Every finding on record at Cityview Healthcare and Rehabilitation

Based on observation, record review, facility policy review and interview, the facility failed to implement protective measures to prevent the development of pressure ulcers when a resident's motorized wheelchair cushion was ill-fitted and metal was exposed. This affected one resident (#23) of three reviewed for pressure ulcers. The facility census was 90.Actual harm occurred on 08/10/26 when Resident #23, who had paraplegia (partial or complete paralysis of the lower half of the body) and was dependent on staff for activities of daily living (ADLs), developed two new in-house acquired unstageable full-thickness pressure ulcers on the left leg due to pressure from a shifting motorized wheelchair cushion and exposed motorized wheelchair metal that went unrepaired or replaced. After identifying the resident's pressure wounds, protective measures to protect the leg from exposed metal were not put into place until 08/24/26, 14 days later. Findings include:Review of the medical record for Resident #23 revealed he was admitted to the facility on [DATE] with diagnoses that included paraplegia, depression, and hypertension. Review of the care plan dated 05/15/26 revealed Resident #23 had paraplegia related to a complete lesion at the fifth cervical vertebra (total loss of sensory and motor function below the site of the damage), was at risk for impaired skin integrity and pressure ulcers related to paraplegia and was at risk for falls. Interventions included an air mattress to the bed, pressure reduction devices, treatments as ordered, staff to anticipate and meet his needs, and to assist with ADLs.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The assessment included Resident #23 was impaired on both sides of his upper and lower extremities, utilized a motorized wheelchair, and was dependent on staff for ADLs. Review of the skin grid pressure assessment dated [DATE] revealed Resident #23 had a new in-house acquired unstageable pressure wound (a full-thickness skin and tissue loss where the true depth and damage cannot be seen) to the back of his left knee measuring 3.3 centimeters (cm) length and 3.8 cm width, and a new Stage III pressure wound (a deep, crater-like wound involving full-thickness skin loss that exposes the underlying subcutaneous fat tissue and may contain dead tissue) to the posterior left lower leg measuring 1.5 cm length, 2.2 cm width and 0.1 cm depth (but it was covered with slough (dead tissue)). The assessment indicated Resident #23's new wounds to the back left knee and posterior left lower leg were caused by his motorized wheelchair cushion moving out of place leaving the back of his left knee and left lower leg exposed to and in contact with the metal part of the motorized wheelchair.Review of the nursing progress note dated 08/10/26 at 2:08 P.M. revealed Resident #23 had two new skin alterations, one on the back of his left leg and one on the back of his left calf. The area on the back of his left calf had a pink skin alteration and the area on the back of his left knee in the crease had a white skin alteration with a pink border. Resident #23's physician was notified. Review of the nursing progress notes prior to 08/10/26 revealed no protective measures implemented to prevent skin breakdown to Resident #23's left leg from his motorized wheelchair cushion moving and exposing his skin to metal on the motorized wheelchair.Review of the physician orders prior to 08/10/26 revealed no protective measures implemented to prevent skin breakdown to Resident #23's left leg from his motorized wheelchair cushion moving and exposing his skin to metal on the motorized wheelchair. Review of the physician orders dated 08/10/26 revealed Resident #23 had an order in place to cleanse his left posterior lower leg with normal saline, pat dry, apply xeroform gauze (a non-adherent wound dressing) and cover with bordered gauze dressing daily and as needed. Review of the progress note dated 08/12/26 at 11:27 A.M. revealed Resident #23 remained in his motorized wheelchair throughout the day without taking recommended rest periods or repositioning and/or offloading. Resident #23 was educated on prolonged sitting and lack of pressure relief may negatively affect wound healing. Other than education, there were no protective measures implemented to protect Resident #23's left leg from additional injury due to his motorized wheelchair cushion moving and exposing his skin to metal on the motorized wheelchair. Review of the progress note dated 08/13/26 at 1:00 P.M. revealed the interdisciplinary team (IDT) met to discuss Resident #23's skin alteration to the back of his left knee and left posterior lower leg. Resident #23 reported the motorized wheelchair cushion moved and the leg possibly pressed against the metal part of his motorized wheelchair. A new intervention was to encourage frequent rest periods throughout the day to reduce prolonged pressure and promote adequate recovery. There were no interventions implemented to address the motorized wheelchair cushion movement or to protect any exposed metal on the motorized wheelchair.Review of the facility provided purchase order receipt dated 08/13/26 at 10:51 A.M. revealed an order was placed for a ROHO AirLite Wheelchair Cushion (a nonadjustable wheelchair cushion for posture support, stability and skin protection without needing manual air inflation or adjustments) through a durable medical equipment (DME) supplier with no tracking information available. The receipt provided an order number listed as CRTN00000017615. The receipt was approved by the Administrator on 08/13/26 at 11:29 A.M.Interview on 08/17/26 at 8:45 A.M. with the Administrator and Director of Nursing (DON) revealed Registered Nurse (RN) #717 completed weekly wound rounds every Monday with Nurse Pratctitioner (NP) #671.Review of the skin grid assessment dated [DATE] revealed Resident #23's left posterior leg had improved. The wound remained scabbed over. The true depth was unstageable due to presence of the scab. The back of the left knee continued to have slough although some of it cleared away. The remaining slough could not be debrided due to adherence to the wound bed. The true depth was unable to be determined. A new treatment was ordered. The assessment indicated the resident was poorly compliant with offloading, making the presence of the wound unavoidable; however, the assessment provided no evidence of any protective measures used to prevent Resident #23's motorized wheelchair cushion from shifting and/or covering the exposed metal of the motorized wheelchair.Review of the physician orders dated 08/17/26 revealed Resident #23 had an order in place to cleanse the back of his left knee with normal saline, pat dry, apply silver alginate (a specialized dressing used to absorb heavy fluids while fighting bacterial infections), cover with silicone super absorbent dressing daily and as needed.On 08/19/26 at 4:30 P.M. Resident #23 was observed seated in his motorized wheelchair with the exposed metal part visible, and when the resident opened his legs, it revealed the left leg in contact with the exposed metal. Interview with Resident #23 at the time of the observation revealed he developed two new wounds on the back of his left leg due to the facility not helping him get a new motorized wheelchair cushion. He stated he informed the staff that the wounds were due to his motorized wheelchair cushion slipping and moving out of place which exposed a metal part that his leg rested on. Resident #23 revealed he needed a new cushion weeks ago.Observation on 08/24/26 at 10:58 A.M. revealed Resident #23 in bed sleeping with his motorized wheelchair positioned adjacent to his bed. The metal part was still exposed and not covered. Interview on 08/24/26 at 11:46 A.M. with Therapy Supervisor (TS) #800 revealed Resident #23 was not currently receiving therapy services; however, he was aware that his wheelchair cushion was not working. TS #800 revealed Resident #23's wheelchair cushion had a slow leak for the past couple weeks, and he would periodically pump air into it as a quick temporary fix. TS #800 revealed he also provided Resident #23 with an air pump to add air to it on his own once it deflated. TS #800 revealed Resident #23 did not have Dycem (a material designed to grip and stabilize objects or prevent slipping) in place to keep the cushion from moving because he was not a fall risk and those were only in place with residents who were identified as being at risk for falls. TS #800 stated a different company was contacted approximately one month ago but declined servicing the wheelchair due to where it had been originally purchased. TS #800 revealed he informed Resident #23 to reach out to the company where it was originally purchased, but he never followed up with the resident. A new inflatable cushion was ordered approximately one week ago but he was not sure when it would be delivered. TS #800 confirmed and verified he was aware Resident #23's cushion needed repaired, the facility did not provide Dycem to prevent it from shifting and that he only provided a temporary fix of inflating the cushion periodically. Interview on 08/24/26 at 12:41 P.M. with RN #717 revealed Resident #23's new wounds were first identified on 08/10/26 during a skin sweep. Resident #23 informed her that the cushion to his wheelchair moved and exposed the metal part. RN #717 stated she informed Resident #23 to stay off his bottom, or out of his chair or to get in bed. RN #717 verified Resident #23 had no Dycem put in place to prevent the wheelchair cushion from slipping and stated this was because he was not at risk for falls. The RN also verified there was no protective covering over the wheelchair metal. RN #717 stated TS #800 ordered a new motorized wheelchair cushion, and it would be available soon. Interview on 08/24/26 at 1:52 P.M. with NP #671 revealed Resident #23 had two new areas to the back of his left leg. NP #671 stated she could not identify when they occurred due to Resident #23 being out of the facility on some days but stated it was brought to her attention on 08/10/26. Resident #23 had informed her that his motorized wheelchair cushion was out of place, and his left leg lay on top of the exposed metal part. NP #671 revealed Resident #23 spent a lot of time sitting in his motorized wheelchair, so the wounds were a result of the metal part being exposed and pressed upon his skin causing pressure wounds. NP #671 revealed Resident #23 had an additional area right under left posterior knee, in the same general area as the other which happened at the same time, however, it had already been scabbed over. Observation on 08/24/26 at 3:44 P.M. revealed Resident #23's motorized wheelchair was not fixed at this time. An interview with the resident at the time of the observation verified his motorized wheelchair cushion was not fixed, but the staff had placed a towel over the metal exposed part. Observation of the motorized wheelchair revealed a white cloth towel positioned over the metal exposed part. Observation on 08/24/26 at 3:47 P.M. with Licensed Practical Nurse (LPN) #637 of Resident #23's motorized wheelchair revealed a white cloth towel was positioned over the metal exposed part of his motorized wheelchair at time. The LPN confirmed a white cloth had been placed at this time. Interview on 08/24/26 at 4:00 P.M. with the motorized wheelchair company Representative #672 revealed Resident #23's motorized wheelchair had been purchased from them in 2024. Resident #23 contacted them on 07/07/26 and inquired about repairing his motorized wheelchair cushion, however, his insurance would not cover the repairs while residing in a nursing home from their company, but other companies could. Representative #672 revealed there were no other documented calls from Resident #23 or the facility regarding a motorized wheelchair cushion or discussion on out-of-pocket cost. Interview on 08/25/26 at 11:19 A.M. with DME Representative #673 revealed the facility had not placed any orders with them for DME (ROHO cushion) since 2025. The last motorized wheelchair cushion purchase from the facility was in May 2018. Interview on 08/25/26 at 11:32 A.M. with DME Representative #674 revealed the facility had not placed an order for motorized wheelchair cushions since 2025 and absolutely nothing within the last 30 days. Interview on 08/25/26 at 11:46 A.M. with Medical Records Coordinator (MRC) #660 revealed she placed an order for Resident #23's motorized wheelchair cushion on 08/13/26 through the DME supplier; however, the purchase had to be approved by the corporate office before it was processed. MRC #660 revealed she had not received any response from the corporate office regarding Resident #23's motorized wheelchair cushion. Interview on 08/27/26 at 9:17 A.M. with the DON revealed Resident #23's wounds to the back of his left leg were due to exposure of a metal part on his motorized wheelchair because the cushion was deflated. The DON revealed the wounds were first identified on 08/10/26 and orders for treatment for his skin were put in place and she stated a new motorized wheelchair cushion was ordered. She stated she did not know exactly when the cushion would arrive as it was controlled by the corporate office. The DON confirmed Resident #23's pressure wounds were a result of the unrepaired cushion and staff did not attempt to cover the exposed metal part until 08/24/26. Interview on 08/27/26 at 9:50 A.M. with the Administrator revealed MRC #660 placed a request for Resident #23's cushion to be ordered and she approved it. After she approved it the request went through the corporate office as the next steps and she had no control over the process after that. The Administrator stated that MRC #660 contacted the corporate office on 08/25/26 for an update and was informed it was getting approved as of 08/25/26. Review of the facility document titled Wound Management Program updated February 2024, revealed the facility had a policy in place to minimize the development of facility-acquired pressure injuries by identifying, treating and putting in place measures to facilitate healing. Further review of the policy revealed avoidable pressure ulcers would develop when the facility did not evaluate the resident's clinical condition and risk factors and implement interventions that were consistent with resident needs and professional standards of practice. This deficiency represents non-compliance investigated under Complaint Numbers 3074279, 3131616, and 3170502.

Based on observation and interview, the facility failed to ensure there was sufficient operating laundry equipment to consistently provide clean washcloths and towels to meet resident needs. This had the potential to affect all 93 residents residing at the facility. Findings include:Observation and interview on 09/17/26 at 9:14 A.M. of the linen closet on the second floor with Certified Nursing Assistant (CNA) #278 confirmed there were no available washcloths or towels to clean her residents. Observation and interview on 09/17/26 at 9:55 A.M. of the third-floor linen closet with Licensed Practical Nurse (LPN) #282 confirmed there were no towels or washcloths available to clean residents. Interview on 09/17/26 at 10:31 A.M. with CNA #213 confirmed her residents resided on the fourth floor. She started her shift at 7:00 A.M. and revealed she had no washcloths or towels to clean up her incontinent residents at all during her shift. Observation at the time of the interview of the linen closet on the fourth floor confirmed there were no washcloths or towels available. CNA #213 stated she just went downstairs to the laundry room and there were no clean washcloths or towels available. Interview on 09/17/26 at 10:40 A.M. with Housekeeping/Laundry Manager #294 confirmed staff on all three residential floors were out of washcloths and towels. Housekeeping/Laundry Manager #294 stated being down a dryer and only one washing machine was working. This had been going on for six to seven months and it was common to run out of linen, washcloths and towels. Observation of the laundry area at the time of the interview with Housekeeping/Laundry Manager #294 revealed one working commercial washer and one working dryer. Housekeeping/Laundry Manager #294 confirmed it was the only laundry equipment in use except for a small washer (not in use at the time of the observation), which was used for personal items only, and stated everyone was aware there was only one working washer and dryer. Housekeeping/Laundry Manager #294 verified it was not enough equipment to keep up with the laundry demand. Interview on 09/21/22 at 10:42 A.M. with the Administrator revealed it was an understanding when a resident was admitted to the facility, the facility would provide the washcloths and towels for resident use, and it was an expectation they would be available when care was needed. Administrator stated there was no policy for providing linen, washcloths or towels.

Based on resident record review, resident interview, staff interview, and facility policy review, the facility failed to provide reasonable and timely access to residents' personal funds along with a documented receipt for withdraw of funds. This affected four residents (Residents #18, #31, #41 and #93) of four residents reviewed for personal funds. The facility census was 90.Findings include:1. Review of the medical record for Resident #18 revealed an admission date of 02/17/26 with diagnoses that included hypertensive heart disease with heart failure, paranoid schizophrenia, and type two diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated no cognitive impairment. Resident #18 required some assistance from staff for activities of daily living (ADLs). Review of the care plan dated 08/11/26 revealed Resident #18 had a self-care performance deficit and was a long-term resident with interventions that included assisting with adjustment to the facility and providing support as needed. 2. Review of the medical record for Resident #31 revealed an admission date of 10/20/21 with diagnoses that included paranoid schizophrenia, major depressive disorder and generalized anxiety. Review of the care plan dated 07/01/26 revealed Resident #31 had potential for ADL self-care performance deficit with interventions to provide assistance as needed. Review of the MDS assessment dated [DATE] revealed Resident #31 had a BIMS score of 10 that indicated moderate cognitive impairment. Resident #31 required some assistance from staff for ADLs. 3. Review of the medical record for Resident #41 revealed an admission date of 01/06/15 with diagnoses that included hyperlipidemia, osteoarthritis, and major depressive disorder. Review of the care plan dated 06/29/26 revealed Resident #41 was a long-term resident with interventions that included assisting with adjustment to the facility and providing support as needed. Review of the MDS assessment dated [DATE] revealed Resident #41 had cognition impairment. Resident #41 required staff assistance for ADLs. 4. Review of the medical record for Resident #93 revealed he was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure, and chronic kidney disease. Review of the care plan dated 08/04/26 revealed Resident #93 had an ADL self-care performance deficit with interventions that included providing support as needed. Review of the MDS assessment dated [DATE] revealed Resident #93 had a BIMS score of 15 that indicated no cognitive impairment. Resident #93 was dependent on staff for ADLs. Review of the facility document titled Trial Balance dated 08/24/26 revealed the facility had 71 resident accounts being managed by the facility with a current balance of $45,827.87. Resident #18 had an allotted allowance of $420.00 with a current balance of $69.16; Resident #31 had no designated allowance with a current balance of $3,214.18; Resident #41 had an allotted allowance of $420.00 with a current balance of $831.21; and Resident #93 had no designated allowance with a current balance of $2,413.02. Review of Resident #93's account transaction history revealed he had two advanced cash withdrawals for $35.00 and $75.00 on 08/24/26. Requests for the receipts for Resident #93's transactions on 08/24/26 revealed the facility was unable to provide it. Interview on 08/24/26 at 2:34 P.M. with Receptionist (REC) #711 revealed she provided assistance to residents regarding access to their funds. Residents were able to come to the receptionist and request money from their account, and if it was available, it was given to them. REC #711 verified if a resident allowance was $75.00, then he/she should get $75.00, but stated sometimes residents were unable to receive the amount they requested due to not having enough money available in the facility. REC #711 revealed residents were provided with receipts for every transaction, but there were no receipts being issued for now because the facility did not have any receipt books. REC #711 confirmed Resident #93 was upset on this date due to him not having access to his requested amount of $75.00, but she had provided Resident #93 with $30.00 because that was all she had left to give. REC #711 stated she was given a different amount each day to distribute among residents and once that amount was depleted, there were no other funds to distribute if requested. REC #711 further stated, If we run out of money, we run out. REC #711 confirmed if a resident balance was $400.00 and they requested $400.00; the facility would deny it because residents had to be capped at a certain amount so that all residents could have access to some of their money. REC #711 revealed if Residents #18, #31, #41, and #93 each requested money from their account, then each resident would only be allowed to receive $75.00 or less depending on what she had in the petty cash safe. REC #711 revealed the process was on a first-come first-served basis. Interview on 08/24/26 at 2:45 P.M. with Administrator revealed the facility was provided with $545.00 per day to distribute amongst all residents requesting money from their accounts. The facility was still waiting for approval from the corporate office to increase the amount provided daily due to the increase in the census. Administrator verified the residents were only able to withdraw $75.00 from their accounts daily despite their allotted allowance amounts and/or requested amounts above that. Interview on 08/25/26 at 3:15 P.M. with Resident #93 revealed he had requested money on the previous day (08/24/26) from the facility out of his account of $75.00, but he was denied the amount requested. Instead, staff told him he could only have $30.00 as it was all they had to give, so he had to take it or leave it. Resident #93 was also not provided with a receipt for it. Review of the facility policy titled, Managing Resident Personal Funds revised January 2021 revealed residents were entitled to maintain personal funds accounts to be used for personal preference items. Resident fund transactions were to be tracked on a log with receipts for all transactions and produced at any time. This deficiency represents non-compliance investigated under Complaint Number 3170579.

Based on resident record review, observation, resident interview, staff interview, and facility policy review, the facility failed to provide a clean and sanitary environment. This affected one resident (Resident #23) of three residents reviewed for physical environment. The facility census was 90.Findings include:Review of the medical record for Resident #23 revealed he was admitted to the facility on [DATE] with diagnoses that included paraplegia, depression, and hypertension. Review of the care plan dated 05/15/26 revealed Resident #23 had paraplegia related to a complete lesion at the fifth cervical vertebra, was at risk for impaired skin integrity and pressure ulcers related to paraplegia, and at risk for falls. Interventions included air mattress to bed, pressure reduction devices, treatments as ordered, to anticipate and meet his needs, and assist with activities of daily living (ADLs). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated he had no cognitive impairment. Resident #23 was impaired on both sides of his upper and lower extremities, utilized a motorized wheelchair, and was dependent on staff for ADLs.Observation and interview on 08/24/26 at 10:58 A.M. revealed there was a pile of soiled linen on the floor of Resident #23's room. The pile of linen was stained with unknown brown and yellow substances with unidentified flying bugs rotating above the pile. Resident #23 was observed in bed sleeping. Housekeeper (HKP) #609 was observed in the room exiting Resident #23's bathroom. HKP #609 verified the pile of soiled linen with bugs flying above it remained on the floor and stated the Certified Nursing Assistants (CNAs) were responsible for removing soiled linen from resident rooms. Observation and interview on 08/24/26 at 3:44 P.M. of Resident #23 in his room approximately three and one half hours after the initial observation revealed the same pile of soiled linen remained on the floor. It was stained with unknown brown and yellow substances with unidentified flying bugs rotating above the pile. Resident #23 was lying in bed and complained that the dirty stuff had been there all day with flies. Interview on 08/24/26 at 3:47 P.M. with Licensed Practical Nurse (LPN) #637 in Resident #23's room verified the pile of soiled linen on the floor with bugs flying above it. LPN #637 stated the facility CNAs were responsible for removing soiled linen from resident rooms. Review of the facility policy titled, Linen: Handling, Storing and Transporting Guidelines, dated April 2018 revealed soiled linens would be contained in a laundry bag, covered bin or pillowcase and placed in a designated container for transport. This deficiency represents non-compliance investigated under Complaint Numbers 3170579 and 3131616.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure an effective call light system and its timely repair. This affected 28 (#2, #8, #10, #14, #15, #18, #23, #25, #26, #30, #33, #39, #42, #44, #45, #48, #53, #58, #60, #65, #66, #69, #72, #76, #81, #82, #86 and #90) of 90 residents reviewed for call lights. The facility census was 90.Findings include:Observation on 08/17/26 from 8:10 A.M. to 8:45 A.M. revealed the second-floor unit did not have an active call light system in place. Residents utilized small silver hand bells to alert staff of care needs. There were 41 rooms with only 28 of the rooms being utilized by residents (Residents #2, #8, #10, #14, #15, #18, #23, #25, #26, #30, #33, #39, #42, #44, #45, #48, #53, #58, #60, #65, #66, #69, #72, #76, #81, #82, #86 and #90) who were given the hand bells. There were no audible sounds heard related to active ringing of hand bells. Interview on 08/17/26 at 8:10 A.M. with Resident #82 revealed his call light did not work, and the facility gave him a hand bell to use instead. Resident #82 stated he did not use the hand bell because staff did not hear it. Interview on 08/17/26 at 8:15 A.M. with Registered Nurse (RN) #642 revealed the second-floor unit did not have a call light system working, but the residents had hand bells to ring if they needed anything. RN #642 stated she could hear the hand bell if it was ringing. RN #642 reported it had been a few weeks since the system was broken. Interview on 08/17/26 at 8:30 A.M. with Resident #15 revealed the facility gave him a hand bell to use as a call light. Resident #15 stated the call light had not worked since the day he arrived at the facility which was the beginning of July 2026. Resident #15 stated when he sat in the common areas he had heard some hand bells ringing, however, staff did not. Interview on 08/17/26 at 8:32 A.M. with Resident #39 revealed staff did not hear his hand bell when he used it. Resident #39 stated he often attempted to reposition himself without help due to staff not hearing his hand bell. Interview on 08/17/26 at 8:45 A.M with Administrator revealed the call light system went down a couple of weeks ago, but she could not confirm the actual date. Administrator stated the facility was waiting on a contractor to fix the call light system. Administrator verified there were 28 residents on the second-floor unit who had to utilize hand bells as a temporary fix. Interview on 08/17/26 at 3:03 P.M. with Licensed Practical Nurse (LPN) #637 revealed the call light system was broken but the residents used hand bells. LPN #637 stated she did not always hear the hand bells, but staff tried to work together to ensure resident needs were met. There was one assigned Certified Nursing Assistant (CNA) that sat in a chair at the opposite end of the unit to listen for the hand bells. Observation at the time of the interview of the second-floor unit hall revealed there was no staff or CNA seated at the opposite end to listen for resident hand bells. Interview on 08/17/26 at 3:06 P.M. with CNA #701 verified the second-floor unit did not have a call light system in place. CNA #701 stated she attempted to round often to listen for hand bells, but the bells were not always heard. Interview on 08/17/26 at 3:10 P.M. with Resident #44 revealed she dd not have a call light in her room. Resident #44 stated she had a hand bell that the staff could not hear and therefore it took a long time to get assistance. Resident #44 complained everyone had a call light except for her unit, and there was not a designated CNA that sat and listed for us to ring the bells. Review of the call light system documents provided by Administrator revealed the call light system went down on 07/20/26 and the contractor came to the facility on [DATE] for an inspection and consultation. The contractor provided an estimate dated 07/23/26 for a total of $23,110.31 with a deposit due of $17,332.73. Review of electronic correspondence between Administrator and the facility corporate office regarding the call light system, dated 07/24/26, revealed the call light system for the second-floor unit went out on 07/20/26 and the contractor quote was sent as it was urgent for replacement due to the acuity of the unit but in the meantime the residents all had cow bells (hand bells). Review of email correspondence between Administrator and the facility corporate office dated 08/13/26 and 08/17/26 revealed a request for an update and a response that the corporate office had made a down payment on 08/17/26 of 50 percent of the required down payment toward the second-floor work to begin.Review of an electronic financial payment dated 08/17/26 revealed the facility transferred a total of $9,763.00 on 08/17/26 to the contractor (50 percent of the required deposit to begin services).Follow-up interview on 08/18/26 at 8:40 A.M. with Administrator revealed that the second-floor unit call light system went down, and she was informed that it was unrepairable and a new system had to be installed. Administrator stated the residents on the second-floor unit used hand bells in the meantime until the new call light system was installed. Administrator reported that the facility had paid for a new call light system to be installed after the outage happened on 07/20/26, approximately 30 days ago and they were waiting on the contractor to begin the process of installation, but she did not know when the install would take place. Interview on 08/18/26 at 9:06 A.M. with the call light system Contractor #670 revealed it was on file that the facility had contacted them to replace the call light system, but there was no information related to repairs for the second-floor unit. The facility was given an estimate, and a full down payment was required before installation services began. Contractor #670 verified the facility was not scheduled to start installation of the call light system and he could not provide a timeframe of when that process would start. Interview on 08/18/26 at 9:30 A.M. with Administrator revealed the facility contacted the contractor to confirm payment was received but she could not confirm a start date for repairs. Interview on 08/18/26 at 9:53 A.M. with Activity Aide (AA) #656 revealed the call light system had been down a few months throughout the facility and residents had to use hand bells. Interview on 08/18/26 at 9:58 A.M. with the Director of Maintenance (DOM) #909 confirmed the call light system had been down for a few weeks and after being notified he contacted the contractor immediately. DOM #909 revealed the contractor ordered the parts required for installation yesterday, 08/17/26. He was informed the call light system would be repaired on 08/24/26. Observation on 08/18/26 from 8:30 A.M. to 10:00 A.M. of the second-floor unit revealed residents who utilized hand bells could not be heard by staff who were providing care to other residents with a closed door. There was no alternative system or method in place for staff to know when a resident still required care or assistance after the ringing of the hand bell stopped, and there was no tracking system to indicate how long a resident was waiting for assistance. Interview on 08/18/26 at 10:15 A.M. with Administrator confirmed the call light system for the second-floor was still not functioning and there was only hand bells in place for the residents to use until it was fixed. Observation on 08/24/26 at 3:50 P.M. with LPN #810 of the second-floor unit revealed the call light system was still not functioning, and residents were still using hand bells. Interview on 08/25/26 at 3:25 P.M. with LPN #810 and CNAs #605 and #666 revealed the call light system on the second-floor unit was still not in working order and it was unknown when it would be fixed. Review of facility policy titled, Call Light Policy, reviewed September 2025 revealed call lights were to be in working order and when needed to contact the call light system vendor to make arrangements for immediate service. This deficiency represents non-compliance investigated under Complaint Number 3131616.

Based on record review and interview, the facility failed to initiate timely wound care orders. This affected one resident (Resident #91) of three residents reviewed for wound care. The facility census was 90.Findings include:Review of the medical record for Resident #91 revealed she was admitted to the facility 04/13/26 and discharged [DATE]. She had diagnoses including atherosclerosis of the right leg, diabetes, and chronic kidney disease. Review of Resident #91's nursing wound assessment dated [DATE] revealed she had a surgical wound measuring 3.5 centimeters (cm) length by 1.8 cm width with a small amount of serosanguinous drainage (light pink or pale red fluid). The nurse practitioner ordered it to be cleaned with normal saline and covered with a calcium alginate wound dressing (a dressing used to absorb heavy drainage and help stop bleeding).Review of Resident #91's treatment administration record (TAR) for April 2026 revealed there was no documentation the 04/13/26 order for a calcium alginate wound dressing was completed for the wound until 04/16/26 when an order for daily wound treatments began.Additional review of Resident #91's medical record revealed she was hospitalized from [DATE] to 04/27/26.Review of Resident #91's nursing wound assessment dated [DATE] revealed she had a surgical wound measuring 3.5 cm length by 1.8 cm width with a small amount of serous drainage (clear, thin, watery fluid). She was to have a moistened gauze treatment daily.Additional review of Resident #91's TAR for April 2026 revealed there was no documentation the 04/27/26 treatment was not ordered or documented as completed until 04/30/26. Interview on 08/17/26 at 5:20 P.M. with Registered Nurse #717 confirmed the above findings.This deficiency represents non-compliance investigated under Complaint Numbers 3131616 and 3074279.

Based on record review, observation, interview, and review of facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were maintained when required. This affected one resident (Resident #20) of three residents reviewed for infection control. The facility census was 93.Findings include:Record review for Resident #20 revealed an admission date of 08/04/26. Diagnoses included chronic obstructive pulmonary disease, muscle weakness, and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. Resident #20 used a motorized wheelchair for mobility, was dependent on toileting and personal hygiene, upper and lower body dressing, bed/chair to bed transfers, toilet transfers, and required substantial/maximal assistance for bed mobility. Review of the physician orders for Resident #20 revealed an order dated 09/09/26 to cleanse the left posterior thigh with normal saline, pat dry, apply calcium alginate (a wound dressing used to keep wounds moist and promote healing), cover with silicone super absorbent dressing every evening and as needed (PRN) for wound healing. Observation on 09/17/26 at 1:13 P.M. of wound care for Resident #20's left posterior thigh pressure ulcer with Registered Nurse (RN) #264 assisted by Certified Nursing Assistant (CNA) #233 revealed neither RN #264 nor CNA #233 put on an isolation gown prior to the wound care. They both confirmed they did not put on an isolation gown at any point prior to or during Resident #20's wound care. RN #264 stated there was no need for EBP for Resident #20 because he was not infectious to the staff and he also did not have a catheter. There was no EBP sign observed to be posted inside or near the entrance of Resident #20's room. Interview on 09/17/26 at 1:45 P.M. with RN Unit Manager #291 revealed any resident who had an indwelling catheter or wound should have an order for EBP, and confirmed Resident #20 did not have an order. RN Unit Manager #291 verified he should have an order for EBP, and staff should be putting on gowns and gloves prior to wound care for him. Review of the Skin Grid Pressure dated 09/21/26 revealed Resident #20 had an in-house stage three pressure ulcer (full-thickness tissue loss where subcutaneous fat may be visible, but muscle, tendon and bone are not exposed) to the left posterior thigh first observed on 08/24/26. Observation on 09/21/26 at 10:00 A.M. of CNA #231 provide perineal care for Resident #20 after toileting revealed CNA #231 did not put on an isolation gown prior to providing the peri care. CNA #231 denied being made aware a gown was needed. There was no EBP sign observed to be posted inside or near the entrance of Resident #20's room.Observation on 09/21/26 at 10:17 A.M. with Licensed Practical Nurse #228 confirmed Resident #20 did not have an EBP sign inside his room nor near the entrance of the room. Review of facility policy titled, Enhanced Barrier Precautions updated April 2024, revealed EBP was used in conjunction with standard precautions and expanded the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multi-Drug Resistant Organisms (MDROs) to staff hands and clothing. EBP were indicated for residents with infection or colonization with a MDRO when contact precautions did not otherwise apply, or with wounds and/or indwelling medical devices. For residents for whom EBP were indicated, EBP was employed when performing high contact resident care activities that included assisting with toileting or wound care. An EBP sign was placed to identify the PPE required during high contact care activity.

