Every finding on record at Continental Nursing & Rehab Center

Based on interview on and record reviewed the facility failed to ensure that a residents legal representative/guardian was notified in a timely manner regarding a significant change in a residents (R1) status. This failure affected one of three residents reviewed for notification of changes. Findings include:R1 has a diagnosis which includes but not limited to chronic obstructive pulmonary disease, essential hypertension, depression, schizophrenia, heart failure, contact with and suspected exposure to other viral communicable disease, vitamin d deficiency anemia, nicotine, anemia, type 2 diabetes mellitus, hypertensives heart disease with heart failure.R1's Brief Interview for Mental Status (BIMS) dated 6/25/26 shows a score of 11 which indicated that R2 has some cognitive impairments. On 08/28/28 at 1:00 pm, R1 was observed alert and able to communicate his needs. R1 explained that on 08/18/26 he went out on independent pass [NAME] Pass at the facility and was aware he was required to return to the facility by 8:00 pm. R1 further explained that he left the faciity on green pass because he had business he had to attend. R1 then explained that he got on the Chicago Transit Authority (CTA) bus to go and check on his house near 87th street in Chicago. R1 further explained that once he checked on his home, he started to feel back pain and sat on a bench in front of a bus stop, and that he did not possess a cellular phone to inform the facility or anyone of his back pain or that he was unable to return to the facility. R1 further explained that the local police saw R1 sitting on the bench and took R1 to the local hospital. R1 stated that the local hospital gave R1 pain medication and then sent R1 back to the facility. R1 denied having injuries while R1 was in the community. R1 also stated that this was his first time not meeting the facility curfew and the facility not being aware of where R1 was. On 8/28/26 at 3:32 pm, V10 (Social Service Director) stated that he is familiar with R1 at the facility and recalls R1 going out on pass on 08/18/26 and did not return to the facility until 08/22/26 via ambulance. V10 explained that on 08/18/26 R1 was issued a green pass to go out to the community and that explained that R1 goes out on pass in the community two to three times a week and he returns to the facility prior to 8:00 pm without concerns. V10 explained that he conducted a survival skills assessment with R1, that R1 walked independently, aware of his surroundings, the facility address, phone number, what to do in case of an emergency and that R1 scored a Brief Interview for Mental Status score of 15 which indicated that R1 was cognitively intact and appropriate for an independent pass into the community. V10 explained that R1 physician gave orders for R1 to be issued an independent pass into the community and denied since V10 has worked at the facility R1 has had concerns with returning to the facility when out on independent pass. V10 explained that on 08/18/26 when R1 did not return to the facility, V10 was not presented and then explained that when he (V10) returned to the facility the next day on 08/19/26 he learned that R1 did not return to the facility at the facility's 8:00 pm, curfew, that V3 (R1's Guardian) had not been informed of R1 not returning to the facility and that V10 then called to inform V3 of R1's status. V10 further stated that if a resident does not return at the facility's curfew time of 8:00 pm, the resident's guardian should be contacted to see if they can give information and may know the residents where abouts and because the state guardian needs to know if the resident is missing. On 08/29/26 at 9:54 am, V11(Licensed Practical Nurse, LPN stated that was R1's nurse on 08/18/26 7:00 pm - 7:00 am shift when R1 did not return to the facility. V11 explained that R1 is not a resident who is known to elope the facility and explained that she did not see R1 in the room when she checked around 8:05 pm and then she checked with staff who stated that they did not see R1 in the facility. V11 then explained that she called the police who gave a police number and informed V11 that they would look for R1 and get back to the facility. V11 further explained that she called all the surrounding local hospital who stated they did not have R1 in their care. V11 then stated that she called V3 (R1's Guardian) but did not receive an answer because it was after hours and explained that she left a message for the V3 to call the facility back. V11 further stated that she proceeded to call R1's family listed on his profile sheet and they stated that they had not seen R1. V11 then stated that she then called R1's physician office as well as V13 (Assistant Director of Nursing, ADON) to inform her of R1 not returning to the facility. V11 explained that she did not document the phone call to V3 (R1's Guardian) and stated, I didn't talk to them (referring to V3). I only document the people who I talked to. V11 explained that it is the facility policy to immediately call and inform the residents guardian when