Every finding on record at Chicago Ridge SNF

Based on interview and record review, the facility failed to follow their abuse policy and failed to protect one resident (R12) from physical abuse by R148. This failure affected one (R12) resident in a sample of 63 residents reviewed for abuse. These failures resulted in R12 being physically assaulted by R148, causing R12 to sustain bruising of right eye, right elbow, and multiple rib fractures that required hospitalization.Findings include:R12's face sheet documents an age of [AGE] years old and diagnoses that include but are not limited to multiple fractures of the ribs, left side, dementia, lack of coordination, muscle wasting and atrophy. R12's BIMS (brief interview for mental status) score, dated 12/02/25, is 12 which indicates R12's cognition is moderately impaired.R12's progress note, dated 8/21/25 at 12:00pm, documents, in part, It was reported to staff that resident (R12) was allegedly involved in social inappropriate interaction with peer. Both residents were separated immediately and placed on 1:1. Resident (R12) did verbalize that she feels safe in the facility. Resident (R12) was reminded she lives in a safe facility and staff is here to assist as much as possible. Resident (R12) was also reminded to report any incidents immediately to staff. Resident (R12) was reminded of coping skills of breathing in and out, watching television, and reading a book. Resident was reminded that social services always has their door open for any resident's concerns/issues. Resident (R12) was reminded to respect others and boundaries. Resident was reminded to attend psychosocial service group therapy Mon-Fri to help alleviate mood concerns or seek SS for 1:1 counseling. R12's progress note, dated 8/21/25 at 5:31pm, documents, in part, Resident (R12) Left the facility this afternoon on the stretcher with ambulance and two agents by her (R12) side to hospital for evaluation. R12's hospital records, dated 8/21/2025, documents, in part, (R12) presents for evaluation after physical altercation at nursing facility where she (R12) was punched in the left lower rib cage and also the right eye. Pt (R12) with bruising to R (right) eye and R (right) elbow. Found to have multiple fractures of left ribs. Plan for admission for continued monitoring given patient's age and risk for respiratory decline with multiple rib fractures. ED (Emergency Department) Diagnosis 1. Closed fracture of multiple ribs of left side, initial encounter. 2. Contusion of face, initial encounter. 3. Victim of assault. R12's x-ray of chest, dated 8/21/25, documents, in part, Findings indicative of posterior left seventh through ninth rib fractures. R12's progress note, dated 8/22/25 at 12:34pm, documents, in part, Writer called hospital and talked to nurse. Resident (R12) is going to admit with diagnosis of multiple left side rib fracture. On 2/04/2026 at 11:51am, R12 said, Oh, that was a while ago. Yeah, she (R148) was blaming me (R12) for the smoking times getting shortened or something. She (R148) was yelling at me and then I started yelling back. I got up to go back inside and she (R148) punched me (R12) in the face and then my side. There were a bunch of punches, almost felt like 2 people could have been hitting me (R12). She's (R148) always yelling at someone. I don't know. I think there was one staff member out there. I can't remember. I don't know which staff. Yeah, couple broken ribs, but I'm still moving. I mean, I guess I feel safe here. I have a lot of friends here. I don't want to leave. R12's care plan, dated 8/21/25, documents, in part, My (R12) comprehensive assessment reveals a hx (history) of suspected abuse &/or neglect or factors that may increase my susceptibility to abuse/neglect. R148's face sheet documents an age of [AGE] years old and diagnoses that include but are not limited to anxiety, schizoaffective disorder, alcohol abuse, and opioid dependence. R148's BIMS (brief interview mental status) score, dated 1/05/26, is 15 which indicates R148 is cognitively intact. R148's progress note, dated 8/21/25 at 12:00pm, documents, in part, It was reported to staff that resident (R148) was allegedly involved in social inappropriate interaction with peer. Both residents were separated immediately and placed on 1:1. Resident (R148) did verbalize that she feels safe in the facility. Resident (R148) was reminded she lives in a safe facility and staff is here to assist as much as possible. Resident (R148) was also reminded to report any incidents immediately to staff. Resident (R148) was reminded of coping skills of talking to the family, breathing in and out, and watching television. Resident was reminded that social services always has their door open for any resident's concerns/issues. Resident (R148) was reminded to respect others and boundaries. Resident (R148) was reminded to attend psychosocial service group therapy Mon-Fri to help alleviate mood concerns or seek SS for 1:1 counseling. On 2/04/26 at 1:45pm, R148 said, She (R12) kept pushing into me (R148) and walking into me (R148). So, I punched her (R12). How many times is someone going to run into someone? I'm gonna defend myself. I had to my whole life. I don't know how many times I punched her (R12). I know I did punch her (R12) in the face. R148's care plan, dated 1/22/24, documents, in part, The resident (R148) demonstrates significant mood distress related to: Feeling angry, guilty and/or out of control (e.g., powerless, hopeless, incomplete, incompetent).R148's care plan, dated 1/23/25, documents, in part, I (R148) demonstrate behavioral distress related to: Problems are manifested by: Verbally abusive behavior when agitated. Problems are manifested by: Physically abusive behavior when agitated. I (R148) presented verbal and physical aggression towards peer.R148's care plan, dated 8/21/25, documents, in part, I (R148) have a history of aggressive, inappropriate, attention-seeking and/or maladaptive behavior, but has demonstrated stability during the admission screening process & is therefore considered appropriate for admission. The history includes: Conflicts/altercations with others. Verbal or physical aggression. The resident (R148) has a diagnoses of: severe, chronic persistent mental illness. The resident (R148) has a diagnoses of: subs abuse disorder. The Resident (R148) has poor judgement & at times show being in denial of her Mental Health conditions, which can lead to depression. The Resident (R148) does at times show aggression but is easily redirected. The Resident (R148) does have signs of attention seeking as well as getting frustrated when not shown the attention she is seeking. I (R148) presented verbal and physical aggression towards peers.R148's progress note, dated 8/05/25 at 2:00pm, documents, in part, It was reported to staff that resident (R148) was allegedly involved in social inappropriate interaction with peer. Both residents were separated immediately and placed on 1:1. Resident (R148) did verbalize that she (R148) feels safe in the facility. Resident (R148) was reminded she lives in a safe facility and staff is here to assist as much as possible. Resident was also reminded to report any incidents immediately to staff. Resident (R148) was reminded of coping skills of breathing in and out, watching television, listening to music, and talking to family. Resident (R148) was reminded that social services always has their door open for any resident's concerns/issues. Resident (R148) was reminded to respect others and boundaries. Administration and DON was made aware. MD made aware. Message left for guardian. Police was called and notified. Care plan and assessment updated accordingly. R148's progress note, dated 8/05/25 at 8:59pm, documents, in part, One of staff members told the writer that the resident (R148) was allegedly involved in social inappropriate interaction with another resident in the smoking area. Both residents were separated immediately and placed on 1:1. Head to toe assessment was completed with no injury noted. MD (Medical Doctor), DON (Director of Nursing), Nurse consultant and family were informed. The psychiatrist called and gave the order of sending the resident to hospital ER (emergency room) for Psych (psychiatry) evaluation. R148's progress note, dated 1/22/25, documents, in part, It was reported to writer that resident (R148) was allegedly involved in an altercation with peer. Both residents were separated immediately. Resident (R148) was reminded she (R148) lives in a safe facility and staff is here to address all her (R148) concerns and issues. Resident (R148) was counseled on conflict resolution skills. Resident (R148) was encouraged to utilize appropriate language and communication when any disagreements occurs. Resident (R148) was educated on behavior management techniques. Resident (R148) was educated to utilize coping strategies for managing heightened agitation. Resident (R148) was encouraged to report all derogatory behavior to staff. Resident (R148) was receptive towards counseling at this time. Care plan and assessment updated. SS (Social Services) will continue to assist. On 2/05/26 at 11:29am, V26 (Psychiatric Rehabilitation Services Coordinator/PRSC) said, I wasn't there (8/21/25). I cannot tell you what really happened. I was notified about it. She (R148) said she (R148) didn't do anything. It was reported by staff. I do not remember what staff. She (R12) bumped into her (R148), maybe cross paths. I wasn't aware that she (R12) had rib fractures. I'm sorry. I don't know much about the incident (8/21/25).On 2/05/26 at 1:59pm, V19 (Licensed Practical Nurse/LPN) said, I was at the nurse's station and Social Services came and said there was an altercation at smoking area. My patient was R12. R148 was claiming R12 hit her, so R148 hit R12 back. R12 denied hitting R148. I can't remember if R12 had injuries, but I did call the doctor, and the doctor gave an order to send R12 out. I think the rib fractures (R12) were prior to this (incident of 8/21/25). Let me check and find out for sure.On 2/05/26 at 3:10pm, V19 (LPN) said, I just checked into R12's rib fractures, and the rib fractures were not old. We (facility) don't have a copy of the x-ray results, but I read a few notes, and it looks like R12 was sent to the hospital the day of the altercation on the 21st (8/21/25) and came back with fractured ribs.On 2/5/26 at 3:44pm V34 (Psychiatric Rehabilitation Services Coordinator/PRSC), said, Yes, I was there (8/21/25). We (V34 and residents) was on the patio. I don't remember if other staff were out there. R12 seemed to get frustrated and round up, and I tried to redirect but she (R12) fell. She (R12) was trying to move to fast, and moved her chair, and slipped and fell. R12 and R148 were arguing back and forth. I heard them (R12 and R148) arguing, and tried to figure it out, and redirect her (R12) back in the building. I did not even see anyone hit anyone. I couldn't figure out what they (R12 and R148) were arguing about.On 2/05/26 at 3:56pm, V25 (Physician) said, Another resident punched her (R12) in the chest. I have been there for two or three years, and I have seen residents become aggressive; it happens frequently. When a person with rib injuries takes a deep breath, it causes pain and can lead to complications such as pneumonia or pneumothorax. If narcotics are administered, they may mask the pain, but healing will not occur. I understand that the pain is significant; however, masking the pain is not appropriate. Ice should be used instead. The benefits and risks must be carefully considered.On 2/6/2026 at 11:11 AM, V1 (Administrator) affirmed that V1 was on vacation and that V36 (Regional Nurse Consultant) was the abuse prevention coordinator in V1's absence. On 2/6/2026 at 11:16 AM, V36 (Regional Nurse Consultant) affirmed that V36 was the abuse prevention coordinator in V1's absence when the allegation occurred between R12 and R148. V36 explained that it was reported to V36 that R12 was pushed by R148. The facility completed an investigation, interviewed staff and residents and the statements showed that R12 was not pushed, that R12 was pushing her (R12) weight trying to get through people and fell. Staff attempted to redirect her (R12), but it was unsuccessful, and she (R12) fell. R12 was sent to the hospital and sustained a rib fracture. She (R12) uses a rolling walker and often does not use it as intended, she (R12) picks it up instead of walking with it, which I think contributed to the situation. V36 stated that there was no video footage of the incident. Residents have the right to be free from abuse.Record review of resident witness interviews for FRI (facility reported incident), dated 8/21/25, documents, in part, that the residents present at the time of the incident did not see anything. Record review of facility policy titled, Abuse Prevention Program Facility Policy and Procedure, dated 1/14/19, documents, in part, Abuse is defined as the willful infliction of injury with resulting physical harm pain or mental anguish. Instances of abuse of all residents irrespective of any mental or physical condition cause physical harm pain or mental anguish. It includes verbal abuse sexual abuse physical abuse and mental abuse including abuse facilitated or an able through the use of technology. Willful, is used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 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. Informing local law enforcement first suspected physical abuse involving physical injury inflicted on a resident by another resident except in situations where the behavior associated with dementia or developmental disability.Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. You should receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to ensure that the ice machine and the ice machine filter were kept clean and free of dust; and the ceiling air vent above the juice dispenser was free of accumulated dust. These failures have the potential to affect all 197 residents that receive oral foods from the facility's kitchen.Findings include:On 2/2/26 after the entrance conference, V1(Administrator) presented the facility's census as 199, minus 2 residents who have NPO status (receive nothing by mouth), total of 197 residents who receive food from the kitchen.On 2/2/26 between 10:10am and 10:30am during observation of the kitchen with V7(Dietary Manager), the ice machine in the kitchen was observed with visible accumulated dust, and visible dirt. V7 stated that the ice machine is supposed to be wiped every day. On 2/5/26 at 11am, the ceiling air vent above the juice dispenser machine was observed with a lot of accumulated dust. V7 stated that the juice machine is in use and there should be no dust in the vent right above where juice is served for the residents. V7 stated that Maintenance would be notified to clean the ceiling vent.Facility's policy titled Chest/Ice Scoop/Ice Machine Cleaning and Disinfecting dated 8/2020 states: Purpose - To Plan and reduce the microorganisms on an inanimate object rendering it safe for use. The ice chest shall be cleaned and sanitized routinely by the dietary department. The ice machine will be cleaned and disinfected monthly by the dietary department. #3: Scrub all surfaces of machine using a clean cloth and fresh detergent solution.Facility's undated Dietary Daily Cleaning Schedule states Clean the ice machine, cards, and clean the walls by the ice machine.

Based on observation, interview, and record review the facility failed to ensure the opened container of the multi blood glucose test strips was labeled with the open date. These failures have the potential to affect six residents (R27, R63, R115, R122, R185, and R221) who received blood glucose monitoring tests residing on the first floor and reviewed for laboratory storage in the sample of 63 residents.Findings include:On [DATE] at 11:17am, with V18 (Registered Nurse/RN) during the observation of medication storage, an opened container of the multi blood glucose test strips with no open date labeled was observed in the medication cart on the first floor. The label on the container of multi blood glucose test strips states open date with a blank place to write the open date on the container. This observation was pointed out to V18. V18 stated, It's (open date) not on there. Let me check because it (open date) might be somewhere else on the bottle. Well, it's (open date) not on here (opened container of the multi blood glucose test strips). The strips expire after a certain number of days once the bottle is opened. Ummm. I'm not sure how long after the container is opened that the strips expire. I think like 30 or 60 days or something. I can check though. If the glucose strips are expired, they (glucose strips) might not work. Yes, possibly give a wrong result too.On [DATE] at 4:21pm, V2 (Director of Nursing) said, Yes, glucometer strips, once you open the bottle expire sooner. I'm not exactly sure how long after it's (glucometer strips container) opened, maybe 30 days expiration. Yes, the glucometer strips have to be labeled once they (glucometer strips container) have been opened. Nothing should be given or used if it is expired.Record review of facility presented document title, (Name of Facility) Blood Sugar Entry, dated [DATE], lists the six (R27, R63, R115, R122, R185, and R221) residents who receive blood glucose monitoring tests on the first floor.Record review of manufacturing manual inside the container of multi blood glucose test strips title (Blood Glucose Monitoring) Test Strips, undated, documents, in part, When you first open the vial, write the date on the vial label. Use the test strips within 3 months of first opening the vial. Do not use test strips beyond the expiration date.Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. You should receive the services and/or items included in the plan of care.

Based on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were five medication errors out of 26 medication opportunities, resulting in a 19.23% medication error rate and affected four of four residents (R40, R95, R171, and R179) observed for medication pass. Findings include: On 2/05/26 at 8:55am, the following was observed while V20 (Registered Nurse/RN) passed medications: R40 was not administered Cholecalciferol 1000 Units (omission error). R40 requested a stool softener and was administered Docusate 100mg (unauthorized medication). Record review of R40's MAR (medication administration record) documents an order for Cholecalciferol Tablet 1000 unit Give 1 tablet by mouth one time a day for low Vit D due 8:00am, and lacks an order for Docusate 100mg. R95 was not administered Procardia XL 60mg (omission error). Record review of R95's MAR (medication administration record) documents an order for Procardia XL Oral Tablet ExtendedRelease 24 Hour 60 MG (Nifedipine) Give 1 tablet by mouth one time a day due 8:00am. R171 was not administered Docusate 100mg (omission error). Record review of R171's MAR (medication administration record) documents an order for Docusate Sodium Oral Capsule 100 MG (Docusate Sodium): Give 100 mg by mouth two times day due for 8:00am. R179 was prepared to receive a dose of Levetiracetam that exceeded the prescribed order (inaccurate dose). V20 was observed, holding a medication cup in the air, pouring 10 ml of Levetiracetam in a medication cup for R179. Review of R179's Medication Administration Record (MAR) indicated an order for Levetiracetam 5 ml by mouth twice daily for unspecified convulsions. Prior to administration, the surveyor questioned the 10 ml dosage prepared for administration. Surveyor requested V20 to put R179's medication cup with Levetiracetam on a flat surface to ensure the dosage was accurate. In response, V20 put R179's medication cup with Levetiracetam on the medication cart (flat surface) and verified that 10 ml of Levetiracetam was in the medication cup. V20 obtained an oral syringe, withdrew 5 mL of Levetiracetam from the medication cup, and returned the remaining 5 mL to R179's Levetiracetam bottle. Record review of R40, R95, R171, and R179's MAR showed the following: As of 2/05/2026 at 10:26am, R40's 8:00am dose of Cholecalciferol, was not signed out as given or refused by V20 (Registered Nurse/RN). As of 2/05/2026 at 10:24am, R95's 8:00am dose of Procardia XL was not signed out as given or refused by V20 (Registered Nurse/RN). As of 2/05/2026 at 10:15am, R171's 8:00am dose of Docusate was not signed out as given or refused by V20 (Registered Nurse/RN). As of 2/05/2026 at 10:30am, R179's 8:00am dose of Levetiracetam was not signed out as given or refused by V20 (Registered Nurse/RN). On 2/5/26 at 4:21pm, V2 (Director of Nursing/DON) said, Double dose of Levetiracetam potentially could cause a person that has a seizure disorder to have a seizure or adverse reaction. Yes, medications should be given per physician's order. Yes, after a medication is given, the medication should be signed off immediately after the medication is given. If a medication is held for whatever reason, the medication also needs to be documented as not given right away. Record review of facility policy titled, Policy and Procedure Medication Administration, dated 1/2025, documents, in part, To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Medications shall be administered in physician's written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. The individual administering the medication shall initial the resident's Medication Administration Record (MAR) on the appropriate line and date for that specific day after administering the medication. 9. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that particular drug and document a rationale. 10. If it is discovered, the person administrating medications has forgotten to initial in the appropriate space, the supervisor shall notify that person to investigate if the medication/treatment has been administered/performed. If the response indicates the medication/treatment was administered the staff member shall return to the facility, initial the MAR. A late entry note will be documented indicating the administration of the medication. If the medication was not administered the missed dose/medication error protocol shall be followed. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. You should receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift on the first floor and failed to ensure the narcotic count was correct for two residents on the second floor. These failures have the potential to affect nine residents (R24, R31, R60, R63, R102, R18, R148, R185, and R221) receiving controlled substances on the first floor and two residents (R151 and R163) receiving controlled substances on the second floor reviewed for medication administration in a sample of 63 residents. Findings include: On 2/4/26 at 11:01am, during observation of the second floor's controlled substances inventory with V17 (Licensed Practical Nurse/LPN). Surveyor observed R151's Controlled Drug Receipt/Record/Disposition Form for Buoren/Nalox Film 8 - 2mg which indicated a remaining count of 4 films; however, the actual count revealed 3 films. V17 stated, Oh, I haven't signed the one I gave this morning. V17 affirmed that the medication should be signed immediately after giving the medication. Also observed R163's Controlled Drug Receipt/Record/Disposition Form for Lacosamide 200mg tab indicated a remaining count 4 tablets; however, the actual count revealed 3 films. V17 stated, Yeah, again, I didn't sign out the ones from the morning after I gave them. Record review of facility document, untitled, undated, documents, in part, that there are 9 residents (R24, R31, R60, R63, R102, R18, R148, R185, and R221) receiving controlled substances on the first floor for the medication cart observed by surveyor. On 2/4/26 at 11:17am, during observation of the first floor's controlled substances inventory with V18 (Registered Nurse/RN), surveyor observed the Controlled Substances Check Form with the following: 2/4/26: The signature for the ongoing nurse was missing for AM (morning) shift.1/30/26: The signature for the off going nurse was missing for PM (evening) shift.1/30/26: The signature for the ongoing nurse was missing for AM shift.1/21/26: The signature for the off going nurse was missing for PM shift.1/20/26: The signature for the off going nurse was missing Night shift.1/20/26: The signature for the ongoing nurse was missing for PM shift.1/19/26: The signature for the off going nurse was missing for Night shift.1/19/26: The signature for the ongoing nurse was missing for PM shift.1/16/26: The signature for the off going nurse was missing for Night shift.1/16/26: The signature for the ongoing nurse was missing for PM shift.1/14/26: The signature for the off going nurse was missing for Night shift.1/11/26: The signature for the off going nurse was missing for Night shift.1/11/26: The signature for the off going nurse was missing for AM shift. On 2/4/26 at 11:17am, V18 (Registered Nurse/RN), said, I still need to sign off this morning. Yes, I did the count with the night nurse. I'm not sure why I didn't sign off. Yes, the controlled substance shift count should be signed off right away. On 2/5/26 at 4:21pm, V2 (Director of Nursing/DON) said, Narcotic (controlled substances) counts have 2 nurses perform a narcotic count on and off duty every shift. The reason the count is done is because if you come up short, you need to explain why the count is off. It's (controlled substance count) also done for safety all away around. Checks and balances per law under your license. Record review of facility policy titled, Policy and Procedure Controlled Medication, dated 1/2025, documents, in part, 3. Narcotic medication that is administered should be signed out on the individual narcotic sign out record and medication administration record (MAR). 4. The individual narcotic-controlled medication sign-out record should include the date and time given, dosage, signature of the nurse administering the medication, and the number of remaining medications. 6. Two nurses must count narcotics at the beginning and end of each shift, initialing the narcotic count record. The two nurses counting should be the incoming and outgoing nurses. 7. If there is a discrepancy in the narcotic count, the DON/designee should be notified immediately. If the DON/designee cannot reconcile the count, the administrator is notified. Record review of facility's Controlled Substances Check Form, undated, documents, in part, Irregularities must be reported immediately to the Director of Nurses.Record review of facility policy titled, Policy and Procedure Medication Storage, dated 1/25, documents, in part, Narcotics should be maintained in the medication cart and counted daily or destroyed if permanently discharged .

Based on observation, interview, and record review, the facility failed to follow their policy to provide wound care services in alignment with professional practice standards by permitting a wound care Certified Nurse Assistant to remove a stage 4 sacral area wound dressing and clean the wound site. The facility failed to have the low air loss mattress at the correct weight settings. The facility also failed to provide wheelchair cushions as a pressure ulcer prevention intervention for residents at risk for pressure ulcers. These failures have the potential to affect six residents (R1, R6, R11, R16, R21, and R46) reviewed for pressure ulcer care, prevention, and interventions, in a total sample of 63 residents. Findings include: On 2/2/26 at 10:45am and 12pm, during observation of residents in the Activity Room, R6, R1, R11, R21, and R46 were observed sitting in the wheelchair without pressure relieving cushion/devices. V13(Certified Nurse Assistant/CNA) in the dining room was notified and stated that those residents not sitting on cushions did not have any, and restorative staff need to provide cushions for them. V13 stated that she was aware that residents' skin can break down if they don't have cushion in the wheelchair. Again, during and after lunch around 1:30pm, the residents were still in wheelchairs without cushions. On 2/4/26 at 12:40pm, the residents still did not have wheelchair cushions. At this time, V21(Restorative Nurse) was notified and stated that she already notified the administrator, and they ordered the cushions for the residents some time ago, but they have not received any cushions yet. V21 added that the residents should have cushions on wheelchairs to prevent pressure ulcers. 1.) R6's Records show the following: Face sheet shows diagnoses which include but are not limited to Type 2 Diabetes with Foot Ulcer, Fracture of Left Lower Leg, Peripheral Vascular Disease, Morbid Severe Obesity, Depression, and Schizoaffective Disorder Bipolar Type. Pressure Ulcer assessment dated [DATE] shows that R6 is at risk for pressure ulcer. MDS (Minimum Data Status) section M dated 1/16/26 states that R6 is at risk of developing pressure ulcers/injuries. Care plan dated 4/17/25 states: R6 is at increased risk for alteration in skin integrity related to: Diabetes, limited mobility, and Resistant/Non-compliant with overall plan of care 2.) R11's records show the following: Face sheet shows diagnoses which include but are not limited to Disorganized Schizophrenia, Protein Calorie Malnutrition, and Acute Respiratory Failure with Hypoxia. Pressure Ulcer Risk assessment dated [DATE] shows that R11 is at risk for pressure ulcer. MDS section M dated 12/8/25 states that R11 is at risk of developing pressure ulcers/injuries. Care plan dated 6/27/25 states: R11 is at increased risk for alteration in skin integrity related to protein calorie malnutrition. 3.) R21's records show the following: Face sheet shows diagnoses which include but are not limited to Obesity, Dementia, Affective Disorder Bipolar Type, Low Back Pain, and Presence of Right Artificial Hip Joint. Pressure Ulcer assessment dated [DATE] shows that R21 is at risk for pressure ulcers. Care plan dated 8/26/25 states: R21 is at increased risk for alteration in skin integrity related to dx: dementia, incontinence of bowel and bladder and impaired mobility, and has MASD (Moisture Associated Skin Damage) to bilateral buttocks. 4.) R46's records show the following: Face sheet shows diagnoses which include but are not limited to Weakness, Schizoaffective Disorder Bipolar Type, Vitamin D Deficiency, and Obesity. Pressure Ulcer Risk assessment dated [DATE] shows that R46 is at risk for pressure ulcer. MDS section M dated 1/7/26 states that R46 is at risk of developing pressure ulcers/injuries. Care plan dated 12/5/24 states: R46 is at risk impaired skin integrity due to weakness and impaired mobility. 5.) R1's records show the following: Face sheet shows diagnoses which include but are not limited to Severe Protein Calorie Malnutrition, Dysphasia, Gastrostomy Type 2 Diabetes, Dementia, Schizophrenia, This Is Affective Disorder Bipolar Type, Hemophilia and Hemiparesis. Pressure Ulcer assessment dated [DATE] shows that R46 is at risk for pressure ulcers. MDS section M dated 1/7/26 states that R46 is at risk of developing pressure ulcers/injuries. Care plan dated 9/29/25 states: R1 is at increased risk for alteration in skin integrity related to dx: Diabetes Type 2 and hemiplegia, needs assistance with ADLs and is incontinent of bowel and bladder, and has a moderate rash to the groin, and bilateral buttocks related MASD. 6.) R16's current diagnoses include but are not limited to End Stage Renal Disease, Chronic Kidney Disease, Type 2 Diabetes Mellitus, Hypertension, Osteomyelitis, Sacral Region Stage 4 Pressure Injury to the Coccyx, and Palliative Care. R16's comprehensive assessment section C Cognitive Patterns dated 01/14/2026 documents a brief interview for mental status score of 8 out of 15 indicating he has moderate cognitive impairment. On 02/04/2026 at 11:21 AM, R16 was observed in bed on a low air loss mattress that is set to a weight of 400 lbs (pounds). V25 (Wound Care Certified Nursing Assistant/CNA) entered R16's room with supplies for his wound care and set them up on the bedside table next to the bed. V25 and V21 (Wound Care Nurse) put on isolation gowns, gloves, and pulled R16's privacy curtain. V25 approached R16's bed. This surveyor asked V21 (Wound Care Nurse) who V25 was and V25 said, I'm the CNA. V21 said, I'm the Wound Nurse. On 2/4/2026 at 11:26 PM, V25 (Wound Care CNA) entered the room, removed R16's soiled dressing to R16's sacral/coccyx area, removed V25's gloves, used hand sanitizer, and cleaned R16's wound with normal saline. V21 (Wound Care Nurse) described the wound stating, It's a stage four pressure ulcer, no tunneling, and it has a small area of slough. The wound care doctor comes every Tuesday, but she didn't come yesterday. R16's wound bed was observed to be pink with no foul odor or drainage noted. V21 then applied (Brand name ointment) and Calcium Alginate and covered the sacral wound with a 4 x 4 bordered gauze. On 02/04/2026 at 11:36 AM, V21 (Wound Care Nurse) was inquired of V25 (Wound Care CNA) doing wound care for R16. V21 stated, She's just supposed to prep it (the wound). That's how it's been since I've been here. She takes off the old bandage and she'll clean the area, and I come and put on the dressing and whatever order says. On 02/04/2026 at 11:47 AM, R16's physician orders for the coccyx wound were reviewed in electronic medical record. The order dated 2/4/2026 at 2:30 PM states to cleanse coccyx with NSS (normal saline solution) pat dry apply honey and alginate cover with dry dressing. Pressure reduction mattress in place date ordered 01/06/2026. On 02/04/2026 at 12:02 PM, V21 (Wound Care Nurse) was inquired about R16's low air loss mattress. V21 said, I think the floor nurses do the low air loss mattress. He has it because of his pressure ulcer to prevent wounds. It's to help his wound heal and prevent new wounds from developing. I'm not sure how it should be set for him, I'd have to check. On 02/05/2025 at 10:41 AM, V2 (Director of Nursing) was inquired about wound care. V2 said, V21 Wound Care Coordinator is responsible for wound care and on the weekends the floor nurses carry out the orders for it. CNAs aren't allowed to do any wound care. The CNA isn't a wound care nurse. The treatment wouldn't be effective. I didn't have any knowledge of CNAs doing wound care. This surveyor requested documentation of V21's wound care training for review. V2 did not provide the requested training documentation prior to the exit of the survey. On 02/05/2026 at 12:12 PM, R16 is asleep in bed on the low air loss mattress. The mattress is set to 400 lbs (pounds). R16's electronic medical documentation states a weight of 135.2 lbs (pounds) on 01/07/2026. There is no documented weight for February 2026. R16's 01/27/2026 physician wound care documentation by V30 (Nurse Practitioner) states in part: Wound care was placed on consult for evaluation and management. Objective: Sacrum: 1. Stage 4 pressure injury to coccyx (tail bone). Measures 8 x 5 x 1.5 cm (centimeters) with circumferential undermining (the separation of skin edges from underlying tissues creating a pocket of dead space in chronic non-healing wounds which indicates extensive damage) with deepest measurement of 3 cm. Wound is 70% granular tissue, 30% necrotic tissue (dead, non-viable tissue). Bone exposed. Moderate serous exudate (a thin watery clear to yellow fluid that seeps from blood vessels into tissues during the inflammatory phase of wound healing). Assessment: Stage 4 pressure injury to coccyx. Plan: Recommend honey (medical grade- a sterilized, antibacterial and anti- inflammatory agent used to treat chronic and acute wounds) and calcium alginate (wound dressing) with dry dressing daily and prn (as needed). Due to patient's multiple comorbidities, he is at high risk for developing new and worsening wounds. R16's 12/01/2025 revised care plan states in part: R16 has a stage IV (4) pressure ulcer on his coccyx. Goal: Management of the pressure ulcer. Intervention: low air loss mattress initiated 11/20/2025, Provide skin care per facility guidelines and PRN as needed date initiated 10/20/2025, Provide wound care per treatment order date initiated 10/20/2025. The (Low Air Loss Mattress) Operation Manual states in part (brand name) system is designed for prevention, treatment, and management of pressure ulcers. The (brand name) pump is a smart pump simple to operate and easy to use, constantly providing pressure redistribution and support to patients. The (brand name) system is intended to reduce the incidence of pressure ulcers while optimizing patient comfort. It also provides the following: Individual customized setting capability. Pain management as prescribed by a physician. PRODUCT FUNCTION Pump Unit The functions of the pump for (brand name) system are described below. v Power Key(1) Ø Press Power key on the panel, the pump will start/stop operation. v Press Weight Range(2) Ø Press minus or plus buttons to select the correct patient weight. Weight/Pressure set up Users can adjust air mattress to a desired firmness according to patient's weight or the suggestion from a health care professional. The Policy titled Pressure Injury Prevention was reviewed. Dated 10/2026 and revised 12/2025, the policy stated that the purpose is to provide guidance on how to prevent pressure injury. The procedure is 1. Maintain clean/dry skin during daily hygiene measures. 2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. Report immediately to the nurse any new or worsening skin concerns. 3. Moisture barrier may be applied by CNAs as needed and may be kept at the bedside. 4. Residents may wear briefs in bed for comfort or during episodes of diarrhea. 5. Change bed linen whenever soiled with urine, feces or other material. 6. Turn and reposition dependent residents. 8. Assist resident with active and/or passive range of motion exercises as ordered by physician to improve circulation. 9. Pressure reduction mattress will be used for residents who are at moderate to high risk of skin breakdown. Pressure relieving mattress will be used for residents who are at severe risk of breakdown. 10. When using low air loss mattress, follow manufacturer's instructions related to use, setting and care. 12. Use positioning devices to relieve the pressure from heels, toes, knees and ankles. 13. Encourage residents to maintain adequate nutrition. 14. Offer snacks and fluids at regular intervals, as needed. 15. Refer to the dietitian and physician as needed. The Job description titled Certified Nursing Assistant updated 7/24 was reviewed and states in part responsibility for this position is with the Director of Nursing. The purpose of this position is to assist the nurses in the providing of resident care primarily in the area of the daily living routine. Main duties include 1. Support the facilities philosophy of care and strive to achieve its goals and objectives. 2. Be sensitive to residents' families and respond in an appropriate professional way as the situation required. 3. Carry out assignments for resident care including (but not limited to): bathing, dressing, grooming, shaving, feeding, restorative nursing procedures. 4. Keep resident' beds, dresser, bathroom, and general living area clean and tidy. 5. Answer call lights promptly, 6, Help check in all new residents and readmissions, as well as assist in the transfer of residents to different rooms. 7. Put resident's clothing away properly. 8. Report any changes in resident's condition – e.g. eating habits, behavior, temperature, etc. to the charge nurse of the unit. 9. Turn bedridden residents every two hours or sooner as indicated. 10. Wash, clean and dry all incontinent residents. 11. Assist the treatment nurse as assigned. 12. Complete assignment report to charge nurse at the end of each shift. 13. Be responsible for well-being and nursing care of all residents assigned to his/her unit while on duty. 14. Take vital signs and monthly weights (with assistance) and record results in EMR. 15. Document the following in the EMR for all assigned residents: a. vital signs, b. weight, c. meal intake, d. bowel and bladder, e. restorative records. 16. Detect and report situations that have a high probability of causing accidents or injuries to residents and/or staff. 17. Assure that work/assignment areas are clean and free of hazardous conditions i.e. spills, excess cart, etc. and that equipment, tools, supplies, etc. are properly stored while working, as well las before leaving such areas for breaks, mealtimes and end of the workday. 18. Assure that established infection control and universal precaution practices are maintained when performing nursing procedures. 19. Follow established safety precautions when performing tasks and when using equipment and supplies. 20. Assure that equipment is cleaned and prepared for the next shift. 21. Assure that work schedules are followed. 22. Maintain the confidentiality of resident information and honor his/her personal and property rights. 23. Attend nursing department, care plan and other meetings as directed by the Director of Nursing or Assistant Director of Nursing. 24. Attend and participate in in-service educational classes and on-the-job training programs as scheduled or as directed. 25. Turn in days off and payroll special request forms in a timely manner. 26. Follow established fire, disaster, safety, infection control and evacuation policies and procedures. 27. Perform other related duties as directed by the DON, ADON, charge nurse or the administrator. V21's (Wound Care Nurse) 12/09/2025 signed Treatment Nurse Job Description was reviewed. It states that the primary purpose of your job position is to provide primarily skin care to residents under the medical direction and supervision of the residents' attending physicians, the Director of Nursing Services or the medical Director of the facility, with an emphasis on treatment and therapy of skin disorders. You will also assist in modifying the treatment regimen to meet the physical and psychosocial needs of the resident, in accordance with established medical practices and the requirements of this state and the policies and goals of this facility. Duties and responsibilities include 1. Confer with the Director of Nursing Services and/or other licensed nursing personnel regarding dermatologic disorders of residents in the facility. 5. Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc. 7. Make written and oral reports/recommendations to the attending physician, Medical Director or the Director of Nursing concerning the status of are of the residents. Under Personnel Functions, the treatment nurse duties and responsibilities include 2. Meet with and solicit advise from the Medical Director, Director of Nursing Services and nursing staff concerning the dermatologic care of residents. Under Medical Care Functions, duties and responsibilities include 1. Identify, manage and treat specific skin disorders and primary and secondary lesions, such as skin abrasions, foot problems such as corns and callouses, decubitus ulcers, bacterial, parasites and viral skin infections, scaling papular diseases, and benign tumors. 2. Provide assessment and diagnostic services to residents. Perform an assessment evaluation using techniques including observation, inspection and palpation. 6. Ensure that residents with decubitus ulcers receive appropriate prophylaxis and treatment, such as daily inspection, turning and activity, a well-planned diet, and maintaining a clean, dry bed.

Based on observation, interview, and record review, the facility failed to assess the restorative needs and provide a left-hand resting hand splint for one resident with hand contracture to prevent further decline. This failure affected one resident (R21) of two residents, reviewed for restorative care, in a total sample of 63 residents.Findings include: On 2/2/26 between 10:35am and 11:55am, R21 was observed in the wheelchair in the hallway with left hand wrist contracted, and the left-hand fingers were in a fist. R21 did not have a device to prevent further contractures.On 2/4/26 at 12:00pm, R21's left hand was still in the same condition. R21 was asked if staff came to encourage him to do exercise his arm and hand, but R21 stated that no one had done anything for him.On 2/4/26 at 12:35pm, V21 (Restorative Nurse) stated I'm new here. I work together with Therapy department to know what needs to be done for each resident, but I'm not aware that his hand is contracted. V21 stated the restorative nurse usually will see the resident and assess the resident to see what restorative services will benefit the resident or refer the resident for therapy.On 2/4/26 at 12:45pm, V22(Therapy Manager) came and stated that no one told them that R21 has contracture. V22 asked R21 to open his hand and stretch the wrist, but R21 attempted it and said it was painful. V22 stated He will benefit from a left-hand resting splint. V22 stated later presented the physician order sheet dated 2/4/26 that states Apply left hand resting splint daily every morning. Remove before bedtime and assess skin with each removal.Face sheet shows that R21 was admitted to the facility on [DATE] with diagnoses which include but are not limited Obesity, Schizoaffective Disorder Bipolar Type, Low Back Pain, Presence of Right Artificial Hip Joint.Care Plan dated 2/15/24 states in part: (R21) will engage in active range of motion active range of motion (AROM) to all 4 extremities.Facility's Restorative Nursing Care Policy dated 9/14 states in part: It is the policy of this facility that a resident is given the appropriate treatment and services to maintain or improve his/her abilities, as indicated by the president's comprehensive assessment, to achieve and maintain the highest practicable outcome. #3: The facility's restorative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. #5: The resident care plan, the goals of restorative nursing care are reinforced in the restorative services.Facility's document Restorative Nurse Job Description states in part: #3 - Evaluate all newly admitted residents for their rehabilitation/restorative appropriateness. Review quarterly and with change of condition. #15: Consult and coordinate with the physical, occupational, and speech therapist and other adjunctive professionals each residence rehabilitation plan of care and follow up with the related staff and personnel. #22: Supervise the management of the rehabilitative/restorative equipment such as special mattresses, wheelchairs, walkers, restraints, and splints.

Based on observation, interview, and record review, the facility failed to ensure that a resident's indwelling urinary catheter drainage bag was covered with a privacy bag to maintain resident's right to privacy and dignity. This failure affected one resident (R19) of two residents, reviewed for privacy and dignity, in a total sample of 63 residents.Findings include:R19 was admitted to the facility on [DATE] with diagnoses which include but are not limited to Chronic Kidney Disease, Retention of Urine, Dementia, Acquired Absence of Kidney, Acute Kidney Failure, Bladder Neck Obstruction, Malignant Neoplasm of Kidney, And Benign Prostatic Hyperplasia.Physician order sheet POS dated 11/18/25 and 11/20/25 both show that R19 has physician order for indwelling urinary catheter.On 2/2/26 at 11:30am, R19 was observed in bed with indwelling urinary catheter drainage bag with yellow urine, hanging at the side of the bed visible to people walking down the hallway, and without privacy bag. Again at 12:45pm, the urinary drainage bag was still in the same position, visible to anyone walking down the hall. At this time, V13 (Certified Nursing Assistant/CNA) was notified. V13 stated she would let the nurse know. On 2/5/26 at 11:55am, V3 (Assistant Director of Nursing) was notified and V3 stated that there should be a privacy bag covering the drainage bag for the resident's privacy. V3 later informed the surveyor that staff members were given in-service training regarding the general care of indwelling urinary catheter. V3 later presented a document In-Service Record dated 2/5/26, with signatures of nursing staff members. This document states in part: Ensure Catheter bag is placed in a privacy bag. R19's care plan dated 5/22/25 states that R19 has an indwelling urinary catheter and Resident at higher risk for infection secondary to presence of catheter and candida auris to left axilla. Facility's policy on Dignity dated 01/15 and latest revision on 1/25 states: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Purpose- To establish guidelines in protecting their residents' rights to be treated with dignity and respect. #11: Examples of promoting dignity and respect include but are not limited to (a): Using privacy coverings for urinary catheter bags.Record review of a document titled, RESIDENTS' RIGHTS For People In Long-Term Care facilities, with latest revision date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. You should receive the services and/or items included in the plan of care.

Based on observation, interview and record review, the facility failed to follow their policy by failing to obtain informed consent for increasing dosage of psychotropic medication and failed to document symptom/behaviors for the use of the medication or any non-pharmacological behavioral interventions attempted prior to increasing the dosage of the medication. This failure affected one (R161) of five residents reviewed in a sample of 65.Findings include:R161 has resided at the facility since 2014. Medical history includes, but is not limited to major depressive disorder, schizoaffective disorder morbid (severe) obesity due to excess calories, other iron deficiency anemias, vitamin D deficiency, etc.On 2/2/2026 at 10:30AM, R161 was in his room, alert and oriented and said that he is concerned about staff giving him a higher dose of Quetiapine (Seroquel). R161 said that he was supposed to be on 100mg of Seroquel, but staff are giving him 300 to 600mg. R161 said he did not consent to the dosage changes and have been refusing the medication. R161 thinks that staff are messing with his medication on purpose.Review of physician order showed that R161 was on Seroquel 100mg at bedtime which started on 8/1/2021 and discontinued on 11/10/2022. Resident's dosage of Seroquel had been increased as follows:11/10/2022 Seroquel 100mg, give 1.5 tablet (total of 150mg) at bedtime.11/17/2022 Seroquel 100mg, give 2 tablets (total of 200mg) at bedtime.11/21/2025 Seroquel 300mg, give 1 tablet at bedtime.12/2/2025 Seroquel 300mg, give 2 tablets (total of 600mg) at bedtime.1/23/2026 Seroquel 200mg and 300mg (total of 500mg) at bedtime.Surveyor requested consent for the above medication increases and facility provided a consent that resident refused to sign. R161 has a guardian, there was no documentation that the guardian was informed or consented to the dose increases.Residents have an order for behavior monitoring daily on all shifts, review of behavior monitoring sheets for December 2025, January 2026 and February 2026 shows that resident does not have any behaviors.On 2/5/2026 at 1:24PM, V32 (Power of Attorney/State Guardian) said, he is the guardian for R161, he requested for the doctors to review resident's medication due to the resident is always worrying about what others are doing, constantly calling the police. V32 said he is aware that resident is on Seroquel 100mg. He wanted his medication reviewed but no one called to inform him of the increase in dosage, he did not give his consent for the dosage increases.On 2/5/2026 at 2:04PM, V3 (Assistant Director of Nursing/ADON) said, if a resident is not exhibiting any behaviors, they probably should not be on psychotropic medications. Surveyor presented behavior monitoring documentation for R161 for the months of December 2025, January and February 2026 and she said that residents do not have any behaviors. Surveyor also presented a consent for R161's psychotropic medication that documented that resident refused to sign. V3 said that this is not an acceptable consent, R161 has a guardian who comes in occasionally, the facility should have called to get a consent from the guardian for the medication dosage increases.On 2/5/2026 at 2:18PM, V33 (Psychiatrist) said, R161's medication decreased recently when he was seen a few weeks ago. V33 said that you want to respect resident's wishes, but at the same time do not want to risk compensation, they are keeping the resident on the medication to avoid trying to get him to a therapeutic dose if anything happens. V33 said, R161 appears to be doing better lately, the staff are supposed to be documenting residents' behavior as ordered, and an informed consent is needed for administering psychotropic medications and dosage increase.On 2/5/2025 at 3:32PM V31 (Licensed Practical Nurse/LPN) said, R161 wanted the Seroquel decreased but the psychiatrist team refused. V31 said, R161 does not have any behaviors that she is aware of.On 2/6/2026 at 11:05AM, V37 (Psychiatrist Nurse Practitioner) said, R161 threatened to fire V37. The resident is very manipulative, can go from very pleasant to being delusional and accusatory. V37 has witnessed some of residents' behavior and staff are also reporting same behavior. Surveyor informed V37 that a review of behavior monitoring documentation presented by the facility shows that residents do not have any behaviors. V37 said, he is aware that most facilities are not good with their documentation, but the resident's behaviors should be documented as ordered. V37 added that he orders treatments based on what he observes and what is reported by staff, it is the duty of the staff to make sure that an informed consent is obtained for any psychotropic medication.Psychotropic medication policy revised 7/1/2025 states in part, to establish the process for monitoring the use of and the reduction of doses of psychotropic medications without compromising the resident's health and safety, ability to function appropriately, or safety of others.Policy specification 1. Psychotropic medication shall not be prescribed without the informed consent of the resident, the resident's guardian or other authorized representative. Additional informed consent is not required for reductions in dosage level or deletion of a specific medication. The informed consent may provide for a medication administration program of sequentially increased dosages or combination of medications to establish the lowest effective dose that will achieve the desired therapeutic outcome.Procedural specifications: 5. Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis including resident response to the medication.

Based upon observation, interview, and record review the facility failed to follow their medication administration policy by leaving medications at the bedside and failed to ensure that residents remained free from significant medication errors for two (R158 and R179) residents reviewed for medication administration in a sample of 63 residents. Findings include: 1.) On 2/05/26 at 9:41am, during observation of medication pass with V20 (Registered Nurse/RN), V20 was observed, holding a medication cup in the air, pouring 10 ml of Levetiracetam in a medication cup for R179. Review of R179's Medication Administration Record (MAR) indicated an order for Levetiracetam 5 ml by mouth twice daily for unspecified convulsions. Prior to administration, the surveyor questioned the 10 ml dosage prepared for administration. Surveyor requested V20 to put R179's medication cup with Levetiracetam on a flat surface to ensure the dosage is accurate. In response, V20 put R179's medication cup with Levetiracetam on the medication cart (flat surface) and verified that 10 ml of Levetiracetam was in the medication cup. V20 obtained an oral syringe, withdrew 5 mL of Levetiracetam from the medication cup, and returned the remaining 5 mL to R179's Levetiracetam bottle. On 2/05/26 at 9:41am, V20 (Registered Nurse/RN) said, Oh, it looked like 5 ml. Yes, the medication cup should have been put on a flat surface. Well, the flat surface evens out the liquid so you know the actual amount the patient is getting. Thanks for catching that. R179's face sheet documents diagnoses that include but are not limited to unspecified convulsions and personal history of traumatic brain injury. R179's BIMS (brief interview for mental status) score, dated 2/04/26, is 15 which indicates R179 is cognitively intact. R179's MAR (medication administration record), start date 7/30/21, documents, in part, Levetiracetam: Give 5 ml orally two times a day related to unspecified convulsions. On 2/5/26 at 4:21pm, V2 (Director of Nursing/DON) said, Double dose of Levetiracetam potentially could cause a person that has a seizure disorder to have a seizure or adverse reaction. Yes, medications should be given per physician's order. Yes, after a medication is given, the medication should be signed off immediately after the medication is given. If a medication is held for whatever reason, the medication also needs to be documented as not given right away. 2.) R158's current diagnoses include but are not limited to Multiple Sclerosis. R158's comprehensive assessment section C Cognitive Patterns dated 12/05/2025 documents a brief interview for mental status score of 13 out of 15 indicating he is cognitively intact. On 02/02/2026 at 11:01 AM, R158 is alert and oriented while sitting in his room sitting in his motorized wheelchair. He was inquired about his concerns. On 02/02/2026 11:15 AM, R158 opened the top drawer of his dresser in his room and took out 2 medicine cups with 2 white round pills inside. He put the cup on the top of the dresser and said, I have this medicine in my drawer. It's 2 or 3 days old. It's all the time. The nurse comes in and sets my meds down and leaves. I know they're supposed to watch me. The meds lower my heart rate and blood pressure. Sometimes I feel weak after I take them. All the nurses have left the meds before depending on what's going on. On 02/02/2026 at 12:09 PM, V3(Assistant Director of Nursing/ADON) was asked about the medications found in R158's room. This surveyor brought V3 into R158's room and showed V3 the medication. This surveyor asked V3 to identify each pill. V3 opened R158's electronic medical record to his physician orders to verify the pills. V3 confirmed each pill with R158's medication administration record and were identified and also verified using Daily Med (U.S. National Library of Medicine; https://dailymed.nlm.nih.gov/dailymed/). R158's physician orders state in part: Tizanidine Hydrochloride 4mg give 1 tablet by mouth every 6 hours for muscle spasms dated 1/15/2026. Baclofen 10mg give 1 tablet by mouth every 6 hours for muscle relaxant/spasms dated 11/27/2025. On 02/02/2026 at 12:12 PM, V3 (ADON) said, They (nurses) can never leave it (medicine) at the bedside. Other residents can come get it (medicine) or the resident can miss his dose. Both medications are active, he (R158) gets it every 6 hours. On 02/05/2026 at 11:51 AM, V2 (Director of Nursing) was asked about nursing staff leaving medications at the bedside during medication administration. V2 said, The nurse should ID (identify) the resident, follow the five rights of medication administration, then administer the medicine at the right time per the order and watch the resident take it, then document it. If the nurse doesn't watch the resident it (medication) might not be taken at the right time, taken by the wrong person or not taken at all. The facility policy titled, Policy and Procedure Medication Administration, dated 1/2025, documents, in part, To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Medications shall be administered in physician's written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. The individual administering the medication shall initial the resident's Medication Administration Record (MAR) on the appropriate line and date for that specific day after administering the medication. 9. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that particular drug and document a rationale. 10. If it is discovered, the person administrating medications has forgotten to initial in the appropriate space, the supervisor shall notify that person to investigate if the medication/treatment has been administered/performed. If the response indicates the medication/treatment was administered the staff member shall return to the facility, initial the MAR. A late entry note will be documented indicating the administration of the medication. If the medication was not administered the missed dose/medication error protocol shall be followed. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. You should receive the services and/or items included in the plan of care.

Based on observation, interview, and record review the facility failed to follow their infection control and hospice services policy ensuring hospice service professionals adhered to all facility policies and procedures related to infection control when in the facility by failing to adhere to the enhanced barrier precautions designation by failing to use a gown during high contact resident care while changing a resident's incontinent brief for one (R3) resident, and failed to transport/handle linen in a manner that prevents contamination. Findings include: 1.) R3's current diagnoses include but are not limited to Cerebral Palsy, Dementia, Unstageable Pressure Injury to the Right Buttock, and Type 2 Diabetes Mellitus. R3's comprehensive assessment section C Cognitive Patterns dated 12/24/2025 documents a brief interview for mental status score of 3 out of 15 indicating she has severe cognitive impairment. On 02/02/2026 at 12:31PM, the entrance to R3's room has an enhanced barrier precautions sign with instructions on what PPE (personal protective equipment) is needed according to the care to be provided. There is a PPE bin with gowns, gloves and face masks at the door. There is a hand sanitizer container on the wall near the room. Upon entrance to the room R3 is lying down in bed awake and alert. R3 was asked how she was feeling. R3 said, I feel tired. R3 is lying on a low air loss mattress. She had an indwelling urinary catheter draining dark amber urine with sediment noted. On 02/02/2026 at 12:39PM, V11 (Hospice Nurse) entered R3's room and stated she was the hospice nurse. V11 was inquired of R3's care. V11 said, I see her once a week. The aide and the musician come once a week. She was treated for a urine infection, and she has a right hip wound that's unstageable. She has a catheter because of her wound and a low air loss mattress. V11 turned R3 in bed and saw she was soiled. V11 said, I'm going to get you cleaned up R3, you pooped. At 12:44 PM, V11 took a pair of gloves from the PPE bin at R3 door and put the gloves on without performing hand hygiene or washing her hands. A facility CNA brought in towels and a gown to the room for R3. V11 filled a wash basin with water and soap and brought it to R3's bedside. V11 removed R3's incontinent brief and began to provide perineal care. R3 has a wound dressing to the right buttock. On 02/02/2026 at 12:46 PM, V11 (Hospice Nurse) was inquired of R3 being on transmission-based precautions- EBP (Enhanced Barrier Precautions) and what PPE (personal protective equipment) should be worn during high contact care. R3 said, What do you mean about enhanced barrier precautions. She doesn't have any infection when it comes to transmission, I just wear gloves. V11 proceeded to continue with R3's perineal care and did not put on an isolation gown during this high contact care. On 02/05/2026 at 11:48 AM, V2 (Director of Nursing/DON) was inquired of hospice staff following infection control practice and procedures regarding enhanced barrier precautions. V2 said, Education for the vendors by the IP (Infection Prevention Nurse). The hospice nurse should follow the isolation procedures and don and doff (put on and take off) PPE (personal protective equipment) as required. R3's physician orders state in part admit to hospice 09/05/2024 related to CVA (Cerebrovascular Accident). Foley catheter insertion for wound prevention 12/15/2025. Enhanced Barrier Precautions related to wounds and foley catheter every shift for infection control PPE (personal protective equipment) must be worn during direct care 12/19/2025. R3's 01/27/2026 wound documentation by V30 (Nurse Practitioner) states in part: Objective: Buttock and Groin: 1. Unstageable pressure injury to right buttock. Reopened. Measures 3.6 x 2.5 x 0 cm (centimeters). Wound is 65% granular tissue, 35% necrotic (dead non-viable) tissue. 2.) On 2/2/2026 at 12:55 PM, observed soiled linen room with V38 (Housekeeping Manager). V38 opened the door to the linen chute and visibly soiled washcloths, shirts, clothing and linen fell into the soiled linen bin. V38 confirmed the observation and stated, the CNA's (certified nursing assistants) should be bagging the linen before they send it down the chute. It should not be loose and not in a bag like this. V38 explained that soiled linen is bagged by the CNA, labeled with the resident's information, and sent down the chute, where it is then sorted and transferred into the washers. On 2/2/2026 at 1:07 PM, observed the laundry room with V38 (Housekeeping Manager). Observed an open bag of chips in the area where the clean linen was folded, chemical (bleach/detergent) barrels connected to the washers on the floor of the laundry room, and dirt/dust around the floors of the clean linen area/shelving area. V38 stated that the floors are supposed to be swept and mopped daily. Observed a bottle of purple fabric detergent on top of the washers that was not the same brand as the facility's bulk detergent. V38 stated, it (the facility's detergent) just doesn't get the clothes clean enough, especially when there is (faces) in the linen. So, I go to (the store) and purchase my own for when the clothes and stuff are real bad. We only have two settings on the washer, one is for detergent, one is for bleach. We don't have other options if it is real badly soiled. V38 was unsure if the store-bought detergent and the facility's bulk detergent were able to be mixed together. On 2/5/2026 at 11:55 AM, V4 (Infection Preventionist, Licensed Practical Nurse) affirmed that soiled linen must be bagged when using the laundry chute to prevent contamination of the chute. The Hospice Policy revised on 1/25 was reviewed. It states in part that it is the policy of the facility to honor the advanced directives and care preferences residents may desire when terminally ill and to provide care that ensures dignity and comfort during the end stages of life. The facility will provide hospice services either directly or through arrangements with a qualified service provider. The purpose of the policy is to ensure that appropriate hospice services are available to residents and families and to outline the responsibilities of hospice service providers as well as facility staff. 4. Hospice service professionals and staff will adhere to all facility policies and procedures related to resident's rights, resident care, safety and infection control when in the facility. The policy titled Enhanced Barrier Precautions was reviewed. The revised 4/28/2025 policy states in part that the purpose of this policy is to reduce the transmission of novel or targeted multi-drug-resistant organisms (MDRO). The procedure includes 1. Enhanced Barrier Precautions (EBP) require the use of gown and glove during high contact resident activities. High-contact resident care activities include: dressing, bathing/showering, transferring, providing hygiene (e.g. brushing teeth, combing hair, shaving), changing linens, changing briefs or assisting with toileting, device care or use of an indwelling medical device , such as urinary catheter, feeding tube, central line (e.g. hemodialysis catheter, PICC line), tracheostomy or ventilator, wound care: any skin opening requiring a dressing (focusing on wound at high risk or acquiring an MDRO, such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic wounds such as chronic venous stasis ulcers. Consideration is taken related to the length of time of resident contact and bundled tasks. Individual tasks may not require EBP. Note: Gown and gloves are the minimum level of PPE. Additional PPE may be required depending on the situation/resident (e.g. face shield may be used when splashes and sprays are likely to occur). 7. Adhere to other infection control practices such as hand hygiene, cleaning and disinfection of environmental surfaces and equipment care. The Infection Control policy issued on 1/2024 was reviewed. The policy of the facility is to maintain an infection control program designed to provide a safe, sanitary and comfortable environment, and to prevent or eliminate, when possible, the development and transmission of disease and infection. The purpose of the policy is to establish methods and criteria, necessary with facility and its operation, to prevent and control infections and communicable diseases. Procedure number 14. All facility personnel are required to routinely wash hands and use appropriate barrier precautions to prevent transmission of infection. 15. All facility personnel shall adhere to the infection Control Program in the performance of their daily assignments. Facility policy titled, Linen and Laundry Handling for the Laundry Dept (10/2014) documents in part, Purpose: To ensure proper handling of soiled and clean linen and personal laundry to prevent the spread of microorganisms. Standards: 1. The laundry department should be designed so that there is a flow of functions that prevents contamination of clean linen. 2. Chemical barrels and other supplies are stored on skids to aid floor care. Work surfaces should be cleaned daily, including sinks, lint traps, and washer dryer surfaces by laundry personnel . 4. Soiled linens shall be placed in plastic bags by nursing personnel . 10. Heavily soiled linens shall be pre-treated prior to washing . 14. Cleaning agents and detergents shall be of sufficient strength to assure linens and laundry items are free of microorganisms .