Based on observation, interview, record review, and facility policy review, the facility failed to prevent medication errors at a rate of five percent or more. This affected two residents (Residents #6 and #68) of three residents reviewed for medication administration. The facility census was 90.Findings include:1. Observation of medication administration for Resident #68 on 08/17/26 at 8:24 A.M. by Licensed Practical Nurse (LPN) #617 revealed the nurse administered one 80 milligram (mg) pill of simethicone (anti-gas medicine) to the resident. Review of the medical record for Resident #68 revealed he was admitted [DATE] and had diagnoses including hemiplegia, dementia, and gastroesophageal reflux disease (GERD). He had an order for simethicone 250 mg to be given with meals. There was no order for an 80 mg dose of simethicone. Interview with LPN #617 on 08/17/26 at 11:50 A.M. confirmed Resident #68 was administered an incorrect dosage of simethicone. 2. Observation of medication administration for Resident #6 on 08/17/26 at 8:40 A.M. revealed LPN #617 drew out and administered two units of insulin from an opened insulin lispro vial from the medication cart with no open date identified. Interview at the time of the observation with LPN #617 confirmed she did not open the insulin, could not confirm when it was opened, and had administered it to Resident #6. Review of the medical record for Resident #6 revealed he was admitted [DATE] and had diagnoses including diabetes mellitus, schizoaffective disorder and major depressive disorder. Review of the Food and Drug Administration website on 08/17/26 regarding insulin storage revealed insulin could be stored at room temperature for up to 28 days and it would continue to work. Review of the facility medication administration policy dated May 2026 revealed nurses were to verify dosage prior to administering medications. The policy made no mention of checking expiration dates before administration. The above findings revealed two medication errors out of 27 observed medication administrations, resulting in a medication error rate of 7.4 percent. This deficiency represents non-compliance investigated under Complaint Numbers 3131616 and 3074279.

Based on record review, interview, and facility policy review, the facility failed to ensure showers were provided when needed or preferred. This affected one resident (Resident #91) of three residents reviewed for showers. The facility census was 90.Findings include:Review of the medical record for Resident #91 revealed she was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, malignant neoplasm of ascending colon and generalized anxiety. Resident #91 was discharged from the facility on 07/01/26. Review of the care plan dated 05/08/26 revealed Resident #91 had an activity of daily living (ADL) self-care performance deficit with interventions that included assisting with care needs and personal hygiene. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 was alert and oriented with some cognition impairment. Resident #91 was dependent on staff for activities of daily living (ADLs). Review of the shower task revealed Resident #91's shower days were Tuesdays and Fridays between 3:00 P.M. and 11:00 P.M. Review of Resident #91's shower sheets for June 2026 revealed there were no documented showers or shower refusals for the entire month. Review of Resident #91's shower sheets for May 2026 revealed Resident #91 received two bed baths on 05/05/26 and 05/18/26 and there were no documented showers provided throughout the month. Interview on 08/17/26 at 8:15 A.M. with Registered Nurse (RN) #642 revealed residents were given showers as needed and requested. All were documented on shower sheets. Interview on 08/17/26 at 3:03 P.M. with Licensed Practical Nurse (LPN) #637 revealed all residents were given showers at least twice a week. Showers were given or bed baths were at least offered if the showers were refused. LPN #637 revealed all showers were documented on shower sheets. Interview on 08/17/26 at 3:06 P.M. with Certified Nursing Assistant (CNA) #701 revealed residents were given showers or bed baths twice a week and it was documented on shower sheets. Interview on 08/18/26 at 8:40 A.M. with Administrator revealed uncertainty about how all showers and/or baths were documented, so she would find out.Follow-up interview on 08/18/26 at 9:30 A.M. with Administrator revealed the facility utilized a combination of shower sheets and/or documented it in the electronic medical record. Administrator verified it was accurate that Resident #91 had two documented bed baths for the month of May 2026 and no showers documented as provided or refused for June 2026. Review of facility policy titled, Activities of Daily Living, updated February 2024 revealed bathing and/or shower needs, including preferences would be honored as much as possible and assisted by facility staff. This deficiency represents non-compliance investigated under Complaint Numbers 3131616 and 3170579.

Based on observation, staff interview, and review of the facility policy and procedure, the facility failed to ensure food was stored in a manner to prevent spoilage and failed to maintain a clean and sanitary kitchen and cooking equipment. This had the potential to affect all 91 residents residing in the facility. The facility census was 91. Findings include:1. Observation during the tour of the kitchen on 03/30/26 from 7:54 A.M. to 8:15 A.M. revealed a moderate amount of dried white splatter on the backside of the stove. Observed on the tray that sat between the stove top and oven had various food items such as corn on it and once the tray was removed revealed dried brown stains. Observed on the silver plate portion of the wall to the right of the three compartment sink had a moderate amount of various, dried food splatter. Interview on 03/30/26 at approximately 8:10 A.M. with Dietary Manager (DM) #611 verified the above findings. 2. Observation on 04/02/26 at 9:56 A.M. of the nursing unit refrigerator on the third floor revealed a moderated amount of dried brown splatter throughout and on the inside door shelves. Observation of the freezer revealed various stains and food debris. Interview at this time with Licensed Social Worker (LSW) #589 verified the findings and stated night shift staff were responsible to clean the refrigerator. 3. Observation on 04/02/26 at 10:45 A.M. of the fourth floor nursing unit refrigerator revealed a tray of five peanut butter and jelly sandwiches, a small dessert dish with fruit cover with a plastic lid, and a pitcher of orange juice that was half full all with no labels or dates. In the freezer were two pitchers of frozen water also with no label or date. Interview at that time with Licensed Practical Nurse (LPN) #622 verified the findings. Review of the facility policy titled, Sanitation, dated 08/01/23, revealed the food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. This deficiency represents non-compliance investigated under Complaint Number 2688708.

Based on review of Quality Assurance (QA) meeting sign-in sheets and staff interview, the facility failed to ensure the Medical Director and the Administrator were active participants and attended QA meetings as required. This had the potential to affect all 91 residents residing in the facility. The facility census was 91.Findings include:Review of the Quality Assurance (QA) committee meeting sign-in sheets revealed the facility Medical Director and the Administrator did not attend the first quarter (03/06/25), second quarter (05/02/25), and third quarter (08/08/25) meetings.Interview with the current Administrator verified the Medical Director and former Administrator did not attend quarterly QA Committee meetings as required in an interview on 04/06/26 at 1:50 P.M.

Based on observation and resident and staff interview, the facility failed to maintain a clean and sanitary environment. This had the potential to affect all 91 residents residing in the facility. The facility census was 91.Findings include:1. Observation during an environmental tour conducted with Assistant Director of Nursing (ADON) #617 on 04/02/26 between 9:00 A.M. and 10:00 A.M. revealed the room occupied by Resident #11 and Resident #86 had a hole in the bathroom ceiling. The soap dispenser in the room occupied by Resident #52 and Resident #74 was detached from the wall and observed lying on top of the closet door, leaving multiple holes in the wall. The wedge pillow utilized by Resident #89 was heavily soiled with visible dirt and debris. The rooms occupied by Resident #46 and Resident #68 had multiple large cracks across several floor tiles. The rooms occupied by Resident #11, Resident #46, Resident #68, and Resident #86 had an unidentified substance on the floor, resulting in a sticky surface. The room occupied by Resident #71 had a hole in the wall with a cable cord fed through the opening. The rooms occupied by Resident #10, Resident #13, Resident #24, Resident #70, Resident #73, Resident #88, and Resident #99 had privacy curtains with varying degrees of staining. There was a water leak observed under the vanity sink in the room occupied by Resident #62, resulting in brown staining on the wall. The pillow utilized by Resident #27 lacked a pillowcase and was torn, worn, and discolored. The rooms occupied by Resident #67 and Resident #79 had multiple missing window blinds. Continued observation on 04/02/26 between 9:00 A.M. and 10:00 A.M., with ADON #617, revealed the rooms occupied by Resident #5, Resident #8, Resident #19, Resident #25, Resident #34, Resident #43, Resident #48, Resident #51, Resident #58, Resident #74, Resident #77, Resident #82, and Resident #84 had multiple water-stained ceiling tiles. The tile surrounding the drain in the second-floor shower room was cracked. The Connections Unit dining area had missing covers on overhead lights. The hallway of the Connections Unit had a missing ceiling tile with exposed wiring. The armrests of the wheelchair utilized by Resident #20 were torn, with exposed padding. The room occupied by Resident #38 had a missing ceiling tile, exposing a water pipe. The recliner chair utilized by Resident #16 and Resident #41 had visible food debris and dirt accumulation. The chair in the room occupied by Resident #34 had torn and tattered upholstery. The vanity base in the room occupied by Resident #35 and Resident #49 was cracked, with pieces observed on the floor. The fall mat utilized by Resident #34 was torn, worn, and contained visible debris. Multiple electrical outlet covers in the room occupied by Resident #111 were missing, exposing wall openings. Resident #7 had a personal miniature (mini) refrigerator in the room with gnats observed flying around it. Upon opening the refrigerator, leftover fast food items were observed inside. The Blue Sky Unit hallway had multiple water-stained ceiling tiles. A window in the Blue Sky Unit dining room had a large crack. The floors in the Blue Sky Unit dining room had significant staining, dirt accumulation, and multiple cracks. The 200 Hall dining area had rusted air vents and the cover to the baseboard heating and cooling unit was detached. ADON #617 verified all of the above findings at the time of the observation during the environmental tour on 04/02/26 between 9:00 A.M. and 10:00 A.M. 2. Observation on 03/30/26 at 8:21 A.M. the dining room on the second floor revealed the floor appeared dirty in various areas, there was a small hole in wall on the left, and observed under the radiator along wall was dirty with various crumbs underneath. Interview on 03/30/26 at 8:48 A.M. with Housekeeping Supervisor #629 verified the above findings. 3. Observation and interview on 03/30/26 at 10:22 A.M. of Resident #17's radiator vent in his room along wall under the window revealed it was heavily dusty. Resident #17 stated it had been that way for a while. Observation on 04/01/26 at 12:51 P.M. with Housekeeper #574 of Resident #17's radiator vent verified the above finding. Housekeeper #574 stated it was their responsibility to clean but the duster they had did not clean the vents well. This deficiency represents non-compliance investigated under Complaint Number 2688708.

Based on staff interview and review of the facility policy, the facility failed to maintain documentation in the staff files indicating the staff were provide education related to the COVID-19 vaccination and offered the vaccination. This had the potential to affect all 91 residents residing at the facility. The facility census was 91.Findings include:Record review and interview on 04/06/26 at 8:44 A.M. with Licensed Practical Nurse (LPN) Infection Control Nurse #617 revealed staff were offered the COVID-19 vaccines and education was provided on COVID-19 annually. LPN Infection Control Nurse #617 revealed she would have to find the education provided and the tracking log for the staff COVID-19 vaccines.Interview on 04/06/26 at 11:21 A.M. with Certified Nurse Aide (CNA) #613 revealed she was employed at the facility for four years and did not receive education on COVID-19 over the past year. CNA #613 stated the facility offered the staff an influenza (flu) vaccine, but not the COVID-19 vaccine. Interview on 04/06/26 at 11:22 A.M. with LPN #593 revealed the facility provided education on COVID-19 upon hire but none since. LPN #593 revealed she did not recall being offered the COVID-19 vaccine.Interview on 04/06/26 at 11:23 A.M. with CNA #578 revealed he had been at the facility 13 months and was offered the COVID-19 vaccine when he was hired but not since then. CNA #578 revealed he did not receive any education on COVID-19 since he was hired.Interview on 04/06/26 at 11:25 A.M. with Housekeeper #505 revealed she was not educated on COVID-19 and did not recall being offered the COVID-19 vaccine.Interview on 04/06/26 at 11:26 A.M. with CNA #501 revealed been employed at the facility two years and had never been offered the COVID-19 vaccine. CNA #501 revealed she did receive education on COVID-19 but was not sure when.Interview on 04/06/26 at 1:21 P.M. with LPN Infection Control Nurse #617 confirmed she did not have documentation of anything that showed staff were educated specifically on COVID-19 over the past 12 months. LPN Infection Control Nurse #617 revealed staff knew she had COVID-19 vaccines available if they wanted them, but she never went to each one individual to offer the vaccine, never logged the vaccines staff received, and never kept tract of staff COVID-19 status nor record vaccines. Interview on 04/06/26 at 1:27 P.M. with Human Resource Director (HR) #607 revealed she never tracked COVID-19 vaccines for any staff.Review of the facility policy titled, Covid Vaccination Policy, dated 08/2025, revealed the facility will offer and provide COVID-19 vaccination as recommended should be documented within by the Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), and other regulatory bodies to minimize the risks of residents and staff acquiring, transmitting, or experiencing complications of COVID-19. Residents and staff will be offered the COVID-19 vaccine as guided by the CDC, state or federal regulations. A consent form will be completed at that time. Prior to offering the COVID-19 immunization to the resident, the residents legal representative or staff, the nursing facility will provide education regarding the benefits and potential side effects of the immunization. The resident or residents legal representative or staff member have the right to refuse the COVID-19 immunization. The refusal and the reason for the refusal should be documented within the staff members personnel file that the staff member was provided education regarding the benefits and potential side effects of the COVID-19 immunization and the staff member either received the COVID-19 immunization or did not receive the COVID-19 immunization.

Based on observation, staff interview, review of the Resident Council meeting minutes, and review of a facility policy and procedure, the facility failed to ensure residents received large portions according to their diet orders. This had the potential to affect 34 (#4, #5, #7, #11, #14, #15, #17, #19, #20, #28, #36, #38, #39, #40, #44, #47, #48, #49, #52, #54, #55, #57, #62, #63, #64, #70, #76, #77, #82, #85, #86, #87, #88, and #90) of 91 residents who received large portions. The facility census was 91. Findings include:Review of the Resident Council meeting minutes dated 12/05/25 revealed resident complaints regarding the food included not getting what they were supposed to get. On 01/05/26 there were complaints of not having enough food on the plate and making sure there were enough portions and the menus matching. On 02/05/26 there were complaints for not receiving enough food and on 03/05/26 there were complaints of not having enough food and making sure there were enough food portions. Observation on 04/02/26 at 1:21 P.M. of the lunch tray line meal service revealed Dietary Manager (DM) #611 was serving the meal. The meal menu was noted to included sausage, baked beans, California blend vegetables, ground sausage, pureed sausage, pureed baked beans, pureed vegetable, green beans, rice, and hamburger for the renal and cardiac diets. Further observation revealed DM #611 served two servings of the main entree (sausage on bun or hamburger) and one four ounce serving each of the baked beans and California blend vegetables or rice and green beans for large portion diets as indicated per therapeutic diet or preference.Observation on 04/02/26 between 12:02 P.M. 12:27 P.M. of dining on the second floor revealed Resident #62 received one hamburger on a bun and a four ounce serving each of rice and green beans. Observation of Resident #62's diet order on his meal ticket revealed the resident was on a large portion renal diet. Observation of Resident #17's lunch tray revealed one sausage on a bun and four ounce serving each of baked beans and California blend vegetables. Observation of Resident #17's meal ticket revealed the resident was on a large portion, regular diet. Interview on 04/02/26 between 12:02 P.M. and 12:27 P.M. with Regional Dietary Manager (RDM) #650 verified Resident #17 and Resident #62 did not receive large portions for their lunch meal. Review of the undated facility policy titled, Large, Small, Double Portions, revealed a large portion was a modest increase above the standard portion 1.5 intended to meet higher caloric or appetite needs while maintaining balance. The definition of a large portion an approved increase above the standard portion that equals 1.5 portion. Large portion should be measured consistently using pre-determined guidelines (e.g. 1.5 scoop instead of one scoop). Interview on 04/02/26 at approximately 2:25 P.M. with DM #611 and RDM #650 verified the facility policy indicated residents were to receive 1.5 portions for large portions. DM #611 stated she thought it meant double entree and verified she gave one four ounce serving of the vegetables (California blend or green beans) and the rice or baked beans. Interview on 04/02/26 at 3:34 P.M. with Activity Director (AD) #561 stated she started in December 2025 and verified during Resident Council, residents consistently complained of not receiving enough food. Review of the diet order report dated 04/01/26 revealed 34 residents (#4, #5, #7, #11, #14, #15, #17, #19, #20, #28, #36, #38, #39, #40, #44, #47, #48, #49, #52, #54, #55, #57, #62, #63, #64, #70, #76, #77, #82, #85, #86, #87, #88, and #90) received large portions at meals.This deficiency represents non-compliance investigated under Complaint Number 2735120 and Complaint Number 2688708.

Based on observation, staff interview, and resident interviews, the facility failed to ensure resident rooms and common areas were maintained at comfortable temperatures to promote a safe and comfortable homelike environment. This had the potential to affect 24 (#1, #3, #7, #13, #14, #16, #18, #23, #41, #42, #43, #46, #53, #58, #66, #67, #68, #71, #73, #76, #78, #79, #81, and #83) of 24 residents residing on the Blue Sky Living Unit (400 Hall). The facility census was 91.Findings include:Interview with Resident #1 on 03/20/26 at 9:08 A.M. revealed his room was often too warm.Interview with Resident #53 on 03/20/26 at 9:11 A.M. revealed his room was really warm.Interview with Resident #3 on 03/20/26 at 9:15 A.M. revealed she had to tell staff all the time that her room was too warm.Observation and interview of the 400 Hall on 03/20/26 between 8:45 A.M. and 9:15 A.M. with Licensed Practical Nurse (LPN) #100 revealed Resident #14's room measured 88 degrees Fahrenheit (F), Resident #1's room measured 85.6 degrees F, Resident #88's room measured 86.5 degrees F, Resident #71's room measured 84.6 degrees F, Resident #46's room measured 86.5 degrees F, Resident #78 and #81's room measured 83.5 degrees F, Resident #3's room measured 81.6 degrees F, Resident #4 and #16's room measured 83.5 degrees F, Resident #18 and #53's room measured 83.3 degrees F, the hallway on the 400 Unit measured 82.6 degrees F, and the dining room on the 400 Unit measured 81.9 degrees F. LPN #100 confirmed all of the above temperatures at the times of discovery.This deficiency represents non-compliance investigated under Complaint Number 2688708.

Based on medical record review and staff interview, the facility failed to develop comprehensive care plans to specify resident care needs. This affected five (#9, #20, #44, #64, and #80) of 30 residents reviewed for care plans. The facility census was 91.Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 01/03/26 and diagnoses including displaced fracture of the surgical neck of the right humerus, type two diabetes mellitus, depression, insomnia, and chronic systolic congestive heart failure. Review of a physician's order dated 01/03/26 revealed Resident #9 had an order for sliding scale insulin coverage for diabetes mellitus. Review of a physician's order dated 01/05/26 revealed Resident #9 had an order for furosemide (diuretic medication) for weight gain and leg swelling. Review of a physician's order dated 02/05/26 revealed Resident #9 had an order for Januvia for diabetes mellitus. Review of a physician's order dated 02/15/26 revealed Resident #9 had an order for metformin for diabetes mellitus. Review of a physician's order dated 02/18/26 revealed Resident #9 had an order for melatonin and Trazodone (atypical antidepressant) at bedtime for insomnia. Review of Resident #9's plan of care revealed no evidence of a comprehensive care plan to address use of diuretic, hypoglycemics, and medications for insomnia. Interview on 04/06/26 at 1:55 P.M. with Regional Minimum Data Set (MDS) Nurse #632 confirmed there was no plan of care developed for Resident #9 for use of diuretics, hypoglycemics, and medications for insomnia. 2. Review of the medical record for Resident #64 revealed an admission date of 01/22/26 and diagnoses including type two diabetes mellitus, borderline personality disorder, schizoaffective disorder bipolar type, and epilepsy. Review of a physician's order dated 02/17/26 revealed Resident #64's had an order for lorazepam for anxiety. Review of a physician's orders dated 03/04/26 revealed Resident #64 had orders for insulin for diabetes mellitus. Review of a physician's order dated 03/05/26 revealed Resident #64 had an order for Farxiga for diabetes mellitus. Review of Resident #64's plan of care revealed no evidence of a comprehensive care plan to address diabetes mellitus and use of medications for anxiety. Interview on 04/06/26 at 1:55 P.M. with Regional MDS Nurse #632 confirmed there was no plan of care developed for Resident #64 for diabetes mellitus or use of medications for anxiety. 3. Review of the medical record for Resident #80 revealed an admission date of 07/15/25 and diagnoses including bipolar type schizoaffective disorder, post-traumatic stress disorder, generalized anxiety disorder, depression, and insomnia. Review of a physician's order dated 07/15/25 revealed Resident #80 had an order for melatonin at bedtime for insomnia. Review of a physician's order dated 02/05/26 revealed Resident #80 had an order for alprazolam (benzodiazepine) for anxiety. Review of Resident #80's plan of care revealed no evidence a comprehensive care plan to address use of medications for insomnia and anxiety. Interview on 04/06/26 at 1:55 P.M. with Regional MDS Nurse #632 confirmed there was no plan of care developed for Resident #80 for use of medications for insomnia and anxiety. 4. Record review for Resident #20 revealed an admission date of 07/24/19. Diagnoses included dementia, abnormalities of gait and mobility, and unsteadiness on feet. Review of the MDS assessment dated [DATE] revealed Resident #20 was moderately cognitively impaired. Resident #20 had adequate vision and did not wear corrective lenses for vision. Record review on 03/31/26 at 10:00 A.M. revealed Resident #20 did not have a care plan related to corrective lenses. Review of the Eye Care chart note for Resident #20 dated 08/26/25 revealed the resident had decreased vision in the right eye and left eye and it affected both near and far vision. The symptom was constant and the condition was moderate. In addition, the condition was associated with daily activity and chores. Review of the social service note for Resident #20 dated 09/03/25 at 4:05 P.M., completed by Licensed Social Worker (LSW) #589, revealed Resident #20 received prescription eyeglasses on that date. Observation and interview on 03/30/26 at 10:29 A.M. revealed Resident #20 was sitting up in his wheelchair. Resident #20 had on a black pair of glasses that appeared to be old with the left side arm of the glasses taped to the rim of the glasses covering the hinge. Resident #20 revealed the glasses broke a year ago. Interview on 03/31/26 at 2:00 P.M. with Licensed Practical Nurse (LPN) MDS Coordinator #628 confirmed Resident #20 did not have a care plan implemented for his decreased vision or glasses. 5. Record review for Resident #44 revealed an admission date of 09/30/22. Diagnoses included paranoid schizophrenia, hemiplegia affecting the left non-dominant side, schizoaffective disorder, bipolar type, cerebrovascular disease, cognitive communication deficit, and personal history of traumatic brain injury. Review of the MDS dated [DATE] revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of six indicating the resident was severely cognitively impaired. Resident #44 had no hallucinations or delusions, or behavioral symptoms directed towards others. Review of Resident #44's medication administration record (MAR) for February 2026 revealed and order for the antipsychotic medication Haldol injection solution five (5) milligrams (mg) per milliliter (ml), inject 5 mg intramuscularly one time only for exit seeking behavior. The Haldol was documented on the MAR as administered on 02/20/26 at 12:23 P.M. Record review for Resident #44 revealed Resident #44 did not have a care plan for exit seeking. Review of the progress note dated 02/20/26 at 12:06 P.M., completed by LPN #555, revealed Resident #44 was exit seeking that shift. The resident was standing in front of the elevator with his coat on stating he was leaving to go and see his cousin. The resident was asked by the nurse to move away from the elevator. It was explained to the resident he was not able to leave at that time. Resident #44 stated that he was leaving, and that he was going to punch the nurse in the face. The psychiatric nurse practitioner was contacted and a one-time Haldol order was given. The injection was given and effective. Resident #44 did speak with his cousin who explained to the resident that he could not just leave the facility and that she would be to the facility to visit him. Resident #44 was in his room at that time awake with eyes open with normal rise and fall of chest. Observation on 03/30/26 at 1:01 P.M. revealed Resident #44 was sitting in the hall up in the wheelchair. Resident #44 did not answer when spoken to. Interview on 03/31/26 at 3:23 P.M. with Certified Nurse Aide (CNA) #582 revealed Resident #44 talked about wanting to leave and did at times go to the elevator wanting to leave and exit seeking. Interview and record review on 04/07/26 at 9:05 A.M. with Regional Director of Clinical Services (RDCS) #631 confirmed prior to 03/30/36, Resident #44 did not have a care plan for exit seeking.

Based on medical record review, resident interview, staff interview, review of personnel records, review of employee timesheets, and review of the employee handbook, the facility failed to ensure residents were provided with a dignified living environment. This affected one (#17) of two residents reviewed for dignity. The facility census was 91. Findings include:Review of the medical record for Resident #17 revealed an admission date of 04/17/18 and diagnoses including paraplegia, end stage renal disease, accidental discharge from a firearm or gun, aneurysm of a renal artery, anxiety disorder, and major depressive disorder.Review of a Brief Interview for Mental Status (BIMS) evaluation dated 10/22/25 revealed Resident #17's BIMS score of 15 indicating intact cognition.Interview on 03/30/26 at 10:22 A.M. with Resident #17 confirmed he observed a physical altercation between staff members a couple months ago but was unable to remember the exact date. Resident #17 stated he did not want to talk about the fight but stated it could have been avoided.Interview on 04/02/26 at 1:44 P.M. with Certified Nurse Aide (CNA) #501 confirmed there was a physical fight between her and Laundry Aide #619. CNA #501 was not willing to discuss any additional information related to the fight.Interview on 04/02/26 at 1:48 P.M. with the Director of Nursing (DON) confirmed the fight happened on the elevator between CNA #501 and Laundry Aide #619. The DON stated the fight was over a misunderstanding between the two staff members but did not elaborate further on what that meant. The DON stated the fight started as yelling and shoving then became more physical. The DON stated there were no residents on the elevator at the time of the fight. The DON stated it was likely Resident #17 did witness part of the fight as the elevator doors had opened but other staff had intervened to stop the fight. The DON stated both staff members were suspended and it was further handled by the Administrator and Human Resources (HR) Director #607.Interview on 04/02/26 at 1:58 P.M. with Laundry Aide #619 confirmed she was in a physical fight with CNA #501 while on the elevator. Laundry Aide #619 stated they had a verbal altercation prior to the physical fight and CNA #501 was the aggressor. Laundry Aide #619 was unable to recall the exact date of the fight but stated it was a couple of months ago. Laundry Aide #619 stated during the fight the elevator doors opened and additional staff got on to break it up. Laundry Aide #619 stated she was unsure if any residents witnessed the fight when the elevator doors opened. Laundry Aide #619 stated they were both suspended for five days with pay.Interview on 04/02/26 at 2:48 P.M. with the Administrator and HR Director #607 revealed they denied any knowledge of a physical fight or suspension of staff members. They reported both CNA #501 and Laundry Aide #619 were sent home for the day following a verbal altercation as they were both upset. The Administrator and HR Director #607 were not willing to discuss any additional information related to the fight or share any investigative findings.Review of the personnel records for CNA #501 and Laundry Aide #619 revealed no findings related to disciplinary actions related to a physical fight.Review of the employee timesheet for Laundry Aide #619 revealed she worked on 01/14/26 from 7:00 A.M. to 12:15 P.M. Laundry Aide #619 did not return to work until 01/22/26.Review of the employee timesheet for CNA #501 revealed she worked on 01/14/26 from 8:30 A.M. to 12:00 P.M. CNA #501 did not return to work until 01/23/26.Review of the employee handbook dated April 2024 revealed threats or actual physical violence was not permitted in the workplace and staff found to be participating could be terminated.This deficiency represents non-compliance investigated under Complaint Number 2735120 and Complaint Number 2725899.

Based on medical record review, staff interview, review of a clinical census, and review of a facility policy, the facility failed to ensure a legal guardian was notified of a change in condition. This affected one (#49) of three residents reviewed for hospitalizations. The facility census was 91. Findings include:Review of the medical record for Resident #49 revealed an admission date of 11/08/23 and diagnoses including dementia, depressive type schizoaffective disorder, impulse disorder, human immunodeficiency virus (HIV), and generalized anxiety disorder.Review of the undated guardianship letter revealed legal guardianship was awarded to Resident #49's sister.Review of a progress note dated 01/07/26 at 9:38 A.M. revealed Resident #49 reported he was short of breath. Vital signs were documented as a blood pressure of 127/65 millimeters of mercury (mmHg), a temperature 99.0 degrees Fahrenheit (F), respirations of 16 breaths per minutes, and an oxygen saturation of 74 percent (%). Licensed Practical Nurse (LPN) #551 notified the physician and received orders to apply two liters of oxygen and call emergency medical services (EMS). LPN #551 documented Resident #49's guardian was notified.Review of a progress note dated 01/07/26 at 3:44 P.M. revealed Resident #49 was admitted to the hospital for acute respiratory hypoxic failure related to possible pneumonia. Registered Nurse (RN) Unit Manager (UM) #598 documented Resident #49's guardian was notified of the admission.Review of a clinical census revealed Resident #49 was hospitalized from [DATE] to 01/22/26.Interview on 04/06/26 at 10:16 A.M. with RN UM #598 revealed she called Resident #49's legal guardian which was identified as his sister around 2:00 P.M. on 01/07/26 to follow up after Resident #49 was transferred to the hospital. RN UM #598 stated the floor nurse did the initial notification of his change in condition and need to go to hospital.Interview on 04/06/26 at 10:42 A.M. with LPN #551 revealed Resident #49 presented with a change in condition on 01/07/26 during her morning medication pass. LPN #551 stated Resident #49 appeared clammy, was having trouble breathing, and had an oxygen saturation of 74%. LPN #551 stated she notified the physician, applied oxygen, and called for EMS to transfer Resident #49 to hospital. LPN #551 stated she notified Resident #49's mother via telephone of the change in condition and transfer to hospital. LPN #551 reported Resident #49's mother was his guardian.Interview on 04/06/26 at 11:16 A.M. with Licensed Social Worker (LSW) #589 confirmed Resident #49's sister was his legal guardian. LSW #589 stated the legal guardian could be hard to get a hold of and the legal guardian gave her approval to contact Resident #49's mother. LSW #589 was unable to provide evidence of this conversation.Review of facility policy titled, Notification of Change in Condition, dated January 2026, revealed the nurse would notify the resident's physician and legal representative when there was a significant change in the resident's physical, mental, or psychosocial status.This deficiency represents non-compliance investigated under Complaint Number 2716185.

