R2 is a confused [AGE] year old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's most recent MDS (Minimum Data Set) dated 2/18/21, R2 requires extensive assist with most his activities of daily living and is unable to ambulate. R1 is a [AGE] year old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS dated [DATE] shows R1 required only supervision in all his activities of daily living and was able to ambulate freely without any assistance from staff as he was also considered a wanderer and elopement risk. Facility reported incident dated 3/12/21 submitted by V1 (Administrator) states in part (but not limited to): On 3/6/21 facility staff observed R1 exiting his room. While redirecting R1 back into his room, R1's roommate, R2, was noted with injuries to his face. R1 and R2 were immediately separated, and R1 was placed on 1:1 with staff and separated from other residents. R1 stated that he responded to internal stimuli and believed he needed to protect himself. R1 then struck out at R2. While interviewing R1, he reported he was defending himself. Interview with V4 (Social Service Director) on 3/29/21 at 11:40 AM stated, This incident happened on a Saturday or Sunday so I was off. The administrator did the investigation but I did assist in it. (R1) and (R2) were roommates and I was told (R1) was agitated and sat on R2's bed and (R1) hit (R2) with his hands and fist. (R2) was injured I think and he was sent out to the hospital. (R1) is a new resident. I think he was admitted here in January but he has never threatened any other resident and he's pretty confused himself. Surveyor asked if R1 ever exhibited any other agitated or aggressive behavior towards any other residents, V4 stated, No this was the only time. Observations on 3/29/21 at 12:40 PM show R2 in bed but awake. R2 had 4 blackened circular shaped scabs above his forehead and his right eye was redddened and with yellowish tinge showing a previous healing black eye. Surveyor asked R2 if he remembered, what happened to him, R2 stated, Roommate but otherwise could not form complete sentences or coherent responses to questions. Interview with V1 (Administrator) on 3/29/21 at 2:25 PM stated, Everything is listed in the investigation I sent you. I did the investigation along with V4. Surveyor asked if there was any other incidents involving R1, V1 stated, No that was the only one. Review of facility records show however, on 1/26/2021 written by V5 (LPN) at 9:07 PM stated, Behavior Charting Describe Behavior/Mood:: (R3)'s room mate (R1) is attempting to hit him with his belt, he is requesting a room change, he says I am afraid to sleep in the room.What was the resident doing prior to or at the time of behavior/mood: unknown. Interventions attempted: to take the belt from him, resident keeps belt close at hand, resident also walks with belt in his hand.as if he he will hit you. Further records show R1's agitated and aggressive behavior: V6 (Social worker) wrote on 1/28/2021 at 11:26: Resident has refused medication. Writer encouraged resident to take medication. V4 (Social Service Director) wrote on 1/28/2021 3:07 PM Resident petitioned out to the hospital due to exit seeking behavior. Resident continues to present with agitation and irritability. Resident currently on 1:1 with staff. V7 (LPN) wrote on 2/4/2021 at 6:43AM, Resident up in hall, verbally aggressive to staff, refusing to put his mask on, resident in non-re-directable. V8 (LPN) wrote on 2/5/2021 at 6:07 AM, Resident has been up since 1AM, confused, in and out of other residents room, taking their coats,shoes. Resident has been redirected to his room [ROOM NUMBER]x and still continues to go in other residents room to pull their plugs out of their tv, cut their tv off, resident has woke up 5 other residents. resident will not stay with nurse, will not stay in room, just up walking around disturbing others. V9 (LPN) 2/5/2021 at 9:45 pm, Nursing Progress Note Text: Resident medicated per protocol, ambulate per self, resident left 3rd floor to sleep on the 2nd floor. At the time he was on 3 rd floor, he was alert, oriented able to make needs known and denies pain or any discomfort. V10 (RN) wrote on 2/10/2021 at 2:30 PM, R1 is alert, disoriented, but can follow simple instructions. This shift, refusing care, (R1) needs supervision / cues for transfers, eating with supervision, dressing/hygiene with 1 assist. V5 wrote on 2/11/2021 at 12:20 AM, (R1) is alert, disoriented, and cannot follow simple instructions; has difficulty making needs known. This shift, refusing care. V5 wrote on 2/12/2021 at 12:04 AM, Room mate of this Individual just informed the nurse that urine was on the floor. Nurse immediately cleaned up urine from the walk way, from the 1st bed to the front of the bathroom. V17 (Social worker) wrote on 2/14/2021 at 8:26 PM, Resident showed signs of confusion by wandering and going through roommates personal belongings. Writer returned all belongings to roommates and resident apologized. 3/6/2021 at 6:58PM, V11 wrote, Event Note. This resident (R1) is a [AGE] year old African American male. Resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident has a history with wandering due to diagnosis. Resident has a history with agitation and attempting to leave facility unauthorized. It was reported to the writer by the second floor nurse that this resident initiated a physical aggression on the second floor in peers room. Resident stated he does not know what writer is talking about, due to resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It was reported to the writer that this resident wandered into peers room. Peer asked resident to leave, resident got agitated and pushed peer into the wall. residents were separated. Writer attempted to educate resident to seek the staff as needed. Writer attempted to encourage resident to refrain from aggression. Writer attempted to educate resident on deep breathing techniques to decrease agitation. V1 and V4 notified. 3/6/2021 at 10:16 PM, nursing progress note written by V15 (RN) stated, (R2) Resident reported by CNA with blood on his face. Resident is alert, oriented x1, able to talk, no deviation in baseline level of consciousness noted. Assessment done, observed [MEDICATION(S)] wound on forehead and some bruising on right arm. First Aid done, cleansed area with normal saline solution, applied ice. Staff assisted resident in change of clothes. Dr. made aware, initially ordered resident to be sent out to hospital, then was informed that resident is going to another hospital via 911. 3/8/21 at 9:32 PM written by V14 (Nurse Practitioner) wrote: PHYSICIAN PROGRESS: This patient (R2) was sent out to hospital on 3/6 for evaluation after he sustained multiple head wounds. Per Emergency Department records, the patient had brain CT scan with and without contrast. They were presumable negative since the patient was not admitted for observation. The patient has sutures on the outer Right eyebrow as well as scattered on the forehead and in the scalp. The patient has a Right eye contusion with a large amount of thick discharge from that eye. The lids are both swollen. the patient reports a headache but denies nausea, vomiting, change in vision, dizziness. Per nursing, the patient has had a good appetite since his return from hospital and sleeps ok during the night. The patient is quite alert today and answering questions appropriately. The patient had a [CONDITION(S)]/dipheria in the Emergency Department and has been on [MEDICATION(S)] for prophylaxis related to multiple puncture wounds. 3/9/2021 at 7:13 AM, V16 (Wound Nurse) wrote, Skin/Wound Note: Resident received from the hospital on 3/7. Resident assessed by wound nurse. Resident has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident has 2 sutures to the forehead, 3 to the right eye. Eye is black, bruising to the nose. Resident has multiple bruising to the left and right arms. Skin tear to the right arm measuring 8.0 x1.5 centimeters. Treatment in place. 