Based on observation, interview, and record review, the facility failed to assist a dependent resident with making transportation arrangements to scheduled appointments, failed to notify physician about missed appointments and failed to re-schedule the appointments. This failure affected one (R179) of 4 residents reviewed in a sample of 63.Findings include:On 02/02/2026 at 11:10AM, R179 was observed in bed, awake and alert, stated that he was supposed to go for an MRI appointment today but did not because the facility does not have anyone to go with him. R179 said that this appointment was supposed to be in November, but it was also cancelled and rescheduled. Resident stated that he is frustrated about missing his appointments.Face sheet the following past medical history for R179: personal history of traumatic brain injury, unspecified convulsion, obstructive and reflux uropathy, disease of gall bladder, bipolar disorder, etc. A list of scheduled appointments for R179 presented by V2 (Director of Nursing/DON) showed an appointment for January 22 at 4:30PM, an MRI scheduled for February 2, 2026, at 10:00AM, and an appointment with Neurosurgery scheduled for February 13 at 1:00PM among others. On 2/4/2026 at 3:10PM, V2 (DON) said, R179 gave her the list of his appointments. The person who was scheduling appointments for residents abruptly quit her job; the responsibility then fell on her and the Assistant Director of Nursing. V2 said that she thought that the veteran clinic arranges for their own transportation. V2 added that R179 missed his January appointment due to transportation and missed the one for February. V2 presented email communication between her and the veteran affairs dated January 21, 2026, and according to the communication, V2 was directed to contact a non-VA facility with a contact number because R179 is not under VA contract, but the arrangement was not made. V2 added that the scheduler is supposed to document it in medical records and notify the physician, as well as reschedule the appointment when residents miss their appointments. V2 is not sure if resident's appointments have been rescheduled.On 2/4/2026 at 12:12PM, V16 (Scheduler) said that she gets appointment information from the residents or nurses, she then schedules the appointment and arranges for transportation. V16 said that R179 had an appointment on Monday (2/2/2026) but he did not go because the transportation people did not show up. V16 said that she just started in this role, the transportation company they are using now has been cancelling a lot, she is in the process of making transportation arrangements with a different company.Review of resident's record did not show any documentation of the missed appointments; no record of resident's physician being notified or that the appointments were rescheduled.Surveyor requested a facility policy on assisting residents with transportation to source of service, but none was provided.

Based on observation, interview, and record review the facility failed to maintain consistent hospice communication for one (R16) of two residents reviewed for hospice care in the sample of 63 residents. Findings include:R16's current diagnoses include but are not limited to End Stage Renal Disease, Chronic Kidney Disease, Type 2 Diabetes Mellitus, Hypertension, Osteomyelitis, Sacral Region Stage 4 Pressure Injury to the Coccyx, and Palliative Care.R16's comprehensive assessment section C Cognitive Patterns dated 01/14/2026 documents a brief interview for mental status score of 8 out of 15 indicating he has moderate cognitive impairment. On 2/04/2026 at 11:07 AM, upon entrance to the room R16 is lying in bed. R16 was asked what hospice facility he is working with or when hospice sees him. R16 was not able to answer.On 02/04/2026 at 11:40 AM, V25 (Wound Care Certified Nursing Assistant/CNA) and V21 (Wound Care Licensed Practical Nurse/LPN) were inquired of R16's hospice care/staff. V21 said, I'm not sure what hospice he's on. V25 CNA said, I've seen the hospice nurse come but I don't know which one (hospice) he's on.On 02/04/2026 at 12:24 PM, V17 (LPN) was asked about R16's hospice nurse and his hospice binder was requested. V17 stated that she was unable to locate the binder. V17 called the hospice agency twice and stated that the hospice agency had R16's binder. V17 stated that there is no documentation of R16's hospice care at the facility at this time. On 02/04/2026 at 1:00 PM, V2 (Director of Nursing/DON) and V3 (Assistant Director of Nursing/ADON) were inquired of R16's hospice communication while at the nurse's station. V2 and V3 were unable to find any hospice communication for R16 at the nurse's station. On 02/04/2026 at 3:15 PM, V3 presented a hospice binder for R16. The documents in the hospice binder were dated 2/04/2026 and timed at 2:48PM. The admission note documents a visit frequency which states in part: Week of 12/31/25 - 01/06/26- nurse visits = 2. No other visits scheduled for other disciplines (hospice aide, social worker, chaplain). Week of 02/04/26- 02/10/26 nurse visits = 1. No other visits scheduled for other disciplines. R16's physician orders document resident admitted under hospice with Dx (diagnosis) End Stage Renal Disease. R16's care plan dated 01/07/2025 states in part: I present with a terminal diagnosis related to End Stage Renal Disease. Interventions: Collaborate with the hospice team to integrate services provided by the facility and hospice. On 02/05/2026 at 1:51 PM, V28 (Hospice Nurse) was inquired of ensuring there is written hospice communication for the facility staff. V28 said, He (R16) was admitted to hospice on January 6th for end stage renal disease. There was an admission nurse that set him up. I see him twice a week. The first time I saw him was on January 7th. The hospice aide should be seeing him twice a week too. I communicate verbally with the staff. There should be a folder, but I haven't seen it. There should be a sign in sheet when we see him and a place to chart to give staff a quick refresher of what happened during my visits. I would be responsible for the folder being there with the other disciplines, social worker, and chaplain. I never noticed he did not have a folder. The admission nurse should have set that up. It is for communicating with the staff and hospice.On 02/05/2026 at 2:43 PM, V2 (DON) was inquired of ensuring there is written hospice communication for the facility staff. V2 said, V3 and I would be responsible for making sure it was here.There is no sign in documentation of R16 receiving hospice visits from the nurse, aide, social worker, or chaplain from the date of admission on [DATE] to 02/05/2026. There is no written documentation of hospice communicating R16's condition after each visit with the nursing facility staff. The Hospice Policy revised on 1/25 was reviewed. It states in part that it is the policy of the facility to honor the advanced directives and care preferences residents may desire when terminally ill and to provide care that ensures dignity and comfort during the end stages of life. The facility will provide hospice services either directly or through arrangements with a qualified service provider. The purpose of the policy is to ensure that appropriate hospice services are available to residents and families and to outline the responsibilities of hospice service providers as well as facility staff. 4. Hospice service professionals and staff will adhere to all facility policies and procedures related to resident's rights, resident care, safety and infection control when in the facility. 5. Hospice service providers will conduct assessments and develop a hospice plan of care, which will be integrated with the resident's overall plan of care and maintained in the medical record or interdisciplinary care plan. 6. Hospice service staff will attend care plan conferences and participate in the resident care planning process as appropriate. 9. Pain and symptom management will prioritize the least invasive routes to minimize discomfort unless other routes are contraindicated or ineffective.

Based on interview and record review, the facility failed to ensure direct care staff were involved in the completion of the facility assessment, failed to consider staffing needs by shift and resident unit. This failure has the potential to affect all 199 residents that reside within the facility. Findings include: Facility census (2/2/2026) documents in part that 199 residents reside within the facility. Facility assessment (reviewed 6/27/25) indicates that the Administrator, Director of Nursing, governing body, and Medical Director were involved in the completion of the facility assessment. There is no indication that direct care staff were involved in the completion of the facility assessment. The staffing plan of the facility assessment documents in part that 14-16 licensed nurses are needed, 18-22 nurse's aides are needed, as well as other management, social services, food and nutrition staff. There is no identification of staffing needs based on shift and unit within the facility assessment. Record review of the facility assessment review signature form (undated) lists V1's (Administrator) signature, the Medical Director's signature, the former Director of Nursing's signature. On 2/4/2025 at 1:57 PM, V1 affirmed that V1 was involved in the development of the facility assessment. V1 explained the purpose of the facility assessment is to govern the facility, identify types of residents it takes, categories the facility can service and to make sure we have appropriate staffing/systems in place to provide care to residents. V1 stated that the facility assessment is updated once per year and as needed. V1 reviewed the facility assessment and affirmed that there was no documentation that direct care staff were involved in the development of the facility assessment. V1 denied that involving residents, their families and direct care staff was a regulatory requirement. V1 reviewed the facility assessment again and affirmed that the facility assessment does not have staffing needs identified by shift and by unit. V1 affirmed that the facility assessment has total staff needs but is not broken down by unit or shift. V1 affirmed that identifying resident staffing needs per shift and per unit is a regulatory requirement. V1 explained that V1 believed this was an old facility assessment and that there had been another facility assessment reviewed and updated that V1 would provide to the survey team. V1 reviewed the Facility Assessment Review Signature Form (undated) and affirmed that the representative of the governing body's signature was blank. V1 stated that V1's regional participated in the development, but must have forgot to sign. On 2/5/2025 at 10:38 AM, V1 affirmed that V1 found the current, most updated, facility assessment and would provide the assessment to the survey team. No further facility assessment was provided prior to the exit of the survey. Facility policy titled, Facility Assessment Policy (1/2025) documents in part, Purpose To provide guidance regarding the completion of the Facility Assessment, as part of the Medicare and Medicaid program requirements. Procedure 1. The facility must conduct a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies . The policy does not document the requirements for direct care staff to be involved in the development of the facility assessment and does not document the requirement that staffing needs must be considered for each unit and shift.

Based on observation, interview and record review, the facility failed to post nursing staffing information in a highly visible area for residents and failed to include required information. These findings have the potential to affect all 199 residents that reside within the facility. Findings include: Facility census (2/2/2026) documents that 199 residents reside in the facility. On 2/4/2026 at 1:42 PM, observed the door to the foyer from the first-floor unit (resident areas) locked and required to be unlocked by the receptionist. On 2/4/2026 at 1:45 PM, the facility daily staffing posting was observed taped to the windows located at the front desk in the facility's foyer area. Facility daily staffing posting (2/4/2026) did not document the total number of hours worked and actual number of hours worked for registered nurses, licensed practical nurses and certified nursing assistants. On 2/4/2026 at 1:46 PM, V16 (Scheduler) affirmed that V16 is responsible for completing the daily staffing posting. V16 reviewed the staffing posting (2/4/2026) and affirmed that the number of total and actual hours for registered nurses, licensed practical nurses, and certified nursing assistants were not on the staffing posting. V16 was unsure if having total hours and actual hours worked on the posting was a regulatory requirement and explained that V16 had recently started in the role and would check. On 2/4/2026 at 1:49 PM, V1 (Administrator) affirmed that the foyer is locked and residents cannot get into the foyer area without ringing the buzzer. V1 affirmed that residents could not freely enter the foyer area (where the posting is located). On 2/4/2026 at 1:34 PM, V1 affirmed that there is no facility policy for the daily staffing posting. No policy was provided prior to the exit of the survey.

Based on observation, interview and record review, the facility failed to ensure that the outside dumpster garbage disposal was covered with lid and failed to ensure that the floor around the dumpsters were free of trash, thus creating an unsanitary environment. These failures have the potential to cause harboring of rodents which can affect all 199 residents in the facility.Findings include:On 2/2/26 after the entrance conference, V1(Administrator) presented the facility census as 199. On 2/2/26 at 10:25am, after kitchen observation with V7(Dietary Manager), the outside dumpster was observed to be open without lids, with bags of trash and spilled trash on the floor around the dumpster. V7 stated that this dumpster was for the oil, and she (V7) was not sure if there was a lid for this oil dumpster. V7 asked V12(cook) and V12 stated there is lid to cover the oil dumpster. On 2/5/26 at 10:20am, the surveyor observed one of the dumpsters without covers and with trash on the floor around the dumpster. V7 stated that she (V7) would send the dietary aide to go and cover the dumpster. V7 added that maybe the housekeeping staff left the dumpster open. V7 stated that leaving dumpsters open could cause rodents to come around the building. Facility's policy titled Waste Management dated 5/14 states: Purpose - Prevent the spread of infection. #5: Maintenance and housekeeping personnel shall ensure the dumpster area is kept clean and all trash bags are inside the dumpster, and dumpster lids are closed. #7 states: Dumpsters will be emptied by a contract trash removal service on a regular basis in sufficient frequency to minimize odors and rodents/insects harborage.

Based on interview and record review, the facility failed to follow its Community Access Determination policy by not completing required Community Survival Skills assessments at least quarterly, annually, and when residents requested outside passes. This failure affected four of four residents reviewed for Social Services assessments (R1, R10, R17, and R18) in a sample.Findings include:On 1/28/26 at 10:42 AM, V9 (Social Services) stated that community survival skills assessments are completed quarterly, annually, and if resident requests outside pass. V9 reviewed R10's medical record with this surveyor. V9 acknowledged that the last community survival skill assessment completed is dated 3/31/25. V9 stated that maybe she did not lock her assessment and that is why it is not showing up. V9 was informed that even an assessment in progress would appear in the resident's electronic medical record.R1's medical record notes his last community skills assessment was completed on 7/9/25.R17's medical record notes his last community skills assessment was completed on 8/1/25.R18's medical record notes his last community skills assessment was completed on 9/8/25.The facility presented a document titled admission, quarterly, annual, and significant change assessments. This document notes community skills assessments are completed on admission, with significant change, and annually. This document is not in alignment with the facility's policy regarding the frequency of community skills assessments.When V2 (Director of Nursing) and V8 (Assistant Director of Nursing) were asked to clarify if this document is a policy, neither responded until after V2 communicated with V1 (Administrator). After discussing with V1, V2 stated that this is not a policy, it is just a document created noting which assessments are to be completed and when. The facility's guidelines for community access determination policy, dated 2/8/23, notes, in part, a community skills assessment will be completed by social services upon admission, quarterly. The community access assessment should be completed quarterly on all residents.

Based on interview and record review, the facility failed to follow its grievance policy by not documenting, investigating, and providing a timely written response to a resident grievance regarding a missing phone. This deficient practice affected one of three residents (R10) reviewed for grievances. Findings include: On 1/27/26 at 1:45 PM, R10 stated that she reported to V15 (Social Service Director/SSD) on 9/17/25 that between 11:00 AM and 12:30 PM on 9/17 R10's personal phone went missing from her room while she was out of her room. R10 stated that V15 wrote the information down on paper but did not give R10 a copy of it. R10 stated that she also informed nurses and CNAs (Certified Nursing Assistants) that her phone was missing. R10 stated that the staff told her they would find her phone and give it back to R10. R10 stated that a staff member informed her that her phone was in the medication room. R10 stated that V15 never followed up with her about her phone. R10 stated that she is afraid if she keeps asking about her phone she will get in trouble and social services won't help her to get a community pass and discharge from this facility. R10 stated that she just wanted her phone back. On 1/28/26 at 12:17 PM, V13 (Registered Nurse/RN) stated that R10 informed V13 of her phone missing months ago, September or October 2025. V13 stated that V13 informed R10 to talk to social services about it. V13 stated that she did not follow-up or report concern of phone missing to anyone. On 1/28/26 at 1:00 PM, R10 showed this surveyor an activity calendar for September 2025. In the box for September 17th R10 noted 'V15 (SSD) was notified between 11:00 AM and 12:30 PM R10's cell phone was taken from R10's room'. On September 22nd R10 noted 'found a cell phone in a medication storage room'. R10 stated that a staff member came to her room earlier today regarding R10's missing phone. R10 stated that she wrote down when she reported phone missing and to whom, but staff would not wait for her to find the paper. R10's pre-admission hospital record, dated 8/23/2024, notes the number for R10's personal phone listed is the same number R10 verbalized during the interview on 1/27/26. On 1/29/26 at 9:35 AM, V15 (SSD) denied R10 informing V15 of her phone missing. V15 stated that whoever is informed of a resident concern is expected to document on a concern form, give this form to her, and once she receives the form, she gives the concern to the department involved for resolution. On 1/29/26 at 11:56 AM, V19 (CNA) stated that R10 informed her that R10's personal phone was missing around 9/29/25. The facility's grievance binder, September until present, does not note R10's grievance regarding her missing phone. On 1/28/26 at 11:05 AM, the facility presented a grievance form/opportunity resolution form. The name of the person completing this form is not documented. It notes R10 has had phone since admission to this facility and phone may have been taken by another resident, R11. R10's belongings inventory, dated 8/30/24, notes R10 with one long sleeved shirt, one sweatshirt/hoodie, and one pair of sweatpants. R10's belonging inventory, dated 6/19/25, notes a pair of eyeglasses. R10's admission photo shows a red blanket not listed on either inventory sheet. There is no documentation noting the scarf that R10 wraps around her head or any other personal items in her room. Neither belonging inventory sheet contain R10's signature to indicate staff documented all R10's belongings. The facility's belongings policy, dated 04/2014, notes resident belongings will be recorded upon admission and whenever brought in. Check and record all belongings brought to facility on clothing list. Resident is to sign for belongings. If resident is unable to sign note this on the clothing list.The facility's grievance policy, revised 01/2025, notes the director of social services will oversee the grievance process to ensure grievances are addressed promptly. All concerns will be documented in writing. Concern resolutions are expected within 72 hours. The concern forms will be maintained in the grievance binder. The records will be kept for at least three years.

Based on interview and record review, the facility failed to implement its abuse prevention policy to prevent a resident-to-resident physical assault. This deficiency affected two of three residents (R10 and R11) reviewed for abuse. Findings include:On [DATE] at 1:45 PM, R10 stated that R10 had been friends with R11 for a long time. R10 stated that when R11 came into R10's room on [DATE], he saw a milk carton on her nightstand. R10 stated that R11 became very upset and began yelling at her about having expired milk in her room. R10 stated that the milk wasn't expired. R10 stated that R10 was trying to speak with R11, but R11 was becoming more upset. R10 stated that R11 picked up the milk carton and hit her on the right side of her head with it. R10 stated that R11 then pushed R10 on the bed and grabbed her by her upper arms and began shaking her violently. R10 stated that other residents came in to get R11 off her and then staff came in and removed R11 from R10's room. On [DATE] at 4:15 PM, V20 (Nurse) stated that she heard a commotion at the back hall and then shouting. By the time V20 got to R10's room, another resident, R13, from first floor nursing unit had already pulled R11 off R10 and was standing between R10 and R11. V20 stated that R13 was telling R11 'you don't hit a lady'. V20 stated that R13 informed her R13 was passing by R10's room and heard screaming and saw R11 hitting R10. V20 stated that R10 was lying on her bed with her arms covering her face to prevent further hits. V20 stated that one of R10's roommates also stated that R11 was hitting R10. V20 stated that V20 reported this event to V1 (Administrator) immediately. V20's note, dated [DATE], stated V20 heard loud voices arguing and asking for help at back hall and observed a male resident, R13, blocking another resident, R11, from trying to reach out for R10 who was moving out of R11's reach. R11 was immediately removed out of the room and brought to social services while R10 was assessed for any injury. R10 complained of a little pain on her right forearm where R11 had held her and moderate pain at the back of her right ear. R11's statement regarding this event, dated [DATE], notes R11 entered R10's room and saw an expired milk carton. R11 stated it was dirty. R11 asked R10 why it was still in R10's room. R11 hit R10's head. When R11 was told, he was not allowed to hit people he responded that having spoiled milk in your room is worse than not showering. R11 no longer resides in this facility and was unable to be interviewed. R13's statement, dated [DATE], notes R13 heard R11 screaming about a phone then about spoiled milk. R13 didn't know who R11 was yelling at, then he heard smacks, R13 got out of his wheelchair to see who R11 was yelling at, saw R11 hitting R10. R13 pulled R11 off R10 and stood between them to protect R10. R11 left R10's room.R13 no longer resides in this facility and was unable to be interviewed. R14's statement, dated [DATE], notes when R14 walked into R10 and R14's room, R11 was on top of R10 punching her in the face. R14 stated other residents and nurses came in trying to get him off R10. On [DATE] at 3:20 PM, R14 was able to state the same details of event as she provided on [DATE]. R11's medical record notes diagnoses including but not limited to unspecified psychosis not due to a substance or known physiological condition, auditory hallucinations, schizophrenia, and bipolar disorder. R11's POS (Physician Order Sheet), dated [DATE], notes orders for mirtazapine 15mg (milligrams) by mouth at bedtime related to bipolar disorder; Risperdal 2mg by mouth one time a day for schizophrenia; Risperdal 1mg by mouth one time a day; trazodone 150mg by mouth at bedtime for bipolar disorder; uzedy subcutaneous suspension 200mg/0.56ml (milliliters) one time a day starting on the 18th for 56 days for psychosis, disorganization, paranoia; and lithium 600mg by mouth two times a day for bipolar disorder. R11's MAR (Medication Administration Record), dated [DATE], notes R11 refused mirtazapine on 9/16, 9/19, 9/20, 9/21, 9/22, 9/23, 9/26, 9/27, and 9/28. R11 refused Risperdal 2mg on 9/16, 9/18, 9/19, 9/20, 9/21, 9/22, 9/23, 9/24, 9/25, 9/26, 9/28, and 9/29. R11 refused Risperdal 1mg on 9/16, 9/18, 9/19, 9/20, 9/21, 9/22, 9/23, 9/25, 9/26, 9/27, 9/28, and 9/29. R11 refused trazodone on 9/16, 9/19, 9/20, 9/21, 9/22, 9/23, 9/26, 9/27, and 9/28. R11 refused uzedy 9/19, 9/20, 9/21, 9/22, 9/25, 9/26, 9/27, 9/28, and 9/29. R11 refused morning dose of lithium on 9/16, 9/18, 9/19, 9/20, 9/21, 9/22, 9/23, 9/24, 9/25, 9/26, 9/27. 9/28, and 9/29; and the evening dose on 9/16, 9/19, 9/20, 9/21, 9/22, 9/23, 9/26, 9/28, and 9/29. Prior to R11's hospitalization on 9/10, R11 refused his psychotropic medications 8-9 days out of 10.There is no documentation in R11's medical record, dated 9/16-9/29, noting R11's attending physician and psychiatrist were notified each time R11 refused psychotropic medications. The nurse practitioner's notes, dated 9/17 and 9/25, notes 'no concerns from the nursing staff'.R11's medical record notes R11 was hospitalized [DATE] - [DATE] for aggressive behavior.The facility's abuse investigation dated [DATE] - [DATE], notes statements from R11, R13, and R14 that R11 was hitting R10. The facility did not provide any staff interviews regarding this event. The final report notes no credible evidence that abuse occurred. The facility's abuse prevention policy, reviewed [DATE], notes the facility desires to prevent abuse by establishing a secure resident environment. The investigator will attempt to interview the person who reported the incident. Any written statements will be reviewed.

Based on interview and record review, the facility failed to implement appropriate interventions to supervise and monitor a resident (R11) with a known history of aggressive behavior to prevent entry into another resident's room. This failure affected two of three residents reviewed for supervision. (R10, R11). As a result, R11 was not adequately supervised and was able to enter R10's room, where R11 verbally and physically assaulted R10.Findings include:On [DATE] at 1:45 PM, R10 stated that R10 had been friends with R11 for a long time. R10 stated that when R11 came into R10's room on [DATE], he saw a milk carton on her nightstand. R10 stated that R11 became very upset and began yelling at her about having expired milk in her room. R10 stated that the milk wasn't expired. R10 stated that R10 was trying to speak with R11, but R11 was becoming more upset. R10 stated that R11 picked up the milk carton and hit her on the right side of her head with it. R10 stated that R11 then pushed R10 on the bed and grabbed her by her upper arms and began shaking her violently. R10 stated that R11 only hit her the one time in the head but the way he was shaking her may have given others the impression he was hitting her multiple times. R10 stated that other residents came in to get R11 off her and then staff came in and removed R11 from R10's room.On [DATE] at 4:15 PM, V20 (Nurse) stated that she heard a commotion at the back hall and then shouting. By the time V20 got to R10's room, another resident, R13, from first floor nursing unit had already pulled R11 off R10 and was standing between R10 and R11. V20 stated that R13 was telling R11 'you don't hit a lady'. V20 stated that R13 informed her R13 was passing by R10's room and heard screaming and saw R11 hitting R10. V20 stated that R10 was lying on her bed with her arms covering her face to prevent further hits. V20 stated that one of R10's roommates also stated that R11 was hitting R10. R11's statement regarding this event, dated [DATE], notes R11 entered R10's room and saw an expired milk carton. R11 stated it was dirty. R11 asked R10 why it was still in R10's room. R11hit R10's head. When R11 was told, he was not allowed to hit people he responded that having spoiled milk in your room is worse than not showering.R11 no longer resides in this facility and was unable to be interviewed.R11's behavior care plan, initiated [DATE], notes R11 demonstrates behavioral distress related to: ineffective coping mechanisms. Problems are manifested, in part, by physically abusive behavior when agitated; attempting to push, shove, scratch, hit, slap, kick, grab, or otherwise harm another person. Interventions, in part, give psycho-active medications as ordered. Record behavioral symptoms.R11 psychotropic medications care plan, initiated [DATE], notes R11 requires psychotropic medications to help manage and alleviate diagnoses schizophrenia, psychosis with hallucinations, and bipolar disorder. Interventions, in part, note report abnormalities to physician. Carry out the medication management regimen as prescribed, report changes, complications to physician. If behavioral symptoms are observed, record and document on behavior tracking form.R11's behaviors care plan, initiated [DATE], notes R11 has a history of behaviors related to severe mental illness. R11 has lack of sound judgement, poor impulse control. Interventions, in part, daily monitoring and supervision.R11's medical record, dated [DATE], notes R11 refused to be medication compliant. R11 was counseled by social services and will be given cues, reminders, and re-direction on the importance of being medication compliant.On [DATE], social services counseled R11 on complying with medications.On [DATE], social services counseled R11 on complying with medications.On [DATE], psychosocial social worker met with R11 in a 1:1 session. It is noted R11's comprehension is moderately impaired; R11 presents with delusions of grandeur, paranoid, delusional material expressed; insight moderately impaired; poor self-awareness; racing thoughts, disorganized thought processes.On [DATE], social services met with R11 regarding noncompliance with medications and refusal of care. R11 not receptive to counseling.On [DATE] at 11:37 AM, social services met with R11 to discuss his refusal of care and medications. R11 not receptive to counseling on taking his medications. R11 presents with auditory hallucinations.R13's statement, dated [DATE], notes R13 heard R11 screaming about a phone then about spoiled milk. R13 didn't know who R11 was yelling at, then he heard smacks, R13 got out of his wheelchair to see who R11 was yelling at, saw R11 hitting R10. R13 pulled R11 off R10 and stood between them to protect R10. R11 left R10's room.R13 no longer resides in this facility and was unable to be interviewed.R14's statement, dated [DATE], notes when R14 walked into R10 and R14's room, R11 was on top of R10 punching her in the face. R14 stated other residents and nurses came in trying to get him off R10.On [DATE] at 3:20 PM, R14 was able to state the same details of event as she provided on [DATE].

Based on interview and record review the facility failed to have an effective contraband policy to prevent illicit drugs from being brought into the facility, distribute and used by the residents. The facility failed to develop a plan to determine how the illicit drugs are coming into the facility. This affects 2 of 2 (R7 and R14) residents that tested positive for fentanyl and opiates and had the potential to affect all 13 (R3, R4, R6, R7, R8, R14, R16, R17, R18, R19, R20, R22, and R23) residents reviewed for illicit substance/contraband within the facility. R7 was observed slumping forward in the wheelchair, fell to the floor, was cyanotic and required Narcan (opioid antagonist/opioid reversal agent) to be given. R14 was transported to local hospital emergency room for a change in condition. R14 tested positive for fentanyl and opiates metabolites.Findings include: The immediate jeopardy which began on [DATE] when R7's urine test was positive for opiates, R7 later was observed slumping forward in wheelchair, R7 fell to the floor, vital signs were very low, R7 was cyanotic, code blue announced, Narcan given. On [DATE] R7 complained of suicidal ideations, sent to hospital tested positive for fentanyl. On [DATE], R14 observed drowsy, opening his eyes and then closing them, 911 summons, R14 tested positive for fentanyl, and opiates metabolites in the emergency room. On [DATE] at 9:53 am, V12 (Corporate Nurse Consultant) was informed of the immediate jeopardy that began on [DATE]. The immediacy was removed on [DATE] after the facility provided an acceptable removal plan on [DATE]. On [DATE] and [DATE] the surveyor was onsite to confirm the removal plan was implemented. Although the immediacy was removed, the deficiency remains at the Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Local police report, dated [DATE] at 2:53pm report number xxxx-xxxxx, denotes in-part: on [DATE] at approximately 253hrs, Reporting Officer (R/O) #XXX was dispatched to Chicago Ridge Nursing Home located at (facility address) reference a report of narcotics inside of the facility. Upon arrival, R/O made contact with the social worker for the nursing home, V13 (Social Service consultant). V13 advised that staff had interviewed three people who advised the following. V13 advised an unknown female nighttime worker at the facility is bringing in narcotics and selling them to a resident named R6. These narcotics are believed to be Cannabis, Methamphetamine, and Heroin. R6 is then selling the narcotics to two other residents: R3 and R8. R3 and R8 are then distributing narcotics to six other residents: R23, R20, R16, R22, R17, and R19. V13 advised that R6, R3, R8, and R23 are being Involuntarily discharged from the facility due to their involvement. V13 advised all of the other above listed subjects are able to stay, for now. V13 then handed R/O a garbage bag containing drug paraphernalia. R/O discarded the garbage bag when he returned to (Police Department). The nursing home is going to continue to attempt to identify the worker who is providing the narcotics to the patients; therefore, this case is to be considered open at this time. Nothing further. On [DATE] at 12:16pm V2 (Administrator) said the facility was cited for a drug overdose in [DATE] and was cleared on [DATE]. V2 said on [DATE] she was made aware that R3, R6 and R8 was involved with selling drugs in the facility. During a follow up interview on [DATE] at 11:11am V2 said, no residents have been transferred to the hospital for illicit drug overdose, suspicion of illicit drug over, or illicit drug related issues. On [DATE] at 2:06pm V13 (Social Services Consultant) said on [DATE] the maintenance staff informed her that when he was routinely changing a ceiling tile in a resident room, he found some items in the ceiling. V13 said the items was identified as drug paraphernalia. V13 said the police was called and all the ceilings in the rooms on the first floor was searched. V13 said, Residents were interviewed, and a male resident informed her that a female staff with burgundy hair that works the night shift was bringing the drugs into the facility and selling them to the residents. V13 said she informed the police of the description of the female staff. V13 said she can't recall who the male resident is, who informed her of the description of the female staff. V13 said she will go and review her information and follow up with the surveyor. V13 said she can't recall the description of the male resident that informed her of the female staff. V13 said she informed the V2 (Administrator) of the description of the alleged female staff supplying the residents with drugs, and allegedly the administrator said that could be anybody. During this survey V13 did not follow up with the surveyor regarding who is the identified resident that gave the description of the female staff with burgundy hair. Review of the police report filed by V13 dated [DATE], there is no documented description of female staff with burgundy hair in the police report, only description given is a female night staff. On [DATE] upon entrance to the facility, the posted notice was observed to be updated to include staff belongings will be searched. On [DATE] and [DATE], the posting did not include search of staff belongings, observed by multiple surveyors. 1.R7 MDS dated [DATE] denotes BIMS score of 15 (cognitively intact). R7 face sheet shows diagnosis of anxiety, depression, presence of pacemaker, chronic atrial fibrillation. On [DATE] at 1:30pm, R7, observed alert to person, place, and situation. R7 stated that he was given cocaine on [DATE], stated that he was hospitalized on [DATE]. R7 said he thought he was purchasing cocaine, and not fentanyl. R7 said he doesn't want to name the female resident that gave him the drug, he doesn't want to get her in trouble because she doesn't have anyone. R7 said he used cocaine in the past, stated that once he took the cocaine that he got from the female he knew it wasn't cocaine, it was different. R7 said he does remember he went to the hospital the next day. R7 said the female resident still resides at the facility. R7 declined to give description of the alleged female resident. [DATE] at 3:40pm V11 (Licensed Practical Nurse/LPN) said she was working on evening shift [DATE], R7's speech was slurred. V11 said it was reported by the day shift Nurse that R7 needed to provide a urine specimen and R7 was unable to provide it during the day shift. V11 said she assumed that R7 was behaving suspiciously on day shift; that's the only reason why staff would collect a urine drug screen. V11 said when R7 was giving the urine sample, R7 kept standing and sitting. V11 said R7's urine specimen tested positive for opiates. V11 said when R7 came out of room after eating dinner, R7 was in a wheelchair. R7 was slumping forward in the wheelchair, then fell to the floor. V11 said R7 vital signs were very low, oxygen was applied to his face, R7 was cyanotic. V11 said she called a code blue. V11 said she administered two doses Narcan. The medical doctor said to monitor R7, neuro checks are scheduled in (electronic records) and vs (vital signs) were done every two hours. V11 said she asked R7, who gave him the illicit drugs? R7 responded, I don't know, I only take my scheduled medications. V11 said she documented the code blue in risk management and the vitals were documented in the records. On [DATE] at 12:38pm V4 (Substance Abuse Coordinator) said R7 did not have a community pass on [DATE] or [DATE] and does not recall him visiting with his family on [DATE] or [DATE]. V4 said she signs and gives the residents community access passes. On [DATE] at 3:01pm V10 (Director of Nursing/DON) said R7 informed him that he got cocaine from a resident but refused to talk about it and give information on the resident. R7's care plan with initiate date of [DATE] denotes in-part, the resident has a history of substance abuse chemical dependency related to clinical depression and anger history of mental illness severe mental illness, poorly developed ability to control impulse, allowing negative inappropriate persons to influence his use of substance. Problem and symptoms are manifested by going into the community to become intoxicated, problems and symptoms are manifested by failure to accept responsibility for actions and to be honest with oneself. The drug of choice is opioids. Date initiated [DATE]. Goals, I will refrain from using non prescribed substance through the next review date. Resident will attend substance abuse group two times a week to address issues of addiction. Staff will conduct random room searches provide supervised visits, and search residents belongings as needed as it relates to substance use. Staff will perform random drug screening to assess for substance use. Upon suspicion that resident has illicit drugs or used illicit drugs they will be placed on one-to-one monitoring/supervision. Work with the resident to establish a verbal or written behavior contract; specify what is and what is not allowed. Make sure the resident is aware of rules prohibiting use of alcohol, illicit substance and intoxication. Meet with the ID team to discuss the extent of the resident's illness the physician may consider a referral for psychiatrist spam or write borders restricting pass privileges. Provide leisure counseling to the resident to help him use free time and productive nondestructive ways. R7's progress note dated [DATE] completed by V11 (LPN) denotes in-part resident was observed with signs and symptoms of substance abuse, Physician notified obtained order for drug screen. Resident tested positive for opioids; order received to monitor vs (vital signs) every 4 hours x 72hours. Restrict pass, supervised pass until further notice. Okay to give scheduled medications. Notify MD (medical doctor) of any additional changes or AMS (altered mental status). Administrator, DON (Director of Nursing), and family member notified. R7's progress note dated [DATE] at 9:27am completed by V4 (Substance Abuse Counselor/SAC) denotes in-part: it was brought to SAC (substance abuse counselor) & SS (social service) attention that the Resident was presenting suspicious behavior affiliated with Substance Abuse. The Resident was showing oddly behavior such as anxiety, sweating, showing a red complexion, and fidgeting with his nose as well as mumbling to himself. The Resident was asked to complete a drug screening whereas at the time stated he cannot go due to using the washroom ten minutes ago. The Resident was present during the room searched and no contraband was found. The Resident was placed on 1:1's with SAC & SS and later with SSA's (social service assistant). This took place on [DATE] at 1:00pm. It was brought to SAC & SS attention that the Resident completed the drug screening, and it was positive for opioids, which the Resident does take Hydrochlorothiazide; a form of the opioids family. SAC spoke with the Resident whereas he stated he did not take any illicit substance and was very adamant on not letting his sister know of what's going on because it's not true. The Resident also was asked; what happened yesterday during the time the Narcan was used, he stated he does not remember. The Resident explained why his test results were positive for Opioids and began mentioning SI (suicidal ideations), which he was placed on 1:1 monitoring until being D/C (discharged ) to the hospital. SAC will update the Resident care plans, assessments, and will upload signed documentation to (electronic records). R7's hospital/emergency room records dated [DATE] denotes in-part chief complaint AMS (Altered Mental Status), elevated blood pressure, and noncompliance. Social history positive for opioid use, urine drug screen is positive for fentanyl, also on prescription narcotic pain medication, smoking positive although unable to quantify, nursing home resident, issues of compliance with medication. Treatment plan hypertension, atrial fibrillation, history of pacemaker placement, peripheral neuropathy chronic low back pain, seizure disorder, hypothyroidism, fentanyl abuse and intoxication, psychosis. Labs collected on [DATE] at 2:36pm urine opiates screen; positive- reference range; negative. Urine fentanyl collected [DATE] at 2:36pm positive, reference range; negative. Review of R7's physician order sheet there are no active or discontinue orders for fentanyl. 2. R14's MDS dated [DATE] denotes BIMS score of 15 (cognitively intact). R14's face sheet shows diagnosis of hemiplegia following cerebral infraction affecting left dominate side, chronic obstructive pulmonary disease, psychoactive substance abuse, pulmonary embolism. On [DATE] at 1:35pm R14 observed alert to person, place time and situation, sitting in wheelchair, able to self-propel. R14 said he purchased twenty dollars' worth of heroin from R3 on [DATE]. R14 said he was sent to the hospital, and the hospital told him that he tested positive for fentanyl. R14 said he didn't know that fentanyl was in the heroin. R14 said, that was not the first-time buying drugs from R3. R14 said the hospital doctor told him he could have died from fentanyl drug overdose. [DATE] at 12:38pm V4 (Substance Abuse Coordinator) said she was not aware that R14 was sent to the hospital and returned with diagnosis of poly substance abuse on [DATE]. V4 said she should have been made aware. V4 said she was not aware that R14 used illicit drugs on [DATE], no one informed her. V4 said R14 does have a substance abuse history. V4 said R14 was readmitted to the facility after relapsing at home. V4 said R14's sister did not visit him on [DATE]. V4 said she is not aware that R14 went out on a community pass on [DATE]. V4 said she signs and gives the residents community access passes. On [DATE] at 3:45pm V17 (LPN) said he was the Nurse on duty on [DATE], when a female staff got off the elevator with R14 and said, “this is your resident”. V17 said he didn't assess R14 at that time. V17 said he don't recall who the Aide was. V17 said he was passing medications, and a resident approached him and said, “there's something wrong with R14”. V17 said that's when he assessed R14 by calling his name, checking R14's vitals, continuing to call R14's name and doing a knuckle rub to R14's chest. V17 said R14 was drowsy, opening his eyes and then closing them. V17 said he called 911, when 911 arrived R14 was more alert. V17 said he did not give R14 any medication that would make him drowsy or any medications after observing R14 drowsy. V17 denied giving R14 Narcan and denied that any other staff gave R14 Narcan. V17 said he was the receiving Nurse upon R14's return to the facility. V17 said he reviewed the after-visit summary from the hospital, and it was documented that R14 diagnosis was transient alteration of awareness, polysubstance abuse, and dyspnea. V17 said he understands polysubstance abuse is when the resident is using medications and illicit substance together. V17 said he notified the Director of Nursing of R14's return and diagnosis. V17 said he doesn't recall if the Director of Nursing gave him any directives for R14. V17 said if the facility gave an in-service on when to administer Narcan, he was not at the facility. V17 said Narcan is used to reverse the effects of illicit drugs. V17 said R14 symptoms was different from someone that's overdosing on drugs. V17 declined to give the signs and symptoms of someone overdosing on drugs. V17 denied having knowledge if R14 has a substance abuse history. V17 did not give a response when asked should he have documented R14's presenting condition on [DATE] or the language “change in condition”. V17 said he don't know what the progress notes show. V17 was presented with R14's progress note that was presented by the facility. V17 said he could see the document. On [DATE] at 3:01pm V10 (Director of Nursing) said he was made aware that R14 tested positive in the hospital for fentanyl. V10 did not respond when asked; when was he was made aware of R14 testing positive for fentanyl. V10 said he was concerned because R14 does not have a physician order for fentanyl. When asked how did R14 say he ingested the fentanyl, V10 said that's a good question. V10 said R14 mentioned that he purchased the heroin from R3, he didn't know fentanyl was in it. V10 said he did not inform the administrator that R14 test positive for illicit drug fentanyl and opiates. V10 decline to answer when asked when the staff should administer Narcan. R14's progress note dated [DATE] completed by V17 (LPN) denotes in-part during routine rounds, resident was observed with a change in condition. Assessment was conducted, and resident was found unresponsive and unable to be aroused. With knuckle rub stimulation, the resident was able to open eyes briefly for a few minutes. Vital signs were as follows: BP: 139/83, Pulse: 116, Respirations: 20, Temperature: 98.2°F, O2 Saturation: 97%. 911 was called, and the resident was transported to (Hospital name) for further medical evaluation. MD (medical Doctor), family member, and ADON (Assistant Director of Nursing) were notified. R14's baseline care plan dated [DATE] denotes in-part, I will comply with the intake procedures of substance abuse treatment program by the next care plan review date. I will refrain from using non-prescribed substance through the next review date. I will behave in a safe manner consistent with resident conduct policies through the next review date. R14's emergency room after visit summary dated [DATE] denotes in-part chief complaint, altered mental status, fatigue. Visiting diagnosis: transient alteration of awareness, polysubstance abuse, and dyspnea. Medications given furosemide, naloxone (Narcan) and sodium chloride. Instructions stop using any drugs that are not prescribed to you or any street drugs at all. Review of R14's physician order sheet there are no active or discontinue orders for fentanyl. 3. On [DATE] at 10:37am R4 observed to person, place, time and situation. R4 said the last time he used drugs was on [DATE]. R4 said he got the crack from R3. R4 said he doesn't have money to buy the drugs and R3 was giving him drugs to keep his mouth shut because he was aware of what was going on. R3 said, he told the administrator at the facility everything. R4 said R3 removes the drugs from under his testicles or from between his butt cheeks when a resident wants to buy it. R4 said a staff member was involved with R3 getting drugs into the facility, and that's why R3 was giving him drugs to keep quiet about it. R4 said when he reported the female staff, the administrator didn't want to hear what he had to say and asked him to leave the office. On [DATE], V2 (Administrator) made aware of the specific name of the alleged staff member given by R4. 4. R3's progress note dated [DATE] at 4:31pm denotes in-part resident present as a risk to himself and others as evidenced by using and selling illicit substance in the facility. Resident is a danger to himself and others due to providing drugs to residents with medical and psychiatric issues. Resident has been placed on one to one with staff until local police and EMT's arrived at the facility. Per peer report, resident had a visitor who dropped off the illegal substance to the resident and he was hiding the items in his body cavity. The resident was immediately notified and given a notice of the need to conduct a room search, resident agreed. Upon room search, staff found a crack pipe. In the search contraband was recovered and discarded. The resident declined to a drug screen. Social service staff offered the resident another level of treatment such as inpatient or residential treatment for his substance use disorder. Resident decline. Resident was counseled on the safety risks associated with bringing in contraband. The resident was interviewed to obtain information on where contraband was coming from. At this time the resident will not identify the person who brought the contraband. The physician has been notified, and assessments have been updated as well as care plan. The resident has been given IVD (involuntary discharge) due to noncompliance related to contraband. R3's progress note dated [DATE] at 4:29pm denotes in-part writer spoke with resident regarding discharge planning to another facility or a shelter. The resident was given a list of shelters that were accepting males. The resident refused help with discharge planning and stated that he is not going anywhere. Resident was educated on the facility rules and substance abuse policy and continues to not sign behavior contract. Resident is currently on one-to-one staff will continue to monitor behavior as needed. On [DATE] the V14 (Assistant Director of Nursing) presents a “investigation” witness statement dated [DATE], statement completed by V4 (Drug Abuse Counselor) denotes in-part resident/staff involved R3, R6, and R8 name is listed. “I conducted multiple residents' room for contraband, and nothing was found”. Review of this “investigation”, there is no information documented that R3, R6, and R8 was interviewed about selling drugs in the facility, this investigation does not denote what areas of the room was searched. Witness statement dated [DATE] completed by V3 (Social Service) denotes in-part resident/staff involved R3, R6, and R8 name is listed. “I conducted a room search that (state surveying agency) mentioned, no contraband found”. Review of this investigation, there is no information documented that R3, R6, and R8 was interviewed about selling drugs in the facility, this investigation does not denote what areas of the room was searched. R22's witness statement dated [DATE] documents: Resident involved R8. R8 came to my (R22) room yesterday and sold me twenty dollars' worth of crack and heroin. V6's (Maintenance Staff) witness statement dated [DATE] documents: I was changing the ceiling tiles in room xxxb, contraband was in the ceiling, suspected illicit drugs. Police report xxxx-xxxxx. R16's witness statement dated [DATE] documents: Resident involved (R6). I was given heroin over the weekend by R6. R20's witness statement dated [DATE] documents: Resident involved (R8). Last week when I got caught on the patio smoking cigarettes during fresh airtime. I was given a cigarette that was laced with crack cocaine by (R8). R19's witness statement dated [DATE] documents: Resident involved (R3 and R8). R3 and R8 sell me drug when I have money. They will sell me crack cocaine and marijuana. R17's witness statement dated [DATE] documents: Resident involved R3. R3 sell cocaine and he has a person who gives him the drugs. He gave me crack cocaine on [DATE]. I told them a letter of a name. R4's witness statement dated [DATE] documents: Resident involved R3, R6, R8. I (R4) witnessed R8, R3, and R6 sell drugs in the facility. They will sell heroin, crack cocaine and marijuana to resident. R20's witness statement dated [DATE] documents: Resident involved (R8). Last week, when I got caught on the patio smoking cigarettes during fresh air time. I was given a cigarette that was laced with crack cocaine by R8. R18's witness statement dated [DATE] documents: Resident involved (R3). R3 sold me crack cocaine [DATE]. R14 witness statement dated [DATE] documents: Resident involved (R3). The man in xxxB gave me fentanyl at 10:30pm. Facility policy titled policy on “Contraband Materials and Inspection of Rooms”, this organization follows federal standards concerning removal of contraband. If the suspected contraband is in plain sight, it shall be promptly removed. If there is reason to suspect/believe that a resident has contraband items/materials in his /her possession the individual will be asked to provide permission to search. If permission is not forthcoming, the individual may be notified that the local police will be notified and asked to complete a search, at the discretion of administration. The following items are NOT ALLOWED in the resident rooms at any time and are not allowed in the resident person. Drugs deemed illegal by federal and state government, prescription medication in the possession of someone to which they were prescribed, alcohol. The organization will try to balance individual rights against the safety needs of peers, visitors, and staff members in making decisions about further investigation of contraband. In situations where illegal activity appears to have taken place appropriate authorities will be notified. Again, safety and security are of the utmost concern. During this survey the facility failed to present witness statements/investigation from female staff with description of burgundy hair. Per V13's (social service consultant) interview, a male resident described a female staff with burgundy hair, selling illicit drugs to residents. During this survey there were multiple staff members observed with hair color hue of burgundy. Upon exit of this survey, the facility failed to present policy/practice related to when to administer Narcan. During this survey V12 (Consultant) was asked, and V10 (Director of Nursing) was asked. It is not clear to surveyor as to when the staff should administer Narcan to a resident. The facility has resident residing that is identified with illicit substance abuse issues. The Immediate Jeopardy began on [DATE]. The immediacy was removed on [DATE]. The surveyor on [DATE] and [DATE] via observation, interview and record review confirmed the following removal plan was implemented by the facility to remove the immediacy: The Chicago Ridge Nursing & Rehabilitation Center outlines its plan to prevent illicit drug use and possible drug overdose among residents. The facility has implemented various measures to monitor residents to ensure a safe environment. R3 no longer resides in the facility. R6 is currently in the facility and is in stable condition. Remains under increased staff supervision. 1:1 supervision with a minimum of 3 days based on compliance with the plan-of-care. R7 is currently in the facility and is in stable condition. Remains under increased staff supervision. 1:1 supervision with a minimum of 3 days based on compliance with their plan-of-care. R8 is currently in the facility and is in stable condition. Remains under increased staff supervision. 1:1 supervision with a minimum of 3 days based on compliance with their plan-of-care. R 14 is currently in the facility and is in stable condition. Remains under increased staff supervision. 1:1 supervision with a minimum of 3 days based on compliance with the plan-of-care. · Immediate health assessments were performed by facility staff and hospital staff on R7 and R14. · Immediate increased supervision was initiated for R3, R6, R7, R8, and R14. · The facility initiated an investigation into the allegation of staff involvement and had no credible evidence that staff had any involvement in the distribution of illegal substances. · The facility conducted a comprehensive search of the facility to locate and remove any illicit drugs or paraphernalia. · The facility enlisted the involvement of external authorities, the (local) Police Department, and the Mayor's Office for assistance and support. · The facility increased surveillance in key areas identified as potential points of vulnerability, such as the residents' rooms, patio area, and facility entrance. Compliance Oversight and Documentation Plan for 1:1 Supervision The following measures will be implemented to support the effectiveness and accountability of the Removal Plan: Responsible Parties for Compliance Administrator: Oversees overall implementation and ensures regulatory compliance. Director of Nursing (DON) and Assistant Director of Nursing (ADON): Responsible for clinical oversight, staff supervision, and adherence to 1:1 monitoring protocols. Social Services Director: Ensures proper assessment, documentation, and coordination of care for residents with substance use history. Interdisciplinary Team (IDT): Reviews resident progress and adjusts care plans accordingly. IDT members include: MDS, Social Services, Wounds, Restorative, Dietary, Activities, DON and ADON. Documentation of 1:1 Supervision, Compliance, and Outcomes Start Date 08-22-205 (ongoing). Daily Logs: Staff assigned to supervision 1:1 will complete detailed logs documenting: Start and end times of supervision: See Exhibit 1 Resident behavior and interactions Any incidents or concerns Compliance with plan-of-care Electronic Health Record (EHR): All 1:1 supervision entries will be uploaded to the resident's EHR, including rationale for initiation, duration, and outcome. Weekly Review: The Administrator or DON will conduct weekly audits of 1:1 supervision documentation to ensure accuracy and completeness. Outcome Tracking: Residents will be assessed based on behavioral changes, adherence to care plans, and preparedness for transitioning out of 1:1 supervision. Enhanced Monitoring Measures started 08-22-2025 (ongoing). · Resident Rooms: Random room searches will continue as part of ongoing surveillance efforts to ensure safety and compliance. · Patio Area: During the resident patio period, at least two staff members will be assigned to observe and supervise the area. · Facility Entrance: Monitoring at the main entrance will be increased, and two employees will be assigned to supervise access and activities from 8 am until 8 pm. · Any staff member suspected of involvement in the trafficking or distribution of an illicit substance will be immediately suspended pending investigation. An internal investigation will begin, and an external investigation may occur if appropriate. · Initiation of random drug urine tests was implemented for residents at risk for drug use. · All facility staff have been in-service in person or via telephone. Staff who have received training via telephone will be required to attend in-person training before the start of their shift. Upon completion of the in-person in-service, the staff will sign the in-service sheet. The administrator and/or social service director will conduct weekly spot checks to ensure the facility staff are knowledgeable of the content. Any staff who were unable to attend the in-service due to a planned vacation or leave of absence will be in-serviced on their next workday before the start of their shift. This in-service training will be conducted by the Administrator, Social Services Director, Director of Nursing (DON), or Assistant Director of Nursing (ADON), with an initial completion date of [DATE]. Ongoing training will be provided for all new hires, and

Based on observation, interview, and record review the facility failed to prevent incident of resident-to-resident physical assault. This affected three of three residents (R1-R3) reviewed for physical abuse/assault. This failure resulted in R1 physically assaulting R2 and R3, however as a result of the assault, R1 sustained bilateral nasal bone fracture and blunt abdominal trauma. The findings include:On entry to the facility R1 had been hospitalized on [DATE]. According to progress notes, R1 returned to the facility on 8/7/25 at approximately 8:00PM. On 8/8/25 at 9:44AM R1 on patio, sitting, smoking. R1 looking down, away from surveyor, not making eye contact, did not interact or greet surveyor. R1 kept looking away. Observed under eyes swollen, light purple crescent shape under each eye, flat scratches/abrasions on right side of nose along bridge. R1 would not speak to surveyor.On 8/8/25 at 10:55AM R1 her room, no visible injury on hands or face. Ambulates freely. R1 said I was sitting outside having a smoke and that lady (R1) came up to me, got in my face and tried to hit, I hit her back. R2 said I'm not hurt. R1 said she not my friend I don't know why she wanted to fight me. R1 said yeah, we were fighting. R1 said V2 (Social Service Aide) was there she saw it. R1 said then R1 got in a fight with another lady; I just came inside. R2 said we was outside on the smoking patio.R1's diagnosis includes but are not limited to Anxiety Disorder, Cognitive Communication Deficit, and Unspecified Psychosis. R1's cognitive assessment dated [DATE] identifies she is cognitively intact. R1's behavior assessment dated [DATE] identifies delusions for potential indicators of psychosis.Witness statement with R1's name with no signature or date states I ran up to (R3) and attempted to hit (R3) and she hit (back). I got in (R2's) face and (was) trying to fight her.Witness statement with R3's name and signature states (R1) hit me and (I) hit her back and we started fighting.Witness statement with R2's name and signature states (R1) came in my face and R1 hit me, and I defended myself. I hit, grabbed her hair, and kicked her.On 8/7/25 at 11:22 V2 (Social Service Aide) said R1, R2, and R3 were outside on the smoking patio. V2 said V2 was inside, and one monitor was outside. V2 said V2 heard arguing and walked out, and saw staff try breaking up the fight. R1 and R2 were yelling at each other, and they were swinging at each other. R1 hit R2 first. R2 was sitting and R1 was standing over R2. V2 saw that R1 and R2 were getting separated. V2 said during that time R1 got away and hit R3, and then they start fighting. V2 said V2 saw R3 swinging at R1. V2 said as we were walking away, I saw R1 had blood on her nose. V2 said R1 came out, she looked frustrated and mad when she came outside, that is usual for her. At 2:11PM V2 said when R1 came down, V2 told her she could not go outside. V2 said I kept redirecting her and R1 took it upon herself to go outside anyway. V2 said V2 did not give her a cigarette. V2 said R4 said R1 woke up mad and irritated. V2 said when a resident is on restriction, Social Service Staff will give us the list, I was told the day before that R1 was on restriction. V2 said V2 told R1 she could not go out, she continued to walk past me, she said she wanted to go out. V2 said when R1 got out there, they started arguing. V2 said it was not reported to anyone that R1 was on the patio until after the fight had occurred.V2's witness statement signed and dated 8/5/25 states R1 went out the door and (V2) heard arguing. I saw V5 (Social Service Assistant) was trying to break up a fight between R2 and R1. I went to help and R1 ran to R3 and hit her, then they started fighting.On 8/7/25 at 12:23PM V3 (Licensed Practical Nurse/LPN) stated R1 was brought to the unit and V3 was notified she had been in altercation with another resident. V3 said V3 assessed her and cleansed her nose. V3 said V3 put an ice pack on her nose. V3 said she was not aware if R1 was on a smoking restriction.On 8/7/25 at 12:47PM R4 said on 8/5/25 R4 was on the patio smoking with R1. R4 said R1 was upset because the smoke girl had told her she can't come out and smoke the rest of the day. R4 said the other lady, lives on the first floor (R3) told her to mind her business. R4 said that made R1 mad and I told R1 to stay here, finish your smoke, be good, and then come back in. R4 said I came inside to talk to the smoke monitor inside. R4 said then I saw V2 run outside, and I just knew it was R1. R4 said when R1 came inside I saw blood on her nose and her cheek. R4 said R1 said she got in a fight. R4 said I spoke to R1 on the phone today, she said they were checking her out because she had blood on the brain.On 8/7/25 at 1:32PM V5 (Social Service Assistant) said R1 and R2 were arguing and then R1 hit R2. They were fighting. V5 said V2 (Social Service Aide) came to help me break up the fight. Then R1 went and hit R3. V5 said I was outside on the patio when the fight happened. V5 said R2 was sitting on the bench near where I was and then R1 walked up to R2, and they were arguing and then they were hitting (each other). V5 said R1 and R2 exchanged some words and R1 was mad. R1 had an attitude the whole time she was there. V5 said I sensed she was angry when she came out. V5 said R1 was on smoke restriction and was not supposed to be on the smoking patio.On 8/7/25 at 1:55PM V1 (Social Services) said R1 was on smoking restriction because she had got caught smoking in her room. V1 said R1 was on restriction for 30 days. V1 said R1 can go outside for fresh air but she can't be out there for smoking time. V1 said R1 wasn't supposed to be down there on 8/5/25. V1 said the V2 (Social Service Aide) should have stopped R1. V1 said V2 was trying to stop her from going out. On 8/7/25 at 2:24PM V6 (Director of Nursing) said R1 became aggressive with one resident and another resident jumped in and separated them. V6 said R1 had scratches on her face, and she was the aggressor. She tried to beat up 2 people at the same time. V6 said if a resident is on restrictions, they should not be on the patio with the smokers. V6 said we need to be vigilant to make sure to not allow the person to be outside. The surveyor asked V6 if not smoking can cause a smoker to be cranky. V6 replied absolutely can be cranky. V6 said for nicotine withdrawal we can offer them something else. V6 said I am not sure if R1 was offered something. V6 said I did not know R1 was on restriction until after the incident happened. V6 said R1 was not even supposed to be down there, on the smoking patio. V6 said if the smoke monitors cannot redirect the resident, they should call the nurse and social services for direction to ensure R1 did not violate her restriction. V6 said the staff did not tell anyone R1 was outside.Review of R1 progress notes include screaming and cursing at staff and punch and choke staff on 1/30/25. On 5/12/25 progress notes states R1 presented verbal inappropriate behavior with obscene language to the writer.On 8/8/25 at 1:17PM V7 (Physician) said I was notified that R1 was attacked by 3 others. V7 said I know I got a call about R1 having been attached by 3 other residents. V7 said I was told she was bleeding, but not from where. I told them to send her out for an evaluation. V7 said they're supposed to have a staff on the balcony (smoking area) watching the residents. V7 said the purpose for them to be watching is for safety. V7 said nasal fractures and blunt abdominal trauma can be a result of trauma or impact. V7 said they didn't tell me where she was hit when they called me.R1's Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors dated 6/7/25 states history or recent episode of aggressive/agitated behavior is substantial or significant problem. It was reported R1 was allegedly involved in inappropriate interaction with peer. assessment dated [DATE] states R1 has history of aggression.Smoking Risk review dated 7/24/25 documents R1 was smoking in room with peer. R1 presented with verbal inappropriate behavior. Smoking Risk review dated 4/24/25 documents R1 smoking in hall bathroom. R1 refused to sign smoke contract and not receptive. Smoking Risk review dated 4/22/25 documents R1smoking in peer's room. R1 counseled on facility policy and safe smoking. R1 not receptive. R1 smoking contract dated 7/24/25 states verbalized to resident, R1 refused to sign.R1's care plan dated 7/24/25 states R1 demonstrates non-compliance with safe smoking regulations by smoking in rooms, bathrooms, halls, stairways, elevators, and other non-designated areas. Smoking at non designated times. Interventions include explaining the safe smoking policy and policy for non-compliance. R1's care plan dated 8/5/25 (revised date) states history of aggressive, inappropriate behavior, includes conflicts/altercations with others, threatening behavior, verbal or physical aggression. Intervention includes intervene when inappropriate behavior is observed.R1's progress notes dated 8/5/25 states involved in social inappropriate interaction. R1 in altercation on patio during smoke break. Skin tear to her face, redness near right side of her face and bridge of her nose. R1 sent to hospital for evaluation.Progress notes dated 8/6/25 state R1 transferred to hospital with diagnosis of Assault & Fracture Nasal bones.R1's facility obtained medical records dated 8/7/25 stated schedule this patient for follow up in plastic surgery clinic to discuss her recent bilateral nasal bone fractures. Hospital discharge diagnosis includes Abdominal pain, Blunt Abdominal Trauma.R3's diagnosis includes anxiety disorder and Psychoactive Substance Abuse. R3's cognitive assessment dated [DATE] identifies cognitive intact. Behavior assessment dated [DATE] identifies no potential indicators of psychosis.Progress notes 8/5/25 document R3 involved in social inappropriate interaction with peer. R3 sent to hospital for psych evaluation. (R3 remained hospitalized upon exit of survey.)R3's care plan includes history of aggression, inappropriate behavior, conflicts/altercations with others, verbal or physical aggression. R3 has severe, chronic persistent mental illness. At times shows aggression. Physically abusive behavior when agitated.R2's diagnosis includes but are not limited to Schizoaffective Disorder, Altered Mental Status, Violent Behavior, and bipolar disorder. R2's cognitive assessment dated [DATE] identifies she is cognitively intact. R2's Behavior assessment dated [DATE] identifies delusions for potential indicators of psychosis.Progress notes dated 8/5/25 states R2 involved in social inappropriate interaction with peer. R3 said another resident approached and attempted to make contact with her and she defended herself. Progress noted dated 8/5/25 at 1:14PM states R1 has been arrested two times for domestic battery.The facility behavior management policy and procedure dated 11/22 states it is the policy of the nursing department to determine the cause of behaviors when possible and initiate interventions to reduce control or prevent identified behaviors. In the event the behavior cannot be managed staff will implement protocols to prevent the residents from harming self or others. The purpose is to prevent the residents from harming self or others. Procedure: notify social service of any behaviors as soon as possible initiate behavior monitoring and recording to provide pattern of behaviors and response to planned interventions when applicable. Targeted behavior agitated behavior which represents a danger to self and others. Preventative measure observe residence for behavior escalation of anxiety aggression such as loud voice tone handwringing swear and yelling and other irritability. Removed from problem area. Allow time for the resident to voice feelings and frustration.