Based on medical record review, review of self-reported incidents and related documents, resident and staff interview, and facility policy review, the facility failed to ensure residents were free from abuse. This affected two (#11 and #64) of six residents reviewed for abuse. The facility census was 91. Findings include: 1. Review of the medical record for Resident #64 revealed an admission date of 08/14/25. Diagnoses include asthma, epilepsy, anemia, bladder dysfunction, psychoactive substance abuse, borderline personality, and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact with mild depression and no behaviors. Resident #64 required supervision with ambulating. Review of Resident #64 care plan dated 01/22/26 revealed a plan for mood distress and anxiety related to a history of depressive illness. Interventions include to speaking about feeling and emotions and to attempt alternative therapies such as music. Review of Resident #64's progress note dated 03/22/26 at 12:09 P.M. revealed the resident had an abrasion measuring two centimeters (cm) in length and 0.1 cm in width. Review of the medical record for Resident #80 revealed an admission date of 09/21/25. Diagnoses include psychoactive substance abuse, post-traumatic stress disorder, anxiety, depression, restlessness and agitation, bipolar, and fracture of right tibia, the right shin bone. Review of Resident #80's care plan revealed the resident presented with moderate to intense anger, poor listening skills often becoming angry and defensive and oppositional when suggestions were provided. Interventions included encouraging the resident to express feelings during support groups and to work on improving listening skills. Resident #80 was care planned for verbally aggression related to her mental illness. Interventions included administering medications as ordered and to anticipate and remove triggers that cause signs of agitation. Review of the self-reported incident (SRI), tracking number 272358, revealed Resident #80 went into Resident #64's room and threw an object towards him. Further investigation revealed Resident #80 may have been triggered by an outburst from Resident #64. Further review revealed Resident #80 was placed on a one-on-one supervision level until sent out to emergency room for an evaluation. Upon readmittance, Resident #80 was placed on another floor in a secure unit and followed up with psychiatric services. Review of a witness statement from Certified Nurse Aide (CNA) #539 revealed she entered Resident #64's room and found Resident #80 lying on the floor. CNA #539 interviewed Resident #56, the roommate of Resident #64, who stated he was told by Resident #80 to shush and then took a shaving cream can and threw it at Resident #64. Interview with Resident #80 on 04/02/26 at 3:12 P.M. stated Resident #64 was teasing her and blew smoke into her face. Resident #80 stated she was extremely upset and retrieved a can of shaving cream and entered Resident #64's room. Resident #80 got up out of her wheelchair and threw the can of shaving cream at Resident #64's head. Resident #64 pushed her as she walked back to her wheelchair. Resident #80 stated the can missed Resident #64's head. Interview on 04/06/26 at 9:15 A.M. with Resident #64 stated he did not smoke and stated Resident #80 walked into his room uninvited and threw a can of shaving cream at him and caused the injury to his forehead on 03/22/26. Interview on 04/06/26 at 2:18 P.M. with Licensed Practical Nurse (LPN) #610 stated she was the nurse on duty the day prior to the incident involving Resident #64 and Resident #80. LPN #610 stated Resident #80 entered Resident #64's room and told the roommate to be quiet as she walked to the back of the room and threw a can of shaving cream at his head. Resident #64 sustained a small abrasion to his head. Resident #80 had an unsteady gait and fell walking back to her wheelchair. The police came and neither resident would file a complaint. Interview with the Administrator on 04/06/26 at 3:30 P.M. stated through his investigation he could not substantiate resident to resident abuse because Resident #80 did not have logical common sense to think it through. 2. Record review for Resident #11 revealed an admission date of 10/28/20. Diagnosis included schizoaffective disorder, acquired absence of the left foot, weakness, and anxiety disorder. Review of the MDS assessment dated [DATE] revealed Resident #11 was cognitively intact, able to understand others and made self understood. Resident #11 had no behaviors with the exception of wandering, used a wheelchair for mobility, and required supervision or touch assist for chair/bed to chair transfers. Review of the care plan dated 04/29/24 revealed Resident #11 needed to reside in the Connections Community due to aggressive behaviors. The unit was appropriate for the resident safety related to schizophrenia. Review of the Current Condition of Skin dated 11/27/25 at 11:29 A.M., completed by LPN #622, revealed Resident #11 had an alteration in skin integrity which include a scratch to the cheek and reddened area. Review of the progress note for Resident #11 dated 11/27/25 at 1:30 P.M., completed by LPN #622, revealed the nurse was made aware the resident alleged he and a peer had an altercation and a skin alteration was noted. The residents were separated, Resident #11's skin alteration was cleansed, and the physician was notified. Record review of the SRI created 11/28/25 at 11:21 A.M., completed by the Administrator revealed Resident #102 went to Resident #11's room and blocked him in. Resident #11 requested Resident #102 to move out of the way and Resident #102 refused. Resident #102 hit Resident #11 in the face. The allegation was unsubstantiated by the facility as evidence indicated abuse, neglect, or misappropriation did not occur. Interview on 04/02/26 at 2:07 P.M. with LPN #355 revealed Resident #11 was alert and oriented to person, place, and time. LPN #355 stated Resident #11 would know the difference between right and wrong, he apologized after he did something wrong, and Resident #11 had not hit staff or other residents. Interview on 04/06/2026 at 4:13 P.M. with Resident #11 revealed he did not recall an altercation with another resident. Multiple observations throughout the day revealed Resident #11 participated in multiple activities, socialized with other residents and did not become aggressive. Record review for Resident #102 revealed an admission date of 03/19/20 and a discharge date of 12/08/25. Diagnoses included schizoaffective disorder and major depressive disorder. Review of the MDS dated [DATE] revealed Resident #102 was cognitively intact, was able to make self understood and was able to understand others. Resident #102 had no hallucinations or delusions and physical behavior symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred one to three days of the seven day look back period. Review of the care plan dated 06/16/25 revealed Resident #102 needed to reside in the Connections Community due to behavior or behaviors of destructive to property safety for self and others related to schizoaffective disorder. Interventions included to encourage daily routine to stay as independent as possible, and encourage outlets of behaviors such as journaling, talking, and group meetings. Review of the care plan dated 07/14/25 revealed Resident #102 had a behavior problem related to aggression, refusing medications, destruction to property, pouring urine on himself, and drinking urine. Resident #102 was also sexually inappropriate. Interventions included to administer medications as ordered. Review of the psychiatric note for Resident #102 dated 10/28/25, completed by Certified Nurse Practitioner (CNP) #630 revealed during the assessment, the resident was observed seated in his room, alert, cooperative, and engaged but distractable. Resident #102 stated his mood was pretty good and had a soft voice. He denied depression and anxiety and denied any auditory hallucinations or experiencing commands. Resident #102 questioned when he will be able to go back down to the second floor and the nurse and staff confirmed the resident had a decrease in behaviors and aggression. Resident #102 was taking medications as prescribed and there had been no recent acute issues or hospitalizations reported. Review of the progress note dated 11/23/25 at 3:53 P.M., completed by LPN #558, revealed Resident #102 had a leave of absence (LOA) with family at 1:00 P.M. and the resident left in stable condition with medications and the physician and family were notified. Review of the progress notes for Resident #102 dated 11/24/25 at 1:17 P.M. and on 11/25/25 at 9:04 A.M. revealed Resident #102 was on a LOA. Interview on 04/02/26 at 2:08 P.M. with LPN #355 revealed Resident #102 was alert and oriented to person, place, and sometimes to time. LPN #355 revealed Resident #102 absolutely knew the difference between right and wrong, he was not normally aggressive, and revealed she did not recall him hitting other residents in the past. Interview on 04/02/26 at 2:16 P.M. with LPN #622 revealed she witnessed the altercation between Resident #11 and #102 on 11/27/25. LPN #622 stated she saw the altercation down the hall; Resident #11 was going back to his room after lunch. Resident #11 was on the outside getting ready to go in his room and Resident #102 was blocking his door. Resident #11 asked him to move and Resident #102 did not say anything, just punched Resident #11 in the face then we separated him. LPN #622 stated staff put Resident #102 on a one-on-one observation and Resident #11 in his room. Resident #11 did not instigate anything and Resident #102 was being aggressive that day all day cussing at staff and residents, yelling, and he was refusing medication and was irritable. LPN #622 reiterated Resident #102 was also aggressive that morning and revealed he went to his sister's for a few days prior to the altercation and his sister said when he came back that he was not taking his medication during the leave of absence. LPN #622 revealed when he returned he also refused medications. LPN #622 confirmed no new interventions were put into place for Resident #102 even though it was reported he refused medications including antipsychotic medications for several days and had increased symptoms of aggression for several hours prior to him hitting another resident. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 05/2025, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain, or mental anguish. Willful meant the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Prevention included completing ongoing assessments and care planning for appropriate interventions and monitoring of residents with behaviors including but not limited to verbally aggressive behaviors, physically aggressive, and wandering into other residents rooms.

Based on observation, resident and staff interview, medical record review, and review of the facility policy, the facility failed to ensure a resident's choice for bathing method and frequency was honored. This affected one (#89) of four residents reviewed for bathing preferences/schedule. The facility census was 91.Findings include:Record review for Resident #89 revealed an admission date of 06/06/18. Diagnosis included spastic diplegic, cerebral palsy, polyneuropathy, spina bifida, and muscle weakness. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #87 revealed it was very important to the resident to choose between a tub bath, bed bath, or sponge bath. Review of the quarterly MDS assessment dated [DATE] revealed Resident #89 was cognitively intact. Resident #89 had impairment on both sides of the upper and lower extremities. Resident #89 used a wheelchair for mobility, was dependent for showers/bathing, personal hygiene, and chair/bed to chair transfers. Review of the care plan dated 12/22/25 revealed Resident #89 had an activity of daily living (ADL) self-care performance deficit related to a decline in functional mobility. Interventions included for bathing to avoid scrubbing and pat dry sensitive skin and to check nail length and trim and clean on bath day and as necessary. Staff were to report any changes to the nurse and the resident was transferred with mechanical (Hoyer) lift. Review of the shower schedule revealed Resident #89 was to receive two showers per week with scheduled days on Mondays and Thursdays.Observation and interview on 03/30/26 at 10:38 A.M. with Resident #89 revealed his fingernails were long, uneven, and embedded with a dark substance. Resident #89 stated he would like his fingernails cleaned and trimmed but staff would not do it. Resident #89 stated he could never get a shower, had not been showered in two weeks, before that was two months. Resident #89 stated the facility gave him a bed bath and he wanted a shower. Resident #89 stated the staff have to lift him for the shower chair and the staff is almost all women and they do not want to do it.Observation and interview on 04/01/26 at 3:31 P.M. with Certified Nurse Aide (CNA) #584 verified Resident #89's fingernails were long, uneven, and embedded with a dark substance. CNA #584 revealed Resident #89 received showers and bed baths. If they run out of Hoyer lift pads, the resident had to receive a bed bath. CNA #584 stated, Resident #89 was a two person assist for transfers and it was hard getting him up and down. CNA #584 stated the staff would have to get him out of the wheelchair, in a shower chair, back in the wheelchair, then to bed, and that was a lot of lifting so sometimes the staff just give a bed bath instead of a shower. CNA #584 revealed Resident #89 never refused staff to trim or clean his fingernails but sometimes there was not enough time for staff to clean the fingernails. Interview on 04/02/26 at 9:26 A.M. with Activities Director #561 confirmed she completed the likes and dislikes form with Resident #89. Activities Director #561 confirmed Resident #89 revealed he preferred showers during the interview. Record review and interview on 04/02/26 at 11:26 A.M. of Resident #89's Bath and Skin Report Sheets for March 2026, with Regional Chief Clinical Nursing Operator (RCCNO) #701, revealed the forms were filled in with Resident #89's name and date to receive the scheduled bath/shower on 03/02/26, 03/05/26, 03/09/26, 03/12/26, 03/19/26, 03/23/26, and 03/26/26. RCCNO #701 confirmed the section of the form revealing the shower/bath was completed was not filled in or documented as completed. Review of the electronic medical record for Resident #89 with RCCNO #701 revealed Resident #89 received four bed baths (03/09/26, 03/23/26, 03/26/26, and 03/30/26) for the month of March 2026. RCCNO #701 confirmed there were no showers documented as received for the month of March 2026 and confirmed residents have the right to choose between a bath, bed bath, or shower.Interview on 04/02/2026 at 11:40 A.M. with the Director of Nursing (DON) revealed residents should receive two showers/baths a week and as needed. Review of the shower schedule in the electronic medical record for Resident #89 revealed the resident preferred showers on Monday and Thursday from 3:00 P.M. to 11:00 P.M., and staff were to offer to shave the resident and clean and trim nails on shower days. Review of the facility policy titled, Bathing Choice Policy, dated 06/2025, revealed the policy was to establish frequency of bathing by resident choice. Residents are interviewed during the admission process regarding the frequency they want the bath or shower. Changes will be implemented if indicated by the residents choice.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, interview, review of Self-Reported Incident (SRI) investigations, and facility policy review, the facility failed to protect Resident #69 and Resident #12's right to be free from physical abuse by Resident #89. This affected two residents (#12 and #69) of five residents reviewed for physical abuse. The facility census was 88. Actual harm occurred on 09/08/25 when Resident #69 was physically abused by Resident #89 when the resident was struck in the head with a [NAME] requiring transfer to the hospital for evaluation and treatment of a skin tear requiring a thick layer of dermal glue and bruising on the left eye. Additional harm occurred on 09/19/25 when Resident #12 was physically abused by Resident #89 when the resident was struck in the head with a rock which required hospital treatment for a head laceration with staples. Findings include: 1. Review of the medical record for Resident #69 revealed an admission date of 07/31/24 with diagnoses including bipolar disorder severe with psychiatric features, history of traumatic brain injury, restlessness and agitation.Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #69 had severely impaired cognition, and exhibited verbal behavioral symptoms directed at others.Review of a general note dated 09/08/25 at 4:26 P.M. revealed Resident #69 had a physical altercation with Resident #89. The resident indicated Resident #89 hit him (Resident #69) in the face. Resident #69 stayed in the dining area with staff. Vital signs were stable. A skin tear to left chin was noted. The area was cleansed with normal saline solution and a dry dressing applied. The physician was contacted and ordered Resident 69 to be sent to the hospital. Review of a general note dated 09/08/25 at 10:47 P.M. revealed Resident #69 returned to the facility at 9:50 P.M. in stable condition. A thick layer of dermal glue was applied to the resident's left chin, and there was bruising on the left eye. Review of a facility self-reported incident (SRI) and investigation dated 09/08/25 revealed staff witnessed Resident #89 hit Resident #69 while in the dining room. Both residents were separated and head-to-toe assessments completed. Resident #69 had a skin tear on the left chin and was subsequently sent to the hospital for evaluation and treatment. Certified Nursing Assistant (CNA) #212 verified it was Resident #89 who hit Resident #69. There were no details in the witness statements or investigation as to what object was used by Resident #89 to hit Resident #69. Interview on 11/24/25 at 9:53 A.M. with the Director of Nursing (DON) revealed on 09/08/25 Resident #69 was hit by Resident #89 with a [NAME] with a wooden handle and a rubber head. The DON revealed staff believed Resident #89 obtained the [NAME] from a maintenance cart. Review of the closed medical record for Resident #89 revealed an admission date of 05/26/24 and discharge date of 09/19/25. Resident #89 had diagnoses including bipolar disorder and paranoid schizophrenia.Review of the plan of care initiated 05/09/24 revealed Resident #89 had the potential to be physically aggressive related to a diagnosis of mental illness. Interventions included administering medications as ordered after attempting non-medicinal approaches, and if the resident's behavior was a threat to other residents or himself, to immediately call for assistance. On 10/07/24, an additional intervention was added which indicated Resident #89 was counseled regarding conflict management and not to react to peers by becoming aggressive. On 07/01/25, the resident was counseled to seek out staff if he had a conflict with peers. On 08/06/25, another intervention was added to refer Resident #89 to the consulting psychiatrist for a psychiatric evaluation as warranted. Additional review of the plan of care initiated 05/09/24 revealed it was updated on 09/08/25 to note Resident #89 had potential to be physically aggressive related to a diagnosis of mental illness. The care plan revealed the resident hit a peer. An intervention added was for one-on-one counseling regarding conflict management, to walk away and not strike out at others.Review of the behavior note dated 09/08/25 at 12:04 P.M. revealed Resident #89 exhibited behaviors of screaming at and threatening others. Non-pharmacologic interventions of redirection and change of scenery were provided and documented as being effective on this date.Review of a general note dated 09/08/25 at 3:36 P.M. revealed staff notified the nurse of Resident #89 being in a physical altercation with Resident #69. Both residents were separated, and staff assisted Resident #89 out of the dining room to his room. Resident #89 was placed on one-on-one supervision. Psychiatry was contacted and made aware of the incident with no new orders placed. Review of the social services note dated 09/08/25 at 3:43 P.M. revealed the social worker (unnamed) met with Resident #89 about the incident. Resident #89 stated Resident #69 had threatened him, so he took it seriously. Resident #89 was counselled to seek out staff when there was a peer conflict and given further counsel on conflict management, including not to strike out but to walk away.2.Review of the medical record for Resident #12 revealed an admission date of 10/28/20 with diagnoses including schizophrenia, borderline personality disorder, obsessive compulsive disorder, and bipolar disorder.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and no behaviors. Review of the head-to-toe assessment dated [DATE] at 10:32 A.M. revealed Resident #12 had a laceration to the back of the head.Review of the health status note dated 09/19/25 at 10:01 P.M. revealed Resident #12 returned from the hospital at 4:00 P.M. with a laceration to the crown of the head which was closed with two staples and left open to air. A Computerized Tomography (CT) scan without contrast resulted in no (additional) anomalies. Review of an SRI dated 09/19/25 revealed Resident #89 struck Resident #12 in the back of the head while in the hallway. The residents had argued over a notebook which was subsequently found in Resident #89's room. Resident #12 was sent to the hospital due to being hit on the head. Staff witnesses confirmed the incident had occurred. Housekeeper #214 saw both residents arguing which resulted in Resident #89 hitting Resident #12. There was no mention of any additional details. CNA #215 noted in her witness statement of Resident #89 being very aggressive that morning.Review of a note contained in Resident #89's medical record revealed a general note dated 09/19/25 at 9:30 A.M. which indicated staff informed the Assistant Director of Nursing (ADON) #209 of a physical altercation between Resident #89 and Resident #12. Resident #12 reported it was about a composition notebook so Resident #89 struck him on the head. The back of Resident #12's head was cleansed, and pressure applied, followed by a clean dry dressing. The physician when notified ordered to send Resident #12 to the hospital for evaluation and treatment. The psychiatric nurse when notified ordered for Resident #89 to be pink slipped (an emergency mental health hold) to the hospital. Emergency services were contacted. The police picked up Resident #89 who was transported to the hospital, and his responsible party was notifiedInterview on 11/20/25 at 9:15 A.M. with Resident #12 confirmed he was knocked in the head with rock by Resident #89. When asked about the incident and the pain it caused, the resident would only state being fine now and safe. He voiced being glad that Resident #89 was no longer there. Interview on 11/20/25 at 12:49 P.M. with the Director of Nursing (DON) revealed Resident #89 had delusions which caused him to feel he had to protect himself. The DON revealed the resident had been placed on one-to-one supervision (from 09/08/25 to 09/16/25 following the incident with Resident #69) and had come to the facility with physical aggression problems. Following the second incident of physical abuse on 09/19/25 Resident #89 was pink slipped to the hospital and did not return to the facility. The deficient practice was corrected on 09/19/25 when the facility implemented the following corrective actions: -On 09/08/25 the DON/designee completed a full body assessment on Resident #69 and all like facility residents. -On 09/08/25 the DON/designee completed resident interviews for safety and/or abuse.-On 09/08/25 the DON/designee completed a whole house audit of residents' rooms for potentially harmful objects.-On 09/08/25 the DON/designee audited five resident rooms daily, five days a week, for four weeks for potentially harmful objects.-On 09/08/25 the DON/designee completed education for all staff on abuse, resident rights, and triggers for aggression in older adults.-On 09/08/25 the Regional Director of Operations (RDO) #217 instructed Maintenance Director (MD) #218 to prohibit all maintenance carts from going onto any resident floors. -On 09/08/25 MD #218 made maintenance staff aware moving forward of maintenance carts being prohibited onto any resident floors. -On 09/08/25 MD #218 audited maintenance cart locations five days weekly for four weeks to ensure all maintenance carts were in designated areas.-From 09/08/25 to 09/16/25 Resident #89 received staff one-to-one supervision. -Following the incident on 09/19/25 Resident #89 was again placed on one-on-one supervision immediately until the psychiatric nurse practitioner had the resident sent out to the hospital. The facility also conducted an investigation with staff statements obtained. Resident skin assessments were completed for all residents with cognitive impairment. -Resident #12 was assessed and transferred to the hospital for treatment and then returned to the facility. -On 09/19/25 all staff were educated on abuse, de-escalation, and handling aggressive behaviors. -On 09/19/25, Resident #89 received an immediate discharge after being pink slipped by psychiatry.This deficiency represents non-compliance investigated under Complaint Number 2622325.