3/31/21 at 8:40 AM interview with V14 (Nurse Practitioner) stated, I saw R2 after he came back from the hospital. I did write that he had sutures on the outer right eyebrow as well as scattered on the forehead and in the scalp. R2 had a right eye contusion with discharge. and both eyes were swollen. Surveyor asked about R2's puncture wounds on his head, V14 stated, Oh yes, I remember seeing them. (R1) may have used some object to inflict those injuries because his hands alone can't make those puncture wounds on R2's head. He must have used some object. Surveyor asked V14 what her thoughts were on what the facility should have done to prevent this, V14 stated, First of all I don't work for that company and I usually come in 4 days a week and see patients and I don't have anything to do with psychiatry. However, my opinion is that sometimes there are issues with patients that should have been placed in a different room or single room to themselves given their history. However, I do know that that the facility has had some issues with their private rooms due to their isolation needs. I do agree however, that if R1 had already had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . I'm not sure why they would have moved him in with R2 who is very dependent. R2's abuse risk assessment dated [DATE] shows that R2 was at risk for physical abuse with risk factors that contributed to this risk as being serious mental illness, reduced social interactions, and frailty and total dependence due to his [CONDITION(S)]. R2's only other abuse risk assessment was created on 3/6/2021, the day of his assault. This abuse risk assessment shows the same risk for physical abuse with an added description entry of Resident received agression from peer. Hospital records dated 3/6/21 show: Assault victim, patient attacked by air mattress inflator (pump) per EMS. [AGE] year old male past medical history significant for [CONDITION(S)], [CONDITION(S)] who presents from prior place for an assault. Patient was attacked by another resident. He was reportedly hit in the face multiple times with an air mattress inflater (mechanical pump). Patient reports diffuse head pain. There's inconsistent reports as to loss of consciousness or the patient's neurologic baseline. Visit Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Laceration of face. 3. Open nasal fracture. 4. Contusion, Avulsion of skin 4/1/21 at 9:06 AM, V1 (Administrator) was asked for their policy on supervision and/or if there was any flow sheet regarding the 1:1 supervision R1 was supposed to be receiving. V1 did not send any 1:1 supervision monitoring flow sheet nor policy requested. Surveyor clarified details about the incident when R2 was attacked, V1 stated, When the incident occured on 3/6/21, I went into the facility to do my investigation. I interviewed staff and was not told there were any weapons involved or if R1 used anything to assault R2. I was told R2 was in bed at the time and when R1 came out of the room he was redirected back inside his room. This was when staff noticed R2 full of blood. His clothes was covered with blood and his bed was covered with blood. R2 cannot walk so he cannot get up from his bed without staff helping him. The staff cleaned him up and they sent (R2) out to the hospital. Surveyor asked again, if there were any other incidents involving R1, V1 stated, Are you referring to when R1 threatened R3 with a belt? Survyeyor then asked if there was an incident report pertaining to that incident, V1 responded, No, I didn't consider that abuse as it was taken care of. Facility policy dated January 4, 2019 titled Abuse Prevention Program states in part but not limited to: This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Resident Assessment: As part of the resident social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis. For residents who are identified offenders, the facility shall incorporate the Identified Offender Report and Recommendations Report into the identified offender ' s plan of care including the security measures listed. Staff Supervision: Supervisors will monitor the ability of the staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs. Situations such as inappropriate language, insensitive handling or impersonal care will be corrected as they occur. Incidents that do not meet the definition of abuse, neglect mistreatment or misappropriation of resident property will be handled through counseling, training and, if necessary or repeated, the facility's progressive discipline policy. Protection of Residents: Residents who allegedly abused 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. Internal Investigation 1. Incidents will be reviewed, investigated and documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. 2. Incidents or allegations involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will be reviewed by administration and shall be investigated, as indicated and appropriate.

Based on interview and record review that facility failed to know when a resident had possession of a razor and failed to have an effective monitoring plan in place to prevent a resident from implementing any attempt to self-harm or possibly kill himself. This applies to one of one resident (R4) identified with a self- harming behavior. As a result, R4 who has a history of self-harm, took a razor and cut both his arms causing massive bleeding and had to be transferred to emergency for treatment. Findings include: R4 is a [AGE] year-old resident admitted to the facility on [DATE]. R4's diagnoses included but not limited to [CONDITION(S)] Disorder, unspecified and Major Depressive disorder, recurrent. R4's social History and Assessment completed on [DATE] indicated a problem with adjustment/mental health behavior issues with a self- harmful behavior. According to an incident report [DATE] at 6:50AM, R4 was observed with bleeding from forearms. Pressure dressing applied. 911 called and resident was transported to the local hospital. R5 (R4's roommate) alerted the facility nurse that R4 was in the washroom where R4 was noted to be bleeding. The facility nurse immediately went to the washroom where R4 was noted to have bleeding coming from bilateral upper forearms. Facility staff called 911 and R1 was transported to the local hospital where he received sutures to both sites. Upon R1's return to the facility, his care plans and assessments will be updated, and 72-hour follow up will be completed. R4's social services notes dated [DATE] at 1:37pm documented; The resident has acknowledged experiencing some anxiety due to infection control and safety practices and changes mandated by the CDC (center of disease), IDPH (Illinois Department Public Health) and CMS (Centers for Medicare and Medicaid Services). R4's social services notes dated [DATE] at 4:50pm documented; writer spoke with resident's psychologist V20 at the VA (veteran administration). V20 identified that resident has been presenting with increased behavior of paranoia and agitation. R4's nurse's notes dated [DATE] at 7:00am documented: resident observed having increased agitation and paranoia. Resident states he is bored and ready to go back to normal. Resident's behavior is being monitored every 15 minutes. R4's social services notes dated [DATE] documented; writer met with this resident to check well-being. R4 appeared anxious and withdrawn. This resident believes he overdosed on water and believes that he is going to hell. [DATE] at 1:30PM, R4 stated, he is a paranoid [CONDITION(S)] and a veteran. R4 stated he cut himself at the facility and does not know why. R4 stated he can't cope. While he was at the hospital the Chaplain told him, he was going to hell, so he cut himself at the hospital. He informed the facility about this incident. Facility had been monitoring and working with him regularly before he cut himself, however he did not give them any indication that he was considering harming himself. The psych doctor never meets with him. He would like to see the psychiatrist and would also like to attend group therapy. R4 stated he has been feeling down. R4 stated part of the reason he feels down is due to isolation and being restricted to the facility and in his room as a result of COVID. Being able to walk around outside the facility would help him feel better. R4 stated the facility has offered him activities and music for psychosocial support. R4 stated he enjoys drinking a 6 pack of soda pop in one sitting. On [DATE] at 1:00PM, the surveyor asked V1 (administrator) how did R4 injury himself? V1 replied with a part of a remote control. The surveyor asked V1 was ever hospitalized for attempting to harm himself. V1 stated the last hospitalized was for [CONDITION(S)]. V1 was asked to present a timeline of how R4 was monitored the late night and earlier morning of the date of the incident for [DATE]. The following information was given regarding a timeline of the incident: V7 (Licensed Practical Nurse/LPN) reported, at 11:55pm R4 in the room sleeping. V18 (certified nurse aide/CNA) reported, at 12:17am R4 was in the room laying across bed. V7 (LPN) reported, at 1am R4 was