there are any changes with the residents status. V11 also stated that it is important to notify the guardian to let them know what is happening with the resident and any situation that is going on with the resident. On 8/29/26 at 10:49 am, V12 (Registered Nurse, RN) stated that R1 is an alert and oriented times four resident and explained that on 08/18/26 around 3:20 pm, R1 requested an independent pass to the community from V12. V12 stated that R1 normally goes out on independent pass in the community 2-3 times a week usually for groceries/snack and that R1 has orders for independent pass to go out to community. V12 explained when R1 requested an independent pass on 08/18/26 R1 stated that he wanted to walk around. V12 then explained when a resident goes out on pass it is documented in the progress notes and a form is issued to the resident to give to the receptionist until the resident returns to the facility. V12 also explained that upon the resident return to the facility, the receptionist completes a form indicating that the resident returned to the facility. V12 explained on 08/18/26 he left for his shift around 7:40 pm, and R1 had not returned to the facility, V12 documented that R1 had not returned to the facility, and V12 informed the oncoming nurse that R1 was still out in the community. V12 explained when a resident is out on green pass Independent Pass the resident is aware they can leave the facility at 8:00 am and must return to the facility at 8:00 pm. V12 explained that R1 did not have a cellular phone and walks independently without any assistive devices. V12 stated if the resident does not return to the facility at the 8:00 pm curfew or call the facility with their whereabout, the nurse calls V2 (Director of Nursing, DON) V1 (Administrator), the police, the resident representative/family/guardian, and the residents physician. V12 stated that the residents responsible party all immediately informed in order to be made aware of the residents status. On 8/29/26 at 11:19 am, V13 (Assistant Director of Nursing, ADON) stated that she received a call 08/18/26 around 8:00 pm from V11 (LPN) regarding R1 going out on pass earlier in the day and not returning to the facility by 8:00 pm. V13 stated that she instructed V11 to follow the facility's policy for when a resident goes out on pass and does not return to the facility by 8:00 pm. V13 explained that she informed V11 to call the resident, the resident's family/guardian/responsible party, the police, the nearest hospitals, the physician. V13 stated that she informed V11 that she would contact V1 (Administrator) to inform him of the event. V11 explained that V2 (Director of Nursing, DON) was on vacation on 08/18/26. V13 then stated that she informed V11 to document in the progress notes that R1 did not return to the facility on [DATE] and everyone who V11 called regarding the incident. V13 stated that R1 did not return to the facility that night and then next day the facility continue to follow up by calling the local hospital again, and the police for any updates. V13 explained that she read V11 documentation the next day regarding R1 not returning to the facility and saw that V11 did not document that she informed R1's guardian that R1 did not return to the facility and V11 stated that she did call V3 (R1's Guardian) left a voicemail but was not able to reach V3 and further explained that she (V11) did not think that she needed to document that she called V3 (R1's Guardian) if she did not reach her. V13 stated it is important to notify the guardian because it is important for the guardian to be aware of any changes with the resident and because the guardian is the legal decision maker for the resident. On 8/29/26 at 11:36 am, V2 (Director of Nursing, DON) stated that on 08/18/26 V2 was on vacation and was not involved with R1 going out on pass 08/18/26 and not returning to the facility by his 8:00 pm curfew. V2 explained he returned to work on 08/23/26 and that R1 had already returned to the facility. V2 explained that after the residents have their morning breakfast and medication around 8:00 am the resident is able to leave out on green pass independently and must return to the facility by 8:00 pm. V2 further explained if the resident does not return to the facility by 8:00 pm, the resident is called if the resident have contacted information on file and the resident's responsible party is informed. V2 explained that the resident responsible is listed on the residents profile as emergency contact #1. V2 further explained that the physician and the police are notified and the local hospitals are called in search of the resident. V2 further explained if the resident has not returned to the facility next day the facility continues to follow up with the local police and local hospitals regarding the resident and the facility will keep the residents responsible party informed. V2 stated that all the information regarding the residents non return is documented in the residents progress notes and then explained if a nurse calls the responsible party and is not able to reach the residents responsible party/ emergency contact #1 the nurse should document the attempt in the residents progress notes. V2 explained that it is important to notify the resident representative emergency contact #1 such as the residents guarding of any changes with the residents status to make them aware of the resident situation at the time and to let them know what the status is of the resident or their loved one is. On 8/29/26 at 1:01 pm, V1 (Administrator) stated that he is familiar with R1 at the facility and is aware that R1 left the faciity on [DATE] and did not return to the facility at the 8:00 pm curfew time. V1 explained that V13 informed V1 on 08/18/26 and that when R1 did not return to the facility the next day on 08/19/26 it was discussed in the morning meeting . V1 stated that the facility continued to look for the resident by calling the local hospital, police, and V3 (R1's Guardian). V1 then explained that he became aware on 08/19/26 that the facility did not notify V3 (R1's Guardian) of R1's status when V10 (Social Service Director) informed V1 that he spoke with V3 (R1's Guardian) and she stated to V10 that she had not been notified of the incident on 08/18/26 when the facility became aware of R1's status. V1 explained that V3 then came to the facility on [DATE] after she was notified that R1 had not returned from out on pass 8/18/26 and discussed with V3 that R1's green pass would be suspended until V3 was okay with R1 going out on independent green pass in the community and R1 being provided with community pass educations once R1 returned to the facility. V1 then explained that V10 informed him that V3 agreed to the facility recommendations. V1 stated that a residents guardian is the priority in notifying the resident representative regarding a residents change in status and staff should be contacting the residents guardian immediately regarding any changes in the residents status such as the resident going out on pass and not returning to the facility at the agreed upon curfew time. V1 explained if the resident guardian is not notified it is a concern because the residents guardian has responsibility for the wellbeing of the resident. V1 stated that when R1 returned to the facility V13 (Assistant Director of Nursing, ADON) R1 did not have any injuries. R1's progress notes dated 08/18/26 at 11:00 pm, authored by V11 (LPN) documents, in part: Resident received out on pass 8/18/26 and has not returned back to the facility. Emergency contact: file sister notified all nearest hospitals contacted. On call nurse practitioner notified Chicago Police Department notified missing person report filed with the Beat number 2011 report JK 378511 V13 (ADON) made aware.R1's progress notes dated 08/22/26 at 7:30 am, authored by V14 (LPN) documents, in part: Resident received out on pass 8/18/26 and has not returned back to the facility. Emergency contact: file sister notified all nearest hospitals contacted. On call nurse practitioner notified Chicago Police Department notified missing person report filed with the Beat number 2011 report JK 378511 V13 (ADON) made aware.R1's document dated October 30, 2019 shows that R1 has a legal guardian.R1's face sheet shows that R1's #1 emergency contact is listed as R1's guardian office. The facility policy dated 6/29/26 and titled Guidelines for Notification of Change in Resident's Condition/Status/Treatment documents in part: Intent it is the intent of the facility to ensure that the resident, their attending physician, and the residents responsible party/POA (Power of Attorney) are notified of changes in the residence condition status, or treatment. This notification will be done properly in order to obtain any orders needed for appropriate treatment and/or monitoring related to the change-as well as to promote the resident right related to the right to make choices about treatment and care preferences. Objective: the objective of the notification to the required parties is to provide appropriate and timely information about changes relevant to a residents condition/status or change in room for roommate to those who will make decisions about care, treatment, and preferences to address the changes . Notification is provided to the resident and/or the residents responsible party/POA in conjunction with the resident right to make choices about care and treatment and to keep them informed of the residents current health status- related to the notification. If a residence responsible party/POA he is not able to be reached for notification on the initial attempt, the attempt in all subsequent attempts to make notifications will be documented. Attempts to notify the next listed contact (after attempts to reach the primary contact have been successful) will be made and documented. These should be continued each shift until someone is reached, or until all contacts have been attempted to be reached and are not reachable. These attempts must be documented.The facility's in-service document dated 08/29/26 documents, in part: V1: Topic Discussion: To guardian: guardian must be notified immediately either by call voicemail, e-mail or any form of communication.