Based on observation, closed record review, review of emergency services report, review of hospital records, facility policy review and interview, the facility failed to maintain a safe environment to prevent Resident #51 from accessing a locked soiled utility room and falling from the third-floor secured unit to the facility basement via a laundry chute. This resulted in Immediate Jeopardy and Actual Harm on 08/07/25 at approximately 1:30 P.M. when Resident #51 was observed in the laundry chute room, inside a laundry bin, behind a locked door in the facility's basement. Maintenance Director (MD) #400 reported he had been in the facility basement outside of the laundry chute room when he heard a loud thud sound from inside the room. Upon opening the locked door of the laundry chute room, MD #400 observed Resident #51 inside a laundry bin, and confirmed the only points of entry into the room were the laundry chute and the locked door he had opened. MD #400 recalled Resident #51 had bleeding around his mouth and eye and a large bump on the back of his right hand. MD #400 reported Former Administrator #500 was present in the facility's basement with another unknown resident at the time of the incident and was informed Resident #51 was in the laundry bin. Former Administrator #500 proceeded to escort Resident #51 out of the laundry chute room and back to his room on the third floor prior to the resident being comprehensively assessed for injury. Resident #51 was transported to the hospital by Emergency Medical Services (EMS) at approximately 2:55 P.M. Upon arrival to the hospital, Resident #51 was found to have a C6 compression fracture (a collapse of one of the cervical vertebra in the neck) of unknown chronicity, an acute T4 anterior fracture (a break of the fourth thoracic vertebra in the mid-back), and multiple left-sided rib fractures of the second through seventh ribs. Resident #51 was hospitalized from [DATE] until 09/03/25 at which time he was transferred to a local long term acute care hospital (LTACH) for ongoing care and treatment. Resident #51 did not return to the facility. This affected one resident (#51) of three residents reviewed for accidents. The facility census was 88. On 09/08/25 at 3:04 P.M., the Administrator, Director of Nursing (DON), and Regional Clinical Support Registered Nurse (RCSRN) #401 were notified Immediate Jeopardy began on 08/07/25 at approximately 1:30 P.M. when Resident #51 was able to gain access to the secured soiled utility room (in which the laundry chute access was contained in) on the third floor and was subsequently observed inside a laundry bin in the laundry chute room of the facility's basement. Resident #51 was transported to a local hospital where he was admitted for multiple traumatic injuries. In addition, the facility failed to ensure an accurate and timely investigation and documentation regarding the circumstances of the incident were completed at the time of the incident. Immediate Jeopardy was removed on 08/08/25 when the facility implemented the following corrective actions: On 08/07/25 at approximately 1:30 P.M., Former Administrator #500 was informed by Maintenance Director (MD) #400 that Resident #51 was in the basement laundry chute room. On 08/07/25 at approximately 1:45 P.M. Former Administrator #500 instructed Licensed Practical Nurses (LPN) #283, #291, #303, and #342 to conduct head counts of their units to ensure all residents were accounted for and had not wandered off their units. On 08/07/25 at approximately 2:00 P.M., Former Administrator #500 checked the soiled utility room containing the laundry chute on the 200 unit to determine if the door was locking properly. On 08/07/25 at 2:11 P.M., the DON called EMS to transport Resident #51 to a local hospital. On 08/07/25 at approximately 2:15 P.M., Former Administrator #500 checked the soiled utility room containing the laundry chute on the 400 unit to determine if the door was locking properly. On 08/07/25 at approximately 2:30 P.M., Former Administrator #500 checked the soiled utility room containing the laundry chute on the 300 unit to determine if the door was locking properly. On 08/07/25 at approximately 3:00 P.M., Former Administrator #500 coordinated an ad hoc Quality Assurance (QA) meeting to discuss the incident with Resident #51. In attendance at the meeting included Former Administrator #500, the DON, Assistant Director of Nursing (ADON) #279, and RCSRN #401. Regional Director of Operations (RDO) #510 and Medical Director #650 attended via phone. A root cause analysis was performed, and the team discussed a plan to prevent the incident of a resident wandering into secured places and/or off the unit. The QA team decided to re-educate staff on the importance of ensuring the utility room doors were latched and always locked, after each entry and exit, as well as installing an extra lock on each (laundry) chute access on each unit. Additional staff training would include ensuring residents on secured units were always supervised and present on their units, ensuring maintenance work orders and all work orders would be placed into TELS (an electronic method for placing, tracking, and communicating work orders that are needed) and emergency orders would be additionally communicated to the Administrator. The meeting was completed at approximately 3:45 P.M. On 08/07/25, RCSRN #401 and Unit Manager (UM) LPN #287 conducted wandering assessments on 87 current residents. All assessments were completed at approximately 3:57 P.M. The facility identified 15 residents (#36, #41, #43, #49, #51, #65, #66, #67, #68, #69, #78, #79, #84, #87 and #88) who triggered as high risk for wandering; the remaining 72 in-house residents were identified as low risk for wandering. On 08/07/25 at approximately 4:00 P.M., the facility installed padlocks on the laundry chute access doors on all three resident care units. On 08/07/25, the DON, ADON #279, UM LPN #253, UM LPN #287, and RCSRN #401 educated all staff on the importance of ensuring utility room doors where the laundry chutes were contained were latched and always locked after each entry and exit. Staff were educated that an extra lock had been applied to the chute access doors on each unit and ensuring the padlocks were in a position after each use. Staff were additionally educated on ensuring residents on secured units were supervised and ensuring maintenance work orders were placed into TELS and emergency orders communicated to the Administrator. All staff education was completed at 5:30 P.M. The facility implemented a plan beginning with staff hired after 08/08/25, that all new hires would be educated during orientation by the Administrator or designee on ensuring utility room doors were secured when not in use, the process for submitting maintenance work orders, and ensuring emergency orders were communicated to the Administrator. Additional new hire training would ensure laundry chute doors would be always locked when not in use. On 08/08/25, the DON or designee began ongoing audits for all three soiled utility rooms in which the laundry chute access was contained, five days per week, for a duration of four weeks to ensure all doors and chutes were locked and secured appropriately. The results of the audits would be reviewed in the facility's QA meetings. On 08/08/25, the DON or designee implemented ongoing, every shift head counts at the end of each nursing shift to ensure all residents were accounted for. The DON or designee would complete these head counts every shift, seven days per week, for a duration of four weeks. The results of the audits would be reviewed in the facility's QA meetings. Although the Immediate Jeopardy was removed on 08/08/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include:Review of Resident #51's closed medical records revealed an admission date of 07/19/23 with medical diagnoses including schizophrenia, dementia, muscle weakness and difficulty walking. Resident #51 resided on the third floor secured Connections unit of the facility. Resident #51 was transferred to the hospital on [DATE] and did not return to the facility. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had a brief interview for mental status (BIMS) score of 8 indicating the resident had moderately impaired cognition. The assessment revealed Resident #51 required supervision with mobility, and bathing. Review of the care plan dated 07/29/25 revealed Resident #51 required the need for placement on the secured locked unit related to aggressive behaviors. Resident #51 had the potential for physical aggression related to schizophrenia and dementia. Interventions included administering medications as ordered and providing redirection when agitated. Resident #51 had displayed verbally and physically aggressive behaviors and had been destructive to property that included removing soap dispenser from the wall and thermostat covers (updated 08/06/25). Interventions included administering medications as ordered, and providing redirection when agitated. Resident #51 was additionally noted to be at risk for wandering and elopement. Interventions included providing a safe environment and noted the need for Resident #51 to reside on the secured unit. Review of Resident #51's physician's orders for August 2025 revealed an order for the resident to reside on the secured unit. Review of an EMS report dated 08/07/25 revealed a call for service was placed at 2:11 P.M. and EMS arrived at the facility at 2:35 P.M. The EMS report stated facility staff reported Resident #51 was found at the bottom of the stairs, it was unclear if he had fallen down the stairs and how many. The EMS report further revealed (upon EMS arrival) Resident #51 was found lying in his bed (on the third floor) and was observed with multiple contusions and hematomas (swelling and discoloration) to his head, arms, and hands. Resident #51 was noted in the report to have bleeding from his mouth, and it was unknown if Resident #51 had broken teeth or if he had bitten his jaw. Resident #51 was transported by EMS to a local hospital on [DATE] at 2:55 P.M. Review of a transfer assessment dated [DATE] authored by Licensed Practical Nurse (LPN) #287 revealed the DON had called report to the hospital at 2:00 P.M. Resident #51 had some scrapes and minor bruising. The assessment did not provide additional details regarding the circumstances of the incident or related to any of Resident #51's injuries (as noted by EMS). Review of a progress note dated 08/07/25 and timed 4:46 P.M., authored by the DON, revealed she had been made aware Resident #51 was observed wandering in the laundry area. The note revealed Resident #51 was returned to his unit; an assessment and vital signs were obtained which noted new skin alterations. Resident #51 was noted to be alert and oriented and denied pain. Nurse Practitioner (NP) #343 had been made aware and ordered Resident #51 to be sent to the hospital for evaluation. An attempt was made to notify Resident #51's guardian and a message was left, and Resident #51's emergency contact was notified. The progress note failed to contain information related to the resident actually sustaining a fall and/or the circumstances of the fall. Review of hospital records dated 08/07/25 and timed 3:37 P.M. revealed Resident #51 had presented to the emergency department (ED) as a trauma activation after a fall down approximately 20 stairs. A physical assessment noted Resident #51 had a hematoma to his left upper cheek, blood at his bilateral nares, and blood in his mouth with broken dentition. Additional injuries listed a right hip hematoma, left upper extremity hematoma, abrasion to his bilateral knees and mid left shin, and cervical spine tenderness. The assessment further stated laboratory and imaging tests were ordered and chest x-ray demonstrated several posterior rib fractures. Imaging revealed a C6 fracture and T4 anterior body and transverse process fracture (a complex injury pattern, likely referring to a T4 vertebra fracture involving both the front (anterior) part of the bone and the small side processes (transverse processes). This type of injury typically results from high-energy trauma and is often unstable, potentially leading to spinal cord or nerve damage. Resident #51 was also noted to have multiple left-sided rib fractures of the second through seventh ribs. Assessment further revealed due to Resident #51's multiple rib fractures and altered mental status he had been admitted to the trauma intensive care unit (TICU). Review of the facility investigation dated 08/07/25 revealed the following: Review of Maintenance Director (MD) #400's written statement dated 08/07/25 revealed he was going to the soiled utility room to let a vendor into check equipment and found Resident #51 in the laundry bin. The report referenced that he immediately notified Former Administrator #500. Review of Former Administrator #500's written statement dated 08/07/25 revealed he observed Resident #51 in the laundry chute area standing up behind the door. When asked what he was doing, Resident #51 mumbled and asked for a soda. Former Administrator #500 proceeded to the vending machine and purchased him a soda, and ambulated Resident #51 to the dining room until the DON and an unspecified Unit Manager arrived. Review of the DON's written statement dated 08/07/25 revealed Resident #51 was observed in the basement in the laundry bin by MD #400. Former Administrator #500 was notified, who was nearby with another (unnamed) resident at the vending machines. Former Administrator #500 left Resident #51 in the care of an unspecified activity staff member while he retrieved clinical staff to assess the resident. Clinical staff (unnamed) assessed Resident #51 and passive range of motion and active range of motion were performed without difficulty. Resident #51 was noted to have several abrasions noted to his skin. Resident #51 was returned to his unit on the third floor, vitals obtained, and EMS was called to transport the resident to the ED for evaluation. The DON's statement further references that staff were interviewed and reported safety checks had been performed and that all doors with locks were secured. Staff denied seeing the resident go into the laundry chute as it was lunch time and they were passing trays. Review of LPN #323's written statement dated 08/07/25 revealed the nurse had last seen Resident #51 at lunch time between approximately 12:45 and 1:00 P.M. Resident #51 was provided with his lunch, and he stood at the nurse's station and ate his lunch. Review of a written statement dated 08/07/25 authored by Certified Nursing Assistant (CNA) #244 revealed she last saw Resident #51 in the dining room at lunch time. CNA #244 handed him his tray, and he walked back into his room. Review of a written statement dated 08/07/25 authored by CNA #203 revealed she did not witness the incident. CNA #203 was passing lunch trays, and referenced the last time she saw Resident #51, she had brought his tray to his room. Review of a facility incident and accident investigation form, dated 08/07/25 revealed Resident #51 was the listed resident, and the type of incident was listed as wandering. Resident #51 was listed to have abrasions and had been wandering and restless. There was no narrative or explanation for what had happened. The section to list immediate actions taken was blank. A corresponding bath and skin report listed the resident had abrasions to his bilateral lower knees and extremities, his right forearm and upper arm, and left hand. There were no measurements or descriptions of any areas. The bottom of the form stated the treatment order was send to ED. The incident and accident investigation form was incomplete to reflect the resident fell down the laundry chute from the third floor to the basement or to clarify why/how EMS and hospital staff were provided information that the resident fell down stairs. The investigation and accident form failed to provide evidence the resident was comprehensively assessed and/or that EMS services were summoned prior to the resident being moved from the ground. Review of a root cause analysis, dated 08/07/25, completed by the QA team members during the ad hoc QA meeting following the incident, , revealed Resident #51 had last been observed during lunch at the nurse's station at approximately 12:45 P.M. Resident #51 had refused his tray due to his hotdog being mechanically altered per his ordered diet. At approximately 1:30 P.M., Resident #51 was witnessed by MD #400 in the laundry bin in the basement and was transported to the hospital. The root cause was listed as Resident #51 having a history of destroying property, removing soap dispensers, and picking locks. Based on review of the facility information as part of the State agency investigation, it could not be determined how the facility reached this root cause for this incident. Interview on 09/03/25 at 3:14 P.M. with Housekeeper #292 revealed he was present on 08/07/25 and had heard Resident #51 had fallen down the laundry chute. Housekeeper #292 stated the laundry chute doors did not have locks on them prior to the incident and stated Former Administrator #500 had asked him to place locks on the chute doors (following the incident). Observation of laundry chute door with Housekeeper #292 at the time of the interview revealed the door to the laundry chute was locked and Housekeeper #292 had to put in a code to open the door. Observation further revealed a pad lock was in place on the outside of the metal door to the laundry chute at the time of the observation. Interview and observation on 09/03/25 at 3:24 P.M. with Maintenance Director #400 revealed on 08/07/25 between approximately 1:00 P.M. and 1:30 P.M., he and an outside vendor were present in the basement outside of the laundry chute area. MD #400 stated he had heard a loud thud from inside the laundry area. MD #400 stated he had attempted to open the locked door to the chute room, but it had been difficult to open, and he had to push the door a few times as it appeared something was blocking the door. MD #400 stated he eventually opened the door to the laundry chute room, and upon entry he observed a laundry bin on its side, and he saw a hand sticking out of it. MD #400 revealed he was able to identify Resident #51 as the person in the area. MD #400 stated Former Administrator #500 was present in the basement with another resident at the vending machine that was near the laundry chute room. MD #400 advised Former Administrator #500 of the situation. MD #400 stated Former Administrator #500 helped Resident #51 up out of the laundry bin and MD #400 observed Resident #51 with bleeding around his mouth and eye and with a large bump on his right hand. MD #400 stated Former Administrator #500 then walked Resident #51 to the kitchenette area located in the basement near the laundry chute area. MD #400 stated the DON then came and checked Resident #51 out in the basement and then Resident #51 was taken back to his room. MD #400 stated that same day Former Administrator #500 had asked him to place locks on the laundry chute doors and new locks on the door that lead to the chute areas. MD #400 further explained the only entry points into the basement's laundry chute room were from the chute itself or through the locked door he had entered after he heard the thud and found Resident #51 in the bin. Observation of laundry chute room with MD #400 at time of interview revealed the laundry room chute door was locked and required a code to access the room. The laundry chute room had two large, plastic bins on wheels inside the room below the metal laundry chute, with no other doors or points of entry. MD #400 stated approximately two days after the 08/07/25 incident with Resident #51, the staff had received a text message from Former Administrator #500 that the Administrator would not be returning to the facility. Interview on 09/03/25 at 3:52 P.M. with the DON revealed on 08/07/25 Former Administrator #500 had informed her Resident #51 was in the basement, however she had not been made aware how the resident had gotten down there. Former Administrator #500 reported to her he had observed Resident #51 wandering in the basement. The DON stated when she had arrived in the basement, Resident #51 was seated in the kitchenette area drinking a soda. The DON stated she had observed Resident #51 had some scrapes and some redness but was not able to state how the injuries occurred. The DON stated she had heard a rumor Resident #51 had gone down the laundry chute but during the investigation no staff had observed Resident #51 to have left the secured unit via the elevator or the stairs. The DON stated based on her nursing judgement and to err on the side of caution she had called EMS to have Resident #51 transferred to the hospital. The DON was asked where Resident #51 was currently and/or information about the resident's status and the DON stated she did not know. Interview on 09/04/25 at 8:06 A.M. with CNA #209 revealed the lock on the door to the third-floor soiled utility room which contained the laundry chute had been broken for approximately a week before the 08/07/25 incident with Resident #51. CNA #209 revealed Former Administrator #500 had been made aware of this. During the interview, CNA #209 stated on 08/07/25 she observed Resident #51 in the dining room during lunch and Resident #51 had refused his lunch tray and had left the dining room. CNA #209 stated approximately 20 minutes later, an unknown staff member had asked her to do a head count of the residents on the unit as Resident #51 had fallen down the laundry chute. Interview on 09/04/25 at 9:09 A.M. with RDO #510, who was the acting Interim Administrator, revealed she had been made aware of the incident involving Resident #51 via phone on 08/07/25. RDO #510 stated the facility had done an investigation and had not been able to determine how Resident #51 had ended up in the basement's laundry chute room and stated the door to the room may have been left open and stated Resident #51 had a history of wandering. RDO #510 denied staff had reported any locks that had been broken. A telephone interview with Resident #51's guardian on 09/04/25 at 10:07 A.M. revealed he had received a call from the facility that Resident #51 had fallen down the stairs and was found in the basement. The guardian stated the caller had not provided any specific information and he was confused on how the resident had gotten off the secured locked unit and into the basement to have fallen. The guardian stated he had spoken with the hospital and had been informed Resident #51 had numerous fractures on his back and he had remained at the hospital from [DATE] unit 09/03/25 at which time Resident #51 was transferred to a local LTACH for continued medical care needs. Interview on 09/04/25 at 12:34 P.M. with CNA #275 revealed he had seen the door to the third-floor soiled utility room containing the laundry chute not functioning properly from time to time prior to the incident involving Resident #51 on 08/07/25. A telephone interview on 09/04/25 at 12:41 P.M. with Nurse Practitioner (NP) #343 revealed she had been on call on 08/07/25 and had received a call from a staff member regarding Resident #51. NP #343 recalled she had received vague information that Resident #51 was found in the basement and had some scratches on him. NP #343 stated she had recalled asking the caller how Resident #51 had gotten into the basement as he resided on a secured unit; however, the caller had not been able to provide an explanation. NP #343 stated she had been told Resident #51 had some scratches on his face and was not made aware of any other injuries. NP #343 stated she had advised the caller if they felt Resident #51 needed to be sent to the hospital to go ahead and send him out. NP #343 stated she had not received any additional follow-up calls regarding Resident #51. A telephone interview on 09/08/25 at 12:57 P.M. with Former Administrator #500 revealed he was in his office on 08/07/25 and received a call from MD #400; however, he did not see the message immediately. Former Administrator #500 was unable to recall at what approximate time he received the message but stated once he received MD #400's message he had gone to the basement and had observed Resident #51 inside the laundry chute room standing up behind the door. Former Administrator #500 stated Resident #51 had told him he was looking for a soda. Former Administrator #500 stated he was unsure how Resident #51 had been inside the laundry chute area as the door was locked and required a code to get inside. Former Administrator #500 stated he had observed some cuts on Resident #51's arms and stated he had gone upstairs to get the DON. Former Administrator #500 stated he had not returned to the basement and had then proceeded to go to the units where he advised the staff to perform a head count of all the residents. Former Administrator #500 stated he had then done an audit of all the doors on each unit with MD #400 and had observed the door on the 3rd floor had not been closing effectively. Former Administrator #500 stated he had advised MD #400 to repair the lock on the third-floor door to the soiled utility room at that time. Former Administrator #500 stated he had done an investigation beginning on 08/07/25 and stated he had turned in his resignation effective immediately on 08/08/25. The Former Administrator did not provide any additional information related to his resignation. Review of the undated facility policy Connections Unit revealed the Connections unit was a secured unit which provided a living environment that was supportive for those with mental health diagnoses that supported a need for increased safety and supervision. It emphasized structured activities and programs to meet physical, mental, and psychosocial needs in a comforting and safe manner. The goal of Connections unit was to respect the privacy and dignity of residents, administer care and treatment, provide a smaller environment with increased supervision that focuses on daily routines, and/or offer an environment that allows individuals to be comfortable with themselves while decreasing the potential for self-harm or escalation of negative behaviors. The Connections unit was a locked unit with coded keypads to unlock the doors. Benefits of the unit include reduction of external stressors and expectations to promote self-worth and a safe living environment. Staff who were trained to provide support and care for residents with aggression and behaviors related to their diagnosis or other need for increased supervision and activities that are specifically chosen for the interest and needs of the residents on the unit. Review of the policy Compliance/Ethics: Records and Documentation dated 08/2025 revealed accurate and complete recordkeeping and documentation is critical to virtually every aspect of the facility's operations. It is the policy of the facility that all documentation should be timely, accurate, and consistent with applicable professional, legal, and facility guidelines and standards. This includes all aspects of the facility's documentation, including resident assessments and care plans, clinical records and all billing and payment documentation. This deficiency represents non-compliance investigated under Complaint Number 2594724.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, closed medical record review, review of an Emergency Medical Service (EMS) report, review of medical examiner records, facility policy review and interviews with facility staff, Medical Director, Certified Nurse Practitioners (CNP) #332 and #334, the facility failed develop and implement comprehensive, individualized and effective interventions/treatment and services to meet the behavioral health care needs of Resident #93 and to assist the resident to attain/maintain his highest practicable mental and psychosocial well-being. This resulted in Immediate Jeopardy and actual harm/death on [DATE] when Resident #93, who had diagnoses including schizoaffective disorder, bipolar, dementia, anxiety, antisocial personality, hallucinations, body dysmorphic disorder and history of suicide attempt was found unresponsive in a communal shower room as a result of a self-inflicted injury with scissors provided to the resident by Licensed Practical Nurse (LPN) #500. Cardiopulmonary resuscitation efforts were initiated, and the resident was transported to the hospital where he was pronounced deceased . The resident's manner of death was listed as suicide. On [DATE] at 4:00 P.M. the Administrator, Director of Nursing (DON), and Regional Clinical Support Nurse #244 were notified Immediate Jeopardy began on [DATE] at approximately 2:40 P.M. when LPN #500 provided Resident #93, who had a significant psychiatric history, with a pair of scissors to cut his hair/bangs. On [DATE] at approximately 3:10 P.M., Certified Nursing Assistant (CNA) #214 found Resident #93 in the communal shower room slumped over in his wheelchair with shallow breathing. There was a large amount of blood on the floor and copious amounts of blood coming from the resident's leg and groin area. CNA #214 summoned assistance from nearby nurses who responded. Resuscitation efforts were initiated, EMS arrived and transported Resident #93 to a local hospital where he was pronounced deceased . The resident's manner of death was listed as suicide. The Immediate Jeopardy was removed on [DATE] and the deficiency corrected on [DATE] after the facility implemented the following corrective actions: On [DATE] at 3:10 P.M. Resident #93 was noted with acute blood loss, Emergency Medical Services (EMS) was notified, and Resident #93 was transported to a local emergency room (ER) by local EMS providers. On [DATE], at 3:55 P.M., LPN #500 was immediately provided 1:1 verbal education by the DON on not providing sharp objects to residents. On [DATE] at 3:55 P.M., LPN #500, was suspended by the Administrator following the incident, pending a thorough investigation. LPN #500 was permitted to return to work beginning on [DATE]. On [DATE] the Director of Nursing (DON), ADON #270, Unit Manager #267, Housekeeping Supervisor #283, Human Resource Manager #262, Licensed Social Worker (LSW) #246, Central Supply #317 and Admissions Director #216 completed a whole house sweep for sharp objects at 4:00 P.M. with no sharp objects noted. On [DATE] by 4:30 P.M., all residents were assessed, and medical records were reviewed (including psychiatric/provider notes) to identify those residents who had self-harm and/or suicidal ideation history. In addition, those who could be, were interviewed, related to suicidal ideation/self-harm. Eleven residents (#100, #15, #16, #28, #33, #38, #40, #101, #57, #61, and #102) were identified as at risk for self-harming behaviors. Care plans and associated Kardex's were reviewed by Regional Clinical Support Nurse #244. On [DATE] by 5:00 P.M. all staff were interviewed regarding any knowledge of residents exhibiting any signs, symptoms, or behaviors which could be indicative of suicidal ideations. This was completed by the Administrator. On [DATE] by 5:00 P.M. Regional Clinical Support Nurse #244 educated all facility interdisciplinary team members (IDT) on updating care plans for resident(s) who have suicide ideations/self-harm and pulling them to the Kardex. On [DATE] by 5:00 P.M. all staff were educated by the DON/Designee on reviewing residents' Kardex, ensuring residents were free and safe from self-harm, and assisting and providing supervision to residents as deemed necessary. On [DATE] by 5:30 P.M. the Administrator completed a quality assessment and performance improvement (QAPI) and a root cause analysis with the Medical Director, DON, ADON #270, Regional Clinical Support Nurse #244, Medical Records #317, Human Resources Manager #262 and LSW# 246. The facility root cause analysis identified the nurse (LPN #500) gave Resident #93 a sharp object and should not have. The facility corrective action plan involved mitigating the risk and availability of sharp objects and identifying those residents at risk for self-harm or suicidal ideations. On [DATE] the DON/Designee began random, ongoing resident audits on care plans for residents with a history of suicidal ideations and/or self-harm. The ongoing audits were completed four times weekly for a total of six weeks, completed on [DATE]. On [DATE] the DON/Designee began random, ongoing audits of staff competencies regarding staff utilization of the resident Kardex's. The audit reviewed five random staff members four times weekly for a total of four weeks. On [DATE], at 9:30 A.M. the Administrator held a QAPI meeting with the DON, ADON, Medical Director, Activities Director #201, Medical Records Coordinator #317, Human Resource Manager #262, Regional Clinical Support Nurse #244 and LSW# 246 to discuss the findings of the facility audits as of this time. Findings include: Review of the closed medical record for Resident #93's revealed an original admitted [DATE] with diagnosis of schizoaffective disorder, bipolar, dementia, anxiety, antisocial personality disorder, hallucinations and body dysmorphic order, and right leg above the knee amputation. Advance directives revealed the resident was a full code. Resident #93 was transported to a local hospital where he was pronounced deceased on [DATE]. Review of Resident #93's care plan dated [DATE] revealed the resident had a self-care performance deficit for activities of daily living related to diagnoses of dementia, paranoid schizophrenia, and limited mobility. Listed interventions included for the resident to be supervised at all times while shaving. A care plan focus dated [DATE] revealed the resident had a mood problem related to paranoid schizophrenia, dementia with behaviors, history of self-harm, antisocial personality disorder, manic episodes, adjustment disorder, psychotic disorder, major depressive disorder, generalized anxiety disorder, and history of suicidal ideations. Interventions included administering medications as ordered and educating residents, family and caregivers regarding expectation of treatment, concerns with side effects, and potential adverse effects. An additional care plan focus dated [DATE] revealed Resident #93 had an identified traumatic event listed as suicide behavior and self-harm with a single listed trigger of being housed on the secured memory care unit. Listed interventions included allowing the resident to express feelings, develop strategies with the resident and/or family to avoid or decrease trauma triggers, discus coping mechanisms, gain as much additional background from family/friends and other healthcare professions as possible, monitor for anxiety, and refer to psych services as needed. Review of Resident #93's primary care progress note dated [DATE] revealed the resident was seen by CNP #334 and was coherent and cooperative upon assessment. Resident #93 was noted to have significant mental illness and had noted delusions and a flat effect. The resident was noted to be unkept and was not well-groomed. Review of Resident #93's psychiatric progress note dated [DATE] revealed the resident was seen by psych CNP #332. The note indicated the resident had a history of 18 prior psychiatric hospitalization s, had chronic passive suicidal ideations, and one prior suicide attempt (date unknown) by throwing himself in front of a semi-truck. The note referenced in the review of systems, Resident #93 was positive for anxiety, had delusions that were evident, and had passive suicidal ideations. Resident #93's general appearance was described as evasive/distant. His mood was recorded as uncomfortable but ok and his affect blunted/flat. Resident #93 was noted to have poor concentration, disorganized thought processes, and delusional thought content. The resident was recorded as having grossly impaired insight and judgement and had self-defeating/endangering behavior without regard to the consequences. The note referenced Resident #93 had no current suicide ideation, intent, or current plan but had a history of chronic, passive suicidal ideations. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition with noted inattention and disorganized thinking. There were no additional behaviors identified. The assessment revealed the resident required (staff) supervision with showers and was independent with personal hygiene. The assessment also noted the resident received anticoagulant and antipsychotic medications. Review of the physician's orders for [DATE] revealed the resident had an order dated [DATE] for Lithium (an anti-manic, mood stabilizing medication) 600 milligrams (mg) by mouth twice daily, an order dated [DATE] for Eliquis 5mg by mouth twice daily, an order dated [DATE] for Olanzapine (an antipsychotic medication) 10 milligram (mg) daily in the morning, and an order dated [DATE] for Olanzapine 12.5 mg daily at bedtime. Review of an Emergency Medical System (EMS) patient care report dated [DATE] revealed a call was received/created at 3:17 P.M., dispatched at 3:25 P.M., arrived on the scene at 3:31 P.M., and EMS arrived at the patient (Resident #93) at 3:36 P.M. The incident summary indicated upon arrival, Resident #93 was located on the floor of his room. There was a copious amount (estimated between three and four liters) of blood on the floor which had already begun to coagulate (clot). The resident was pale, unresponsive, and breathing shallow. Nursing home staff reported they had done chest compressions but had detected a weak carotid pulse. The patient was noted to have a significant stab-like wound to his medial thigh on his left leg. The wound was wrapped (to control the bleeding) by the fire department. The nursing home staff reported they had no idea what happened but advised he had asked for a pair of scissors earlier for an unknown reason. The nursing home staff had come to check on him after not seeing him for some time and found him on his bathroom floor with blood everywhere and not responding. The nursing home staff's suspicion was that the resident self-inflicted the wound on his leg and went an unknown amount of time before being discovered in the bathroom. The local fire department and EMS providers noted they did not notice or locate any scissors present on the scene but noted their primary focus was on the condition of the patient. The report indicated the amount of blood lost was immediately noted as life-threatening and indicated that cardiac arrest from exsanguination was likely-to-imminent. What vitals could be obtained on the scene indicated the resident had a slow, weak pulse, poor respiratory effort, and non-discernable blood pressure. EMS did apply a tourniquet to the extremity as the amount of blood lost was indicative of an arterial wound. Once in the ambulance the initial assessment indicated that the patient no longer had a palpable pulse. CPR was initiated and his heart rhythm monitor indicated a slow rhythm. Resuscitation was attempted while enroute to the hospital. No pulse was ever recovered, and the resident was left in the care of emergency room (ER) staff who promptly terminated further efforts. Resident #93 was pronounced deceased at the local hospital. Review of a progress noted dated [DATE] at 5:00 P.M. authored by the DON revealed the note was created on [DATE] at 1:33 P.M. and included on [DATE] at approximately 3:10 P.M., the nurse was notified by the activity assistant that there was an emergency on the second floor. Upon arriving on the floor, Resident #93 was observed seated in a wheelchair with his back towards the door. The resident was pale, clammy cool to touch. There was a large amount of saliva coming from the resident's mouth and large among of blood on the floor. There were copious amounts of blood coming from the resident's groin area. A second nurse assessed the resident for a pulse and could not identify one. The resident was lowered to the floor and CPR was initiated. The second nurse applied pressure to the bleeding leg. EMS arrived and continued to work on the resident. Resident #93 was transported to the hospital. According to EMS, the resident had a pulse before leaving the facility. Review of local medical examiner office records revealed Resident #93's body was received at the local medical examiner's office on [DATE]. Resident #93's cause of death was recorded as sharp force trauma of the left leg with vascular and soft tissue injuries, complicated by Eliquis. The manner of death was suicide. The place of death was recorded as a local hospital. Review of the facility's investigation dated [DATE] revealed statements were obtained from staff members working that day. All staff interviewed reported no concern or indication that the resident was suicidal. There were no reported behaviors or statements that Resident #93 had wanted to harm himself. The facility completed a root cause analysis which concluded the cause of the incident was the Charge Nurse (LPN #500) provided Resident #93 with a sharp object. Interview on [DATE] at 10:40 A.M. with Licensed Practical Nurse (LPN) #500 revealed she was not assigned to care for Resident #93 on [DATE]. LPN #500 stated at approximately 2:40 P.M., Resident #93 asked her for a pair of scissors to cut his bangs (hair). LPN #500 stated initially she could not find her scissors and went searching for another pair. LPN #500 asked another nurse for a pair of scissors who did not have one. LPN #500 continued to look and found a pair of scissors in her bag and handed them to Resident #93. The scissors were described as safety scissors with a rounded blunted end. LPN #500 provided the scissors to Resident #93 due to her belief the resident was fairly independent with his activities of daily living and had no aggressive behaviors. LPN #500 verified she never looked at the resident's Kardex or care plan prior to giving the resident her scissors. In addition, the resident was not provided any level of supervision while having the scissors. Interview on [DATE] at 11:40 A.M. with psychiatric CNP #332 revealed Resident #93 had a very flat affect with baseline depression. The CNP stated it was her belief the resident had no recent changes in his medication regimen and no change in behavior indicating he had wanted to self-harm. CNP #332 denied knowledge of the resident having any type of current delusions or self-injury but documented them to remind herself that residents do have these behaviors. Interview on [DATE] at 11:13 A.M. with LPN #281 revealed she was assigned to care for Resident #93 the day of the incident (on [DATE]). The LPN revealed CNA #214 approached the shower and noticed blood on the floor. CNA #214 immediately went to get the nurses. Upon entering the shower room, the resident was slumped over in his wheelchair and was moaning. LPN #281 stated they lowered the resident to the floor and started CPR. LPN #281stated she was not sure if the resident(s) were allowed to have sharp objects on the unsecured unit since it was a more liberal environment than the secured unit. LPN #281 stated following the incident with Resident #93 on [DATE], rooms were searched for sharp objects and education was provided for staff. Interview on [DATE] at 1:38 P.M. with CNA #214 revealed she worked second shift and was assigned to care for Resident #93 on [DATE]. CNA #214 stated she was doing a walk-through to see what residents were in their rooms, and noticed Resident #93 was not in his room. Resident #93's roommate told her someone was in the shower room bleeding. CNA #214 proceeded to the shower room, opened the door, and from the back saw Resident #93 slumped over in his wheelchair with blood on the floor and called for help. CNA #214 walked in front of the resident and called his name. Resident #93 was breathing, and he opened his eyes. CNA #214 summoned help from the nursing staff. Interview on [DATE] at 10:37 A.M. with Resident #50, who had been Resident #93's roommate, revealed (on [DATE]) he had opened the shower room door and saw Resident #93 seated back in his wheelchair with blood on the floor. He stated he quickly closed the door and went to his room and looked out the window and saw an ambulance. Resident #50 stated he was afraid to tell staff because he did not want to get blamed. Resident #50 stated he liked to shave his own face and body, he would get a razor from the supply area and shave in the shower or at the sink in the room which staff allowed. Interview on [DATE] at 11:47 A.M. with LPN #330 revealed CNA #214 came out of the shower room and yelled that a resident was bleeding. LPN #330 and another nurse went into the shower room, observed the resident (#93) was unresponsive, and called a code. LPN #330 stated the nurse had a hard time finding the resident's pulse. EMS was called, arrived on scene, and continued resuscitative efforts. Resident #93 had a pulse when he left the unit. She stated it was very chaotic, and LPN #500 was crying. LPN #330 did not observe anyone else in the shower room upon entering the room. The LPN stated it was common that Resident #93 would occasionally ask for a razor to shave and scissors to cut his bangs. She stated it was unfortunate that the nurse given him the scissors. Record review revealed no safety assessment or care plan interventions were in place related to the resident's independent use of razors and/or scissors. Interview on [DATE] at 1:51 P.M. with Registered Nurse (RN) #276 revealed Resident #93 had periods of depression but stated not to the point of any concerns. RN #276 was aware of Resident #93's extensive psychiatric history. The RN revealed the resident had a right above-the-knee amputation and always wanted his legs to match. Prior to coming to the facility, he had jumped out of a moving car so his legs would match. RN #276 stated at the time of the incident on [DATE], there was a whole lot of blood on the floor, and she had applied pressure to the resident's leg. Resident #93 did not respond initially, but made an occasional grunting sound as the staff and EMS were providing resuscitative efforts. RN #276 stated EMS reported Resident #93 had a faint pulse at the time he left the unit. Interview on [DATE] at 2:38 P.M. with Resident #93's primary care CNP #334 revealed she saw the resident for a left lower extremity vascular issue that severely damaged circulation to his leg. The resident had lymphedema in the left leg, saw an outside vascular medicine provider, but would refuse therapy to treat the leg. CNP #334 reported Resident #93 was moody, quiet, had poor eye contact and could be very manipulative when he wanted something. CNP #334 stated she would not expect staff to provide sharp objects to residents. Interview on [DATE] at 3:53 P.M. with Medical Director (MD) #610 revealed Resident #93 was schizophrenic and was visited monthly. MD #610 revealed the resident had been at the facility for many years and was believed to be stable. MD #600 recalled the resident was withdrawn and did not communicate much information, which was a classic sign of schizophrenia. MD #600 was surprised about the incident (on [DATE]) and was unaware that a nurse provided Resident #93 with a pair of scissors. Interview on [DATE] at 3:33 P.M. with LPN #296 revealed a CNA called her into the shower room (on [DATE]) and Resident #93 was observed sitting in his wheelchair with his clothes on. On the floor around the resident was a large puddle of blood. LPN #296 called 911 to summon EMS. Resident #93 was unresponsive and at first staff could not locate a pulse, eventually locating a weak pulse. LPN #296 stated EMS arrived promptly. LPN #296 was surprised that LPN #500 had provided scissors to Resident #93. LPN #296 stated the resident could not handle shaving and would cut himself. Additionally, she noted Resident #93 would occasionally exhibit delusions and talk to walls. Interview on [DATE] at 9:30 A.M. with Regional Clinical Support Nurse #244 revealed the facility had no policy addressing suicidal behavior, residents at risk for self-harm, or sharp object safety. Telephone interview on [DATE] at 11:30 A.M. with the DON revealed on [DATE] she located the scissors involved in Resident #93's incident after the resident had left the facility. The DON reported the scissors were disposed of in the facility's sharps container. Review of the policy Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated ,d+[DATE] revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, and misappropriation of resident property, including injuries of unknown source. The policy defined an alleged violation as a situation or occurrence that was observed or reported but had not yet been investigated and, if verified, could be noncompliance with federal requirements. The policy defined an injury of unknown source as an injury which occurs when the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury was suspicious because of the extent or location of the injury. The policy defined neglect as the failure of the facility, its employees, or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. This deficiency represents an incidental finding of non-compliance identified during the complaint investigation.