Based on interview and record review, the facility failed to follow their stated protocol for signing residents out on community pass by not verifying the identity of the individual who signed out a resident (R11). The facility did not have an effective supervised community pass protocol in place. This failure applied to one (R11) of two residents reviewed for community pass and resulted in R11 leaving the facility on pass on 4/30/2025 and not returning. R11 has a significant history of substance abuse disorders and R11's whereabouts are currently unknown. Findings include: R11 is a [AGE] year-old female who originally admitted to the facility on [DATE]. R11 has multiple diagnoses including but not limited to the following: multiple orbital fractures, nasal bone fracture, psychoactive substance abuse, opioid dependence, and alcohol abuse. R11's BIMS (Brief Interview for Mental Status) Score is 15. Community Survival Skills assessment dated [DATE] shows that R11 is not capable of unsupervised outside pass privileges at this time. R11's care plan states in part but not limited to the following: Interventions: A community survival skills assessment will be conducted to reasonably determine the person's ability to safely and respectfully negotiate within the outside community. Progress note dated 4/29/2025 states in part that V21 (R11's Friend) will be taking R11 on a day pass on 4/30/2025 from 5PM-7PM. Pass Request Form states in part but not limited to the following: Pass to begin on 4/30/2025 at 5PM and end on 4/30/2025 at 7PM and accompanied by V21. It is to be noted that the ID scanned and attached to the community pass is not the same name/person listed on the Community Pass Request Form (V21). On 6/3/2025 at 9:40AM, V7 (Psychosocial Rehabilitation Services Clinician/PRSC) said our process for the facility is that when a resident needs a supervised pass: the family/friend they are going out with requests to take them out. We get the name and phone number of this person. We document where they are going, when they are leaving, and when they will return. When the date and time comes, the visitor takes the pass, the nurse signs off on it, then the receptionist makes a copy of the ID of the individual taking them out. The copy of the ID is done to ensure the person taking the resident out on supervised pass is the same individual listed on the pass request form. We explain the rules to them and to ensure they are safe that way. On 6/3/25 at 1:30PM, V22 (R11's Family Member) said R11 is constantly drug seeking. Before she came to the facility, she was in the hospital due to someone assaulting her. She is unsafe to herself and others when in the community. I have an order of protection against her for me and my family's safety. R11 is very manipulative. On 6/3/25 at 1:50PM, V16 (Licensed Practical Nurse) said I was the nurse on duty on 4/30/2025 when R11 said she had a pass to go out to the grocery store for a couple hours. A friend came and picked her up, I scanned the ID. I then gave the pass and the copy of the ID to the receptionist. After 7PM came and went, I called to follow up. R11 never came back to the facility, to my knowledge. On 6/3/25 at 3:00PM, V6 (Social Service Aide) said I was the receptionist on 4/30/25 when R11 went out on pass. However, I was passing out cigarettes and not at the front desk at the time R11 left. The receptionist usually scans the ID of the person taking the resident out on pass, but I was busy. I never spoke with the person that took R11 out. The reason we scan the ID is to ensure that the ID matches the name on the pass request form. This is for the resident's safety, in case of an emergency where we would have to call the police or if the resident does not come back to the facility. On 6/4/2025 at 11:45AM, V1 (Administrator) said when a resident has a supervised pass, a pass request form is filled out listing the name of the person taking the resident out including the date and time the resident is leaving and when they will return. The person's ID is scanned to ensure that the pass and the ID match. V1 said when R11 did not return to the facility, we did not notify the police. I do not consider this elopement. It is to be noted that facility policy titled Community Pass does not lay out the procedure of the facilities supervised pass system.

Based on interviews and record reviews the facility failed to have a system in place for monitoring and investigating how illicit drugs got into the facility, to be alerted when illicit drugs enter the facility and to prevent resident use and possible drug overdose. This failure applied to one (R12) of three residents reviewed for supervision and resulted in R12 obtaining and using illicit drugs while in the facility, that led to a drug overdose, requiring the administration of Narcan (opioid reversal agent) and emergent hospital transfer. Findings include: The Immediate Jeopardy began on [DATE] when R12 was administered Narcan for drug overdose while in the facility. V32 (Assistant Administrator) was notified on [DATE] at 1:00PM of the Immediate Jeopardy. The immediacy was removed on [DATE] but noncompliance remains at Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. 1.) On [DATE] 10:48 AM R7 stated he knows other residents are using drugs in the facility because he recognizes the abnormal behaviors from drug use. R7 stated he recognizes these behaviors because he used to be a drug addict. R7 stated when he sees this it does tempt him to abuse drugs. R7 is a [AGE] year-old male with diagnosis not limited to history of Schizophrenia, Depression, Suicidal Ideations, a History of Suicidal Behavior, Crohn's Disease, Blindness of Left Eye, and Encounter for Palliative Care. R7 was admitted to the facility [DATE]. 2.) R12 is a [AGE] year-old female with diagnosis not limited to history of Epilepsy, Restlessness and Agitation, Psychotic Disorders with Delusions, Paranoid Schizophrenia, Bipolar Disorder, Generalized Anxiety Disorder. Recurrent Major Depressive Disorder, Psychoactive Substance Abuse Disorder. R12 was admitted to the facility [DATE]. R12's Hospital Record dated [DATE] documents she is a [AGE] year-old female with a past medical history of depression who presents to the emergency department from a Behavioral Health/Substance Abuse Treatment Center for evaluation of a seizure sensation. R12 is at the Treatment Center for a history of drug, alcohol, and marijuana use. R12 reports last using cocaine 15 days ago. R12's Facility admission Contract includes a Social Services Quick Reference Interview form that documents she was admitted to the facility on [DATE] and in response to the question do you have a history of substance abuse? She answered yes and in response to the to the question which one? Regarding substance use she answered, all of them. R12's Nurse Practitioner Progress note dated [DATE] documents she is a [AGE] year-old woman admitted to the facility on [DATE], with chronic diagnoses of Drug Use Disorders and Depression. R12's Preadmission Screening and Resident Review dated [DATE] documents she has been to the Behavioral Health/Substance Abuse Treatment Center for cocaine detox and rehab. R12's progress note dated [DATE] created by V21 (Licensed Clinical Social Worker) documents resident has a history of alcoholism and drug addiction (marijuana and cocaine). On [DATE] at 1:36 PM V18 (Licensed Practical Nurse/LPN) confirmed she responded to R13's room on [DATE] when R13 informed her that something was wrong with R12. When V18 arrived at the room, she observed R12 was unresponsive, laying across R13's bed and V23 (Certified Nursing Assistant/CNA) helped get R12 to the floor. V18 stated she performed a sternum rub on R12, R12 still had a pulse and was slowly trying to open her eyes but she still wasn't responding as normal. V18 stated R12's oxygen levels were dropping so we applied oxygen and once she placed the non-rebreather mask on R12 she had already grabbed Narcan (Opioid Antagonist) just in case. V18 stated she had just talked to R12 at 8:30 or 9 o'clock PM and she wasn't in that condition. V18 stated R12's eyes were rolling into the back of her head and R13 said he thought she had something. V18 stated R12's oxygen level was at like 82%. V18 said she used Narcan because one of the residents said they saw R12 coming out of another resident's room, and she doesn't visit everyone. The only room she ever sees R12 in is her room or in the resident's room she calls her boyfriend. V18 stated when the first Narcan dose was administered R12 slowly came back but not right away. Then when she gave R12 the second dose, her eyes opened, and she came back to us. V18 stated she still had oxygen on R12. By that time the paramedics arrived, and the police came, and they asked R12 in the presence of the paramedics did she take anything or have anything, and she said no it wasn't a pill. V18 stated R12 was asked if it was it a powdery substance that she took and she told the paramedics yes and began throwing up. V18 stated R12 gave the police the name of the resident's room she was in. V18 stated she went with the police to that resident, and he denied having anything. V18 stated the resident was R8 and the police advised they could not search his room because it was illegal. When asked by the surveyor if she or anyone else had R8 tested for drugs V18 stated that on the day of the incident she called V2 (Director of Nursing) and was told the social worker will follow up with R8 in the morning. When asked by the surveyor if any of the administrative or management staff followed up with her and asked any questions about the incident V18 stated on the day of the incident she called and spoke with V2 and called V1 (Administrator) who advised her to notify V24 (Nurse Consultant) and she then notified V24. When asked again by the surveyor if any of the administrative or management staff followed up with her and asked her any questions about the incident V18 stated all three managers did check on her and V23 about their well-being soon after the incident because it was a traumatic experience that she had never been through. V18 stated they gave her the next day off. V18 stated R13 is always in his room, and she has never seen him go out of the facility. V18 stated on that night that R8 was in his room the majority of the night. V18 stated this incident happened at approximately 9:40 PM. V18 stated she had not observed any abnormal behaviors from R8, R12, or R13 that night prior to the incident. V18 stated she is unaware if any drug testing was done on R8. V18 stated V25 (Registered Nurse) was also working during the incident and assisted her. R12's progress note dated [DATE] at 9:42PM created by V18 (LPN) documents she was visiting with a friend in his room, peer came to desk to get nurse stating, She's not responding to me. Writer entered peers room noticed a change of condition with patient not responding appropriately. Vital Signs noted oxygen at 82%. Writer applied oxygen at 5L via non-rebreather mask. Oxygen saturation increased to 92%. Narcan (Opioid Antagonist) administered twice, 911 called. Fellow co-workers assisted with patients care. At 9:50 PM it was documented that 911 paramedics arrived at facility to assess patient's status and scenario. 911 took over CPR (Cardiopulmonary Resuscitation). At 10:00 PM a late entry documented R12 discharged to the hospital on [DATE] at 9:42 PM; Reason for transfer: Patient not responding appropriately at her normal. At 10:10 PM it was documented patient being transported to the Hospital emergency room for further evaluation. R12's progress note dated [DATE] created by V31 (LPN) documents resident admitted to the Hospital with diagnosis of Overdose and Pneumonia. On [DATE] at 10:04 AM R13 stated on the day when R12 was sent to the hospital when he reported to V18 (LPN) that something was wrong with R12. R12 was sprawled out on the floor in his room and when she was revived there were multiple people standing around her and he asked her if someone gave her something. R13 stated R12 initially said she couldn't remember but then he pressed her further she finally admitted she got it from R8. R13 stated he went down to R8's room and asked him if he gave R12 anything and he denied it, however R13 stated he saw the bag in R8's hand. R13 stated he saw a dope bag in R8's hand with some of the substance in it and he was nodding off in his wheelchair. R13 stated he sometimes sees R8 nodding off in a way the indicates he may have used drugs. When asked by the surveyor if V1 (Administrator), V32 (Assistant Administrator), V2 (Director of Nursing) or V19 (Assistant Director of Nursing) came and asked him any questions about the incident after it happened R13 said no. R13 stated the next night after the incident V18 worked and she asked him if knew where R12 got the drugs from, and he told her R8. R13 stated V18 told him they would get R8 out of the facility. R13 stated the police came and didn't do anything and R8 is still here. R13 is a [AGE] year-old male with diagnosis not limited to history of Stroke, Dependence on Renal Dialysis, and End stage renal disease. R13 was admitted to the facility [DATE]. R12's progress note dated [DATE] documents resident is readmitted to the facility day 1 of 3. Resident transferred from Hospital related to overdose and pneumonia. On [DATE] at 12:21 PM, observed R12 in her room handling her belongings showing no signs of distress, illness, or injury. When asked by surveyor about her being hospitalized on [DATE] R12 confirmed she was hospitalized for an overdose. R12 stated she has a habit of roaming around and going in and out of rooms and on that day, she had been wandering in and out of rooms and when she arrived to R8's room she saw him snorting heroin. R12 asked if she could join him and she snorted heroin six times, then went to her boyfriend (R13's) room and passed out. R12 stated was told she was given CPR (Cardiopulmonary Resuscitation) because she was not responding. R12 stated she told them in the hospital she was suicidal. R12 stated while in the hospital, she was told she that she has a heart murmur and pneumonia and that if she has another incident she could end up in the ICU (Intensive Care Unit). R12's Community Survival Skills Assessments dated [DATE], [DATE], [DATE], and [DATE] documents that R12 does not appear to be capable of unsupervised outside pass privileges at this time. R12's current care plan does not include interventions for monitoring for drug seeking behaviors. The surveyor reviewed the facility's reportable investigations from May and [DATE]. There were no reports of an investigation of R12's overdose. On [DATE] at 4:59 PM V27 (Family Member) stated peer pressure, and the environment are triggers for R12's drug use. V27 stated she doesn't know how but R12 will be in the company of not good people and monkey see monkey do with her. V27 does go out with R12, and she monitors her closely and R12 does not use drugs when she's with her. When R12 was in the hospital after her ordeal on [DATE] she received a phone call from the hospital physician that was treating R12, and he said they found her unresponsive. She doesn't know what kind of drug R12 does or how much or what she does. The hospital physician may have mentioned what kind of drug R12 used but V27 couldn't recall. V27 stated the hospital physician informed her that R12 overdosed. R12 was nonresponsive, the paramedics were called, and they had to detox her. No one from the facility contacted V27 to ask any questions about R12's overdose incident. V27 confirmed she found out from the hospital that R12 was there and doesn't recall receiving a phone call from the facility notifying her of R12 being admitted to the hospital. V27 stated she asked R12 how she was able to get drugs while in the facility and R12 sometimes can deflect and not answer questions directly but from what R12 told her it sounds like one of the residents in the facility was able to bring in the drug. V27 stated she is not sure what drug, but she thinks it was heroin. V27's greatest concern is that R12 was unresponsive, it could have been a matter of moments, and if she took just a little bit more of the drug or there was a delay in getting to her, she could have been lights out meaning passed away. V27 stated her concern is she could have lost R12 and if there's a way to prevent drugs from coming in, she would want that. V27 stated R12 said they had to do electric shocking to resuscitate her. V27 stated thankfully R12 didn't die but hopefully it doesn't happen to someone else or another resident's family. V27 stated R12's overdose caused her and V33 (Family Member) a lot of distress. V27 asked what if the nurse hadn't gotten to R12 at the time she did or if there was a minute delay? V27 stated every moment or second is imperative to life in that situation. 3.) On [DATE] at 11:09 AM R8 stated a few weeks ago he was threatened to be put out by V16 (Substance Abuse Coordinator/Psychosocial Rehabilitation Services Coordinator) because he had a verbal altercation with her about not letting him go out on pass. R8 stated V16 told him he was going to be put out. R8 is a [AGE] year-old male with diagnosis not limited to history of Recurrent Major Depressive Disorder, Bipolar Type Schizoaffective Disorder, Psychoactive Substance Abuse, COPD, Peripheral Vascular Disease, and Prostate Cancer who was admitted to the facility [DATE]. On [DATE] at 1:15 PM V17 (Receptionist) stated R8 had an outside pass and was going out regularly. When asked by surveyor was R8's outside pass privileges removed in the past few weeks, V17 stated R8's outside pass was revoked and she isn't sure why. V17 stated residents are supposed to sign in on a log at the front desk whenever they go in and out of the facility. V17 stated R12 never had an independent pass and always goes out of the facility with family or friends. On [DATE] at 1:23 PM V16 (Substance Abuse Coordinator) initially stated R8's outside pass privileges were revoked due to suspicious behaviors of hanging around other residents. V16 could not provide information on when these behaviors were reported. When asked by surveyor if suspicious behavior is documented, V16 stated it depends on if a resident's name keeps coming up or if she keeps hearing their name brought up involving behaviors. V16 stated she followed up on the report about R8's suspicious behavior of hanging around people by asking him what's going on and who he's been hanging around etc. and his response was nothing was going on. At the time of the survey R8's progress notes from [DATE] did not include any behavioral documentation concerning drug use. R12's progress notes from [DATE] and the facility's resident reception log dated [DATE] do not document any record of R12 leaving the facility on that date. However, the resident reception log dated [DATE] does document that R8 left the faciity on [DATE] shortly after 9AM. On [DATE] at 1:47 PM V10 (Psychosocial Rehabilitation Services Director) stated when residents leave the facility independently it is documented in the resident log kept at the front desk. V10 stated if Narcan (Opioid Antagonist) is used on a resident, and it is effective or if they were hospitalized related to an overdose that should be communicated to the Director of Nursing and V16 (Substance Abuse Coordinator) because she is the substance abuse coordinator. V10 stated she is not aware of R12 engaging in any substance use while in the facility. On [DATE] at 2:44 PM when asked by the surveyor if there was an investigation regarding staff's documented report of R12 being hospitalized for an overdose, V2 (Director of Nursing) stated he doesn't have an investigation for R12's overdose incident because they said she overdosed but couldn't specify what it was. V2 stated that he did not see the paperwork from the hospital with any information on what substances were involved. V2 said you can talk to the patient and ask about the overdose, but you can't just accuse people based on allegations; and you have to be careful to accuse people. If an overdose is an admitting diagnosis for a resident this should be investigated. People overdose on a lot of stuff but most commonly drugs. The facility should follow up and ask for the toxicology result if there is a report of an overdose for a resident. V2 agreed it is standard practice to obtain hospital paperwork when residents return from the hospital. It is important to follow up on this situation to ensure the patient is safe and possibly remove the source to prevent reoccurrence. On [DATE] at 4:10 PM R8 stated he was drug tested within a day of a female resident reporting that he gave her some drugs. On [DATE] at 2:11 PM V2 (Director of Nursing) stated Narcan (Opioid Antagonist) is used when there is a suspected overdose. V2 stated Narcan will revive someone even if they don't have drugs in their system. V2 stated Narcan is also effective for Catatonia. V2 stated there are 9000 reasons that someone could become unresponsive and that the use of Narcan depends on the assessment of the patient and it's better to be safe than sorry. V2 stated that in his opinion; in order to suspect someone is under the influence of a substance you have to have the toxicology. If there were any investigations of any incidents they would be included with the reportable investigations, and he doesn't believe there were any reportable investigations for R12 in the month of May. The National Institute on Drug Abuse's Drug Facts page accessed [DATE] documents Narcan (Brand name for Naloxene) is a medicine that rapidly reverses an opioid overdose. It is an opioid antagonist. Naloxene has no effect on someone who does not have opioids in their system. Examples of opioids include heroin. On [DATE] at 3:25 PM, when asked by the surveyor how the facility responds if a resident experiences an overdose while in the facility V26 (Medical Director) stated the facility performs random routine drug testing, they are more vigilant with vitals, and if there are any signs of intoxication, they will drug test them. V26 stated he heard some sort of rumor about residents bringing recreational drugs in the facility and selling it to other residents. V26 stated he met with the administrator last week and discussed this issue and as a result they planned to work on fixing the cameras and doing some undercover investigating to get to the bottom of this. When informed by the surveyor that she was inquiring about a specific resident who was documented as being hospitalized for an overdose incident that occurred while in the facility V26 stated he didn't hear about a specific resident having an overdose otherwise they would have been kicked out of the building or it would have been investigated further. When asked by the surveyor if any report of a resident overdosing while in the facility should be investigated, V26 stated 100% this should have been investigated and that's common sense. V26 stated he doesn't know how drugs got in the facility in the first place, and he doesn't expect drugs to be inside the facility. Narcan is just a reversal agent and reverses an opioid overdose and won't do anything for an infection, or pneumonia, or sepsis. If the facility is not investigating an overdose incident that is unacceptable because the facility should be, and something should be done about it. When asked by the surveyor why would it be important to investigate such incidents V26 stated, the facility is a place of rehab, and they should try to prevent these incidences for the purpose of the safety of the residents and the staff. On [DATE] at 10:28 AM V1 (Administrator) stated she did participate in an unscheduled meeting with V26 (Medical Director) and V2 (Director of Nursing) a week ago because they wanted to discuss workflow. V1 stated V26 provided suggestions on how to improve the workflow by asking them to prioritize a list on the residents he needs to see when he comes in. V1 stated V26 did not discuss anything during that meeting about residents bringing drugs in the facility. V1 stated she had not received any concerns about residents having drugs in the facility. V1 stated there's always a speculation about this because of the type of population of residents we have in the facility. On [DATE] at 12:26 PM and 4:07 PM the surveyor requested confirmation as to whether V25 (Registered Nurse) or any other nurse performed drug testing on R8 on [DATE]. On [DATE] at 4:40 PM V32 (Assistant Administrator) advised that V2 (Director of Nursing) would provide this information. As of the time of the survey exit [DATE] the facility had not provided this information. On [DATE] at 11:00 AM R8 stated the next day after R12 alleged he gave her drugs V2 (Director of Nursing) and V16 (Substance Abuse Coordinator) asked him if he gave R12 anything and he told them no. R8 stated he told them R12 asked him for an ice cream sandwich, and he didn't have one and she left. On [DATE] at 11:02 AM V31 (LPN) stated she didn't know much about R12's incident on [DATE] that involved her being hospitalized . V31 stated it happened after she left for the day. V31 stated the next morning she contacted the hospital and was informed that R12 was admitted for an overdose and pneumonia. V31 stated she did not attempt to perform drug testing on R8. When asked by the surveyor if V1 (Administrator), V32 (Assistant Administrator), V2 (Director of Nursing) or V19 (Assistant Director of Nursing) came and asked her any questions about the incident V31 said no. On [DATE] at 2:55 PM V16 (Substance Abuse Coordinator) stated she doesn't recall asking R8 on [DATE] about whether he had any drugs in the facility. When asked by the surveyor if she was involved in any investigation regarding R12 being hospitalized on [DATE], V16 stated she heard bits and pieces about it and spoke with R12 about coping skills and provided her with some which was documented but that's all. 4.) On [DATE] at 11:14 AM R14 stated he has heard about other residents using drugs and 3 or 4 months ago he heard about residents overdosing. R14 is a [AGE] year-old male with diagnosis not limited to history of Single Episode Major Depressive Disorder, Generalized Anxiety Disorder, Opioid Use, and Accidental Poisoning by Unspecified Narcotics who was admitted to the facility [DATE]. On [DATE] at 12:35 PM V16 (Substance Abuse Coordinator) confirmed R12 was admitted with a substance abuse history and was referred to her. V16 stated she sometimes hears about R14 being under the suspicion of bringing drugs in the facility and supplying it. V16 stated approximately 3 months ago a resident who was discharging informed them that there is a resident who grabs drugs that you want and gave a description of a tall dark resident who fit R14's description. V16 stated she overheard this conversation while in the social services office when the resident was on the phone with one of the social-services staff, however she couldn't recall which staff were taking this phone call. V16 stated the resident said he would call back and give a name, but they never called back. V16 stated she is unsure of the resident's name because they were only in the facility for one or two days. V16 stated she doesn't believe she reported this to any of the management staff and they were just waiting on the resident to call back. When asked by the surveyor if there was anyone that should be notified if they received information about residents allegedly bringing in drugs V16 stated the abuse coordinator. When asked by the surveyor if she knows what triggered R12 to use drugs in the past V16 stated R12 just said if she's around certain people or gets involved at parties; and V16 believes that's what lead up to R12 using substances in the past. The facility's list of residents receiving treatment for substance abuse disorders printed [DATE] documents there are currently 52 residents in the facility with active substance abuse disorders receiving treatment including R8, R12, R13, and R14. The facility's Alcohol/Substance Use/Abuse Policy received [DATE] states: It is the policy of the nursing facility to provide a safe and healthy living environment. The use of drugs that are not prescribed by the physician are not allowed in this facility or on the facility campus. Illicit drugs may not be brought inside the facility. Documentation should include the resident's own admission of drug use. The facility's Incident/Accident Reports Policy received [DATE] states: The accident report is completed for all accidents where there is injury or the potential to result in injury. The purpose of the policy is To report, record, and investigate all accidents. To provide a process for monitoring of planned corrective actions to prevent or reduce the risk of reoccurrence of reported accidents. An accident is defined as any happening, unexpected, unintended event not consistent with the routine operation of the facility that can result in bodily injury other than abuse. An accident report will be completed for: All serious accidents of residents; All accidental unusual occurrences; All accidental situations requiring the emergency services of a hospital or police; All unexpected events that occur that cause actual or potential harm to a resident. An accident report is to be completed by a Licensed or Registered Nurse and is to include date and time of accident, full written statement and possible cause of incident, and notification of appropriate parties. The Administrator, Director of Nursing, Assistant Director of Nursing, or Nursing Supervisor must notify the following if a serious injury occurs: The Illinois Department of Public Health as soon as possible within 24 hours of the occurrence. Public Health is to be notified of incident resulting in emergency services provided by the police (911), accidents resulting in serious injury requiring hospitalization, or any accident which has or is likely to have a significant effect on health, safety, or welfare of a resident. All accident reports are reviewed, signed, and investigated by: The Administrator and The Director of Nursing or the Assistant Director of Nursing. Results of investigations are analyzed, and findings discussed in safety meetings. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. On [DATE] the survey team verified by observation, interview, and record review, that the facility implemented the following to remove the immediacy. Removal Plan: The Chicago Ridge Nursing & Rehabilitation Center outlines its plan to prevent illicit drug use and possible drug overdose among residents. The facility has implemented various measures to monitor residents to ensure a safe environment. R12 currently resides in the facility and remains in stable condition. R12 has had no ill effects from the alleged deficient practice. Education was initiated on [DATE] by the DON, ADON, and Social Service Director and is ongoing. All facility staff have been in-service in person or via telephone. Staff who receive training via telephone will be required to attend in-person training before the start of their shift. Upon completion of the in-person in-service, the staff will sign the in-service sheet. The administrator and/or social service director will conduct weekly spot checks to ensure the facility staff are knowledgeable of the content. Any staff who were unable to attend the in-service due to a planned vacation or leave of absence will be in-serviced on their next workday before the start of their shift. The administrator, social service director, DON, or ADON will lead this in-service [DATE], ongoing. Upon hire new staff are educated by social service and sign the in-service sheet ongoing The Facility does not contract with agency staffing. Education includes: All staff ' s education will be ongoing. Monitoring and investigating includes the steps to determine how illicit drugs got into the facility, prevent illicit drugs from entering the facility, are alerted when an illicit drug enters the facility and prevention of resident ' s use of illicit drugs and possible drug overdose. Substance abuse and prevention is a process that attempts to prevent the onset/relapse of substance use. Staff ensure the safety of residents and monitor the residents by conducting random room searches, supervised visits, and searching the residents' belongings. Anyone who appears under suspicion of illicit drugs are placed under 1:1 supervision, notifications will be made to the administrator, DON, family, and MD. Narcan will be administered per the physician's orders. The facility staff is responsible to reasonably prevent the entry of contraband into the facility and removing it from any resident who has it on them, including calling the police if applicable. Upon admission/re-admission to the facility, the resident ' s packet and PASSR screen is reviewed by the social services director. The social service director has re-educated the social service department on the resident ' s diagnosis and discuss therapeutic programming and care plan development. The resident's SMI/substance abuse disorder assessment was initiated, and care plan interventions updated 6-4-2025 to allow staff to adequately supervise and provide care to reduce the risk of substance use/ overdose. Education is covered in annual competency for all facility staff. Education on signs and symptoms of substance abuse and reporting signs and symptoms to the charge nurse. Educated on confiscation of contraband and labeling non-contraband items. The police department will be called immediately if contraband or illicit drugs are discovered, suspicious packages are delivered, or visitors bring them in. Or if a visit or resident refuses to have their packages searched. Prevention of illegal substances in the facility: The facility has posted signage in the lobby on 6-3-2025 alerting staff, residents, and visitors to the facility's policy of searching for contraband. This information has been provided to each resident in writing 6-4-25 and ongoing. Mouth checks on residents will be performed on residents with a history of substance abuse and residents who receive scheduled control medications. This will be performed to ensure medications are being taken when administered. This will be performed by licensed nurses. 6-4-2025 (ongoing). Upon admission/re-admission, the receptionist or designee will obtain the resident ' s belongings to be searched and inventoried before items are taken to the unit. 06-3-2025 and ongoing. Residents who refuse to be searched will be placed on 1:1 supervision, notifications will be made to the family, local police, and the physician, and the resident will be petitioned to t[TRUNCATED]

Based on interviews and record reviews the facility failed to follow their policies and procedures for providing services and supports for chemical dependence and substance abuse by not offering substance abuse group programming to a resident who reported a history of substance abuse and not ensuring a resident with a diagnosis history of Psychoactive Substance Abuse Disorder received psychiatric, group, or behavioral health counseling and services for two (R7, R12) of three residents reviewed for behavioral health services. These failures resulted in R12 using illicit substances in the facility and requiring emergent transfer to local hospital for overdose. Findings include: 1. R7 is a [AGE] year-old male with diagnosis not limited to a history of Schizophrenia, Depression, Suicidal Ideations, a History of Suicidal Behavior, Crohn's Disease, Blindness of Left Eye, and Encounter for Palliative Care. R7 was admitted to the facility [DATE]. On [DATE] at 10:48 AM observed R7 sitting in the hallway in his wheelchair. R7 stated the facility does have a substance abuse group however, he was told he is not allowed to attend the substance abuse group because in order to attend he had to have a substance abuse history when he was admitted to the facility. R7 stated he knows other residents are using drugs in the facility because he recognizes the abnormal behaviors from drug use. R7 stated he recognizes these behaviors because he used to be a drug addict. R7 stated when he sees this it does tempt him to abuse drugs. R7 stated he uses a substance abuse program app on his phone for drug counseling and showed the app to the surveyor. R7 stated it would be helpful if he was able to attend substance abuse counseling groups at the facility or receive some substance abuse counseling at the facility. R7's Current Care Plan initiated [DATE] documents he has a substance use disorder with interventions including involve him in individual counseling as appropriate and it does not include attending substance abuse groups. Substance Abuse Group Attendance Sheets from April - [DATE] did not include R7's signature in the attendance sheets for the substance abuse group meetings. On [DATE] at 1:59 PM V10 (Psychosocial Rehabilitation Services Director) stated V16 is the Substance Abuse Coordinator and conducts substance abuse groups 3-4x week. V10 stated V20 (Psychologist) also conducts Psychosocial programming every Tuesday and Thursday which includes three different groups on those days, and he also comes on Fridays. V10 stated V21 and V22 are Licensed Clinical Social Workers who see residents Monday - Friday and social services staff also meet with residents. V10 stated none of the current residents want to go to outside day programs and the few that do are in wheelchairs and those programs don't accept them. On [DATE] at 2:54 PM V16 (Substance abuse Coordinator) stated she conducts substance abuse classes twice weekly on Mondays and Wednesdays for two half hour sessions between 11AM - 12PM; Residents attend the substance abuse groups based on their hospital documentation upon admission, and she did not find any documentation of a history of substance abuse in R7's records. V16 stated she reviews all resident referrals and hospital packets on admission and if it specifies a substance use history she will complete an admission packet for the substance abuse department, offer the programming, and if they decline, she has a one-to-one session with them on Tuesday. V16 stated she will encourage residents to come to the Groups during the one-to-one sessions. V16 stated approximately three months ago R7 mentioned to her he had a substance abuse background, and she told him she would have to review his admission packet and would get back to him. V16 stated when R7 returned from going in and out of the hospital for health issues he brought to her attention that he was enrolled in a substance abuse program online. V16 stated this was the second time he mentioned this, and she encouraged him to stay on the online program and advised it was really good. When asked by surveyor would a resident be invited to the substance abuse group program based on informing her of having a history of substance abuse or of her becoming aware of this information V16 stated she reviewed R7's admission packet and didn't find anything in his history and they must have this history in order to attend the group. On [DATE] at 1:47 PM V10 (Psychosocial Rehabilitation Services Director) stated R7 should not be restricted from attending the substance abuse groups based on a substance abuse history not being identified on admission. V10 stated V16 should initiate a care plan and document on his history of substance use. V10 stated residents with a substance abuse history should receive services to address whatever behaviors or issues they have. On [DATE] at 2:44 PM V2 (Director of Nursing) stated once a substance abuse history is identified for a resident, they should immediately be enrolled in the substance abuse group unless they decline. V2 stated this is important because you want to initiate the treatment protocols that are available to the patient. On [DATE] at 3:25 PM V26 (Medical Director) stated the facility wouldn't treat residents with a substance abuse history any differently than any other patient, all the residents have medical conditions and substance abuse is just another type of medical condition. When asked by the surveyor should the facility monitor or be aware of a resident's triggers for substance use for residents with a substance abuse history V26 stated the facility has psychiatry that sees the residents to make sure they don't have any symptoms or withdrawals. V26 stated assessing triggers and monitoring the residents desire for drug use is part of the psychiatry evaluation and residents with a substance use history are managed by a psychiatrist for their addiction problems. 2. R12 is a [AGE] year-old female with diagnosis not limited to history of Epilepsy, Restlessness and Agitation, Psychotic Disorders with Delusions, Paranoid Schizophrenia, Bipolar Disorder, Generalized Anxiety Disorder. Recurrent Major Depressive Disorder, Psychoactive Substance Abuse Disorder. R12 was admitted to the facility [DATE]. On [DATE] at 12:21 PM observed R12 in her room handling her belongings. When asked by surveyor about her being hospitalized for drugs on [DATE] R12 confirmed she was hospitalized for an overdose. R12 stated she has a habit of roaming around and going in and out of rooms and on that day, she had been wandering in and out of rooms and when she arrived to R8's room she saw him snorting heroin. R12 stated she asked if she could join him and she snorted heroin six times, then went back to her room then to her boyfriend R13's room and passed out. R12 stated she heard that she was given CPR (Cardiopulmonary Resuscitation) because she was not responding. R12 stated she was told while in the hospital if she has another incident she could end up in the ICU (Intensive Care Unit). R12's Hospital Record dated [DATE] documents she is a [AGE] year-old female with a past medical history of depression who presents to the emergency department from a Behavioral Health/Substance Abuse Treatment Organization for evaluation of a seizure sensation; she is at the Behavioral Health/Substance Abuse Treatment Organization for a history of drug, alcohol, and marijuana use; she reports last using cocaine 15 days ago. R12's admission Contract includes a Social Services Quick Reference Interview form that documents she was admitted on [DATE], and in response to the question do you have a history of substance abuse? She answered yes and in response to the to the question which one? Regarding substance use she answered, all of them. R12's Nurse Practitioner Progress note dated [DATE] documents Chief Complaint is to Establish care. This is a [AGE] year-old woman admitted to the facility on [DATE], with chronic diagnoses of Drug Use Disorders and Depression. R12's (PASRR) Preadmission Screening and Resident Review dated [DATE] documents she has been to a Behavioral Health/Substance Abuse Treatment Organization for cocaine detox and rehab. R12's Social Service Initial Interview for SMI (Severe Mental Illness) Substance Abuse Disorder dated [DATE] completed by V16 (Substance Abuse Coordinator) documents and answer of no in response to the question have you been in treatment for substance abuse? R12's progress note dated [DATE] documents V16 (Substance Abuse Coordinator) spoke with her about the Substance Abuse admission whereas she received the Addiction & Diagnosis contracts. She is strongly encouraged to participate in Substance Abuse groups which will result in a 1:1 if a group is missed. Substance Abuse Counselor will assist as needed. R12's drugs of choice are Alcohol, Marijuana, and Cocaine. R12's Current Care Plan initiated [DATE] documents her Comprehensive Assessment reveals a history of suspected Substance Abuse whereas the Resident is placed in the Substance Abuse Counseling group held on Mondays & Wednesday at 11 AM and alcoholics group which is held on Fridays at 11 AM. Her Drugs of choice are Alcohol, Marijuana, & Cocaine with interventions including emphasize treatment of causal factor and/or intervention designed to moderate/reduce symptoms (make treatment of compulsive behavior, Substance abuse, anger, and mental health issues available to the Resident, as indicated). R12 has a history of substance abuse/chemical dependency related to: Clinical depression and anger (substance abuse often indicates an attempt at self-medicating depression and disturbing thoughts), History of mental illness/severe mental illness, poorly developed ability to control impulses, and Allowing negative, inappropriate persons to influence his/her use of substances with interventions including: The physician may consider a referral to the psychiatrist. Provide leisure counseling to the resident to help him/her use free time in productive, not destructive ways. R12's Psychiatric Progress Note dated [DATE] documents the type of visit as acute and she was seen for a chief complaint of assessment after admission from other facility. History of present illness includes recently using crack cocaine which may have precipitated either a seizure or behavioral disinhibition. She reports a history of mixed substance abuse before coming to Chicago Ridge at the end of [DATE]. Diagnosis Assessment and Plan includes Alcohol dependence. R12's progress note dated [DATE] documents a referral packet was sent to V20 (Psychologist) for group therapy. R12 was denied for V20's services. R12 was referred to (another provider). R12's Psychiatric Progress Notes dated [DATE] do not include substance abuse counseling. R12's progress note dated [DATE] created by V21 (Licensed Clinical Social Worker) documents Reason for Referral as Comprehensive biopsychosocial assessment for initial psychiatric diagnostic evaluation as per referral by the Director of Social Services. Resident has a medical diagnoses history of Uncomplicated Other Psychoactive Substance Abuse. Resident has a history of alcoholism and drug addiction (marijuana and cocaine). Drug Use: Remote. R12's Psychiatric Progress Note dated [DATE] created by V29 (Addiction and Psychosocial Nurse Practitioner) documents the type of visit as addictions program follow up and she was seen for a chief complaint of assessment of current alcohol use. Substance use history includes her reporting a history of using heroin and cocaine for 1-2 years. Reports alcohol is a problem for her and refused to discuss her history with alcohol. Patient reports she would like to think about it regarding MAT (Medication-Assisted Treatment - a comprehensive approach to treating substance use disorders that combines medications with counseling and behavioral therapies). Per chart review patient was previously on an alcoholism medication although she can't recall this. Relapse prevention discussed. R12's Psychiatric Progress Notes dated [DATE] created by V28 (Psychiatric Nurse Practitioner) do not include substance abuse counseling. R12's progress note dated [DATE] documents resident is seen by the facility Psychiatrist once a month. R12's progress notes from April and [DATE] document she attended substance abuse group once on [DATE] and does not include any notes of one-to-one substance abuse counseling. R12's Psychiatric Progress Notes dated [DATE] created by V28 (Psychiatric Nurse Practitioner) do not include substance abuse counseling. R12's progress note dated [DATE] at 9:42PM created by V18 (Licensed Practical Nurse) documents she was visiting with a friend in his room, peer came to desk to get nurse stating, She's not responding to me. Writer entered peers room noticed a change of condition with patient not responding appropriately. Vital Signs noted oxygen at 82%. Writer applied oxygen at 5L via non-rebreather mask; Oxygen saturation increased to 92%. Narcan (Opioid Antagonist) administered twice, 911 called. Fellow co-workers assisted with patients care; at 9:50 PM it was documented that 911 paramedics here at facility to assess patient's status and scenario. 911 took over CPR (Cardiopulmonary Resuscitation); at 10:00 PM a late entry documented R12 discharged to: the hospital on [DATE] at 9:42 PM; Reason for transfer: Patient not responding appropriately at her normal; at 22:10 it was documented patient being transported to the Hospital emergency room for further evaluation. R12's progress note dated [DATE] created by V31 (Licensed Practical Nurse) documents resident admitted to the Hospital with diagnosis of Overdose and Pneumonia. R12's Physician Order History documents an order effective [DATE] for being able to be seen by a psychiatrist or psychologist. R12's Physician Order History does not include any previous orders for seeing the psychiatrist. R12's progress note dated [DATE] documents resident is readmitted to the facility day 1 of 3. Resident transferred from Hospital related to overdose and pneumonia. On [DATE] at 12:35 PM V16 (Substance Abuse Coordinator) confirmed R12 was admitted with a substance abuse history and was referred to her. V16 stated R12 attends every group. V16 stated on admission she does ask residents what their current drug use is and if they have cravings. V16 stated she completes the substance abuse assessments yearly or whenever the residents get into trouble she revises them. When asked by the surveyor what are R12's triggers for drug use V16 stated she just told me she needed some coping skills. When asked by surveyor to specify what coping skills R12 needed V16 stated R12 was struggling with coping skills regarding sex, it's like difficult to explain, she needs something to keep her mind off things, so she gave her coping skills suggestions of meditation and finding inspirational speakers online. V16 stated R12 also received a paper with coping skills suggestions from V3 (Psychiatric Rehab Services Coordinator) her social worker. V16 stated residents receive coping skills guidelines through the documentation she provides during substance abuse groups. V16 stated every Tuesday she provides one to one substance abuse counseling for all the residents that don't attend the substance abuse groups which include for gambling, for alcoholics, and for narcotics and cocaine. V16 stated the residents are referred to groups based on their drug of choice. V16 stated R12's substance abuse care plan should include gambling and alcoholics and now she is interested in all three groups. On [DATE] at 11:09 AM V10 (Psychosocial Services Director) stated (provider name) is the program that V21 and V22 the LCSW's (Licensed Clinical Social Workers) work from. V10 stated V20 (Psychologist) provides psychosocial groups and one to one counseling. V10 stated R12 was denied V20's program due to insurance. On [DATE] at 11:23 AM V1 (Administrator) stated it's not part of their process to acquire any information from the substance abuse treatment center where R12 was being treated in just prior to her admission to the facility, however it's a good idea. On [DATE] at 12:10 PM V30 (Psychiatrist) stated R12 is seen once per month for schizophrenia by V28 (Psychiatric Nurse Practitioner) and seen once per month by the addiction provider V29 (Addiction and Psychiatric Nurse Practitioner). V30 stated V29 last saw R12 in March and believes this was the first time she saw her. V30 stated R12 has a history of alcohol use and was evaluated by V29 for this. V30 stated it looks like R12 also reported a history of cocaine for 1-2 years and said she would think about MAT (Medication Assisted Treatment). V30 stated he isn't sure if there was any discussion with R12 and V28 regarding using cocaine or heroin but there is no documentation of it in V28 notes. V30 stated R12 was seen by the psychiatric nurse practitioner once monthly and V29 was seeing her parallel to that. V30 stated he's not sure if R12 was in the hospital when V29 was rounding at the facility. V30 stated V29 comes to the facility approximately every two weeks and R12 would have been seen during those visits. V30 stated V29 was at the facility [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. V30 stated he did not find any notes from V29 for R12 other than on [DATE]. V30 stated R12 was on the list to be seen on 04/18 however there was no notation as to why she wasn't seen. V30 stated V28 is seeing R12 more for hallucinations, anxiety, and schizophrenia symptoms. On [DATE] at 2:23 PM V28 (Psychiatric Nurse Practitioner) stated the last time she saw R12 was [DATE] and she sees her monthly. V28 stated there has been no discussion about R12's use of cocaine or heroin during their meetings. V28 stated during her meetings with R12 she addresses her mental health and R12 is being seen by an addiction specialist as well. On [DATE] at 3:55 PM when asked by surveyor if during his meetings with R12 there is any discussion about her use of heroin or cocaine V21 (Licensed Clinical Social Worker) stated no, he lets V16 (Substance Abuse Coordinator) do that with R12 during her groups. The facility's Chemical Dependency and Relapse Prevention Support Group Policy received [DATE] states: The purpose of the policy is To help the resident with a substance abuse diagnosis and/or history remain (clean) in the least restrictive setting. The group is an adjunct support in the patient's effort to decrease and eliminate the role and influence of chemical dependency in his/her life. Referral Criteria: History/Diagnosis of substance abuse and some desire to achieve sobriety or remain sober. History of in-patient substance abuse treatment and need for aftercare. The facility's Alcohol/Substance Use/Abuse Policy received [DATE] states: 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. 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. Persons assessed with an active substance abuse problem are offered appropriate treatment and rehabilitative services. Follow-up interventions and treatment recommendations will be communicated to the resident and documented in the medical record. Outside treatment sources will be utilized as appropriate.

Based on interviews and record review, the facility failed to protect a resident's right to be free from physical abuse from another resident for one (R5) of five residents reviewed for abuse in a sample of 14. This failure resulted in R5 being physically assaulted and emergently transferred to the hospital for evaluation of facial trauma. Findings inlcude: R5 was dmitted to the facility on [DATE] with diagnosis including but not limited to Gout, Unspecified; Hypothyroidism, Unspecified; Chronic Obstructive Pulmonary Disease, Unspecified; Essential (Primary) Hypertension; Hyperlipidemia, Unspecified; Other Muscle Spasm; and Nondisplaced Fracture of Cuboid Bone Of Right Foot, Subsequent Encounter For Fracture With Routine Healing. According to R5's MDS (Minimum Data Set) assessment dated [DATE] under section C, R5 has BIMS (Brief Interview of Mental Status) score of 15 indicating, indicating intact cognition. Prior to 03/02/2025 absent are any care plans related to R5's susceptibility to abuse. R6 was admitted to the facility on [DATE] with diagnosis including but not limited to Schizophrenia, Unspecified; Primary Insomnia; Opioid Dependence with Withdrawal; Chronic Obstructive Pulmonary Disease, Unspecified; Chronic Viral Hepatitis B Without Delta-Agent; Unspecified Viral Hepatitis C Without Hepatic Coma; Essential (Primary) Hypertension; and Opioid Dependence, Uncomplicated. According to R6's MDS (Minimum Data Set) assessment dated [DATE] under section C, R6 has BIMS (Brief Interview of Mental Status) score of 14 indicating, indicating intact cognition. Prior to 03/02/2025 absent are any care plans related to R6's predisposition to abuse. R10 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Obstructive Pulmonary Disease, Unspecified; Edema, Unspecified; Hypotension, Unspecified; Hypertensive Heart Disease Without Heart Failure; Type 2 Diabetes Mellitus Without Complications; Hypokalemia; Major Depressive Disorder, Single Episode, Unspecified; and Schizoaffective Disorder, Unspecified. According to R10's MDS (Minimum Data Set) assessment dated [DATE] under section C, R10 has BIMS (Brief Interview of Mental Status) score of 15 indicating, indicating intact cognition. On 04/02/2025 at 1:27 PM Surveyor observed 19 residents in the third-floor dining room, no monitoring staff present. On 04/02/2025 at 1:36 PM Surveyor observed 11 residents in the second-floor dining room, no monitoring staff present. On 04/07/2025 at 10:57 AM Surveyor observed 3 residents in the second-floor dining room, no monitoring staff present. On 04/02/2025 at 12:23 PM, R5 stated, On 03/02/2025 around 7:00 PM, I was sitting in the dining room (third-floor unit). (R6) came up to me and wanted to grab a chair that I was using to keep my leg elevated. My right ankle was fractured at that time. There were multiple empty chairs in the dining room. I told (R6) to leave it and then he just punched me. I had a black eye out of that, but it healed. I was sent out to the hospital after the incident. There was no staff in the dining room at the time of the incident. (R10) was there, he can confirm there was no staff monitoring. Surveyor asked if R5 feels safe in the facility, R5 said apprehensively, I feel safe in the facility. This is what I think, if I stay in my room, nothing is going to happen, right? Surveyor did not observed trauma on R5's face at this time. On 04/02/2025 at 12:39 PM, R6 said, I had no altercation with no other residents. On 04/02/2025 at 12:41 PM, R10 said, I saw when (R6) hit (R5). It was in the dining room. There was no staff monitoring the dining room. All staff came in after they heard the commotion; otherwise, they're never there. On 04/08/2025 at 12:06 PM, V22 (Social Service Assistant Director) said, The altercation between (R5) and (R6) happened on the evening of 03/02/2025, which was Sunday. I don't work on Sundays, so I was notified the following day. I was told that (R6) was the aggressor, and both residents were sent out, (R5) due to injury and (R6) for behavioral evaluation. I don't remember why they got into a fight. On 04/08/2025 at 2:35 PM, V26 (Licensed Practical Nurse/LPN) said, I worked on 03/02/2025 3:00 PM - 11:00 PM. (R5) came to the nursing station in the evening and complained about being hit by (R6). We notified (V1 (Administration/Abuse Prevention Coordinator)) and (V3 (Director of Nursing)). We assessed (R5)'s face. (R5) had swelling to the left side. (R5) said Don't worry about it, but I told him that the (V1) had to be notified. The doctor and the family were notified as well, and I received an order to send (R5) out for evaluation. We went and looked for (R6). (R6) was smoking on the smoking patio. We brought (R6) back to the third-floor unit. (R6) had no injuries and was sent out later in the evening for behavioral evaluation. We usually have, 1 to 2 CNAs on afternoon shifts on weekends and sometimes weekdays. 1 nurse passes medications and another nurse along with the CNA monitors. Some of the residents stay in the dining room to watch TV but we don't have to monitor all the time. On 04/08/2025 at 3:22 PM, V27 (Certified Nurse Assistant?CNA) said, I worked on 03/02/2025 from 3:00 PM to 11:00 PM. I was the only CNA on duty on the third-floor unit that evening. I was staying in the dining room for 30 to 35 minutes at the time and alternating with one of the two nurses who worked with me that evening. Towards the end of my shift, (R5) came up to the nursing station. (R5)'s face was red; you could see right away that something happened. (R5) said that (R6) punched him when they were in the dining room. No one was monitoring the dining room at that time, so I didn't see the altercation. Both nurses were charting, and I was completing my forms at that time, it was almost the end of the shift. I know that (R10) was there and saw what happened. I was assigned to watch (R6) after the altercation. (R6) told me that (R5) is just exaggerating. (R6) was pacing around the unit, so I just followed him around. At some point, (R6) went into his room and fell asleep. On 04/09/2025 at 2:51 PM, V28 (Psychiatric Nurse Practitioner) said, Residents with psychiatric diagnosis should be monitored, especially, if they are in the common area with other residents. Safety is a major reason to monitor residents with psychiatric diagnosis. On 04/14/2025 at 10:07 AM V1 (Administrator/Abuse Prevention Coordinator) said, I was notified of the incident on the same evening (03/02/2025). I was told that there was an altercation between (R5) and (R6) and that they were separated immediately. (R5) and (R6) were arguing over a chair. It happened in the dining room; (R5) and (R6) may have been left alone at the time of the incident. All residents should be monitored while they're in the dining room. However, the investigation revealed that R6 denied hitting R5 and there were no witnesses who witnessed the incident; therefore, the incident was unsubstantiated. The investigative process is always the same. We obtain involved residents' statements, staff, and other residents who may have witnessed the incident. We always make a police report and send residents out if ordered by the physician. I send an initial report to (regulatory agency), inform responsible parties for the residents' and then continue with the investigation until concluded what happened. Progress note dated 03/02/2025 at 8:50 PM written by V26 (LPN) reads in part, Writer was informed via staff member that resident (R5) was hit by co-resident (R6). Head to toe assessment completed with slight swelling noted to left eye. First aid rendered, denies pain at present time. VSS. Residents separated and in close observation with staff. Administrator, MD, Family member made aware. Obtained order via MD to send pt out to hospital for medical and psychiatric eval. R5's hospital record dated 03/02/2025 reads in part, (R5) reports he got an argument with another resident (R6). (R5) had a chair, other resident (R6) tried to take the chair from him. The other resident (R6) punched him in the face. Differential diagnosis includes but not limited to Blunt trauma, contusion, assault. Police report dated 03/02/2025 8:16 PM reads in part, Physical altercation between two residents in the day room; event number provided over the phone; both parties separated. Facility staffing for 03/12/025 3:00 PM to 11:00 PM shows V27 (CNA) as the only aid working on the third-floor unit housing 75 residents. The facility Abuse Prevention Program last reviewed 01/04/2019 reads in part, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 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; Staff Supervision.

Based on interviews and record review, the facility failed to assess and identify resident's new onset of right hip pain and administer PRN (as needed) pain medications for one (R8) of three residents reviewed for pain in a sample of 14. This failure resulted in R8 having increased pain level for 24 hours before R8 was hospitalized for pain management and later surgery of the right hip fracture. Findings include: R8 was admitted to the facility on [DATE] with diagnosis including but not limited to History Of Falling; Epilepsy, Unspecified, Not Intractable, Without Status Epilepticus; Restlessness And Agitation; Paranoid Schizophrenia; Hypertensive Heart Disease Without Heart Failure; Cognitive Communication Deficit; Need For Assistance With Personal Care; and Other Abnormalities Of Gait And Mobility. On 04/02/2025 at 1:31 PM, Surveyor attempted to interview R8, R8 answered surveyor's questions unintelligibly. Surveyor unable to interview R8. On 04/07/2025 at 12:41 PM, V19 (Therapy Director) said, (R8) was seen by therapy 2/14/2025, 2/18/2025, 2/19/2025, and 2/20/2025. (R8)'s pain to the legs was first documented by me on 2/19/2025. I reported the pain in the IDT (interdisciplinary team) meeting later in the day on 2/19/2025, nursing staff was notified. I also noticed change in (R8)'s condition, most of all, (R8) became not ambulatory. (R8) was then hospitalized on [DATE]. During the hospitalization (R8) had ORIF (open reduction internal fixation) of right hip. On 04/08/2025 at 12:40 PM, V4 (Assistant Director of Nursing) said, On 2/19/2025, (V19 (Therapy Director)) notified me that (R8) was complaining of pain to his right hip. I went and talked to (R8), and he said that he has pain in the right leg. I asked (R8) about the number on pain scale but (R8) didn't give me a number. I tried to do ROM (range of motion) but (R8) refused. I notified (V23 (Licensed Practical Nurse)) and (V24 (Family Nurse Practitioner)). (V24) placed an order for x-ray. X-ray service came in late that night and results were reported on 2/20/2025 around 3:25 AM. X-ray showed fracture in the right hip and (R8) was sent out to the hospital on 2/20/2025 around 10:15 AM. (V23) was told to give (R8) pain medication. I didn't give (R8) anything for pain after my assessment. On 04/08/2025 at 12:56 PM, V24 (Family Nurse Practitioner) said, I was in the facility on 02/19/2025 when (V23) told me about (R8)'s pain. I went to assess (R8), and he said he's scared to move his right leg due to pain. I ordered an x-ray and told the nurse to offer (R8) pain medication. I reviewed the x-ray on 2/20/2025 at 9:57 AM, it showed right femoral neck fracture, and R8 was sent out to the hospital shortly after. As far as pain, nurses were supposed to give (R8) his PRN (as needed) pain medication, there was already order for that. When a resident complains of pain, nurses should do assessment first, and give pain medication. Pain medication administration is important to prevent any additional physical symptoms, such as elevated blood pressure, stress, tachycardia, or even depression. (R8) stated his pain was 6/10 on the pain scale and it was definitely appropriate for nurses to administer pain medications. On 04/08/2025 at 3:58 PM, V25 (Registered Nurse) said, I worked on 2/19/2025 from 3:00 PM to 11:00 PM. I never heard (R8) complain of pain on my shift, so I didn't give (R8) any pain medications. I knew (R8) was waiting for an x-ray due to pain in his leg, but that's all I know. On 04/09/2025 at 11:37, AM V23 (Licensed Practical Nurse) said, I worked on 2/19/2025 and 2/20/2025 from 7:00 AM to 3:00 PM. I know (R8) very well, I take care of him almost every day. I was doing my morning medication pass on 2/19/2025 when (V4 (Assistant Director of Nursing)) told me that (V19 (Therapy Director)) notified her of (R8)'s pain in the hip and asked me to give (R8) pain medication. I went to get pain medication and gave it to (R8). I didn't document it. (R8) was complaining of hip pain on 2/19/2025 but never gave me a number on the pain scale. I did not document any pain assessments for (R8). I didn't give (R8) any additional pain medications after the morning of 2/19/2025 nor before (R8) was sent out to the hospital (2/20/2025 10:15 AM). I noticed that (R8) wasn't getting out of bed few days prior to 2/19/2025. It was a pretty big change for (R8) because normally he would walk around but I didn't ask him why (R8) is not himself, I thought he was just not in the mood to get out of bed. On 04/09/2025 at 2:24 PM, V3 (Director of Nursing) said, If a resident complains of pain, nurses should first assess a resident to determine location, intensity, and number on the scale related to pain. Nurse should document a pain review. Nurses should then administer pain medication if there is an existing order for PRN (as needed) pain medication. The pain review should be completed with any change in resident's condition, new pain, or fall. Absent are any progress notes or pain reviews related to R8's new onset of pain in the right hip on 2/19/2025. R8's physician order dated 02/12/2025 reads in part, Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours as needed for pain. R8's Medication Administration Record for February 2025 does not show any pain medication given to R8 on 02/19/2025 nor 02/20/2025. Progress note dated 02/19/2025 written by V19 (Therapy Director) reads in part, Response to session interventions: (R8) required max encouragement to participate with skilled interventions. (R8) c/o BLE (bilateral lower extremities) discomfort during functional bed mobility performing self-care tasks, nursing notified. Progress note dated 02/19/2025 1:35 PM written by V24 (Family Nurse Practitioner) reads in part, HPI: (R8) seen for complaints of right hip and thigh pain. (R8) was found lying in bed stated he is scared to move his right leg, rated pain 6/10. Assessment/Plan: Localized pain, continue pain management, 3 views x-ray of right hip and thigh. R8's x-ray physician order dated 02/19/2025 1:53 PM reads in part, Right hip and thigh x-ray, 3 views; standard diagnostic. R8's Radiology Results Report read sin part, Examination date: 02/19/2025; Reported date: 02/20/2025 3:25 AM' reviewed by V24 (FNP) on 02/20/2025 9:57 AM. Clinical information: Post Fall, r/o, Fracture. Findings Right Hip: Examination reveals impacted subcapital fracture of the right femoral neck with varus deformity and no significant displacement. R8's hospital record dated 02/20/2025 reads in part, (R8) was sent form his (facility) to outpatient XR which showed right hip fracture and was send to ED for further evaluation. (R8) states he fell out of bed a couple of days ago, he says he does not know why he didn't come after his fall. (R8) says that his pain 8/10. R8's Operative Notes dated 02/21/2025 read sin part, Procedure: Right Hip Anterior Hemiarthroplasty. The facility Pain Management and Assessment policy last reviewed 11/2022 reads in part, It is the policy of the facility to assess the resident for the presence of pain in order to determine the appropriate interventions. Assess and document pain including onset and duration, location, severity, alleviating, and aggravating factors, possible causes, and accompanying signs and symptoms. Identify the pain rating scale used for consistency with subsequent assessments. Routine pain assessment reviews will be conducted quarterly, upon significant change in condition, and more frequently as necessary to evaluate the effectiveness of the individualized pain management program and comfort level of the resident.