in bed sleeping. V18 reported at 2:30am R4 was pacing back in forth and came to nurse station for water. V7 reported, at 3:17am R4 came to the nurse's station to ask for water. V18 reported at 4:17am R4 was in his room on the bed. V7 reported at 5:15am R4 was in the bed not sure if he was sleep. V18 reported at 5:45am he was going into the room with a resident. R4 came out the room and went to the nurse station. V18 was providing care to another resident. V7 reported at 6:20am, R5 (R4's roommate) came and asked for more water. He was told he had to be in his room, he was PUI (person under interest for COVID). Morning meds (medications) with water was given and he was told to keep his mask on. V7 reported at 6:50am while she was passing medication, R5 came and got her and said my roommate was in the bathroom for 10 minutes. I have to use it, I tried pushing the bathroom open and saw him on the floor. While the nurses were assisting the resident the battery cover of the remote was noticed. On [DATE] at 1:29PM, V7 reported R4 had been to the nursing station asking for water and asking what time it was. I gave him medication between 5:,d+[DATE]:45 AM. I do my rounds every hour. R5 came to the nursing station and said his roommate was on the bathroom floor. I went to the room and saw blood on the floor. I saw R4 on the floor and I though he may have fallen but I saw the blood coming from his arm. I yelled out for help. Another nurse came to help me put the pressure bandage on the wounds. The surveyor asked V7 to describe the wounds. V7 stated the cuts were deep but she didn't measure them because she was wrapping the resident's arms. The surveyor asked V7 was there much blood? V7 said it was blood in the sink and over the floor. The surveyor asked what did R4 cut himself with? V7 all I could see because the police came, and search was a screw from an electronic device. The surveyor asked V7 if she documented in the resident's medical record would be an accurate account of what happen on [DATE] involving R4's incident? V7 respond, Yes. Two entries were noted in R4's medical records written by V7 as follows: [DATE] 6:50am, This writer was called to his room per roommate stating My roommate is on the floor there is some blood. Resident observed on the floor with cuts to both inner arms, pressure dressing applied. 911 on scene. Administrator made aware. [DATE] at 6:50am, R5 came to nurse's station to inform writer that his roommate had been in bathroom for a few minutes. I attempted to open door and observed resident laying on the floor with blood. This writer went immediately to room and observed resident laying on the floor bleeding from both arms, pressure dressing applied and 911 was called. Police and 911 on scene administrator made aware. Resident transferred to hospital. On [DATE] at 2:54PM, V11 (social worker/ PRSC) was asked by the surveyor how did R4 injure himself on [DATE]? V11 stated, she talked with R4 after he was readmitted and R4 told her he used a razor. R4's physician progress note completed by nurse practitioner dated [DATE] at 11:32am documented; Patient seen in his room, patient was recently hospitalized for slitting forearms with razor, no surgery was needed . Local hospital emergency room records for R4's visit [DATE] indicated: Chief Complaint: Pt (patient) was brought in by EMS (emergency medical service) from the facility for a suicide attempt. Pt cut both wrists and was found unresponsive on the floor. EMS stated CPR due to difficulty feeling pulse. Pt has a pulse upon arrival and CPR was discontinued on route. HPI (History Physical Information): [AGE] year-old with history of [CONDITION(S)] disorder and recurrent visits due to SI (suicidal ideations). Per EMS he was found on the floor with bilateral wrist lacerated and about ,d+[DATE] ml (milliliters) of blood on the floor per the paramedic estimates. ED (emergency department) Course documented: Pt communicated to RN (registered nurse) staff, disappointment on not going to the light and will continue to try until I see it. He (R4) also admitted to me he has chronically been wanting to kill himself I drink a lot of water and I won't stop until I see the light. Pt has history of becoming [CONDITION(S)] and being hospitalized due to excessive free water intake. Procedure Note: Laceration Repair- Description of wounds: 16 cm (centimeters) complex linear wound. The wound was reapproximated in two layers utilizing #29 sutures. The EMS run sheet contained the following information about R4: Dispatched to above location (facility address) for the psychiatric evaluation. Arrived on scene and saw PD (police department) on scene running back into building with an AED (automated external defibrillator). Initial contact with our [AGE] year-old male pt. (patient) lying down outside of the bathroom unresponsive covered in blood. Staff does not know how long pt. is down for. They bandaged and have bleeding controlled on both wrists which have bilateral lacerations deep to the tendon and approx. (approximately) 4 inches. Bathroom floor has approx. 200mL (milliliters) of blood present and it has started to clot. A razor was found in the trash. On return to the facility on [DATE] the following was noted among the hospital's records upon transfer: Behavioral Health Department for a local hospital dated [DATE] had instruction to keep the resident safe including but not limited to removing harmful objects. R4's comprehensive care plan with the date of [DATE] & revision date [DATE] contained the following information: R4 has history of suicidal ideation and attempt. R4 was hospitalized of suicidal ideation/gestures. R4 identified has triggers and stressors as stress and COVID-19. R4's warning sign are also note when he becomes angry, yells or shuts down. Inventions included the following: Educate the resident on coping skills he can utilize when feeling depressed, Initiated [DATE]. Provide resident with 1:1 support when experiencing heightened depression, Initiated [DATE]. Provide resident with [CONDITION(S)] medication as prescribed. Initiated [DATE]. Resident was provided a picture of his niece to place in his room as a protective factor for self-harm, Initiated [DATE]. Resident will be placed on behavior monitoring to assess for suicide behaviors and gestures, initiated [DATE]. Resident will call family such as his sister or father when feeling down or depressed, Initiated on [DATE]. There was no comprehensive plan for monitoring R4 for self-injury behaviors prior to his incident of [DATE] when the resident had a documented increase agitation starting [DATE]. It also, does not identify how R4 injured himself and lead to his last hospitalization . In addition, the care plan does not address R4's behavior of excessive water intake to harm himself.

Based on interview and record review, the facility failed to meet the resident's special dietary requirements by providing her with a food item that did not meet the criteria of the mechanically soft textured diet ordered. This failure resulted in a choking incident for (R1) of rhree residents reviewed for accidents and supervision. R1 was hospitalized and later expired due to asphyxia as a consequence of choking on food. This situation was identified as an immediate jeopardy. The immediate jeopardy began on [DATE]. The immediate jeopardy was identified on [DATE]. The Administrator was notified on [DATE]. The surveyor confirmed by observation, interview, and record review the immediate jeopardy was removed on [DATE] but noncompliance remains at the level two because additional time is needed to evaluate the implementation and effectiveness of the facility's inventions (including staff in-services). Findings include: R1 is a [AGE] year old female who was admitted to the facility on [DATE], with past medical history including, but not limited to [MEDICAL CONDITION], Other Fracture of unspecified lower leg, Sequela, Unsteadiness on feet, [MEDICAL CONDITION] Disorder current episode, stiffness of right shoulder not elsewhere classified, Dysphagia Oral Phase, Cognitive Communication Deficit, Obesity Unspecified, etc. Death certificate documents that R1 expired on [DATE] and lists cause of death as asphyxia as a consequence of choking on food. Per record review, R1 was sent to the hospital on [DATE] after she became unresponsive while eating grilled cheese sandwich for dinner, and as documented in nurse progress note dated [DATE], While resident on supervised eating at nurses station, R1 was noted to drop her head and become limp and flaccid. Staff