Based on interview and record review, the facility failed to ensure one resident (R3) was free from abuse from another resident (R8). This failure resulted R3 being evaluated at the hospital and diagnosed with a closed head injury, sprain of right wrist and sprain of left shoulder. Findings include:According to R3's face sheet, R3 is a [AGE] year-old resident with diagnoses that include but are not limited to polyneuropathy; type 2 diabetes mellitus; heart failure; pulmonary hypertension.According to R3's Minimum Data Set (MDS), 3/20/26, R3 has a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition. R3 is dependent and requires assistance for mobility performance.According to R8's face sheet, R8 is a [AGE] year-old resident with diagnoses that include but are not limited to major depressive disorder; sequelae of unspecified cerebrovascular disease.According to R8's MDS, 2/27/26, R8 has a BIMS score of 12 indicating moderate cognitive impairment.R8's care plan, initiated 12/2/25, reading in part: R8 displays behavioral symptoms related to a history of non-compliance with recommendations from health care professionals, history of or current symptoms for substance abuse, poor and/or ineffective coping skills. Disagreement and conflict with roommate.R8's Screening Assessment for Indicators of Aggressive and/or Harmful Behavior, 12/11/25, reads in part: Potentially able to integrate with structure, direction, and supportive counseling.On 6/2/26 at 11:46 AM, R3 stated, their roommate (R8) assaulted them. R8 slammed R3 on the head with a glass jar of instant coffee. I had a knot on my head. I was sent to the hospital. I got x-rays and an MRI (Magnetic Resonance Imaging). There was no concussion and my skull was intact. I had a major headache. My right wrist is injured. I was trying to block the shots to defend myself. R8 was cussing at my roommate, trash talking to them, I don't remember anything R8 said. I told R8 to leave them the f*** alone. On 6/3/26 at 11:44 AM, R8 said they and R3 just exchanged some words. There was no physical hitting. I did not hit R3 with a jar. If I had hit R3 with a jar they would have been knocked out. I don't know what we were exchanging words about, just mouthing off. Nobody else was in the room. They immediately took me to another room. R3 did not hit me. I don't remember what was said. I went to the hospital, and they sent me back. On 6/3/26 at 12:59 PM, V13 (Registered Nurse) stated I am familiar with R3 and R8. I was their nurse the evening of the incident. I was in the nursing station. I think it was V16 (Certified Nursing Assistant) who told me that R3 and R8 were having an argument. I went to their room to check what's going on. I saw R8 standing arguing with R3. I only saw a verbal argument. I couldn't tell what it was about. I saw it was escalating so I took R8 out of the room. I would interpret a closed head injury as an internal injury resulting from possible trauma to the head. Sprain can also be a result of possible trauma to the joint and cause inflammation but not total dislocation.On 6/3/26 at 3:49 PM, V14 (Physician) stated I am familiar with R3. From the hospital discharge papers that reflect closed head injury, sprain to wrist and shoulder, I think R3 had an altercation, and someone hit their head. It sounds like someone hit R3 and it resulted in a head injury and sprains. It could be physical abuse. A closed head injury and sprains are indicative of physical abuse.On 6/4/26 at 2:48 PM, V1 (Administrator) stated I was called and told R3 was claiming physical abuse by R8. I came to the facility and went to talk to R3. R8 had already been moved to another room. R3 told me that they told R8 to shut up because R8 talks too much. R3 said R8 hit them with a coffee cup.R3's progress note 5/8/26, 4:25 PM, documents in part: Writer called into resident room on seeing the ongoing verbal disagreement. Writer went ahead to separate them. Resident (R3) stated they got into a verbal disagreement with their roommate (R8).R3's progress note 5/8/26 4:45 PM, stricken from record, documents in part: Writer notified of an altercation with their roommate (R8). On assessment, resident noted to have a bump on the back of their head and redness on their wrist. No change to shoulders noted. Resident stated they have pains to their head and shoulders. Ice placed to the back of the head. Orders placed for x-ray of head and shoulders to rule out injury. R3's hospital discharge instructions, 5/8/26, documents in part: Diagnosis: closed head injury, initial encounter; sprain of right wrist, unspecified