Based on observation, interview, and record review, the facility failed to have a system in place to ensure that a resident who was assessed to not be able to navigate safely and independently in the community, leave the facility unsupervised. This failure applied to one (R1) of one residents reviewed for supervision and resulted in R1 eloping from the facility on 01/10/25 with no access to ordered medical care and was subsequently found (at an undetermined date) intoxicated by local police and taken to local hospital. The Immediate Jeopardy began on 01/10/25 when R1 eloped from the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 01/22/2025 at 3:39 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 01/28/25 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 male who was admitted to the facility on [DATE], past medical history includes, but not limited to other seizures, unspecified psychosis it due to a substance or known physiological condition, gastroesophageal reflux disease, chronic obstructive pulmonary disease, encephalopathy, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, essential primary hypertension, encounter for general psychiatric examination requested by authority, suicidal ideation, depression, etc. Community survival skills assessment dated [DATE] documented that R1 does not appear to be capable of unsupervised outside pass privileges at this time. Discharge planning review dated 12/31/2024 documented resident's discharge potential as fair, nursing facility required to help resident attain or maintain highest practical health status. Minimum Data Set (MDS) assessment dated [DATE] section C (cognitive) scored resident with a BIMS (Brief Interview of Mental Status) score of 12, section GG (functional) of the same assessment coded R1 as requiring staff supervision for all Activities of Daily Living (ADLs) including ambulating within the facility. Section P (alarms and restraints) documented that R1 does not use any restraints or alarms. It is to be noted that the facility is located on a busy highway, in a high traffic area. Care plan initiated 12/23/2024 documented that R1 is at increased risk for alteration in pain and discomfort related to diagnosis of GERD. R1 is at risk for seizure activity related to seizure disorder, has a diagnosis of severe mental illness and significant mood distress related to a diagnosis of depressive illness. R1 is also care planned as requiring supervised smoking and community access. Police report number ****** dated 01/11/2025 17:23 stated in part: On 11 [DATE] at approximately 1723 hours, responding Officer received a call from Southwest Central Dispatch (SWCD) regarding a missing person at a nursing home (address). SWCD advised that a patient left yesterday without permission and still has not returned. Responding officer arrived on scene at the Nursing Home and spoke with Staff Director V3, she related that on 10 [DATE] at approximately 1830 hours, the bed alarm in room (#). V3 related that her staff conducted a headcount immediately after the bed alarm went off and realized that the patient in room (#), (R1), was missing. V3 advised that R1 was last seen wearing a winter hat, jeans, and a winter jacket. V3 stated that she contacted R1's only emergency contact that she has listed in their computer system, (V6) several times with negative results. V3 related that R1 has been a patient at the nursing home since November 2024 and is unsure where he could be. V3 advised responding officer that R1 has dementia and has never left the Nursing Home since he`s been a patient there. V3 also stated that R1 does not have a cell phone. On 1/15/2025 at 4:46PM, V3 (Social Service Director) said that a staff reported to her that R1 was not in the facility, she asked other staff, (a nurse and smoking monitor) and they said that he did not come out for the morning and afternoon smoke breaks. V3 said that she did not see R1 leave the building, did not speak to the assigned nurse, she called the police because the administrator instructed her to do so, V3 filed a report, the police told her that it was a missing person report and gave her the report number. V3 said that R1 does not have an independent pass, can only go out with supervision, he has never tried to leave the facility before and does not have any behaviors. On 1/22/2025 at 10:39 AM, V3 (Social Service Director) was interviewed again regarding the bed alarm mentioned in the police report and she said that she does not recall starting that a bed alarm went off, or mentioning the exact day and time the resident left the facility, she just told the police that it was reported to her on Saturday. 1/16/2025 at 9:47AM, V6 (Family Member) said that she does not know where resident is, the facility called her on Saturday morning around 6:30AM, stating that the resident left the facility yesterday and had not returned. V6 said that the facility did not call her till 6:30AM the following day, she cannot get in touch with R1 because he does not have a phone, he does not have any other family and V6 is worried that he might be in danger. 1/15/2025 at 4:59PM, V4 (Licensed Practical Nurse - LPN) said that R1 is pleasant, he walks around the facility, V4 did not see resident leave the facility, she documented that he was appropriately dressed for the weather because that's what the roommate told her. 1/15/2025 at 5:10PM, V5 (Certified Nursing Assistant - CNA) said that she was the person that reported resident missing, she saw the resident on Friday around 8:00PM, when V5 came back to work on Saturday around 3:00PM, she was hearing people saying that R1 is not in the facility, the CNA she took over from said that she did not see resident all day, he did not eat breakfast or lunch. V5 said she reported to social services after searching the rooms on every floor, they thought he was out on pass. 1/15/2025 at 6:00PM, V1 (Administrator) said that they were made aware that resident left the facility, they spoke to the roommate, and he told them that resident said he was leaving, and he left. V1 said that there is only one main entrance and a back door through which they get supplies. V1 was asked why resident was discharged in the system and she said, if a resident leaves unauthorized, we call the police, and they consider it the same as going against medical advice (AMA). V1 was asked if residents are required to sign an AMA form when going AMA and she said yes, she was asked if R1 signed any papers and she said no. 1/23/2025 at 2:05 PM, V12 (Local Police Detective) called surveyor and stated that R1 had been located. V12 did not know all the details surrounding the whereabouts of R1 but said that R1 had been found in (Nearby Town) (which is over 30 miles away from the facility). V12 added that R1 was intoxicated when found and taken to a local hospital. V12 did not know which hospital but gave surveyor the report number. Surveyor attempted to contact (Nearby Town) police department for more details and left several messages with no call back. Requested for an authorized pass policy but the facility did not have one to provide during the course of this survey. Supervision policy (undated) presented by V1 (Administrator) states in part, our policy strives to make the environment as free from hazards as possible. Resident safety and supervision are facility-wide priority. The same document also stated: Our facility oriented approach to safety addressees risk for group of residents such as wanderers, behaviors, aggressiveness, confusion, etc. Resident supervision is a core component to resident safety. Discharge against medical advice policy revised 7/2024 states in part, It is the policy of this organization to provide medical and psychological care to residents of the facility. In the majority of the situations, it is not in the resident's best interest to leave against medical advice (AMA). Staff to utilize good public relations to .Contact the attending physician and notify psychiatrist and administrative representative prior to allowing the individual to leave the premises .2. Carefully document when a resident leaves AMA. Make sure that the physician, and administrator designee agree that the person is competent to leave. 3. Require resident to sign the AMA form. 6. Scan the AMA form into the electronic medical record (EMR). The Immediate Jeopardy that began on 01/10/25, was removed on 01/28/25, when the facility took the following actions to remove the immediacy: The facility will continue to provide a safe environment for the residents through written policies and procedures to prevent elopement and to use as a baseline to maintain a secure resident environment. Corrective action that will be accomplished for those residents found to have been affected by the deficient practice. R1 no longer resides in the facility. Investigation: The facility initiated an investigation on 1/11/2025. It has been determined that the resident exited the facility from the basements back door. As a system revision, the facility has implemented the following measures. How the facility will identify other residents having the potential to be affected by the same deficient practices. All residents who reside in the facility have the potential to be affected by this alleged deficient practice. Measures the facility has taken or systems the facility will alter to ensure the problem will be corrected and will not recur. Director of Social Services, Assistant Director of Social Services and PRSCs has re-assessed facility residents' elopement risk assessment and community survival skill assessments. Initiated: 1/11/25 Completed: 1/13/25 The facility has provided an elopement binder to all facility units with pictures identifying residents at risk for elopement. (Exhibit 1) Initiated: 1/11/2025 Completed: 1/13/2025 Director of Social Services, Assistant Director of Social Services and PRSCs have re-screened and assessed All residents to determine any factors that would put them at risk for elopement. Factors including History of elopement (prior to admission), exit seeking behaviors, attempts at elopement, hanging around exit doors, wandering between units, verbalizing a strong desire to leave. Initiated: 1/11/2025. Completed: 1/13/2025 Director of Social Services, Assistant Director of Social Services and PRSCs will continue to meet and assess all residents upon admission, quarterly, annually, and with change in condition or behavioral observations that may put the resident at risk for elopement. All residents that were assessed with indicators of history of elopement will be considered high risk for elopement, in addition to those that score 6 or more. (Exhibit 2) Initiated: 1/11/2025. Completion: Ongoing Administrator, Director of Social Services and all staff will continue to monitor residents for potential signs of elopement. Initiated: 1/11/25. Completion: Ongoing o Staff were re-educated but not limited to the facility elopement policy and procedures. The re-education emphasized identifying residents at risk for elopement and providing a safe environment. This re-education provided a return verbalization and understanding. This education was completed by the Regional Nurse Consultant and Director of Social Services. Initiated on 01/17/2025. Completion: Ongoing. o DON/Designee will in-service all newly hired staff at the time of hire on the facility's elopement policy. Initiated: 1/23/2025. Completion: Ongoing o DON/Designee will in-service staff out on leave or on vacation upon their return to work. Initiated: 1/23/2025. Completion: Ongoing o Additionally, elopement binders have been placed on all facility units including the front reception area. Initiated: 1/11/2025. Completion: Ongoing o All exit doors have been rechecked to ensure all alarms are functioning properly and to check staff response time. Initiated and Completed on 1/17/2025. o The facility Assistant Administrator conducted an ad hoc QA meeting on 0/15/25 which reviewed the facility elopement policy as it relates to safeguarding current and future residents from elopement. Quality Assurance plans to monitor the facility's performance to make sure that the corrections are achieved and are permanent. o Quality Assurance will audit 5 random resident files to ensure the risk for elopement has been properly assessed and care planed. This audit was initiated on 1/23/2025 and will occur weekly for a period of two months. Completion: 3/28/2025 o The Administrator/Designee will perform weekly audits will be performed on all newly admitted and readmitted residents to ensure the risk for elopement has been properly assessed and care planned. The Administrator/Designee will conduct this audit weekly for 2 months and present its audit to the QA Committee. Initiated: 1/23/2025. Completion: 3/28/25 o As part of the Quality Assurance Committee the Administration/DON will in-service all staff monthly on the elopement policy for a period of two months. The in-servicing and any allegations of elopement will be monitored by the Regional Nurse Consultant. Initiated: 1/23/2025. Completion: 3/28/25

Based on observation, interview, and record review, the facility failed to follow their policy and procedures for behavior Management for Agitated Behavior by not providing one to one supervision for a resident, with a history of self-harming behavior, who was threatening and attempting self-harm and being physically aggressive towards staff. This failure applied to one of three residents (R9) reviewed for accidents and injury and resulted in R9 sustaining a fracture to their right arm. Findings include: R9 is a [AGE] year-old female with a diagnoses history of Quadriplegia, Multiple Sclerosis, Vitamin Deficiency, Anxiety Disorder, and Recurrent Major Depressive Disorder who was admitted to the facility 03/21/2022. On 05/28/2024 at 12:23 PM R9 is observed sitting in her wheelchair in her room with a cast and brace on her right arm. R9 stated it was a soft cast and her arm was broken through in 2 pieces. R9 stated one evening between 8-9 PM she blocked her room door from V6 (Licensed Practical Nurse) and V7 (Licensed Practical Nurse) with her wheelchair and told them she wasn't ready to go to bed. R9 stated she was yelling, and they didn't care and put her in bed anyway. R9 stated she was yelling the entire they picked her up from her chair. R9 stated after they left the room, she was being rebellious and tried to get out of bed. R9 stated she swung her feet out of bed first and doesn't recollect how she got her arm caught in the rail, but it makes sense that's how she injured her arm. R9's progress note created by V6 (Licensed Practical Nurse) on 5/7/2024 at 2:20 PM documents on 05/05/2024 resident was asked can she be assisted to bed, because she was asleep in the wheelchair by the elevator, resident became verbally aggressive and went into her room and tried to block the door with her wheelchair. Staff was able to talk her into opening up the door, resident became very aggressive trying to throw herself out the chair onto the floor. Resident released her seat belt and tried to slide herself out her chair. Writer and the other nurse were able to prevent her from sliding onto the floor. Writer and the other staff transferred resident onto the bed resident and began fighting stating that it's my right to throw myself on the floor. Writer repositioned the resident for comfort. The certified nursing assistant was walking by and noticed the residents legs hanging out the bed, Writer and the other nurse came in and saw that the resident legs and arms were stuck between the chair and the side rail. Resident stated leave me alone it's my right to throw myself on the floor, I don't care. Writer turned and repositioned the resident so she wouldn't fall. Resident stated it's my right leave me alone. Writer explained the importance of not trying to cause harm to herself and that she would cause an injury, resident stated that it's my body and my right. R9's Progress note created by V6 (Licensed Practical Nurse) dated 5/5/2024 9:07 PM documents resident was being very aggressive trying to take her seat belt off to throw herself on to floor. Resident was swinging and trying to hit writer. Resident's right arm got caught between the bed rail and her motorized wheelchair trying to throw herself out the bed stating that it was her right to harm herself. R9's Stricken note created by V6 (Licensed Practical Nurse) on 5/5/2024 at 10:28 PM documents resident refused to be changed and she is trying to climb out the bed. Writer entered the room saw resident trying to climb out the bed and she was stuck between the bed and wheelchair. Writer asked a Certified Nursing Assistant to help to get resident back in the bed. R9's Hospital Admission report dated 05/06/2024 - 05/08/2024 documents it was reported she was being moved into bed by nursing staff when her right arm was injured; she was reportedly being combative and was being placed back into bed and apparently forearm got caught in the railing and sustained injury; past medical history includes Multiple Sclerosis; an x-ray of her arm showed a fracture likely due to a combination of trauma and pathological osteoporosis/osteopenia as there was evidence of bone demineralization. Facility Reported Incident Investigation Reports initiated 05/06/2024 documents on 05/06/2024 R9 reported that V6 (Licensed Practical Nurse) and V7 (Licensed Practical Nurse) were rough while transferring her to her bed causing her to have a bruise on her right arm, upon body assessment staff noted R9's right arm was swelled and bruised; the facility contacted the physician by phone and orders were given to send R9 to local hospital for further evaluation where it was reported that she has a fracture to her right arm; During staff and resident interviews it was noted that R9 was attempting to throw herself on the floor while sitting in the wheelchair; while attempting to throw herself to the floor she started to slide out of the wheelchair when V6 and V7 prevented the fall and assisted R9 to bed; While R9 was in bed and noted to be calmed the CNA (Certified Nursing Assistant) walked by and observed R9 in a prone position on the edge of the bed with her right arm between the rail and wheelchair. Witness statement dated 05/05/2024 from V45 (Certified Nursing Assistant) documents R9 was sleep in her wheelchair, she heard R9 was asked if she could move from in front of the elevator, R9 became upset, went to her room and blocked the door; V45 was in the room and R9 was yelling at her and telling her to go back to Mexico, R9 moved and V7 and V6 were trying to calm her. R9 kept trying to put herself onto the floor, started sliding out and they stopped her from falling and put her into the bed; All the while R9 was in the bed she was yelling; V45 walked by and R9 's legs were stuck between the wheelchair and turned onto her side trying to move the wheelchair; R9 kept saying she had the right to fall; V45 and others had to move the wheelchair to prevent R9's legs from getting hurt. Witness statement dated 05/05/2024 from V7 (Licensed Practical Nurse) documents R9 was screaming out loud and using profanity and insisted she has rights; R9 tried to throw herself on the floor, and he stopped her by placing his hand across her chest area; R9 tried to release her seat belt; V7, V6 (Licensed Practical Nurse), V45 (Certified Nursing Assistant) and V39 (Certified Nursing Assistant) placed R9 in the bed and she continued to scream; V7 came back into the room and R9 was trying to reach over and turn her motorized chair on and he moved the chair out of the way. R9's current physician order documents an active order effective 02/17/2024 for Behavior Monitoring. R9's current care plan initiated 03/01/2024 documents she has a history of self-harmful ideation (thoughts) and/or behavior. This appears related to: Evidence of severe mental illness (i.e., active psychosis, major depression, lack of sound judgment, poor contact with reality) with interventions including: as warranted conduct/carry out Behavior monitoring of the resident, look especially for any change. A safety contract was established with R9 and documents on 03/01/2024 R9 she signed an agreement to not harm herself in any way. R9's Screening Assessments for Evaluation of Self Harm/Suicide Risk dated 03/01/2024 and 04/24/2024 document she has a history of suicidal ideations and is at risk. On 05/29/2024 at 10:46 AM V6 (Licensed Practical Nurse) stated on the date of R9's incident at 10:30 PM R9 was being combative. V6 stated R9 was sleeping in her wheelchair at the nurses station and was asked by V27 (Certified Nursing Assistant) if she could ambulate herself in her wheelchair to her room. V6 stated R9 became combative and didn't want to get in her bed and she responded to R9 fine she'll just document that she refused to get in bed. V6 stated R9 started taking her seat belt off and appeared as though she may fall. V6 stated V7 (Licensed Practical Nurse) broke R9's fall by catching her in the front of her chest with his arms. V6 stated V7 then repositioned himself behind R9 and lifted her underneath her arms while she then assisted V7 by grabbing R9's legs and both placed her in bed. V6 stated she and V7 had left the room and a Certified Nursing Assistant walking by R9's room noticed her legs were hanging out of her bed and called her for assistance. V6 stated she then went into the room to assist that CNA (Certified Nursing Assistant) along with V7 and another CNA with getting R9 back into bed and R9 became combative. V6 stated R9 then began fighting, tried to bite V7 multiple times and hit her in the chest with her right arm. V6 stated she believes R9 may have been on smoke restriction and when this happens she becomes combative. On 05/29/2024 at 11:13 AM V45 (Certified Nursing Assistant) stated on the date of R9's incident V27 (Certified Nursing Assistant) informed her she needed help with R9 because she was partially out of her bed. V45 stated when she entered the room she observed R9 bent over her side rail with her arm pinned underneath her and her legs underneath her wheelchair which was directly next to the bed. V45 stated she, V27, V6 (Licensed Practical Nurse), and V7 (Licensed Practical Nurse) rolled R9 back into her bed and R9 hit V6 in the chest. V45 stated she believes R9's vape was taken and when this happens, she becomes out of control. On 05/29/2024 at 4:20 PM V7 (Licensed Practical Nurse) stated on the date of R9's incident she was in her chair at the nurses station and he believes there was a conversation about someone getting ready to change her and she wanted to stay in the chair to be changed. V7 stated R9 was told it was not safe to be changed in the chair and needed to be in the bed probably for safety. V7 stated R9 didn't want to be changed, became angry, she ambulated in her motorized wheelchair to her room and then tried to close her door. V7 stated on a previous day R9 closed her room door and tried to place her motorized wheelchair in front of the door to prevent anyone from entering. V7 stated he and V6 (Licensed Practical Nurse) stopped R9 from closing her door during this instance. V7 stated R9 then stated well I'll just throw myself on the floor then took her hand and unbuckled her seat belt. V7 stated R9 then leaned forward as if she was about to throw herself on the floor. V7 stated he then grabbed R9 from underneath her arms from in front of her and the repositioned himself behind R9's wheelchair and V6 grabbed her feet. V7 stated he then grabbed R9 from behind her back underneath her arms and V6 grabbed her feet and both placed her in the bed. V7 stated he and V6 put up the side rail and lowered R9's bed all the way down as low as it can go. V7 stated R9 was still angry and cursing. V7 stated he and V6 left the room and then someone came back to check on R9 five or ten minutes later and she was still in the bed but it was like she was trying to throw herself out of bed. V7 stated R9 was observed lying against the side rail of her bed in a sideways lying position and her feet were still in the bed. V7 stated R9's wheelchair was next to the bed and he thinks she may have tried to turn it on or grab a hold of it to pull herself out of the bed. V7 stated R9 was caught in the side rail, so he came in with two other aides, V45 (Certified Nursing Assistant), V27 (Certified Nursing Assistant), and the Nurse and all of them helped R9 out of the siderail and she was still angry and cursing. V7 stated when R9 is angry she just does things. V7 stated in his time at the facility for the past 2 and a half years R9 has exhibited these behaviors. V7 stated he has documentation of R9 in the past year stating she was going to throw herself on the floor. V7 stated R9 has a history of making verbal threats of self-harm of throwing herself on the floor when something isn't going her way. V7 stated R9 is able to take off her seatbelt and show that she can throw herself on the floor. V7 stated he believes R9 is physically capable of throwing herself out of the chair. On 05/30/2024 at 12:34 PM V29 (Regional Nurse Consultant) stated during R9's incident on 05/05/2024 she became aggressive, blocked her room door, unbuckled her seat belt, and attempted to throw herself on the floor. V29 stated R9 has a history of this behavior. V29 stated R9 was placed in her bed to prevent her from falling on the floor. V29 stated R9 has a history of osteoporosis and osteopenia and could have had worse than a fracture. V29 stated because of R9's Multiple Sclerosis she couldn't fully place herself on the floor, however R9 obtained a fracture because of her behavior and because of how she was positioning herself out of bed. On 05/30/2024 at 12:42 PM V2 (Director of Nursing) stated due to R9's condition it's unsafe for her to be alone in her room by herself. V1 (Administrator) stated when R9 declined to have staff in her room the appropriate response would be verbal de-escalation, talking to her through the door to get her to remove her wheelchair. V2 stated after breaking R9's fall from her wheelchair when trying to throw herself on the floor, the nurses should have seen if it's ok to place her in bed, or somewhere they know she would be safe. V2 stated she would expect staff to make a decision of where R9 can be kept safe whether it's place her back in her bed or chair. V2 stated after it was determined R9 would be safer in her bed whomever was in the room should have then placed R9 in the bed and monitored her. V2 stated with the behaviors R9 was exhibiting she would expect staff to implement 1:1 (one to one) monitoring or have someone in the room with R9, then the nurse should have called the doctor and notified the family. V2 stated If R9 was not closely monitored, she could have experienced harm and safety would be a significant concern. V2 stated one to one monitoring was necessary because R9 threatened to place herself on the floor and threatened to harm herself. V2 stated if staff left the room after R9 threatened to place herself on the floor and hear her yelling, they should immediately respond and see what is going on. On 05/30/2024 at 1:27 PM V44 (Restorative Nurse) stated R9 can slide out of her wheelchair if sitting straight up in it. Behavior Management for Agitated Behavior Policy received/reviewed 05/30/3034 states: Observe resident for behavior escalation of aggression such as a loud voice tone, swearing, yelling, and/or other irritability. Allow time to calm down with 1:1 (one to one) explanation of why behavior is inappropriate and unacceptable in a calm, soft voice. Allow time for resident to voice feelings and frustration. If uncontrolled anger, aggression cannot be redirected, i.e. (in other words). the resident is in danger of harming self or others after attempting the above interventions, administer physician ordered medication for anxiety for the symptoms being exhibited. Document all interventions attempted and administered and the resident's response to medical interventions. Notify the physician of the resident's signs/symptoms and lack of response to medications and other interventions. Monitor the response to the drug therapy 1:1 (one to one) until dangerous symptoms are reduced. If the resident responds to the medication by becoming quiet and anxiety free and aggressive acts have minimized, i.e. (in other words) no longer harm to self, 1:1 (one to one) monitoring will be discontinued. In the event staff needs to physically intervene to prevent the resident from harming self or others, techniques to provide interim control will be implemented which include non-violent crisis intervention. When interim control is used, the physician will be notified, and a determination made as to the need for acute mental health services. R9's progress notes and medical records do not include documentation of an attempt to provide medical interventions nor provision of 1:1 (one to one) monitoring during the course of exhibiting self-harming and physically aggressive behaviors. R9's May 2024 Medication Administration Record does not document any evidence of administration of medication for anxiety, aggression, or self-harming behaviors on 05/05/2024 between 8-10:30 PM.

There are two separate deficient practices statements for this citation. I. Based on interviews and records reviewed the facility failed to develop a plan of care to prevent a resident with a history of suicidal ideation from obtaining items that can cause self-harm. This failure affected one of three residents (R4) reviewed for safety and supervision in the sample. This failure resulted in R4 being able obtain a belt and was found hanging from a towel rack on the bathroom floor on 02.29.24. The Immediate Jeopardy began on [DATE]. V12 and V13 (both Administrators) were notified on [DATE] at 10:53AM of the Immediate Jeopardy. The surveyor confirmed by observation, interview, and record review that the immediate jeopardy was removed on [DATE], but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R4 with a diagnosis including, but not limited to: Borderline Personality Disorder, Spondylosis with Radiculopathy, Schizoaffect Disorder, Major Depressive Disorder, Anxiety Disorder, Restless Leg Syndrome, Suicidal Ideations, and Bipolar Disorder, Current Episode Mixed, Severe without Psychotic Features. R4 was admitted to the facility on [DATE]. R4 was assessed on [DATE] to have a BIMS (Brief Interview of Mental Status) of 15 indicating R4 is cognitively intact. According to the facilities final investigation of incident occurring on [DATE], R4 observed lying on the floor unresponsive, staffed observed a belt around R4's neck and Cardio Pulmonary Resuscitation (CPR) was initiated. R4 was transported to the hospital for evaluation. The facility was informed that R4 died from his self-inflicted injuries. On [DATE] at 10:25AM, V14, Licensed Practical Nurse (LPN), said (V15, Certified Nursing Assistant (CNA)), came to get me and said (R4)'s roommate, (R8), could not get in the room. I went down to the room. When I got there the Director of Nursing (DON), V15, and I tried to get in the room so we pushed the door in. V14 explained the bathroom door was open against the room door blocking it from opening. V14 said the first person in the room was the Director of Nursing. V14 said When we got the room open and I went in, I saw (R4) half out the bathroom, with his feet out the bathroom, half his body in the bathroom and half out, and he was face down. We flipped him over and saw a belt around his neck, it was buckled on his neck. (V15) took the belt off. I didn't see if (R4) had any marks on his neck. I got the pulse ox (Oximeter) device and I took carotid pulse. (R4) was purple, I don't recall if his eyes were open or closed. (R4) was the only resident in the room and there is no other entrance to the room. It looked like the belt was on one part on the towel rack, the end was tied in a knot. V14 said 911 took R4 to the hospital. V14 said she later found out R4 was on a vent a few days later. V14 said she had seen R4 sitting on his bed talking to R8 and the last time she saw him was around 9:40AM. On [DATE] at 10:49AM, V6, Psychiatric Rehabilitation Services Coordinator (PRSC), said R4 had a history of homelessness. V6 said R4 said he planned to be here short term. V6 said I did a 1:1 session with (R4) on [DATE], the day before the incident because he was in cigarette room and so was I. V6 said R4 was placed in Symptoms and Behavioral Management because of his history with suicide. V6 said We have a safety contract, I got him to sign it for the suicide and I did the suicide risk assessment. I believe (R4) had been hospitalized before admission for suicide attempt and depression. The information is in the referral packet. I don't recall the method he used. On [DATE] at 12:09PM, V16, Housekeeping, said (in Spanish, with designated Spanish Speaking Surveyor) The roommate, (R8), called me over to him near the door to his room. The bathroom door was blocking the room door from opening. I peeked around the door and I saw (R4) on the floor. I ran to the CNA and she told the nurse. I thought there was a fabric tied from the towel bar to his body, but I didn't stay to see where it was tied. I saw (R4) was face down. V4 said this was around 12:10PM. On [DATE] at 11:38AM V16 said the police took the towel bar when they came in. On [DATE] at 12:47 PM, V8, CNA, said I was not assigned to (R4). I had seen him at breakfast. This happened before lunch. On [DATE] at 1:25 PM. V17, CNA, said I arrived to work at 7:00AM on [DATE]. I did my rounds, (R4) was awake. V17 said R4 went to eat breakfast in the dining room. V17 said I peeked in on (R4) about 11:30 AM, both residents (R4 and R8) were watching television in the room. I then went to break. I was outside and saw the ambulance and police cars. I thought that was crazy, he was just ok, laughing, and making jokes. It's weird that they said he tried to kill himself, I never got that vibe. I'm not sure if he had a history of suicide. If I had known, I may have checked on him more often. On [DATE] at 2:19PM, V10, DON, said (V15, CNA), came to get me and said (R4) was on the floor. I moved the door a little, (R4)'s legs were blocking the door. I saw on object on his neck. I untied it, it was a belt, it was around his neck and the other end was on the towel bar with 2 knots. V10 said R4 was face down and there was blood on the floor that came from the side of R4's head. V10 said (R4) was bluish- purplish when I saw him. V10 said there is only entrance to the room. V10 said I don't know where (R4) got the belt from. V10 said Cardio Pulmonary Resuscitation was initiated. V10 said 911 arrived and took over. V10 said the police took the belt. On [DATE] at 10:04AM V4, Psychiatric Rehabilitation Services Director (PRSD), said Social Services does the Cognitive BIMS assessment, Discharge Potential, Community Assessment, Aggression, Suicide Risk, Trauma, Substance Abuse, Social History and level of function for those with SMI (Serious Mental Illness), and Smoking Assessments. V4 said We review the admission packet. The purpose of the assessments are to determine what the patient needs are. V4 said the PASRR are done at the hospital before they are admitted to the facility to determine facility placement. V4 said We use the section of what the patient will benefit from to help determine the type of groups they need. Any abnormal findings on the PHQ9 (Mood assessment) requires updates to the care plan and possibly placement in new groups. We give the, DON, Floor Nurse, and/or the MDS nurse the results if any are abnormal assessment findings. The Care plan should be individualized. If a resident has a plan to use sharp items for self injury, we would remove them and do routine checks. (R4) was on hourly checks, from when he first got here. V4 said the forms are filled out by the social worker. V4 said We complete a belongings inventory. (R4) would not have been allowed a belt and he would not have been able to keep his phone and laptop chargers. I don't know where (R4) got the belt from. Any group, 1:1's or groups refusals should be documented. At 12:12PM V4 reviewed the handwritten Nursing Observation Sheet presented for hourly monitoring on R4. The observation started on [DATE]. V4 said The observation sheets are kept in my office. The Nurse Observations sheets are continued until the resident is stable, then we would stop the nurse observation sheet. We meet twice a day, morning (8:00AM) and afternoon (PM) to discuss if they should continue the observations. The surveyor asked V4 why the observation on [DATE] is not completed for night shift (12AM-6AM). V4 replied I don't know. There is no documentation to say when to stop the hourly monitoring sheets. (R4) was in Symptom and Behavior Management. If any resident has suicide ideation or history they'll be placed in the group. The majority of the time the group topics are not always discussed on 1:1 visit. V4 reviewed R4's Preadmission Screening and Resident Review (PASRR) with the surveyor. V4 read from the PASRR, V4 said R4 should have been placed on 3 group programs. V4 said programs including behavior management, development, maintenance, and consistent implementation across settings of those programs designed to teach daily living skills, grooming, personal hygiene, nutrition, health, and drug therapy. V4 continued reading and said crisis intervention program to keep yourself safe. Individual, group, and family psychotherapy. V4 said R4 could have Psychiatrist and Psychologist services. V4 said the Psychologist comes to the facility every 2 weeks and the psychiatrist comes once a week. V4 said the psychologist had not seen R4 yet. V4 said R4 should have been in Symptom and Behavior management, Traditional Living, and Self Maintenance groups. The surveyor asked for the documentation of the mentioned programs. V4 said I didn't bring those copies of programs or 1:1, I misunderstood what you wanted. I only brought the Symptom & Behavior Management Group records. At 1:26PM V4 provided group confirmation form for R4. V4 said R4 should have received more groups. The surveyor reviewed R4's care plan and V4 said it should state the frequency not just # for days for programs. On [DATE] at 1:30PM, V12, Administrator, was interviewed regarding R4's (State Agency) final report. V12 said a moderate risk is more severe, it does not mean the same as minimal risk. V12 said the Medical team is the medical nurse practitioner and the psychiatrist, V9, and his Nurse Practitioner. V12 said I wrote the final report based on the progress notes and records I reviewed. V12 Reviewed PASSR and said there is no recommendation for specialized services. V12 said there is a list at each nurse's station of residents with suicide ideation and suicide attempts history. V12 said staff need to make frequent rounds, checking, any signs or symptoms, or if they present with any behaviors staff should notify nurse and social services. V12 said the police took the belt and towel rack. V12 said while hospitalized , R4's plan was to cut himself or walk into traffic. V12 said if staff was supervising R4, then staff should be aware if he had a belt. V12 said V31, Transport CNA, said she saw R4 15 minutes before the code. V12 said we don't have video. V12 said the nurse said 2 hours was when she last saw R4. On [DATE] at 2:35PM V39, MDS (Minimum Data Set) Nurse, said Social Services does not communicate with me what they do. I don't check their assessments sections, only that is gets done. I just make sure its completed, sections C, D, and E. Each department is responsible for their own assessments and care planning. On [DATE] at 3:11PM V31, Transport CNA, said I was at the nurses station on [DATE] and I saw (R4) get off the elevator. I was hanging the appointments list. V31 said R4 had books in his hands. V31 said R4 did not say anything. V31 said R4 may have gotten the books form the library or another resident. V31 said Then I got on the elevator and 5 minutes later, I heard them call a code blue. Lunch was maybe 30 minutes to 1 hour after the code happened. I probably seen (R4) between 10:30AM- 11:00AM. On [DATE] at 11:50AM, V9, Psychiatrist, said the plan for R4 was to monitor him. V9 said R4 had no complaints of depression or anxiety. V9 said regarding R4's symptoms for impulsive and racing thoughts they are part of his diagnosis of Borderline Personality Disorder (BPD). V9 said R4 also had a Bipolar diagnosis. V9 said Bipolar is usually treated with medications and BPD is treated with talking therapy at least monthly. V9 said We did not write an order for him to be in psychotherapy. Usually the providers (facility) provide supportive psychotherapy by way of a trained Nurse Practitioner or Physician Assistant. V9 said R4 can't be held accountable for what he signed on a behavior contract. V9 said the contracts are only a tool used to help to establish rapport with the patient. V9 said behavior contracts are not shown to prevent self harm. V9 reviewed R4's PHQ-9 (mood assessment) on his computer. V9 said of the PHQ-9, I don't know how accurate these are. With a diagnosis of BPD they may have a negative response, maybe they just woke up or are upset about something vs when they are in a good mood all the answers may be positive outlook. I would like to have seen a follow up to this one. V9 said while in the hospital R4 admitted to having chronic Suicide Ideation and racing thoughts but no harming behaviors. V9 said initially what got R4 hospitalized was because he said his plan was to stab himself or walk in front of traffic. V9 said The facility told me (R4) attempted suicide. I am not sure what method he used. On [DATE] at 10:29AM, V25, Assistant Director of Social Services, said the licensed social worker did not see R4 while he was in the facility. R4's Screening Assessment for Evaluation Self Harm/Suicide Risk dated [DATE] completed by V6 documents R4 past history of suicidal ideations, history or problems, major depression and personality disorder diagnosis: Significant/Severe problems. Struggling with poor performance, perfectionist personality and/or a negative view of the future: Moderate Problem. Category Score = 11 (,d+[DATE]) Moderate Risk. Comments: per hospital referral packet, has history of suicide ideation but denies at this time. R4's Belongings Inventory dated [DATE] documents nothing for possession of belt, no accessories, 1 pair of shoes but no description of the shoes. 1 cell phone with charger and 1 laptop with charger. Review of Medication Administration Record (MAR) [DATE]-[DATE] notes a list from ,d+[DATE] of Behaviors. Interventions are listed ,d+[DATE]. Outcome results. Documentation prompts list Beh (behavior) Int (interventions) and Out (outcome) for every shift. ,d+[DATE]-[DATE] on days and evening document 0 (none) behaviors. On ,d+[DATE] evening and night shift document NA. Per DON interview indicated Not Applicable. Monitoring of medication side effects on ,d+[DATE]-,d+[DATE] documents NA. Review of Mood assessment dated [DATE] indicates R4 reported he was feeling down, depressed, or hopeless nearly everyday. R4 reported trouble with sleep nearly everyday. R4 reported feeling tired or little energy half or more of the days assessed. R4 reported feeling bad about self or that he is a failure or have let himself or his family down on several days. R4's care plan initiated on [DATE] states he has a history of self harm ideation (thoughts) and behaviors related to his mental illness. The intervention prompts what occurred, where, circumstances surrounding the events, precipitants and any current plan to harm. The facility did not documented the information mentioned in the prompt. R4's care plan he resist care related to medication compliance. This was not documented in R4's progress notes or MAR. R4's care plan identifies he has a need for specialized rehabilitation, support, counseling secondary to mental illness. R4's care plan identifies he has coping problems. Group and one to one programing are identified interventions but no specification of frequency or identification of programs R4 was assessed to need. Nursing Observation Sheet for R4 reviewed. Observation initiated on [DATE] at 12:00AM for every shift. Observation sheet ends on [DATE] with comments and signatures from 8:00AM-11:00AM. R4's Group Therapy Progress Notes dated [DATE] and [DATE] for Symptom and Behavior Management reviewed. (skill groups indicated on Group Form are Behavior Management, Suicide Prevention Group, Smoking Safety, and Symptoms and Behavior Management. A progress note written by V6 dated [DATE] states a 1:1 for Symptom and Behavior Management was completed. There is no record R4 participated or was offered a group program or 1:1 for Suicide Prevention. R4's PASRR Summary dated [DATE] documents if you are admitted to a Medicaid certified nursing facilities what services and supports are nursing facility staff required to provide for you? You made better you may benefit from programs to teach daily living skills to help improve independence. Crisis intervention services or plan. You would benefit from a plan to keep yourself safe. Individual, group, and family psychotherapy. You may benefit from psychotherapy to decrease mental health symptoms and develop healthy coping skills. R4's Progress Notes dated [DATE] indicated he observed on the floor face down with an object around his neck. The facility final State Report dated [DATE] states R4 was transported to local hospital for evaluation. The facility was informed R4 passed from his self inflicted injuries. Fire Department Run sheet dated [DATE] documents onset 12:07PM. Run sheet documents intubation attempted but unsuccessful due to airway obstruction and tracheal trauma. R4 transported to closest facility. Hospital records states admitted [DATE] after hanging D/C [DATE]. The death certificate was requested on [DATE] and [DATE]. Cause of Death is pending. The facility Safety and Supervision of residents policy dated [DATE] states safety risk and environmental hazards are identified on an ongoing basis. Our resident oriented approach to safety addresses safety and accident hazards for individual residents. The facility oriented and resident oriented approaches to safety are used together to implement systems approach to safety which considers the hazards identified in the environment and individual risk factors and then adjust interventions accordingly. The Immediate Jeopardy that began on 02.29.24 was removed 03.29.24 when the facility took the following actions to remove the immediacy. R4 No longer resides in the facility. Education was initiated on [DATE] by the Administrator, DON, ADON, and Social Service Director and completed on [DATE]. Education consisted of suicide risk assessment, notifying the physician of any change in condition, a residents score moderate or greater than moderate on the suicide risk assessment, the social service department will create a safety plan with the resident. The resident's plan of care will be updated, and the resident will be contracted to safety. The PRSD and APRSD will create a monitoring schedule and the nursing, activity, and social service department will be in-serviced on a monitoring schedule for the residents. If the resident is noted to have SI (Suicidal Ideations) their physician will be notified, and an order will be obtained to transport them to the local hospital. Staff educated on residents with a history of SI. Residents will attend assigned groups and if refuse MD and family will be notified. A. Completion of the suicide risk assessment. B. If a resident scores moderate or greater than moderate on the suicide risk assessment the resident will be presented a safety contract. If the resident refuse to contract to safety, the resident will be transported to the local hospital for a psychiatric evaluation. C. If the resident has a contract to safety, the resident plan of care will bed updated and the resident will be placed on monitoring: 15 minute check, then will gradually move to 30 minutes checks, to hour checks until the resident has been deemed able to move off of monitoring by the IDT (Interdisciplinary Team). D. Notifying the physician of any changes in resident condition/mood and if the resident trigger for an alteration in mood based on the PHQ9. E. If the resident is noted to have SI, the resident's physician will be made aware and the resident will be transported to the local hospital for evaluation. F. The resident will be encouraged to attend assigned groups and if the resident decline, the physician and family will be made aware and interventions and incentives will be put into place to encourage the resident to attend scheduled groups. All Staff (Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Housekeeping Director, MDS Coordinators and Maintenance Director, receptionist, dietary aide, Cooks, housekeepers, social service case manager, Social Service Aides, restorative aides, C.N.As, RNs, LPN, activity aides, Laundry aides), including those off duty ( receptionist, Social Service Case Managers, social service assistants, housekeepers, Laundry aides, RNs, LPNs, dietary aides, and cooks) were educated via phone with the same training as the staff educated in person. However, the staff who received the in-service over the phone were notified that they will also be required to attend an in-person training before the beginning of the next shift worked. Upon completion of this in-person training, staff will sign education sheets. Administrator and Social service director will complete weekly spot checks to ensure the facility staff is knowledgeable the informed content: i.e., who are the residents at risk for SI, has there been any mood changes in the resident, was the psychiatrist made aware of the change in mood, does the resident attend group and if not was there interventions in place for refusals. The in-service date of completion is [DATE]. a. Upon admission, a suicide risk assessment will be completed. If a resident scores moderate or greater than moderate on the suicide risk assessment, the social service department will create a safety plan with the resident. The resident's plan of care will be updated, and the resident will be contracted to safety. The PRSD and APRSD will create a monitoring schedule and the nursing, activity, and social service department will be in-serviced on a monitoring schedule for the residents. If the resident is noted to have SI their physician will be notified, and an order will be obtained to transport them to the local hospital. Prevention of self-harm items: - Upon admission/readmission residents' belongings will be checked for any self-harm items. i.e.- belts, razors, knives, guns, sharps, and any items that states to keep out of reach from children. - Searches will be conducted before and after family/friend visits. - Visitors brining in items will be asked to keep their personal belongings in the car and any items brought into the facility will be check for items of self-harm that places the resident at risk for self-harm. - Residents will have random room searches to monitor the accessibility of self-harm items. - Residents will be thoroughly search when they return from out of pass. B. The facility will ensure residents with history of suicidal ideations are safe by preventing residents from having access to items of self-harm i.e. knife on meal trays, belts, wire hangers, chemicals, items labeled keep out of reach of children. c. The facility will ensure frequent and consistent rounding is conducted to monitor residents' whereabouts. d. Upon admission/readmission residents' belongings will be checked for any self-harm items. i.e.- belts, razors, knives, guns, sharps, and any items that states to keep out of reach from children. e. Searches will be conducted before and after family/friend visits. f. Visitors brining in items will be asked to keep their personal belongings in the car and any items brought into the facility will be check for items of self-harm that places the resident at risk for self-harm. g. Residents will have random room searches to monitor the accessibility of self-harm items. h. Residents will be thoroughly search when they return from out of pass. - The facility will establish a therapeutic relationship with the resident. - The facility will monitor for passive statements of wanting to harm them self i.e. I wish I was dead or I'd be better off dead. - The facility will identify characteristics or behaviors pertaining to suicide ideations. - The facility assesses for early signs of distress or anxiety and investigates the possible causes. - The facility staff will assess suicidal intent on a scale of 0 to 10 or by asking the resident directly if they are thinking of harming themselves or has a plan or means to do so. - The facility will place the resident on 1:1s and notify the psychiatrist and family if the resident is unable to contract to safety and the will then obtain an order to petition the resident out for psychiatric services. i. The facility will notify the psychiatric MD of mood changes j. The facility will ensure all staff are aware of a resident with a history of suicidal ideation. Ongoing education will be provided to all staff on monitoring, preventing residents from having access to items of self-harm, notifying the psychiatrist of any mood changes, and ensuring all staff are aware of a resident who has a history of suicidal ideations. residents at risk for suicide attempts. All staff including Nursing, Certified Nursing Assistants, Housekeepers, Dietary, Activities, Business Office, Admissions, Human Resources, and Social Services. Ongoing education will be provided during the new hire orientation, re-education during all staff meetings for three quarters, and added to the yearly competency program and will be implemented by the PRSD. On [DATE] the social service staff updated all residents in house suicide with risk assessment. Risk assessments were completed on [DATE]. On [DATE] the social service staff updated all residents' suicide risk care plans with interventions Care plan updates were completed on [DATE]. Facility staff members were re-serviced on residents at risk for suicidal ideations on [DATE]. Staff knowledge will be assessed by random knowledge-based spot checks which will be conducted by the Administrator, PRSD, and APRSD. Any employee who was not able to be in-serviced will be mandated before working their next shift. No policy changes have been made to the change in condition policies. The Medical Director was made aware of the IJ [DATE]. On [DATE] the Medical Director reviewed and approved the facilities plan to prevent any recurrence of suicide in the facility. - The facility will establish a therapeutic relationship with the resident. - The facility will monitor for passive statements of wanting to harm them self i.e. I wish I was dead or I'd be better off dead. - The facility will identify characteristics or behaviors pertaining to suicide ideations. - The facility assesses for early signs of distress or anxiety and investigates the possible causes. - The facility staff will assess suicidal intent on a scale of 0 to 10 or by asking the resident directly if they are thinking of harming themselves or has a plan or means to do so. - The facility will place the resident on 1:1s and notify the psychiatrist and family if the resident is unable to contract to safety and the will then obtain an order to petition the resident out for psychiatric services. Audits to be conducted include did the resident with a history of SI have access to items to self-harm, is there a plan to monitor the resident's whereabouts frequently in place, was the psychiatrist notified of any mood changes, Did the facility staff know the resident who is at risk for SI. Audits will be analyzed and presented as part of the monthly Quality Assurance Performance Improvement Committee (QAPI). This will be overseen by the Administrator and Medical Director. This committee will determine if the audits continue after three months. II. Based on interviews and records reviewed the facility failed to prevent the use of illicit drug in the facility. This affected two of three residents (R10, R11) reviewed for safety and supervision. This failure resulted in R10 with a history of substance abuse being found unresponsive at the bedside without respiration or pulse on [DATE] at approximately 8:00am. R10 death certificate documented cause of death as Fentanyl Acetyl Fentanyl and 4-ANPP (Despropionol Fentanyl)) toxicity. The Immediate Jeopardy began on [DATE]. V12 and V13 (Co-Administrators) were notified on [DATE] at 09:09AM of the Immediate Jeopardy. The surveyor confirmed by observation, interview, and record review that the immediate jeopardy was removed on [DATE], but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: 1. R10, age 69, with diagnosis including but not limited to Viral Hepatitis C, Opiod Abuse ([DATE]), and Altered Mental Status. R10 was assessed on [DATE] to have a BIMS (Brief Interview of Mental Status) of 6 indicating R10 has severe cognitive impairment. R10 was initially admitted to the facility on [DATE] with a history of substance abuse. Progress Notes dated [DATE] states R10 observed unconscious with respiratory distress while in bed. Sternal rub performed; resident difficult to arouse and not responding to stimuli. Writer administered PRN (As Needed) Narcan. The resident became alert and responsive but remained in a mentally altered state. Vitals: T-,d+[DATE], P-110, T-98.3F, RR-24, 02 sat (oxygen saturation) 95% via nasal cannula 2 L/min (Liters per minute). Resident sent to Hospital for evaluation via 911. Progress notes dated [DATE] document R10 in his bed at 3:05AM. On [DATE] at 11:03AM, V34, Registered Nurse, said On ([DATE]), I stopped at (R10)'s room and (R10) was in the bed. I was checking him for breathing or a sign that he is alive. (R10) had labored breathing. I haven't seen too many patients with overdose or using heroine. I was checking (R10)'s vitals and then thought to check the chart and saw his diagnosis of history of drug use. I saw (R10) had an order for Narcan and I administered it. V34 said after administering the Narcan R10 came right out. On [DATE] at 11:42AM, V41, Licensed practical Nurse (LPN), said On ([DATE]) between 7:30AM and 7:45AM, not after 8:00AM, I saw (R10) was unresponsive and I called for a code blue. I had not done vitals on him prior to this. V41 said R10 was newly moved to her unit. V41 said I found him unresponsive about an hour or little over an hour after I last saw him. V41 said R10 was in his bed when she saw him unresponsive. V41 said I tried calling his name and he was not waking up. I applied the pulse ox (oximeter) device and did not get a reading, I could not feel a pulse and was not able to get a blood pressure. I had heard that (R10) went to the hospital before he came to my unit, but they said his drug test was clean. I was not aware they had given him Narcan in the past. I am not aware of any resident having had drugs or contraband in the facility. On [DATE] at 2:14PM V30, CNA, said I was here on ([DATE]) and ([DATE]) when (R10) had an unresponsive episodes. I was not assigned to (R10) on ([DATE]), I don't know who had him. At the start of the shift, I saw (R10) in his room and he spoke to me. This was sometime after 7:00AM and breakfast trays had not been passed. On [DATE] at 2:25PM, V37, CNA, said If someone has a drug use history or recent finding the nurses will let us know to keep a close eye on them. I was not here on ([DATE]), I don't know who worked (R10). On [DATE] at 2:56PM, V38, CNA, said she was not assigned to R10 on [DATE]. V38 said on [DATE] she was not aware R10 was being sent to the hospital. V38 said she was retuning from break and saw R10 as the ambulance was taking him out. On [DATE] at 10:20PM, V17, CNA, said I had no interaction with (R10) on ([DATE]). V17 said V30 was assigned to R10 on [DATE]. V17 said I didn't see (R10) before the code blue was called. V17 said the last time she worked with R10 was on [DATE] and he was not on hourly rounding. V17 said R10 did not leave the facility or go outside. The surveyor asked V17 if she was made aware that R10 had been to the hospital on [DATE] with suspicion of drug use. V17 said I was not notified. On [DATE] at 11:36AM, V6, Psychiatric Rehab Service Counselor, said when she assessed R10 the daughter notified R10 has a history of drug abuse. V6 said R12 has a history of drug use. On [DATE] at 9:54AM, V43, Substance Abuse Coordinator, said R10 was not attending group and he was not on 1:1's. V43 s [TRUNCATED]