Based on observation, medical record review, facility policy review and interviews, the facility failed to ensure a safe environment free from a potential accident hazard when smoking materials were not secured to prevent unsafe smoking in resident rooms. This resulted in Immediate Jeopardy and the potential for serious harm, injury and/or death on [DATE] at 1:03 P.M. when Resident #38, who was assessed to require staff supervision and the use of a smoking apron (device worn to protect from burns caused by hot ashes or lit cigarettes) was observed alone in his room with a strong cigarette odor and visible cigarette smoke in the air. Certified Nursing Assistant (CNA) #300 verified the odor and presence of smoke in Resident #38's room and further stated Resident #37, who was Resident #38's roommate and away from the facility at the time of the observation, had been seen previously smoking in the room. Additionally, Resident #37 and Resident #38's bathroom had cigarette ashes on the floor, burn marks on the toilet seat and toilet paper holder and two cigarette butts were found in the plastic trash can located next to Resident #38's bed. Resident #37 and Resident #38 resided in a room located across the hall from Resident #32, who was identified to utilize oxygen. This affected two residents (#37 and #38) of seven residents reviewed for smoking with the potential to affect all residents residing in the facility. The facility census was 101. On [DATE] at 1:08 P.M., the Administrator, Regional Registered Nurse (RRN) #333 and Regional Director of Operations (RDO) #334 were notified Immediate Jeopardy began on [DATE] at 1:03 P.M. when a strong cigarette odor and visible smoke was observed in Resident #37 and Resident #38's room. Additionally, there were cigarette ashes on the bathroom floor, burn marks on the toilet seat and toilet paper holder and two cigarette butts located in the plastic trash can next to Resident #38's bed. While Resident #37 was away from the facility at the time of the observation, Resident #38 was in the room and identified to be a smoker who required supervision and the use of a smoking apron while smoking. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 3:00 P.M., the Interdisciplinary Team (IDT), including Housekeeping Manager (HM) #283, Medical Records Coordinator (MRC) #322, Activities Director (AD) #202, Maintenance Director (MD) #271, the Administrator, Human Resources (HR) #262, Scheduler #261, Licensed Social Worker (LSW) #301, Social Services Designee (SSD) #260, the Director of Nursing (DON), Assistant Director of Nursing (ADON) #273, Unit Manager Registered Nurse (UM/RN) #256 and UM/RN #302, conducted room sweeps on all resident rooms for the presence of smoking materials. On [DATE] at 3:15 P.M., UM/RN #302 searched Resident #37's room and any smoking materials identified were secured. On [DATE] at 3:15 P.M., the DON searched Resident #38's room and person and any smoking material identified were secured. On [DATE] at 3:25 P.M., the DON assessed Resident #32, Resident #37 and Resident #38 for injuries, with no adverse effects noted. On [DATE], at 5:00 P.M., the Administrator re-educated all staff on the facility smoking policy and procedure related to supervision of residents who smoke. The education was provided electronically via On-Shift software messaging and texting to staff. The education was completed by all staff by 6:00 P.M. On [DATE], at 5:00 P.M., LSW #301 re-educated all 64 residents who smoke (#2, #3, #4, #5, #6, #8, #10, #12, #15, #18, #19, #20, #21, #22, #24, #26, #27, #28, #29, #31, #32, #33, #34, #35, #36, #37, #38, #40, #41, #47, #48, #51, #52, #60, #61, #62, #63, #64, #65, #67, #70, #71, #72, #73, #74, #77, #79, #80, #81, #82, #83, #84, #86, #88, #90, #91, #92, #93, #96, #97, #98, #99, #100 and #101) on the smoking policy, which included residents smoking only in designated areas, securing smoking materials and other applicable policies. Failure to follow the facility smoking policy would result in a discharge notice. On [DATE] at approximately 5:00 P.M., a root cause analysis was performed by the Administrator, the DON, ADON #273, HM #283, MRC #322, AD #202, MD #271, HR #262, Scheduler #261, LSW #301 and SSD #260. It was determined residents who had left the facility for appointments or other leave of absences (LOA) may have purchased and brought back smoking materials without staff knowledge and policies and procedures for securing smoking materials had not been adhered to. On [DATE] by 5:00 P.M., the IDT, including RRN #333, the DON, ADON #273, UM/RN #302 and UM/RN #256 completed an audit of the smoking assessments for all 64 residents who smoke to ensure accuracy and updated care plans as needed. On [DATE] by 5:00 P.M., the DON, ADON #273, UM/RN #256 and UM/RN #302 completed a skin assessment on all residents who smoke. On [DATE] at 5:00 P.M., the Administrator provided all staff two questionnaires to ensure education from [DATE] was effective. On [DATE] at 7:00 P.M., the Administrator updated the procedure for securing smoking materials when a resident leaves and returns to the facility, to include signing out smoking materials and signing them back in. The Administrator educated all staff and residents on the procedure. Staff would contact the Administrator or designee if smoking materials were not returned. Beginning on [DATE], the Administrator or designee would audit smoking material sign out/sign in sheets one time daily to ensure smoking materials were returned. Beginning on [DATE], the Administrator or designee would complete room audits on all residents who smoke, and throughout the facility, two times per day for eight weeks to ensure residents have no smoking materials in their rooms and were adhering to the facility's smoking policy. On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee meeting was held to review the root cause analysis and corrective action plan. Those in attendance included the Administrator, the DON and Medical Director (MD) #355. Review of five (#6, #15, #71, #80 and #98) additional open resident records revealed no concerns. Interviews on [DATE] from 7:37 A.M. through 2:09 P.M. with Dietary Aide (DA) #226, DA #285, CNA #203, CNA #211, CNA #328, CNA #329, CNA #357, Licensed Practical Nurse (LPN) #241, LPN #257, LPN #318, Activities Assistant (AA) #236, Housekeeping #321 and Receptionist #279 confirmed the facility provided education on the smoking policies and procedures, including signing smoking materials in and out. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of Resident #37's medical record revealed an admitted [DATE] with diagnoses including nicotine dependence, end stage renal disease and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #37 had impaired cognition. Review of the care plan dated [DATE] revealed Resident #37 was a smoker. Interventions included assess resident for smoking safety, educate resident on where smoking may occur, not giving or trading cigarettes with other residents, encourage safe smoking practices at all times, explain the consequences for smoking including removal of all smoking materials and only being allowed to smoke when supervised, provide a copy of the facility safe-smoking policy and explain so resident is aware of all obligations and consequences of violating the rules, smoking may not occur in residents rooms, bathrooms, hallways or other non-designated areas. Review of the Smoking Assessment, dated [DATE], revealed Resident #37 was assessed by the facility to require supervision while smoking. Review of a Last Chance Agreement, dated [DATE], revealed Resident #37 had agreed to not smoke without proper supervision. Review of Resident #38's medical record revealed an admitted [DATE] with diagnoses including nicotine dependence, bilateral amputations, muscles weakness and muscle weakness. Review of the MDS assessment, dated [DATE], revealed Resident #38 had intact cognition. Review of the care plan dated [DATE] revealed Resident #38 was a smoker. Interventions included monitor for compliance with smoking policy, smoking apron and supervision while smoking. Review of the Smoking Assessment, dated [DATE], revealed Resident #38 was assessed by the facility to require a smoking apron and supervision while smoking. Observation on [DATE] at 1:03 P.M. revealed a strong odor of cigarette smoke outside of Resident #37 and Resident #38's room. Further observation of the residents' room confirmed the presence of cigarette smoke odor and further revealed visible smoke in the air. Concurrent interview with Certified Nursing Assistant (CNA) #300 verified the odor and presence of smoke in the residents' room. CNA #300 stated Resident #37 had previously been observed smoking in the room (date(s) not provided). At the time of the observation, Resident #37 had been out of the facility for approximately one and one-half hours. Resident #38, who also smoked, was lying in bed with a blanket pulled up over his head. An attempted interview with Resident #38 at the time of the observation revealed the resident denied smoking in the room. At the time of the observation, UM/RN #302 entered the room and opened Resident #37 and Resident #38's bathroom door and revealed cigarette ashes on the floor and burn marks on the toilet seat and toilet paper holder. LSW #301 was also present and discovered two cigarette butts in the plastic trash can, which had some paper waste, located next to Resident #38's bed. An interview with UM/RN #302 at the time of the observation verified the findings and further confirmed Resident #38 was to be supervised by staff while smoking and required a smoking apron to prevent burns. A continuous observation at this time revealed Resident #32 resided in the room across the hall from Resident #37 and Resident #38 and had a sign posted outside of the room indicating the resident had oxygen in use. Interview with LSW #301 and UM/RN #302 verified Resident #32 was on oxygen and smoking was not permitted in the area. An interview on [DATE] at 3:48 P.M. with the Administrator revealed staff and residents had been educated on the facility process for signing out smoking materials and signing them back in upon re-entry to the facility. No additional information was provided to determine or support the facility had effective systems in place to ensure smoking materials were actually being signed out and then back in or to prevent residents from engaging in unsafe smoking practices and smoking in their rooms. Review of the facility policy titled Resident Smoking, revised [DATE], revealed smoking was only permitted in designated smoking areas, all resident smoking materials were to be kept locked at all times and non-compliance with the smoking policy could result in a thirty-day discharge notice. This was an incidental finding discovered during the complaint investigation.

Based on observation, medical record review, review of Emergency Medical Service (EMS) records, hospital record review, review of the facility Elopement and Secure Unit policy and procedures and interviews, the facility failed to provide adequate supervision and individualized interventions to prevent Resident #87 from eloping from the third floor secured behavioral unit. This resulted in Immediate Jeopardy on 09/02/23 at approximately 9:00 P.M. when Resident #87, with a known history of elopement and poor judgement and insight, was last seen by facility staff before eloping from the facility third floor secure behavioral unit without staff knowledge. Actual serious harm/injury occurred when Resident #87 exited the window of his third story room and either jumped/fell to the ground or descended via a ledge to a first story rooftop before jumping/falling to the ground. Resident #87 was not identified as missing from the facility until 09/03/23 at approximately 6:00 A.M. when he was observed outside the facility covered in blood and feces by Dietary Aide #805. The resident was subsequently transported to the hospital where he was diagnosed with a right acetabular non-weight bearing fracture (socket of hip bone), left distal radial (wrist) fracture, right fifth rib fracture, comminuted fracture (bone fractured into more than three separate pieces) of the lateral right orbital wall (eye socket), right parietal bone (part of skull) fracture, right temporal bone (part of skull) fracture, and sphenoid (sinus) fracture. This affected one resident (#87) of three residents reviewed for elopement. The facility census at the time of the survey was 101. On 09/12/23 at 1:42 P.M. the Administrator was notified that Immediate Jeopardy began on 09/02/23 at approximately 9:00 P.M. when Resident #87 lacked sufficient supervision, exited the facility unsupervised from the secured care unit without staff knowledge, resulting in serious bodily injury/hospitalization . The Immediate Jeopardy was removed on 09/05/23 when the facility implemented the following corrective action: On 09/03/23 at 6:00 A.M. Resident #87 returned to the facility and was assessed to have swelling to his head and eye. Licensed Practical Nurse (LPN) #803 notified the Director of Nursing (DON), Administrator, Nurse Practitioner (NP) and on-call NP. On-call NP indicated they would contact the resident's guardian and give report to hospital. Staff performed a head count to ensure all residents were accounted for. Emergency Medical Services (EMS) arrived to the facility at approximately 8:00 A.M. and transferred Resident #87 to hospital. Upon the resident's return, an STNA was assigned to remain in the room until the window was secured. The STNA remained in Resident #87's room from 7:00 A.M. until secured by Maintenance at 10:40 A.M. On 09/03/23 the Maintenance Director verified all windows on the 100, 200, 300, and 400 units were secured and unable to be opened enough to prevent a resident from exiting. On 09/03/23 the Maintenance Director verified all exits on the secured behavior unit were functioning. On 09/03/23 the facility completed a re-assessment of Resident #87's elopement risk. The resident was assessed to be at risk of elopement. On 09/03/23 the Director of Nursing (DON) completed an elopement assessment for all residents. There were no new interventions or changes to any other residents' care plans as a result of the assessments. On 09/03/23 the DON/designee educated all shift nurses (Licensed Practical Nurses (LPNs) and Registered Nurses (RNs)), on all floors to complete a head count at the start of each shift. Any variances were to be reported daily to the DON and Administrator. Results would be shared with the Quality Assessment Performance Improvement (QAPI) committee as needed. On 09/03/23 the DON educated the secured behavior unit staff on duty, to complete a head count each hour. At the time of the head count, environmental observations (for safety) were also to be completed until further notice. Any variances were to be reported to the DON and Administrator. There were no variances reported as all residents were accounted for. The DON/designee used the OnShift messaging system to educate all staff on the head count requirement at the start of each shift, and the third floor every hour requirement. The DON/designee also educated all facility staff on the facility elopement process and procedures. On 09/03/23 the DON and Administrator completed a QAPI plan. Beginning 09/04/23 the Administrator/designee implemented a plan to complete weekly random audits of 10 resident rooms for four weeks to ensure the resident room windows were secure. Beginning 09/04/23 the facility implemented a plan for the Maintenance Director/designee to verify all resident room windows on the secured behavior unit were secure daily for four weeks. Variances would be reported to the Administrator/designee immediately. Beginning 09/04/23 the facility implemented a plan for the Maintenance Director/designee to check the 100, 200, and 400 resident room windows once a week to ensure the windows were secure. Variances would be reported to the Administrator/designee immediately. On 09/05/23 the QAPI plan was reviewed by the IDT committee including the DON, Administrator, and Medical Director. On 09/05/23 the DON and Administrator reviewed the facility head count process. The results would be shared with the QAPI committee as needed. On 09/05/23 the Administrator/designee conducted an elopement drill. On 09/05/23 the Administrator contacted Resident #87's guardian to discuss the elopement incident and interventions in place. On 09/08/23 Resident #87 returned to the facility from the hospital and an admission assessment was completed. A head-to-toe assessment was also completed. Resident #87 was scheduled for a follow up appointment with the vascular surgeon for his left distal radius fracture. On 09/11/23 the facility completed a social services review and evaluation for Resident #87. The facility identified continued support and opportunities to discuss feelings would be provided. On 09/12/23 the facility completed a psychological evaluation for Resident #87 with new physician orders for medications, including Zoloft for depression and Risperdal for paranoid schizophrenia. On 09/13/23 Resident #87's care plan was reviewed with revisions and new interventions related to Resident #87's elopement risk, actual elopement, and sustained injuries. The facility provided information that by 09/22/23 the Maintenance Director would replace all 100, 200, 300, and 400 unit window screws with self-tapping hex washer head screws for added security. Although the Immediate Jeopardy was removed on 09/05/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of a Care Coordination Note dated 08/04/21 revealed the probate court had issued an order of detention for psychiatric admission for Resident #87. Resident #87 once stabilized would be referred to Cityview Healthcare and Rehabilitation. Review of an Emergency Department Biopsychosocial Assessment Note dated 08/04/21 revealed Resident #87 presented via Sheriff's Department and was on a probate order. Resident #87 was noted to have a long history of schizophrenia. Resident #87 was a patient at a skilled nursing facility (SNF) and had eloped by climbing over a fence. Resident #87 refused to answer questions and had no understanding of the need for medications to maintain his life. Resident #87 was admitted for inpatient psychiatric stay. Review of a Behavioral Health Institute Admission Note dated 08/05/21 revealed Resident #87 had a tendency to isolate self, had difficulty with relationships, poor social skills, and generalized negative attitude about future/recovery. Resident #87 was noted to have poor judgement and insight. Review of the medical record for Resident #87 revealed an admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, major depressive disorder, insomnia, brief psychotic disorder, schizoaffective disorder, and mental disorder due to known physiological condition. Resident #87 was identified to have a legal guardian. Review of medical record revealed Resident #87 was admitted to the facility third floor secured behavioral unit. Review of an Elopement Evaluation dated 08/11/21 revealed Resident #87 had history of attempting to leave the facility without informing staff and was recently admitted without accepting situation. Staff were notified of Resident #87's wandering risk. Review of the plan of care dated 08/30/21 revealed Resident #87 required a room on the secure unit related to unawareness of safety needs and to promote psycho-social well-being due to mental illness. Interventions included encourage the resident to participate in activities of choice and provide distraction with diverse activities throughout the day. Review of the plan of care dated 08/30/21 revealed Resident #87 was at risk for elopement due to history of eloping. Interventions included apply wander guard (a monitoring device that activates audible alarm if an individual approaches a set boundary), check function of wander guard every shift, change battery monthly of wander guard, and complete elopement risk assessment upon admission/quarterly/and as needed. Review of a social service note, dated 10/13/21 revealed Resident #87 was asking to go home and had no understanding of his reason for placement. Resident #87 had a guardian. The guardian explained Resident #87 had required adult protective services (APS) assistance while in community and had eloped from last skilled nursing facility he had resided in. Resident #87 had many behaviors requiring attention and would need to stay long term care (LTC) for the foreseeable future. Review of a physician's order dated 04/15/22 revealed Resident #87 was in the least restrictive environment possible and needed a secure unit due to behaviors related to paranoid schizophrenia. Review of facility Consent to Resident on the Connections Unit dated 10/13/22 revealed Resident #87's guardian signed consent for him to reside on the Connections secured unit. The consent gave description of the Connections secured unit: a secure unit which provided a living environment, supportive for those with mental health diagnosis and supports a need for increased safety and supervision. The unit was a locked unit with coded keypads to unlock the doors. The form noted Resident #87 was admitted for reason of: chooses to be on the unit because of personal preference such as a specific room, smaller physical environment, and comfort in a focused daily routine. Review of the plan of care note dated 11/29/22 revealed Resident #87 continued to require long term care (LTC) per guardian due to inability to care for self in community. Review of an Interdisciplinary Care Conference Summary dated 05/08/23 revealed Resident #87 was requesting to go home to live with his sister. Resident #87 was noted to have cognitive loss. Placement on secured unit was reviewed and remained appropriate. Review of an Interdisciplinary Team (IDT) Note dated 05/11/23 revealed Resident #87's guardian continued to recommend placement at Cityview Healthcare and Rehabilitation for mental health and medical care. Guardian indicated Resident #87 was a danger to himself and others. Review of the plan of care dated 05/12/23 revealed Resident #87 had the need to reside in the Connections Community due to behavior of physical aggression with others. Interventions included encourage daily routine to stay as independent as possible, encourage outlets of behaviors, review for potential contracts to motivate the resident, reinforce with positive rewards when positive behavior displayed, utilization of behavior modification, and when positive behavior is noted address immediately with a compliment. Review of physician's order dated 05/30/23 revealed Resident #87 required room on secured unit to promote psychosocial well-being and interaction with peers. Review of a Bi-Annual Comprehensive Visit note, dated 06/26/23 revealed Resident #87 was assessed by a Nurse Practitioner (NP). Resident #87 was assessed to be alert and oriented to person and place. The NP noted Resident #87 was forgetful and difficult to understand. The NP questioned Resident #87's ability to provide accurate answers to questions. The NP assessed Resident #87 to have memory loss and cognitive impairment of intellectual disabilities. The NP noted Resident #87 had paranoid schizophrenia which was managed by a psychologist. Review of an Elopement Evaluation dated 07/14/23 revealed Resident #87 was assessed to be not at risk for elopement. Review of annual Medicare Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #87 had unclear speech, a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact), and no wandering behaviors. Resident #87 required staff supervision with set up assistance for transfers, toileting, and bathing, and was independent with no set up for walking in room/corridor. Resident #87 was noted to be occasionally incontinent of bowel and bladder. The assessment indicated there were no wandering or elopement alarms used. Review of a PsychoTherapies Skilled Nursing Facility Encounter note, dated 08/08/23 revealed Resident #87 was seen for follow up management of chronic mental health and psychiatry conditions. Staff and Resident #87 reported no concerns or behaviors. On Mental Status Examination, Resident #87 was assessed to have poor judgement and insight, poor attention and concentration, and poor fund of knowledge. The facility was to continue to provide Invega medication for schizophrenia and Trazodone medication for insomnia as ordered. Review of a quarterly social service [NAME] dated 08/14/23 revealed Resident #87 resided on a secured behavior unit and placement was appropriate due to need for monitoring for safety. Resident #87 was noted to have paranoid schizophrenia and indicated the resident was well adjusted to unit with no behaviors. Review of a Secured Unit assessment dated [DATE] revealed Resident #87 was assessed for Connections behavioral community. Continued placement was recommended due to Resident #87 liked the unit and preferred to stay on unit. Review of the facility Behavior Monitoring Response History revealed on 08/31/23 Resident #87 had an episode of wandering. Review of Medication Administration Record (MAR) for September 2023 revealed the last confirmed time Resident #87 was seen by a nurse on 09/02/23 was at 9:00 P.M. when he was administered Trazodone for insomnia, Atorvastatin Calcium for hyperlipidemia, and insulin for diabetes mellitus. Review of an electronic medical record entry (General Note) dated 09/03/23 and entered as a late entry on 09/05/23 by LPN #803 revealed Resident #87 exited the elevator to third floor secure behavioral unit at approximately 6:00 A.M. on 09/03/23. Resident #87 was noted to be covered in feces and blood. Resident #87's head and eye were swollen. The nurse attempted to assess Resident #87; however, the resident was insistent on going to his bedroom. Nurse and nurse's aide followed Resident #87 to his bedroom and observed him immediately go over to bedroom window to close it. Nurse assessed window and noticed it was able to open and close fully. Resident #87 indicated a staff member with blonde and silver hair had taken him outside and left him outside. Resident #87 indicated he slept across the street. Resident #87 then indicated he may have gone out the window but was unsure. Nurse again attempted to assess Resident #87 and vital signs were stable. The nurse notified the DON, Administrator, NP and on-call NP. The on-call NP indicated they would contact resident's guardian and give report to hospital. Staff performed a head count to ensure all residents were accounted for. Emergency Medical Services (EMS) arrived to the facility at approximately 8:00 A.M. and transferred Resident #87 to hospital. EMS indicated they were unsure which hospital Resident #87 was being taken to as it appeared he fell from a third story window. Review of Transfer Form dated 09/03/23 revealed Resident #87 was transferred to the hospital from the facility for trauma related to fall or other. The transfer was unplanned and Resident #87's guardian was notified. Review of an Elopement Evaluation dated 09/03/23 revealed Resident #87 was at risk for elopement due to history of elopement or attempted leaving the facility without informing staff, resident wanders, wandering behaviors was a pattern and goal directed. Review of the Cleveland Emergency Medical Services (EMS) Patient Care Report dated 09/03/23 revealed a call was placed for services at 7:32 A.M. on 09/03/23. EMS arrived on scene at 7:47 A.M. however were unable to reach Resident #87 until 8:00 A.M. due to the resident residing on a locked unit. Resident #87's chief complaint was a fall victim. Resident #87 reported pain to his face with noted abrasions and swelling to right eye. Resident #87's right eye was noted to be swollen shut. Resident #87 also reported pain in his neck. Resident #87 reported to EMS approximately 12 hours prior he had jumped from third floor window and landed on face. Resident #87 stated he crawled back into the nursing home and staff put him back to bed. Staff confirmed Resident #87 had jumped from the window. Resident #87 reported no suicidal ideations and indicated he had jumped to escape from nursing home staff. Resident #87 was transported to hospital without incident. Review of the hospital History and Physical dated 09/03/23 revealed Resident #87 was admitted to the emergency department status post fall from three stories. Resident #87 was noted to be agitated and perseverating on making sure his money was safe. Resident #87 complained of pain around his neck due to cervical collar and pain to left wrist. Resident #87 was noted to have right frontal cephalohematoma (an accumulation of blood under the scalp), scattered abrasions over right side of face, and right periorbital edema (swelling around eye) and ecchymosis (discoloration around eye). The hospital staff were unable to obtain a past history due to the resident's mental status. Resident #87 was sent for radiology services including computerized tomography (CT) scan of chest, abdomen, pelvis, facial bones/head and x-ray of wrist. Resident #87 was found to have right acetabular fracture, left distal radial fracture, right fifth rib fracture, comminuted fracture of lateral right orbital wall, right parietal bone fracture, right temporal bone fracture, and sphenoid fracture. It was recommended to admit Resident #87 to trauma intensive care unit (TICU) and consult with neurosurgery, orthopedics, plastic surgeon, and ophthalmology. Resident #87 required Haldol for agitation. Review of a hospital daily progress note dated 09/03/23 revealed no acute surgery per plastic surgeon was needed however the resident should remain on sinus precautions. Ophthalmology suggested to avoid blowing nose, use ice packs, and administer nasal decongestant. Orthopedics recommended no acute surgery for right acetabular fracture, right fifth rib or left distal radial fracture. Orthopedics recommended to allow weight bearing to right hip, start therapy, splint left upper extremity and pad pressure points. Review of hospital Clinical Event Note dated 09/04/23 revealed neurosurgery reviewed follow up imagining and Resident #87 was stable. Neurosurgery suggested follow up in two weeks for repeated scan. Review of a hospital daily progress note dated 09/05/23 revealed Resident #87 continued to have agitation. Resident #87 was given dose of Haldol and started on Risperidone. Review of a social services note dated 09/06/23 revealed Resident #87 had called the facility social worker and asked to be picked up so he could return to facility. Resident #87 was asked what had happened and Resident #87 indicated he wanted to go back to Austintown, but his guardian would not let him. Resident #87 was informed they could discuss further with guardian upon return to facility from hospital. Resident #87 was noted to become delusional and spoke of playing professional football. Review of a hospital Gold Form: Provider Orders dated 09/08/23 revealed Resident #87 was accepted for return to Cityview Healthcare and Rehabilitation. Resident #87 was provided with orders for sinus precautions, ice packs and nasal decongestant as needed, to follow up with outpatient services for right temporal bone fracture, sphenoid fracture, right parietal bone fracture, right acetabular fracture and left distal radial fracture, and follow up with primary care provider for rib fracture. Resident #87 was also provided with medication orders for Risperidone one milligram (mg) oral tablet twice per day, Sertraline 25 mg oral tablet once per day, Trazodone 50 mg oral tablet once per day at bedtime, Melatonin 5 mg oral tablet as needed daily, and Haloperidol 2 mg oral tablet every eight hours as needed. Review of a general note dated 09/08/23 revealed Resident #87 returned to the facility from the hospital. Resident #87 was assessed to be alert and oriented to person, place, and time and able to make his needs known. Resident #87's vital signs, bowel sounds, lung sounds, and skin were assessed with no abnormal findings. Resident #87 was able to ambulate with stand by assist and was non-weight bearing to left arm. Resident #87 was noted to have dark discoloration to the right side of face and soft cast on left arm. Resident #87 had a scheduled follow up appointment with vascular surgeon for left distal radius fracture. Orders were verified with NP and faxed to the pharmacy. Review of a head-to-toe assessment dated [DATE] revealed Resident #87's skin integrity was assessed with noted bruising to face. Review of a social service note, dated 09/11/23 revealed Resident #87 was seen for return from hospital. The Social Worker assessed Resident #87 as alert and oriented to person, place, and time with BIMS score of 15. Resident #87 was asked about the (elopement) incident, and he stated he did not remember. It was noted Resident #87 had rib fracture, orbital fracture, and radius fracture. Social Services would continue to provide opportunities to express feelings about desire to go to Austintown. Social Services noted Resident #87's guardian requested continued placement at Cityview Healthcare and Rehabilitation related to past failures in group homes and other SNFs. Interview upon entrance conference on 09/11/23 at 8:51 A.M. with the Administrator and Director of Nursing (DON) confirmed there had been an elopement involving Resident #87. On 09/11/23 at 9:31 A.M. Resident #87 was observed lying in his bed in his room on the third floor secured behavioral unit. Interview on 09/11/23 at 12:12 P.M. with Maintenance Supervisor #802 revealed he received a phone call on 09/03/23 and was notified Resident #87 was found outside of the building. Maintenance Supervisor #802 reported he was asked to come to the facility and check all windows for security. Maintenance Supervisor #802 indicated windows were secured using screws in the window tracks. Maintenance Supervisor #802 indicated the window in Resident #87 was found to be tampered with upon inspection. Observation on 09/11/23 at 12:16 P.M. with Maintenance Supervisor #802 of Resident #87's bedroom window revealed the screw in window track had been replaced and the window was secure when pushed on. Maintenance Supervisor #802 indicated he planned to replace all screws in windows with a flat head screw that required a special tool to remove. Maintenance Supervisor #802 indicated with the current screws a resident could use a flat object to loosen/remove it over time. Observation on 09/11/23 at 12:23 P.M. with Maintenance Supervisor #802 of Resident #87's bedroom window from outside the facility revealed the building consisted of four floors with a basement. Below Resident #87's window was access to the basement level via stairway. Below windows on each floor was a ledge that ran the length of the building. Branching off on first floor level was a roof top identified on map as boiler room. Maintenance Supervisor #802 indicated each floor was approximately 10 to 12 feet tall. There was chain-link fence surrounding the facility parking lot with gate. Maintenance Supervisor #802 indicated the gate does not get closed at night. Telephone interview on 09/11/23 at 12:46 P.M. with Licensed Practical Nurse (LPN) #803 revealed he was the nurse from 11:00 P.M. on 09/02/23 to 7:00 A.M. on 09/03/23. LPN #803 indicated he came in and completed initial rounding at 11:00 P.M. LPN #803 noted Resident #87 appeared to be in bed with covers over his head. However, LPN #803 was unable to verify if Resident #87 was actually in bed at time of observation. LPN #803 revealed he normally checked on residents every two hours but could not confirm if he did this for Resident #87 as he was assisting another resident with behaviors that night. LPN #803 indicated he started morning medication pass at 5:00 A.M. LPN #803 indicated he went to nurses' station to get a glucometer and saw Resident #87 get off elevator. LPN #803 indicated Resident #87 returned to the third floor secured behavioral unit via elevator at approximately 6:00 A.M. LPN #803 indicated Resident #87 was not accompanied by any staff members. LPN #803 reported he was unaware Resident #87 was out of the facility until his return at approximately 6:00 A.M. on 09/03/23. LPN #803 indicated Resident #87 was covered in blood and feces. LPN #803 indicated he began questioning Resident #87 who brushed past him and walked down to his bedroom. LPN #803 indicated he followed Resident #87 to room and observed Resident #87 closing his bedroom window. LPN #803 indicated that was unusual and he went to the window to inspect. LPN #803 noted the window was able to fully open and close. LPN #803 indicated Resident #87 reported pain in arm and noted swelling on head during assessment. LPN #803 questioned Resident #87 again on what had happened. Resident #87 initially reported a nursing assistant with blonde or silver hair took him outside and he slept across street. LPN #803 questioned how the wounds were inflicted and Resident #87 later indicated he may have gone out the window. LPN #803 indicated he then contacted the DON and Administrator. LPN #803 indicated he was instructed to contact the nurse practitioner. LPN #803 indicated he was advised to send Resident #87 to hospital via EMS. LPN #803 noted it took about 30 minutes until Resident #87 left with EMS services. Telephone interview on 09/11/23 at 12:56 P.M. with State tested Nursing Assistant (STNA) #804 revealed she was working from 11:00 P. M on 09/02/23 to 7:00 A.M. on 00/03/23. STNA #804 indicated she usually sits within view of the elevator on her break in case a resident tried to get on elevator. STNA #804 indicated on 09/03/23 she observed Resident #87 exit the elevator. STNA #804 indicated she followed Resident #87 to his room and observed Resident #87 close the window in his bedroom. STNA #804 indicated she was unaware Resident #87 was not in his room until he exited the elevator. STNA #804 indicated Resident #87 appeared dirty upon his return. STNA #804 indicated she does rounds every two hours, however she was not supposed to wake the residents if they were sleeping. STNA #804 indicated Resident #87 appeared to be in bed with covers over his head during her rounds but was unable to verify if Resident #87 was actually in bed at time of observations. The resident's medical record documentation included an entry in the Walk In Room Response History section on 09/02/23 at 11:24 P.M. However, the interview with STNA #804 on 09/11/23 at 12:56 P.M. verified she did not physically see Resident #87 at this time, but rather thought the resident was in bed with covers over his head. Interview on 09/11/23 at 1:35 P.M. with Resident #87 confirmed he had gone out the window of his bedroom on the secured behavioral unit. Resident #87 indicated he walked along the ledge under window and jumped down to first floor roof then jumped again to the ground. Resident #87 indicated he went across the street to an open area, but stated he came back after an hour. Resident #87 indicated the hospital tried to put casts on his legs and arms, but he stated he didn't get hurt. Resident #87 was unable to provide any additional details involving the incident. Interview on 09/11/23 at 1:50 P.M. with the DON revealed the facility had security cameras located on the back of building but they were not in working order. The DON indicated an interview was not completed with Resident #87 at the time of the incident as he appeared to have a head injury and was not coherent at that time. The DON indicated she had attempted follow up interviews with Resident #87, however he had reported he does not remember the situation. The DON indicated the facility was working with resident's guardian to move Resident #87 off the secured unit prior to the incident, but Resident #87 did not want to move from secure unit. The DON indicated, prior to the incident, Resident #87 had been provided with the access codes to the elevator as Resident #87. The DON indicated the nurse aide had reported Resident #87's bed was arranged that night with a pillow and blanket as if he was in bed (resulting in an inability to determine exactly when Resident #87 left the facility or was not in his bed). The DON verified Resident #87 returned to the third floor via elevator at 6:15 A.M. on 09/03/23. The DON reported the resident had been let back into the facility by Dietary Aide #805. Interview on 09/11/23 at 2:15 P.M. with STNA #807 revealed she started her shift on 09/03/23 at 7:00 A.M. and was responsible for monitoring unsecured window in Resident #87's room until it could be secured. STNA #807 indicated she asked Resident #87 what he was trying to do by going out window and he responded I want to go home. STNA #807 noted Resident #87 appeared injured and she let him rest until EMS services arrived. Telephone interview on 09/11/23 at 3:39 P.M. with Guardian #809 verified he was Resident #87's guardian. Guardian #809 revealed the resident was an elopement risk, however Resident #87 had initially been compliant since arriving to facility. Guardian #809 indicated Resident #87 had a challenging mental health history and was found in unsafe living conditions prior to admission. Guardian #809 indicated Resident #87 was originally placed in a group home, however due to non-compliance was discharged . Guardian #809 indicated Resident #87 was then admitted to a skilled nursing facility in Youngstown, Ohio. Guardian #809 indicated Resident #87 had eloped from the skilled nursing facility and was missing for several days. Guardian #809 indicated it was then Resident #87 was moved to Cityview Healthcare and Rehabilitation for additional security the facility could provide and change in environment. Guardian #809 indicated there was an on-call guardian for the weekend who was notified of Resident #87's elopement between 09/02/23 and 09/03/23. Guardian #809 indicated he followed up with the facility on 09/05/23 regarding the situation. Guardian #809 indicated the facility informed him Resident #87 presented at the back door of facility and stated he was out most of the night. Guardian #809 indicated the facility was unable to report how long Resident #87 was actually out of the facility. Guardian #809 indicated when speaking with Resident #87 he reported he was in a fight then changed his story