attended resident immediately, bolus of food removed from mouth. Resident become unresponsive to verbal and tactile stimuli. Pulse check, thready and faint. Lowered resident to floor, rechecked pulse via carotid, and no pulse obtained. CPR initiated. [DATE] at 1:29PM, V6 (C.N.A/Scheduler) stated that she was the person monitoring R1 at the nurses station the day R1 was sent out to the hospital. V6 said that resident stretched her hand out, called her name and laid her head on the nursing station desk. She added that R1 does not need assistance with eating, just monitoring, R1 was eating a grilled cheese sandwich, peas and carrots and milk. As far as she can recall, the grilled cheese was not cut. V6 added that she did not think R1 was choking, she believed R1 was having a [MEDICAL CONDITION], though she removed some food from her cheek, the nurse checked R1's mouth and there was nothing, they laid R1 on the ground and started performing CPR. Nurse also checked her pulse and she was not breathing, R1 eats in her room or in the nursing station. V6 added that she cannot recall what type of diet R1 was getting, but she thinks she was on a regular diet because she had a regular tray that day. [DATE] at 11:21AM, V6 (C.N.A) stated that she was providing visual assistance to R1 the day she was sent to the hospital, she was standing beside resident watching R1 eat, but was not providing any physical assistance. V6 added that the signs to look for when someone is choking is grabbing their neck or chest, she did not perform [MEDICATION NAME] maneuver because R1 was breathing and you do not perform [MEDICATION NAME] maneuver on someone who is breathing. Resident does not require any assistance for eating only supervision. Review of physician order [REDACTED]. MDS (Minimum Data Set assessment) dated [DATE] coded R1 for eating as ,[DATE], meaning supervision with one person physical assist. Care plan for R1 dated [DATE] stated a focus of nutrition concern related to Mechanical soft diet and in the intervention section, the care plan states to monitor for pocketing, supervision at meals to ensure small bites, slow rate and liquid wash, assist as needed with meals, document signs and symptoms of aspiration or choking, etc. In the same care plan, it was documented that R1is currently on a mechanical diet textured and requests a grilled cheese for dinner and regular food for lunch. [DATE] at 12:55PM, V23 (Physical Therapy) stated that residents on one staff physical assist for eating will usually have a C.N.A with them who can assist when needed like for opening a carton of milk or cutting up something. Those who are supervision alone needs to be watched and may not need assistance. [DATE] at 2:16PM, V24 (MDS Coordinator) stated that one staff physical assist means that one staff can assist with cutting something for resident, or help with those that need a little cueing or touch to help them eat. MDS assessment is done for resident's baseline and may not represent their daily need. [DATE] at 2:06PM, V2 (DON, Director of Nursing) stated that he believed grilled cheese is a mechanical soft diet if cut up, pears and carrots can also be considered mechanical soft if cooked soft. [DATE] at 11:09AM, V12 (Dietician) stated that she thinks grilled cheese is appropriate for someone on mechanical soft diet but it could be cut in half. She added that peas and carrots could be appropriate if they are cooked and soft. V12 states that mechanical soft diet should have a soft consistency like ground meat and should not include things like salad or raw vegetables or anything crunchy. [DATE] at 4:14PM, V14 (Speech Therapist) stated that R1 was on her case load from July to October, (R1) had a change in function due to difficulty eating and was downgraded to mechanical soft, supervised eating and small bites at a time. V14 added that someone on mechanical sot diet can have food in the consistency of ground meat, mashed potatoes, bread as long as it is soft and vegetables if it is cooked soft Hospital emergency room (ER) record dated [DATE] states, Patient brought in by EMS after systolic arrest, patient from nursing home with history of MS, patient apparently choked on food. Chief complaint was documented as patient choking on food, CPR initiated by staff. Review of a document titled Diet Manual, Mechanically Altered undated presented by V10 (Dietary Manager) states in part that the liberal diet, mechanical soft is served with the meat mechanically ground (Preferably with gravy), raw and soft fruits will be served without seeds or skin, raw salads will be served finely shredded. In addition to this diet order, the Speech Language Pathologist (SPL) may recommend mixed textures to meet the functional needs of the patient. Review of a menu for grilled cheese sandwich also presented by V10 (Dietary Manager) states after the procedure of washing hands and preparing the food, to refer to the International Dysphagia Diet standardization Initiative (IDDSI) and HACCP guidelines. The guideline outlined IDDSI Level 5, 6 and 7, indicating that level 5 is Minced and Moist, level 6 is soft and bite size and level 7 is easy to chew. [DATE] at 11:45AM, V10 (Dietary Manager) stated that he does not know what the IDDSI levels on their menu stand for, he said that they just follow the menu and any recommendation from the hospital or speech therapy. [DATE] at 12:05PM, V1 (Administrator) stated that the facility is not following the IDDSI guidelines on their menu, they are just following the regular menu. When asked why that is not indicated in their policy, she said, that V10 should have consulted her before giving the surveyor that policy. On [DATE], V19 (Registered Dietician) stated that the International Dysphagia Diet standardization Initiative (IDDSI) guideline is a new consistency system that is being rolled out, it is not a requirement but some facilities are using the guidelines. She added that if a facility is not following the IDDSI guideline, the staff should be made aware of that. Facility census on [DATE] is 221 residents. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: On [DATE], V1 (Administrator) presented list of staff in-serviced on the following: providing resident with food items appropriate for mechanical soft or modified textured diet as ordered by the physician; providing resident with appropriate physical assistance while dining according to the resident assessment and care-plan; re-education included following the policy on a choking resident; and all staff were re-educated on recognizing signs of choking and using the [MEDICATION NAME] maneuver to clear the airway of food particles prior to initiating CPR. The facility also developed an audit and QA (Quality Assurance) tool to monitor staff on an ongoing basis.

Based on interviews and record reviews, the facility failed to implement a plan of care with interventions to include supervison to minimize the risk falling for one resident (R1) in a sample of three reviewed for falls. This failure resulted in R1 having (2) falls on the same day and being sent to the local hospital, where R1 was assessed and admitted for treatment of [REDACTED]. Findings include: On 11/5/2020 at 12:50pm, V6 (nurse) stated that R1 was alert and oriented x 3; able to make needs known. V6 stated that any change in a resident's condition, such as new complaints of pain after a fall, the physician/nurse practitioner should be notified and the resident sent to the hospital for further evaluation. V6 stated that the nurse is expected to complete a head to toe assessment, obtain vital signs, and notify the physician and family. V6 stated that if resident complains of pain or has injury due to fall, the nurse is expected to notify physician. V6 stated that it is up to the physician to determine if resident should be sent to the hospital for further evaluation; unless the resident is unstable, then sent out via 911. V6 stated that each section of the fall report is expected to be completed by the nurse on the day of the fall. On 11/5/2020 at 2:05pm, V3 ADON (assistant director of nursing) stated that R1 had two falls on 6/10/20. V3 stated that after the first fall, V13 LPN (licensed practical nurse) informed V3 that R1's physician ordered intravenous fluids and urgent laboratory testing. V3 stated that R1 was confused and lethargic; symptoms showed some improvement after receiving some intravenous fluids. V3 stated that R1 should have been sent out after this fall when V13 observed R1's left hip swollen and tender to touch. V3 stated that this information