Based on interviews and records reviewed the facility failed to develop interventions for one resident (R4) with a history of suicide ideation with a plan for skill groups, including suicide prevention group, and failed to provide therapeutic programming. The facility failed to develop a plan for check in to assess daily mood or notify the attending psychiatrist of R4's change in mood which documents feeling down, depressed, or hopeless nearly every day. This failure resulted in R4 found unresponsive hanging from a towel rack in his bathroom. This failure affected 1 of 3 residents reviewed. R4 was pronounced dead in the hospital on 3/5/24. The Immediate Jeopardy began on 2/29/24 V12 and V13 (both Administrator) was notified on 3/21/24 at 10:54AM of the Immediate Jeopardy. The facility presented an initial removal plan on 3/21/24. The plan was accepted, and 04/03/29 the surveyor conducted an onsite observation, record reviews, and interviews to confirm the removal plan was implemented. V1 was informed the Immediate Jeopardy was removed on 3/29/24. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation The findings include: R4 with diagnosis including, but not limited to Borderline Personality Disorder, Spondylosis with Radiculopathy, Schizoaffect Disorder, Major Depressive Disorder, Anxiety Disorder, Restless Leg Syndrome, Suicidal Ideations, and Bipolar Disorder, Current Episode Mixed, Severe without Psychotic Features. R4 was admitted to the facility on [DATE]. R4 was assessed on 2/22/24 to have a BIMS (Brief Interview of Mental Status) of 15 indicating R4 is cognitively intact. R4's medication administration record dated 2/1 through 2/29/24 includes behavior monitoring every shift with documentation stating the letters NA on 2/28/24 on evening and night shifts. (The two shifts prior to R4 being found.) On 3/8/24 at 10:25AM V14, Licensed Practical Nurse (LPN), said I saw a belt around R4's neck. (R4) was purple. It looked like one part of the belt was on the towel rack tied in a knot. V14 said 911 took R4 to the hospital. V14 said regarding her charting in the Medication Administration Record (MAR) she charted NA because NA and none basically stand for the same thing. On 3/14/24 at 12:31 V10, Director of Nursing, said I am not sure what NA means on the MAR. At 12:46PM, V10 said none and nonapplicable are not the same. V10 said NA means that situation does not apply, we should say none not NA. On 3/8/24 at 10:49AM V6, Psychiatric Rehab Services Counselor, said R4 was calm and there was nothing out of the ordinary. V6 said R4 said he had history of being homeless. V6 said R4 said he planned to be here short term. V6 said R4 had no suicide thoughts. V6 said I did 1:1 session on (2/28/24), the day before the incident, because he was in cigarette room and so was I. V6 said R4 was in Symptom and Behavior management group because of his history with suicide. V6 said I got him to sign the safety contract for suicide. I believe (R4) was hospitalized for suicide attempt and depression. V6 said the information is in the referral packet. V6 said I don't remember his method for attempting. On 3/8/24 at 1:25PM, V17, Certified Nursing Assistant (CNA) said when she found out about R4, she thought that was crazy. V17 said this was weird that they said R4 tried to kill himself. V17 said I never got that vibe. I am not sure if he had a history of suicide. If I had known, I may have checked on him more often. On 3/8/24 at 2:04PM, V18, CNA, said some residents are at more risk for suicide. V18 said no one was on suicide risk watch on 2/29/24 on the second floor. On 3/8/24 at 2:19PM V10, Director of Nursing, said on 2/29/24 V15 knocked on her office door and told her R4 was on the floor. V10 said I went to (R4)'s room and I moved the room door a little, his legs were blocking the door. When I got in the room, I saw an object on (R4)'s neck. I untied it, a belt, it was around (R4)'s neck and the other end was on the bar. V10 said R4 was bluish/purplish. V10 said the towel bar stayed attached to the wall, there were 2 knots on the towel bar. R4 was face down. R4 was dressed. V10 said there was blood on the floor, it came from the side of R4's head. V10 said there is only one entrance to the room. V10 said I don't know where R4 got the belt from. V10 said the belt was black or blue. V10 said the police took the belt. On 3/14/23 at 10:04AM, V4, Psychiatric Rehab Services Director, said social serviced does a suicide risk assessment and reviews the admission packet. V4 said the purpose of the assessments is to determine what the patient needs are. V4 said the PASRR is done at the hospital before they are admitted to the facility. V4 said We use the section of what the patient will benefit from to help determine the type of groups they need. Any abnormal findings on the PHQ9 (mood indicators) requires updates to the care plan and possibly new groups. We give the Director of Nursing, Floor Nurse, and/or MDS (Minimum Data Set) nurse the results if any are abnormal findings. V4 said the Care plan should be individualized for each resident. V4 said R4 was on hourly checks, from when he first got here. V4 said based on R4's history he would not have been allowed a belt. V4 said R4 would not have been able to keep his phone and laptop chargers. V4 said I don't know where he got the belt from. On 3/14/24 at 12:28PM, V4 said The nurse observation sheet is stopped once the patient is stable. We meet twice a day, morning (10:00AM) and afternoon (3:00PM) to discuss if they should continue or are stable. The surveyor asked V4 why the observation dated 2/28/24 is not completed for night shift and evening. V4 said I don't know. V4 said there is no documentation to say when to stop the observations. V4 said R4 was in Symptom and Behavior Management group. V4 said if the resident has suicide ideation or history of suicide attempts, they will be placed in Suicide Prevention group. V4 said if a resident does not attend group they will get a 1:1 session. V4 said the group topics are not always discussed the same as during a 1:1 session. V4 a reviewed PASRR with the surveyor. V4 said R4 should be in Group for management and monitoring medication. Development, maintenance, and consistent implementation across settings of those programs designed to teach individuals daily living skills necessary to become more independent and self determining including but not limited to grooming personal hygiene, mobility, nutrition, vocational skill, health, drug therapy, mental health education, money management, and maintenance of the living environment. You may benefit from programs to teach daily living skills to help improve independence. Crisis intervention services or plan. You would benefit from a plan to keep yourself safe. Individual, group, psychotherapy to develop healthy coping skills. Psychiatrist and psychologist services. V4 said the Psychologist comes every 2 weeks and the psychiatrist comes once a week. V4 said the psychologist had not seen R4. V4 said R4 should be in Symptom and Behavior Management, Traditional Living, and Self Maintenance Groups. V4 said R4 should have been on 3 programs. At 1:26 V4 provided group Confirmation Form for R4. V4 said R4 should have received more groups. Reviewed R4's Care plan with V4, V4 said the care plan should state the frequency not just # for days to attend groups. On 3/14/24 at 1:30PM, V12, Administrator, said Moderate risk is more severe, it does not mean the same as minimal risk. V12 reviewed R4's PASSR with the surveyor. V12 said it says no recommendation for specialized services. V12 said staff need to make frequent rounds, checking, any signs or symptoms present with any behaviors staff notify nurse and social services. V12 said R4's hospital plan for suicide was to cut him self or walk into traffic. V12 said staff should be aware. V12 said if R4 was being supervised they should know if he had a belt. On 3/14/24 at 2:35PM, V39, MDS Nurse, said social services does not communicate with me what they do. V39 said I don't check their sections, sections C, D, and E, only that is gets completed. Each department is responsible for their own assessments and careplanning. On 3/15/24 at 11:50AM, V9, Psychiatrist, said R4's symptoms for impulsive and racing thoughts are part of his diagnosis of Borderline Personality Disorder (BPD) and Bipolar diagnosis. V9 said Bipolar is usually treated with medications and BPD is treated with talking therapy at least monthly. V9 said R4 can't be held accountable for what he signed on a behavior contract. V9 said the contracts are only a tool used to help to establish report. V9 said the contracts are not shown to prevent self-harm. V9 reviewed R4's PHQ-9 on his computer. VI9 said I don't know how accurate (R4)'s answers are. V9 explained with BPD they may have negative response, maybe they just woke up or got upset about something; versus when they are in a good mood, all answers may be positive. V9 said I would like to have seen a follow up to this one (R4's PHQ-9). V9 said on hospital assessment R4 admitted having chronic Suicide Ideation and racing thoughts. V9 said initially, what got R4 hospitalized was R4 said his plan was to stab himself or walk in front of traffic. On 3/17/24 at 10:29AM V25, Assistant Director of Social Services, said the Licensed Social Worker did not see R4 while he was in the facility. R4's Preadmission Screening and Resident Review (PASRR) dated 2/12/24 states: mental health disorders: Bipolar disorder. mental health symptoms: suicidal talk. Pharmacotherapy including administration and monitoring of the effectiveness and side effects of medications which have been prescribed to change inappropriate behavior or to alter manifestations of psychiatric illness. You may benefit from programs to teach daily living skills to help improve independence. Crisis interventions or plan. You would benefit from a plan to keep yourself safe. You may benefit from psychotherapy to decrease mental health symptoms and develop healthy coping skills. You are currently in the hospital because you had thoughts of ending your own life. You appear overly tearful to others. You have anxious thoughts. Nursing Observation Sheet dated 2/28/24 includes documentation from 8:00AM- 11:00AM. There is no documentation prior to that. There is no documentation in the progress notes or care plan to explain the discontinuation of the observation. R4's Progress note dated 2/15/24 identified as welcome note resident has a BIMS of 15. Per record, resident does have racing thoughts and has sign symptoms of mood distress. Resident has a history of suicide ideation with a plan. Resident was homeless prior to going to the emergency room for suicide ideation with a plan. Per record, resident has auditory hallucinations. R4's Screening assessment for evaluation self harm suicide risk dated 2/16/2024 past history of suicidal ideations. History of psychiatric mental health problems, major depression and or personality disorder diagnosis significant severe problems. Category score= 11 score indicates 6-15 moderate risk. Her hospital referral packet, resident has a history of suicide ideation but denies at this time. R4's Belongings inventory dated 2/16/2024 has nothing written for belts, scarves, gloves, mittens, etc. One cell phone with charger and one laptop with charger identified in R4's possession. R4's mood assessment dated [DATE] states R4 reported feeling down, depressed, or hopeless, nearly every day. Trouble sleeping nearly every day. Feeling bad about himself or that you are a failure or have let yourself or your family down several days. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual states the intent of Mood Assessment. The items in this section address mood distress and social isolation. Mood distress is a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity. It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable. Social isolation refers to an actual or perceived lack of contact with other people and tends to increase with age. It is a risk factor for physical and mental illness, is a predictor of mortality, and is important to assess in order to identify engagement strategies. Progress note dated 2/28/24 state social service met with R4 to check on his well-being. There is no notation that resident was asked about thoughts of harming himself or if he had a plan to harm himself. A second progress note on 2/28/24 titled skills training participation record states symptoms and behavior management. Willingness motivation to engage in session good compliance progress towards care plan objectives: good. Movement towards positive stages of change: good. Acquiring enhanced life skills: good. Comments: understanding our diagnosis. No mention of questions related to suicide ideation or suicide plan. This is the only skills training participation record found for R4 from 2/15/24 through 2/28/24. The facility presented two handwritten group therapy progress notes for R4, the first is dated 2/16/2024. Group goals: confronting fears and anxieties. Focus of session: symptom and behavior management. Plan: discuss how to manage stress. There is no discussion of suicide prevention. Group therapy progress note dated 2/20/2024. Discussing techniques on how to manage stress. Plan: enhancing social skills. There is no discussion of suicide prevention. R4's Care plan initiated 2/16/2024 includes his history of self-harm ideation thoughts and or behavior. Interventions are all dated 2/16/2024. Care plan initiated 2/16/2024 states I am in need of specialized rehabilitation, support, counseling and or psychotherapy services secondary to a mental illness diagnosis, depression diagnosis. All interventions are dated 2/16/2024. Care plan includes demonstrates a pattern of situational and or coping problems in areas such as psychosocial well-being, mood state and or behavior symptoms. This appears related to symptoms are manifested by mood distress, anger, anxiety, sadness, and insomnia. Interventions are dated 2/16/2024. There were no updates or additional interventions added after the completion of the mood assessment completed on 2/22/24. During the survey the facility provided a list of residents that have a history of suicide ideation slash suicide history (SI/SH) dated 3/1/2024. There are 52 residents named on this list. The facility policy and procedure for behavior management dated 1/1/2021 states document evaluation of the presence of behavioral symptoms or the potential for behavioral symptoms in the residence medical record and care plan. Document the initiation of behavioral interventions and mental health professional visits in the residence medical record and care plan. Document education provided to resident and or family responsible party. Document nonpharmacological interventions attempted and resident response. Document notification of physician and family member of actions taken to reduce or prevent behaviors. The Immediate Jeopardy that began on 02/29/24 was removed 03/29/24 when the facility took the following actions to remove the immediacy. R4 no longer resides in the facility. Education initiated on 3/1/2024 by the Administrator, DON, ADON, and Social Service Director completed on 3/1/2023. All Staff (Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Housekeeping Director, MDS Coordinators and Maintenance Director, receptionist, dietary aide, Cooks, housekeepers, social service case manager, Social Service Aides, restorative aides, C.N.As, RNs, LPN, activity aides, Laundry aides), including those off duty ( receptionist, Social Service Case Managers, social service assistants, housekeepers, Laundry aides, RNs, LPNs, dietary aides, and cooks) was educated via phone with the same training as the staff educated in person, however, the staff who received the in-service over the phone were notified that they will also be required to attend an in-person training before the beginning of the next shift worked. Upon completion of this in-person training, staff will sign education sheets. Education Content: staff to ensure residents are placed in therapeutic group programming that was identified on the PASSR screener. Notifying the psychiatrist of any mood changes, and ensuring residents attend skilled group programming indicated or recommended. Ensuring skilled group documentation consists of the frequency/title of the group for all group programming. Make sure that staff documents any refusals of the skilled group and that there are interventions in place to address the refusals. The Administrator, PRSD, and APRSD will conduct weekly knowledge base spot checks to assess the staff's knowledge of the topics for three quarters. The in-service date of completion is 3/21/2024. Topic of education: - Staff to ensure residents are placed in therapeutic group programming that is identified on PASRR Screener. - Notify psychiatrist of any mood changes based on staff assessment or PHQ9. - Ensure residents attend skilled group programming indicated or recommended. - Ensure skilled group documentation is completed and names the topic and frequency of the group programming. - Staff to ensure they document the any refusals of skilled group and utilize interventions to address refusals. a. Upon admission, a suicide risk assessment will be completed. If a residents score moderate or greater than moderate on the suicide risk assessment, the social service department will create a safety plan with the resident. The president's plan of care will be updated, and the resident will be contracted to safety. The PRSD and APRSD will assign the resident to a therapeutic. Program based on the resident's assessment. The psychiatrist will be updated on any resident presenting with mood changes identified by staff or based on the PHQ9 in section D of the MDS. The resident will be placed on frequent monitoring i.e. residents will gradually move through the behavior monitoring bases on the severity of the behaviors: 1:1, 15 minute checks, 30 minute checks, 1 hour checks, 2 hour checks and then will be discharged from behavior monitoring once the IDT determination. and asked to sign for safety. An order will be obtained from the psychiatrist to transport the resident to the local hospital for a psychiatric evaluation. b. The facility social service team will assess admitting residents' PASSR screen and provide therapeutic programming based PASSR recommendations. c. When mood changes are observed the PRSD/APRSD, PRSC, DON, and ADON will immediately address residents' mood changes by notifying the psychiatrist. d. The DON, ADON, RN, or LPN will notify the psychiatrist of any mood changes when identified. e. The PRSD, APRSD, and PRSC will ensure residents attend the skilled group programs indicated/recommended. i.e. Crisis Prevention Intervention, symptom and behavior management, Transitional living, Anger Management and Moving forward programming. f. The PRSD, APRSD, and PRSC will document the frequency and title of groups and programs including 1:1s. g. The PRSD, APRSD, and PRSC will ensure residents who refuse groups attend scheduled groups rescheduling the resident's group for a time that better suits the resident and or placing the resident into an incentive program to motivate them to attend the group. h. Group determination will be based on the resident's admission packet, PASSR screen, resident diagnosis, and behaviors. i. The facility will complete daily check-ins to assess for any mood, thoughts, and behavioral changes. Ongoing education will be provided to all staff on ensuring therapeutic programming as assessed on the PASSR screen indicates, identify and notify psychiatrist of any mood changes. Provide skilled group programs as indicated and recommended. Ensure groups, programming, and 1:1s frequency and title are documented. Ensure residents who refuse groups attend scheduled groups. of All staff including Nursing, Certified Nursing Assistants, Housekeepers, Dietary, Activities, Business Office, Admissions, Human Resources, and Social Services. No policy changes have been made to the change in condition policies. Ongoing education will be provided during the new hire orientation, re-education during all staff meetings for three quarters, and added to the yearly competency program and will be implemented by the PRSD. The Medical Director was made aware of the IJ on 3/21/2024 and approved the abatement plan on 3/22/2023. On 3/1/2024, the Medical Director reviewed and approved the facilities plan to prevent any further suicides in the facility. - Staff to ensure residents are placed in therapeutic group programming that is identified on PASRR Screener. - Notify psychiatrist of any mood changes based on staff assessment or PHQ9. - Ensure residents attend skilled group programming indicated or recommended. - Ensure skilled group documentation is completed and names the topic and frequency of the group programming. - Staff to ensure they document the any refusals of skilled group and utilize interventions to address refusals. Weekly audit consists of : was the resident therapeutic programming assessed based on the PASSR screen, did the facility complete a daily check-in to assess the resident's mood, did the facility notify the psychiatrist of any mood changes, did the resident attend a skilled group that's indicated or recommended, does group documentation reflect the frequency and title of the group program or 1:1, are interventions in place to address the refusal of groups. Audits will be analyzed and presented as part of the monthly Quality Assurance Performance Improvement Committee (QAPI). This will be overseen by the Administrator and Medical Director. This committee will determine if the audits continue after three months.

Based on interview and record review, the facility failed to provide adequate supervision, assistive devices and proper transfer technique to prevent a fall of 1 (R1) of 3 residents reviewed for accident/hazards in the sample. This failure resulted in R1 being emergently transferred to the hospital after a mechanical fall during transfer from bed to chair causing excruciating pain and femoral fracture. Findings include: R1 is a [AGE] year old resident with diagnosis of spinal stenosis, lack of coordination, heart failure, end stage renal disease, absence of left leg above knee amputation, absence of right leg below knee amputation, and femur fracture. MDS (Minimum Data Set) dated 11/1/2023 assessed resident's ability to perform chair/bed-to-chair transfer and states, The ability to transfer to and from a bed to a chair (or wheelchair). Not attempted due to medical condition or safety concern. Records showed: On 10/18/23 at 1:14 PM V27 (LPN/Licensed Practical Nurse) wrote, Patient being sent to hospital for x-rays to rule out possible injury for right hip/leg that occurred during transfer from bed to specialty chair. Calls to interview V27 went unanswered and V27 is no longer an employee of the facility. V2 (Director of Nursing) interview with V11 (CNA/Certified Nurse's Aide) Spoke to (V11) and she stated she transferred (R1) with a bear hug. The resident was complaining of pain prior to transfer. She stated R1 did not hit her leg on the chair nor bed. Efforts to contact V11 (CNA) on 1/3/24 and 1/4/24 were left unanswered and V11 is no longer an employee of the facility. Care plan dated 10/13/23 states, Resident is at risk for falls related to falls. Goal: Will have no serious fall related injury through next review. Interventions: 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. Anticipate and meet individual needs of the resident. Complete the Fall Risk Review per the facility protocol. A facility fall protocol policy was requested but was never provided during the course of the survey. R1's fall risk assessment dated [DATE] assessed by V31 (LPN) showed R1 to be a moderate risk for falls. On 1/8/24 at 11:30 AM, V3 (Assistant Director of Nurses) stated, I remember this resident, but she was not here long. She was being transferred by this CNA (V11) and this CNA wasn't here long either. She was being transferred from bed to chair to get to dialysis and I think she may have fallen but I'm not sure how she got the fracture. Surveyor asked how this resident should have been assisted from bed to chair, V3 stated that the resident required a mechanical lift, so the way this aide transferred her was inappropriate to transfer resident in a bear hug method. On 10/18/23 at 12:20, V33 (Nurse Practitioner) noted, Nurse approached writer stating patient was being transferred from bed to wheelchair to go to dialysis when patient stated she heard a pop in her right hip and patient screaming in excruciating pain. Patient seen reclined in geriatric chair and crying in pain I heard a pop in my hip, I know it ' s broken. Upon palpation, right hip deformity noted, unclear if patient position in wheelchair/ or due to injury. Initially stat x-ray ordered of right hip, but radiology could not give a timeframe of when x-ray would be completed. Order given to send patient to hospital for further assessment. On 10/19/23 at 8:20 PM, V34 (RN) noted, Writer called hospital; resident to be admitted with diagnosis of femoral fracture, hepatic lesion, and pleural effusion. Hospital records dated 10/18/23 authored by V72 (Emergency Department Doctor) reads, This is a [AGE] year old female patient on Eliquis (blood thinner), congestive heart failure with preserved ejection fraction, COPD on home oxygen 3 liters, hyperlipidemia, prior stroke, peripheral artery disease status post right BKA (Below the knee amputation) and left AKA (Above the Knee Amputation) presents to the emergency department today from dialysis center for severe pain and deformity of her right thigh. Patient in excruciating pain so it is somewhat difficult to get the full story of what happened. Apparently, she was being transferred from 1 bed to the dialysis when her right leg was injured. There was immediate deformity of the right femur and pain over the site with tenting of the skin. Patient denies change in temperature or color or paresthesia of the limb distal to the deformity. Patient ultimately was reduced at bedside with orthopedic surgery. Patient received pain dosages of ketamine and fentanyl and tolerated the procedure decently well. Vascular surgery consulted and will follow inpatient but no indication for heparinization at this time. Social work consult placed to assess for safety at nursing home given severe injury with unclear mechanism. Discussed with hospitalist for admission. Surveyor asked facility for policies related to the safe transfer of residents from bed to chair and was provided an ADL (activities of daily living) policy that reads, Activities of daily living (ADLS) reads in part, Transfers (standing pivot). Apply gait belt per plan of care, position resident to assist with further transfer. Place hands correctly (Do not hold under the arms) Provide cues to resident to let them know what you are doing. Assist resident to stand, using appropriate body mechanics. Pivot resident to the chair or bed, then lower slowly asking them to reach back for the chair.

Based on observation, interviews and records reviews the facility failed to ensure to continue to provide substance abuse maintenance medications for one resident admitted with opioid dependency. This failure affected one of three residents reviewed for treatment orders followed in the sample. This resulted in one resident (R372) not receiving her medication for 3 days, following admission to the facility. R372 reported not feeling well, being sweaty, and staff observed R372 to be fidgety. In addition, the facility failed to follow MD orders by not securing an abdominal wound dressing. This affected one of three residents (R222) reviewed for wound dressing in the sample. This failure resulted in R222 not having the dressing change at least twice a day which left the wound and wound packing exposed with noted fecal matter on the wound area. The findings include: R372 is a [AGE] year old admitted to the facility on [DATE] from the hospital. Diagnosis include but not limited Type II Diabetes, Asthma, and Psychoactive Substance Dependence. On 10/15/23 at 10:04AM R372 said I have not received my methadone in 2 days. On 10/15/23 at 2:55 PM V5, Nurse, checked the medication cart. V5 said no, R372's medications have not been delivered yet. V5 said R372 is on Seroquel and Methadone only. V5 said I am calling the pharmacy about R372's medications. On 10/16/23 at 9:51AM R372 said I still have not received my Methadone. I'm feeling sick. I don't feel good and I'm all sweaty. The nurse gave me Tylenol this morning, but it's not working. R372 said I need my medications. On 10/16/23 at 9:53 AM V7, Licensed Practical Nurse said R372 did not get her Methadone. V7 said I gave her Tylenol this morning. At 9:56AM R372 came to the nurses station holding her right side and said to V7 my whole side hurts. On 10/16/23 at 1:05PM V15, Transportation Scheduler said, R372 has been scheduled to go to the Methadone Clinic for treatment on 10/19/23 (6 days since admission). On 10/16/23 at 1:15PM V15 said V2, Regional Director, just told me to send R372 to her appointment tomorrow by private transportation. I saw R372 in the hallway and she was looking fidgety in the hallway, I noticed her as I was walking by. On 10/16/23 at 1:20PM V7 said I assessed R372 this morning, she was fine, no symptoms. On 10/17/23 at 9:43AM V17, Substance Abuse Counselor, said I saw R372 in group yesterday. R372 is an alcoholic and participated in the group for alcoholism. I got the list yesterday when she came to group. V17 said today I am working on my admission evaluation for R372 with her answering questions personally. V17 said R372 did not report any symptoms of withdrawal to me yesterday. V17 said symptoms can include sick to her stomach, pain, restless anxious, behaviors, disruptive behaviors, shakes, and chills or hot flashes. V17 said for Heroin use the Methadone is used to help the body adjust and may stop the craving. V17 said it will throw the patient off if they are cut off. She did not tell me anything yesterday. On 10/17/23 at 1:48PM V3, Director of Nursing, said I receive an email when potential new admissions are coming. V3 said I was notified by email (as reading to the surveyor) that R372 is being admitted for Methadone. V3 said when a resident is admitted from the hospital it is important for the residents to get their dosing. V3 said residents should not be waiting 6 days to get their Methadone dosing because they could go into withdrawals. On 10/18/23 at 12:07PM V28, Nurse Practitioner, V28 said when a resident is admitted I expect them to receive their Methadone within a day. On 10/18/23 at 12:32PM V3 said the facility does not have a policy to address residents admitted for Methadone Treatment. Physician order dated 10/14/23 reads Methadone HCl Oral Solution 5 MG/5ML (Methadone HCl), give 18 ml by mouth one time a day for antipsychotic, 18ml daily x7days. Progress Notes dated 10/15/23 states Methadone HCl Oral Solution 5 MG/5ML, give 18 ml by mouth one time a day for antipsychotic, 18ml daily x7days. On order. Care plan reviewed on 10/16/23 morning by the surveyor, does not identify R372's history of substance use/abuse. Care plan provided to the facility on the morning of 10/17/23 includes substance abuse. R372's hospital records dated 10/6/23 state R372 is a heroin and history of cocaine user. 34069 On 10-17-23 at 10:04 AM, surveyor noted R222 lying in bed with abdominal dressing partially open exposing the wound and wound packing. Surveyor noted small amount of fecal matter on the wound dressing with stool visible in the colostomy. R222's abdominal pad was twisted and taped across the top and the right lower corner. The lower left corner of the abdominal pad was not secure, tape was noted on R222 left lower abdomen. R222's wound and abdominal packing could be seen from the entire left lateral side of the dressing. On 10-17-23 at 10:04am, R222 said, I have been waiting on staff for three hours to change my dressing. My dressing was last changed at 11:00 AM yesterday. My dressing has been open all night. On 10-17-23 at 10:00 AM, V2 (DON) said R222's TAR documents the wound dressing was done once on 10-14-23, 10-15-23, 10-16-23, and 10-17-23. On 10-17-23 at 10:09am, V2 (DON) said, R222's dressing is soiled with spots of feces and was not secure. V2 said she expected R222's dressing to be clean and secure. V2 said R222 is at risk for infection related to the wound being exposed, dressing soiled with feces from the colostomy bag, and dressing not being secure and intact. On 10-17-23 at 11:58 AM, V25 (LPN) said she say R222's abdominal dressing was moderately saturated with drainage and the dressing was partially open. exposing view of the wound and wound packing. V25 said she did not see any fecal matter. During R222's med pass, R222 said he needs a dressing change and dressing was partially open. R222's treatment administration record documents (dated 10-1-23 to 10-31-23) abdominal treatment was provided once on 10-14-23, 10-15-23, 10-16-23, and 10-17-23. Physician order sheet dated 10/12/23 documents: Abdomen- Clean with normal saline, then pat dry, then place wet to dry gauze inside wound, cover with ABD pad and secure with tape 2x daily and as needed. Physician Order Policy (reviewed 11/22) documents Purpose: To provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards.

Based on observation, interview, and record review the facility failed to ensure a resident's medication was available for administration for more than 72 hours following admission. This failure affected 1 (R372) of 2 residents reviewed for missed medication. This failure resulted in R372 reporting they were not feeling well, being sweaty, and staff observing R372 to be fidgety. The findings include: R372 is a [AGE] year old admitted to the facility on [DATE] from the hospital. Diagnosis include but not limited Type II Diabetes, Asthma, and Psychoactive Substance Dependence. On 10/15/23 at 10:04AM, R372 said I have not received my methadone in 2 days. On 10/15/23 at 2:55 PM V5, Nurse, checked the medication cart. No, R372's medications have not been delivered yet. Surveyor with V5 at the medication cart who said there are no bottles/vials of Methadone on the medication cart. On 10/16/23 at 9:51 AM R372 said I'm feeling sick they haven't given me my Methadone, I'm feeling sweaty, I need my medications. On 10/16/23 at 9:53 AM V7, Licensed Practical Nurse said R372 did not get her Methadone. On 10/16/23 at 1:15PM V15, Transportation Scheduler, said I saw R372 in the hallway and she was looking fidgety in the hallway, I noticed her as I was walking by. On 10/17/23 at 1:48PM V3, Director of Nursing, said I receive an email when potential new admissions are coming. V3 said I was notified by email (as reading to the surveyor) that R372 was being admitted on [DATE] for Methadone. V3 said when a resident is admitted from the hospital it is important for the residents to get their Methadone dosing. V3 said residents should not be waiting 6 days to get their Methadone dosing because they could go into withdrawals. Physician order dated 10/14/23 reads Methadone HCl Oral Solution 5 MG/5ML (Methadone HCl), give 18 ml by mouth one time a day for antipsychotic, 18ml daily x7days. Progress Notes dated 10/15/23 states Methadone HCl Oral Solution 5 MG/5ML, give 18 ml by mouth one time a day for antipsychotic, 18ml daily x7days. On order

Based on interview, and record review, the facility failed to develop and implement an effective maintenance plan to ensure the equipment in the kitchen remains in a proper working condition. As a result, the facility failed immediately to identify and address a gas leak from the kitchen's cooking appliances and to eliminate the threat of carbon monoxide poisoning. This failure has the potential to affect all residents residing within the facility. The Immediate Jeopardy began on 7/6/23 when the gas leak was identified in the kitchen by the local fire department. V1 (Administrator) was notified on 7/11/23 at 1:28 PM of the Immediate Jeopardy and a template was presented. The facility presented an initial removal plan on 7/12/23. The plan was accepted on 7/13/23. On 7/14/23 the surveyor conducted an onsite observation, record reviews, and interviews to confirm the removal plan was implemented. V1 was informed the Immediate Jeopardy was removed on 7/12/23. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings Include: On 7/6/23 at 11:00AM, V86 (Firefighter) came to the library to notify the survey team of the condition of the appliances in the kitchen and that there was a smell of gas. V86 said V88 (Firefighter) tested the gas lines in the kitchen and found 2 separate leaks on separate appliances. V86 reported the gas company found the same gas leaks the fire department did so they shut the gas off and told them they could not use it until it was repaired. On 7/6/23 at 2:41PM, V16 (Dietary Manager) stated the flat top grill has not been working for about 1 to 2 months, and maintenance has known that it was broken, but they haven't taken it out of the kitchen yet. V16 stated, maintenance has not had time to break it down. V16 reported the wires were exposed and it was past the point of fixing so it just needed to be disposed. V16 said the flat top grill was also not clean. V16 stated staff has not been using the flat top grill but need to turn it on for the gas to light the other two stoves. V16 stated the fire department said there was a gas leak in the kitchen, so the gas company came out and said the facility had to shut the gas off until it was fixed. On 7/7/23 at 10:25AM, V88 (Firefighter) stated being on an ambulance call when V86 reported smelling gas in the kitchen. V88 stated two gas leaks were found in the kitchen: One on each different appliance. V88 said that the gas line next to the flat top grill and then the stove was also leaking at the control valves, so the gas company was dispatched to verify the findings. V88 stated the gas company found the same issues so the main gas line was shut down. V88 reported the reading was 4500 ppm and a normal range should be zero. V88 endorsed the gas leaks present a hazard risk because if enough gas accumulates it can trigger an explosion. V88 reported the flat top grill isn't being used because it was in a fire a couple months ago when the fire department was there, and a small gas leak was found at that time. V88 endorsed the facility informed the fire department that they would be fixing it and would be on top of it immediately. On 7/7/23 at 12:55PM, V15 (Maintenance) stated V86 said the flat top grill wasn't in working condition and that they found a gas leak. V15 reported removing the flat top grill from the kitchen yesterday and fixing the gas leaks with sealant. V15 confirmed the fire department said there was a gas leak on a couple different appliances, so the gas company came out and checked and found the same leaks. V15 said the fire department was called out here back in April for that flat top and there was gas leaking where the knobs were at, and it caught fire. V15 stated the flat top grill has just been giving the facility too many problems lately. V15 stated it wouldn't light with the igniters on the grill, so they had to use one of them long lighters, and when staff uses a lighter, the grill went up in flames a little bit. V15 stated, It was like a big whoosh and then the fire went out. V15 said the facility still called the fire department to investigate, and they just told V15 to not turn it on and to get it fixed. V15 reported the flat top grill wasn't being used, but they did have to turn it on because gas goes through that stove to get to the others (cooking appliances) because they are on the same gas line. V15 stated, the life safety (surveyor) was at the facility around the first of the year and the same problems with a gas leak on one of them (appliances) with some exposed wires was noted. V15 confirmed smelling gas in the kitchen. V15 stated, any time you smell it you should test for it. On 7/7/23 at 3:43pm, V1 (Administrator) stated V86 smelled gas so V86 called some more firefighters, and they found a gas leak. V1 reported the gas company then came out and said that we had a gas leak as well, and they shut down the gas line. V1 said V15 fixed the gas line by unhooking the one line and giving every appliance their own gas line. V1 stated the kitchen (staff) should have notified maintenance about the repairs that need to be done. V1 said V15 should have disposed of the flat top grill if it was not in working condition, and it should've been done the same day that it was brought to their attention. V1 stated, V1 wasn't notified of the gas leak until maintenance told me that the gas company was on their way. V1 said a gas leak is dangerous because it can cause fire. On 7/13/23 and 7/14/23 the surveyor verified by observation, interview, and record review that the facility implemented the following to removal plan: -Education initiated on 7/11/2023 by the Administrator, DON, ADON, Social Service Director completed on 7/11/2023. The education was Ensuring the facility has an effective maintenance plan in place by ensuring the kitchen appliances using natural gas are in good working repair and in good working condition to prevent fire hazards. -All Staff (Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Agency C.N.A(Clipboard) Housekeeping Director, MDS Coordinators and Maintenance Director, receptionist, dietary aide, Cooks, housekeepers, social service case manager, Social Service Aides, restorative aides, C.N.As, RNs, LPN, activity aides, Laundry aides), including those off duty ( receptionist, Social Service Case Managers, social service assistants, housekeepers, Laundry aides, RNs, LPNs, dietary aides, and cooks) were educated via phone with the same training as the staff educated in person, however, the staff who received the in-service 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. Upon completion of this in-person training staff will sign education sheets. In-service date of completion 7/11/2023. -The flat top grill was removed from the facility on 7/06/2023. Maintenance Director disconnected the flat top from the gas line and redirected the gas line to the working oven. -The maintenance director was educated by the facility Administrator on 07/11/2023 to ensure an effective plan is in place to ensure the kitchen appliances are maintained without exposing wiring, igniter unit and clean and free of grease and debris to prevent any potential fire hazards. -A weekly audit was completed by the Maintenance Director to ensure all kitchen appliances are in good working repair, appliances using natural gas are in good working repair and in a condition that will prevent a fire hazard, the kitchen appliances are free from exposed wires, all kitchen appliances are free from dirt/grease/hazardous conditions, the ignitor unit is clean and free from grease and debris, and the appliance has received weekly deep clean. The initial audit was started and completed on 7/11/23 by the Maintenance Director and reviewed by the Administrator. These audits will continue to be completed weekly by the Maintenance Director and audited weekly by the Administrator. Audit tool attached. -On 07/11/2023 a meeting was held with the facility IDT members. Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director, Social Service Director, Medical Records, Staffing Coordinator, Housekeeping Director, MDS Coordinators and Maintenance Director to discuss the nature of the IJ and the interventions that were put in place to ensure an effective plan is in place to prevent fire hazards. -A weekly routine equipment inspection will be conducted by the Maintenance Director or the Assistant Director of Nursing. The Administrator will review the Maintenance Director's audits to validate completion. -The Maintenance Director will assess gas leaks during weekly inspection. -The natural gas detector was ordered on 07/12/2023 by the Administrator with an expected delivery date 07/17/2023. -No policy changes have been changed. -Medical Director Dr. was made aware of the IJ. -Audits will be analyzed and presented as part of the monthly Quality Assurance Performance Improvement Committee (QAPI). This will be overseen by the Administrator and Medical Director. This committee will determine if the audits continue after three months.

1. Based on interview and record review, the facility neglected to notify the in-house dialysis and nephrologist that a new resident was admitted , neglected to assess the resident after an acute change in condition, neglected to notify the physician of an acute change in condition of a resident experiencing shortness of breath, and neglected to round on a resident every two hours per protocol for one (R50) out of three reviewed for change in condition in a total sample of 56. The Immediate Jeopardy began on [DATE] V1 (Administrator) was notified on [DATE] at 12:55 PM of the Immediate Jeopardy. The facility presented an initial removal plan on [DATE]. The plan was accepted, and [DATE] and [DATE] the surveyor conducted an onsite record reviews and interviews to confirm the removal plan was implemented. V1 was informed the Immediate Jeopardy was removed on [DATE]. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings Include: R50 is a [AGE] year old with the following diagnosis: end stage renal disease, dementia, and congestive heart failure. R50 was admitted on [DATE] and expired in the facility on [DATE]. A Nursing note dated [DATE] documents R50 had difficulty breathing. The nurse checked the vital signs and they were within normal limits. The oxygen level was 93%. R50 had bronchi and some wheezes noted in the lung sounds. The nurse elevated the head of the bed and the breathing improved. The oxygen level increased to 97%. A Nursing note dated [DATE] at 1:21 AM documents R50 was talking but sounded upset. R50 would not tell the nurse what was wrong. R50 was sitting up in bed. R50 answered being fine. R50's breathing sounded congested but R50 refused to be suction. R50 was assisted to lie back with head part elevated and covered with a blanket to keep warm. The door was left open so the nurse (V56) could hear R50 if help was needed. A Nursing note dated [DATE] at 7AM documents R50 was changed by the CNA at 5:45 AM. R50 was verbally responsive. Around 6:45 AM, the morning nurse (V20) noted R50 unresponsive. R50's arms were cold and clammy. The second nurse (V56) went to assess R50. Vital signs were checked, but none were appreciated. CPR was not attempted since it was a presumptive death. On [DATE] at 2:00PM, R21 was R50's roommate. R21 stated that R50 was screaming and yelling almost all night. R21 reported that R50 was coughing to the point where R50 was almost choking. R21 endorsed the nurse (V56) came in 1 time and told R50 to sit up and drink some water. R21 stated that R50 never got better and continued to scream, I can't breathe. Help me. R21 denied any staff coming to help R50 while R50 was screaming. R21 endorsed telling R50 to shut up after R50 continued to yell. R21 was not able to give a timeframe on how long R50 was yelling before the yelling stopped because R21 fell asleep. R21 stated waking up around ,d+[DATE]AM because a bunch of people were in the room talking about how he was dead. R21 endorsed R50 was begging for someone to come help and no one ever came back. On [DATE] at 10:16AM, V22 (CNA) stated when I was coming around the corner, the night nurse (V56) was coming down the hall in a panic saying R50 was dead. The night nurse said that the CNA (V79) changed R50 around 5:45AM and was talking with R50 fine. I think it was an agency CNA but I didn't see her that morning. On [DATE] at 10:50AM, V20 (Nurse) stated I came in about 6:30 or 6:45 that morning. I was going around doing my morning rounds and I called R50's name and R50 didn't respond. I started to do a sternal rub and to pinch R50 and R50 was still unresponsive. I called the night nurse (V56) down there and she came to take some vital signs. There were no vital signs. R50's chest was not moving and R50's pupils were dilated and fixed. Since it was both nurses, we presumed R50 dead. The night nurse said R50 was having some trouble breathing and had some secretions in R50's throat, but R50 refused to be suctioned and did not want oxygen. Usually when someone has a lot of sputum you will call the doctor and send them to the hospital. They cannot breathe. We round on residents every two hours to make sure they are OK or see if they need anything. R50 had end-stage renal failure. Those residents you want to check every shift for vital signs, check the catheter site, and check for edema or fluid overload. If someone is having edema, that means they are holding onto the fluid or if they are having trouble breathing. On [DATE] at 12:01PM, V47 (Detective) stated R21 was alert and told me that R50 was screaming all night. R21 said that R50 was saying R50 couldn't breathe and that R50 needed help. On [DATE] at 12:07PM, V2 (DON) stated if R50 was having any trouble breathing, then a doctor should've been called. If they put in orders that should've been completed but if those didn't help, they should've just been sent out to the hospital. When someone is having a change of condition, I expect staff to do a full assessment, so they can have more information on what is going on with the resident. An assessment should always be completed when there's a change of condition. If a resident was refusing oxygen or suctioning, then I would just call 911 to get them out to the hospital where they can do more for them. I know R50 was a dialysis resident so they should've been monitoring R50 for a fluid overload. That happens when you have too much fluid in your body and it backs up into your lungs so you basically drown. On [DATE] at 3:51PM, V13 (Nurse) stated R50 was coughing and spitting up secretions. R50 just kept spitting them out. I adjusted the head of R50's bed so it was more elevated. The first time I checked him it was 93% and then after R50 raised the head of the bed, it came up to 97%. I passed medications in the morning and R50 wasn't really coughing but when I saw R50 in the afternoon, R50 was coughing a lot. I did not listen to R50 with my stethoscope. I was too busy to listen to R50. I told the next nurse just to monitor R50 because R50 was having a lot of coughing with secretions. I never called the doctor. Yes, this would be considered a change in condition because, R50 was having more secretions and R50's oxygen level was lower. I didn't think to call the doctor at that time. I just passed it on to the next nurse. On [DATE] at 11:08AM, V56 (Nurse) stated it was right before 7 AM when V20 came to get me to tell me that R50 was unresponsive. The CNA (V79) told me that V79 changed R50 around 5:45AM, and R50 was talking fine. I checked on R50 at 1 AM. R50 was talking in an angry voice, so I thought R50 was crying. I went to R50's room and R50 told me R50 was fine. I asked if R50 was congested and R50 said no R50 was fine. I didn't hear anything else from R50 that night. R50 sounded congested. When I went to check on R50 at the time (1AM), I could hear R50 congested when R50 talked. I didn't listen to R50 with my stethoscope. It was at the nurse's station so I couldn't listen to R50. I could hear R50 was congested in R50's throat. I elevated the head of R50's bed. I tried to suction R50, but R50 refused. I did not take any vital signs. That was my first time seeing him at 1 AM. It just sounded like R50 had stuff in R50's chest and in R50's throat. The nurse before me said R50 was congested and coughing a lot. R50 did not have any orders. We normally do rounds every two hours. The last time I checked on R50 was at 1 in the morning. I didn't check on R50 after that because I was busy. I think the CNA was checking on R50. When I talked to V79, V79 said V79 checked on R50 at 5:45. I didn't see V79 go in the room. I didn't call the doctor about R50 sounding congested. R50 was new, so I wasn't really sure if that's how R50 normally was. It didn't seem that serious to me. I did hear R50 talking still during the night. I don't know who R50 was talking to and I don't know what R50 was saying. You call the doctor anytime there's a major change in a resident. I don't know why I didn't call the doctor. I was just very busy. On [DATE] at 12:06PM, V66 (Nurse) stated the nurse before me actually admitted R50. I did get R50's medication ordered, but that was the only thing. I didn't order dialysis at that time because that was the only important thing to order because of the time of night it was. I know R50 was getting dialysis. Those residents you have to watch for fluid overload. Fluid overload would be a resident having trouble breathing or needing oxygen when they didn't before. Dialysis isn't there on the weekend, so if any residents are having problems with breathing because their fluid overloaded then you just send them out to the hospital for an extra treatment. I didn't call the doctor for an order for dialysis. I was only able to put in the medication at that time. On [DATE] at 2:16PM, V30 (Dialysis Administrator) stated when the facility is looking over the paperwork and see that they need dialysis, they will send over the referral information to our department. The facility give us an estimated date of arrival and they will let us know when the resident is actually admitted to the facility. The floor nurse will call us if we are here. Otherwise, we get an email from someone in the facility. For dialysis residents, you want to monitor for signs and symptoms of fluid overload, the vital signs, any infections to their access site. Signs of fluid overload would be trouble breathing, swelling anywhere, decreased oxygen saturations, and diminished lung sounds. If a resident is experiencing something like this, the only treatment really for them would be to get dialysis. A doctor should be immediately notified. The breathing treatment and suctioning is not something that would help a resident having respiratory distress if they are getting dialysis. The fluid needs to be removed from buildup in the blood. If they don't send them out 911 at the very least, the physician should be notified that the resident is having changes in the respiratory status. If they're having trouble breathing, then 911 should be called immediately. I have no notification that R50 actually arrived to the facility. On [DATE] at 3:20PM, V69 (Nephrologist) stated I am notified of a new resident in the building by the company contracted for dialysis. I was never notified that R50 was in the facility or that R50 was coming. We never do an extra treatment for a new admission, if anything was off, he would need to be sent to the hospital. Dialysis patients can have very serious situations occur pretty quickly. The most prominent is fluid buildup in the lungs. Since I didn't get a notification that the resident was in the facility, I would expect the nurse to notify the Medical Director or primary physician. These residents can go into respiratory distress fairly quickly and need urgent dialysis. If a resident is unstable, you should default and just call 911. This resident has no IV and dialysis cannot be done in the facility. Oxygen would only be a temporary fix. Suctioning would not help a resident in fluid overload because it would never get the fluid off that needs to come off in certain areas. A physician should be notified immediately that this is going on. If R50's not at the level to be sent out to the hospital yet; then staff need to be keeping a closer eye on R50 to make sure things don't become worse. On [DATE] at 3:47PM, V46 (Nurse) stated R50 was admitted around 7 PM, but at that time we had no Internet. I couldn't complete the admission on the computer. I don't remember anything about dialysis or R50 needing extra dialysis. The admitting nurse will also check the paperwork from the hospital to make sure that all the orders are in place. When the system is working, we normally call the doctor and let them know that they are here and on dialysis. They will put in all the orders regarding dialysis. For those type of residents, you just want to make sure that you were doing assessments for fluid overload. I didn't tell the dialysis company that they were here. If someone is having a change in the respiratory status, you should listen to the lungs and see if they are congested. You should also do their vital signs and notify the doctor. For a dialysis resident any respiratory distress can mean that they have extra fluid in their body. Usually for cases like that they get sent out to the hospital for evaluation and extra dialysis. If you have extra fluid in your body, it usually backs up into your lungs causing you not to be able to breathe better. On [DATE] at 1:40PM, V19 (ADON) stated the nurse will either do the admission or pass it onto the next shift depending on what time the patient comes. Also, the DON and ADON will make sure everything is completed the next time later in the facility. When we are not here, it is just the nurses responsibility to get the orders. If dialysis is in the building, then the nurse will call down to let dialysis know. The nurse will also review the paperwork from the hospital to make sure the orders are correct. If a resident is having any type of change in condition, then the nurse practitioner or physician must be notified. They should call as soon as it is noticed. They either need to get orders for some type of treatment or to be sent out if there's any type of change then they should always call to see what should be done. They should also do another assessment if there's a change. They should check the vital signs, check their mental status, check for pain, and check the area of the complaint. If it is specifically for respiratory distress or shortness of breath, then the head of the bed should be elevated and the oxygen level should be checked. The doctor should immediately be called for a situation like this. If their doctor gave orders and there's no relief, the doctor should be called back or 911 should be called if they get worse. Rounds are done every two hours. This let's us check on the residents to see how they are doing and if they need anything. If a resident is having a change of condition, they need to round every two hours just to make sure it hasn't changed. Dialysis residents can have fluid overload because they cannot urinate. They cannot get the fluid out of their body. This can cause respiratory distress. If there is too much, then they cannot breathe and need a dialysis treatment or to be sent to the hospital. On [DATE] at 12:49PM, V1 (Administrator) stated the Internet went down around 2:30PM that Friday and didn't come back until 1AM on Saturday. The nurses were trying to do all the admissions on their phones. I was asking if anything happened over night and no one could give me an answer that would make me think R50 was going to die. If something crazy happens with a resident where they need attention right away I would expect them to call 911. If it is something they can manage then they should call the doctor first. If they aren't breathing right or they need immediate interventions then 911 should be called immediately. Dialysis gets notified before they get here so they can also approve the patient and have everything set up when they arrive. The order for dialysis should have been put in once R50 arrived. I know the Internet was down so it should have been put up once everything was up and running. I talked with the nurses that admitted R50 and both were kind of blaming each other for all the orders not being put in. Myself, the DON, or our marketer will notify the dialysis center through email when they are arriving. When they arrive to the facility an email is sent when they get here so they can get things set up. I know they knew R50 was coming that day but since the Internet was down I don't know if something got lost in translation. I don't know if they were notified when R50 was actually admitted . The admitting nurse is responsible for going through the paperwork and making sure all the orders from the hospital are carried over and going through them with the doctor. The Admission/Readmission Screen are dated [DATE] documents R50 admitted to the facility on [DATE] at 7 PM. R50 was admitted from the hospital. Vital signs were taken and within normal limits. R50 is alert and oriented to person and place. R50 has a regular respiratory rate with no cough. Breath sounds on the left side are clear and on the right side has a slight rhonchi. R50 is able to clear the rhombic. R50 has a dialysis schedule of Monday, Wednesday Friday with a dialysis port to the left upper chest. Emails between the in-house dialysis and the facility were submitted for review. An email on [DATE] at 10:36AM from the in-house dialysis to the facility documents the in-house dialysis was asking for confirmation that R50 was being admitted to the facility that day. The facility replied to this email at 10:37AM confirming R50 is scheduled to arrive on [DATE]. This is no more email confirmation letting the in-house dialysis what time R50 arrived. There is no email communication on [DATE]. An email on [DATE] at 3:44PM from the in-house dialysis to the facility documents the in-house dialysis asked if the facility was still expecting R50. This confirms the in-house dialysis had no knowledge R50 was admitted to the facility. The facility replied to this email at 10:41PM letting in-house dialysis know R50 expired. The Physician Order Summary documents a renal diet order was placed on [DATE]. There are also orders for 11 medications placed on [DATE] and [DATE]. There is no documentation of a dialysis order or anything pertaining to dialysis. The policy tilted, Dialysis Care, dated [DATE] documents, Purpose: To adequately assess residents needs and provide care goals which achieve the highest practicable level of care to residents with end stage renal disease receiving hemodialysis or peritoneal dialysis. Procedure: 1. Arrangements should be made prior to admission for acquisition and storage of supplies, location and type of dialysis and room accommodations. The policy titled, Supervision and Safety, dated ,d+[DATE] documents, . 10. Staff to make visual rounds on residents minimally every 2 hours and more often if necessary based on resident's assessment needs. The policy titled, Change in Resident's Condition, dated [DATE] documents, General: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician/NP, and resident's responsible party of a change in condition. Responsible Party: RN, LPN, Social Services. Policy: 1. Nursing will notify the resident's physician or nurse practitioner when: a. The resident is involved in an accident or incident. b. There is a significant change in the resident's physical, mental, or emotional status . e. It is deemed necessary or appropriate in the best interest of the resident. 2. Appropriate assessment and documentation will be completed based on the resident's change in condition or indication . 4. The communication with the resident and their responsible party as well as the physician/NP will be documented in the resident's medical record or other appropriate documents. On [DATE] and [DATE] the surveyor verified by interview and record review that the facility implemented the following to remove the immediacy: -Education initiated on [DATE] by the Administrator, DON, Restorative Nurse, Social Service Director, Dietary Manager completed on [DATE]. -Prior to residents being admitted to the facility, the facility (Administrator/DON/ Social Service Director/RN/LPN) team must communicate/coordinate with in-house dialysis that the resident is admitting to the facility. -During the referral process the facility team (Administrator/DON/Social Service Director) will communicate via email with the Dialysis Director on resident ' s admission/readmitted to the facility. -DON will notify Team (RN/LPN) via Admission Notice of residents scheduled admission. -The staff nurse (RN/LPN) will contact the Nephrologist upon resident admission to the facility that the resident has arrived and will obtain admission orders and place the orders into PCC. -Facility staff (RN/LPN) must notify the nephrologist that a resident in need of dialysis has been admitted to the facility. -The facility nurse (RN/LPN) must assess all residents who are having an acute condition change (shortness of breath). -The facility nurse (RN/LPN) must notify the physician of any resident having an acute change in condition (having shortness of breath). -Rounding: Facility staff will obtain their assigned schedule and conduct rounds. Facility staff (RN/C.N.A/Social service aids) will then round every two hours -All Staff (Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Agency C.N.A(Clipboard) Housekeeping Director, MDS Coordinators and Maintenance Director, receptionist, dietary aide, Cooks, housekeepers, social service case manager, Social Service Aides, restorative aides, C.N.As, RNs, LPN, activity aides, Laundry aides), including those off duty ( receptionist, Social Service Case Managers, social service assistants, housekeepers, Laundry aides, RNs, LPNs, dietary aides, and cooks) was educated via phone with the same training as the staff educated in person, however, the staff who received the in-service 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. Upon completion of this in-person training staff will sign education sheets. In-service date of completion [DATE]. -There were no changes made to the rounding policy. -Facility staff (RN/LPN/C.N.A/Social Service Aids) will check their assigned group upon arriving to duty. -Nurse to Nurse rounds will be conducted at shift change then every two hours. -C.N.A to C.N.A round will be conducted at shift change then every two hours. -Social Service Assistant will conduct rounds every two hours while on duty. -Ongoing education will be provided to all staff on notifying the in-house dialysis that the resident was admitted . The facility nurse (RN/LPN) to notify the nephrologist of the resident ' s requiring dialysis has been admitted to the facility, staff nurses (RN/LPN) to follow the facility policy and assess residents who have been identified of having an acute change of condition and to notify the physician immediately. Staff educated on the importance of conducting rounds every two hours. All in services were completed on [DATE]. -A baseline audit was completed by the DON on [DATE] to identify if any newly admitted resident or potential admits that have a diagnosis of ESRD needing dialysis services. The audit will continue weekly for three months by the DON/Restorative Nurse. Audit tool attached. -On [DATE] a meeting was held with the facility IDT members. Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Housekeeping Director, MDS Coordinators and Maintenance Director. -RN, LPN, Social Workers, Social Service Assistance, and C.N.As will conduct rounds every two hours. -No policy changes have been made to the change in condition policies. -Medical Director was made aware of the IJ. -Audits will be analyzed and presented as part of the monthly Quality Assurance Performance Improvement Committee (QAPI). This will be overseen by the Administrator and Medical Director. This committee will determine if the audits continue after three months. 2. Based on observations, interviews, and record reviews, the facility neglected to ensure a resident recieved activities of daily living, food and water during a 24 hour period. This failure affected one resident (R18) reviewed for neglect. This failure resulted in R18 family removing R18 from the facility AMA (Against Medical Advise) Findings include: On [DATE], V1 (Administrator) stated that there is no POC (point of care) charting found in R18's medical record for [DATE] or [DATE]. V1 presented a documented noting no POC documentation. On [DATE] at 3:40pm, V59 CNA (Certified Nurse Aide) stated that he provides care only to his assigned residents. V59 reviewed the assignment sheet for [DATE] 3:00pm-11:00pm shift. V59 stated that he was assigned to rooms 223A-233B. V59 stated that he was not assigned to provide care to any residents in room [ROOM NUMBER]. V59 stated that he is responsible for completing his charting in this facility's computer system, POC, prior to leaving at end of each shift worked. V59 stated that if he was assigned to R18, he would have documented on him. On [DATE] at 9:40am, V64 CNA stated that V64 does not recall R18. V64 stated that all care she provides to her assigned residents is documented in the resident's electronic medical record, POC charting. Review of this facility's CNA assignment sheet for [DATE] 3:00pm-11:00pm, does not note a CNA was assigned to provide care to R18 in room [ROOM NUMBER]. Review of this facility's CNA assignment sheet for [DATE] 7:00am-3:00pm notes V64 was assigned to R18. Review of this facility's CNA assignment sheet for [DATE] 3:00pm-11:00pm, does not note a CNA was assigned to provide care to R18 in room [ROOM NUMBER]. Review of R18's POS (physician order sheet), dated [DATE], notes orders for vital sign monitoring every shift for three days then daily; weekly weights; general diet; and Braden score for skin breakdown on admission and weekly x 4. Review of R18's vital sign documentation notes R18's vital signs were obtained on ,d+[DATE] at 00:04am and 8:07am. There is no documentation noting R18's weight was obtained. R18's POC (point of care) charting for [DATE] and [DATE] was reviewed. There is no documentation found noting R18 received morning care, evening care, incontinence care, meals and amount eaten, fluid intake, or bedtime snack. Review of R18's medical record does not note a Braden score assessment was completed. Review of R18's progress notes, dated [DATE] at 10:43pm, V46 (nurse) noted R18 requires extensive staff assist with ADL's and transfers. Incontinent of bowel and bladder functions. On ,d+[DATE] at 00:03am, R18's vital signs were noted. The next documentation in R18's progress notes was ,d+[DATE] at 7:30pm when R18's family member removed R18 from this facility against medical advice. Review of R18's pre-admission hospital record, dated [DATE] at 4:29pm, notes R18 requires assistance with ADLs. Review of R18's referral packet, dated [DATE], notes R18 with frequent falls secondary to progression of underlying Parkinson's disease. Occupational Therapy noted R18 presents with impaired balance, coordination, and cognitition which limit safety with ADLs. 3.Based on interview and record review, the facility failed to follow their abuse policy, failed to prevent resident to resident abuse both verbal and physical. This affected 4 of 4 (R2-R5) residents reviewed for abuse. This failure resulted in R2 calling R3 a racial slur and R5 punching R4 repeatedly with a closed fist. Findings Include: R2 is an [AGE] year old with the following diagnosis: dementia and bipolar disorder. R2 admitted to the facility on [DATE]. R3 is a [AGE] year old with the following diagnosis: bipolar disorder and paranoid schizophrenia. R3 admitted to the facility on [DATE] and discharged on [DATE]. On [DATE] at 12:08PM, R3 stated that R2 was throwing food out the window so R3 reminded R2 to keep food inside. R3 endorsed R2 became upset at R3 for telling R2 what to do. R3 reported R2 began to yell at R3 and called R3 the N-word. R3 stated everyone started yelling after that so R3 was not able to remember exactly what was said, but knows R2 called R3 the N-word. R3 reported staff then came into the dining room and removed R2. On [DATE] at 12:28PM, R2 doesn't remember the incident with R3. R2 admitted to saying the N-word but not where other people can hear it. When it was brought to R2's attention that R3 heard R2 call R3 the N-word. R2 did not want to speak any more on that incident. On [DATE] at 10:16AM, V3 (Asst Social Service Director) stated I have heard R2 say the 'N word' a few times so I believe that happened. Saying the 'N word' should be considered aggressive behavior. This would be verbal abuse because R2 verbally assaulted R3. On [DATE] at 1:50PM, V35 (Nurse) stated R2 does have a habit of using the N-word. R2 has said it to both residents and staff. Any kind of racial slurs would be considered verbal abuse. On [DATE] at 12:49PM, V1 (Administrator) stated I don't remember this situation. Saying the N-word to someone else would be derogatory and considered verbal abuse. An Event note dated [DATE] documents R2 is alert and oriented times 3. It was reported to staff that R2 had initiated verbal aggression towards R3. Both residents were separated immediately. The Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors dated [DATE] documents a total score of 5 indicating a substantial or significant problem with aggressive behavior for R2. The Minimum Data Set (MDS) Section B dated [DATE] documents R2 has the ability to express ideas and wants and has the ability to understand others with no deficits. Sections C of the MDS documents a Brief Interview for Mental Status score is a 10 (moderate cognitive impairment). A Care Plan dated [DATE] documents R2 displays socially inappropriate and maladaptive behavior due to a diagnosis of dementia, dysfunctional behavior, and mental illness. R2 has periods of anger and agitation. R2 presents with signs and symptoms of persistent anger towards self and others. This problem is manifested by verbal hostility and abuse as well as physical hostility and abuse. R2 makes negative sarcastic remarks with frequent complaints. R2 displays angry outbursts towards staff and sometimes makes racial slurs towards peers. The Care Plan dated [DATE] documents R2 has a history of aggressive and inappropriate behavior. The history includes conflict/altercations with others, threatening behavior, verbal or physical aggression, acting impulsively and disrespectful demeaning behavior. R2 has a history of aggressive behavior toward peers and staff. The Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors dated [DATE] documents a total score of a 4 indicating R3 is at a substantial risk for abuse due to an increase in vulnerability, mental health diagnosis, diagnosis of depression, and denial or evasiveness when discussing mental health issues. The Minimum Data Set, dated dated dated [DATE] documents a Brief Interview for Mental Status score as 14 (no cognitive impairment). An Event note dated [DATE] documents R3 received verbal aggression from a peer. Both residents were separated immediately. R3 was encouraged to utilize coping skills. R3 was receptive to counseling. The Care Plan dated [DATE] documents the comprehensive assessment reveals a history of suspected abuse and/or neglect or factors that increase R3's susceptibility to abuse/neglect. R3 is at risk for abuse and risk factors include history of irritability, delusional thoughts, auditory hallucinations, confusion, poor insight, verbal aggressive behavior, wandering, and dysfunctional behavior. The Facility Reported Incident dated [DATE] documents R3 received verbal aggression from R2 in the first floor dining hall. R3 observed R2 sliding food out of the window. R3 verbalized to R2 to not do this. R2 stated to R3 to mind, your ni**er business. Both residents were separated immediately and counseled on appropriate behavior. R4 is a [AGE] year old with the following diagnosis: major depressive disorder. R4 admitted to the facility on [DATE]. R5 is a [AGE] year old with the following diagnosis: schizophrenia and dementia. R5 admitted to the facility on [DATE]. On [DATE] at 12:45PM, R [TRUNCATED]

Based on interview and record review, the facility failed to follow its abuse policy and thoroughly review an employee application documenting history of conviction of a crime and child abuse. The facility hired the employee and failed to report with known knowledge of action from the courts to the State Agency. This affected 1 of 60 staff reviewed for background checks. This system failure has the capacity to affect all residents (214) residing in the facility. The Immediate Jeopardy began on 2/7/23. V1 (Administrator) was notified on 6/21/23 at 12:55 PM of the Immediate Jeopardy. The facility presented an initial removal plan on 6/21/23. The plan was accepted, and on 6/27/23 and 6/28/23 the surveyor conducted onsite record reviews and interviews to confirm the removal plan was implemented. V1 was informed the Immediate Jeopardy was removed on 6/21/23. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings include: On 5/31/23 at 10:42 AM, V1 (Administrator) said V27 is currently on hold as an employee and said she received an anonymous call saying V27 is a murderer. V1 said the caller accused the facility does not do background checks. V1 said V27's employee background checks were done and V27 had no disqualifiers noted. V1 said V27 took the CNA class and was ready to become certified however, V1 is unaware of V27 taking the CNA exam. V1 interviewed V27 and was told V27 went to jail for murder in TN. V1 said the employee's daughter is still alive. V1 said V27 is trying to get the conviction expunged from her record. V1 said V27 presented a letter saying the expungement is in process. V1 said the facility is requesting court documents and lawyer paperwork. V1 said V27 has not produced paperwork. V1 said V27's files are sealed, and this may be keeping the documents delayed. V1 said Human Resources Personnel are responsible for reviewing the employee application. V1 said she was not aware of V27's felony conviction. V1 said the facility received an anonymous call and caller told V1 they hired a convict. On 5/31/23 at 12:48 PM, V8 (Human Resources Personnel/ Assistant Administrator) said she is responsible for reviewing employee applications. V8 said she did not notice the wrongful conviction in the employment application. V8 said she did a background check and found the employee was ok to work per employee background checks. When V8 did the background check they came back as eligible, and she looked no further. V8 said she did not see the felony conviction documented in the employee application. V8 said she would have shown corporate office and they would have done extensive background checks. V8 said if she saw the felony conviction, she would have not hired the employee. V8 said she made the error of scanning margins for no responses and missed the detailed writing stating the felony conviction. V8 said employee started [DATE]th through [DATE]th (date of anonymous call received). V8 said employee applied on 1-30-23. V8 said employee was a Resident Assistant (RA) throughout her employment. V8 said she was unsure if V8 was able to work at the facility and was asking the surveyor to clear V27 to return to work. On 6/7/23 at 9:01 AM, V1 (Administrator) said V27 applied on 1-30-23, background checks were done on 1-30-23 and started 2-7-23 working as Resident Assistant . V1 said after 30 days, V27 is eligible for CNA training class. V1 said CNA training classes are done in Joliet. V1 said V27 was in CNA classes 3-6-23 to 4-17-23. V1 said CNA class is for 2 months. V1 said V27 started as CNA on 4-5-23. V1 said employee can work as a CNA for 120 days, license pending to sit for exam. V1 said she was not aware of R27's child abuse conviction upon hiring. V1 said if known V27 had a conviction, V27 would have not been hired. V1 said employee does not work here. V1 said facility asked for further documents in regard to expungement and V27 did not provide documentation for over 30 days. 2On 6/7/23 at 10:17 AM, V8 (Human Resources Personnel/ Assistant Administrator) said V27 applied 1-30-23, background checks done on 1-30-23, biometric fingerprint on 1-30-23, orientation and started working on 2-7-23 (as RA). V8 said V27 started working as CNA on 4-5-23. V8 said she is unsure of date of phone call received. V8 said V27 was fired due to not providing documentation 30 days after phone call and no documents provided. V27's Legalaid paper is not clear about V27's conviction expungement. V8 told V27 she had 30 days to provide more documents and V27 has not done so. On 6/12/23 at 10:29 AM, V27 said she started work in February 2023. V27 said she reviewed her conviction with Human Resources and Scheduler upon hire. V27 said she was removed from the schedule on 4/10/23 and she has not been terminated. V27 said she was not called by anyone at the facility or given a written notice for termination. V27 said she was removed for the schedule after a phone call that reported V27 killed her daughter by V1 (Administrator). V27 said she was placed on hold pending submitting paperwork regarding the conviction. V27 said she was told once everything clears, V27 would be given back pay for the days she was off the schedule. V27 said she was called about the paperwork related to her conviction the day IDPH surveyors walked in the building. V27's Court Record (dated 9-6-18) documents: Petitioner, (V27), was indicted by the [NAME] County Grand [NAME] for one count of attempted first degree murder. Petitioner pleaded guilty to the amended charge of attempted second degree murder and received a sentence as a Range I offender of eight years in the Tennessee Department of Correction. V27's Employee File does not show any documentation of termination nor any documentation of reporting conviction to the State Agency. V1's Timeline (no date) does not document any notification of conviction to State Agency. Application For Employment (dated 1-30-23) documents: Have you ever been convicted of a crime? Yes. If yes, explain: wrongful conviction pending lawsuit. Have you ever been convicted of, or do you have a prior employment history of child or resident abuse, or mistreatment? Yes, If yes explain: wrongful conviction pending lawsuit. 17. Were you ever convicted of a felony or released from prison after a felony during the year before you were hired? If yes, enter date of conviction: 9-18-15 and date of release: 2-10-21. Was this a federal: No or a State conviction: TN. Abuse Prevention Program Facility Policy and Procedure (reviewed 1-18) documents: This facility will not knowingly employ any staff convicted of any of the crimes listed in the Illinois Healthcare Worker Background Check Act (unless waivered under the provision of the Act) or with findings of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property listed on the Illinois Health Care Worker Registry. On 6/27/23 and 6/28/23 the surveyor verified by interview and record review that the facility implemented the following to remove the immediacy: -V27 no longer works at the facility. -V8 (HR) was thoroughly trained in an effective application review process, that includes investigating admission of felony conviction on 6/21/2023. This training was completed on 6/21/23. -The Administrator, DON, and Assistant Social Service Director will continue to educate staff on completing a thorough review of a new employment application with an emphasis on investigating admission of felony convictions. Staff includes Business Office, Admissions, Human Resources, and Social Services. -Ongoing education will be provided to staff on thoroughly reviewing a new employment application with an emphasis on investigating admission of felony convictions. Staff includes Business Office, Admissions, Human Resources, and Social Services. -A baseline audit was completed on 6/21/2023 by the Director of Human Resources. This audit included a review of the applications on file for all current staff as well as a review of background checks for all current staff. All current staff includes Nursing, Certified Nursing Assistants, Housekeepers, Dietary, Activities, Business Office, Admissions, Human Resources, Wound Care, Medical Records, Staffing, MDS, Maintenance, and Social Services. Routine audits will be conducted weekly by the HR Director to ensure ongoing compliance. -On 6/21/2023 a meeting was held with the facility IDT members. Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Housekeeping Director, MDS Coordinators and Maintenance Director. The facility will not hire an employee or engage an individual who was found guilty of abuse, neglect, exploitation, or mistreatment or misappropriation of property by a court of law; or who has a finding in the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, or has a disciplinary action in effect taken against his/her professional license. The facility will report knowledge of actions by a court of law against an employee that indicates the employee is unfit for duty. -Upon hire the facility will initiate a reference check from previous employers. -Obtain a copy of state license of any individual being hired for a position requiring a professional license. -Check the Illinois Heath Care Worker Registry on an individual being hired for prior reports of abuse, neglect or misappropriation of resident property, previous fingerprint check results, and sexual offender Website links on the Registry. -Initiate an Illinois State Police Livescan fingerprint check for any unlicensed individual being hired without a previous fingerprint check. -Upon the facility (Administrator/ Assistant Administrator) has known knowledge of action from the court against a new employee, the facility will notify the state nurse aide registry, IDPH, and IDFPR . -No policy changes have been made to the healthcare worker background check policy. -Medical Director was made aware of the IJ. -Audits are being conducted weekly by the HR Director to ensure thorough backgrounds are being checked upon hire, and applications are reviewed for criminal background checks. The QAPI committee determine if the audits will continue after three months. -Audits will be analyzed and presented as part of the monthly Quality Assurance Performance Improvement Committee (QAPI). This will be overseen by the Administrator and Medical Director.