location, initial encounter; sprain of left shoulder, unspecified shoulder sprain type, initial encounter.R8's progress note 5/8/26 4:28 PM, documents in part: Writer called into resident room on seeing the ongoing verbal disagreement. Writer went ahead to separate them. Resident (R8) stated they got into a verbal disagreement with their roommate (R3). Resident remained anxious and agitated. Resident placed on 1:1 supervision. Medical Doctor notified, orders to send to hospital for psych evaluation.R8's progress note 5/8/26 4:30 PM, stricken from record, documents in part: Writer notified of an altercation with roommate (R3). On assessment, no physical bruising or injury noted. Resident overly agitated and verbally aggressive. Writer tried redirection but no change. Medical Doctor notified, orders to send to hospital.Incident report, 5/8/26, reads in part: Nurse on duty reported that R1 (R3) alleged that they had physical contact from roommate R2 (R8)Facility Abuse Prevention Program, 1/2019, documents in part: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility.

Based on interview and record review, the facility failed to ensure proper discharge planning by not verifying placement and not arranging services for one resident (R4) in a total of 14 residents. Findings include:MDS (minimum data set) with review date of May 4, 2026, BIMS (brief interview of mental status) indicates R4's cognition is intact.Care plan dated 02/18/2026, documents in part, at risk for self-care deficit and required/ potentially requires assistance with ADLs (activity of daily living) to maintain the highest possible level of functioning; use walker for mobility, occupational therapy to screen/ evaluate and treat per order. Physical therapy to screen/ evaluate and treat as indicated per orders. Provide assistance with all ADL's as required per my dependence needs: eating, transferring, bed mobility, bathing dressing, personal hygiene, ambulation and personal hygiene. Eating set up or clean up assistance, oral hygiene partial/ moderate assistance, toileting hygiene partial/ moderate assistance. Shower/ bathe self-partial/ moderate assistance.On 06/02/2026 at 10:39 AM, this surveyor had a phone interview with R4. R4 stated he is currently in Texas since he was discharged from the facility on 04/30/2026. R4 stated V9 (Social Services Director) has been terminated, from his position and no longer works for the facility. R4 stated before V9 left the facility he was supposed to send out all of the required documents to the new facility. R4 stated the facility has not received any medical records. R4 stated he has asked to speak to staff regarding this issue, but no one is available to speak with him. R4 stated he has copies of the XRAY of his knee and arm, but the new facility in Texas is requesting images from former facility in Chicago.On 06/03/2026 at 11:51 AM, V2 (Director of Nursing) stated R4 had an order from the provider to discharge back to the community. V2 stated he spoke with R4's brother who lives in Texas, in which he provided an address, telephone number, and a train station ticket for R4. V2 stated R4 was given all his discharged documents as well as his belongings. V2 stated R4 signed the checklist and did not voice any concerns at the time of discharge. V2 stated R4 has not called this facility requesting any additional documents. V2 stated the facility provided transportation to the train station.On 06/04/2026 at 9:54 AM, surveyor asked V2 if he or anyone had verified the address provided. V2 stated he did not call the phone number that was provided to verify placement. V2 stated R4's brother and R4 both confirmed the address, and they stated it was their home. V2 stated he was not aware that R4 wanted to transfer to another facility. V2 stated there is a process that needs to occur before a resident is discharged . V2 stated a referral must be sent out to the new facility, and then after the acceptance letter received then the interdisciplinary team will meet and discuss any additional services are needed, making sure all goals have been met, referrals are given if needed [NAME] physical therapy, occupational therapy or speech, etc. V2 stated R4 with a referral for the orthopedic for a right wrist fracture, which was included with his discharge documents.On 06/04/2026 at 12:01 PM, V1 (Administrator) stated when a resident is requesting a discharge the interdisciplinary team will have a care plan meeting to discuss the discharge process with resident or responsible party. V1 stated if it is an immediate discharge then the