was not communicated to V3. V3 stated that staff are expected to complete a fall report after each resident fall. On 11/5/2020 at 2:30pm, V2 DON (director of nursing) stated that staff are expected to notify the physician/nurse practitioner and V2 of any resident fall. V2 stated that staff are expected to complete a fall report noting head to toe assessment findings, vital signs, any predisposing factors, and time physician and family notified. On 11/5/20 at 3:00pm, V11 (nurse) stated that with any resident falls the nurse is responsible for performing head to toe assessment on resident for any injuries; obtain vital signs, ask resident details of fall; notify administrator, physician, and family; and complete a fall evaluation form in resident's medical record. V11 stated that any resident sustaining a head injury or unwitnessed fall will have neurological checks done for 72 hours post fall. V11 stated that any resident presenting with altered mental status, lethargy, abnormal vital signs, and new complaints of pain should be sent to the hospital for further evaluation after notifying the physician. On 11/6/20 at 10:25am, V9 CNA (certified nurse aide) stated that V9 provided care for R1 on 6/10/20. V9 stated that V9 found R1 on floor, R1 was asking for help as R1 was unable to get off floor by self. V9 stated that V9 informed nurse immediately. V9 stated that R1 was confused that day. Review of R1's fall incident report, dated 6/1/2020, notes V10 (nurse) was told by peer that R1 was on the floor in room. V10 went to R1's room, saw R1 standing at bedside. Body assessment done, R1 observed with two long skin tears to inner left arm. No redness, bruising, or swelling noted to left side/hip. R1 complained of pain, as needed pain medication given. R1 stated that R1 was coming out of bathroom and fell on left side. There are no further details documented related to R1's mental status, level of pain, any predisposing environmental/physiological/situation factors, or if physician and family notified. Review of R1's fall incident report, dated 6/10/20 at 8:21am, notes V12 (nurse) was called to R1's room by CNA on duty. Upon entering R1's room, V12 observed R1 sitting on the floor with right arm holding onto bed. Head to toe assessment completed and R1 has small purple and yellowish bruises on both lower extremities. R1's physician notified; no new orders received. R1's family notified. R1 stated that R1 slid onto the floor while trying to transfer self from wheelchair to bed. Mental status: oriented to person; pain 0 out of 10. Predisposing physiological factors: drowsy, confused, sedated. There is no documentation noting vital signs were obtained. Review of R1's fall incident report, dated 6/10/20 at 11:30am, notes R1 with fall. Predisposing physiological factors includes: confused, recent change in condition, gait imbalance, impaired memory. R1's physician and family notified. Review of R1's care plan, initiated 5/16/2019, notes R1 is at risk for falls related to [MEDICAL CONDITIONS], history of [MEDICAL CONDITION], and [MEDICAL CONDITION] medications. This care plan was revised on 10/28/2019. Interventions identified include: R1 educated to use wheelchair at all times, be sure call light is within reach and encourage R1 to use it for assistance as needed, staff to respond promptly to all requests for assistance, antiipate and meet individual needs, and complete the fall risk review. There is no documentation found noting R1's care plan was reviewed after fall on 6/1/20 or if any interventions were put in place to minimize the risk of future falls. Review of R1's hospital record, dated 6/10/20, notes R1 presented to the emergency room after falling at this facility and presented with weakness, low blood pressure, and altered mental status. Blood pressure 75/54. R1 was hypoxic (low oxygen level), tachypneic (increased breathing), and [MEDICAL CONDITION] (increased heart rate). R1 was admitted to the hospital with [REDACTED]. CT (computerized tomography) of abdomen showed an acute comminuted left [MEDICAL CONDITION] with multiple displaced fragments present and bleeding into the surrounding muscle, multiple acute [MEDICATION NAME] (T8, T11) and lumbar (L1, L3, and L4) vertebral bodies compression fractures. R1 withdraws all extremities to painful stimuli, swelling and tenderness to left hip. X-ray of R1's right hip showed chronic right [MEDICAL CONDITION] with possible non-union of the fragments; CT scan showed hardware in the right hip extending across an incompletely healed right [MEDICAL CONDITION]. T2, T9, and T10 vertebral bodies may also be fractured.

Based on interview and record review, the facility failed to provide supervision to prevent residents from becoming involved in a physical altercation. This failure resulted in one of three residents (R4) sustaining a right [MEDICAL CONDITION] and bruising to the right side of the head in a total sample of 11 reviewed for supervision. Findings include: R4 has the following Diagnoses: [REDACTED]. R7 has [MEDICAL CONDITION] disorder [MEDICAL CONDITION] type. On 0[DATE] at 2:55PM, R4 was unable to recall the incident that happened with R7. R4 is not cognitively aware to answer questions. On 02/25/2020, R7 stated, I was getting ready to smoke and V13 (Laundry Aide) grabbed me a chair to sit down. R4 wanted the chair and put her hand on my face. R4 cussed at me. I tried to block her and I pushed her and she fell to the floor. R4 put her hands in my face very quickly, staff could not get to her. Incident report dated 1/20/2020, notes R7 was sitting in a chair near the beauty shop awaiting smoke break. R4 observed R7 sitting in a chair and proceeded over to take the chair. R7 declined to give R4 the chair and R4 reached into R7's face. R7 pushed R4 and she fell to the floor. R4 has a [DIAGNOSES REDACTED]. Witnesses report that R7 was defending herself and did not use a great deal of force during this event. R4 and R7 were separated. R4 was sent to a local hospital and was diagnosed with [REDACTED]. Progress note dated 1/15/2020, notes that R4 was involved in an altercation with R7. R4 was unable to bear weight on her lower extremities, complained of pain to the entire right side of her body, and a contusion noted on the right side of her head. On 02/25/2020, at 12:41PM, V11 (Social Services Assistant) stated, I was coming down to the basement to help with smoke break. I saw R7 push R4. R4 had grabbed R7's face. I cannot recall the staff that was there. On 02/25/2020, at 1:29PM, V13 (Laundry Aide) stated, there was a chair in the hallway. I moved the chair for R7. I turned and walked away. Somehow R4 and R7 got into an altercation. I heard commotion. I turned around and R4 was on the floor. It was smoking time and I could not see any staff. There is usually a smoking monitor, but I could not recall who it was. On 02/25/2020, at 2:12PM, R8 stated, it was smoking time. It was crowded as always. R7 was sitting in a chair and got up. R4 tried to get the chair and pushed R7 in the face. R7 pushed R4. I am not sure who the smoke monitor was. On 02/25/2020, at 2:16PM, R9 stated, R4 got into R7's face and was trying to hit R7. R7 pushed R4 and she fell . Staff is usually outside of the smoking room, handing out cigarettes, not on the inside of the room. There was no staff in the room. It happened so fast. R4 has an anger issue. On 02/26/2020, at 1:21PM, V2 (Director of Nursing) stated, there are psychiatric residents in this facility. Their behaviors can go from one extreme to the other. Residents could fly off of the handle at any moment. Staff are responsible to keep order; that no fighting occurs. There are some areas where residents cannot be supervised. It is unacceptable that this happened and it should not be occurring. R4's care plan documents to observe frequently and place in supervised area when she is out of bed. R4 demonstrates behavioral distress and has a history of physical aggression towards others. R7's care plan notes R7 is at risk for aggressive behavior, poor impulse control, anger/hostility, and has a history of hitting other residents. Ambulance documentation dated 1/15/2020, noted that the ambulance was dispatched to the nursing facility. Upon assessment, R4 was noted to have a head injury; hematoma (bruising) to the right side of her head and pain to her right hip and femur (lower leg) area. Medical records dated 1/15/2020, note R4 was in a fight at the nursing facility. R4 was pushed, fell , hit her head, and landed on her right hip. R4 has a confirmed right [MEDICAL CONDITION].