1. Based on interview and record review, the facility failed to notify the in-house dialysis and nephrologist that a new resident was admitted , failed to assess the resident after an acute change in condition, neglected to notify the physician of an acute change in condition of a resident experiencing shortness of breath, and failed to round on a resident every two hours per protocol for one (R50) out of three reviewed for change in condition in a total sample of 56. This failure caused R50 to have an acute change of condition and subsequently expire. The Immediate Jeopardy began on [DATE]. V1 (Administrator) was notified on [DATE] at 12:55 PM of the Immediate Jeopardy. The facility presented an initial removal plan on [DATE]. The plan was accepted, and [DATE] and [DATE] the surveyor conducted an onsite record reviews and interviews to confirm the removal plan was implemented. V1 was informed the Immediate Jeopardy was removed on [DATE]. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings Include: R50 is a [AGE] year old with the following diagnosis: end stage renal disease, dementia, and congestive heart failure. R50 was admitted on [DATE] and expired in the facility on [DATE]. There is one set of vital signs documented for R50's entire stay on [DATE] at 6:34 AM. A Nursing note dated [DATE] documents R50 had difficulty breathing. The nurse checked the vital signs, and they were within normal limits. The oxygen level was 93%. R50 had bronchi and some wheezes noted in the lung sounds. The nurse elevated the head of the bed and the breathing improved. The oxygen level increased to 97%. A Nursing note dated [DATE] at 1:21 AM documents R50 was talking but sounded upset. R50 would not tell the nurse what was wrong. R50 was sitting up in bed. R50 answered being fine. R50's breathing sounded congested but R50 refused to be suction. R50 was assisted to lie back with head part elevated and covered with a blanket to keep warm. The door was left open so the nurse (V56) could hear R50 if help was needed. A Nursing note dated [DATE] at 7AM documents R50 was changed by the CNA at 5:45 AM. R50 was verbally responsive. Around 6:45 AM, the morning nurse (V20) noted R50 unresponsive. R50's arms were cold and clammy. The second nurse (V56) went to assess R50. Vital signs were checked, but none were found. CPR was not attempted since it was a presumptive death. The Police Report dated [DATE] documents the police were called at 5:15 PM and arrived on scene at 5:51 PM. The family member of R50 wanted documentation due to R50 dying and there were reports of a verbal argument between R50 and R21 the previous night. V1 reported the CNA last checked on R50 around 5:45 AM on [DATE]. The day nurse began the shift at 6:30 AM and checked on R50 around 6:45 AM where R50 was found unresponsive. V1 reported there was a verbal altercation between R50 and R21 the night of [DATE]. R21 complained to staff that R50 was talking to himself loudly making it difficult for R21 to sleep. R21 reported telling R50 to shut up but at no point did they ever make physical contact. Due to nursing staff, not following proper protocol, the police department, fire department, and the on-call detective were not notified of R50's passing for nearly 12 hours. On [DATE] at 1:42PM, V75 (Family Member) stated I got a phone call at 2 PM from someone at the facility. They told me that R50 had died . I did have a call from a blocked number at about 9 AM. The voicemail said that R50 had gotten into an argument with R21, and they last checked on him around 5:30 AM and R50 was fine. The morning nurse went in there around 6:45am and found R50 unresponsive and tried to resuscitate R50 but couldn't revive R50. They said anything about R50 having a hard time breathing. On [DATE] at 2:00PM, R50's roommate, R21, stated that R50 was screaming and yelling almost all night. R21 reported that R50 was coughing to the point where R50 was almost choking. R21 endorsed the nurse (V56) came in 1 time and told R50 to sit up and drink some water. R21 stated that R50 never got better and continued to scream, I can't breathe. Help me. R21 denied any staff coming to help R50 while R50 was screaming. R21 endorsed telling R50 to shut up after R50 continued to yell. R21 was not able to give a timeframe on how long R50 was yelling before the yelling stopped because R21 fell asleep. R21 stated waking up around ,d+[DATE]AM because a bunch of people were in the room talking about how he was dead. R21 endorsed R50 was begging for someone to come help and no one ever came back. On [DATE] at 10:16AM, V22 (CNA) stated when I was coming around the corner, the night nurse (V56) was coming down the hall in a panic saying R50 was dead. The night nurse said that the CNA (V79) changed R50 around 5:45AM and R50 was talking fine. I think it was an agency CNA, but I didn't see her that morning. On [DATE] at 10:50AM, V20 (Nurse) stated I came in about 6:30 or 6:45 that morning. I was going around doing my morning rounds and I called R50's name and R50 didn't respond. I started to do a sternal rub and to pinch R50 and R50 was still unresponsive. I called the night nurse (V56) down there and she came to take some vital signs. There were no vital signs. R50's chest was not moving and R50's pupils were dilated and fixed. Since it was both nurses, we presumed R50 dead. The night nurse said R50 was having some trouble breathing and had some secretions in R50's throat, but R50 refused to be suctioned and did not want oxygen. Usually when someone has a lot of sputum you will call the doctor and send them to the hospital. They cannot breathe. We round on residents every two hours to make sure they are OK or see if they need anything. R50 had end-stage renal failure. Those residents you want to check every shift for vital signs, check the catheter site, and check for edema or fluid overload. If someone is having edema, that means they are holding onto the fluid or if they are having trouble breathing. On [DATE] at 12:01PM, V47 (Detective) stated R21 was alert and told me that R50 was screaming all night. R21 said that R50 was saying R50 couldn't breathe and that R50 needed help. On [DATE] at 12:07PM, V2 (DON) stated if R50 was having any trouble breathing, then a doctor should've been called and if they put in orders that should've been completed but if those didn't help, they should've just been sent out to the hospital. When someone is having a change of condition, I expect staff to do a full assessment, so they can have more information on what is going on with the resident. An assessment should always be completed when there's a change of condition. If a resident was refusing oxygen or suctioning, then I would just call 911 to get them out to the hospital where they can do more for them. I know R50 was a dialysis resident, so they should've been monitoring R50 for a fluid overload. That happens when you have too much fluid in your body, and it backs up into your lungs so you basically drown. On [DATE] at 3:51PM, V13 (Nurse) stated R50 was coughing and spitting up secretions. R50 just kept spitting them out. I adjusted the head of R50's bed so it was more elevated. The first time I checked him it was 93% and then after R50 raised the head of the bed, it came up to 97%. I passed medications in the morning and R50 wasn't really coughing but when I saw R50 in the afternoon, R50 was coughing a lot. I did not listen to R50 with my stethoscope. I was too busy to listen to R50. I told the next nurse just to monitor R50 because R50 was having a lot of coughing with secretions. I never called the doctor. Yes, this would be considered a change in condition because, R50 was having more secretions and R50's oxygen level was lower. I didn't think to call the doctor at that time. I just passed it on to the next nurse. On [DATE] at 11:08AM, V56 (Nurse) stated it was right before 7 AM when V20 came to get me to tell me that R50 was unresponsive. The CNA (V79) told me that V79 changed R50 around 5:45AM, and R50 was talking fine. I checked on R50 at 1 AM. R50 was talking in an angry voice, so I thought R50 was crying. I went to R50's room and R50 told me R50 was fine. I asked if R50 was congested and R50 said no R50 was fine. I didn't hear anything else from R50 that night. R50 sounded congested. When I went to check on R50 at the time (1AM), I could hear R50 congested when R50 talked. I didn't listen to R50 with my stethoscope. It was at the nurse's station so I couldn't listen to R50. I could hear R50 was congested in R50's throat. I elevated the head of R50's bed. I tried to suction R50, but R50 refused. I did not take any vital signs. That was my first time seeing him at 1 AM. It just sounded like R50 had stuff in R50's chest and in R50's throat. The nurse before me said R50 was congested and coughing a lot. R50 did not have any orders. We normally do rounds every two hours. The last time I checked on R50 was at 1 in the morning. I didn't check on R50 after that because I was busy. I think the CNA was checking on R50. When I talked to V79, V79 said V79 checked on R50 at 5:45am. I didn't see V79 go in the room. I didn't call the doctor about R50 sounding congested. R50 was new, so I wasn't really sure if that's how R50 normally was. It didn't seem that serious to me. I did hear R50 talking still during the night. I don't know who R50 was talking to, and I don't know what R50 was saying. You call the doctor anytime there's a major change in a resident. I don't know why I didn't call the doctor. I was just very busy. On [DATE] at 12:06PM, V66 (Nurse) stated the nurse before me actually admitted R50. I did get R50's medication ordered, but that was the only thing. I didn't order dialysis at that time because that was the only important thing to order because of the time of night it was. I know R50 was getting dialysis. Those residents you have to watch for fluid overload. Fluid overload would be a resident having trouble breathing or needing oxygen when they didn't before. Dialysis isn't there on the weekend, so if any residents are having problems with breathing because their fluid overloaded then you just send them out to the hospital for an extra treatment. I didn't call the doctor for an order for dialysis. I was only able to put in the medication at that time. On [DATE] at 2:16PM, V30 (Dialysis Administrator) stated when the facility is looking over the paperwork and see that they need dialysis, they will send over the referral information to our department. The facility give us an estimated date of arrival and they will let us know when the resident is actually admitted to the facility. The floor nurse will call us if we are here. Otherwise, we get an email from someone in the facility. For dialysis residents, you want to monitor for signs and symptoms of fluid overload, the vital signs, any infections to their access site. Signs of fluid overload would be trouble breathing, swelling anywhere, decreased oxygen saturations, and diminished lung sounds. If a resident is experiencing something like this, the only treatment really for them would be to get dialysis. A doctor should be immediately notified. The breathing treatment and suctioning is not something that would help a resident having respiratory distress if they are getting dialysis. The fluid needs to be removed from buildup in the blood. If they don't send them out 911 at the very least, the physician should be notified that the resident is having changes in the respiratory status. If they're having trouble breathing, then 911 should be called immediately. I have no notification that R50 actually arrived to the facility. On [DATE] at 3:20PM, V69 (Nephrologist) stated I am notified of a new resident in the building by the company contracted for dialysis. I was never notified that R50 was in the facility or that R50 was coming. We never do an extra treatment for a new admission, if anything was off, he would need to be sent to the hospital. Dialysis patients can have very serious situations occur pretty quickly. The most prominent is fluid buildup in the lungs. Since I didn't get a notification that the resident was in the facility, I would expect the nurse to notify the Medical Director or primary physician. These residents can go into respiratory distress fairly quickly and need urgent dialysis. If a resident is unstable, you should default and just call 911. This resident has no IV and dialysis cannot be done in the facility. Oxygen would only be a temporary fix. Suctioning would not help a resident in fluid overload because it would never get the fluid off that needs to come off in certain areas. A physician should be notified immediately that this is going on. If R50's not at the level to be sent out to the hospital yet and then staff need to be keeping a closer eye R50 to make sure things don't become worse. On [DATE] at 3:47PM, V46 (Nurse) stated R50 was admitted around 7 PM, but at that time we had no Internet. I couldn't complete the admission on the computer. I don't remember anything about dialysis or R50 needing extra dialysis. The admitting nurse will also check the paperwork from the hospital to make sure that all the orders are in place. When the system is working, we normally call the doctor and let them know that they are here and on dialysis. They will put in all the orders regarding dialysis. For those type of residents, you just want to make sure that you were doing assessments for fluid overload. I didn't tell the dialysis company that they were here. If someone is having a change in the respiratory status, you should listen to the lungs and see if they are congested. You should also do their vital signs and notify the doctor. For a dialysis resident any respiratory distress can mean that they have extra fluid in their body. Usually for cases like that they get sent out to the hospital for evaluation and extra dialysis. If you have extra fluid in your body, it usually backs up into your lungs causing you not to be able to breathe better. On [DATE] at 1:40PM, V19 (ADON) stated the nurse will either do the admission or pass it onto the next shift depending on what time the patient comes. Also, the DON and ADON will make sure everything is completed the next time later in the facility. When we are not here, it is just the nurses responsibility to get the orders. If dialysis is in the building, then the nurse will call down to let dialysis know. The nurse will also review the paperwork from the hospital to make sure the orders are correct. If a resident is having any type of change in condition, then the nurse practitioner or physician must be notified. They should call as soon as it is noticed. They either need to get orders for some type of treatment or to be sent out if there's any type of change then they should always call to see what should be done. They should also do another assessment if there's a change. They should check the vital signs, check their mental status, check for pain, and check the area of the complaint. If it is specifically for respiratory distress or shortness of breath, then the head of the bed should be elevated, and the oxygen level should be checked. The doctor should immediately be called for a situation like this. If their doctor gave orders and there's no relief, the doctor should be called back or 911 should be called if they get worse. Rounds are done every two hours. This lets us check on the residents to see how they are doing and if they need anything. If a resident is having a change of condition, they need to round every two hours just to make sure it hasn't changed. Dialysis residents can have fluid overload because they cannot urinate. They cannot get the fluid out of their body. This can cause respiratory distress. If there is too much, then they cannot breathe and need a dialysis treatment or to be sent to the hospital. This surveyor attempted to call V79 (Agency CNA) for an interview but a call was never returned during this survey. The Hospital Records dated [DATE] document R50 was admitted on [DATE] for failure to thrive in an adult. R50 attends hemodialysis on Monday, Wednesday, and Friday. The plan is to continue dialysis 3 times a week with a 1.5 L fluid restriction upon discharge. R50 received a full hemodialysis on [DATE]. On [DATE], R50 received a half session of dialysis due to not being able to complete the entire session. R50 had a 0.8 L removed on this day. The Admission/Readmission Screen are dated [DATE] documents R50 admitted to the facility on [DATE] at 7 PM. R50 was admitted from the hospital. Vital signs were taken and within normal limits. R50 is alert and oriented to person and place. R50 has a regular respiratory rate with no cough. Breath sounds on the left side are clear and on the right side has a slight rhonchi. R50 is able to clear the rhombic. R50 has a dialysis schedule of Monday, Wednesday Friday with a dialysis port to the left upper chest. The Death Certificate dated [DATE] documents the cause of death as end-stage renal disease. Emails between the in-house dialysis and the facility were submitted for review. An email on [DATE] at 10:36AM from the in-house dialysis to the facility documents the in-house dialysis was asking for confirmation that R50 was being admitted to the facility that day. The facility replied to this email at 10:37AM confirming R50 is scheduled to arrive on [DATE]. There is no more email confirmation letting the in-house dialysis know what time R50 arrived. There is no email communication on [DATE]. An email on [DATE] at 3:44PM from the in-house dialysis to the facility documents the in-house dialysis asked if the facility was still expecting R50. This confirms the in-house dialysis had no knowledge R50 was admitted to the facility. The facility replied to this email at 10:41PM letting in-house dialysis know R50 expired. The Physician Order Summary documents a renal diet order was placed on [DATE]. There are also orders for 11 medications placed on [DATE] and [DATE]. There is no documentation of a dialysis order or anything pertaining to dialysis. The policy tilted, Dialysis Care, dated [DATE] documents, Purpose: To adequately assess residents needs and provide care goals which achieve the highest practicable level of care to residents with end stage renal disease receiving hemodialysis or peritoneal dialysis. Procedure: 1. Arrangements should be made prior to admission for acquisition and storage of supplies, location and type of dialysis and room accommodations. The policy titled, Supervision and Safety, dated ,d+[DATE] documents, . 10. Staff to make visual rounds on residents minimally every 2 hours and more often if necessary, based on resident's assessment needs. The policy titled, Change in Resident's Condition, dated [DATE] documents, General: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician/NP, and resident's responsible party of a change in condition. Responsible Party: RN, LPN, Social Services. Policy: 1. Nursing will notify the resident's physician or nurse practitioner when: a. The resident is involved in an accident or incident. b. There is a significant change in the resident's physical, mental, or emotional status . e. It is deemed necessary or appropriate in the best interest of the resident. 2. Appropriate assessment and documentation will be completed based on the resident's change in condition or indication . 4. The communication with the resident and their responsible party as well as the physician/NP will be documented in the resident's medical record or other appropriate documents. On [DATE] and [DATE] the surveyor verified by interview and record review that the facility implemented the following to remove the immediacy: - Education initiated on [DATE] by the Administrator, DON, Restorative Nurse, Social Service Director, Dietary Manager completed on [DATE]. - Prior to residents being admitted to the facility, the facility (Administrator/DON/ Social Service Director/RN/LPN) team must communicate/coordinate with in-house dialysis that the resident is admitting to the facility. - During the referral process the facility team (Administrator/DON/Social Service Director) will communicate via email with the Dialyze Direct on resident ' s admission/readmitted to the facility. - DON will notify Team (RN/LPN) via Admission Notice of residents scheduled admission. - The staff nurse (RN/LPN) will contact the Nephrologist upon resident admission to the facility that the resident has arrived and will obtain admission orders and place the orders into PCC. - Facility staff (RN/LPN) must notify the nephrologist that a resident in need of dialysis has been admitted to the facility. - The facility nurse (RN/LPN) must assess all residents who are having an acute condition change (shortness of breath). - The facility nurse (RN/LPN) must notify the physician of any resident having an acute change in condition (having shortness of breath). - Rounding: Facility staff will obtain their assigned schedule and conduct rounds. Facility staff (RN/C.N.A/Social service aids) will then round every two hours. -All Staff (Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Agency C.N.A(Clipboard) Housekeeping Director, MDS Coordinators and Maintenance Director, receptionist, dietary aide, Cooks, housekeepers, social service case manager, Social Service Aides, restorative aides, C.N.As, RNs, LPN, activity aides, Laundry aides), including those off duty (receptionist, Social Service Case Managers, social service assistants, housekeepers, Laundry aides, RNs, LPNs, dietary aides, and cooks) were educated via phone with the same training as the staff educated in person, however, the staff who received the in-service 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. Upon completion of this in-person training staff will sign education sheets. In-service date of completion [DATE]. -There were no changes made to the rounding policy. - Facility staff (RN/LPN/C.N.A/Social Service Aids) will check their assigned group upon arriving to duty. - Nurse to Nurse rounds will be conducted at shift change then every two hours. - C.N.A to C.N.A round will be conducted at shift change then every two hours. - Social Service Assistant will conduct rounds every two hour while on duty. - Ongoing education will be provided to all staff on notifying the in-house dialysis that the resident was admitted . The facility nurse (RN/LPN) to notify the nephrologist of the resident ' s requiring dialysis has been admitted to the facility, staff nurses (RN/LPN) to follow the facility policy and assess residents who have been identified of having an acute change of condition and to notify the physician immediately. Staff educated on the importance of conducting rounds every two hours all in services were completed on [DATE]. - A baseline audit was completed by the DON on [DATE] to identify if any newly admitted resident or potential admits has a dx of ESRD needing dialysis services. The audit will continue weekly for three months by the DON/Restorative Nurse. Audit tool attached. - On [DATE] a meeting was held with the facility IDT members. Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Housekeeping Director, MDS Coordinators and Maintenance Director. - Prior to admission the Administrator will coordinate a schedule with the in-house dialysis center for the newly admitted resident. - The facility nurses will contact the nephrologist to make them aware of the resident ' s arrival. - The facility nurse will assess the resident for any acute change in condition and notify the physician. - RN, LPN, Social Workers, Social Service Assistance, and C.N.As will conduct rounds every two hours. - No policy changes have been made to the change in condition policies. - Medical Director was made aware of the IJ. - Audits will be analyzed and presented as part of the monthly Quality Assurance Performance Improvement Committee (QAPI). This will be overseen by the Administrator and Medical Director. This committee will determine if the audits continue after three months. 39340 2. Based on interview and record review, the facility failed to follow their seizure policy by not adjusting seizure medication and having precautionary measures in place for one resident (R26) with a history of epilepsy and traumatic brain injury who was identify as having subtherapeutic Dilantin levels. This failure resulted in R26 sustaining a seizure and hospitalization with a diagnosis of epilepsy for one of three reviewed for improper nursing. Findings include: R26 was admitted to facility on [DATE] with a diagnosis of other psychological development, vitamin D, traumatic brain injury, epilepsy and bipolar disorder. R26's physician orders dated [DATE] documents: Phenytoin Sodium Extended Capsule (Dilantin) 100 MG. Give 1 capsule by mouth two times a day for seizures. R26's laboratory results dated [DATE] documents: Phenytoin level (Dilantin) 4.3 low. Reference ranges 10XXX,d+[DATE].0. R26's laboratory results dated [DATE] documents: Phenytoin level (Dilantin) 4.3 low. Reference ranges 10XXX,d+[DATE].0. R26's medical record or physician orders do not document any changes or notification of results for [DATE]. R26's progress note dated [DATE] documents: Nurse was notified that resident was noted on the floor in a lying down position with seizure. Resident alert and responsive. Body assessment done, no injuries or bleeding noted. Resident was assisted back to bed. Vital signs checked and stable. MD made aware and received an order to send her to hospital for evaluation. R26's hospital record dated [DATE] documents: Patient presented from a nursing home due to breakthrough seizure. The patient Dilantin level was low. She was loaded with antiepileptics and admitted because she had another breakthrough seizure while in the emergency department. Patient was admitted for further management and evaluation of her breakthrough seizures which are likely due to inadequate dosing and missed medication doses. Dilantin level documented at 4.6. On [DATE] at 1:11PM, R26's was observed in her bed. Observed unpadded bilateral side rails and no fall mats in place. On [DATE] at 12:20PM, V67(MD) said he is unable to recall if he was notified of R26's Dilantin levels. V67 said he would expect to be notified of any abnormal laboratory results and would put in recommendations or changes based on results. V67 said if Dilantin levels are low, he would consult with neurology and/or adjust the dose of the medication. If Dilantin levels are low, it can increase the risk for seizures. Facility policy titled Seizure Care dated ,d+[DATE] documents: to provide care and treatment to the resident having a seizure that protects the resident from harm when possible. Notifications should be made with each episode unless seizures are occurring in conjunction with a pattern of consistency known to physician. Consider laboratory testing and review of anticonvulsant drug therapy. Initiate precautionary measures to prevent injuries: padded side rails, pad next to the bed.

A. Based on observation, interview, and record review, the facility failed to prevent potential fire hazard conditions in the kitchen when the kitchen's flat top grill remained uncleaned resulting in buildup grease and had exposed wiring within the appliance. This has a potential to affect all residents residing within the facility. This was identified as an Immediate Jeopardy which began on 7/6/23 when the surveyor observed an accumulation of grease on kitchen appliances and exposed wiring on the kitchen's flat top grill and oven. V1 (Administrator) was notified on 7/11/23 at 1:28 PM of the Immediate Jeopardy and a template was presented. The facility presented an initial removal plan on 7/12/23. The plan was accepted on 7/13/23. On 7/14/23 the surveyor conducted an onsite observation, record reviews, and interviews to confirm the removal plan was implemented. V1 was informed the Immediate Jeopardy was removed on 7/12/23. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings Include: On 7/6/23 at 11:00AM, V86 (Firefighter) came to the library to notify the survey team of the condition of the appliances in the kitchen and that there was a smell of gas. V86 reported the flat top grill was covered in old, black, grease and paneling in the front of the grill was broken off with wires exposed and knobs missing on both the stove and flat top grill. V86 said having the grill and the stove in that condition is a fire hazard because the grease and wires exposed can catch fire and with the gas leak there could be an explosion. V86 stated something like that puts the whole building at risk. On 7/6/23 at 11:53AM, the flat top grill was observed to have exposed wiring, exposed pilot igniter covered in a black grease like substance, broken knobs tin foiled used for a gas control knob, and a broken and cracked face plate. The double door oven was observed to be dirty with a black grease substance, exposed wire from the underneath next to the igniter and tin foil used on the oven door handles. The flat top grill was not being used but was on to have gas travel through the pipes to the other appliances. On7/6/23 at 2:41PM, V16 (Dietary Manager) reported the wires (on the gas grilled top) were exposed and it was past the point of fixing so it just needed to be disposed. V16 said the flat top grill was also not clean. V16 stated staff has not been using the flat top grill but needs to turn it on for the gas to light on the other two stoves. V16 denied having a cleaning schedule for the appliances before this incident. V16 denied being aware of the last time the appliances were cleaned. V16 said this is just the way the appliances were being used when V16 got here so we just kept using it that way. On 7/7/23 at 12:55PM, V15 (Maintenance) stated, V15 said the fire department was called out here back in April (2023) for that flat top and there was gas leaking where the knobs were at, and it caught fire. V15 stated the flat top grill has just been giving the facility too many problems lately. V15 stated it (the gas top grill) wouldn't light with the igniters on the grill, so they had to use one of them long lighters, and when staff uses a lighter, the grill went up in flames a little bit. V15 stated, It was like a big whoosh and then the fire went out. V15 said the facility still called the fire department to investigate, and they just told V15 to not turn it on and to get it fixed. V15 reported there was a lot of grease on the appliances. V15 said having the appliances in that condition is dangerous, because not only does it put everyone at risk in the kitchen who is working; it also puts the residents at risk if there was a big enough fire. On 7/7/23 at 3:43pm, V1 (Administrator) stated V86 smelled gas so V86 called some more firefighters, and they found a gas leak. V1 reported the gas company then came out and said that we had a gas leak as well, and they shut down the gas line. V1 said the kitchen should have notified maintenance about the repairs that need to be done. On 7/13/23 and 7/14/23 the surveyor verified by observation, interview, and record review that the facility implemented the following removal plan: Education initiated on 7/11/2023 by the Administrator, DON (director of nurses), ADON (assistance director of nurses), Social Service Director completed on 7/11/2023. a. Preventing a fire hazard in the kitchen by ensuring the flat top grill remains clean and in proper working condition. b. Ensuring that all kitchen appliances that use natural gas are in good repair and good working condition to prevent a potential fire hazard. All Staff (Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Agency C.N.A(Clipboard) Housekeeping Director, MDS Coordinators and Maintenance Director, receptionist, dietary aide, Cooks, housekeepers, social service case manager, Social Service Aides, restorative aides, C.N.As (certified nurse aides), RNs (registered nurses), LPN (licensed practical nurses), activity aides, Laundry aides), including those off duty ( receptionist, Social Service Case Managers, social service assistants, housekeepers, Laundry aides, RNs, LPNs, dietary aides, and cooks) was educated via phone with the same training as the staff educated in person, however, the staff who received the in-service 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. Upon completion of this in-person training staff will sign education sheets. In-service date of completion 7/11/2023. The flat top grill was removed from the facility on 07/06/2023. Maintenance Director disconnected the flat top from the gas line and redirected the gas line to the working oven. The Maintenance Director was educated by the facility Administrator on 07/11/2023 on preventing hazards in the kitchen by ensuring the flat top grill remains clean and in proper working condition with an emphasis on ensuring that all kitchen appliances that are used are in good working repair. A weekly audit was completed by the Maintenance Director to ensure all kitchen appliances are in good working repair, appliances using natural gas are in good working repair and in a condition that will prevent a fire hazard, the kitchen appliances are free from exposed wires, all kitchen appliances are free from dirt/grease/hazardous conditions, the ignitor unit is clean and free from grease and debris, and the appliances have received weekly deep clean. The initial audit was started and completed on 7/11/23 by the Maintenance Director and reviewed by the Administrator. These audits will continue to be completed weekly by the Maintenance Director and audited weekly by the Administrator. On 07/11/2023 a meeting was held with the facility IDT members. Administrator, Assist Admin/HR Director, DON, Restorative Nurse, Wound Care Nurse, Dietary Manager, Business office Manager, Activity Director Social Service Director, Medical Records, Staffing Coordinator, Housekeeping Director, MDS Coordinators and Maintenance Director to discuss the nature of the IJ and the interventions that were put in place to ensure an effective plan is in place to prevent fire hazards. A weekly routine equipment inspection will be conducted by the Maintenance Director or the Assistant Director of Nursing. The Dietary Manager and the Cooks completed a deep clean of the kitchen on 7/11/23. The dietary staff will complete a deep clean of the kitchen weekly. The deep clean will address the cleanliness of the stove top/range/grill, steamer, microwave, oven, toaster, slicer, mixer, tilt skillet, knife storage rack, food scale, can opener, food processor/blender, worktable, mop buckets/mops, coffee machine, juice machine, steam table, tray delivery carts, serving line conveyor, and sanitizer buckets. The Maintenance Director will audit weekly to ensure the deep clean was completed as scheduled. The Administrator will review the Maintenance Director's audits weekly. No policy changes have been changed. Medical Director was made aware of the IJ. Audits will be analyzed and presented as part of the monthly Quality Assurance Performance Improvement Committee (QAPI). This will be overseen by the Administrator and Medical Director. This committee will determine if the audits continue after three months. 39340 B. Based on interview and record review, the facility failed to develop fall interventions for one resident with the diagnosis of syncope. This affected 1 of 3 residents (R23) reviewed for fall prevention interventions. This failure resulted in R23 having a fall sustaining a subdural hematoma. The facility also failed to monitor/supervise residents in the dining room to prevent verbal/physical resident to resident altercations. This affected seven of seven residents (R1-R7) reviewed for supervision. This failure resulted in a verbal resident to resident altercation escalating to a physical altercation and R1 slipping during the altercation sustained a hip fracture. Findings include: 1. R23 was admitted to the facility on [DATE] with a diagnosis of syncope and collapse. R23's fall risk assessment dated [DATE] documents R23 as a high risk for falls. R23's fall plan of care dated 4/6/23 documents: Be sure call light is within reach and encourage the resident to use the call light as needed; anticipate and meet individual needs of the resident; complete fall risk review per facility protocol. Facility reportable dated 4/7/23 documents: R23 was standing in front of the nursing station waiting for the elevator when he suddenly fell back onto the floor and hit his head. The nurse immediately assessed R23 and no injuries were noted. Order obtained to transport R23 to local hospital via 911. R23 returned to the facility with diagnosis of subdural hematoma. R23's hospital record dated 4/7/23 documents under diagnosis: traumatic subdural hematoma with loss of consciousness. Under head CT: acute left parietal subdural hematoma measuring 7mm in maximal thickness. Heterogeneous subdural hematoma with areas of hyper density noted underlying the right frontoparietal convexity measuring 6mm in maximal thickness. Findings compatible subacute or acute on chronic subdural hematoma. On 6/1/23 at 2:52PM, V5(Restorative Nurse) said R23 fell backwards when waiting by the elevator. V5 said the root cause of the fall was caused by a syncope episode and wheelchair a was provided. V5 said she was not aware of R23's diagnosis of syncope prior to the fall and if she would have known of the diagnosis, she would have had R23 utilize a wheelchair for safety prior to the fall. On 6/8/23 11:05AM, V39(MDS) and V40 (MDS) said they did not generate a baseline care plan and that it is developed upon admission assessment from the nurse. V39 and V40 said they did not see any interventions related to R23's syncope until after the fall. Fall prevention program dated 2/28/22: It is policy of this facility to have a fall prevention program to assure the safety of all residents in the facility. The program will include measures which determine the individual needs of each resident by assessing the risk for falls and implementation of appropriate interventions to provide necessary supervision and assistive device are utilized as necessary. 2. R1 is a [AGE] year old with the following diagnosis: heart failure, osteoporosis, cerebral vascular accident, presence of right artificial hip, and fracture of the right femur. R1 admitted to the facility on [DATE]. R2 is an [AGE] year old with the following diagnosis: dementia and bipolar disorder. R2 admitted to the facility on [DATE]. On 6/6/23 at 11:01AM V5 (Restorative Nurse) stated, in the fall report it says R1 slipped on water. R1 didn't see it and slipped on it. It says no witnesses in the fall report so I have to guess no one was in the dining room when it happened. R1 was unsteady but able to ambulate independently. R1 had a slight limp to one side. Locomotion off unit would be R1 walking to and from floors. We usually say supervision for everyone with that so we can keep an eye on them. R1 ended up with a fracture to the left hip. I educated staff on cleaning up spills even if you aren't housekeeping. Anything wet can be a fall hazard even for people who don't have issues walking. No one saw R1 fall besides other residents that I know. There should always be someone in the dining room supervising people. On 6/6/23 at 12:29PM, V32 (Former Nurse) stated I was on break when a CNA came to tell me that R1 fell . I was told they got into an argument about something and R2 threw a cup of water at R1. I guess R1 went to go back after R2 and slipped and fell in the water that was all over the floor. I asked the CNA what happened and she said she didn't see it either. R1 was making faces like R1 was in pain so we sent R1 out to the hospital. When I called later to check on R1, they said R1 had a broken hip. R1 wasn't a fall risk. I think it was just because of the water on the floor and we weren't in there to redirect R1 from going through it. No one must have been in the dining room if they didn't see it happen. Yes, we should have people in there when they are eating but that didn't always happen. On 6/7/23 at 1:57PM, V36 (CNA) stated there were no staff in the dining room. I was the first in there when I heard the screaming. There was maybe four or five other residents in there. We don't have any set designated person to watch them. We just keep an eye on them as we're walking by. We might get called down the hall to something. I need to go on break so there might not be enough people to watch at all times. We don't really have any system to monitor them when they are in the dining room. We don't really know who's responsibility is. Like I said, we just watch them when we can. I heard screaming. I was by the nurse's station. I came in and I saw R1 on the floor. R2 said R1 was trying to rearrange the seats and then somehow water ended up being thrown at each other and R1 was on the floor. I didn't see any staff in there to witness what happened. I was the first one down there again. We don't have any special plan that we use for before they have an outburst. We do not have any security. If someone was in there, watching them, they might have been able to step in before R1 slipped and fell . On 6/16/23 at 2:03PM, V74 (Medical Director) stated there are a lot of psych patients there and their behaviors need to be managed. The facility needs to identify the patient with behaviors to help control them more. They should be working with a psych doctor to better manage the behaviors. I can't see how R1 fell or remember anything about the situation, but anyone can slip on the water. Even you and I, slipping on the water doesn't matter what your fall risk level is so being monitored could've potentially stop this fall. On 6/20/23 at 12:49PM, V1 (Administrator) stated R2 was cleaning the tables and one of them was eating and wasn't done. They were both in the dining room. They some how ended up spilling water on each other. I think they were pulling on the tray and the water spilled. I guess R1 fell after slipping on the water. R1 was sent to the hospital and had a femur fracture. I don't remember this situation between R2 and R3. Saying the N-word to someone else would be derogatory and considered verbal abuse. This happened in the dining room again. R4 was talking loud to himself which can be disturbing for others around R4. I know R4 and R5 ended up getting in an argument then R5 hit R4. This also happened on the third floor in the dining room. I think R7 was talking to herself responding to stimuli and R6 went up and staring hitting R6. R7 started hitting R6 back and staff separated them. I had to have a meeting with staff saying that someone needs to be present in there at all times. If they have to pass a room tray or answer a call light, they need to change out with someone. We have a lot of psych behaviors in this facility so we need people monitoring the residents at all times in the common areas. A General note dated 3/4/23 documents the nurse was made aware R1 fell in the dining room. The nurse reported to the scene of the fall and observed R1 sitting in the chair pointing to the left leg. The doctor was called in order to send R1 out to the hospital based off x-ray results. A Behavior note dated 3/4/23 documents R2 had an altercation with R1. R2 reported telling R1 that if R1 moved the table again R2 would throw water on R1. R2 did end up throwing water on to R1. The residents were separated and educated on proper behavior. An Event note dated 3/5/23 documents staff was notified that R2 displayed physical aggressive behavior towards R1. Both were separated immediately. R2 was counseled on behavior and educated on the policies of the facility. The Hospital Records dated 3/4/23 documents R1 admitted to the emergency department for a fall with a left leg injury. The left leg is noted to be rotated and shorter. R1 is unable to answer in clear sentences, due to advanced dementia and history of a stroke. Left hip and left femur x-rays were ordered and show a comminuted fracture of the left hip. R1 was admitted to the floor due to the fracture and surgery was consulted. The Facility Reported Incident dated 3/6/23 documents R1 was ambulating past R2. The liquids in R1's cup from the dinner tray spilled over onto R2. R2 threw the contents of R2's cup towards R1. R1 then turned to walk towards R2 and slipped and fell on to the floor. R1 was immediately assessed by the nurse. The x-ray results revealed R1 had a femur fracture. R1 was sent to the hospital for further evaluation. R1 was admitted to the hospital with a diagnosis of a femur fracture. The Fall Report dated 3/7/23 documents the nurse was made aware that R1 fell in the dining room. The nurse reported to the scene of the fall and observed R1 sitting in a chair pointing to the left leg. R1 was unable to give a description. R1 was sent to the hospital. No injuries are observed. There were no staff witnesses of the fall. The Care Plan dated 10/18/17 documents R1 is at risk for falls due to periods of confusion, history of falls, decreased strength, and possible side effects of medications taken. R1 has a diagnosis of dementia, CHF, arthritis, and seizures. An intervention documented for this care plan is to ensure the floor is free of glare, liquids, and foreign objects. R6 is a [AGE] year old with the following diagnosis: traumatic brain injury and schizophrenia. R6 admitted to the facility on [DATE]. R7 is a [AGE] year old with the following diagnosis: paranoid schizophrenic, psychotic disorder with delusions, and cerebral infarction. R7 admitted to the facility on [DATE]. R32 is a [AGE] year old with the following diagnosis: type 2 diabetes and paranoid schizophrenia. On 5/31/23 at 12:16PM, R7 reported sitting in the dining room on the day of the altercation when R6 rolled over to R7 in a wheelchair and began punching R7. R7 stated R6 hit R7 in the head twice then R7 started punching back. R7 endorsed knocking R6 out of the wheelchair and began wrestling on the ground. R7 reported they kept trying to punch each other and R6 was pulling R7's hair. R7 denied any staff members being in the dining room when the fight occurred. R7 endorsed they fought for 2-3 minutes before facility staff came to break them up. R7 denied staff ever staying in the dining room to monitor residents. On 5/31/23 at 12:52PM, R6 admitted to getting in a physical altercation with R7. R6 also admitted to hitting R7 first because R6 thought R7 called R6 a racial slur. R6 stated that R6 hit R7 in the head with R6's fist and continued hitting R7 when R7 began hitting back. R6 denied remembering if any staff were in the dining room monitoring the residents. R6 was unable to state how long the fight went on for before staff intervened. R6 On 5/31/23 at 1:49PM, R32 was asked if R32 was witness to the altercation between R6 and R7 and R7 reported yes. R32 endorsed R7 has a habit of yelling out and R6 thought R7 was yelling at R6 so R6 hit R7 in the face with a closed fist. R32 stated that R7 then began to throw punches back at R6 hitting R6 all over the face and body. R32 endorsed the two residents then fell to the ground and began wrestling while continuing to punch each other. R32 reported calling out for staff to break up the fight. R32 stated that about 10 residents were in the dining room waiting for dinner when the fight happened. R32 denied any staff in the dining room with them when the fight occurred. R32 endorsed staff responded about 1-2 minutes after the fight started and immediately separated R6 and R7. A General note dated 3/12/23 documents R6 was very agitated and had an altercation with another resident in the dining room. The doctor was notified and ordered to send R6 out to the hospital for a psych evaluation. An Event note dated 3/12/23 documents staff made social services aware that R6 was presenting physical aggression by punching appear in the face with a close fist due to delusional ideation. R6 thought R7 was talking to him, but R7 was presenting with auditory hallucination. The Hospital Records dated 3/13/23 document R6 presented to the hospital for a psych evaluation. Per the nursing home petition, R6 was aggressive and hit another resident. R6 was admitted for decompensated schizophrenia. R3 is a [AGE] year old with the following diagnosis: bipolar disorder and paranoid schizophrenia. R3 admitted to the facility on [DATE] and discharged on [DATE]. On 6/1/23 at 12:08PM, R3 stated that R2 was throwing food out the window so R3 reminded R2 to keep food inside. R3 endorsed R2 became upset at R3 for telling R2 what to do. R3 reported R2 began to yell at R3 and called R3 the N-word. R3 stated everyone started yelling after that so R3 was not able to remember exactly what was said but knows R2 called R3 the N-word. R3 reported staff then came into the dining room and removed R2. R3 denied any staff being present in the dining room at the time R2 said the N-word. On 6/1/23 at 12:28PM, R2 was not able to remember the incident with R3 but did remember they had a disagreement. R2 denied any staff being in the dining room and reported staff are never in there when we are. R2 admitted to saying the N-word but not where other people can hear it. When it was brought to R2's attention that R3 heard R2 call R3 the N-word. R2 did not want to speak any more on that incident. An Event note dated 4/13/23 documents R3 received verbal aggression from a peer. Both residents were separated immediately. R3 was encouraged to utilize coping skills. The Facility Reported Incident dated 4/19/23 documents R3 received verbal aggression from R2 in the first floor dining hall. R3 observed R2 sliding food out of the window. R3 verbalized to R2 to not do this. R2 stated to R3 to mind, your ni**er business. Both residents were separated immediately and counseled on appropriate behavior. On 6/6/23 at 10:16AM, V3 (Asst Social Service Director) stated there should always be a staff member in the dining hall if residents are in there especially if they have behaviors. This just helps us better monitor them. We don't really have a system. We just take turn doing rounds in there. R4 is a [AGE] year old with the following diagnosis: major depressive disorder. R4 admitted to the facility on [DATE]. R5 is a [AGE] year old with the following diagnosis: schizophrenia and dementia. R5 admitted to the facility on [DATE]. On 5/31/23 at 12:45PM, R5 denied remembering having a physical altercation with any other residents. On 5/31/23 at 1:01PM, R4 reported R5 came up to R4 while they were in the dining room and began punching R4 with closed fists all over R4's body. R4 endorsed no staff was in the dining room and just waited for him to stop hitting me. R4 stated that R4 then went to tell staff what occurred. On 6/6/23 at 11:20AM, V29 (PRSC) stated I believe they (R4 and R5) were in the dining room and whatever happened they were separated. That would be resident to resident physical abuse because R5 was hitting R4 with R5's hands. I don't remember that incident again. I know they were getting ready for dinner and some residents were in the dining room but I was told no staff. R32 had to call out for staff. There are supposed to be a staff in the dining room monitoring residents at meal times. Staff was on the floor but maybe bringing people to the dining room. An Event note dated 4/12/23 documents it was reported to staff that R4 received physical aggression from another resident (R5). An Event note dated 4/12/23 documents R5 presented with aggression towards another resident. R5 was counseled on presenting social and verbal appropriate behavior. The Facility Reported Incident dated 4/12/23 documents R4 was in the dining room on this day waiting for breakfast to arrive. R4 started to respond to internal stimuli and yelled out due to auditory hallucinations. This upset R5. When R5 asked R4 to lower R4's tone, R4 then begin to yell at R5. R5 responded by hitting R4 with an open hand. The policy titled, Fall Prevention Program, dated 2/28/22 documents, Policy: It is the policy of the facility to have a fall prevention program to ensure the safety of all residents in the facility when possible .3. Safety interventions will be implemented for each resident identified at risk using a standard protocol . STANDARD FALL/SAFETY PRECAUTIONS FOR ALL RESIDENTS: . 6. The resident's environment will be kept clear of clutter, which would affect ambulation and remove hazards. The policy titled, Supervision and Safety, dated 03/2015 documents, Policy: Our policy strives to make the environment as free from hazards as possible. Resident safety and supervision are facility wide priorities. 1. Our facility-oriented approach to safety addresses for groups of residents such as wanders, behaviors, aggressiveness, confusion, etc . 4. Resident supervision is a core component to resident safety. C. Based on observation, interview and record review, the facility failed to monitor and supervise a a resident identified to be at high risk for elopement. This affected one of three residents (R56) reviewed supervision. This failure resulted in R56 being able to leave the resident care area unauthorized and leave the facility through the loading dock while a food shipment was being delivered. R56 is a [AGE] year old with the following diagnosis: delusional disorder, violent behaviors, bipolar disorder and schizophrenia. R56 admitted to the facility on [DATE]. On 6/21/23 at 1:45PM, A code pink was called over the intercom system. This surveyor looked out the third-floor library windows and saw V3 (Assistant Social Service Director) exiting the facility parking lot on foot walking on the sidewalk adjacent to the facility. V3 then crossed the 4-lane highway and walked towards the gas station that is across the street from the facility (approximately 900 feet) until V3 was out of view. Multiple other staff from the facility were then noted walking across the parking lot down the sidewalk to where R56 was. R56 was not observed until staff walked R56 back to the facility parking lot. Police and ambulance arrived when R56 returned to the parking lot and took R56 to the hospital because R56 refused to return inside the facility. R56 was not able to be interviewed because of being taken to the hospital. The code pink was cleared over the intercom at 1:49PM. V1 (Administrator) played the security camera footage from the smoking patio which shows the facility parking lot. According to V1, the security camera in the back of the facility where R56 eloped was not working at that time. The camera off the smoking patio shows R56 walking across the facility parking lot at 1:44PM, leave facility grounds, and walk down the sidewalk before R56 is not able to be seen anymore. V3 then comes into the frame at 1:45PM (about 1 minute and 30 seconds after R56 is noted on camera) crossing the parking lot and walking down the same side walk R56 walked down until V3 walk out of view of the camera. On 6/21/23 at 2:05PM, V12 (Restorative Aide) stated I went outside to respond to the code pink. The resident went out the back door while we were getting a delivery. No alarms went off that I heard. For residents that are elopement risks just going to watch them to make sure that they're not standing by the doors or saying they want to leave because that usually means they're going to try. On 6/21/23 at 2:15PM, V1 (Administrator) stated R56 was in the basement. There was also a vendor in the basement unloading a delivery. R56 walked out the door while he was unloading. It was a food vendor. V3 was in the basement in V3's office and V3 was right behind the resident when R56 ran out the door. V3 called the Social Service Director from V3's cell phone and we called a code pink. There were no alarms because the door was open. The door normally does alarm if it's pushed open but it has to be closed to alarm. R56 said R56 wanted to leave. R56 was sent to the hospital because R56 did not want to come back inside. R56 can kind of go wherever R56 wants but we normally don't want them in the basement around that area. On 6/21/23 at 2:50PM, V15 (Maintenance Director) stated the delivery door keypad alarms when it opens. Staff opens the door for vendors. When the staff uses the keypad to open the door, the alarm won't sound. Residents are not allowed past the laundry area. Laundry room is closest to delivery door. On 6/21/23 at 2:55PM, V3 stated I was in my office which is in the basement, and there was a delivery being unloaded at the dock. The delivery person told me that R56 left out the door. I immediately called the Social Service Director when I was outside in the parking lot to call the code pink. When I caught up to R56, R56 didn't want to come back at first. The residents aren't really supposed to be down in the basement. We try to refrain from having them down there as much as possible. We don't really like them going past the laundry area. After you go past the laundry area, that is where the loading dock is for deliveries. R56 is an elopement risk. R56 came from the hospital with paperwork saying that R56 needed a 1:1 because R56 was a high risk for elopement. We did have to have R56 be a 1:1 sitter a couple times for trying to elope. R56 does not have a access to the community unsupervised. R56 can go out if R56 is supervised but R56 cannot be out alone because R56's BIMS is not high enough. I believe R56 has a score of an 8. This means that she is really limited cognitively. R56 also has a developmental delay. R56 stayed on the sidewalk on our side of the street and then R56 did cross the street to go to the other side and was at the other gas station. When we're having a delivery, we normally have a staff member over there or the vendor responsible for monitoring who is coming in and out of the door. I didn't see anyone monitoring the door at that time. R56 does have the ability to go to other floors. The Community Survival Skills assessment dated [DATE] documents R56 does not appear to be capable of an unsupervised outside pass privilege at this time due to mental diagnosis. R56 cannot navigate safely on community streets. The Nursing Observation Sheets from 04/2023 through 06/2023 document R56 was on 1:1 observations from 8:30 AM to 5 PM a total of 9 times for elopement and aggressive behavior. The Elopement Risk Review dated 5/1/23 documents a score of a 10 indicating R56 is a high risk for elopement and should be placed on elopement risk protocol. In the comment section of this document, the guardian specified that R56 has a history of elopement and it is high. The [TRUNCATED]

Based on interview and record review, the facility failed to follow their wound prevention policies and procedures to include not providing physician ordered wound treatments, not developing interventions to prevent the development and/or wounds worsening, and not conducting assessments to identify residents with new wounds and obtaining treatment. This affected five of 5 residents (R24, R25, R57, R37, and R12) reviewed for wound prevention protocols. These failures resulted in R24 developing a non-stageable wound, and stage 3 to the right elbow. R25 developed a sacral wound with 10% necrotic tissue, coccyx wound 6.5x6.0x0.8 with undermining, and a peri wound with macerated skin with scattered partial and full thickness wounds with purulent draining. Findings include: 1. R24' s admission skin assessment dated [DATE] documents skin intact. R24's Braden scale dated 3/31/23 documents: moderate risk for wounds. R24's skin alteration dated 4/13/23 documents: nonstageable pressure sore measuring 5.0x2.7x0 CM(centimeter), scant drainage. R24's skin alteration dated 4/23/23 documents: stage 3 pressure sore right elbow measuring 3.5x1.5x0.1CM, scant drainage. On 6/14/23 at 10:03AM, V63 (Wound NP) said poor nutrition would aid in development of wounds. Wounds can develop within a day if there is poor nutrition or intake. This could have attributed to wound development for R24. R24's nutritional risk review dated 4/3/23 documents: pureed diet and thick liquid diet, also bolus feeding if he eats less than 60% of tray. R24's point of care charting for April for amount eaten documents: 97- not applicable on 4/2/23 and 4/3/23 at 0900 and 1300. On 4/5/23 document 3 which indicates 76-100% eaten at 0900 and 1300; on 4/11/23 documents a score of 1 which indicates 26-50% at 0900 and a score of 2 which indicates 51- 75% at 1300; on 4/12/23 at 1800 a score of 1 which indicates 26-50%; on 4/13/23 at 0900 and 1300 documents 98 which indicates refused. All other dates and times are not completed and blank. R24's medical record does not document any bolus feedings were given to R24 until after 4/20/23. 2. R25 was admitted to the facility on [DATE] with a diagnosis of rheumatoid arthritis, abnormalities of gait, lack of coordination, pressure ulcer of sacral region unspecified stage, ankylosing spondylitis, scleritis with corneal involvement, severe protein caloric malnutrition. R25's physician order dated 5/12/23 documents: sacrum cleanse with normal sterile saline. Pat dry and apply calcium alginate to wound bed and cover with a dry dressing daily. There were no documented treatment changes after 5/12/23. R25's treatment record for May 2023 does not document any new treatment orders after 5/12/23. Dated 5/12/23 documents: cleanse with normal sterile saline and apply calcium alginate and cover with dry dressing. R25's wound care note dated 5/15/23 documents: Sacrum measures 5.4x3.3x 0.6cm with 10 % necrotic tissue. Deteriorated in amount of necrotic tissue. No other active wounds. Under plan: change to honey and calcium alginate and dry dressing daily and as needed. On 6/14/23 at 10:03AM, V63 (Wound NP) said R25's order was changed because the wound developed some necrotic tissue. Medihoney was added to help debride the wound. If Medihoney was not applied, the wound can get worse. V63 said she verbally sends a report of wound dressing recommendations and changes. V63 said she would expect her orders to be followed. R25 hospital record dated 5/18/23 documents - coccyx 6.5x6x0.8cm with undermining noted from 6- 10 o'clock. Periwound noted with macerated skin with scattered partial and full thickness wounds. Purulent drainage noted. R25's care plan dated 12/9/23 documents: administer wound treatments per MD orders. 40102 3. R57 is a [AGE] year old with the following diagnosis: end stage renal disease, type 2 diabetes, human immunodeficiency disease, myocardial infarction, and hemiplegia of the right side. R57 admitted to the facility on [DATE] and discharged on [DATE]. A General progress note dated 2/16/23 documents R57 is a new admission from the hospital. R57's skin is intact but has mild redness to the coccyx. A Skin note dated 3/2/23 documents R57 was readmitted to the facility and had an admission assessment. There is a skin alteration to right buttocks. The Treatment Nurse Initial Skin Alteration Review of 3/1/23 documents there's a stage two pressure ulcer to the right buttocks that was found on 2/28/23. The size of the wound is 2.5 cm x 2 cm x 0.2 cm. There is a scant amount of serous drainage. The wound is 100% red smooth tissue. The preventative measures are to perform skin treatments done as physicians order, moisture barrier, and daily skin checks during routine rounds. It is documented that the family, physician, and register dietitian were notified of this wound. There is no further documentation on the wound. There are no physician wound notes documenting that R57 was ever seen by a physician for this wound. The Physician Order Summary documents an order for the right buttocks to be cleansed with normal saline, patted dry, and covered with a hydrocolloid three times a week and as needed and was ordered on 3/1/23. The Treatment Administration Record dated 03/2023 documents no treatments were given during this month. There's a treatment order to cleanse the right buttocks with normal saline, pat dry, and cover with hydrocolloid three times a week and as needed. A total of 12 treatments were missed before R57 was sent to the hospital and 3/27/23. The Care Plan dated 3/1/23 documents R57 has a stage 2 pressure ulcer and/or potential for pressure ulcer development related to pressure ulcers present and epithelial scarring over the buttocks. Interventions include to assess/record/monitor wound healing by measuring the length, width, and depth where possible; report improvements and declines to the physician; monitor dressings to ensure it is intact and adhering; report loose dressings to the treatment nurse; and staff will follow facility policies for the prevention/treatment of skin breakdown. On 7/7/23 at 10:40AM, V89 (Former Wound Care Nurse) stated R57 had a stage 2 pressure ulcer to the buttocks that was present after being readmitted from the hospital. V89 said that if dressing changes are not completed in the computer system; then it suggests the wound care is not completed. V89 reported wound care needs to be completed as the physician orders because it helps prevent the wound from getting worse. V89 was not able to say how many dressing changes were missed. V89 reported a physician normally sees residents with wounds on a weekly basis and that is when updated charting needs to be entered into the system. On 7/7/23 at 11:11AM, V48 (Nurse) said she does not remember R57 having any wounds. V48 reported V89 was responsible for changing the dressings at that time. V48 endorsed staff need to chart the care that is given to the residents in the computer or there is no proof that care was done. On 7/7/23 at 3:34PM, V1 (Administrator) said wound care treatment needs to be completed as ordered. V1 stated if the dressing changes are not charted as completed then it is to be assumed that they were not completed. V1 reported the wound care nurse or any nurse that completes the dressing change needs to chart it in the computer upon completion. 41758 4. On 6/2/23 at 12:09pm, during ADL care, R37 was observed with two opened wounds on the left lateral lower buttock with no dressing. No dressing was observed on bed chuck or sheets. V65 (CNA) said, R37 did not have a dressing in place this morning. On 6/2/23 at 12:14pm, V19 (ADON) said, R37 should have had a dressing in place. On 6/2/23 at 12:24pm, V31 (Treatment Nurse) said, R37 did not have any treatments in place. R37's wounds measures 1.0 x 1.7 x 0 (length, width and depth). Care plan initiated 10/28/2021 documents: R37 has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to: DX of incomplete quadriplegia C5-C7, DM II, spinal stenosis, psychotropic med use per MD orders, G-Tube only source of dehydration and nutrition, and incontinence of B&B, non-compliance with wound care and turning/repositioning. 5. Physician order sheet dated 6/2/23 documents: site-left Ischium-clean with normal saline then pat dry, then apply skin prep, then apply xeroform, then cover with dry dressing three times weekly and as needed. On 6/1/23 at 11:10am, V22 (CNA) said, R12 was left soiled with urine and feces for more than 3 hours. This happened to R12 five times when I reported to worked with R12. On 6/1/23 at 11:20am, R12 who was assessed to be alert, oriented to person, place and time said, I was left soiled in urine and feces for over five hours. I was told by staff that, I had to wait until I ate breakfast to be changed. I was not changed/given incontinence care on the night shift for over five hours on multiple occasions while crying. I wasn't repositioned. No one should be treated that way. On 6/13/23 at 5:08pm, V19 (ADON) said, I would expect R12's treatment to be changed when R12's sacrum wound increased in size. Treatment administration record dated 3/31/23 -5/10/23 documents: Hydrocolloid three times a week. Weekly Skin Assessment 5/2/23 documents: Sacrum pressure injury, stage II measured 2.5 x 1.5 x 0.1 Length x Width x Depth (LxWxD). Treatment: Hydrocolloid. Wound doctor note dated 5/5/23 documents: Stage II pressure injury to sacrum reclassified to stage III. Measuring 4 x 1.5 x 0.1 cm. Deteriorated in surface area. Weekly Skin assessment dated [DATE] documents: Sacrum pressure injury, stage III, measuring 4 x 1.5 x 0.1 (L x W x D). Treatment: Hydrocolloid.