Based on observation, closed medical record review, review of Centers for Disease Control (CDC) guidance, review of American Diabetes Association guidance, review of the facility policy for wound care, review of the facility diabetes clinical protocol and interview, the facility failed to implement an individualized and effective plan of care to prevent the development of a foot ulcer for Resident #107, who was admitted with intact skin, identified to be a risk for pressure ulcer development and had co-morbidities including diabetes and diabetic neuropathy, peripheral circulatory disorders, renal failure and was visually impaired requiring extensive assistance of one staff with bed mobility and staff supervision for dressing and personal hygiene. This resulted in Immediate Jeopardy and serious life-threatening harm to Resident #107 beginning on [DATE] when the resident reported foot pain and his shoes feeling too small without staff assessment or interventions. The resident subsequently developed an ulcer to his right foot, fever and symptoms of infection without evidence of immediate treatment or adequate monitoring/interventions being implemented to prevent the development. Before the facility initiated a treatment plan, on [DATE] Resident #107 was found unresponsive and without vital signs requiring cardiopulmonary resuscitation (CPR). CPR was unsuccessful and the resident passed away of cardiac arrest per the resident's death certificate; however, an autopsy was not performed to identify the exact cause of death. A situation that did not rise to Immediate Jeopardy occurred when the facility failed to follow physician orders for wound care for Resident #25's right foot. This affected two residents (#25 and #107) of three residents reviewed for foot care. The census was 105. On [DATE] at 1:48 P.M. the Director of Nursing (DON), Regional Support Administrator #226, Regional Support Nurse (RSN) #219 and the Regional Director of Clinical #227 were notified Immediate Jeopardy began on [DATE] when the facility failed to provide necessary assessment and interventions when Resident #107 complained of foot pain and his shoes potentially being too small. The lack of assessment/monitoring and intervention contributed to the development of a foot ulcer to Resident #107. On [DATE] Resident #107 experienced an acute condition change (vomiting, diarrhea, sweating and had a significantly elevated white blood cell (WBC) count of 29,000 (normal 4XXX,d+[DATE].3) reflective of infection. The WBC went unreported to the physician from [DATE] to [DATE], delaying treatment and identification of a potential source of infection. On [DATE], staff identified an ulcer to the resident's right anterior ankle measuring 0.9 centimeters (cm) in length by 6.8 cm in width and a depth of 1.7 cm. The wound bed had slough (a specific type of nonviable tissue that occurs as a byproduct of the wound inflammatory process. It presents as a yellowish, moist, stringy substance that can delay healing and increase the risk of infection) and the wound edges had edema (swelling) with a moderate amount of drainage. On [DATE] Resident #107 was found without vital signs and subsequently passed away prior to receiving treatment for the right foot ulcer and changes in condition associated with the ulcer. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] Resident #107 expired in the facility. On [DATE] from 6:00 A.M. to 4:00 P.M., all facility residents' skin was assessed by the DON. No new wounds were identified. On [DATE] from 6:00 A.M. to 4:00 P.M. the DON reviewed five of five residents with wounds for signs of infection. This included Resident #12, #16, #22, #25, and #27. No infections were identified. On [DATE] between 8:00 A.M. to 1:00 P.M., 34 out of 34 residents with diabetes (Resident #1, #3, #5, #7, #10, #14, #16, #17, #18, #25, #30, #34, #40, #43, #45, #50, #60, #64, #67, #71, #78, #79, #82, #85, #87, #89, #92, #94, #95, #98, #100, #101, #104, and #105's) care plans were reviewed by Regional Support Nurse (RSN) #219 to ensure there was a diabetic care plan and the interventions included daily foot inspection. On [DATE] between 8:00 A.M. and 4:30 P.M. RSN #219 reviewed all facility residents care plans to ensure care plans were in place to address resident skin care needs according to the Braden Scale assessment (assessment to determine risk for pressure ulcer development) and diagnoses. Any missing care plans were corrected at the time of the review. On [DATE] at 2:00 P.M. the Wound Care Nurse/ADON was suspended pending investigation due to not completing a proper skin assessment for Resident #107 on [DATE]. On [DATE] at 2:00 P.M. all 54 State tested Nursing Assistant (STNA) staff were educated by the DON via written notice on observing skin daily during care and reporting any areas of skin alteration to the licensed nurse. Only licensed nurses were to complete weekly skin assessments and follow up any reported skin alterations observed by STNA's during their routine care. On [DATE] 2:00 P.M. all licensed nursing staff (12 Registered Nurses (RNs) and 23 Licensed Practical Nurses (LPNs)) were educated by the DON via written and verbal confirmation acknowledgement on assessing skin weekly head to toe including removing socks and assessing feet, (reflecting Nursing Rule [DATE] and Rule [DATE]). Education was provided related to standards of competent nursing practice, on following up on all labs including STAT labs, on timely notification to the physician of changes in condition and accurate and complete documentation related to wound assessments, repercussions of falsification of documentation which included immediate suspension pending investigation and leading up to termination. The facility also indicated the DON would notify the Ohio Board of nursing related to falsification of wound care per incident. On [DATE] beginning at 2:00 P.M. and ending at 5:00 P.M., RSN #219 completed a stat lab audit from [DATE] to [DATE] to identify if any other residents were affected by failing to notify the physician of a change in condition. Resident # 107 had the only identified lab not reported to the physician timely. On [DATE] at 9:00 A.M. the Medical Director met with the DON and Administrator and reviewed the corrective action/removal plan which was approved by the Medical Director at that time. On [DATE] all 34 residents with diabetes had daily foot inspections added to the Treatment Administration Record (TAR) by RSN #219 to be completed and acknowledged by the nurse. On [DATE] at 12:00 P.M. all licensed nurses (23 LPNs and 12 RNs) were educated via written notice regarding logging STAT labs in a binder with the time ordered, time of collection, and a check list hourly of the RN/ LPN checking fax machine. If there were no results after four hours, the RN/LPN would call the lab. Routine lab results would also be included in the audit. They would be checked by the charge nurses every shift, and marked to confirm if they were obtained, and reported beginning [DATE]. Beginning [DATE], an audit of the lab binder would be completed daily times four weeks by DON or designee to ensure timely reporting of laboratory studies and accuracy of documentation. Beginning [DATE], the DON or designee would observe five nurses completing and documenting head to toe skin assessments on five residents' weekly times four weeks. Beginning [DATE], the DON or designee would audit five residents dressing changes by observing weekly for four weeks to determine if dressings were completed appropriately/as ordered. Beginning [DATE], the DON/designee would audit 10 resident charts weekly times four weeks to ensure those at risk have care plans in place to address their needs. On [DATE] in-person education was provided on skin assessments/wound care/falsification by the DON, any staff who have not attended were removed from the schedule until they could be educated. LPN #300 and STNA #310, both as needed employees, were removed from the schedule until education was completed. To ensure all new hires have received education, the DON would demonstrate head to toe skin assessments at orientation to all LPNs and RNs. STNAs would be educated on notifying the nurse of any skin altercations they observe on residents, as only licensed nurses assess skin. On [DATE] LPN #201 who was the facility wound care nurse and Assistant Director of Nursing (ADON) was terminated. The facility indicated all findings would be reported and addressed in Quality Assessment Performance Improvement (QAPI) monthly beginning [DATE]. Although the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Closed record review for Resident #107 revealed an admitted [DATE] with diagnoses including type two diabetes mellitus with diabetic neuropathy, age related bilateral cataracts, and detachment of retina left eye. Review of the resident's plan of care, initiated on admission ([DATE]) revealed no care plan had been developed to address Resident #107's diabetes mellitus with diabetic neuropathy and/or risk for potential complications including skin breakdown. Review of the physician's orders revealed an order, dated [DATE] for a full code status (cardiopulmonary resuscitation in the event of cardiac arrest). The resident also had a physician order, dated [DATE] for weekly skin checks by the licensed nurse. The resident was to receive a carbohydrate consistent/no added salt regular texture thin consistency diet. Medication orders included: Trulicity pen injector 1.5 milligrams (mg) per 0.5 milliliters (ml)inject 1.5 mg subcutaneously every Friday evening for diabetes mellitus, Insulin Glargine 100 units per ml, inject 40 units sq at bedtime related to diabetes mellitus, Humalog solution inject as per sliding scale dosing before meals and at bedtime for diabetes mellitus, Latanoprost ophthalmic drops instill one drop in the left eye at bedtime for glaucoma, Brimonidine tartrate ophthalmic drops- instill one drop in the left eye every morning and evening for eye care. Review of a podiatry note dated [DATE] and authored by Doctor of Podiatric Medicine (DMP) #220 revealed the resident legs/feet were absent hair growth and he had atrophic (a reduction in epidermal and dermal thickness, reduction of oil glands, subcutaneous fat loss, and muscle-layer atrophy) skin texture. No edema was noted. The resident's toenails were thin, trimmed, and debrided to patient's tolerance and noted nonprofessional treatment was hazardous to the patient. Podiatric Diagnosis: type two diabetes mellitus with peripheral circulatory disorders, onychomycosis (fungal infection of the nail) and xerosis (dry skin). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #107 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (cognitively intact). The assessment revealed the resident required extensive assistance of one staff for bed mobility, supervision with transfers, ambulation, dressing, eating, toilet use and personal hygiene. He was independent with bathing and was always continent of bowel and bladder. Resident #107 was at risk for pressure ulcer development but did not have any wounds. The assessment revealed the resident received insulin injections seven days a week, had moderately impaired vision and had no behaviors of rejecting evaluation or care. Review of a progress note dated [DATE] at 11:03 A.M. and authored by LPN #208 revealed, (Resident #107) has complained of his shoes hurting his feet. Patient stated that his shoes feel like they are too small. Patient may need a new pair of shoes. Record review revealed there was no assessment related to this resident complaint and no further information documented regarding the resident's feet/skin or complaints of his shoes noted through [DATE]. Review of a Skin Check Weekly Assessment form, dated [DATE] at 3:51 A.M. for Resident #107 and authored by LPN #202 documented temperature and turgor were normal with no new alterations in skin integrity. Review of a progress note dated [DATE] at 9:09 A.M. and authored by LPN #221 revealed Resident #107 was not feeling well. When the LPN entered Resident #107's room, Resident #107 was diaphoretic. Resident #107 revealed to the nurse that he was weak, dizzy and could not stand. Resident #107 also revealed that he had multiple incontinent episodes. CNP (#207) was made aware of Resident #107's condition and new orders were received for a STAT (instantly/immediately) laboratory testing including a Complete Blood Count (CBC), Basic Metabolic Panel (BMP) and for a urinalysis and a chest x-ray (CXR). A Covid test was completed and negative. Review of a progress note dated [DATE] at 11:32 A.M. and authored by LPN #208 revealed Resident #107 complained of not feeling well today. Resident #107's vital signs included a pulse of 99 (elevated) per minute and an elevated temperature of 101.6 degrees Fahrenheit (F). Resident #107 was incontinent of bowel. The physician was notified and ordered the same STAT orders and to continue to monitor for an increased temperature (no further clarification was provided related to the monitoring). Review of the STAT BMP results collected on [DATE] revealed a sodium level at 135 (normal ,d+[DATE]), BUN 46 (normal ,d+[DATE]) C02 level at 16 (normal ,d+[DATE]), and creatinine level at 3.0 (normal was 0XXX,d+[DATE].2). Review of the progress note dated [DATE] at 4:35 P.M. authored by LPN #208 revealed Resident #107's lab work was reported to CNP (#207). The note revealed to encourage fluids and repeat BMP Thursday. Review of the CBC results for Resident #107 collected on [DATE] as a STAT lab and faxed to facility nurse on [DATE] at 9:00 P.M. (but not timely reported to the physician or CNP) revealed the resident's WBC count was 29.3 (normal 4.4 - 11.3) (this is reflective of potential infection and the immune system working to destroy infection), RBC count was 3.72 (normal 4.5 - 5.9) (RBCs carry oxygen from the lungs and deliver to the body, potential cause to be low would-be infection), neutrophil count was 25.40 (normal 1.20 - 7.70) (helps the immune system fight infections and heal injuries), lymphocyte count 0.90 (normal 1.20 - 4.80) (survey the bodies environment detecting foreign antigens, can be caused by infection) and monocyte count 2.47 (normal 0.10 - 1.00) (type of WBC that find and destroy germs). Further review of Resident #107's medical record revealed no documented evidence of the physician or CNP being notified of the STAT CBC results on [DATE] or [DATE]. Review of the progress note dated [DATE] at 5:32 A.M. authored by LPN #202 revealed Resident #107 had loose stool, a small emesis, and was diaphoretic. Chest x-ray results indicated no issues with lungs. Resident #107's blood sugar was 71 (the resident's usual blood glucose levels during February 2023 were greater than 110). The note indicated fluids and food were given. Review of a progress note dated [DATE] at 7:00 A.M. authored by LPN #202 revealed the physician was in the facility and CXR results were given to him. No new orders were received. Reported loose stool and diaphoresis due to the blood sugar being 71. No new orders were received. Review of Physician #203's documentation for Resident #107 revealed there was no progress note completed for Resident # 107 on [DATE] when Physician #203 visited the facility and was informed of Resident #107's CXR results, loose stool, diaphoresis, and his blood sugar of 71. Review of a progress note dated [DATE] at 2:41 PM. authored by LPN #209 revealed Resident #107 had a low-grade temperature of 100.1 this morning. Resident #107 was given Tylenol, and the temperature was reduced to 98.2. Review of a Skin Check Weekly assessment dated [DATE] at 3:51 P.M. authored by ADON/Wound Care Nurse LPN #201 for Resident #107 documented skin temperature and turgor was normal with no new alterations in skin integrity. Review of a progress note dated [DATE] at 10:31 P.M. authored by LPN #222 revealed Resident #107 was seated in chair all through this shift. Resident #107 did not want to lay in bed, stated he preferred to sit up in the chair. Resident had no episode of diarrhea or vomiting. Pulse was 88 and Temperature was 98.2. Review of a Skin Grid assessment dated [DATE] at 9:03 A.M. authored by ADON Wound Care Nurse LPN #201 for Resident #107 revealed Resident #107 had a new non pressure area. The date the wound was first observed was documented to be [DATE]. The wound was located on the resident's right anterior ankle and was classified as a diabetic ulcer. The wound measured 0.9 centimeters (cm) in length by 6.8 cm width with 1.7 cm in depth. The wound had no tunneling. The wound bed had slough. The wound edges had peripheral tissue edema. There was a moderate amount of exudate (drainage) with no odor. The LPN documented there were symptoms of infection but did not list what those symptoms actually were. The note revealed a culture was obtained and calcium alginate AG with foam dressing was ordered daily and as needed. Review of a progress note dated [DATE] at 9:22 A.M. authored by LPN #221 for Resident #107 revealed CNP (#207) was in the facility and new orders were received for intravenous (IV) antibiotics for a wound infection. A peripherally inserted central catheter (PICC), a special intravenous line for long term antibiotic use, line was to be placed for the IV antibiotic. A wound culture was collected by the wound nurse and was to be picked up the following morning ([DATE]). An x-ray to right foot was scheduled and blood cultures were to be drawn the following morning. The note indicated CNP #207 was made aware of the start date of the IV antibiotic related to the line placement. Record review revealed no written progress note from CNP #207 was available to review. Review of a progress note dated [DATE] at 2:58 P.M. completed by ADON Wound Care Nurse LPN #201 revealed Resident #107's lab work was reported to CNP #207 (the documentation did not specify the lab work reported). Resident #107 received an order for two liters of intravenous fluids, normal saline at 80 milliliters per hour. Review of a progress note dated [DATE] at 3:20 P.M. authored by ADON Wound Care Nurse LPN #201 for Resident #107 revealed the right Foot x-ray results were reported to the CNP. No new orders were obtained at that time. Review of the right ankle x-ray results, dated [DATE] revealed no acute fracture or dislocation, joint spaces were aligned and maintained. Soft tissue swelling was noted. Review of a progress note for Resident #107 dated [DATE] at 6:30 P.M. authored by RN #205 revealed RN (from RN Access Company) placed a PICC line in resident's left upper arm. Review of a progress note for Resident #107 dated [DATE] at 3:20 A.M. authored by LPN #202 revealed the RN entered the resident's room to start IV fluids at 2:00 A.M. This nurse entered room at 2:20 A.M. and spoke to (Resident #107) with no response. Noted Resident #107 was absent of vitals. Staff were notified to call code and chest compressions started. Call placed to 911 at 2:25 A.M. CPR continued with no vital signs noted. EMS arrived at 2:40 A.M. and continued with CPR measures and EKG verification. EMS verified time of death at 2:54 A.M. Review of ADON Wound Care Nurse LPN #201's employee file revealed a record of corrective action, dated [DATE] authored by DON. The record revealed counseling was given to ADON Wound Care Nurse LPN #201 which included failure to properly identify wounds on skin. The plan was for the nurse to complete an assessment in front of the DON which was completed. Interview on [DATE] at 11:05 A.M. with ADON Wound Care Nurse LPN #201 confirmed she authored the Skin Check Weekly dated [DATE] at 3:51 P.M. for Resident #107. ADON/Wound Care Nurse/LPN #201 shared during weekly skin assessments the nurses only had to look at bony prominences. ADON/Wound Care Nurse/LPN #201 revealed when she did this skin check for Resident #107, she did not look at the resident's feet, she was looking in general at bony prominences and stated Resident #107's wound was subsequently found more on top of the foot and because there were no pressure points in the feet, she did not look at the feet making her documentation of the resident's skin assessment inaccurate. Interviews on [DATE] between 11:23 A.M. and 5:00 P.M. with RN #210, LPN #216, STNA #211, STNA #212, STNA #213, STNA #214, STNA #215, and STNA #217 all reported the STNA staff complete resident skin assessments on shower days. If the STNA sees a problem with a resident's skin, they would tell the nurse, then the nurse would check the area of concern. The STNAs interviewed (#211, #212, #213, #214, #215, and #217) all confirmed they had no training on skin assessments, did not look in all areas including under the feet and stated nursing staff did not come into the shower room unless they report a skin concern to the nurse. RN #210 and LPN #216 confirmed they have the STNAs complete the weekly skin assessments on the resident's shower day, if the STNA does not report a concern with the skin condition, the nurse would then document under the Skin Check Weekly assessment that the skin assessment was completed with no new alterations in skin integrity. Interview on [DATE] at 11:40 A.M. with the DON revealed the nurses were required to do the weekly skin assessments so they could assess each resident's skin head to toe. The DON revealed she did not have a facility policy regarding skin assessments, but stated each resident had a physician order for weekly skin assessments to be completed by the nurse. The DON revealed on [DATE] she gave the ADON/Wound Care Nurse LPN #201 a written counseling for documenting she completed the skin assessment on Resident #107 on [DATE] when she had not. The DON shared Resident #107 was independent with care and completed his own showers independently, dressed himself and put his own shoes and socks on therefore, no staff would have visualized his feet unless they completed a thorough skin assessment, monitoring for changes which should have been completed especially since the resident was diabetic and visually impaired. However, the DON verified this was not completed. Interview on [DATE] at 12:02 P.M. with CNP #207 confirmed the infection Resident #107 had could have been due to the wound in his foot. Resident #107 was legally blind, and he could not see the wound on his foot although he had complained of pain to the area on [DATE] with no evidence of staff follow up. Interview on [DATE] at 12:16 P.M. with RSN #219 revealed nurses were expected to complete weekly wound assessments. During the interview, RSN #219 revealed Resident #107's wound culture was not sent to the lab because the resident expired before lab pick up occurred. Telephone interview on [DATE] at 3:01 P.M. with Funeral Director #223 at the Funeral Home where Resident #107's deceased body was sent revealed Resident #107's death certificate read the resident's cause of death was cardiac arrest. No autopsy was completed. Interview on [DATE] at 8:25 A.M. with LPN #208 revealed Resident #107 walked independently with a rollator (walker). Resident #107 was partially blind, but he was able to shower himself. LPN #208 confirmed on [DATE] Resident #107 complained of his feet hurting, revealing his shoes felt too tight. LPN #208 stated she did look at the resident's feet and they were swollen but she did not recall seeing any open areas. LPN #208 verified her assessment of the resident's skin at the time of his complaint was not documented in the resident's medical record. An in-person interview on [DATE] at 8:42 A.M. and telephone interview on [DATE] at 3:35 P.M. with Primary Physician #203 confirmed he provided primary care for Resident #107 during the resident's stay in the facility. During the interview, Primary Physician #203 revealed he did not recall if he personally evaluated Resident #107 on [DATE] at 7:00 A.M. while he was at the facility. Primary Physician #203 revealed after being notified of changes in the resident's condition, he decided to treat Resident #107 at the facility because prior to the acute illness, Resident #107 was stable. The physician reviewed the STAT CBC ordered [DATE] during the interview. Primary Physician #203 verified he was not updated on the results for the CBC until sometime, he was not sure when, on [DATE], probably when the wound was found, and the antibiotics were ordered. Primary Physician #203 revealed if he would have seen the results of the CBC earlier, he would have ordered the IV antibiotics at the time he reviewed the results. Primary Physician #203 verified the results of the CBC revealed Resident #107 very well could have been septic, it would have been most likely he was septic from the wound on his foot. Primary Physician #203 confirmed sepsis can cause cardiac arrest if severe enough. Interview on [DATE] between 4:20 P.M. and 4:54 P.M. with the DON confirmed the CBC for Resident #107 ordered on [DATE] was ordered to be STAT. The DON confirmed STAT orders were to be completed within four hours and results reported to the ordering practitioner upon receipt. The DON confirmed there was no documentation in Resident #107's medical record verifying when the STAT CBC was reported to the physician or the CNP, but verified the antibiotics were not ordered until [DATE]. The DON then confirmed the CBC results were not reported to the physician or CNP until [DATE] because that was when the IV antibiotics were ordered. The DON revealed the fax machine for all lab results and all fax transmittals was located on the first floor of the facility and residents resided on the second, third and fourth floors. The nurses were to go to the fax machine on the first floor to obtain results, but stated the nurses did not check the fax machine timely and when someone non-medical checked the fax machine, Resident #107's results for the STAT CBC were set aside and no one saw them. Further interview revealed the DON stated she discussed with LPN #208, on [DATE], her concern that a skin assessment was not completed for Resident #107 on [DATE] when he complained of pain in his feet and his shoes feeling too tight. The DON shared she saw the measurements of Resident #107's wound on his right foot on [DATE] and the wound was so large and deep and infected that she felt the wound had to be there on [DATE] when Resident #107 first complained of pain to his feet. The DON shared LPN #208 was a brand-new graduate, and she gave LPN #208 a verbal warning on [DATE] regarding not documenting the skin assessment on [DATE]. The DON confirmed Resident #107 went without treatment for his infection from the time he became symptomatic on [DATE] through the time he died on [DATE]. During a telephone interview on [DATE] at 9:50 A.M. with CNP #207, the CNP was asked if she had completed any type of progress note after seeing Resident #107 on [DATE] as there was no note in the resident's medical record to review as of this date. The CNP revealed she was unable to send this progress note from [DATE] for Resident #107 and verified the note was currently unavailable for review. CNP #207 revealed she first saw Resident #107's wound on [DATE] when she visited the resident in the facility. CNP #207 shared she was not a wound doctor, and she told the nurses (not identified) at the facility to call the wound doctor (when the wound was discovered). CNP #207 revealed she had no idea what the wound on Resident #107's foot started out as, she never diagnosed it, but stated it seemed impossible no one knew about it, it was huge and his whole foot was swollen. CNP #207 stated she treated the (wound) infection as soon as she saw the wound on [DATE]. She stated she sent Primary Care Physician #203 a picture she took of the wound on Resident #107's foot on [DATE] after she saw it. The CNP shared the wound was bad, it had a strong foul odor and stated there was no way nobody knew about it prior to this date. CNP #207 shared the wound was in the crease of the dorsal foot and by the time she saw it, the resident's foot was so swollen he could not put his shoe on. CNP #207 shared she told the (unidentified) nurse to have him see the wound physician. CNP #207 revealed she did not save the picture of the wound after she sent it to Primary Care Physician #203 on [DATE] and repeated, It was a bad wound and there was no way nobody knew about it. There was no documentation in Resident #107's medical record indicating the visiting wound physician was notified of the resident's infected ulcer to his foot. Telephone interview on [DATE] at 1:27 P.M. with LPN #202 revealed weekly skin assessments were set up to be completed on the resident's bath day. The resident's skin would be assessed by the STNA during the shower, and the STNA would notify the nurse if there was a new area observed. LPN #202 shared she did not look at the resident's skin unless the STNA reported a concern. LPN #202 revealed she remembered Resident #107 and confirmed she authored Resident #107's skin assessment on [DATE]. LPN #202 revealed Resident #107 was alert and oriented, so she did not need to look at his skin, she just needed to ask him if he had any new areas. LPN #202 confirmed she did not look at Resident #107's skin on [DATE], she just asked him if he had any new open areas and he said no. LPN #202 reiterated you just need to ask the resident if they are alert and oriented, and if they say no, that's what you put there, there is no need to look, they know their own body. There was no evidence the LPN acknowledged that although the resident was cognitively intact, he had visual deficits which might impact his ability to know if there were areas of skin compromise to his feet. A follow up interview on [DATE] at 2:35 P.M. with the DON revealed Primary Physician #203 documents in the progress note when he visited a resident. The DON confirmed Primary Physician #203 did not physically assess Resident #207 on [DATE]. A telephone interview with RN #228 on [DATE] at 8:57 A.M. revealed she was the RN who started the IV fluids on [DATE] at 2:00 A.M. for Resident #107. RN #228 revealed when she entered the resident's room, she told him she was going to hang the IV bag and he responded with MmmHmm. The RN shared she didn't want to fully awaken the resident because it was the middle of the night, and he was sleeping. Once he acknowledged her, she hung the bag and left the room to return to her assigned floor. The RN shared she did not return to the resident's room after the IV fluids were initiated due to the resident's death. Review of the facility policy titled, Diabetes - Clinical Protocol revised [DATE] included the staff would identify and report complications such as foot infections, skin ulcerations, increased thirst and hypoglycemia. Review of guidance from the Centers for Disease Prevention and Control (CDC) titled What is Sepsis and Protect Your Residents from Sepsis dated, [DATE], included sepsis was the body's extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a train reaction throughout your body. Infections that lead to sepsis most often start in the lung, urinary tract, skin, or gastrointestinal tract. Without timely treatment sepsis can rapidly lead to tissue damage, organ failure and death. People at higher risk for sepsis in [TRUNCATED]