Based on observation, interview and record review, the facility failed to follow care plan interventions and their Aspiration Precautions and Care Plan polices and procedures, failed to have a comprehensive care plan addressing aspiration precautions and failed to have the necessary emergency equipment on a crash cart, for one of three residents (R1), reviewed for incidents/accidents in the sample of four. These failures resulted in R1 choking on a grilled cheese becoming unresponsive 911 called cardiopulmonary resuscitation being administered, R1 arriving at the hospital in [MEDICAL CONDITION]/asystole. Findings include: Review of facility's final incident report (04.06.2018) notes: . (R1) was noted in hall way by staff under distress. Staff approached resident who was unable to speak and grabbing (R1's) throat. Staff immediately responded by performing [MEDICATION NAME] on resident. Code Blue and 911 initiated. [MEDICATION NAME] noted to be successful as resident stated I can't breathe while attempting to ambulate. Staff redirected resident to remain calm and in place while staff continued to provide resident with care. Resident then became nonresponsive. Staff began CPR and continued until EMT/Fire Department arrived. Resident was transported to local hospital ED. Facility contacted local coroner office cause of death accidental, choking on food bolus. Review of R1's ambulance run sheet narrative (04.01.2018) documents: Called to the nursing home for the patient choking. Upon arrival patient was supine floor w/ (with) staff doing Cardiopulmonary resuscitation compressions only. Per staff patient was choking and they tried to perform abdominal thrusts but patient went unresponsive. Staff states they slowly lowered patient to floor. Cardiac monitor applied and asystole showing. Cardiopulmonary resuscitation and ventilation continued. Patient's airway was clogged with food particles. Food was large enough that it could be removed with forceps. Once airway was cleared patient was intubated with a 7.5 tube and placement verified with proper lung sounds .I/o (intraosseous) initiated in patient's left leg. Three rounds ([MEDICATION NAME]) pushed via i/o. Patient remained asystole throughout run. High quality Cardiopulmonary resuscitation maintained constant throughout call. (Local hospital) contacted and patient transported to (local hospital). Review of R1's emergency room Record (Emergency Department Triage Form, 04.01.2018) documents: Chief Complaint: Patient arrived in [MEDICAL CONDITION]/asystole (asystole), from (nursing home), (R1) choked on food prior to arrival, EMS found patient apneic and in asystole patient arrived in ER intubated with 3 Epi given prior to arrival and Cardiopulmonary resuscitation in progress. Review of R1's MDS (Minimum Data Set, 03.01.2018) documents: -BIMS (Brief Interview for Mental Status) of 9 (moderately impaired) -Eating ,[DATE] (limited assistance/one person physical assist) -Active Diagnoses: [REDACTED]. V6 (Licensed Practical Nurse, 05.03.2018 at 10:48 AM and 05.10.2018 at 3:08 PM) said V6 gave R1 a grilled cheese sandwich. She said R1 walked away with the sandwich, I had my back to (R1), then, ,[DATE] minutes later, I heard (R1's) choking, (R1's) choking. V6 said R1 had (R1's) hand to (R1's) throat, (R1's) mouth was wide open, as if (R1) was choking. V6 said there was no [MEDICATION NAME] suction catheter(rigid, curved catheter with smooth edges) on the crash cart. V6 said V6 felt not having a [MEDICATION NAME] on the crash cart made a difference, you can't control those flexible catheters. V13 (Speech Language Pathologist, 05.04.2018 at 11:48 AM) said V13 last saw R1 over a year ago for diet modification. R1 already had a [DIAGNOSES REDACTED]. V13 said R1 required this modified diet because R1 had difficulty chewing and was on swallow precautions because of R1's impulsivity, (R1) ate really fast. V13 said I recommended (R1) be supervised in the dining room for meals. (R1) shouldn't have been in the hallway eating. V13 said compensatory strategies for R1 included monitor for slow rate and alternating liquids/solids. V8 (CNA-Certified Nursing Assistant, 05.03.2018 at 2:19 PM) said R1 began to eat the grilled cheese sandwich offered to R1 by V6 and then left the dining room. V8 said R1 should have been in the dining room so that staff could monitor R1. R1 should have been supervised because R1 was on a mechanical soft diet with thickened liquids. They always tell us when someone is on a mechanical soft diet to watch them. V9 (CNA, 05.03.2018 at 3:06 PM) said V6 gave R1 a grilled cheese sandwich. V9 said V9 was still in the dining room when V9 heard someone say (R1's) choking. V9 said V9 left the dining room, found R1 in the hallway. V9 said V9 performed the [MEDICATION NAME] and saw grilled cheese sandwich come up. V9 said R1 was on a mechanical soft diet because R1 had difficulty swallowing and shouldn't have been in the hallway eating. V9 said the suction machine didn't have enough suction and V6 was using a small catheter to suction R1. V12 (LPN, 05.10.2018 at 11:10 AM) said R1 was on a mechanical soft diet with thickened liquids and was not allowed to eat in R1's room. V12 said R1 required supervision including cueing to slow down (when eating) and to take small bites. V14 (CNA. 05.04.2018 at 3:22 PM) said R1 didn't like R1's diet and would take food from peer's trays as well as trays on tray cart; only regular consistency. V14 said R1 wasn't allowed to eat in R1's room because resident was on choking precautions. R2 (Director of Nursing, 05.04.2018 at 1:42 PM) said residents who are on mechanically altered diets must eat in the dining room. R2's Physician order [REDACTED]. R2's diet ticket notes NCS Mechanical Soft (No concentrated sweets, mechanical soft), Nectar Thick Liquid-Aspiration Precautions. R2's care plan (Problem start date 06.18.2015, last reviewed/revised 01.22.2018) states: Resident is on a therapeutic mechanically altered diet with nectar thick liquids Interventions include Encourage resident to eat slowly. Review of R1's Speech Therapy SLP (Speech Language Pathologist) Evaluation & Plan of Treatment (12.24.2015) documents under Recommendations: Swallow Strategies/Positions: To facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake; alteration of liquids/solids, rate modification, bolus size modifications and general swallow techniques/precautions. This was the only Speech Therapy documentation provided by the facility to this writer; swallow strategies were not listed on meal ticket or added to R1's care plan. Review of the facility's Aspiration Precautions Policy states: 1. B. Feed according to recommendations. Review of the facility's Care Plan policy states: A. Policy: All residents will have comprehensive assessments and an individualized plan of care developed to assist them in achieving and maintaining their optimal status. Review of R2's Certificate of Death Worksheet documents R1's immediate cause of death as Choking on food bolus. Review of the facility's Nursing Crash Cart Audit Tool and Crash Cart Equipment list (located on top of crash carts) state that there should be two [MEDICATION NAME] in Drawer B of crash cart. Crash carts were inspected on 05.14.2018 from 3:35 PM to 4:22 PM. The following issues were found with two of three of the facility's crash carts: 2nd Floor Crash Cart Drawer A -expired IV Administration Set (10.2017) 1st Floor Crash Cart Drawer A -expired 24 G x ,[DATE] inch needles x4 (x2 2014, x2017) -expired IV Start Kit x2 (08.2017) -expired 1 ml syringe 29 G x ,[DATE] inch syringe x5 (10.2017) -IV Administration Kit (10.2017) -expired [MEDICATION NAME] Needle-Pro (07.2017) -expired Angiocath Autoguard 24 G x 0.75 inch x3 (x1 02.2015 with non-intact wrapper, x2 10.2017) -expired 22 G needle (10.2014) Drawer B -expired [MEDICATION NAME] x1 (only one on cart, 04.2018) -expired connector tubing (suction tubing-06.2017)