Based on observation, interview and record review the facility failed to follow their weight management protocols by not following physician ordered weekly weights, obtaining admission weights and preventing unplanned significant weight loss. This affected six of six (R24, R25, R16, R33, R34, and R35) all reviewed for weights. This failure resulted in R25 sustaining a severe unplanned weight loss of 17% in 6 months and R24 sustaining an unplanned weight loss of 3.8% in just 19 days. Finding include: 1. R24 was admitted to the facility on [DATE] with a diagnosis of dysphagia, vitamin D, hypertension, constipation, and gastro-esophageal reflux disease. R24's point of care charting for April for amount eaten documents: 97- not applicable on 4/2/23 and 4/3/23 at 0900 and 1300. On 4/5/23 document 3 which indicates 76-100% eaten at 0900 and 1300; on 4/11/23 documents a score of 1 which indicates 26-50% at 0900 and a score of 2 which indicates 51- 75% at 1300; on 4/12/23 at 1800 a score of 1 which indicates 26-50%; on 4/13/23 at 0900 and 1300 documents 98 which indicates refused. All other dates and times are not completed and blank. R24's Minimum Data Set, dated dated dated [DATE] documents under nutrition proportion of total calories received through feeding documents 25% or less. Under eating documents one person assist. R24's progress note dated 3/31/23 documents: puree diet and feeding through j-tube. R24's diet order dated 4/4/23 documents: pureed texture. There were no prior diet orders. R24's physician order under enteral feed dated 4/20/23 documents: enteral feed osmolyte 1.5 @70 CC/HR x 20 hours. There was no documentation of any prior feeding orders. R24's physician order document dated 4/4/23 weekly weight times 4 then monthly. R24's admitting weight dated 3/31/23 document 180 pounds. R24 has only one documented weight for April dated 4/18/23 which documents weight of 173.6 pounds. R24's nutritional risk review dated 4/3/23 documents: puree diet and thick liquid diet, also bolus feeding if he eats less than 60% of tray. R24's skin alteration dated 4/13/23 documents: nonstageable pressure sore measuring 5.0x2.7x0CM, scant drainage. R24's skin alteration dated 4/23/23 documents: stage 3 pressure sore measuring 3.5x1.5x0.1CM, scant drainage. On 6/13/23 at 4:08PM, V19 (ADON) said R24 was admitted with pureed diet and if he didn't eat at least 60 % of meal staff would inform the nurse to give bolius feedings; but, he did not require bolus feedings because he was eating ok. R24 had a change on 4/20 and put in new order for continuous feeding. CNAs are responsible for informing the nurse if he didn't eat. V19 was shown point of care documentation and asked to provide any documentation that bolus feedings were provided; but, was unable to find that any bolus feedings were provided to R24. On 6/1/23 at 1:00pm. V5(Restorative) said weights should be done on admission and then weekly x4. On 6/9/23 at 11:58AM, V73 (dietician) said she was unaware of any prior feeding orders for R24 prior to an assessment on 4/20/23. On 6/14/23 at 10:03AM, V63 (Wound NP) said poor nutrition would aid in development of wounds. Wounds can develop within a day if there are poor nutrition or intake. This could have attributed to the wound development of R24. Nutritional monitoring policy dated 3/20 documents: it is the policy of the nursing department to monitor the residents nutritional intake at each meal and to record the average percent consumed. Under purpose to maintain a record of nutritional consumption to detect potential nutritional problems. Ensure staff awareness of resident diet order. 2. R25 was admitted to the facility on [DATE] with a diagnosis of rheumatoid arthritis, abnormalities of gait, lack of coordination, pressure ulcer of sacral region unspecified stage, ankylosing spondylitis, scleritis with corneal involvement, severe protein caloric malnutrition. R25's admitting packet documents weight on 11/16/22 of 102.8 pounds. R25 first documented weight on 1/4/23 documents 80.4 pounds R25 weights dated 5/10/23- 85 pounds. R25's Minimum Data Set, dated dated dated [DATE] documents under eating one person assist. R25's nutritional risk dated 12/9/22 does not document any current weight. Documents fed by staff. R25's point of care charting for amount eaten for May 2023 documents: no amount eaten for evening for all of May. No documented food eaten on 5/9/23, 5/12/23, 5/14/23 ad 5/16/23. On 6/1/23 at 1:00pm. V5(Restorative) said weights should be done on admission and then weekly x4. Nutritional monitoring policy dated 3/20 documents: it is the policy of then nursing department to monitor the residents nutritional intake at each meal and to record the average percent consumed. Under purpose to maintain a record of nutritional consumption to detect potential nutritional problems. Ensure staff awareness of resident diet order. 34072 On 6/8/23 at 10:58am, V41 NP (Nurse Practitioner) stated that V41 is aware that staff are not obtaining weights daily. V41 stated that she has to ask staff to weigh residents with diagnosis of CHF (congestive heart failure) when she comes to facility. On 6/8/23 at 12:15pm, V42 NP stated that obtaining weights is important for residents with CHF to monitor for increases in weight over a short period of time. V42 stated that these residents need to be monitored to prevent fluid overload. On 6/8/23 at 3:00pm, V44 (Cardiology NP) stated that it is the standard of care for residents with CHF to monitor weights daily, to monitor for fluid overload. V44 stated that she would expect staff to follow her orders and weigh residents daily. On 6/13/23 at 4:20pm, V19 ADON (Assistant Director of Nursing) stated that staff should monitor CHF residents' weight daily. V19 stated that residents are weighed on the morning shift. V19 stated that the restorative staff are expected to weigh the residents daily. V19 stated that any weight variations of +/- 3 pounds, the physician should be notified. V19 stated that the nurse is expected to document when the physician is notified and if any new orders are received. On 6/15/23 at 12:30pm, V67 (Attending Physician) stated that he expects the nurse to carry out all orders given. V67 stated that it is very important to monitor weights daily for CHF residents. V67 stated that weight needs to be monitored closely for accumulation of fluid in the resident's body to prevent fluid overload, worsening CHF. V67 stated that it is also important for weight monitoring to be consistent by using the same scale and weighing resident at the same time of day due to weight fluctuating throughout the day and to ensure accuracy of weights obtained. 3. Review of R16's medical record notes R16 was admitted to this facility on 5/4/23 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, syncope and collapse, and chronic respiratory failure. Review of R16's POS (physician order sheet), dated 5/24/23, notes an order for daily weights in the morning due to congestive heart failure (CHF) and recent hospitalization due to CHF exacerbation. Daily weights were re-ordered on 5/31/23. Review of R16's medical record notes R16's first weight was not obtained until 5/19/23. There is no documented admission weight. Review of R16's weight documentation notes: On 5/19/23, R16's weight was 250.6 pounds, scale used, and time weight obtained are not documented. On 5/22 at 1:44pm, weight 256.1 pounds using a mechanical lift device. On 6/1 at 8:28pm, weight 262.6 pounds using a mechanical lift device. On 6/3 at 10:07pm, weight 256.6 pounds using a mechanical lift device. On 6/5 at 12:16pm, weight 256.2 pounds using a mechanical lift device. On 6/6 at 851am, weight 255.3 pounds using a mechanical lift device. 6/7 at 10:04am, weight 256 pounds using a standing scale. 6/8 at 9:29am, weight 256 pounds using a mechanical lift device. 6/9 at 3:00pm, weight 258 pounds using a mechanical lift device. 6/12 at 5:17pm, weight 259 pounds using wheelchair scale. 4. Review of R33's medical record notes R33 with diagnoses including congestive heart failure, cardiomyopathy, cardiac pacemaker, and hypertensive heart disease with heart failure. Review of R33's POS, dated 5/15/23, notes an order for weekly weights x 4 then monthly. On 6/1/23, there is an order for daily weights. Review of R33's weight documentation notes: On 5/12 at 4:50am, R33's weight was 109 pounds standing scale. On 5/23 at 11:37am, R33's weight was 112.2 pounds standing scale. On 6/1 at 2:05pm, R33's weight was 115.3 pounds standing scale. There is no documentation found in R33's medical record, between 5/12/23 and 6/13/23, noting R33's weights were obtained per physician orders. 5. Review of R34's medical record notes R34 was admitted to this facility on 5/8/23 with primary diagnosis: congestive heart failure. Review of R34's POS, dated 5/10/23, notes an admission order for weekly weights x 4 then monthly. Review of R34's weight documentation notes: On 5/11/23 at 2:04pm, R34's weight was 388 pounds mechanical lift. On 6/1 at 2:05pm, R34's weight was 391 pounds on standing scale. Review of R34's care plan does not note a CHF care plan was initiated. 6. Review of R35's medical record notes R35's primary diagnosis: congestive heart failure. Review of R35's POS, dated 3/3/23, notes an order for daily weights. On 5/30/23, V44 (cardiology NP) ordered daily weights. Review of R35's weight documentation notes: On 2/9/23, R35's weight was 152 pounds using mechanical lift device. On 3/8, R35's weight was 142.2 pounds using mechanical lift device. On 3/9, R35's weight was 140.8 pounds using mechanical lift device. On 4/18, R35's weight was 140.8 pounds using mechanical lift device. On 5/10, R35's weight was 139.8 pounds using mechanical lift device. On 6/1, R35's weight was 142.1 pounds using mechanical lift device. There is no documentation found in R35's medical record noting daily weights were obtained. Review of dietary's note dated 6/13/23, notes weight 142.1 pounds. +10.0% change. Significant weight gain x 6 months noted; question accuracy of weights previously of 117 pounds and 120 pounds. Review of R35's care plan notes R35 is at risk for cardiac and respiratory distress related to CHF. An increased risk for lower extremity edema and shortness of breath related to fluid overload. Interventions identified: monitor R35 for edema of extremities, observe for shortness of breath, notify physician of any changes in condition, administer diuretic as ordered. Review of this facility's weighing residents policy, dated 02/2020, notes each resident is weighed on admission and monthly thereafter, or in accordance with Physician orders. A licensed nurse evaluates weight changes and determines if there is a 3 pound or greater weight loss/gain in one week and notifies physician of unanticipated or undesired weight gain or loss. Weight gain may be due to CHF (congestive heart failure) with edema (swelling).

Based on observations, interviews, and record reviews, the facility failed to follow its pain management policy by not having tramadol 50 mg available for administration as prescribed. This affected one resident (R16) out of three residents reviewed for pain management. This failure resulted in R16 being observed crying in pain on 5/30/23. R16 stated R16 has chronic left knee pain, and the pain was 10 out of 10. Findings Include: On 5/30/23 at 2:39pm, R16 who was assessed to be alert and oriented to person, place and time stated while crying, my left leg hurts. My pain level is a 10 out of 10. I didn't get my pain medication it was not ordered. On 5/30/23 at 2:40pm, V13 (Nurse) stated that R16 was admitted to this facility on 5/4/23. V13 stated that R16's pain medication has not been ordered. V13 stated that V13 needed to call the doctor. On 5/31/23 at 2:36pm, V4 (Rehabilitation Director) stated that R16 has arthritis in both knees and history of left knee surgery. V4 stated that R16 complains of pain throughout her therapy sessions and needs to keep being re-directed to stay on task with therapy. When questioned for the reason therapy was not stopped and the nurse notified so the nurse could assess R16's pain level and administer pain medication? V4 stated that the therapist assesses the resident's pain level before starting the session. V4 stated that staff are informed of therapy times so the resident can receive pain medication prior to therapy. This surveyor informed V4 that this facility did not order R16's pain medication until 5/30/23 and R16 was without pain medication since 5/4/23. V4 did not respond. On 5/31/23 at 3:06pm, V18 (Doctor of Pharmacy) stated that R16's tramadol (pain medication) order was filled today. The facility did not print out and manually fax the order for controlled medication prior to today. Once the medication is entered into the computer system, the facility can take the medication out of the emergency kit or have it delivered urgently. On 6/14/23 at 8:25am, V41 NP (Nurse Practitioner) stated that the nurse should be checking the resident's chart for any new orders placed. V41 stated that she expects the nurse to carry out all orders written. V41 was informed that R16 was admitted on ,d+[DATE] with an order for tramadol and this medication was not ordered until 5/31. V41 stated that staff know that they can ask her for medication orders, and she would have ordered the tramadol for R16. R16's PT (Physical Therapy) daily progress notes, dated 5/12/23-5/30/23, were reviewed. There is no documentation found noting R16's pain was assessed prior to, during, or after each therapy session. R16's OT (Occupational Therapy) daily progress notes, dated 5/15/23-5/30/23, were reviewed. On 5/15/23, R16's pain was assessed to be 4-7 out of 10. There is no documentation found noting R16's pain was assessed prior to, during, or after each subsequent therapy session. Review of R16's POS (physician order sheet) dated 5/4/2023, notes an order for tramadol 50mg (milligrams), take one tablet by mouth every six hours as needed for mild pain. Review of R16's MAR (medication administration record), dated May 2023, documents: tramadol was not signed out or administered to R16. Review of R16's new prescription summary, dated 5/31/23, documents: R16 has an order for one hundred and twenty tablets, thirty day supply with five refills of tramadol 50mg tablets. Review of this facility's pain management program, dated 11/2021, documents: to establish a program which can effectively manage pain in order to adverse physiologic and physiologic effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness.

Based on interview and record review, the facility failed to notify the physician of abnormal lab levels. This affected 2 of 3 (R26, R33) residents reviewed for laboratory results and notification of abnormal labs. This failure resulted in R26 having an incident of a seizure requiring hospitalization and treatment. Findings include: R26 was admitted to facility on 2/15/23 with a diagnosis of other psychological development, vitamin D, traumatic brain injury, epilepsy and bipolar disorder. R26's physician orders dated 2/16/23 documents: Phenytoin Sodium Extended Capsule (Dilantin) 100 MG. Give 1 capsule by mouth two times a day for seizures. R26's laboratory results dated [DATE] documents: Phenytoin level (Dilantin) 4.3 low. Reference ranges 10.0-20.0. R26's medical record or physician orders do not document any changes or notification of results for 3/10/23. On 6/15/23 at 12:20PM, V67(MD) said he is unable to recall if he was notified of R26's Dilantin levels. V67 said he would expect to be notified of any abnormal laboratory results and would put in recommendations or changes based on results. V67 said if Dilantin levels are low, he would consult with neurology and/or adjust the dose of the medication. If Dilantin levels are low, it can increase the risk for seizures. R26's progress note dated 4/10/23 documents: Nurse was notified that resident was noted on the floor in a lying down position with seizure. Resident alert and responsive. Body assessment done, no injuries or bleeding noted. Resident was assisted back to bed. Vital signs checked and stable. MD made aware and received an order to send her to hospital for evaluation. R26 hospital record dated 4/10/23 documents: Patient presented from a nursing home due to breakthrough seizure. The patient Dilantin level was low. She was loaded with antiepileptics and admitted because she had another breakthrough seizure while in the emergency department. Patient was admitted for further management and evaluation of her breakthrough seizures which are likely due to inadequate dosing and missed medication doses. Dilantin level documented at 4.6. Facility policy reviewed 2/1/22 titled change in condition documents: It is the policy of the facility to alert the resident, physician/ nurse practitioner and resident party of a change in condition. Nursing will notify the residents physician when: there is a significant change in the resident's physical, mental or emotional well-being. The communication with the resident and their responsible party as well as the physician will be documented in the resident's medical record or other appropriate documents. Facility policy dated 5/14 titled Laboratory test processing and reporting documents: To assure physician ordered diagnostic test is performed and to assure test results are promptly reported to the physician. A licensed nurse is responsible for monitoring the receipt of test results; test results are promptly reported to the physician or other practitioner who ordered them. 34072 On 6/13/23 at 4:10pm, V60 (Psychiatrist) stated that V60 has not received lithium or Depakote level laboratory results since 10/14/22. V60 was informed that now (urgent) orders for lithium and Depakote levels on 4/4/23 and the now order for lithium level on 6/1/23 were not carried out for R33. V60 stated that he expects the nurses to carry out his orders. On 6/13/23 at 4:20pm, V19 ADON (Assistant Director of Nursing) stated that the nurse enters the order into the facility's computer system, completes a laboratory requisition form, calls the lab for all now/urgent orders. V19 stated that a now order is to be ordered urgent. V19 stated that the nurse will receive a confirmation number from outside laboratory company, the nurse is expected to write the number on the lab requisition form. V19 stated that with urgent labs, the outside lab company will come in within 2-3 hours, sometimes it takes longer before lab tech comes to facility, but it is the same day. V19 stated that the nurse is expected to check for laboratory results online via the outside laboratory company's portal. V19 stated that the nurse is expected to check for any/all outstanding lab results. V19 stated that the nurse is expected to hand off to the on-coming nurse when there are any pending lab results. On 6/14/23 at 8:25am, V41 NP (Nurse Practitioner) stated that the nurse should be checking the resident's chart for any new orders placed. V41 stated that V41 expects the nurse to carry out all orders written and follow-up on any outstanding laboratory test results. V41 stated that the nurse should be notifying the physician of laboratory results. On 6/14/23 at 9:30am, V19 presented this surveyor with a lithium level from a blood sample collected on 4/5/23 at 11:17am and not reported until 6/13/23 at 4:49pm. The lithium level result was 0.33 (normal range is 0.60-1.20). V19 stated that she was unsure if the abnormal results had been reported to the physician. When questioned reason it took more than 60 days after blood sample collected and results known for V19 to obtain results, V19 was unable to explain. Review of R33's medical record does not note the physician was notified of the low lithium level. On 6/15/23 at 9:30am, V70 (Outside Laboratory Supervisor) stated that they absolutely would not process a blood sample, obtain results, and not enter those results in their portal for this facility to review. V70 stated that R33's lithium level was drawn on 4/5/23 and results known on 4/5/23. V70 stated that she is unsure of the reason this facility did not follow up with this outside lab company if they were not able to see R33's lithium results on 4/5/23. V70 stated that this facility did not contact this lab until 6/13/23 at 4:49pm requesting R33's lithium level from 4/5/23. Review of R33's POS (physician order sheet), dated 4/4/23, notes orders for lithium level and Depakote level now. On 6/1/23, there is an order for lithium level now. Review of this facility's laboratory tests processing and reporting policy, dated 05/2014, notes a licensed nurse is responsible for assuring the laboratory is notified of physician's orders for testing. Urgent (STAT) or same day orders will be called to the laboratory service by the nurse who transcribes the order. Laboratory test(s) will be written on either MAR (medication administration record)/TAR (treatment administration record). A nurse is responsible for monitoring the receipt of test results. Test results are promptly reported to the physician. The licensed nurse is responsible for documenting in the nurses notes physician notification.

Based on observations, interviews, and record reviews, the facility failed to develop and implement interventions to ensure direct care staff could effectively communicate with residents, whose primary language is not English. This failure affected one resident (R16) out of three residents reviewed for resident rights. This failure resulted in one Spanish speaking resident (R16) experiencing psychosocial harm as evidenced by expression of feeling scared and isolated. Findings include: On 5/30/23 at 2:39pm, R16 was interviewed via a Spanish speaking surveyor. R16 who was assessed to be alert and oriented to person, place and time. R16 was observed lying in bed. R16 stated while crying, my left leg hurts. R16's right side of the bed was observed to be positioned against the wall and the head of bed positioned against an adjacent wall. R16 stated that staff only turn her on her right side by pushing her left leg causing pain to her left knee. R16 stated that R16 wants to be moved to the bed closest to the door so staff can turn her onto her right side. On 5/30/23 at 2:45pm, the State surveyors informed V19 ADON (Assistant Director of Nursing) R16 wants to be moved to the bed closest to the door. R16 was thankful to the surveyors for listening to R16 and getting her bed moved. On 5/31/23 at 1:30pm, R16 was interviewed via a Spanish speaking surveyor. R16 stated that R16 speaks little English and does not understand when spoken to in English. R16 stated that R16 has had one shower since admission to this facility on 5/4/23. R16 stated that her hair has not been washed x 2 weeks. R16 stated that her whole head is itchy due to hair not being washed. R16 stated that she has all of the supplies in her room to wash hair. R16 stated that she asks for her hair to be washed but staff have not done it. R16 stated that staff do not get her out of bed. R16 stated that it is easier for her to transfer on the right side of bed. R16 stated that she has pain in her left knee when staff turn her to the left. R16 stated that she had been requesting for one week to be moved to the bed closer to the door. R16 stated that there aren't any Spanish speaking clinical staff or residents she can talk to. R16 stays in the room all day every day isolated. R16 stated that R16 is scared to be at this facility because R16 does not know what medications/treatments she is receiving. R16 was thankful to the surveyor for communicating with her in Spanish so she could make her needs known. On 5/31/23 at 2:36pm, V4 (Rehabilitation Director) stated that R16 speaks English fairly well. V4 stated that R16 was asking for a while, at least one week, about switching beds. V4 stated that the nursing staff had a Spanish speaking housekeeper speak with R16. When questioned reason it took State surveyors 5 minutes to understand what R16 wanted and it took staff with housekeeper translating one week to understand what R16 wanted, V4 responded R16 was not asking the question correctly so staff did not understand what she wanted. On 6/1/23 at 3:35pm, V61 (R16's family member) stated that R16 understands a little English. V61 stated that the staff use a housekeeper to translate for R16, which is not appropriate. V61 stated that housekeeping staff do not have any health care training and would not be able to identify any changes in R16's medical condition. V61 stated that R16 does not know what medications she is receiving, because R16 does not understand what the staff are saying. On 6/2/23 at 10:42am, V2 DON (Director of Nursing) stated that residents whose primary language is not English should have a communication board to utilize during their stay at this facility. V2 stated that this facility does not have a translator/interpreter service. V2 stated that prior to R16's admission to this facility there should have been a communication board in place in her room. V2 stated that this facility does not have an effective communication policy or provide communication training for its staff. Review of R16's shower documentation, dated 5/4/23 - 5/31/23, notes R16 received a shower on 5/20/23. There is no further documentation that R16 received a shower during this time period. Review of R16's hospital pre-admission transfer record, dated 5/4/23, notes on the first page R16's spoken language is Spanish. Review of R16's BIMS (brief interview of mental status) score, dated 5/11/23, notes R16's score is 14 out of 15. R16 is alert and oriented x 3. Review of this facility's residents' rights policy, revised 11/2018, notes your facility must provide services to keep your physical and mental health, at their highest practical levels. You have the right to complete information about your medical condition and treatment in a language that you can understand.

A. Based on observation, interview and record review, the facility failed to follow their dignity policy by not ensuring residents are appropriately dressed. This affected 2 of 3 (R41, R42) reviewed for dignity. This failure resulted in R41's penis being exposed during mealtime, and R42's briefs exposed during mealtime. Using the reasonable person concept R41 would have been humiliated and embarrassed. B. Based on interview and record review, the facility failed to follow their dignity policy by putting a resident's deceased body in the beauty supply room with garbage cans and boxes for the family final viewing for one (R50) resident out of one reviewed for dignity during postmortem care. Findings Include: A. R41 has a diagnosis of Encephalopathy, Mental disorder and Bipolar disorder. Minimal data set dated [DATE] section C (cognitive pattern) documents a five which indicated severe impairment, section G (functional status) documents: R41 required extensive with one person physical assist with dressing. On [DATE] at 12:54pm and 1:00pm, R41 was observed sitting in his wheelchair on a white towel, eating lunch in the dining room with his adult brief and jogging pants around his thighs with his penis exposed. R41 was asked why his clothing and adult brief was down, R41 replied, they did not pull them up. On [DATE] at 2:09pm, V1 (Administrator) said, a resident should not be in the dining room with their penis exposed, it is a dignity issue. R42 has a diagnosis of Dementia. Minimal data set dated [DATE] section C (cognitive patterns) documents a score of nine which indicates moderately impaired. Section G (functional status) dated [DATE] documents R42 required supervision with dressing with set up assist. R42 has self-care deficits Interventions: Performs dressing/grooming task without physical assist; cues and/or supervision as needed. On [DATE] at 12:56pm, R42 was observed sitting with his pants and belt around his mid thighs exposing his adult brief. R42 said, he did not know why his pants were not pulled up. On [DATE] at 2:09pm, V1 (Administrator) said, resident should not be in the dining room with their adult brief exposed, it is a dignity issue. Dignity Policy dated ,d+[DATE] documents: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. B. R50 is a [AGE] year old with the following diagnosis: end stage renal disease, dementia, and congestive heart failure. R50 was admitted on [DATE] and expired in the facility on [DATE]. A Nursing note dated [DATE] at 7AM documents R50 was changed by the CNA at 5:45 AM. R50 was verbally responsive. Around 6:45 AM, the morning nurse (V20) noted R50 unresponsive. R50's arms were cold and clammy. The second nurse (V56) went to assess R50. Vital signs were checked, but none were reported. CPR was not attempted since it was a presumptive death. The power of attorney was called. The administrator, DON, and nurse practitioner were also called to inform of the R50's demise. Postmortem care was completed. Due to nursing staff, not following proper protocol, the police department was called. The Police Report dated [DATE] documents the police were called at 5:15 PM and arrived on scene at 5:51 PM. The day nurse began the shift at 6:30 AM and checked on R50 around 6:45 AM where R50 was found unresponsive. Life-saving measures were performed on R50 around 6:45 AM but R50 continued to be unresponsive and showed no vital signs. The staff then moved the deceased body to the beauty shop located in the basement of the nursing home. R50's body was laying on a gurney with a blanket covering R50 in the beauty shop. On [DATE] at 1:42PM, V75 (Family Member) stated I got there around 4 PM because I was coming home from work. They had R50 downstairs wrapped in a sheet in the beauty room. There were a bunch of boxes in garbage cans next to R50's body. I couldn't believe they were having me view R50's body like that. I felt horrible. It was something that was happening out of a movie. On [DATE] at 10:16AM, V22 (CNA) stated no family came to get the body right away so they took it downstairs. They held it there until the family came. Normally what we do is remove the roommate out of the room temporarily, so the body is still in the room when the family comes. We normally let them visit with the body where they passed away. I don't know why that didn't happen this time. On [DATE] at 12:01PM, V47 (Detective) stated When I saw R50's body, R50 was in the basement in a room with some other supplies. There were some garbage cans in the room and some beauty chairs and R50 was wrapped in a sheet. The family member told me that this is how they first saw R50 as well. On [DATE] at 12:49PM, V1 (Administrator) stated R50's family and the police viewed the body in the beauty room in the basement. I know there are some chairs in there like when you go to the salon. I'm not sure what else was in there at that time. Normally, family come pretty quick, so the resident's body is left in the room until the family gets there. The family wasn't answering so we moved R50 down there for the comfort of his roommate.

Based on interview and record review the facility failed to ensure a resident was treated with dignity by not providing personal care prior to being transported to the hospital. This affected 1 of 3 residents (R11) reviewed for dignity. This failure resulted in R11 being transported to the hospital soiled with human excrement, R11 said he felt embarrassed and ashamed. Findings include: R11 census denotes was admitted to the facility on [DATE] and transferred to the hospital on 3/5/23. R11's care plan denotes R11 has a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease, essential hypertension, convulsion, abnormal enzymes levels, schizophrenia disorder, asthma, preexcitation syndrome, chronic venous hypertension with ulcer of bilateral extremity, other psychoactive substance abuse with unspecified psychoactive substance- induced disorder, opioid abuse. R11 MDS dated [DATE] denotes in-part R11 needs limited assist with toilet use. R11 care dated 3/7/23 denotes in-part 2 assist with toileting. On 3/16/23 at 3:57p.m V47 (Nurse) said she was the nurse responsible for R11's care on 3/5/23 when R11 was sent to the hospital. V47 said she worked the 3-11:00pm shift. V47 said there was not any aide on duty for that shift. V47 said she did not provide R11 with incontinent care at all. V47 said she did the best that she could for the residents that evening. V47 said she got report from V42 (Nurse) that R11 was to be sent to the hospital for further evaluation for the surgical wound that opened. V47 said she did not assess R11's surgical wound, but she did see that it was open a little when the medics were at the bedside. V47 said she did not assess R11 before sending R11 to the hospital with the medics to ensure that R11 was clean, dry, and free of human excrements. V47 said R11 did not walk and R11 needed assistance with toileting. On 3/16/23 at 2:23p.m V42 (Nurse) said R11 required assist with ADL (Activity of Daily Living) care, R11 needs one person assist with incontinent care. V42 said she was R11's nurse for the morning shift (7:00-3:00pm) and R1's wound was open and leaking yellow drainage. V42 said she did not put a dressing over the wound because it was supposed to be open to air. V42 was asked if she notified the physician of the open surgical wound that was leaking yellow drainage. V42 did not respond. V42 said stool could get in the wound if it is not covered, because of the location of the wound. On 3/17/23 at 2:10pm V56 (physician) said R11's surgical wound should not be covered up, and R11 was being transported to hospital for further care for the surgical wound. On 3/15/23 at 3:28p.m V7 (Captain of Fire Department) said he was the supervisor responding to a call to transport R11 to the hospital because R11's wound opening. V7 said R11 had on an ill-fitting adult brief, the brief was full of feces. V7 said the feces had dryed up. V7 said R11's surgical wound was covered in feces. V7 said R11 was awake and talking. On 3/17/23 at 3:20pm V23 (Director of Nursing) said incontinent care should be provided every two hours or as needed to all residents as appropriate. V23 said the resident should be provided incontinent care prior to being escorted to the hospital, a resident should not be escorted to the hospital soiled with stool. On 3/21/23 at 10:10am V9 (Administrator) said all residents should be treated in a dignified manner, the resident has a right to be treated in a dignified manner. V9 said the residents should be clean, dry and not be soiled in feces when escorted to the hospital. On 3/21/23 at 1:07pm V62 (social services) said R11 is not on her case load, but she had an opportunity to work with R11 and make observations of R11. V62 said R11 showed signs and symptoms of poor self-esteem, R11 presents with isolative behavior, R11 wouldn't call for assistant, R11 was not vocal about the help he needed. V62 said she didn't document her observations of R11 as mentioned, and she has to do better with her documentation. V62 said R11 behaved in a manner, like he was not worthy of being helped and that is why R11 was care planned for poor self-esteem. R11's fire department run report dated 3/5/23 denotes in-part 70 y/o male patient (R11) AOx3 (alert and orient) per norm found sitting on edge of bed naked and covered in feces. Nursing staff reported that PT needs to be transported to the ER (emergency room ) for staples from a wound that have opened. Crew noted an open wound/scar, approx. 3-4 inches on patient (R11) upper inner right thigh. Crew also noticed that patient wound was not dressed at all, leaking puss, and covered in feces. Patient (R11) stated that his scar/staples were from a triple bypass. Crew assisted the patient to the stretcher where he was secured in position of comfort. While assisting the patient to the stretcher crew noticed that the patient's diaper was full of feces. The patient's diaper was not placed on the patient correctly. BLS (basic life support) care provided as noted and patient (R11) transported to local Hospital without incident. R11's care plan dated 2/27/23 denotes in-part the resident (R11) presents with symptoms of poor self-esteem related to: Health & lifestyle changes imposed by medical symptoms & condition. Feeling abandoned by family, friends, physician, God & religion, etc. Feeling incompetent, incomplete because of a medical condition or not being able to contribute as he/she once did. Loss of important lifestyle, lifelong roles. This problem is manifested by minimal social interaction and self-imposed isolation. This problem is manifested by, not behaving assertively, not speaking up for oneself. I will discuss his/her feelings & the factors contributing to poor self-esteem during counseling sessions (#) time(s) per week. I will demonstrate increased self-esteem as evidenced by saying daily affirmations. Help resident build self-esteem through frequent/daily verbal positive affirmations. Help resident build self-esteem through writing out positive thoughts & affirmations. Help resident build self-esteem through: Focusing on abilities instead of disabilities. Help resident build self-esteem through helping the resident regain involvement in lifelong roles. Help resident build self-esteem through working with appropriate mental health professionals. Encourage the resident to become involved with an appropriate support group or individual counseling to work towards self-awareness & self-improvement goals. R11 care plan dated 3/7/23 denotes in-part R11 has incontinence of bladder and/or bowel, R11 will be clean, dry & odor free through the next review. Administer appropriate cleansing & peri-care after each incontinent episode. Observe for signs of skin irritation &/or breakdown. Report irritation/breakdown to the physician. R11 has a self-care deficit (ADLs/Mobility), R11 will improve/maintain his highest level of function with participation in therapies and/or restorative programs through next review. One assist with dressing/ hygiene tasks; encourage as much self-performance as safely able. Assist with repositioning when in bed/chair. Encourage resident to participate as much as safely able with ADL hygiene tasks. PT/OT (physical therapy/ occupational therapy) to screen / eval as ordered. Toilet with 2 assists. Transfer with mechanical lift x 2. Review of R11's documentation survey report for date of 3/5/23, there is not documentation noted for incontinent care provide, personal hygiene to R11. Using the reasonable person concept R11 should expect to feel embarrassed, ashamed when not provided incontinent care prior to going to the hospital, R11 should expect to feel embarrassed and ashamed when not treated with dignity, R11 should expect to feel embarrassed and ashamed when escorted to the hospital and having to wear an adult brief full of feces and not cleaned and changed. Facility policy titled Incontinency Care dated 9/14 denotes in-part incontinent residents will be checked periodically every two hours and provided perineal and genital care after each episode. Purpose: to prevent excoriation and skin breakdown, discomfort and maintain dignity. The resident rights for people in the long-term care facilities denotes in-part your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source. Review of R11's progress notes, there were no documentation noted that R11 refused incontinent care on 3/5/23.

Based on interview and record review the facility failed to prevent incidents of resident-to-resident physical assault, and incidents of staff to resident verbal abuse. This affected 3 of 5 (R31, R32, and R3) residents reviewed for physical and mental abuse. This failure resulted in R31 being physically assaulted by R32 resulting in R31 sustaining a bump on her head, displaying fear and expressing being scared and unsafe. Findings include: 1.R31 was admitted to the facility on [DATE] with a diagnosis of schizophrenia, weakness, unsteadiness on her feet, major depressive disorder, and type II diabetes. R31's brief interview for mental status dated 1/18/23 documents a score of 15/15 which indicates cognitively intact. On 3/16/23 at 11:06AM, R31 who was alert and oriented at time of interview, said R32 hit her in the head three times with her hand. Small bump noted on her forehead along with three superficial scratches. R31, who was crying during the interview, said she feels scared and does not feel safe at the facility. R31 said R32 is always going through her belongings and taking items. On 3/17/23 at 3:38PM, V9 (Administrator) said R31 said R32 was going through her drawers and R32 hit R31. R31 had a bump on her head. Physical abuse would be hitting someone. R31's progress note dated 3/16/23 documents: Nurse was informed that the resident was involved in physical aggression with her roommate in her room. Noted small bump on her forehead. Resident complaint of pain on her bump site. Resident stated her roommate was going through her stuff and she asked her to stop it. Roommate got aggressive and her hit her. Facility abuse prevention program revised 1/4/18 documents: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse. 38796 2.R3 is not available for interview or observation. R3's MDS dated [DATE] denotes R3's BIMS score is 15, cognitively intact. On 3/15/23 at 1:18pm V32 (CNA- Certified Nursing Assistant) said she does remember the situation when the agency staff got into R3's face, and said that she would kick R3's a**. V32 said V33 (Agency CNA) pushed her out the way to try to get to R3. V32 said her and V35 (Nurse) had to pull V33 out of R3's face. V32 said V33 wanted to fight R3. V32 said she could tell that V33 wanted to fight by her V33's aggression and body language. V32 said she had to tell V33 that R3 was a resident and that she could not be getting in his face, and she asked V33 why she was acting like that. V32 said V33 was mad and walked out of the facility that night. V32 said the nurse was there and the nurse reported it to the Administrator and the Director of Nursing. On 3/15/23 at 2:46pm V35 (Nurse) said she was one of the nurses working on the first floor when V33 (CNA) and R3 got into it. V35 said V33 was arguing with R3, and V33 was so aggressive that she was about to call the police. V35 said someone pulled V33 away from R3 and V33 left the facility. V35 said she doesn't remember the details, she just knows V33 was aggressive with R3. V35 said she reported this to V60 (Prior Administrator). On 3/15/23 at 2:30pm V9 (Administrator) said she was the Administrator on 1/22/23, not V60. V9 said the staff should have reported the incident to her. V9 said she was not aware of the incident with V33 and R3. On 3/21/23 at 10:10am, V9 said R3 has the right to be free from abuse. V9 said V60 was not the Administrator on 1/22/23. On 3/17/23 at 10:27am V33 said R3 was a resident on the third floor, and she was assigned to work with R3 on 1/22/23. V33 said she was scheduled to work a double shift. V33 said R3 was complaining about the nurse and banging on the nurse's station desk. V33 said R3 was aggressive, and she was afraid of R3. V33 said R3 had left the floor and R3 must have gone to the first floor. V33 said she decided that she was leaving and going home because R3 was so aggressive. V33 said she got her coat and got on the elevator. V33 said when she exited the elevator R3 was at the first-floor nurse's station. V33 said R3 must have gone there to tell them what happened. V33 said she stopped at the nurse's station and that's when her and R3 began arguing. V33 said one of the staff got in between her and R3, V33 said she doesn't know who it was. V33 said nothing happened. V33 was asked why she stopped at the nurse station if she was afraid of R3 and R3 was so aggressive, and why didn't she continue out the door as she had planned if R3 was aggressive and she was afraid? V33 said she had to tell the nurse she was leaving. Facility abuse prevention program policy dated 1/4/18 denotes in-part this facility, Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 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, irrespective of any mental pr physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental anguish. The facility abuse policy does not address the resident right to be free from verbal, physical, mental, emotional abuse. The resident rights for people in the long-term care facilities denotes in-part you must not be abused, neglected, or exploited by anyone- financially, physically, verbally, mentally, sexually.

Based on interview and record review, the facility failed to monitor, failed to follow physician orders and failed to notify the attending physician of a scrotum rupture. This affected 1 of 3 residents reviewed for pressure sore preventions. This failure resulted in R7 being observed in bed with his testicles outside of the scrotum, being sent to the local hospital and being diagnosed with a diagnosis of protrusion of scrotal content through the superficial ulceration area, scrotal swelling, necrosis to anterior right scrotum with purulent discharge and a stage II pressure ulceration to the posterior left scrotum. Findings include: R7 was admitted on [DATE] with the diagnosis of Diabetes Mellitus, Hypertension and Hydrocele. Skin integrity review dated 1/9/23 documents: swollen scrotum. Admission Summary dated 1/9/23 documents: Enlarged scrotum noted upon inspection. Care Plan dated 1/10/23 documents: R7 has incontinence of bladder and or bowel. On 3/14/23 at 12:47pm, V10 (ADON) said, R7 had a wound. R7's treatment administration record is blank with no nurse initial; no documentation means the treatment wasn't completed as ordered. I expected the nurse to provide the treatment as ordered and sign the treatment out on the treatment administration record (TAR). R7 did not receive any treatments. R7 was not seen by the wound doctor. On 3/15/23 at 2:19pm, V48 (Previous Treatment Nurse) said, R7 was admitted with enlarged testicles with a small amount of redness. R7 received barrier cream for the redness and was on a diuretic for the enlarge testicles. R7 did not require any treatment upon admission. One week after R7's admission, R7 had a small, opened area. R7 had a skin irritation similar to a diaper rash on R7's scrotum. R7 had a Foley catheter that was leaking. R7 had urine in his adult brief. R7 was given a wound paste that absorbed excessive moisture. On 1/17/23, I was informed, R7 needed to be seen. I went to assess R7. R7's testicle was out of the scrotum sack. R7's testicle was laying on the bed. On 3/15/23 at 2:50pm, V45 (Nurse) said, R7 was getting a wound treatment every day. R7 had gauze wrapped around his scrotum daily. R7's scrotum was the size of a grapefruit. On 1/17/23 when R7 was discharged to the hospital, R7's scrotum was leaking green and yellow fluid. R7s scrotum was leakage due to the pressure of the swelling. R7's scrotum was similar to a boil coming to a head and bursting. There was so much pressure on R7's scrotum the fluid had to come out. On 3/16/23 at 3:43pm, V23 (DON) said, full thick skin altercation is caused by pressure. R7's scrotum was elevated with a towel. The towel could have caused pressure to R7's scrotum. On 3/16/23 at 4:38pm, V17 (Treatment Nurse) said, necrosis does not occur within twenty-four hours. Necrosis occurs over time. A wound must go through four other stages (stage 1 -4) before necrosis occurs. On 3/17/23 at 2:14pm, V56 (Medical Doctor) said, I was not informed R7 had a ruptured scrotum. R7 was admitted with a hydrocele of testie. The facility has a wound care nurse and wound care doctor/specialist. I expect the physician orders to be followed for whatever treatment the wound doctor orders. On 3/17/23 at 2:24pm, V49 (Nurse Practitioner) said, I was not aware R7 had an opened skin area on 1/12/23. I expect the nurses to follow the doctors' orders. R7 was not in the building long enough to see the wound doctor. Physician order sheet (order date) 1/11/23 documents: Venelex external ointment ([NAME]-[NAME] oil)-is an ointment that is used on skin to cover wounds, it can also help to get rid of smells and might relieve pain from the wound. Venelex Ointment is a wound dressing for topical use in the management of chronic and acute wounds and dermal ulcers including pressure ulcers (stage 1-4) (National Institutes of health) --- apply to scrotum topically as needed to wound every day and evening. -No TAR was provided for this order. Medication Administration Record dated 1/11/23 documents: Venelex external ointment ([NAME]-[NAME] oil) apply to scrotum topically every day and evening. R7's Medication Administration Record was blank with no nurse initial. Skin/Wound note dated 1/12/23 documents: R7 has been noted to have scrotal edema, and skin impairment to the area. Medication Administration Record dated 1/17/23 documents: Venelex external ointment ([NAME]-[NAME] oil) apply to scrotum topically as needed for wounds. R7's Medication Administration Record was blank with no nurse initial. Treatment Administration Record dated 1/1/23 - 1/31/23 documents: Site; Scrotum-Clean with Saline, pat dry, apply triamcinolone topical twice a day, as needed and evening shift start date 1/12/23 discontinue 1/20/23- was blank, no nurse initials. Nurse Practitioner Note dated 1/17/23 documents: Called to see R7 because of a potential rupture of the scrotum. Upon assessment, Foley in place but skin has opened on R7's scrotum and there was foul smelling drainage coming from the open wound. R7 had edema of the scrotum and it had been elevated on a towel. General Progress note date 1/17/2023 documents: R7 was sent to the hospital, due to scrotum being enlarged, open and draining. Hospital paperwork dated 1/17/23 documents: chief complaints: penis/scrotum problems worsening, skin breakdown and swelling to the scrotum. History of swelling with bilateral Hydroceles. On Monday, R7 developed some sores to the hemiscrotum-staff began to apply ointment. R7's family saw R7's wound on Tuesday. R7's family states, wounds looked very bad, the skin was falling off. GENITOURNARY: bilateral soft tissue swelling of hemiscrotum, right hemiscrotum full- thickness ulceration of the skin, with protrusion of scrotal content through the ulceration area. Superficial ulceration noted on the undersurface of scrotum bilaterally. Scrotal swelling and necrosis to anterior right scrotum with purulent discharge. Small area of stage II pressure ulceration to posterior left scrotum Physician Order Policy dated 1/2020 documents: to provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards.

Based on interview and record review the facility failed follow their abuse policy and prevent resident to resident mental abuse that affected 2 of 4 residents (R7/R8) reviewed for mental abuse. This failure resulted in R7 showing copies of the nude photos and video of R8 to co-peers without R8's consent. R8 said that she feels terribly embarrassed, and it feels like her peers are holding something over her. Findings Include: R7 is a [AGE] year-old with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R7 admitted to the facility on [DATE]. R7's Minimum Data Set (MDS) dated [DATE] documents the Brief Interview for Mental Status score as 15 (no cognitive impairment). R8 is a [AGE] year-old with a following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 admitted to the facility on [DATE]. R8's MDS dated [DATE] documents the Brief Interview for Mental Status score as a 14 (no cognitive impairment). A Social Service note dated 3/9/22 documents R7 was named in an incident for mentally abusing R8. This matter was reported to the administrator and the DON as well as the non-emergency police department. R7 was counseled to be of good behavior to peers and staff. R8 was counseled to remain calm, avoid confrontation, and be focused. The Facility Incident Investigation Report dated 3/15/22 documents R8 allowed R7 to take a video on his phone when R8 was naked several months ago when they were in a romantic relationship. R8 alleged that R7 has shared the video with other residents without her consent and R7 is making negative comments. R8 reports they are no longer friends. R7 admitted to taking the video several months ago with the consent of R8, when they were in a relationship. R7 denied having the video any longer and reports deleting it. The cell phone was examined by the police department, and they were unable to find the video on the phone. Both residents have been receptive to 1:1 counseling and have agreed to avoid close contact. R8 was also counseled against allowing compromising videos or pictures to be taken of her. The police department did not take any action. Both residents reported feeling safe in the facility. On 04/02/22 at 1:27PM, R7 stated, R8 and I used to date. I did take a video of her that she knew about when we first started dating. We ended up breaking up and now we don't really talk or like each other. It was just over some boyfriend girlfriend stuff. I showed two other residents the video. R8 didn't know I was showing them. We were mad at each other, but I can't remember for what. I was just kind of talking to R8 crazy and then she told the staff members. I wasn't showing it to everybody, and I wasn't going to make a show out of it. I only showed it to 2 people. On 04/02/22 at 2:55PM, R8 stated, The first week I was here R7 took a video of me when I was naked. I had only a bra on. I don't remember what I was doing in the video. Last month, R7 started threatening to show people. He said he was upset with me, but I don't know why. I know R7 showed two residents. They told me not to have any contact with him, but he was telling me all this through text message. I was very manic when I first got here so I had no idea what I was doing. I was off my medication when I first got here so I would act in a way that I normally wouldn't. I feel terrible. I'm embarrassed to look at some of the staff members. I just feel like they think of me differently now when that person who was in those videos wasn't even me. It feels like he constantly has something over me. When I don't do something, he says, or I don't do something he likes then he's going to show the video to someone. I'm constantly having to worry about who's going to have to see the video. At this time R8 showed the surveyor text messages between R7 and R8. The conversation started with R7 threatening to show a video of R8 to unnamed residents. The text messages read the following: R7 wrote, You might as well shoot to kill because I told everyone there was going to be a show Friday or Saturday with the video. R8 replied, The video made me sick. R7 replied, I'm going to show them you dancing and singing. I'm going to show them the one of you sticking things in your pu**y. R8 endorsed the police were called and a report was made. R8 denied any other issues with R7 at this point. R8 denies any other issues in the facility at this time. On 04/05/22 at 11:36AM, V2 (Assistant Administrator) stated, I know there was an issue with R7 allegedly showing video of R8 to other people. I didn't do that investigation so I can't say who is interviewed. No, I haven't looked at R8's phone and seen the text messages from R7. On 04/05/22 at 2:14PM, V9 (Social Service Director) stated, R7 had a video on his phone of R8. Some residents say they did see it and other residents said no they didn't see it. When I talk to R8 about it she told me that the video was taken and that R7 said he was going around showing people, so I told the administrator. We called the police and we had them search his phone, but we couldn't find the video. We asked him for the [NAME] card, but he said that phone was broken, and he didn't know where the [NAME] card was anymore. We told him that he can't be showing videos like that without people consenting. I counseled R8 to tell her to not make videos like that. R8 told me I made it when I just came here, and I wasn't myself. The only thing that she told me was that she didn't feel like herself when she first got here so that's why she made the video. One resident I know that saw it was R10. I went and talked to him, and he said he did see it. This would be considered mental abuse. R7 keeps using it in a threatening way. On 04/05/22 at 2:40PM, R9 stated, Yes, R7 showed me a video of R8. R8 was dancing and smoking something, I think. She didn't have any bottoms on. She only had a bra on top. I saw her butt and her vagina. I can't remember where we were but R7 just came up to me and said, 'hey you want to see this video?' I watched it but I didn't think he was going to show me that. He didn't tell me what he was showing me before. I went and I told R8 that R7 was showing people pictures of the video because I didn't want her to feel stupid. If someone showing videos of you like that you should know about it. On 04/05/22 at 2:57PM, R10 stated, R7 is a bully. He bothers a lot of women in here. One day R7 just approached me as a friend and said he had something to show me. I saw it was a video of R8 dancing around naked and doing some other stuff with her vagina. I was shocked. I told him I don't want to see anything like that. I also told him that it was really disrespectful of him to be showing that video even if they weren't together anymore. I stopped dealing with him after that. I don't want to associate with nobody like that. On 04/07/22 at 11:54AM, V16 (Medical Director) stated, I don't know if I'm involved with these residents; I'm not aware of the situation. I can't comment specifically on this. The facility needs to make sure that everyone is safe, and no one is causing harm to themselves or anyone else. The psychiatrist would better be able to take a look at their history to see what they should be doing to help that. They should be able to see if the resident is a good fit for the facility or if they need to go somewhere else. Everyone should feel safe in the facility. R7's Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors dated 3/9/22 documents a total score of a four which indicates a substantial or significant problem with aggressive or harmful behavior. R7 has a history of destructive statements, behaviors, and threats. The Care Plan dated 3/9/22 documents R8 demonstrates a pattern of situational and/or coping problems in areas such as psychosocial well-being, mood state and/or behavior symptoms related to alleged mistreatment. Symptoms are manifested by conflictual relationships with staff and peers. R8's Screening Assessment for indicators of Aggressive and/or Harmful Behaviors dated 4/3/22 documents R8 is at a moderate risk for abuse due to a history of abuse, a psychiatric history and/or mental health diagnosis, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Policy titled, Abuse Prevention Program Facility Policy and Procedure, dated 1/4/18 documents, Abuse is defined as the willful inflection of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, I've got your services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residence, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enable through the use of technology. Willful, as using this definition of abuse, means of individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on interview and record review that facility failed to monitor and supervise a high fall risk resident and failed to implement appropriate interventions for one resident (R1) out of three residents reviewed for falls in a total sample of 10. This failure resulted in R1 falling when ambulating unassisted and sustaining multiple brain bleeds requiring hospitalization . Findings Include: R1 is a [AGE] year-old with the following diagnosis: cerebral infarction, [CONDITION(S)], and [CONDITION(S)] disorder. R1 admitted to the facility on [DATE]. A Nursing note dated 3/10/22 documents R1 was observed lying on the left side next to the bathroom door following a loud noise. According to R2 (R1's roommate), R1 had just finished using the restroom and fell . R1 was placed on his back and a pressure dressing was applied to the bleeding site. A moderate amount of blood was noted to be coming from the head. There was an approximately 2-inch laceration to the left side of the face. 911 was called immediately. R1 remained verbally unresponsive for 5 minutes with labored breathing. R1 was noted with post ictal upper body movements. A Nursing note dated 3/10/22 documents R1 was admitted to the hospital. The hospital called questioning R1's [CONDITION(S)] activity. V6 clarified that the [CONDITION(S)] activity happened after the fall. The Fire Department Report dated 3/10/22 documents the injury for R1 occurred at 7:45 PM. The fire department was dispatched at 7:56 PM and arrived to R1 at 8:04 PM. The fire department was dispatched to the facility for a possible [CONDITION(S)]. R1 was found lying on the floor with Kerlix wrapped around the head with a small amount of blood on the pillow that was beneath the head. Bleeding was controlled. R1 would look at you and talk; but when he would talk words were incomprehensible. The Hospital Records dated 3/10/22 document R1 was found on the floor at the facility and may have had a [CONDITION(S)]. R1 is alert and oriented times two at baseline, and normally gets around with a wheelchair but had gotten up out of bed to go to the bathroom and fell on the way back. The fall was unwitnessed and R1 has a laceration to the forehead. In the emergency room , R1 is alert and oriented times 1 to 2 and is arousable to voice. R1 has a 3 cm diameter abrasion with central maceration to the left frontal temporal region with a pressure dressing applied. There is bruising on the left frontotemporal region as well as the gluteal region. The CT of the head showed subarachnoid hemorrhages to the bilateral frontal and left temporal lobes and probable contusions. No fractures are noted. R1 was admitted to the neuro intensive care unit and was giving an anti-[CONDITION(S)] medication. The admitting diagnosis was subarachnoid bleed and laceration of forehead. R2 (R1's roommate) was the only person to witness the fall. On 04/02/22 at 3:33PM, R2 stated, He (R1) always got up by himself. This time he fell in the doorway by the bathroom. It was around nighttime, but he got up by himself and fell . He wasn't supposed to walk alone but he always did. I know he had a wheelchair that he was supposed to use but he wasn't using it that night. He wasn't right towards the end. He couldn't do what he used to do. The staff got up and helped him right away. He wasn't laying there for a long period of time. It was maybe only a couple minutes. I don't really know anything other than that. No, he didn't look like he had a [CONDITION(S)] before he fell . He just went down. On 03/31/22 at 3:28PM, V6 (Nurse) stated, I was at the nurse's station, and I heard a loud thump. Like a crack and we ran down there to see what happened. He was lying just outside the doorway of his bathroom. When I saw him, he was doing like a jerking tight motion, and he wasn't talking. After about a minute that went away and then it was a couple more minutes before he could start talking. He was only saying one or two words. Normally he talks fine in full sentences to you, so I knew that was wrong. He doesn't have a history of seizures, but he told me he had one before. I've never knew him to have a [CONDITION(S)] here and he isn't on any medication for it. He normally uses a wheelchair to get around too. When I went into his room his wheelchair was at the foot of his bed. He was getting [CONDITION(S)] treatments and chemo for cancer. He had recently become incontinent and wasn't doing well but the last three days he really came around. For this fall he basically just forgot to sit in the wheelchair and got up and went to the bathroom himself. The lighting was good, nothing was slippery, so he must've just lost his balance. There was a laceration to his forehead. I know the hospital called back to get some information and the nurse told me that they said that he had a subdural bleed. When he fell , I called 911 right away. I didn't wait. He wasn't on the ground more than 10 or 15 minutes before they got here. His bed was low, and his call light was in reach. That is all I can remember. He was too weak to get up from the chemo. He should've used a wheelchair. I don't remember him having any other falls before this. Not anything recent. We document our falls in a 24-hour sheet. After the fall we put in a new intervention. Normally restorative puts in an intervention. They investigate the fall and put in an intervention related to that. It should be done after every fall. It's also reported to the DON, the administrator and the doctor. I would say he had a change since having his chemo. He was just a lot weaker. He had become incontinent which it wasn't like him. Before that he would remind the nurse of his medications and what times he had to take them out. He also go down to the vending machine a lot for pop. Once he started getting chemo, he never did any of that because he couldn't. I don't remember of them putting in any other interventions when he first started getting chemo and weaker. Maybe he got some physical therapy, but I can't remember anything specific other than that. The Fall Risk Review dated 1/13/22 documents R1 is at high risk for falls due to being chair bound and requiring assistance with elimination. R1 uses an assistive device. R1 has predisposing conditions/diseases (cerebral infarction) that make him at risk for falls. The Fall Event dated 3/10/22 documents R1 was observed laying on the floor with a laceration to the left side of the face and a moderate amount of blood. R1 was verbally unresponsive with labored breathing. The level of consciousness is documented as responsive only to vigorous stimulation. The predisposing physiological factors are documented as: gait and balance, weakness/fainted, decreased safety awareness, decreased strength/endurance, and [CONDITION(S)] activity. The predisposing situation factors are documented as: not using wheelchair. R1 also had falls on the following dates: 1/13/22, 1/17/22, and 3/4/22. The following interviews are regarding these falls and policy and procedures the facility follows regarding falls. On 03/31/22 at 2:37PM, V4 (CNA) stated, The nurse will usually tell me who fell . I think we have a book at the nurse's station, but I don't know. I don't know how the agency staff find out about the High fall risks. I think they look at the book. I know they're supposed to put an intervention in after every fall so the falls stop. On 03/31/22 at 2:42PM, V5 (Nurse) stated, I think we just go off the fall risk assessment. I don't know who is a fall risk. You just kind of watch out for people that aren't walking right. We do the assessment after a fall but I'm not really sure who the Fall risk is here. I just started here a couple months ago. I don't see any book or list up here on who are high for us. I don't know who puts in the interventions. At this time, V5 was unable to provide a list or tell this surveyor who the high fall risks were on the 2nd floor. On 04/05/22 at 6:22PM, V10 (Agency Nurse) stated, He got up to get to the bathroom and I guess he fell in there. I didn't see it, but the CNA came to get me to tell me. I went in there and he was laying down on the floor with his head kind of under the toilet. He couldn't tell me what happened, but I saw the floor was wet. I don't know if it was urine or if he was trying to wash his hands and slipped. He said he lay down because he got tired of sitting up. I assessed him and there wasn't any injuries. He denied hitting his head. He said he fell down on his butt and just laid back down to rest. He told me he tried to get up himself and I just told him that he couldn't do that. I told him he needed to call us for help before he did that again. I don't know what interventions he had in place. I don't know if he had a fall recently. I know he was using a wheelchair to get around, but I didn't see the wheelchair in the bathroom. Yes, he was a High fall risk. I don't really know why but he was unsteady. I don't know who puts in any interventions after a fall. I wouldn't know how to do that. No, I never saw a list of any High fall risks at the nurse's station. Usually, the nurse will tell you and report if someone is a High fall risk or you just kind of watch out. I reported the fall to everyone, but I never put in any interventions. I don't know how to do that. I'm guessing someone else did. I don't know who would. This was the fall on 03/04/22. On 04/06/22 at 1:21PM, V3 (DON/Fall Coordinator) stated, The fall coordinator goes and investigates the fall and puts an intervention in place. They try to see what causes the fall and put an intervention in place that relates to the fall. We then try to educate the resident and the family on the fall and what we're doing after to help prevent a fall from occurring again. We communicate the new interventions with the team, and we also care plan. We base the intervention and the care plan off of what kind of fall happened. This should be discussed the next day. The more serious things are put first but I wouldn't say any more than a day or two to have an intervention put in. There is no reason an intervention should not be put in in that timeframe. We do have a fall program here. We complete the fall risk assessments on admission, quarterly, after a fall, and any changes with the resident. I don't know how staff knows which residents are High fall risks. The fall coordinator we had just resigned so we are in the process of redoing the full program to better fit our facility needs. On 04/06/22 at 1:37PM, V14 (Nurse) stated, I don't remember the fall to be honest. I know lately he was very weak. I'm not sure why. He used to walk fine before his stroke. That was last year but then he was still able to get around in the wheelchair after the stroke. I don't know what his interventions were. I think those are on the care plan. I know restorative puts them in, but I don't know what happens after that. We know who is a High fall risk if you see someone walking around that's unsteady. We do fall risk assessments and those stay in the computer and that's how we know who is a High fall risk. I know we used to have a paper at the nurse's station with the names of the residents who are high fall risk so you could know but we haven't had that for about six months now. I don't know what happened to it. I also go around and check on the residents. If we hear something between round, we check on them to make sure nothing happened. I don't know how to find out what interventions to put in for people. If someone is up walking around that shouldn't be I just redirect them or guide them back to their room to sit down. This was regarding the fall on 01/17/22. On 04/06/22 at 5:08PM, V15 (Director of Rehab) stated, He was in therapy with us since January. We ended up having him evaluated after a fall and decided because of the decline he had he should receive therapy. We would work on educating him about the safety precautions and making sure he was using the assistive devices. He was always instructed to have supervision when he got up and most of his falls resulted because of that. He never called for assistance. He was also instructed to use the call lights and wait until someone came in for help. He was very impulsive and attempted to do stuff on his own. I would say he was oriented, but he was impulsive. On 04/07/22 at 11:54AM, V16 (Medical Director) stated, I only saw this resident once so I can't tell you much about him. I don't really know his history or what he was capable of. I don't know if he had a recent decline or not. If a resident does have a decline the facility needs to inform us. For falls they need to follow their protocol and put strategies in place for High fall risk patients. I don't know when they should put in these interventions all I can say is follow the protocol. I don't handle any interventions really unless they are from a medical standpoint. If any medications need to be changed around then I can do that, but the facility is responsible for putting in other interventions. Their main goal should be to be keeping people safe. A Nursing note dated 1/13/22 documents staff observed R1 lying on the left side of the face on the floor with both knees flexed in buttocks pointed upward. R1 reported attempting to reach for food and fell . No injuries were noted but the doctor ordered R1 to be sent to the hospital, but family declined. The physician also gave orders for therapy to evaluate and treat as R1 continues to decline. A Nursing note dated 1/17/22 documents R1 was noted on the floor on the left side lying position. R1 reported rolling out of bed after not realizing he was near the edge and fell . No injury was noted, and it was ordered to send R1 to the hospital for imaging but R1 refused. A Nursing note dated 3/4/22 documents R1 was found on the bathroom floor lying on the back with his head under the toilet. R1 reported falling but could not report how. The nurse noted the floor was wet at the time of the incident. R2 reported feeling dizzy. R1 initially fell and landed on the butt and reported laying back down afterwards. No injuries were noted. R1 was able to ambulate with assistance back to bed. The Fall Event dated 1/13/22 documents R1 fell after reaching for food. R1 was found lying on the floor with both knees flexed and buttocks in the air. Predisposing physiological factors are documented to be: recent illness, gait and balance, incontinent, weakness/fainted, impulsive, and decreased safety awareness. The predisposing situation factors are documented as: admitted within the last 72 hours, wheelchair unlocked, and incident during unassisted self transfer. The Fall Event dated 1/17/22 documents R1 was noted on the floor beside the bed after rolling out of the bed. Predisposing physiological factors are documented as: recent illness, incontinent, and decreased strength/endurance. The Fall Event dated 3/4/22 documents R1 was found lying on the bathroom floor with his head under the toilet. Water was noted on the floor. R1 was unaware how the fall occurred but thinks he was dizzy. R1 reported initially falling and landing on his buttocks and got tired and laid backward. The predisposing physiological factors are documented as: decreased safety awareness. The predisposing situation factors are documented to be: incident during an assisted self transfer from bed. The Care Plan dated 6/23/20 documents R1 is at risk for falls related to history of falls, weakness, cerebral infarction, and use of antipsychotic medications. There are no interventions documented after the fall on 1/13/22 and 1/17/22. The interventions that are documented include: educate R1 to use wheelchair instead of walking on wet slippery surfaces, ensure that R1 is wearing appropriate footwear when ambulating, keep needed items within reach, use side rails to enhance bed mobility, ask R1 during rounds if he needs to use the bathroom, and be sure R1 call light is within reach, and encourage R1 to use it for assistance as needed. R1 needs prompt response to a request for assistance. The Care Plan dated 03/2/22 documents R1 is at risk for falls related to (blank). There is nothing documented as to why R1 is at risk for falls. The interventions are documented as: be sure call it is within reach and encourage use for assistance, anticipate and meet individual needs of R1, and complete the fall risk review per the facility protocol. The Physician Order Sheet dated 3/31/22 documents R1 was ordered a physical therapy evaluation and treatment due to gait and new therapy provider. The original physical therapy was from 1/13/2022. The Minimum Data Set (MDS) dated [DATE] Section G of the MDS Documents R1 needs a one-person physical limited assist for transfers, walking in the room, walking in corridors, locomotion on and off unit, and toilet use. It is documented when walking and moving in and off toilet R1 is not steady but is able to stabilize without staff assistance. It is documented that R1 uses a wheelchair as an assistive device. Section I of the MDS dated [DATE] documents R1 has not had any falls since readmission or reentry or the prior assessment. This documentation is incorrect because in progress notes it is documented that R1 had a fall on 1/13/22 and 1/17/22. The Physical Therapy notes from 3/1/22 document R1 has been referred to skilled physical therapy to address remaining deficits to be able to return to previous level of function therapy is necessary to address impairments in muscle strength, balance, activity tolerance, cognitive and safety deficits. Without therapy, R1 is at risk for falls and functional decline. R1 has been in therapy since 1/14/22. R1's safety awareness is documented as minimally impaired. The cognition functional limitations are safety is limited by need for assistance in transfers, gait, and bed mobility. Current level of function for transfers is documented as R1 is able to safely complete a bed to wheelchair transfer with contact guard assist. R1 needs initiation of cues in verbal, tactile and visual instructions. R1 is able to ambulate 150 feet on level surfaces and requires a contact guard assist with a rolling wheelchair with initiation of cues and verbal, tactile and visual instructions for safety. The Occupational Therapy notes dated 3/1/22 documents R1 presented to occupational therapy following a decline in function and recent fall on 1/13/22. R1 presents with deficits in balance, endurance, strength, and cognition. Recovery further complicated by occupational deprivation and current [CONDITION(S)] treatment. Fall risk balance is documented as a high risk and fall recovery balance is documented as severely impaired. R1 is documented to have moderate cognitive abilities with frequent direction required in occasional situations. R1 requires cues and redirection for safety. The physical therapy discharge summary documents R1 had been improving in all areas but still required some assistance only to sustain safety in closer assist with functional gait. The policy titled, Fall Prevention Policy, with no date noted documents Purpose: To ensure safety to all residents within their functional abilities, maximizing their independence and minimizing their risk for falls and associated injuries . 2. Residents at high risk will be monitored closely by staff for: gait, coordination and balance problems, lack of safety awareness and physical endurance.