doctor will be called for discharge orders and recommendations. V1 stated if there is enough notice for a discharge, then the interdisciplinary team can determine the residents' needs. V1 stated when a resident is to be discharged to the community, the facility must contact the family member and verify the placement, V1 stated once the placement has been confirmed, the facility will ensure that the residents' needs are met, and that transportation is set up. V1 stated if the resident is interested in a facility-to-facility discharge, the facility must contact the providers for discharge order. V1 stated a referral is sent to the facility, and an acceptance letter is required to move forward with discharge. V1 stated if a resident is discharged with an orthopedic referral, the facility must ensure that the order is sent to the facility, make sure that the insurance will cover the services.On 06/04/2026 at 2:20 PM, V1 (Administrator) stated from his understanding V9 and V2 coordinated the discharge, however he is not sure if V9 verified the address that was provided or arranged any services for the orthopedic consult for R4. V1 states they spoke to the brother because he was the one coordinating the discharge. V1 stated R4's brother provided the address and phone number, R4 was discharged . V1 stated the facility provided R4 with transportation to the train station. V1 stated the facility gave him a rollator to take with him. V1 stated R4 had not called him or left any messages for him.Reviewed physician order sheet, documents in part, outpatient referral to occupational therapy for consultation. Policy titled, Guidelines for discharge/ transfer with review date of 02/202/2025, documents in part, A resident will be discharged / transferred (home or another facility) by order of their attending physician in accordance with the specific state/ federal standard and practice guidelines. All discharge plans will be planned. lower level of care (planned) 1). Discharge instructions are completed when the resident is discharged to home or to another facility. Send face sheet, send advanced directives, send MAR/ TAR, other pertinent information or required information as per state regulation.

Based on observation, interviews and review of records facility failed to provide residents with proper equipment (wheelchair) per therapy recommendation for 1 out of 3 residents (R2) for a total of 3 residents reviewed for activities of daily living. Findings include: R2 is [AGE] years old, initially admitted in the facility on 01/22/2026 medical diagnosis includes stage 5 chronic kidney disease, diabetes mellitus, bipolar disorder among others. R2 cognition is intact with BIMS score of 14. On 06/02/2026 at 01:22 PM, R2 was seen in his room alert and able to express his thoughts clearly and within topic. R2 stated that he has been without a wheelchair since he was initially admitted . R2 stated that he was using specialized chair for all his needs. The chair was seen on the bedside of R2 Per R2's referral dated 01/01/2026 documents that R2 is continually interested in obtaining electric wheelchairs. admission functional assessment and goals dated 01/22/2026 reads: R2 was assessed dependent on staff help on transfers, mobility and needs of wheelchair. On 06/02/2026 at 01:42 PM, V3 (Director of Rehab / Occupational Therapist) stated that R2 is not currently on therapy and does not ambulate. R2 was in therapy from April 22, 2026, and was discharged on May 20, 2026, because he reached his full potential. V3 stated, I think he has manual wheelchair from restorative. V3 stated that R2 was doing very well after being discharged for therapy. On 06/02/2026 at 02:22 PM, V11 (Director of Restorative) stated that R2 is non-ambulatory and uses a specialized wheelchair when getting out of the bed, for dialysis and for locomotion. V11 stated that R2 did not request wheelchair and is not appropriate to use a wheelchair, due to poor trunk control. He cannot sit up straight. V11 stated that he cannot say if an adjustable wheelchair or a wheelchair that can recline it will be appropriate for R2 because he did not test R2 with that equipment. V11 stated, The specialized chair has a cushion that a wheelchair does not have. V11 was asked if R2 can use wheelchair. V11 replied I did not try that if he (R2) can wheel himself. V11 stated that R2 was not assessed for wheelchairs but for the specialized chair. He (R2) never did have manual wheelchair. On 06/03/2026 at 10:19 AM, V3 stated that he needs to clarify about wheelchair of R2. V3 stated that he requested R2 