Based on observation, interview and record review, the facility failed to provide the following services to prevent physical harm: to follow care plan interventions, to follow their Aspiration Precautions and Care Plan policies and procedures, failed to have a comprehensive care plan addressing aspiration precautions and failed to have the necessary emergency equipment on a crash cart, for one of three residents (R1), reviewed for incidents/accidents in the sample of four. These failures resulted in R1 choking on a grilled cheese becoming unresponsive 911 called cardiopulmonary resuscitation being administered, R1 arriving at the hospital in [MEDICAL CONDITION]/asystole. Findings include: Review of facility's final incident report (04.06.2018) notes: . (R1) was noted in hall way by staff under distress. Staff approached resident who was unable to speak and grabbing (R1's) throat. Staff immediately responded by performing [MEDICATION NAME] on resident. Code Blue and 911 initiated. [MEDICATION NAME] noted to be successful as resident stated I can't breathe while attempting to ambulate. Staff redirected resident to remain calm and in place while staff continued to provide resident with care. Resident then became nonresponsive. Staff began CPR and continued until EMT/Fire Department arrived. Resident was transported to local hospital ED. Facility contacted local coroner office cause of death accidental, choking on food bolus. Review of R1's ambulance run sheet narrative (04.01.2018) documents: Called to the nursing home for the patient choking. Upon arrival patient was supine floor w/ (with) staff doing Cardiopulmonary resuscitation compressions only. Per staff patient was choking and they tried to perform abdominal thrusts but patient went unresponsive. Staff states they slowly lowered patient to floor. Cardiac monitor applied and asystole showing. Cardiopulmonary resuscitation and ventilation continued. Patient's airway was clogged with food particles. Food was large enough that it could be removed with forceps. Once airway was cleared patient was intubated with a 7.5 tube and placement verified with proper lung sounds .I/o (intraosseous) initiated in patient's left leg. Three rounds ([MEDICATION NAME]) pushed via i/o. Patient remained asystole throughout run. High quality Cardiopulmonary resuscitation maintained constant throughout call. (Local hospital) contacted and patient transported to (local hospital). Review of R1's emergency room Record (Emergency Department Triage Form, 04.01.2018) documents: Chief Complaint: Patient arrived in [MEDICAL CONDITION]/asystole (asystole), from (nursing home), (R1) choked on food prior to arrival, EMS found patient apneic and in asystole patient arrived in ER intubated with 3 Epi given prior to arrival and Cardiopulmonary resuscitation in progress. Review of R1's MDS (Minimum Data Set, 03.01.2018) documents: -BIMS (Brief Interview for Mental Status) of 9 (moderately impaired) -Eating ,[DATE] (limited assistance/one person physical assist) -Active Diagnoses: [REDACTED]. V6 (Licensed Practical Nurse, 05.03.2018 at 10:48 AM and 05.10.2018 at 3:08 PM) said V6 gave R1 a grilled cheese sandwich. She said R1 walked away with the sandwich, I had my back to (R1), then, ,[DATE] minutes later, I heard (R1's) choking, (R1's) choking. V6 said R1 had (R1's) hand to (R1's) throat, (R1's) mouth was wide open, as if (R1) was choking. V6 said there was no [MEDICATION NAME] suction catheter(rigid, curved catheter with smooth edges) on the crash cart. V6 said V6 felt not having a [MEDICATION NAME] on the crash cart made a difference, you can't control those flexible catheters. V13 (Speech Language Pathologist, 05.04.2018 at 11:48 AM) said V13 last saw R1 over a year ago for diet modification. R1 already had a [DIAGNOSES REDACTED]. V13 said R1 required this modified diet because R1 had difficulty chewing and was on swallow precautions because of R1's impulsivity, (R1) ate really fast. V13 said I recommended (R1) be supervised in the dining room for meals. (R1) shouldn't have been in the hallway eating. V13 said compensatory strategies for R1 included monitor for slow rate and alternating liquids/solids. V8 (CNA-Certified Nursing Assistant, 05.03.2018 at 2:19 PM) said R1 began to eat the grilled cheese sandwich offered to R1 by V6 and then left the dining room. V8 said R1 should have been in the dining room so that staff could monitor R1. R1 should have been supervised because R1 was on a mechanical soft diet with thickened liquids. They always tell us when someone is on a mechanical soft diet to watch them. V9 (CNA, 05.03.2018 at 3:06 PM) said V6 gave R1 a grilled cheese sandwich. V9 said V9 was still in the dining room when V9 heard someone say (R1's) choking. V9 said V9 left the dining room, found R1 in the hallway. V9 said V9 performed the [MEDICATION NAME] and saw grilled cheese sandwich come up. V9 said R1 was on a mechanical soft diet because R1 had difficulty swallowing and shouldn't have been in the hallway eating. V9 said the suction machine didn't have enough suction and V6 was using a small catheter to suction R1. V12 (LPN, 05.10.2018 at 11:10 AM) said R1 was on a mechanical soft diet with thickened liquids and was not allowed to eat in R1's room. V12 said R1 required supervision including cueing to slow down (when eating) and to take small bites. V14 (CNA. 05.04.2018 at 3:22 PM) said R1 didn't like R1's diet and would take food from peer's trays as well as trays on tray cart; only regular consistency. V14 said R1 wasn't allowed to eat in R1's room because resident was on choking precautions. R2 (Director of Nursing, 05.04.2018 at 1:42 PM) said residents who are on mechanically altered diets must eat in the dining room. R2's Physician order [REDACTED]. R2's diet ticket notes NCS Mechanical Soft (No concentrated sweets, mechanical soft), Nectar Thick Liquid-Aspiration Precautions. R2's care plan (Problem start date 06.18.2015, last reviewed/revised 01.22.2018) states: Resident is on a therapeutic mechanically altered diet with nectar thick liquids Interventions include Encourage resident to eat slowly. Review of R1's Speech Therapy SLP (Speech Language Pathologist) Evaluation & Plan of Treatment (12.24.2015) documents under Recommendations: Swallow Strategies/Positions: To facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake; alteration of liquids/solids, rate modification, bolus size modifications and general swallow techniques/precautions. This was the only Speech Therapy documentation provided by the facility to this writer; swallow strategies were not listed on meal ticket or added to R1's care plan. Review of the facility's Aspiration Precautions Policy states: 1. B. Feed according to recommendations. Review of the facility's Care Plan policy states: A. Policy: All residents will have comprehensive assessments and an individualized plan of care developed to assist them in achieving and maintaining their optimal status. Review of R2's Certificate of Death Worksheet documents R1's immediate cause of death as Choking on food bolus. Review of the facility's Nursing Crash Cart Audit Tool and Crash Cart Equipment list (located on top of crash carts) state that there should be two [MEDICATION NAME] in Drawer B of crash cart. Crash carts were inspected on 05.14.2018 from 3:35 PM to 4:22 PM. The following issues were found with two of three of the facility's crash carts: 2nd Floor Crash Cart Drawer A -expired IV Administration Set (10.2017) 1st Floor Crash Cart Drawer A -expired 24 G x ,[DATE] inch needles x4 (x2 2014, x2017) -expired IV Start Kit x2 (08.2017) -expired 1 ml syringe 29 G x ,[DATE] inch syringe x5 (10.2017) -IV Administration Kit (10.2017) -expired [MEDICATION NAME] Needle-Pro (07.2017) -expired Angiocath Autoguard 24 G x 0.75 inch x3 (x1 02.2015 with non-intact wrapper, x2 10.2017) -expired 22 G needle (10.2014) Drawer B -expired [MEDICATION NAME] x1 (only one on cart, 04.2018) -expired connector tubing (suction tubing-06.2017) Review of R1's medical record (Progress Notes 09.28.2017 and 10.20.2017 written by V16 Psychiatric rehabilitation Services Coordinator) document: monthly wellbeing check. Writer met with resident to discuss wellbeing, resident is alert and oriented at this time, resident denies any pain, issues or concerns at this time, resident as (has) aggressive behavior and also pick up other peer food. Resident was encouraged to seek staff assistance as needed, resident was encouraged to participate in the activities of the facility and to be in compliance with medication regimen, resident verbalized understanding to writer, and staff will follow accordingly. The progress note written by V16 for 10.20.2017 is exactly the same as the progress note V16 wrote on 09.28.2017. Progress note for 11.28.2017 written by V16 is the same as the previous two notes with the exception that V16 documents resident always stated (stating) he needs his tooth pull (pulled). Progress Note (09.09.2017 written by V16) documents Resident presented with constant behavior has (as) evidenced by picking up other peers food tray in the second floor dining room. Resident was unable to be redirected. Staff will follow up accordingly. Progress Note (10.13.2017 written by V16) documents Writer was informed that resident can only drink nectar thick liquids, resident was educated but resident not receptive as evidenced by resident not been (being) able to compliance (comply) with redirection of staff, resident shout at staff and go behind staff. Staff will continue to monitor and follow up accordingly.