Based on interview and record review, the facility failed to provide appropriate and sufficient supervision, and failed to provide adequate interventions for a resident to prevent him from falling and sustaining injuries. This failure affected one resident (R7) who had two falls within one week with injuries requiring hospital evaluation. Findings include: R7 is an [AGE] year-old man who has resided in the facility since 2018 with the following past medical history: Hypertensive [CONDITION(S)] without heart failure, [CONDITION(S)] Unspecified organism, [CONDITION(S)] disease, [CONDITION(S)] unspecified affecting right dominant side, Dementia, Essential primary hypertension, Dysphagia oral phase, unsteadiness on feet, need for assistance with personal care, Senile entropion of unspecified eye etc. On 2/28/2022 11:55AM, R7 was noted in bed alert, and awake, states that he is doing okay. He does not remember how long he has been in the facility. Bed in low position, wheel- chair noted at bedside, no floor mats. On 2/28/2022 at 2:13PM, V7 (Restorative Nurse) said that when there is a fall, the care plan is updated, she is not sure of the time period, they will do investigation and update as necessary. Fall is considered an incident, sometimes, the intervention may have been there and becomes a repetition, but care plan should reflect a revision date. On 2/28/22 at 2:39PM, V4 (Wound Care Nurse) said that she is familiar with R7, he is a total care and a fall risk. R7 had a fall on 1/14/2022, she was working on the floor when the C.N.A notified her, resident was on the floor, when she got to the room, he was sitting in his wheelchair in his room before the fall, he may have tried to get up. Resident sustained an injury in the same site he had one after the last fall, he was sent to the hospital. On 2/28/22 at 4:00PM, V20 (RN) said that R7 is a very high fall risk, he requires staff assistance for transfer and eating, resident is also disoriented and incontinent of bowel and bladder. V20 added that R7 should not be in his room by himself. He should always be at the nursing station when not in bed. Review of R7's care plan initiated 11/01/2016 and revised 10/16/2018, 5/4/2020, 5/12/2020 and 2/08/2022 states: I am at risk for falls r/t Use of Cardiovascular medications, [CONDITION(S)] Accident ([CONDITION(S)]), [CONDITION(S)], Arthritis, and Visual impairment; I had a fall with injury and sutures to head on 5/4/2020. Interventions include to encourage resident to sit back in wheelchair, frequent observation to assist resident in sitting back in w/c. Facility Minimum Data Set (MDS) assessment dated [DATE] section C coded R7 scored a BIMs of 00, section B coded R7's vision as moderately impaired, and section G coded him as 4/2, indicating extensive with one-person physical assist for transfer, eating and toilet use. Facility fall incident presented by V1 (Administrator) showed that R7 had an unwitnessed fall in his room on 1/09/2022 and sustained a laceration on right side of forehead; and was sent to hospital for evaluation. R7 had another unwitnessed fall in his room 5 days later, on 1/14/2022, sustained an injury at the same site and was also sent to the hospital for evaluation. Resident's care plan was not revised or updated after both fall incidents. Progress note dated 1/09/2022 at 21:40 states; Called to resident's room by roommate after he states he heard a loud noise in the next bed. Writer and nursing staff observed resident laying on his right side in a fetal position with blood on the floor surrounding the resident's head. Another progress note dated 1/14/2022 at 22:06 states: Roommate call for help, went to attend the call noticed resident on the floor with face down. Hospital record dated 1/14/2022 states that resident was brought for treatment after falling face forward out of his wheelchair, similarly, this happened about 5 days ago, he was in the same emergency room with laceration and was admitted for COVID-19. The same hospital record listed clinical impression as intraparenchymal hematoma of right side of brain due to trauma without loss of consciousness, facial laceration and COVID-19. On 3/01/2022 at 10:34AM, V1 said that if someone falls out of bed, they can lower the bed and put down a floor mat. R7 was falling out of his wheelchair, not from bed. He is very particular about the time he wants to go to bed and if staff put him in the room, he might try to get out of the chair by himself. He is usually in the nursing station or dining room; he is not supposed to be in his room by himself. V1 also said that the facility has used alarms in the past for fall prevention, but they just make annoying noise every time the resident moves. It was not helping so she got rid of them. A document presented by V1 (Administrator) tilted fall prevention policy (Undated) states its purpose as to ensure safety to all residents within their functional abilities, maximizing their independence and minimizing their risk for falls and associated injuries. Some of the interventions that could be used to prevent falls include placing a pad, mat or mattress next to the bed on the floor, chair/bed alarms to alert staff of resident movement, keeping resident at the nursing station for supervision. Another document also presented by V1 titled Care Plan (Undated) states that all residents will have a comprehensive assessment and an individualized plan of care developed to assist them in achieving and maintaining their optimal status. Under item 8, the document states in part that care conferences for review and revision of resident's care plan are scheduled at a conducive time .when a change occurs in a resident's condition .the care plan is then reviewed and updated.

Based on interview and record review, the facility failed to identify, assess, accurately document the existence of a sacral wound, notify physician, and implement necessary treatment orders in preventing the development and or worsening of sacral wound for one (R4) of three residents reviewed for pressure ulcers. This deficiency resulted in R4 developing a facility acquired Stage 3 pressure ulcer on the sacrum. Findings include: R4 is a [AGE] year old resident admitted in the facility on 11/29/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 was discharged from the facility on 01/17/22. According to R4's Admission Skin Integrity Review dated 11/29/21, R4's skin was intact upon assessment. Bath and Skin report dated 12/01/21 indicated that a skin abnormality was observed on R4's sacrum. R4's Treatment Nurse Initial Skin Alteration Review dated 12/02/21 documented: Stage 3 pressure injury to coccyx, measuring 2 centimeters (cms) in length by 2 cms in width. This wound was noted as date of onset 11/29/21. Physician Wound Notes dated 12/03/21 documented: Exam - Sacrum; Stage 3 pressure injury to sacrum. Measures 2cm (centimeters) x 1 cm x 0.1 cm. Wound is 100% granulation tissue. Scant serous exudate. Plan - Recommend [MEDICATION(S)] applied every three days and PRN (when necessary). Due to patient's (R4) comorbidities she is at high risk for developing new and worsening wounds. On 02/08/22 at 11:47 AM, V13 (Wound Care Nurse) was interviewed regarding R4's sacral wound. V13 stated, Upon admission on 11/29/21, her skin assessment documented skin intact. I did her skin assessment on 12/01/21, but I documented the assessment on 12/02/21 with her having stage 3 pressure ulcer on the sacral/coccygeal area. R4 was actually admitted with Stage 3 pressure ulcer on the sacral area. I cannot recall what happened exactly, but I don't know what happened. According to the measurements, the size was small measuring 2cm (centimeters) x 2cm. On 12/03/21, it was measuring 2cm x 1cm x 0.1cm. R4 was seen by V14 (Wound Physician) on 12/03/21 and V14 ordered a [MEDICATION(S)] pad treatment. On 11/29/21, there was no order for any wound treatment. The wound treatment wound order was given on 12/03/21. V13 also verbalized, Her (R4) hospital records prior to admission showed that she has sacral coccyx wound, here is the proof. V13 provided documentation written as: Hospital Records 11/03/21 - Wound orders 11/05/21: Wound care daily; cleanse sacral coccyx with wound cleanser; pat dry; cover with DuoDerm every three days. The hospital records did not specify exactly the stage of R4's wound on the sacral/coccyx area. The wound orders were dated 11/05/21. There was no other documentation provided by the facility regarding R4's wound assessment and orders during hospital discharge. R4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no other treatment orders prior to 12/03/21. On 02/08/22 at 3:23PM V16 (Registered Nurse/RN) was asked about his assessment on R4 upon admission. V16 replied, I don't remember her exactly, maybe I did the skin assessment. If a resident is admitted , I do the skin assessment. If the skin assessment is documented as skin intact, the skin has no lesion and there are no pressure ulcers. On 02/09/22 at 1:46 PM, V27 (Assistant Director of Nursing) was asked about R4. V27 stated, R4 was admitted with a wound on the sacral area; I don't know what stage. Admitting nurses will do the assessment and document and notify the treatment nurse for any skin issues. After that, wound care nurse takes care of the wound by calling the wound doctor for orders. Upon admission, wound orders from the hospital will be carried out. If there is no wound order upon admission, the primary doctor will be notified, and he will order something and also a referral to wound doctor. In case of R4, I don't see any wound orders when she was admitted . I don't know exactly what happened that time with the wound orders. On 02/08/22 at 4:30 PM, V14 (Wound Physician) and V15 (Nurse Practitioner) were interviewed regarding R4. Both V14 and V15 stated that they cannot recall if they were notified of any skin issues on R4 when she was admitted . V14 stated, Generally, if there is a new wound, yes we would hear from the wound care nurse. I don't know from the top of my head if this is something present on admission or not. Typically, the way it works is if nurses identify a site, they would have the wound care nurse come in and evaluate the patient and we would typically hear from the wound care nurse and we will give orders. Generally, our expectation is if there is a new wound, we should hear about it so decision could be made as far as treatment. On 02/09/22 at 10:15 AM V2 (Director of Nursing) was asked about expectations of staff in preventing the development and worsening of pressure ulcers among residents. V2 replied, Keeping patients dry; turning and repositioning every two hours or when needed for comfort; use of devices like pillows, boots for support and offloading; encouraging high protein diet and fluid intake. In terms of assessment, staff need to do skin checks once a day at least; the nurses have to do skin checks per shift. CNAs (Certified Nurse Assistants) should report anything unusual like pinkness, bruise or skin discoloration to the nurse and the nurse should assess and evaluate and contact physicians for orders. We also do skin assessment upon admission and notify wound care nurse for any skin issues. R4's care plan regarding increased risk for alteration in skin integrity related to CKD ([CONDITION(S)]), date initiated 11/30/21, documented: Intervention initiated 11/30/21 - skin will be checked during routine care on a daily basis and during the weekly bath or shower schedule per resident preference. R4's care plan regarding alteration in skin integrity and at risk for additional and/or worsening of skin integrity issues, Pressure injury sacrum, date initiated 12/06/21, was reviewed. Interventions initiated 12/06/21 documented: pressure reducing/relieving mattress and wheelchair cushion as needed.; Precautions for preventions of pressure ulcers will be completed: Good pericare and drying of the skin; Apply protective barrier cream; Reposition resident frequently when in bed/chair/geri chair (reclining chair) and or wheelchair; Offload heels PRN (when needed); CNA shower/skin observations to be reported to nurse for any unusual findings/changes in the resident's skin integrity. Facility Pressure Ulcers: Prevention policy dated 7/96 documented in part but not limited to the following: Policy: Residents who are at risk for developing pressure ulcers will be protected from skin breakdown. Skin Care and Early Treatment Guideline: Inspect skin at least once a day. Facility Incontinence policy, undated, documented in part but not limited to the following: Policy: 6. Skin checks are to be done during incontinent care and if any areas of redness or possible breakdown is observed the nurse/treatment nurse is to be notified ASAP (as soon as possible).

Based on interviews and record reviews, the facility failed to ensure that supervision and monitoring of a resident with cognitive impairment and swallowing difficulties were implemented in preventing a choking incident for one (R1) of three residents reviewed for accidents and supervision. This deficiency resulted in R1 who was found unresponsive, with a piece of sandwich inside the mouth and subsequently died . Findings include: R1 is a [AGE] year-old, female, admitted in the facility on [DATE] with diagnoses of Unspecified Sequelae of Cerebral Infarction; Cerebral Infarction, Unspecified; Unspecified Dementia with Behavioral Disturbance; Alzheimer's Disease, Unspecified; Need for Assistance with Personal Care; [CONDITION(S)], Unspecified and Manic Episode, Unspecified. Physician Order Sheet (POS) dated [DATE] recorded R1's diet as no added salt, pureed texture. According to progress notes dated [DATE], R1 was found unresponsive in bed. A small piece of sandwich was found inside her mouth. Paramedics were called and came. R2 was pronounced dead at 9 PM. Death Certificate dated [DATE] documented R1's causes of death as follows: Asphyxia; Choking on food bolus. On [DATE] at 2:50 PM, V3 (Assistant Director of Nursing) was interviewed regarding R1. V3 stated, She had been here for a while in the facility. She was alert, oriented to time, place and person. She had behavior issues by going to other residents' rooms and pulling the lights. She is able to move her upper extremities and able to transfer self from bed to wheelchair. She is able to feed herself without supervision. I don't remember if she has any swallowing difficulties. She was able to eat with no issues. She eats in her room. V3 was asked about what happened to R1 on [DATE] when she was found unresponsive. V3 replied, that day, she was found unresponsive by V10 (Registered Nurse, RN) and I was informed. He (V10) called paramedics. I went to the room, she (R1) was lying on the bed, unresponsive. Paramedics were there but they did not take her to the hospital. They said they cannot do anything because she was a DNR (do not resuscitate) and expired. He (V10) told me that when he saw her, she was lying on the bed and unresponsive. V10 said she was sitting in the wheelchair roaming in the hallway 10 minutes before. I don't know if they intubated her or not, paramedics were in the room and said they found a small piece of food in her throat. She was not a feeder and needed tray set up only. We just leave the tray on the table and R1 eats her foods without staff supervision. She does not need a staff supervising her when eating. On [DATE] at 11:15 AM, V4 (RN) was also asked regarding R1. V4 stated, She was alert, oriented to person and place; and has to be redirected constantly. She had behaviors by going into other residents' rooms, would put herself on the floor and crawl and lie on the floor. She was able to feed herself. Staff needs to do a tray set up and she can eat independently without supervision. She does not need any supervision during eating. She eats in her room. Staff just need to give her the tray and she can feed herself without staff present. She needs to be redirected; she was not one on one. She does the behaviors on purpose; she does not need constant supervision due to behavior. V8 (RN) also stated in an interview on [DATE] at 11:29 AM regarding R1. V8 replied, She was alert, oriented to person, place and time. She was able to verbalize what she wants but she wanders from one room to another and in the hallway. She needs redirection, she had a lot of behaviors. She eats independently. I am not sure if she needs supervision during eating. Most of the time I do the treatment and can't remember. Per MDS (Minimum Data Set) dated [DATE], R1's BIMS (Brief Interview for Mental Status) score was 2 which means severe cognitive impairment. Her functional status for activities of daily living (ADL) assistance indicated that she needs supervision from one person physical assist during eating. Her MDS also recorded: Section K100 - Swallowing disorder: A. Loss of liquids/solids from mouth when eating or drinking - yes. Nutritional Risk Review dated [DATE] documented: B. Oral Intake: Food 6. Signs and Symptoms of possible swallowing disorder - 2. Pocketing and/or drooling Care plan date initiated [DATE] documented: ADL self-care performance deficit related to Dementia - Intervention: Eating - supervision assistance one person physical assist. On [DATE] at 12:12 PM V17 (Dietary Technician) was asked regarding swallowing ability of R1, V17 stated, She was alert, had a mechanically altered diet which is a pureed diet. She had some swallowing difficulties when she was eating. I do know she was verbal and had a diagnosis of Dementia. She was alert enough to feed herself but needed set up with her meals and needed supervision while eating. She had some difficulty with swallowing. She had drooled lots of foods indicating swallowing difficulties. She can only eat pureed foods and thin liquids. She did not have any sandwiches in her diet but pureed. V10 was asked on [DATE] at 12: 55 PM regarding R1's incident on [DATE]. V10 verbalized, That day, when I did my rounds from room to room I found her unconscious. I immediately called paramedics. She (R1) actually has a behavior - she likes to eat foods from other residents. She was not alert or oriented. I remember that she went to residents' rooms and ate their foods, she does that ,d+[DATE] times. I remember she steals foods from other residents. She cannot walk and uses a wheelchair and keeps on moving and moving around. I don't remember if she was a feeder, but she steals foods from other residents meaning she is able to eat by herself. Care plan date initiated [DATE] regarding impaired cognitive function/dementia or impaired thought processes. Intervention: Date initiated [DATE] - Cue, reorient and supervise as needed. Care plan date initiated [DATE] regarding at risk for a decline: I will be able to feed self after set up with supervision. Intervention: Monitor/document/report to MD (Medical Doctor) PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Care plan date initiated [DATE] regarding at risk for falls and injury due to decreased functional mobility skills, impaired cognition, poor safety awareness. Intervention: Resident (R1) requires frequent monitoring secondary to Dementia. V3 was asked regarding R1's behavior of stealing and eating other residents' foods. V3 mentioned, She goes to other residents' rooms just to pull the bathroom call lights and said she did it purposely. I am not aware that she steals or eats other residents' foods. It was care planned regarding her room to room wandering. She needs to be redirected and educated because she is alert and oriented. She does not need supervision. There were no care plans formulated addressing R1's behaviors of going to other residents' rooms, stealing foods and eating the foods from other residents. On [DATE] at 3:08 PM, V16 (Nurse Practitioner) was asked regarding R1. V16 stated, She was not alert and oriented. She had memory impairments. She had a [CONDITION(S)] ([CONDITION(S)], Stroke). She also had psychiatric issues. She does not talk. I am not aware of her behavior of going to other residents' rooms. I don't know. She passed away. When they called me, they found like a food in her mouth. She was unresponsive, a DNR and was declared dead. Most of the [CONDITION(S)] residents are on aspiration precautions. Staff needs to do supervision on residents at least every two hours, do rounds to make sure that residents are safe, no falls and alive. Staff are also expected to know their residents, their care plans and other medical information. Facility's policy titled Policy and Procedure Safety and Supervision of Residents dated ,d+[DATE] documented in part but not limited to the following: Policy Statement Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation Resident-Oriented Approach to Safety 1. Our resident-oriented approach to safety addresses safety and accident hazards for individual residents. 2. Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS. 3. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff; d. ensuring that interventions are implemented; and e. documenting interventions 5. Monitoring the effectiveness of interventions shall include the following: a. ensuring that interventions are implemented correctly and consistently Systems Approach to Safety 1. The facility-oriented approaches to safety are used together to implement systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

1. Based on interview and record review, the facility failed to ensure that agency staff were trained on facility specific protocols related to abuse and misappropriation of resident property prior to working at the facility; facility staff admitted to accepting a resident's debit card to accommodate personal requests for the resident against facility protocol. This failure applied to one (R89) of one resident reviewed for abuse in a sample of 35. Findings include: R89 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Abuse risk assessment dated [DATE] documents as factors that increase resident's vulnerability (e.g., dementia, confusion, disorientation, poor insight/poor judgement, poor communication skills, poor ambulation or inability to ambulate/propel wheelchair, frailty/weakness, history of exploitation, heavy care needs, unable to make needs known, on [CONDITION(S)] meds.) R89's current plan of care includes focus: (Date Initiated 6/21/2021) R89 is at risk for abuse; he may voice allegations of mistreatment or exploitation by caregivers - Interventions are dated (Initiated 10/20/2021) Assure resident that he is safe and secure. Assure him that needs will be addressed by trained caregivers. Facility reported incident dated 10/14/21 documents: R89 gave his debit card to (V39) (Agency CNA) on 9/2/2021 and asked her to withdraw 100.00 and purchase him some items. Resident claims more than 100.00 was withdrawn and money was kept by the CNA. Interview of (V39) was done with local Police Department and Assistant Administrator. (V39) stated that she was given the debit card by resident on three different occasions to purchase items and to get resident cash which he was giving to another resident in exchange for favors. (V39) also stated that the resident was giving money to his brother who was supposed to be helping him to get out of the nursing home. When resident was questioned, he denied all of the above except for giving her the debit card to get him things. Bank statements show multiple withdrawals at multiple locations during the month of September. Local Police Department informed (V39) that she would need to meet with a detective from the local Police Department on Monday 10/11/2021. (Staffing Agency) representative was notified of all of the above. A follow up call to detective at local Police Department was made on 10/13/2021 to find out if (V39) did come in to talk with them and see if anything was determined. A message was left to let us know. At this time, it is inconclusive, and investigation is ongoing. 10/20/2021 at 10:35AM, V1 (Administrator) was asked for status of this investigation regarding misappropriation of property, and she stated that (V39) (Agency CNA) is no longer working here and not allowed to come back because that is not something that we do here - referring to staff accepting resident debit cards to purchase items. It is not allowed. If the resident needs something, then we can help them obtain it but that is not our policy (to take the debit card and make purchases). V1 was asked how are agency staff made aware of facility policies and policies related to abuse/misappropriation of property and V1 responded that agency staff get training from their agency unless they are at the facility on a day that they are doing training. Per (staffing agency liaison) the CNA should have known that this is not allowed behavior. Review of employee file for V39 does not include any documentation that V39 was trained on what constitutes abuse and misappropriation of resident property by their respective staffing agency. There was no documentation in V39's employee file nor was it indicated by interview with V1 that V39 was ever oriented to facility specific policies, practices, and/or procedures. Facility abuse policy (revised 11/28/17) includes (but not limited to): Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse III. Orientation and Training of Employees What constitutes abuse, neglect, exploitation, mistreatment and misappropriation of resident property . Staff obligations to prevent and report abuse, neglect, exploitation, mistreatment and misappropriation of resident property . On an annual basis, supervisory personnel will receive training on their obligations under law when receiving an allegation of abuse, neglect or misappropriation of resident property, and how to monitor and correct inappropriate or insensitive staff actions, words or body language. 2. Based on observation, interview, and record review, the facility failed to keep a resident free from neglect by failing to provide the necessary care and services to ensure that the resident maintained a clean and sanitary environment as well as proper hygiene to promote the resident's well-being. This failure applied to one (R77) of one resident reviewed for neglect and resulted in R77 being neglected by being left to lie in her own urine and feces and her bedroom to be in unsanitary conditions. Findings include: R77 is a [AGE] year-old with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/17/21 at 11:30 AM, R77 was in bed with sheets covering her entire body. Upon entering the room, you were met with sharp, pungent odors of urine and a lingering smell of feces. Flies were buzzing about the room with numerous flies that covered R77's body. Surveyor called to R77 to see if R77 was awake, R77 stated, What do you want? Surveyor asked if everything was okay, R77 responded, I'm asleep go away. On 10/18/21 at 11:35 AM R77 was covered up under her sheets and laying on her side. Her sheets appeared to have dried yellowish, brownish stains and reeked of urine. Flies that were present the previous day, appeared to multiply and covered the majority of R77's body. As the surveyor fanned R77's body to get a better glimpse of R77, the flies dispersed but then quickly landed back atop R77's body and covered most of her back and buttocks area. The flies apparently were drawn to the accumulated urine and fecal matter on her body. V31 (RN) was asked about R77 and stated, I'm an agency nurse. I can't tell you much about these people here. I saw (R77) earlier and yes, she was in bed. She doesn't like anyone dealing with her. Is there a problem? Surveyor asked if she was aware of the flies and the condition of the resident, V31 stated, Yes but I think she likes to be left alone. Surveyor asked whether anyone could clean the room or change R77's clothes or bed linens, V31 stated, I'll let housekeeping know. 10/19/21 at 12:40 PM, surveyor entered the room with another surveyor and observed R77 in bed partially covered with soiled linens and a black winter coat. Urine odors that pervaded the room were more pungent and sharper smelling then the previous day. Numerous flies were buzzing about and were on R77 and appeared to be feeding and attracted to R77's backside which appeared stained with urine, and fecal matter as observed the previous two consecutive days. The sheets R77 were laying on appeared to have dried up urine and tinged with dark brown and almost blood-tinged stains. Surveyor asked if she was bleeding or needed medical attention, R77 stated, I'm fine, I'm not bleeding, go away. V34 (Housekeeper) was across the hall from R77's room and was asked whether she had already cleaned R77's room and V34 stated, Yes, I'm done with that side already. Surveyors asked V34 to accompany them back to R77's room and asked who maintained the room and bed linens. V34 stated, I saw that, but I don't clean her, that's the CNA's (certified nurse's aide) job; I don't do that; I just clean the room. Surveyor asked whether the room looked clean to her as the room was pungent with odors and filled with flies. V34 stated, That's because they don't clean her (referring to R77). Surveyor asked if she pointed this out to the nursing staff and V34 stated, No that's not my job. Surveyor asked V18 (Licensed Practical Nurse) if R77 was her patient and V18 responded, Yes, I'm the nurse today, but I'm not normally on this floor because I usually work another floor. They just put me up here today so I can't help you much. Surveyor asked V12 (CNA) if she had seen or took care of R77 and V12 stated, It's my second day here. I'm from the agency but I saw R77 earlier I think about 8am or 8:30am. Surveyor asked V12 to describe what she saw and V12 stated, She's (R77) got flies all over her and it smells in there, but I didn't notice this before. R77's current care plans include (but not limited to): 1) Create a warm, safe & inviting environment for care (e.g., pull down blinds, close curtains/doors, make sure the lighting is adequate, try to create a home-like bathroom/shower area. Emphasize dignity. Resident has a self-care deficit (ADL-activities of daily living/Mobility). 2) Encourage resident to participate as much as safely and able with ADL hygiene tasks. There was no other documentation provided during the course of the survey to show that facility was making attempts to meet the basic hygiene and care of the resident. 3. Based on interview and record review, the facility failed to keep a resident free from verbal abuse by staff as a result of staff making inappropriate comments to resident. This failure applied to one (R56) of one resident reviewed for abuse in a sample of 35. Findings include: R56 is a [AGE] year-old male with a diagnosis's history of [CONDITION(S)] and [CONDITION(S)] who was originally admitted to the facility 06/04/2014. On 10/18/21 at 12:48 PM R56 stated he experiences verbal abuse from one nurse. R56 stated V37 (Licensed Practical Nurse) at times asks him When is the baby due, because he is overweight? R56 stated V37 has been making these statements for the last month or two and has recently began doing so in front of other people. On 10/19/21 at 8:28 PM V1 (Administrator) stated V37 (Licensed Practical Nurse) admitted to making the comment to R56 asking When is the baby due and acknowledged that it was inappropriate, however, she stated it was meant it in a playful manner? The facility's abuse policy (revised 11/28/17) states: Abuse is defined as the willful infliction of mental anguish. Abuse includes verbal abuse. Willful, as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict harm.

Based on interview and record review the facility failed to assess and monitor a resident at risk for elopement and failed to implement interventions to prevent the resident from leaving the facility through a first floor window for 1 of 3 residents (R1) reviewed for accidents and incidents in a total sample of 10. This failure resulted in R1 leaving the facility and walking towards a 4 lane intersection. R1 was found sitting on the ground the next day at a nearby gas station. R1 requires continuous oxygen and did not have oxygen available after elopement. R1 was noted in respiratory distress and transferred to the hospital where the resident was diagnosed with Pneumonia requiring intubation. This was identified as immediate jeopardy that began on 8/19/21 when R1 eloped from the facility and was removed on 9/16/21. V1(administrator) was informed of the immediate jeopardy on 09/10/21. However, the deficiency remains at a level 2 harm until the facility can evaluate the effectiveness of the in-services given to the facility staff members. Findings Include: The Face Sheet documents that R1 was admitted to the facility on [DATE] with a diagnosis of [CONDITION(S)], heart failure, [CONDITION(S)] and [CONDITION(S)]. R1's hospital record dated 8/8/21 prior to admission to the facility documents that the resident was seen in the emergency room for respiratory distress. R1 was requesting to leave, and a psychiatric evaluation was done. R1 presented with poor judgment and insight and was placed on elopement precautions with 1:1 monitoring and a sitter prior to being discharged . Nurse's Notes dated 8/18/21 documents that R1's vitals were stable, and the resident was on oxygen and being monitored. Resident on inhalers prescribed during hospital admission. Nurse's Notes documents that R1 was not in the his room on 8/19/21 at 10:40pm. A search of the building was done, and the resident was not located. A chair was noted up against the resident's window with the screen pushed out. The Police were called, and a missing person report filed. R1's family notified. Nurse's Notes dated 8/20/21 at 7:03am documents that R1 was found walking outside of the building. R1 was short of breath. The paramedics called and R1 transferred to the local hospital for evaluation. On 9/2/21 at 1:45pm V3 (Nurse) stated Doing rounds when I got there, I noticed R1 wasn't in the room. This was around 10:30-10:40pm and we started a search of the building. I went back to the room when the resident wasn't found in the building. I noticed a chair against the window and 2 latches snapped on the window so the window would be able to open wide. The window screen was missing. I went outside and the screen was on the ground. R1 jumped out of the window. I notified the Physician and the family. I couldn't find the resident outside at all. I called the Police and filed a missing person report. Staff found the resident walking back to the facility around 6am. The oncoming nurses saw R1 and got a wheelchair to bring the resident back into the building. I asked the resident what happened and R1 said 'I wanted to get out of here, I wanted to have a good time.' I checked the resident's vitals and R1 was short of breath. I gave the resident oxygen, I called 911, within 5 minutes the paramedics were here and R1 was transferred to the hospital. On 9/2/21 at 1:55pm V4 (DON) stated When I came in that morning, I was told by the nurse that R1 was absent from the resident's room during rounds. On second shift the resident was in bed and was last seen around 10:20pm. When the oncoming Nurse did rounds for third shift around 10:30pm the resident was gone. Staff did search the building and could not find the resident. Staff called the Physician and the family. R1 had been telling staff 'I want to go home.' The day shift staff saw the resident by the gas station and the nurses went to get the resident. R1 continued to say, 'I want to go home.' The Physician was notified and R1 was sent to the hospital. R1 did not come back to the facility. The family came in and picked up the resident's belongings. Social Service does the Elopement Risk Assessment but the nurse's complete the initial assessment on admission. They look for things like the resident saying they want to leave, behaviors of hanging around doors or exits and stairwells, and residents asking guests about getting out of the facility. If the resident is alert and oriented staff will talk with them and have social service talk with them to find out the reason for wanting to leave. Staff will increase monitoring and get family involved. I'm not sure if R1 ever talked with Social Services. On 9/2/21 at 2:20pm V6 (Social Service Director) stated R1 was not assessed for elopement by Social Services. Social Service met with the resident for MDS assessment and got a BIMS Score of 14 out of 15. R1 was also monitored for being depressed. I was not aware of any exit seeking behaviors. No one told me that R1 was requesting to leave the facility. If notified we would chart the behaviors, notify the Administrator, and create a care plan with interventions. We would also update the care plan quarterly. We meet with the residents within 2 weeks of admission for elopement risks unless there's behaviors present. I wasn't aware of any behaviors. On 9/2/21 at 2:35pm V7 (Nurse) stated R1 was supposed to be on 5 liters of continuous oxygen but the resident was constantly taking it off. I kept redirecting and educating the resident. R1 was also on isolation and the resident was non-compliant and kept leaving the room asking for cigarettes, getting cigarettes, and going outside to smoke. Sometimes I would go in to check the resident's oxygen levels and R1 would not be in the room, R1 would be out smoking. I called R1's family and I heard the resident on the phone saying, 'I want to leave, I want to go home, and I don't want to be here.' The family said they would come and bring the resident some things from home. R1 understood but was still non-compliant, leaving the room and not wearing the oxygen. I last saw the resident around 10:30pm and R1 was in the room. I told the Nurse that R1 was non-compliant, the resident was smoking, leaving the room and wouldn't listen. I notified the family, and I notified Social Services but I'm not sure which social service person I spoke to. I always tell social services if I notice elopement behaviors. Hospital records reviewed and documents that on 8/20/21 at 7:50am R1 was brought to the emergency room after escaping the nursing facility overnight and being found wandering the streets. R1 was wrapped in blankets and presented with chills. R1 had an increased heart rate and had an increase in oxygen needs. R1 was diagnosed with pneumonia and [CONDITION(S)]. R1 had increased respiratory distress and increased [MEDICATION(S)] levels. R1 was intubated and placed on the ventilator. R1 did not return to the facility. On 9/3/21 at 12:05pm V9 (CNA) stated I was going to the gas station before my shift started and I saw someone sitting on the sidewalk. R1 was having trouble breathing. R1 hollered to me 'I need help, have staff at the nursing home bring a wheelchair.' I had never seen R1 before. I went back to the facility and let the staff know that the resident was at the gas station. The staff came and brought the resident back to the facility and R1 was sent out. R1's Community Survival Skills assessment dated [DATE] documents that R1 did not appear capable of unsupervised outside pass privileges and staff will continue to monitor. R1's Elopement assessment dated [DATE] documents that R1 did not have a history of elopement, R1 did not have any behaviors and staff will continue to monitor. R1's care plan on admission documents that R1 presents with altered respiratory function requiring oxygen therapy due to a diagnosis of [CONDITION(S)]. R1 presented with movement behaviors that may be interpreted as wandering, pacing, or roaming due to a diagnosis of [CONDITION(S)] and problems understanding the immediate environment. Staff is to implement preventative intervention strategies: assess for potential elopement or unauthorized departure risk and make rounds or room checks per facility protocol to minimize the chance of unauthorized leave. The surveyor confirmed via observation, record review and interview the facility did the following to remove the immediacy: Immediate action taken: R1 no longer resides in the facility. On 9/09/21 reassessments were completed for all residents (9) who have been identified at risk for elopement/exit seeking behaviors and their care plans have been updated as needed as of 9/09/21 and 09/10/21 this was completed by Psychiatric Rehabilitation Services Director (PRSD). On 9/10/21 hospital referral paperwork is reviewed prior to admission by administrator and DON to review resident needs and recommendations. Audits were conducted by the DON of hospital paperwork sent at time of admission to review hospital recommendations of a new resident to the facility. DON will provide staff nurses with information and place in the 24-hour report for ongoing communication. There will be a weekly audit to ensure residents are assessed and monitored along with interventions as needed. 09/09/21 The affected window in the Resident's room and all windows in the facility have been checked and immediate repairs (tightening of screws, replacement of window straps showing any signs of wear and tear) have been completed and are ongoing to ensure they are secure. Completed by maintenance staff. On 09/16/21 All exit doors and alarms were checked and will continue to be checked per shift by designated staff. On 9/16/21 additional security measures were put in place for windows by adding a mechanism (one way screw) to prevent windows from manually being unscrewed by resident(s). This was installed on first floor level 09/16/21 but will be installed throughout the facility completely by 9/24/2021 to ensure the safety and security of residents in the facility. On 09/10/21 all staff members on duty have been in-serviced on the new facility elopement policy, elopement assessment and intervention, elopement monitoring procedure and implementation of interventions based on resident's hospital recommendations and behaviors. All remaining staff not within facility premises have been contacted and provided education as of 09/10/21. On 09/10/21 audits will be conducted by the PRSD upon admission of a new resident and weekly to ensure residents at risk for elopement are assessed and monitored along with interventions as needed. An elopement communication binder was placed at the front desk and at each nursing station which entails the list of residents at risk elopement/exit seeking behavior with pictures, diagnoses, behaviors, and interventions to utilize.

Based on interviews and record reviews, the facility failed to follow their abuse policy and manage a resident with a history of aggressive behavior for one (R5) out of four (R4, R5, R6, R9) residents reviewed for abuse. This failure resulted in R5 setting R1 hair's on fire. R1 sustaining first and second [MEDICAL CONDITION] her scalp and left ear. Findings include: R5 was admitted on [DATE].R5 has a BIMS (brief interview for mental status) score of 15 which indicates cognition is intact. R5's PASSR (Preadmission Screening) was dated 9/2/2014. The PASSAR screen denotes R5 needs services for aggression/anger management. On 8/17/19, a Psychiatric Evaluation was done by V18 (Nurse Practitioner). The Comprehensive plan recommendation included: continue to provide assistance with ADL (Activities of Daily Living), encourage to group therapy/activities provided by the facility, continue to monitor behavioral issues, and to continue current medications. On 8/26/19, a Social Service (S.S.) initial interview for SMI/Substance Abuse Disorder was completed by V6 (psychiatric rehabilitation service coordinator) for R5. This assessment is completed for newly admitted residents to the facility with mental illness and substance disorders. A review of the assessment indicates R5 reported that she experienced symptoms of hearing voices, seeing things, and homicidal/suicidal thoughts. On this assessment, R5 answered yes to a question in regards to ever trying to injure or kill another person. R5 also answered yes to a question in regards to have you ever caused harm by setting a fire. On 8/26/19, A Smoking Risk Review was completed by V6 (PRSC) for R5. The recommendations and outcomes were that R5 may independently be able to handle smoking materials. On 8/27/19, A Screening Assessment for Indicators of Aggression and/or Harmful Behavior was completed by V6. The assessment recommends R5 is potentially able to integrate with structure, direction, and supportive counseling. The Criminal History Analysis Security Recommendation Report prepared on 9/6/19, indicates R5 is a moderate risk which means R5 requires closer supervision and more frequent observation than standard or routine for most residents in an open facility. Regular monitoring should be attentive to behavioral changes that may signal a need for closer observation or sustained visual monitoring on a time-limited basis. Periodic assessments should ascertain whether the level of supervision is sufficient. R5's state criminal history background indicates she has a history of battery/bodily harm and knowingly damage to property. Progress note documentation on 10/4/19 at 9am reflect, R5 had an argument with her roommate 10/4/19 at 10am. R5 was then moved to (another) Room XXX. Further progress note documentation on 10/4/19 reflects R5 was upset about the move and wanted to leave AMA (Against Medical Advice). R5 became more agitated, verbally abusive, and threatening violence. The physician was notified and R5 was given [MEDICATION NAME] 5mgs. R5 continued verbally abusive and threatening behaviors and subsequently sent out to the hospital for a psychiatric evaluation. A review of progress notes dated 11/17/2019, 12/11/2019, and 12/16/19, all reflect smoking violations that include R5 smoking in her bedroom or bathroom. Each time R5 was re-educated on the facility smoking policy by V9 (Psychiatric Rehabilitation Service Coordinator-PRSC). On 12/23/19, a Smoking Safety Screen was completed by V9 (PRSC) for R5. Per review of the smoking safety screen, R5 is aware of the facility smoking policy but continues to not follow protocol. Staff will continue to give cues, reminders, and redirection as needed. R5 is aware of the smoking destination but choses to not use it which at times she smokes in her room. Staff will continue to give her reminders. R5 is safe to smoke with supervision. On 1/14/2020 at 1:43 PM, V14 (certified nursing assistant) stated on 1/3/2020 around 10:50 PM she assisted R1 to the bathroom. At that time, R5 was in her bed sleeping. At approximately 11:40 PM, V14 stated she heard screams, and when she entered the room she observed R1's hair on fire. V14 stated, R5 was standing in the bathroom holding a lighter. On 1/14/2020 at 3:25PM, V15 (registered nurse) stated on 1/3/2020 at approximately 10:30 PM, she rounded on R1 and R5. At that time, she stated R1 was sleeping, and R5 was in bed but awake. V15 stated around 11:40 PM, she heard screaming, and when she entered the room she saw a flame on R1's head. V15 stated the fire was put out, and 911was then called. V15 stated she asked R1 what happened, and R1 pointed to R5. V15 stated she assessed R1, and [MEDICAL CONDITION] her head. V15 stated when she entered the room, R5 was in the bathroom doorway smoking a cigarette. V15 stated R5 had a lighter, and she took it away from her. V15 stated R5 flushed the cigarette down the toilet, and R5 did not say where she got the lighter from. V15 stated she asked R5 if she set R1's hair on fire, and she stated she replied I did this and what are you going to do. R5 did not give a reason for why she lit R1's hair on fire. A review of the Unusual Occurrence Report Form for R1 was completed by V15 on 1/4/2020 indicates the occurrence occurred 1/3/2020 at 11:40 PM. R5 set her roommate (R1) hair on fire while she was asleep. The occurrence is described as the following: R1 was screaming and V15 and V14 ran to see what was going on. R1 was noted with a fire (flame) on her hair. The fire was put out, and R1 was asked what happened, and R1 stated her roommate (R5) did it. A review of the Investigation assessment dated [DATE] denotes V15 heard a yell from a room, and when she went to the room, she observed R1 hair on fire. The fire was put out. R5 was noted to be smoking in the bathroom. Per report, R5 stated yes I did, what are you going to do about it *****. R1 received first aid, while staff was doing 1:1 supervision with R5. R1 had blisters to right top of her scalp and to the top of both ears. R5 was sent to the hospital for a psychiatric evaluation. A review of the hospital records dated 1/4/2020 for R5 denotes she presented with homicidal ideation towards roommate. Her admitting [DIAGNOSES REDACTED]. R5 reported to hospital staff she did light her roommate on fire because she did not like her and she just wanted to. R5 was not permitted to return back to the facility. A review of the hospital records dated 1/4/2020 for R1 denotes she had a burn to her scalp with [DIAGNOSES REDACTED] (redness) and a small blister to the right parietal. R5 was diagnosed with [REDACTED]. On 1/14/20 at 11:45 AM, R1 was observed with dry scabbed areas over her scalp and an open area to left ear. Approximately 75% of her hair was short. On 1/16/2020 at 12:53 PM, an interview was conducted with R1 and V20 (Certified Occupational Therapy Assistant) interpreting for R1. R1 stated someone lit her hair and ear on fire, and her head is burned and she wants to go home. R1 stated she has pain to her ear and her scalp, and the medication the nurse applies to her ears help. On 1/15/2020 at 10:03 AM, during interview with V16 and V17 (Licensed Practical Nurse), V16 stated R5 has gotten verbally aggressive with staff in the past if R5 was asked to do something by staff members. V17 (Licensed practical nurse) stated R5 has been verbally aggressive towards other residents in the past. On 1/15/2020 at 12:39 PM, during interview with V9 (PSRC) and V11 (Director of Social Service) V11 stated he was not aware R5 had a history of [REDACTED]. V9 stated R5 did not attend group for anger management when R5 was moved to the third floor in (MONTH) 2019. V9 stated she encouraged R5 to attend group sessions, but V9 did not have 1:1 anger management sessions with R5 when she was moved to the third floor. A review of the Weekly 1:1 charting indicates the last 1:1 anger management session was done on 9/8/19 with R5. There is no documentation for October, November, or (MONTH) of 2019 and (MONTH) 2020 of R5 refusal to attend anger management or 1:1 sessions for anger management. On 1/16/2020 at 9:32 AM, V13 (Medical Doctor) stated 1st [MEDICAL CONDITION] defined as redness of the skin. Second [MEDICAL CONDITION] blisters form and then open, causing the first layer of the skin to open. V13 stated on examination of R1, he observed R1 with 1st [MEDICAL CONDITION] her scalp, and second [MEDICAL CONDITION] her left ear. He stated she has no complaints or sign or symptoms of pain. The current treatment is to apply antibiotic cream until the skin is healed. The purpose of the antibiotic cream is so the areas do not become infected. V13 stated the scalp and left ear are healing. On 1/16/2020 at 9:48 AM, V18 (Nurse Practitioner) stated homicidal ideation is defined as hurting others. The last psychiatric evaluation was completed on 12/31/19 for R5. V18 stated R5 was alert and oriented x3, and based on his observation, R5 is aware of what she is doing. V18 stated R5 stated R5 did not have any psychiatric issues. V18 stated if R5 made the statement she lit her roommates (R1) hair on fire, then he would believe R5. V18 stated R5 has a history of anger issues, and she should be in group for anger management. He stated the purpose for anger management is to help recognize anger issues and manage symptoms of anger and irritation. He stated 1:1 therapy for anger management could also be effective if R5 chooses not to attend group anger management. V18 stated he does not know if R5 was attending group or 1:1 sessions for anger management. A review of the Care Plan did not reflect group or 1:1 sessions as an intervention for anger management. Abuse Policy-Undated: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of [REDACTED]. The purpose of this policy is to assure that the facility is doing all that is within is control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of [REDACTED]. Resident assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS (minimum data set) 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. Facility will assess, prevent and manage aggressive reactions of resident in a way that protects both residents and staff.

Based on interviews and record reviews, the facility failed to comprehensively access, re-evaluate, and supervise 1 of 4 residents (R5) reviewed for smoking safety. The facility failure to follow their smoking and contraband policy resulted in R5 obtaining a cigarette lighter, smoking in areas deemed unsafe/ prohibited by the facility, and subsequently setting her roommate's (R1) hair on fire. This led to R1 sustaining first and second [MEDICAL CONDITION] her scalp and left ear. Findings include: R5 was admitted on [DATE]. A review of the progress notes reflects that on the day of admission, R5 was caught smoking in the bathroom. R5 was informed of the no smoking in the facility rule. On 8/26/19, a Social Service Initial Interview for SMI/Substance Abuse Disorder (S.S.) was completed by V6 (Psychiatric Rehabilitation Service Coordinator-PRSC) for R5. A review of the assessment indicates R5 answered yes to a question in regards to have you ever caused harm by setting a fire. Per this interview, the fire was at another facility. On 8/26/19, A Smoking Risk Review was completed by V6 (PRSC) for R5. The recommendations and outcomes were that R5 may independently be able to handle smoking materials. On 1/17/2020 at 10:09 AM, V6 (PRSC) stated she conducted the Social Service Initial Interview for SMI/Substance Abuse Disorder (S.S.) in which R5 participated in the interview. V6 stated she asked R5 to elaborate on the question regarding causing harm by setting fires, but R5 did not want to provide more details on what occurred. V6 stated the history of setting fire could be a factor, but at the time of the assessment, she did not see R5 as a smoking risk because she did not have her own smoking materials. V6 stated when she was responsible for R5 she had not been caught smoking in undesignated areas. A review of progress notes dated 11/17/2019, 12/11/2019, and 12/16/19, all reflect smoking violations that include R5 smoking in her bedroom or bathroom. Each time R5 was re-educated on the facility smoking policy by V9 (Psychiatric Rehabilitation Service Coordinator-PRSC). On 12/23/19, a Smoking Safety Screen was completed by V9 (PRSC) for R5. Per review of the smoking safety screen, R5 is aware of the facility smoking policy but continues to not follow protocol. Staff will continue to give cues, reminders, and redirection as needed. R5 is aware of the smoking destination but choses to not use it which at times she smokes in her room. Staff will continue to give her reminders. R5 is safe to smoke with supervision. During interview on 1/14/20 V9 (PSRC) stated, Question 8 on the Smoking Safety Screen should have been answered yes in regards to if resident needs the facility to store lighter and cigarettes. V9 stated R5 should have had a Smoking Safety Screen completed after the 2nd violation. After the 2nd encounter room searches are conducted. The room and the person are searched with their consent. On 1/14/2020 at 1:38 PM, V11 (Director of Clinical Services) stated R5 was to smoke with supervision which means there are designated smoking times, and smoking material is handled by staff. V11 stated he was aware that R5 was non-compliant with the smoking policy. V11 stated social services may conduct a random room searches if residents are suspected of having contraband. The room searches are to be documented. V11 stated room searches were done on 12/11/19 and 12/16/2019 in which smoking material was found in R5's room and removed. V11 stated it is safety issue if someone is smoking in the bathroom, and everyone must be kept safe. On 12/26/19 at 0600 progress notes denote R5 was smoking in the bathroom. On 1/16/2020 at 3:13 PM, V19 (Licensed Practical Nurse) stated on 12/26/19 at approximately 5:00 AM, she smelled cigarette smoke in R5's bathroom. V19 stated she asked R5 if she was smoking and R5 admitted to smoking. V19 stated she reported the occurrence to the oncoming nurse and charted on the 24 hour report sheet to inform Social Services. There was no documentation of a room search being completed after the 12/26/19 occurrence. On 1/14/2020 at 1:43 PM, V14 (Certified Nursing Assistant) stated she has observed R5 smoking in the bathroom in the past, but she was not asked to do a room search. She stated she reported her observation to social services, and she was not aware R5 required supervision with smoking. V14 stated that on 1/3/2020 around 10:50 PM she assisted R1 to the bathroom. At that time, R5 was in her bed sleeping. At approximately 11:40 PM, V14 stated she heard screams, and when she entered the room she observed R1's hair on fire. V14 stated, R5 was standing in the bathroom holding a lighter. On 1/14/2020 at 3:25PM, V15 (Registered Nurse) stated on 1/3/2020 at approximately 10:30 PM, she rounded on R1 and R5. At that time, she stated R1 was sleeping, and R5 was in bed but not asleep. V15 stated around 11:40 PM, she heard screaming, and when she entered the room she saw a flame on R1's head. The fire was put out, and 911was called. V15 stated she asked R1 what happened, and R1 pointed to R5. V15 stated she assessed R1, and [MEDICAL CONDITION] her head. V15 stated when she entered the room, R5 was in the bathroom doorway smoking a cigarette. V15 stated R5 had a lighter, and she took it away from her. V15 stated R5 flushed the cigarette down the toilet. She stated R5 did not say where she got the lighter from. V15 stated she asked R5 if she set R1's hair on fire, and R5 replied I did this and what are you going to do. She stated R5 did not give a reason for why she lit R1's hair on fire. A review of the hospital records dated 1/4/2020 for R1 denotes she had a burn to her scalp with [DIAGNOSES REDACTED] (redness) and a small blister to the right parietal. R5 was diagnosed with [REDACTED]. On 1/14/20 at 11:45 AM, R1 was observed with dry scabbed areas over her scalp and an open area to left ear. Approximately 75% of her hair was short. On 1/16/2020 at 12:53 PM, an interview was conducted with R1 and V20 (certified occupational therapy assistant) interpreting for R1. R1 stated someone lit her hair and ear on fire, and her head is burned and she wants to go home. R1 stated she has pain to her ear and her scalp, and the medication the nurse applies to her ears help. 1/15/2020 at 9:35 AM, V2 (Assistant Administrator) stated residents can lose their smoking privileges if they are not compliant with the policy. Staff is not constantly monitoring residents while smoking on the patio. On 1/15/2020 at 10:14 AM, V22 (Certified Nursing Assistant) stated she has observed cigarette butts and smelled smoke in R5's bathroom. She stated she was not instructed to do a room search. V22 stated she was not aware that R5 needed supervision with smoking, nor did she ever escort her to the patio to smoke. V22 stated R5 was an independent smoker as she would come and go and she pleased. On 1/15/2020 at 10:37 AM, V17 (Licensed Practical Nurse) stated R5 was an independent smoker and she was not aware she required supervision with smoking. She stated R5 continued to smoke up until the day she was discharged . She stated approximately three weeks ago, she observed R5 asking other residents for cigarettes. V17 stated approximately one month ago, she observed smoke in R5 bathroom, and R5 admitted to smoking. V17 stated she did not search R5 or her belongings. On 1/15/2020 at 12:39 PM, during interview with V11 (Social Service Director) and V9 (PSRC), V11 stated he was not aware R5 had a history of [REDACTED]. He stated a person having a history of setting fires, needs to have some level of monitoring. V11 stated certified nursing assistants and nurses are to monitor residents who are on supervised smoking. V9 also stated R5 should not have been safe to handle her own smoking material with her history of setting fires, and this history should have been care planned. V9 stated she suspected R5 of smoking in her room after 12/16/19, but no room searches were documented after 12/16/19. V9 stated R5 told her she was getting cigarettes from other people. V9 stated we can't stop R5 from getting cigarettes from others because we are not around her 24/7. V9 stated she does not know who monitors R5 while she is smoking when V9 is not there. On 1/17/2020 at 12:10 PM, V5 (Administrator) stated the smoking patio opens at 6 AM, closed at meal time, and then closed for the night at 10 pm. The independent smokers were allowed to smoke anytime the patio was open and were allowed to handle their own smoking material. V5 stated if a resident was on supervised smoking, they were on a schedule. V5 stated she was aware R5 was non-compliant with the smoking policy, but she did not know where R5 was getting smoking materials or lighters from. Facility Safe Smoking Safety Policy-undated Smoking is only allowed in the designated area established by management. Indoor smoking is prohibited by state or local law and the interior of the facility will remain smoke-free at all times. The organization has the right to enforce a policy prohibiting residents from keeping any smoking materials in their possession for health, safety and security reasons. Smokers will be evaluated to determine their ability to comply with safety rules and their ability to carry materials. Residents requiring supervision shall receive their monitoring consistent with their assessment and plan of care. Individuals who are non-compliant, potentially dangerous, exercise poor judgment and show a lack of concern for the welfare of others will be counseled accordingly. The facility maintains the right to limit and restrict access to smoking products, matches and lighters for person deemed unsafe. Smoking privileges will be revoked if there is a pattern of persistent, hazardous behavior. All persons interested in retaining smoking privileges must follow the guidelines set forth in this policy. The following behaviors and/or conditions will jeopardize and cause revocation of the person' independent privileges: Smoking in any non-designated area, such as residents' rooms, bathrooms, hallways, elevators, stairways and/or smoke-free courtyard. Self-harmful/injurious behaviors, such as burning clothing, hands, fingers, face or lips. This category includes residents who are generally careless while smoking and may present a significant risk of fire setting. Residents on supervised smoking are not permitted to have/carry any smoking materials in their possession at any time Residents living quarters shall be randomly searched/checked for smoking material/contraband Policy on Room Searches, Contraband Items and Removal of Contraband dated (MONTH) 7, 2011 This organization reserves the right to conduct inspections if there is reason to suspect/believe that a resident has contraband items/materials in his/her possession. These items include, but are not limited to, alcohol, illicit street drugs, weapons (including any sharp objects), and smoking material (if the individual has proven to be dangerous and irresponsible with smoking related items). The following items are not allowed in the resident's possession if he/she has been assessed as an unsafe smoker (i.e.) smoking in residents' room, other unauthorized areas, [MEDICAL CONDITION] otherwise exposing self or peers to a dangerous situation by dropping lit matches or cigarettes.