Based on observation, interview, record review, and facility policy review, the facility failed to ensure sufficient staffing and care planned interventions were in place to prevent one resident (Resident #86) from physically abusing a second resident (Resident #4) on the secured dementia nursing unit on 12/10/21 at 3:01 P.M. This affected two residents (Resident #4 and #86) out of four residents reviewed for abuse. The facility census was 95. On 01/04/21 at 4:17 P.M. the Administrator, was notified Immediate Jeopardy began on 12/10/21 at 2:59 P.M. when State tested Nursing Assistant (STNA) #393 and an unidentified staff member left the secured dementia nursing unit and did not return, leaving the unit unsupervised by facility staff. Review of the facility camera footage with Human Resources Manager (HRM) #333 on 12/10/21 revealed at 3:01 P.M. Resident #86 entered Resident #4's room. The camera footage revealed STNA #370 arrived at the nursing unit at 3:02 P.M., heard screaming, and entered Resident #4's room at 3:03 P.M. STNA #370 observed Resident #86 straddling Resident #4 on her bed and was punching her with a closed fist. STNA #370 immediately attempted to remove Resident #86 from Resident #4, and he turned on her, cursing at her, swinging his arms, and trying to hit her. Further review of the camera footage revealed STNA #370 was able to redirect Resident #86 out of Resident #4's room at 3:04 P.M. HRM #333 verified the times of the camera footage. STNA #370 stayed with Resident #86 and did not leave him alone until Licensed Practical Nurse (LPN) #395 arrived at the unit around 3:15 P.M. After LPN #395 arrived, STNA #370 notified Administrator #355 regarding Resident #86's assault on Resident #4. STNA #370 stated Resident #4 had red marks on her right eye and jaw and Resident #86 had a scratch on his chest. Resident #86 was sent to the local hospital on 12/10/21 at 4:21 P.M. to be evaluated for aggressive physical behavior towards other residents and staff. The Immediate Jeopardy was removed on 01/10/22 when the facility implemented the following corrective action: · On 12/10/21 at 4:21 P.M., Resident #86 was sent out to the local hospital via 911 for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .M. · On readmit 12/13/21 upon readmission, Resident #86 medications were changed as followed: [MEDICATION(S)] 50 mg was changed from three times a day schedule at 9:00 A.M., 1:00 P.M. and 5:00 P.M. to every eight hours at 6:00 A.M., 2:00 P.M., and 10:00 P.M. which gives more coverage of medication in a 24-hour period. · On 12/10/21 at 9:33 P.M., post incident, Resident #4 was assessed, and no discolorations of skin were noted. · On 12/12/21 at 9:04 P.M., post incident, Resident #4 was followed up by nursing and the resident voiced had no complaints of pain or discomfort. · On 12/13/21 at 11:39 A.M., Resident #4 was followed up on by Social Worker (SW) #362 and Resident #4 denied feeling fearful. · On 12/14/21 at 1:47 P.M. psych Services evaluated Resident #4 and no medication adjustments were recommended. · On 1/3/22 at 12:21 P.M. psychiatry evaluated Resident #86 and agreed with plan for a neurology consult scheduled 01/19/22. · On 1/05/22 Regional Point Click Care Associate (RPCCA) #432 added a task to all residents for STNA documentation for Frequent rounding on the unit (at least every hour) to observe residents and unit atmosphere. · On 1/05/22 RPCCA #432 special instructions were added to every resident's care profile for frequent rounding on the unit (at least every hour) to observe residents and unit atmosphere which shows on the Medication Administration Record/Treatment Administration Record (MAR/TAR). · On 01/05/22 RCF/IDON #425 educated Administrator #433, Human Resource (HR) #333, Scheduler #388, Assistant Director of Nursing (ADON) #335 on the Action Steps: Projecting ahead for sufficient staffing levels. In the situation when call-offs occur, or staff are absent related to positive COVID-19 symptoms or other illness, the following actions will be taken: - Call all remaining staff and offer bonus - Call agency for available staffing - Call closest sister facility for available staff - All hands-on deck for all department managers to assist - Crisis staffing criteria as outlined by Centers for Disease Prevention and Control (CDC) and approved by Center for Medicare and Medicaid Services (CMS) will be enacted · On 01/06/22 by 3:00 P.M., Assistant Director of Nursing (ADON) #335 assessed all like residents who have been identified as residents who reside on secured dementia unit. All residents had QIS Abuse questionnaires completed if cognitively intact, and skin assessment were to be completed for those who were cognitively impaired. · On 01/06/22 at 12:11 P.M., Regional Clinical Support/ Interim Director of Nursing RCS/IDON (RCS/IDON) #425 provided all nursing staff education via electronic text message through On-shift regarding the Activity of Daily Living Policy and the addition of frequent rounding on the unit (at least every hour) to observe residents and unit atmosphere, that a task was added to all residents for the frequent rounding, and the special instructions were added and is reflected in the Grey Bar on the MAR/TAR for every resident. · On 1/06/22 at 4:50 P.M., RCS/IDON #425 provided an Abuse in-service to all staff via electronic text message through On-Shift. · Starting 01/06/22, Administrator #433, HR #333, Scheduler #388, DON/designee will meet five days a week for four weeks, to review adequate staffing each shift of each day while meeting the daily requirement of 2.50 hours per resident. This meeting will be recorded on an audit with the Hours Per Patient Day (HPPD) for the previous day and the projected for the next day. · Starting 01/06/22, change of shift audit of the units to ensure proper staffing coverage will be conducted three to five days per week alternating shifts for four weeks and will be conducted by Administrator #433, Scheduler #388, DON, ADON ##335, and/or other management designee. · On 01/10/22 the DON initiated an additional in-service regarding the added task to all residents for STNA documentation for frequent rounding on the unit (at least every hour) to observe residents and unit atmosphere. The DON educated the nursing staff on the Activity of Daily Living Policy and the addition of frequent rounding on the unit (at least every hour) to observe residents and unit atmosphere, that a task was added to all residents for the frequent rounding, and the special instructions were added and is reflected in the Grey Bar on the MAR/TAR for every resident. · Results of audits will be reviewed in QAPI for tracking and trending purposes. Although the Immediate Jeopardy was removed on 01/10/22, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure continued compliance. Findings include: Review of Self-Reported Incident Form (SRI), tracking number 9 created on 12/10/21 at 6:23 P.M., revealed a confused resident (Resident #86) wandered into Resident #4's room and struck her for no reason. Staff were immediately notified, and the residents were immediately separated. Due to aggressive behavior Resident #86 was sent to the local hospital via 911 for evaluation. The guardian was notified, and social services were made aware. Psychiatric services were to follow-up, the nurse practitioner was notified, and the emergency department was notified. Nursing assessed the resident, and no injuries were noted, vital signs were within normal limits, Resident #4 denied pain and feeling fearful. The allegation of physical abuse was substantiated, and the witness to the incident was listed as State tested Nursing Assistant (STNA) #370. Review of STNA #370's Witness Statement, dated 12/10/21, revealed upon arriving to the unit loud noises were heard. STNA #370 went into Resident #4's room and witnessed Resident #86 hitting her. STNA #370 redirected Resident #86 from Resident #4 and he began to swing at her. STNA #370 called the Administrator and monitored Resident #86 until he was sent to the hospital via 911. Review of Resident #86's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #86's Minimum Data Set (MDS) 3.0 assessment, dated 10/02/21, revealed cognition was not assessed, and Resident #86 required extensive assistance of one person for bed mobility and transfers, required extensive assistance of two staff for activities of daily living, and required supervision for locomotion on the unit. Resident #86 used a wheelchair and was not steady but was able to stabilize without staff assistance for walking. Review of Resident #86's admission evaluation on 07/30/21 revealed resident was confused and disoriented. Review of Resident #86's care plan dated 11/05/21, revealed the resident demonstrated movement behavior that may be interpreted as wandering, pacing, or roaming, and became agitated, oppositional, and combative when redirected. Resident #86 paced, roamed, or wandered in and out of peers' rooms and took other residents belongings or food. Resident #86 would respond to staff direction to redirect attention from a potentially problematic situation (such as elopement or entering a peer's room) when any difficult behavior occurred. Interventions included if the resident left the building or went into a peer's room or became aggressive, redirect by limiting the number of staff who redirect the resident. If another person is needed for safety, the second person should remain out of sight, in the background or behind the primary caregiver. Resident #86 had a behavior problem related to attempting to eat nonedible items such as plants, bingo chips, and complained of hunger, confusion. Resident #86 would have no evidence of behavior problems. Interventions included to monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved, and situations, and document behavior and potential causes. Review of Resident #86's progress notes on 12/10/21 at 4:21 P.M. written by Licensed Practical Nurse (LPN) #395 revealed Resident #86 was transferred to the hospital via 911 due to aggressive physical behavior towards staff and residents. Guardian #430 and Nurse Practitioner (NP) #421 were notified. Review of Resident #86's medical record on 12/10/21 did not reveal documentation vital signs were taken or Resident #86 was evaluated for injuries. Review of Resident #86's hospital Discharge Summary on 12/13/21, revealed upon admission to the hospital Resident #86 had a change in behavior and mental status agitation, and had an extensive neurological injury from a previous [CONDITION(S)] with baseline confusion. Computer-assisted tomographic holography (CTH, radiographic images that visualize calcified tissues) did not show acute findings. Resident #86 had a urinary tract infection and was discharged back to the facility on antibiotics for two days. Review of Resident #86 psychiatric services note on 01/03/22 written by NP #428 revealed she was asked to evaluate Resident #86 due to mental status changes. NP #428 and Psychiatrist #429 attempted to evaluate Resident #86, but he was uncooperative and walked away while the interview was being conducted. NP #428 was notified Resident #86 was to be scheduled for a neurology consult, Resident #86 had a known TBI, and NP #428 agreed to the plan for a neurology consult. Review of Resident Service Director (RSD) #351's progress notes on 01/06/22 revealed Resident #86 had a neurology consult scheduled for 01/19/22 at 1:00 P.M. to evaluate change in mental status and TBI. Review of Resident #4's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's MDS 3.0 assessment, dated 08/19/21, revealed the resident was cognitively intact, required extensive assistance of one staff member for bed mobility, transfers, and activities of daily living. Resident #4 required supervision for locomotion on the unit, walking was not steady, but resident was able to stabilize without staff assistance. Review of Resident #4's care plan, dated 08/19/21, included resident had a behavior problem related to putting large amounts of tissue in nose, pulled fire alarm, came out of room with shirt rolled up exposing her torso and putting a mesh bag over her head, at times screams in hallway using profanity. Resident #4 was sexually inappropriate with other residents and made false accusations. Interventions included to intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, and remove from situation, take to alternate location as needed, monitor Resident #4's behavior episodes and attempt to determine underlying cause. Review of Resident #4's medical record on 12/10/21 from 3:00 P.M. until 9:25 P.M. did not reveal documentation Resident #4 was evaluated for injuries right away. Review of Resident #4's medical record after Resident #4 was struck by Resident #86, revealed a progress note on 12/10/21 at 9:25 P.M. written by LPN #395 indicated no discoloration to the resident was noted. Resident #4 came out of her room and asked for medications, and stated she felt alright. Resident #4's vital signs were within normal limits and Resident #4 would continue to be monitored. Review of Resident #4's progress notes on 12/13/21 at 11:34 A.M. written by Social Worker (SW) #362 revealed she met with Resident #4 following an incident where Resident #86 wandered into her room and began hitting her. Resident #4 stated Resident #86 was removed from the floor. Resident #4 denied feeling fearful and requested to speak with Psychiatrist #429 concerning a possible medication change. Review of the facility camera footage from 12/10/21 of the secured fourth-floor nursing unit on 01/04/22 at 4:30 P.M. with Human Resources Manager (HRM) #333 revealed STNA #393 and an unidentified staff member gathered personal belongings and coats and left the secured fourth-floor dementia nursing unit at 2:59 P.M., leaving no staff on the unit to provide resident care and supervision. The camera footage at 3:01 P.M. revealed Resident #86, barefoot and wearing only an incontinence brief, pushed a plastic cart on wheels down the hall, then walked into Resident #4's room. STNA #370 arrived at the nursing unit at 3:02 P.M. and entered Resident #4's room at 3:03 P.M. The camera footage at 3:04 P.M. revealed STNA #370 escorted Resident #86 out of Resident #4's room. HRM #333 verified the above information. Interview on 12/21/21 at 4:02 P.M. with Administrator #355 revealed a confused resident (Resident #86) went into Resident #4's room and struck her. Administrator #355 stated Resident #4 was not injured, Resident #86 was sent to the local hospital for evaluation of physical behavior and was now back in the facility, and there were no further issues since he returned. Interview on 12/21/21 at 4:25 P.M. with Licensed Practical Nurse (LPN) #395 revealed on 12/10/21 State tested Nursing Assistant (STNA) #370 heard screams, went to the source of the screams and saw Resident #86 on Resident #4's bed, and he was punching her. STNA #370 immediately threw herself on Resident #86 to try to protect Resident #4, Resident #86 began to swing his arms and try to hit STNA #370, and she was able to redirect Resident #86 away from Resident #4. LPN #395 stated Resident #86 was sent to the hospital for evaluation for a couple days and was back on the secured fourth-floor dementia nursing unit. LPN #395 stated Resident #4 was traumatized by the incident. LPN #395 stated the staff on the fourth-floor nursing unit had to constantly monitor the residents, because many of them were cognitively impaired and did not know what they were doing. LPN #395 stated there were usually only two STNAs assigned to the unit, but there really should be three to provide supervision and care for the residents. LPN #395 stated she did not understand why Resident #86 was still residing on the fourth floor and had not been moved to the third-floor secured nursing unit after he assaulted Resident #4. Interviews on 12/21/21 at 4:32 P.M. and 01/04/21 at 3:00 P.M. with STNA #370 revealed she arrived on 12/10/21 at 3:00 P.M. to the fourth-floor nursing unit to begin her shift and heard screaming. STNA #370 stated a resident told her another resident was getting beat up and she immediately went to the resident's room where the screaming could be heard and saw Resident #86 straddling Resident #4 on her bed and was punching her with a closed fist. STNA #370 stated Resident #86 was beating up Resident #4, she pulled him off Resident #4 and he started swinging at her. STNA #370 stated it was very hard to get him off Resident #4. STNA #370 stated she was able to redirect Resident #86 out of the room, and he started cursing at her, and calling her names. STNA #370 stated Resident #86 had a scratch on his chest and Resident #4 had redness to her right eye and jaw. STNA #370 stated Resident #86 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . STNA #370 stated when the residents yelled at Resident #86, he started cussing and calling them names, and it was very upsetting to her when this happened. STNA #370 stated when she arrived at 3:00 P.M. there were no staff working on the floor, they had all left, and she wondered why they had left. STNA #370 stated she was very upset there were no staff members on the floor when she arrived because if there was Resident #4 would not have been hit. STNA #370 stated she did not see any nurse or STNA, including STNA #393 on her way to the nursing unit or after she arrived. STNA #370 stated there was no nurse or STNAs available to help her get Resident #86 away from Resident #4. STNA #370 stated she was so happy she was prompt to work and was able to save Resident #4 from getting really hurt. STNA #370 stated the fourth floor needed more staff than was usually assigned because there were a lot of residents with behaviors. STNA #370 stated quite a few residents wandered in and out of other resident rooms and bothered the personal items, it caused arguing and fighting, and it was not safe to only have two STNAs assigned to the unit because they could not be in two places at once. STNA #370 stated sometimes there was not a nurse assigned to the third floor, and when this happened the nurse from the second floor was supposed to come to the fourth floor, pass medications, and address any problems but this did not always happen. Interview on 12/21/21 at 4:50 P.M. with Resident #4 revealed Resident #86 came in her room when she was lying in bed and a fan was on by the bed. Resident #4 stated the fan fell , she saw Resident #86 charging at her, and she tried to kick at him. Resident #4 stated it all happened so fast and she was so scared. Resident #86 climbed on the bed, straddled her, and started punching her, she tried to get him off her by pushing and kicking, and he said he was going to knock the hell out of her. Resident #4 stated she called out for help but the girl on duty did not answer her call right away and she was scared because she did not know what Resident #86 was going to do. Resident #4 stated she finally got Resident #86 off her, he hit her eye and shoulder hard. Resident #4 stated she had bruises that were faded now, but her arm still hurt. Resident #4 stated Resident #86 had been in her room before looking for candy but had never been this aggressive. Resident #4 stated Resident #86 was still living on the fourth floor, she did not know why, and she was worried because she never knew what he was going to do. Interview on 12/21/21 at 5:10 P.M. with LPN #395 revealed on 12/10/21 she was assigned to work on the secured dementia nursing unit Resident #86 resided on. LPN #395 stated she had not arrived at the unit and was not there to assist STNA #370 when Resident #86 attacked Resident #4, and STNA #370 was the only staff member on the nursing unit when the attack occurred. LPN #395 stated she did not remember the exact time she arrived, but it was around 3:15 P.M. and she did not see any other staff members on the floor, including STNA #393 when she arrived. LPN #395 stated the day shift STNAs often left the nursing unit before the second shift STNAs arrived because they clocked out at 3:00 P.M. Interview on 12/21/21 at 5:39 P.M. with Administrator #355 revealed Resident #86 belonged on the fourth-floor nursing unit due to his cognitive abilities. Administrator #355 stated she was not aware there was no staff on the floor when the attack took place, and she did not think that was the case. Administrator #355 stated she only took witness statements from those directly involved in the situation and STNA #370 was the only witness. Administrator #355 stated no further interviews of staff or residents were conducted. Interview on 12/21/21 at 5:45 P.M. with STNA #370 revealed on 12/10/21 she was the only STNA assigned for the 3:00 P.M. to 11:00 P.M. shift for the fourth floor, and she notified Administrator #355 she was not going to stay if she had to work alone. STNA #370 stated STNA #330 was called and asked to work, and he arrived between 4:00 and 4:30 P.M. Interview on 12/21/21 at 5:06 P.M. with STNA #332 revealed she usually worked on the fourth-floor dementia nursing unit, there was not enough staff, and it was hard to supervise the residents. STNA #332 stated the residents got into arguments so fast, it only took a second, and an example would be one resident bumped into another resident then a big brawl broke out. STNA #332 stated there was not enough help, and they could not be in three places at the same time. STNA #332 stated two STNAs were not enough to supervise the residents because one STNA had to monitor the elevator to make sure residents did not elope when visitors arrived and left the nursing unit. Interview on 12/21/21 at 6:10 P.M. with STNA #357 revealed she worked second shift on the fourth-floor secured dementia nursing unit, usually two STNAs were scheduled, and sometimes there was only one STNA scheduled. STNA #357 stated she had worked by herself as the only STNA and it was not safe to only have one STNA scheduled because there could be multiple situations happening at the same time. STNA #357 stated the management staff told her to run if a resident became aggressive, lock herself in the nurse's station and call for help. Interview on 01/03/22 at 3:49 P.M. with STNA #393 revealed on 12/10/21 she worked on the secured fourth-floor dementia nursing unit and left the floor at 3:00 P.M. STNA #393 stated she filled a form out for the hours she worked on 12/10/21 because the time clock was not working properly for the pay period that included 12/10/21. Observation on 01/03/22 at 4:38 P.M. of Resident #86 revealed he was sitting in a wheelchair in the hall, had a moderate amount of thick clear material draining from his mouth and he was sleeping. Interview on 01/03/22 at 4:40 P.M. with Resident #41 revealed Resident #86 often entered his room and tried to take his food, and when Resident #41 tried to prevent Resident #86 from taking his food, Resident #86 would try to hit him. Interview on 01/04/22 at 9:16 A.M. with Nurse Practitioner (NP) #421 revealed she did not have anything to do with residents' placement on the third and fourth floor secured nursing units and did not know the policy for placement. NP #421 stated Resident #86 was transferred to the hospital to be evaluated for physical aggression after he assaulted Resident #4, and NP #421 was told he would be transferred to the third-floor secured nursing unit when he returned. NP #421 stated Resident #4 was also told Resident #86 would be transferred to the third-floor nursing unit. NP #421 stated Resident #86 had more issues with female residents than males and the third-floor secured nursing unit would be appropriate for him. NP #421 stated she recently observed Resident #86 walking around the fourth-floor unit wearing only an incontinence brief, he was easily redirected, he cursed at her, and she did not agitate him or get close enough to agitate him. NP #421 stated she evaluated Resident #4 a day or two after she was attacked by Resident #86, Resident #4 stated her right cheek and right deltoid hurt, but NP #421 did not see any bruises. Interview on 01/04/22 at 11:50 A.M. with NP #428 and Behavior Health Physician #429 revealed when they arrived at the facility today (01/04/22) Assistant Director of Nursing (ADON) #335 asked about transferring Resident #86 to the third-floor nursing unit. NP #428 stated Resident #86 was drooling excessively and needed a neurology consult and a magnetic resonance imaging (MRI) before they transferred him to the secured third-floor nursing unit. Interview on 01/04/22 at 1:13 P.M. with STNA #393 revealed on 12/10/21 she worked day shift on the secured fourth-floor nursing unit. STNA #393 stated if the second shift STNA was a regular and usually assigned to the fourth-floor nursing unit she left around 2:58 P.M. because the STNA knew the residents and did not need a report. STNA #393 stated on 12/10/21 she did not see a nurse or STNA, including STNA #370 on the unit before she left and did not see one after she left the unit on her way to clock out for the day. Interview on 01/04/22 at 1:21 P.M. with LPN #311 revealed on 12/10/21 she worked on the fourth-floor dementia nursing unit and left the unit and clocked out for the day at 2:15 P.M. LPN #311 stated she was in nursing school and left at 2:15 P.M. due to school related activities. LPN #311 stated she did not remember how many STNAs were working or who they were on 12/10/21. Interview on 01/04/22 at 3:30 P.M. with Staff Development Coordinator (SDC) #388 verified on 12/10/21 STNA #427 did not show up for work and was scheduled to work 7:00 A.M. to 3:00 P.M. on the fourth-floor dementia nursing unit. Interview on 01/04/22 at 3:32 P.M. with Assistant Director of Nursing (ADON) #335 confirmed on 12/10/21 STNA #427 did not show up for work and STNA #393 was the only STNA scheduled 7:00 A.M. to 3:00 P.M. for the secured fourth-floor dementia nursing unit. Interview on 01/06/22 at 2:02 P.M. with Medical Director (MD) #431 revealed he did not know Resident #86 assaulted Resident #4 on 12/10/21 until this date when the surveyor called him, or if he was told he forgot. MD #431 stated Resident #86 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MD #431 stated Resident #86 had increased drooling from his mouth, he ordered lab work, a chest x-ray, and after he received the results, he might order a neurology consult. MD #431 stated Resident #86 needed to be on the third-floor secured nursing unit but stated if he touched residents' belongings on the third floor they would get upset and it could cause fighting between the residents. MD #431 stated Resident #86 was not an easy case to determine what should be done. Interview on 01/06/21 at 2:42 P.M. with LPN #395 revealed on 12/10/21 she arrived for work and STNA #370 told her she witnessed Resident #86 punching Resident #4. LPN #395 stated she checked Resident #4 to make sure she was not injured and noticed bluish discolorations on her right and left upper arms, and on her face. LPN #395 stated she should have completed an evaluation, including vital signs and injuries on both Resident #86 and Resident #4, but so much was going on, she was busy, and she did not do it until later in her shift for Resident #4. LPN #395 stated she did not complete an evaluation or take vital signs for Resident #86. LPN #395 stated Resident #4 had bluish discolorations on her right and left upper arms and face, did not remember charting she had no discolorations, but she was so busy she might not have charted accurately. Interview on 01/06/21 at 3:55 P.M. with Interim Director of Nursing #425 revealed psychiatric services first evaluation of Resident #86 was on 01/03/22. Interim Director of Nursing stated due to the holidays the evaluation was not done before 01/03/22. Review of the facility staff assignment sheets on 12/10/21 revealed LPN #311 and STNA #393 were scheduled to work 7:00 A.M. to 3:30 P.M. on the fourth-floor dementia nursing unit. LPN #395, STNA #330, and STNA #370 were scheduled to work 3:00 P.M. to 11:00 P.M. on the fourth-floor dementia nursing unit. Interview on 01/10/22 between 2:50 P.M. and 3:25 P.M. with STNA #322, STNA #330, STNA #342, STNA #368 and STNA #370 revealed they were not aware of nursing staff education sent via electronic text regarding the Activity of Daily Living Policy and the addition of frequent rounding on the unit (at least every hour) to observe residents and unit atmosphere, that a task was added to all residents for the frequent rounding, special instructions were added and is reflected in the Grey Bar on the MAR/TAR for every resident. They were also not aware a task was added to all residents for STNA documentation for frequent rounding on the unit (at least every hour) to observe residents and unit atmosphere. Review of the facility policy titled, Abuse, Neglect, and Exploitation Policy 2019, revised 06/2021, revealed abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Abuse also included the deprivation by an individual including a caretaker, of goods, or services that were necessary to attain or maintain physical, mental, or psychosocial well-being. In the event an allegation was made, the facility would take measures to protect residents from harm during an investigation. In the event the alleged abuse involved resident-to-resident altercations an appropriate physical assessment would be completed on each resident and documentation of facts and findings would be completed in each resident's medical record. Review of the facility policy titled, POLICY: SECURED UNIT (Dementia), dated 12/2017, revealed the facility strived to provide a safe environment for all residents with additional precautions and support for those residing in the secured unit. The goal of the unit was to respect the privacy and dignity of residents, administer care and treatment, provide a secure environment with increased supervision and, or offer an environment that makes unsupervised wandering or elopement more difficult. To reside on the secured unit a resident should meet at least one of the following criteria, have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On admission, routinely and upon a significant change, residents will be assessed to determine if they meet any or continue to meet the criteria to reside on the secure unit. This deficiency substantiates Complaint Number OH 072 and is an example of continued noncompliance from the survey dated 10/05/21.

Based on observation, medical record review, Self-Reported Incident review, witness statement review, nursing schedule review, policy review and interview, the facility failed to prevent resident to resident abuse. This affected two of six residents reviewed for abuse (Resident #2 and Resident #6) and resulted in actual harm when Resident #2 sustained a hematoma/laceration and fracture of the [MEDICATION(S)] spine (T8). The facility census was 95. Findings include: 1. Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 resided on the secured, dementia unit and across the hallway from Resident #3. Review of the general note dated 06/21/21 timed 2:08 P.M. revealed the nurse was notified by staff that Resident #2 had been pushed by another resident. Resident #2 was sitting in upright position on floor in hallway, unable to state what happened. Witnesses stated he was pushed by another resident, Resident #3. Resident #3 stated he pushed Resident #2 because he was standing over him while he was sleeping, but he wasn't trying to harm him. Resident #2 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the general note dated 09/06/21 revealed Resident #2 ambulated as desired. The note further indicated staff would continue to monitor due to Resident #2 going into other resident rooms and eating their snacks. The resident was redirected x 1 for going into neighbor's room and eating his snacks. Review of the general note dated 09/17/21 timed 11:00 P.M. revealed at approximately 9:45 P.M. the nurse called for help. Resident #2 was on the floor with full upper body touching the floor and both legs up in the air. The note indicated a moderate amount of deep red blood coming from back of head. Vital signs were taken and the resident was assisted off floor via three-person lift. The doctor was notified and the resident was sent to hospital via 911(Emergency Medical Services) per doctor's orders. Review of the general note dated 09/18/21 timed 5:07 A.M. revealed the writer spoke with staff at the hospital emergency department and Resident #2 was still in the emergency department waiting for neurology consult and MRI due to X-ray indicated a fracture of T8. Review of the hospital emergency department patient education dated 09/18/21 timed 12:57 P.M. revealed Resident #2 was diagnosed with a vertebral fracture. Review of the general note dated 09/19/21 timed 2:41 A.M. revealed Resident #2 arrived via stretcher from hospital. Back brace in place and should not be removed. Review of the behavior problem care plan updated 09/23/21 indicated Resident #2 had a behavior problem, impaired cognition due to Alzheimer's disease, dementia, [CONDITION(S)] and mood disorder, and wandering into peers' room and eating their food. An intervention included to minimize potential for the resident's disruptive behaviors by redirecting and offering tasks which divert attention and to provide snacks and diversion when wandering. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the social service note dated 09/27/21 indicated Resident #2 was admitted to hospice related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 resided on the secured, dementia unit and across the hall from Resident #2. Review of the general note dated 06/21/21 timed 2:33 P.M. revealed Resident #3 stated his reason for pushing another resident [Resident #2] was because he woke up and the resident was standing over him. Resident #3 stated his Post-Traumatic Stress Disorder ([CONDITION(S)]) kicked in and he thought at the time he was defending himself, however he wasn't trying to hurt the other resident. Resident #3 stated he was not harmed or hit at any time. The note indicated Resident #3 was alert and oriented times three spheres and able to make needs known. Resident #3 expressed regret and concern for Resident #2. Resident #3 was educated to notify staff when another resident wandered in room and verbalized understanding. Review of the general note dated 09/06/21 revealed Resident #3 was forgetful at times. The note indicated Resident #3 complained of the resident across the hall coming into his room and eating his sweets. Resident #3 was encouraged not to touch the other resident but to come and tell staff. The note indicated the writer would continue to monitor Resident #3's room and his neighbor. Review of the general note dated 09/18/21 timed 8:08 A.M. revealed the writer received report from previous shift nurse that Resident #3 was involved in a physical altercation with another resident [Resident #2]. Resident #3 stated the other resident came into his room to take his snacks and he told him to leave and then pushed him causing the other resident to fall and hit his head on the floor. The note indicated the other resident was sent to the emergency department and call was placed to the police for a report. Review of the social service noted dated 09/21/21 indicated the writer met with Resident #3 about the incident with peer. Resident #3 was asked to seek out staff and not punch peer who was injured. He stated he did not want to hurt anymore. The noted indicated staff would monitor and redirect wandering peers. Review of the physical behaviors care plan dated 09/21/21 revealed Resident #3 had potential to demonstrate physical behaviors related to anger and dementia. Peer entered his room going through his belongings he then pushed peer causing peer the resident fall with injury. An intervention included to keep wandering peers out of Resident #3's room. Review of the Self-Reported Incident dated 06/21/21 revealed Resident #3 woke up with Resident #2 standing over him. Resident #3 pushed Resident #2 and he stumbled back and fell on buttocks. Staff immediately intervened and took Resident #2 back to his room. Resident #3 was able to give statement that he thought the other resident was reaching for his food. Resident #3 did not mean for other resident to fall, he just startled him. Review of the Self-Reported Incident dated 09/17/21 revealed Resident #3 was in his room and called for nurse. Upon entering resident room, Resident #3 was standing in his door with another resident, Resident #2 lying on the floor in the hall. Resident #3 stated that Resident #2 had entered his room and started eating his food items. Resident #3 stated that he told Resident #2 to exit his room, when resident did not, he pushed resident out of his room causing Resident #2 to fall backwards into hallway, hitting head on floor. Both residents were separated and assessed. Resident #2 was assessed, assisted up, hematoma noted to back of head with some bleeding. Resident #2 was sent to hospital for evaluation and treatment. Resident #3 was educated to use call light to ask for help from staff and not to take matters into his own hands. Resident #2 was treated at the hospital for hematoma and fracture of T8. Resident #2 did return to facility, order for back brace to be worn at all times and not to be removed, room to be moved closer to the nurses' station. Nurse practitioner ordered a hospice consult after discussing with family due to resident's progressive advancing dementia. Review of the witness statement dated 09/17/21 authored by Registered Nurse (RN) #4 revealed the nurse was called by staff members. Resident #2 was observed laying in hall on floor near Resident #3's room with corn twisters on floor. Resident #2 was non-verbal with no evidence of pain. Resident #2 was assisted off the floor via a three-person lift. A moderate amount of bleeding hematoma (laceration) was noted to the side of the back of Resident #2's head. No other injuries were noted. The doctor was notified and Resident #2 was sent 911 to hospital. The Administrator and emergency contact were notified. Review of the witness statement dated 09/17/21, authored by State tested Nurse Aide (STNA) #11 revealed STNA #11 heard someone yell and looked up and it was Resident #3. When STNA #11 got to his room, Resident #2 was on the floor. The statement indicated they helped him up and he was bleeding from his head. They put him in a wheelchair at the nurses' station. Review of the witness statement dated 09/17/21, authored by STNA #12 revealed at around 9:45 - 9:50 P.M. STNA #12 was in another room when STNA #12 heard a loud bump. STNA #12 came out of the room and saw Resident #2 laying on the floor and Resident #3 standing over him. The nurse was called and vital signs were taken. STNA #12 asked Resident #3 what happened and he stated Resident #2 kept coming in his room taking his snacks, so he pushed him, and that Resident #2 lost his balance and fell backwards. Resident #2 hit his head. Review of the witness statement dated 09/18/21, authored by STNA #10 revealed STNA #10 was completing resident care and as STNA #10 walked out of the resident room, STNA #10 saw Resident #2 fall to the floor and Resident #3 in the doorway. The statement indicated Resident #2 had went into Resident #3's room and got some chips and Resident #3 pushed Resident #2 out of his room. Observation on 10/04/21 at 9:48 A.M. revealed Resident #2 lying in a low bed, on his left side, in a hospital gown, facing the door with his eyes open. The surveyor attempted to interview the resident however the resident made two soft grunts then closed his eyes. Observation on 10/04/21 at 9:55 A.M. revealed Resident #3 sitting on the side of his bed, wearing a sweatsuit and tennis shoes. There was a large cardboard box of snack bags sitting on the foot of his bed. Interview, during the observation, with Resident #3 revealed when the surveyor asked about Resident #2, Resident #3 replied, is that the guy that gets in my food, he's a big guy, he came in my room and was getting into my food. I checked his hands, and he didn't take nothing, then he fell backwards, the staff thought I pushed him but I didn't. The surveyor asked Resident #3 if Resident #2 had hurt him, Resident #3 replied, no but a memoriam gets posted when I get snacks and he wants to go through them. Observation on 10/04/21 at 11:40 A.M. revealed Resident #2 dressed in a sweatsuit sitting in a wheelchair on the first floor with two visitors. The visitors were talking to Resident #2 and Resident #2 was slighting moving his upper body in the wheelchair, making soft grunts. Interview on 10/04/21 at 2:18 P.M. with RN #4 revealed on 09/17/21, RN #4 was sitting at the desk, getting medications ready when a STNA stated, nurse, nurse, nurse. RN #4 went down the hallway and Resident #3 stated, he came in my room and I told him to stay out. RN #4 assessed Resident #2 and his head was bleeding, so she called 911. RN #4 explained that Resident #2 and #3's rooms were across the hallway from each other and Resident #2 wandered into Resident #3's room. Interview on 10/04/21 at 4:30 P.M. with STNA #9 revealed Resident #2 wandered in everyone's room. Observation on 10/04/21 at 4:31 P.M. revealed Resident #3 was walking up the hallway towards the nurse's station with a slow, unsteady gait. Interview on 10/04/21 at 4:45 P.M. with the Administrator verified resident-to-resident abuse occurred between Resident #2 and #3. Review of the nursing schedule from 09/17/21 revealed RN #4, STNA #10, STNA #11 and STNA #12 were assigned to Resident #2 and #3's (the secured, dementia unit) unit during the evening shift from 3:00 P.M. to 11:00 P.M. Review of the facility's Abuse, Neglect and Exploitation policy revised on June 2021 indicated it was the intent of the facility to prevent abuse, mistreatment, or neglect of resident. The accurate and timely identification of any event which would place a resident at risk was a primary concern of the facility. The policy included procedures to assist the staff in the identification of incidents and direct them to appropriate steps of intervention. 2. Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the behavior charting dated 09/10/21 timed 3:28 A.M. revealed Resident #5 was witnessed pushing and choking another resident by trash door. Victim screaming for help and for Resident #5 to stop. Resident #5 would not stop. The nurse ran to phone and dialed emergency services. Staff member was able to tell Resident #5 to stop and he stopped. Resident #5 walked to his room where he remained until police arrived. Resident #5 was sent to the hospital. Review of the behavior problem care plan updated 09/22/21 indicated Resident #5 had a behavior problem related to paranoid [CONDITION(S)] and brief psychotic disorder. The care plan indicated the resident was physically aggressive towards staff and other residents. The resident displayed inappropriate behaviors and was intimidating to other residents. The resident invaded others space and touch peer on the head. An intervention included to minimize potential for disruptive behaviors by offering tasking which direct attention. Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the general note dated 09/10/21 timed 3:36 A.M. revealed at 11:47 P.M., Resident #6 was witnessed being pushed and choked by another resident by the trash door. Resident #6 began screaming for help and for other resident to stop. Resident would not stop. The nurse ran to phone and dialed emergency services. Staff member was able to tell resident to stop, and he stopped. The other resident walked down to his room where he remained until police arrived. Review of the Self-Reported Incident dated 09/09/21 indicated staff heard yelling and went to sound and found Resident #5 with his hands around Resident #6's neck and pushing her against the wall. Staff immediately intervened and separated the residents. Residents were assessed and no injuries were noted to Resident #6. Resident #5 had scratches on arm from Resident #6 trying to get his hands off of her. 911 was called and took Resident #5 to hospital. Review of the witness statement dated 09/09/21 authored by STNA #13 revealed STNA #13 was doing resident care in a room when STNA #13 heard screaming. STNA #13 ran down the hall and saw Resident #5 pushing Resident #6 into the trash room. Interview on 10/05/21 at 4:15 P.M. with the Administrator verified resident-to-resident occurred between Resident #5 and #6. Review of the facility's Abuse, Neglect and Exploitation policy revised on June 2021 indicated it was the intent of the facility to prevent abuse, mistreatment, or neglect of resident. The accurate and timely identification of any event which would place our residents at risk was a primary concern of the facility. The policy included procedures to assist the staff in the identification of incidents and direct them to appropriate steps of intervention. This deficiency substantiates Self-Reported Incident Investigation Control Number OH 111.