Based on interview and record review the facility failed to ensure that supervision was implemented for 2 of 3 residents(R1,R2), in the sample of 13, reviewed for supervision. This failure resulted in R1 entering the 3rd Floor tub room undetected at an undetermined time. R1 was found unresponsive, floating face down in the tub. R1 was later pronounced dead at the facility. Findings include: The facility's incident report (Initial and Final of 8.24.16) notes in part: At approximately 8:15pm R2 went into the tub room and observed R1 in the tub face down with blood in the water. R2 immediately went to get E2 (LPN-Licensed Practical Nurse), the nurse on duty. R1 is a full code. E2 called a code blue and 911 was called. The water was drained from the tub and R1 was brought to the floor where CPR was initiated and continued until EMS arrived. Blood was noted coming from R1's nose during chest compressions. No injuries noted. Police arrived at 8:30pm with EMS coming at 8:35pm. E2 last came into contact with R1 at approximately 4:30pm while administering his medications. E3 ( CNA-Certified Nursing Assistant) last came into contact with R1 at approximately 6:00pm during dinner. R1 had not voiced any complaints to either E2 or E3 (. R1 had last seen Physician on [DATE] with nothing remarkable noted. No s/s (signs/symptoms) noted today or in history. Local Police was notified of the event CR#,[DATE]. M.E. (Medical Examiner) Evidence Technicians arrived to complete their report. Per M.E. Technicians they did not see any obvious physical trauma to R1. R1 was transported to the M.E.'s office at 10:30pm. Review of R1's medical record (Face Sheet, Progress Notes) notes in part, R1 was admitted to the facility on 7.5.16 with [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set 7.12.16, Section G0120. Bathing) scores R1 as ,[DATE] (Self-performance/Support provided) or Supervision-oversight help only/Setup help only. R1's Psychosocial Well-Being care plan (7.5.16) notes in part (under Problem), Resident experiences delusions per admission papers . R1's documented long term goal is: Resident's delusions will not interfere with resident's ADLs (Activities of Daily Living) . Approaches include in part, Ensure resident safety. Additional review of R1's care plans notes a care plan with following problem: Resident is limited in ability to bathe self r/t (related to) [DIAGNOSES REDACTED]. Goal: Resident will shower body 2x per week with supervision from staff through next review. R2 (8.26.16 at 10:00 AM) said in part, he went into the 3rd Floor tub room, at approximately 8:00 PM or a little after on the date of the incident, to get hot water to make instant coffee. R2 said he saw R1 face down under water in the tub, there was blood in the water and streaming from (R1's) mouth. R2 said he immediately told nurse (E2), who went to the tub room and called a Code Blue. R2 said he did not see R1 go into the tub room. R2 said prior to the incident, there were no locks on any shower/tub room doors on any of the units; residents could come and go to shower/tub rooms at will on any day at any time. R2 said staff staff would occasionally check on residents in the shower/tub rooms, but didn't check all the time. E2 (8.30.16 at 3:05 PM) said in part, a resident called someone's in the bath tub. E2 went to tub room and found R1, undressed, on right side, face down in the water in bath tub. E2 shook R1, called his name; R1 was unresponsive. E2 said he left the tub room to call Code Blue. E2 returned to the tub room, drained water from tub; staff responding to Code Blue helped E2 get R1 out of the bath tub. CPR was initiated; 911 was called. CPR was continued until paramedics arrived and took over. E2 said he saw R1 at 4:30 PM when he gave R1 his medications; R1 left the floor after he got his medications. E2 said he was not aware that R1 was in the tub room. E2 said CNAs are supposed to conduct hourly checks on residents and code residents location (on Daily Round sheet). E2 said staff do not stay in shower/tub room while resident(s) is/are bathing; We tell them to pull the call light if they need us. E2 said he is not aware of any policy or expectation that staff will periodically check shower/tub rooms. E3(CNA, 8.26.16 at 2:23 PM and 8.31.6 at 2:30 PM) said in part, she didn't see R1 when she arrived on the floor at 5:00 PM and began her rounds. She said she first saw R1 around 6:00 PM walking past the Nurses Station. E3 said she does hourly rounds and documents (codes) on Rounds Sheet residents' location. The Rounds Sheet for 8.24.16 was reviewed. No codes were documented for all of the residents for the entire 3(PM)-11(PM) shift. E3 said she was not aware that R1 had gone into the tub room. E3 said her usual routine is to stay with residents while they are bathing; if resident does not want E3 in room, E3 will leave when asked and then periodically check on resident. E5 (RN-Registered Nurse, 8.30.16 at 4:30 PM) said she was working on the 3rd floor but not on the floor when R1 was discovered in the bathtub. E5 said she did not see R1 prior to the incident. E5 said she sometimes checks on residents when they are bathing, but not all the time. E5, when asked if she was aware of any policy that staff check on residents while they're bathing, said; Not that I know of. E5 said staff (Nurses and CNAs) should check on residents when they're bathing. E6 (CNA, 8.31.16 at 12:29 PM) said in part, she makes hourly rounds on the unit and codes whereabouts of residents on Round Sheet. If a resident is not seen for more than two-three hours, E6 said she will check with the nurse on the unit and also with security to see if they have seen that resident. E6 said it is not her routine to check shower/tub rooms during hourly rounds. E6 said some residents she would check on, others she wouldn't (while they were bathing); if she knew a resident didn't want her in there, she wouldn't go in because she wouldn't want to upset the resident. E7 (CNA, 8.31.16 at 12:46 PM) said in part, she makes hourly rounds; if she hasn't seen a resident in more that an hour she will check with the nurse and also come to security and check the in/out file. E7 said she doesn't routinely check the shower/tub rooms during her hourly checks and would check the shower room (not the tub room) only if she knew a resident was going to take a shower. R3 (8.30.16 at 10:31 AM) said in part, when staff are busy they don't check on residents in the shower rooms. R4 (8.30.16 at 10:49 AM) said in part, They don't actually check on me unless I'm in there (shower room) too long. R8 (8.30.16 at 1:03 PM, wearing helmet) said in part, he has a history of seizures and wears helmet (for protection) in case he has a seizure. R8 said he gets his linen from the linen room; We're not supposed to but the CNAs are busy, so I just ease in there and get my linens. R8 said he takes a bath or shower every day and staff have never checked on him when he's bathing nor have they stayed with him. During a group interview (8.31.16 at 10:09 AM) R9 said in part, staff never checked on him (while he was bathing) until just recently. R10 said in part, staff never checked on her (while she was bathing) prior to locks being installed (on shower/tub rooms doors). E1 (Administrator, 8.31.16 at 3:12 PM) said in part, Round Sheets were in place when he started working at the facility; CNAs were in the habit of checking on residents every hour so, we continued it. E1 said the expectation is staff will check on residents every two hours as per facility policy. E1 said prior to the incident on 8.24.16 involving R1, no shower or tub room door in the facility had a lock. Locks were put on all shower/tub room doors after the incident as a preventative measure to ensure incident doesn't happen again. E1 also said most residents on the 3rd floor are independent and prior to the incident, there was no policy/procedure requiring staff to stay with or check on residents while they are bathing.