Based on record review and staff interview, the facility failed to administer insulin as ordered and failed to immediately notify the physician and guardian of a significant increase in one resident's (Resident #102) blood sugar. Actual Harm occurred when there was no evidence of monitoring and reporting of significant symptoms to the physician that led to hospitalization for diabetic ketoacidosis (a life-threatening diabetes complication where the body produces excess blood acids/[MEDICATION NAME]) with a blood sugar of 1200 (normal is 80-130) requiring the resident to be placed on a ventilator. This affected one of one resident reviewed for a notification of change in condition. The facility census was 116. Findings include: Review of Resident #102's medical record revealed an admission date of [DATE] at 5:30 P.M. with [DIAGNOSES REDACTED]. Review of Resident #102's Clinical Admissions Evaluation revealed the resident was alert and oriented to person, place and time. Review of Resident #102's Minimum Data Set (MDS) 3.0 assessment, dated 12/29/20, revealed the resident required assistance with activities of daily living. Review of electronic physician orders [REDACTED].M. revealed insulin [MEDICATION NAME] solution (diabetes); inject 10 units subcutaneously at bedtime. Review of electronic physician orders [REDACTED].M. revealed Humalog insulin solution 100 units per milliliter (ml); inject per sliding scale subcutaneously before meals for diabetes. Call the physician if the blood sugar was greater than 400. Review of Resident #102's Medication Administration Record [REDACTED]. There was no documented evidence the physician and the pharmacy were notified the insulin was unavailable for administration. Further review of Resident #102's MAR indicated [REDACTED]. The MAR indicated [REDACTED].M. Review of the MAR indicated [REDACTED].M. revealed Resident #102's blood sugar was 500, and Licensed Practical Nurse (LPN) #411 administered 12 units of Humalog solution. Review of the MAR indicated [REDACTED].M. revealed Resident #102's blood sugar was 500, and LPN #411 administered 12 units of Humalog insulin. Review of Resident #102's progress notes from 12/27/20 through 12/28/20 revealed no documented evidence the physician was notified the blood sugar was 500. Review of Resident #102's electronic physician's orders [REDACTED]. Review of Resident #102's progress notes dated 12/29/20 revealed Resident #102 was restless during the night, his blood sugar at 3:00 A.M. was 400. When LPN #411 tried to wake him to get ready for [MEDICAL TREATMENT], Resident #102 was diaphoretic, hard to arouse, and his blood pressure was 97/45, pulse 90, oxygen saturation 93 percent, and his temperature 98.8 degrees Fahrenheit (F). LPN #411 called the emergency medical services (EMS) and notified the physician. Review of Resident #102's progress notes dated 12/30/20 at 4:37 A.M. revealed Resident #102 was admitted to the hospital with [REDACTED]. Review of the EDK (on hand pharmacy medications) (IV and Cold Kit Usage Form) revealed [MEDICATION NAME] (insulin [MEDICATION NAME]) 100 units per ml, and Admelog (Humalog 100 units per ml) were stocked in the facility. Review of Resident #102's care plan, revision 04/01/18, included give diabetes mellitus medication as ordered by the physician. Monitor/document for side effects and effectiveness and educate resident/family/caregiver as to correct protocol for glucose monitoring and insulin injections and obtain return demonstrations. Interview on 01/21/21 at 3:57 P.M. with LPN #411 revealed Resident #102's blood sugar was 500 on 12/27/20 and 12/28/20 around 6:00 A.M. He administered Humalog insulin 12 units both days as ordered but did not notify Nurse Practitioner (NP) #430. LPN #411 stated he did not notify NP #430 because the NP usually did her resident rounds in the morning, and he thought she would see the high blood sugar at that time. LPN #411 stated on 12/29/20 around 3:00 A.M. he checked Resident #102's blood sugar and it was 400. LPN #411 stated he did not think 400 was an unusual blood sugar for Resident #102 and did not notify NP #430. When LPN #411 attempted to wake Resident #102 for [MEDICAL TREATMENT] at 5:00 A.M. he was diaphoretic and hard to arouse. LPN #411 checked his blood sugar and the glucometer read High. At that time, he called the EMS and notified the physician. Observation and interview on 01/26/21 at 3:49 P.M. with Administrator #408 and the Director of Nursing (DON) revealed review of Resident #102's hard chart revealed no documented evidence including admission instructions/orders, for Resident #102's admission on 12/24/20 through 12/29/20 when he was sent via ambulance to the hospital. The DON stated she did not know where the missing documentation was, and it could possibly be in medical records. The DON stated Resident #102 was only in the facility a few days, and there might not be any documentation. The DON stated she would forward any documentation she found. No documentation was provided by the facility for the admission 12/24/20 through 12/29/20. Phone interview on 01/27/21 at 4:30 P.M. with NP #430 revealed she was unable to answer any questions regarding residents at the facility unless the DON was present. She stated it was her company's policy that the interview must be done at the facility with the DON in the room. Interview on 01/28/21 at 12:30 P.M. with Administrator #408 revealed the facility was unable to provide documentation of medications used from the on-hand pharmacy supply for Resident #102 from 12/24/20 through 12/29/20. Interview on 01/28/21 at 4:49 P.M. with Family Member (FM) #436 stated the facility was a terrible place, they did not take care of her son, and he ended up being transported by ambulance to a local hospital. The physician in the Emergency Department (ED) called her and told her Resident #102's blood sugar was 1200, and he needed to be placed on a ventilator. FM #436 stated Resident #102 received insulin every day, and the facility was not giving it to him before he was taken to the hospital. FM #436 stated she called Receptionist #437 at least ten times begging her to ask the staff to take care of her son. FM #436 stated her son was too sick to be interviewed, he was confused and would not be able to answer questions. Interview and review of packing invoices on 01/29/21 at 7:19 A.M. through 4:30 P.M. with Pharmacy Representative (PR) #438 revealed Resident #102's orders were received on 12/24/20 at 11:03 P.M. but did not include [MEDICATION NAME] (insulin [MEDICATION NAME]). Additional orders received on 12/27/20 at 12:19 A.M., delivered on 12/27/20, included [MEDICATION NAME]100 units per ml (Humalog 100 units per ml). Interview on 01/29/21 at 1:39 P.M. with LPN #403 revealed she worked on 12/24/20 and admitted Resident #102 to the facility. LPN #403 stated shortly after he was admitted she went through the admission packet, reviewed the medication list, and verified the medications with the physician. She made sure Resident #102 was in the computer system. LPN #403 stated the next thing she did was assess Resident #102 and put the orders into the electronic medical record. When asked about why Resident #102 was not administered insulin on 12/24/20 and why the Humalog insulin did not get ordered until 12/26/20 (delivered on 12/27/20), LPN #403 stated she didn't remember if Resident #102 had insulin orders when he was admitted . LPN #403 stated it was very busy on 12/24/20, and she was assigned more than one nursing unit. She stated she could not remember all of the details of Resident #102's admission. Interview on 01/30/21 at 5:15 P.M. with Receptionist #437 confirmed FM #436 called her many times on 12/24/20 to ask her to talk to the nurse and state tested nurse aide (STNA) taking care of her son to check on him and make sure he was alright. Receptionist #437 stated the phone at the nursing station just rang and rang, and she had to walk to the nurse's station to talk to the staff. Receptionist #437 stated there was not a nurse on the unit, she thought the nurse was assigned to another nursing unit as well as the first floor nursing unit, but she did ask the STNA to check on Resident #102 each time FM #436 called. Receptionist #437 did not know the name of the STNA she talked to. This deficiency substantiates Complaint Numbers OH 507, OH 485, OH 155 and OH 091.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on review of the medical record, a facility Self-Reported Incident (SRI) to the State Agency, police report, facility policy and interview with staff and residents the facility failed to ensure one resident (Resident #1) was free from physical abuse by a staff member. This resulted in Immediate Jeopardy that was actual harm on 08/30/19 when Resident #1 was attempting to enter the smoking area and State tested Nurse Aide (STNA) #605 blocked her way and forcibly pushed her back causing the resident to fall to the floor. The resident tried a second time and the STNA pulled the resident's shirt up over her head causing scratches to her chest area. This affected one of three residents reviewed for abuse. The facility census was 132. On 09/24/19 at 2:10 P.M. the Executive Director was notified that Immediate Jeopardy began on 08/30/19 at approximately 7:30 P.M. when Resident #1 stated STNA #605 threw her to the ground. On that date, STNA #605 stated he physically grabbed Resident #1 and turned her around preventing her from entering the smoke room resulting in her falling to the floor and he pulled her shirt over her head resulting in scratches to her chest. The Immediate Jeopardy was removed and corrected on 09/03/19, when the facility implemented the following corrective action: · On 09/03/19 at 11:30 P.M. the police were notified by Assistant Director of Nursing (ADON) #604, the police arrived at the facility, and a report was filed on 09/03/19 at 3:25 P.M. · On 09/03/19 at 11:45 AM, the Administrator and Clinical Psychologist #603 educated the Director of Nursing, Staffing Coordinator #607, Human Resource Director #608, Assistant Director of Nursing (ADON) #609, Social Service Director (SSD) #610, #606, Registered Nurse (RN) Unit Manager #612, Licensed Practical Nurse (LPN) Unit Managers #611 and #613, Minimum Data Set (MDS) coordinators #614 and #616, and Business Office Manager #615 regarding Abuse, Neglect and Misappropriation, Resident Rights, Techniques on de-escalating residents with behaviors and scenarios to be used to educate staff. · STNA #605 was terminated on 09/03/19 at 12:30 P.M. · On 09/03/19 at 2:55 P.M., the facility submitted the initial SRI tracking number 4 to the State Agency. · On 09/03/19 from 12:00 P.M. to 6:30 P.M. the DON, Staffing Coordinator #607, Human Resource Director #608, and ADON #609 educated all staff members on Abuse, Neglect and Misappropriation, Resident Rights, Techniques on de-escalating residents with behaviors and scenarios to be used to educate staff. All staff completed a staff questionnaire if they had witnessed a staff member abuse a resident at the facility with no adverse effects noted. · On 09/03/19 from 12:00 P.M. to 6:30 P.M. SSDs #610, and #606, RN Unit Manager #612, LPN Unit Managers #611 and #613, RN Minimum Data Set (MDS) Coordinators #614 and #616, and Business Office Manager #615 completed the Quality Indicator Survey (QIS) Resident Interview and Resident Observation on all residents residing in the facility and had no adverse effects. · ADON #609, RN Unit Manager #612, and LPN Unit Managers #611 and #613 continued to conduct 12 random staff competencies including scenarios related to abuse, resident rights and de-escalation weekly for four weeks. The following competencies were completed: 09/09/19 with the DON, 09/10/19 with LPNs #601, #630, #631, #632, STNA s #602, #628, #629, #633, on 09/11/19 with Maintenance #634, STNA #636, on 09/13/19 with Housekeeping #635, 09/16/19 with ADON #604, RN Unit Manager #612, RN MDS #616, #614, SSD #606, Speech Therapist #623, Occupational Therapist #624, #625, LPN #630, STNA #622, #627, Housekeeping #626, on 09/17/19 with LPN Unit Manager #613, on 09/23/19 with STNA #637, #638, #641, #642, Housekeeping #639, Maintenance #640, Dietitian #643, Social Service Director #610, Central Supply #644, Maintenance Director #645, Physical Therapist Assistant #646, and on 09/25/19 the Receptionist #647. · The DON, Staffing Coordinator #607, Human Resource Director #608, SSD #610, #606, and MDS Coordinators #614 and #616 continued to conduct the QIS Resident Interview and Resident Observation tool to ascertain abuse for three residents per each floor (4 floors) weekly times four weeks. · The facility held a Quality Assurance Performance Improvement (QAPI) on 09/03/19 at 3:00 P.M. with the Administrator, DON, ADON #609, and Social Service Director #610 and discussed the incident on 09/03/19. The team reviewed the current smoking process on the third-floor secured unit. They discussed adjusting the smoking times into two simultaneous 30-minute breaks with two groups or assigning two smoke monitors for each break to increase supervision versus current process where residents line up at the smoking room and go in ten at a time. The team decided to increase supervision at this time. The team will review at the next QAPI meeting on 09/27/19. The Medical Director was contacted on 09/03/19 at 4:00 P.M. and QAPI meeting was reviewed. · The facility continues to participate in the [MEDICATION NAME] Touch Care Giver Training - CMP reinvestment program under the coordination of Occupational Therapist Training Education Consultant #617 with scheduled baseline survey to be submitted on 09/27/19 and coach training scheduled for 10/03/19. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had intact cognition with delusions and verbal behaviors towards others. The resident required supervision with transfers, walking and locomotion. Review of the care plan dated 08/05/19 revealed Resident #1 had potential to be verbally aggressive related to her mental illness and anger with placement. Interventions included: administer medications as ordered and document side effects, analyze key times, places, circumstances, triggers and what de-escalated her behavior and document, and psychiatric and psychologist consults as indicated. Review of the facility substantiated SRI for physical abuse with tracking number 4 and discovery date of 09/03/19 revealed when ADON #604 completed a skin assessment for Resident #1 she observed scratches to Resident #1's upper chest. ADON #604 asked Resident #1 how the scratches occurred, and Resident #1 stated STNA #605 threw her on the floor when she attempted to go into the smoke room to smoke. The SRI revealed STNA #605 was interviewed and revealed on 08/30/19 at 7:30 P.M. Resident #1 was attempting to go into the smoke room to smoke a second cigarette. STNA #605 stated he blocked the smoke room entrance to prevent Resident #1 from entering. STNA #605 stated Resident #1 became upset and attempted to push past him, and he grabbed Resident #1 by the arm and turned her away from the door causing her to fall to her knees. Resident #1 then got up and ran towards STNA #605, and STNA #605 pulled Resident #1's shirt over her head causing scratches to Resident #1's chest. Neither Resident #1 or STNA #605 reported the incident until 09/03/19 when the resident told the nurse. Review of a witness statement dated 09/03/19 by LPN #618 revealed he was the nurse on duty on 08/30/19 and indicated Resident #1 asked him if she could smoke a cigarette even though she had smoked two cigarettes. LPN #618 stated he directed STNA #605 to let Resident #1 have another cigarette. LPN #618 indicated he did not witness or hear anything regarding the altercation between Resident #1 and STNA #605. Review of a witness statement dated 09/03/19 by STNA #619 revealed she was the other STNA on the 300 hall on 08/30/19. STNA #619 indicated Resident #1 was upset about not smoking. STNA #619 indicated she did not see any physical altercation between Resident #1 and STNA #605. Review of the local Police Report #2019- 5 revealed on 09/03/19 at 3:34 P.M. Police Officers #620 and #621 responded to an assault allegation. Police officers #620 and #621 revealed upon arrival staff had informed them Resident #1 was assaulted by STNA #605. Resident #1 revealed to Police Officers #620 and #621 on either 08/30/19 or 08/31/19 at 7:30 P.M. she was taking a smoke break in the designated area when she was in an altercation with STNA #605 about another resident's cigarettes. Resident #1 revealed STNA #605 prevented her from leaving the area and was holding a room key attached to a wooden pole. Resident #1 revealed STNA #605 motioned to Resident #1 as if he was going to strike her with the room key. Resident #1 revealed she pushed STNA #605, and STNA #605 pushed Resident #1 to the ground and punched her an unknown amount of times. The report revealed the police were not contacted at the time of the incident. Police Officers #620 and #621 indicated Resident #1's mental capacity was severely diminished, and staff was advised to contact Resident #1's guardian. Interview on 09/24/19 at 9:17 [NAME]M. with Psychologist #603 revealed Resident #1 had [MEDICAL CONDITION] with delusions. She was verbally aggressive at times but easily re-directed utilizing de-escalation interventions such as she liked to rock in a chair, re-direction, and one on one. Psychologist #603 was notified on 09/03/19 regarding STNA #605 being physically aggressive to Resident #1. He indicated he routinely educated staff on deescalating interventions to use in the event of any resident displaying verbal or physical behavior. He stated STNA #605 did not attempt to de-escalate Resident #1's behavior. He indicated he had instructed if an event got to the level that de-escalation interventions were not effective staff were to call him for further interventions and hands on should have never been used. Interview on 09/24/19 at 9:23 [NAME]M. with Resident #1 revealed she was abused one time at the facility by STNA #605. She stated she was at the end of the hallway by the smoke room and STNA #605 came up to her and pushed her to the ground for no reason. She revealed she had a long scratch to her chest, and it hurt. She began rocking with increased anxiety in the chair and stared in the opposite direction not answering any further questions. Interview on 09/24/19 at 12:34 P.M. with ADON #604 revealed she completed Resident #1's weekly skin assessment on 09/03/19 at approximately 11:00 [NAME]M. and observed two superficial scratches to Resident #1's upper chest. She stated she asked Resident #1 about the scratches, and Resident #1 stated STNA #605 caused the scratches a few days ago when the STNA threw her on the ground and pulled her shirt over her head. ADON #604 indicated she informed the Administrator immediately, and they started an investigation. ADON #605 revealed they contacted STNA #605 and interviewed him over the phone. She stated STNA #605 indicated on 08/30/19 at 7:30 P.M. he had attempted to block Resident #1 from the smoke room and she became upset and pushed him. He grabbed her and turned her in the opposite direction, and Resident #1 fell to the ground. ADON #604 stated STNA #605 indicated Resident #1 then came at him, and STNA #605 pulled Resident #1's shirt over her head causing the scratches to her chest. ADON #604 stated neither STNA #605 or Resident #1 reported the event. ADON #604 stated STNA #605 verified he had not attempted any deescalating interventions during the incident, and stated he was justified in physically grabbing Resident #1. STNA #605 stated if anyone touches him then he would touch them back, and it did not matter who the person was. ADON #604 stated at that time STNA #605 was asked to come into the facility to complete a witness statement and to continue the interview. Interview on 09/25/19 at 11:20 [NAME]M. with Resident #111 revealed several weeks ago she was in the hallway when Resident #99 stated STNA #605 just pushed Resident #1 down to the floor. Resident #111 revealed she looked down the hallway by the smoke room and saw Resident #1 on the ground and STNA #605 over her. She stated she did not report the incident because she tried to stay out of trouble. She revealed she went to the dining room and did not witness any other altercations. Interview on 09/25/19 at 11:28 [NAME]M. with Resident #99 revealed he was standing in the hallway a little in front of the nursing station and he observed STNA #605 push Resident #1 with both his hands knocking her to the ground. Resident #99 revealed he felt it was hard. Resident #99 indicated he did not know if any staff or residents were in the area. He stated he walked to the dining room because he did not like to see that. He revealed he did not report the incident to anyone. Interview on 09/25/19 at 11:42 [NAME]M. with SSD #606 revealed ADON #604 had informed her of Resident #1's allegation on 09/03/19. SS #606 stated she interviewed Resident #1 and the resident shared the same details as she conveyed to ADON #604. SSD #606 revealed she and the Administrator interviewed STNA #605 when he came into the facility on [DATE]. SSD #606 stated STNA #605 revealed on 08/30/19 at 7:30 P.M. Resident #1 had attempted to go into the smoke room and he attempted to stop Resident #1 from entering. STNA #605 indicated Resident #1 continued to push past him, and he grabbed her by the arm and physically attempted to redirect her away and when he turned her in the opposite direction Resident #1 fell to her knees. SSD #606 indicated STNA #605 stated Resident #1 then charged at him, and he pulled her shirt over her head. SSD #606 verified STNA #605 revealed he did not attempt any de-escalating interventions during the incident. SSD #606 stated STNA #605 stated if someone put their hands on him then he will on them. SSD #606 revealed she was shocked when she heard him say that in the interview especially after all of the training, she felt the facility had done on deescalating techniques and abuse. Interview on 09/25/19 at 12:04 P.M. with the Administrator revealed both times she interviewed STNA #605 on the phone and in person he stated he did not attempt any de-escalating techniques and verified both times he had said if someone touched him, he felt he should be able to do it back. The Administrator revealed STNA #605 was terminated on 09/03/19. Review of facility policy titled, Abuse, neglect, and Misappropriation dated (MONTH) (YEAR) revealed residents shall be free from abuse as abuse was defined as willful infliction of injury. Employees and supervisors would be trained on recognizing indications of abuse and appropriate interventions to deal with such situations and how to recognize signs of potential abuse. The facility through quality assurance process and clinical morning meeting process would provide monitoring of the physical environment, appropriate staffing, staff behavior, delivered care and services, and review of information for negative trends. The facility would train staff on any special care and techniques required for specific residents. The facility management would make routine rounds to identify concerns with staff related to stress and identify signs and symptoms of abuse of residents. This deficiency substantiates Complaint Number OH 009

Based on clinical record review, review of a facility incident investigation, staff interview and review of the facility policies and procedures titled Case Management: Condition Report Sheet ([DATE]), Code Status: Automated External Defibrillator Use ([DATE]), and the Code Status: DNR (Do Not Resuscitate) Comfort Care Protocol ([DATE]), the facility failed to provide necessary care and services when staff did not implement cardiopulmonary resuscitation (CPR) for Resident #131who was a full code. This resulted in Immediate Jeopardy for one of five residents (Resident #131) reviewed for emergency measures. The facility census was 120. On [DATE] at 4:12 P.M. the Administrator, the Director of Nursing (DON), and the Regional Clinical Manager were notified Immediate Jeopardy began on [DATE] at 5:15 P.M., when Resident #131 experienced difficulty speaking and complained of increased pain of an undetermined origin. Resident #131 was not assessed following the change in condition. On [DATE] at 12:20 A.M., Resident #131 was found in bed without respirations or pulse and CPR was not initiated. The resident expired at the facility. The Immediate Jeopardy was removed on [DATE] at 2:00 P.M., when the facility implemented the following corrective actions: ? On [DATE] at 7:00 A.M., RN #135 was placed on unpaid leave during the facility's investigation of the incident. RN #135 did not return to work and was no longer employed by the facility effective [DATE]. ? On [DATE] and [DATE], the facility provided 29 of 34 licensed nurses an in-service on policies and procedures regarding change of medical condition, staff responsibility during cardiopulmonary arrest, and calling a medical code. The remaining five licensed nurses were on a as needed part time basis and were in-serviced upon return to work and prior to resident care. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy), because the facility failed to initiate an audit of all current medical records to ensure code status was clearly visible and failed to establish a monitoring system. Findings include: Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #131's face sheet indicated she was to receive full life saving measures. Review of a nurses progress note dated [DATE] timed 9:55 A.M revealed Resident #131 was found without respirations or pulse on [DATE] at 12:20 A.M. The note did not indicate lifesaving measures were provided. There were no other entries addressing the incident. Review of the facility's internal investigation report of the incident revealed Resident #131 was observed by another resident's daughter slumped over in the dining room during the evening meal on [DATE]. On [DATE] at 12:20 A.M., the resident was found without respirations or pulse. Lifesaving measures were not initiated. The investigation revealed RN #135 indicated she was unaware of the resident's code status so she did not call a code. On [DATE] at 4:40 P.M., a phone interview with State tested Nursing Assistant (STNA) #146 was conducted. She indicated she was assigned to care for Resident #131 the evening of [DATE] and the morning of [DATE]. STNA #146 stated around supper time, approximately 5:15 P.M., Resident #131 had difficulty getting her words out and complained of not feeling well. STNA #146 stated she informed Licensed Practical Nurse (LPN) #142 that Resident #131 was not feeling well and was having difficulty speaking. STNA #146 stated she told LPN #142 Resident #131 was unable to eat dinner. STNA #146 stated at the beginning of the third shift, around 11:30 P.M., on [DATE] when she was leaving the unit to go on break, Resident #131 was still not feeling well and was calling out "nurse, nurse." STNA #146 stated she informed RN #135 that resident #131 wanted to see her. She stated it was 12:00 A.M. when she returned to the Advanced Rehabilitation Unit (ARU). She found Resident #131 unresponsive during her rounds. On [DATE] at 4:55 P.M., an interview with STNA #147 was conducted. She worked the ARU the evening of [DATE]. STNA #147 stated Resident #131 refused dinner which she indicated was totally unlike her as she usually ate everything. STNA #147 stated Resident #131 normally mumbled a little, but that evening she was having difficulty speaking, shaking her head to communicate. STNA #147 stated Resident #131 indicated she was experiencing a lot of pain. STNA #147 stated Resident #131 had never complained of pain like that before. Resident #131 did not indicate the location of the pain. STNA #147 stated she reported her concern to LPN #142. On [DATE] at 5:08 P.M., an interview with LPN #142 was conducted. She verified STNA #147 had reported concerns about Resident #131. LPN #142 indicated she assessed Resident #131. She stated Resident #131's speech was always garbled and she had no difficulty understanding her. LPN #142 stated Resident #131's only complaint was nausea. LPN #142 stated she gave Resident #131 her ordered as needed (prn) nausea medication. LPN #142 indicated Resident #131 always complained of nausea. Review of the medical record revealed no documented assessment of Resident #131 by LPN #142. On [DATE] at 9:45 A.M., RN #149 (Unit Manager on ARU) and Regional Clinical Director #150 confirmed there was no indication Resident #131 was assessed on [DATE] when she had complained of pain, inability to speak and inability to eat. Review of the physician orders [REDACTED]. Review of the pharmacy log revealed 10 vials of [MEDICATION NAME] had been sent for Resident #131and the facility returned all ten vials after Resident #131 expired. There was no evidence [MEDICATION NAME] had ever been administered to Resident #131 for frequent complaints of nausea as stated by LPN #142. On [DATE] at 12:15 P.M., the Administrator and the DON verified Resident #131 was to receive full life saving measures and no life saving measures were initiated for Resident #131. This deficiency substantiated Complaint Number OH 182.