to have a lightweight wheelchair presenting an email communication and correspondence dated 05/20/2026 to 05/26/2026 requesting lightweight manual wheelchair. V3 stated that the specialized chair does not help R2 at all because he does not perform anything when in the specialized chair. Unlike the wheelchair that helps with upper body strength. On 06/03/2026 at 12:08 PM, V2 (Director of Nursing) stated that restorative does functional assessment upon admission. V2 stated that residents that are assessed need DME (Durable Medical Equipment) such as walkers, canes, crutches, wheelchairs facility will order and provide. Upon reviewing R2's functional assessment dated [DATE] date when R2 was admitted . R2 was assessed to use wheelchair. V2 called V11 (Director of Restorative), upon arrival V11 verified R2's functional assessment. V2 stated that the special chairs cannot be used as a means of locomotion while wheelchairs can be used, which is less restrictive. As to R2, he may not be able to use manual wheelchair properly because he needs motorized wheelchair. V2 was made aware that V3 (Director of Rehabilitation) through email requested for a lightweight wheelchair. V2 called V3 who stated upon arrival that R2 will benefit using ultra lightweight wheelchair that is why it was ordered. On 06/04/2026 at 10:15 AM, V2 was asked what the prospective plan for R2's equipment for locomotion. V2 replied that wheelchairs will help R2 to assist him with locomotion. If R2 continues to use the specialized chair it will not help him and may decline. The goal is to help him progress by using wheelchair. He was placed in therapy to help him with his lower and upper extremities. The facility needs to provide equipment if it benefits the residents and needs to be implemented. If he refuses, we will give education because wheelchairs will benefit him compared to using the specialized chair. Per R2's record, he was seen by physical and occupational therapists from 04/22/2026 to 05/20/2026. Per physical therapy documentation reason for discharge on [DATE] of R2 was maximized functional potential. PT reports further read, R2 made consistent progress throughout physical and occupational therapy and has reached maximum potential with skilled services. R2's prognosis current level of function (CLOF) excellent with consistent staff support. Discharge recommendation functional maintenance program (FMP) and restorative nursing program (RNP). R2's community mobility documents wheelchair use, and management. Restorative nursing program to facilitate R2 in maintaining current level of performance to prevent decline. R2's care plan on activity of daily living (ADL) dated 01/23/2026 identified R2 as self-care deficit requiring assistance with ADLs to maintain the highest possible level of functioning. Intervention in the same plan of care is provided R2 assistance with all ADLs due to being dependent including transferring, mobility, ambulation, etc. To provide education on the risk factors associated with refusing to comply with ADL care and/or restorative program. Per Guidelines for Activities of Daily Living (ADL) policy of the facility with no date, it reads:Residents are given routine daily care and health services care by nursing staff. ADL care is provided throughout the day, evening and night as care planned and/or as needed. ADL care is coordinated between the residents and the care givers with emphasis on resident preference as much as possible. ADL includes assisting with movement and ambulation and range of motion (ROM) as indicated and care planned.

Based on review of records and interviews the facility failed to follow reporting procedures of injury of unknown origin or source for 1 out of 3 residents (R8) total sample of 3 residents reviewed for right of every resident to be free from all forms of abuse. These failures are not in accordance with facility's abuse policy applicable to 1 resident (R8) who sustained injuries of unknown origin or source. Finding includes: R8 is [AGE] years old, initially admitted in the facility on 04/10/2018 medical diagnosis dated 07/13/2025, includes metabolic encephalopathy, displaced fracture of anterior wall of right acetabulum, wedge compression fracture of first lumbar vertebra. R8 has impaired cognition unable to perform brief interview of mental status assessment (BIMS) dated 07/28/2025. V28 (Registered Nurse) nursing notes dated 07/08/2025, documents that R8 was transferred to hospital due to weak, pale, difficult to arouse and minimal respond to call. Facility submitted initial transmittal report to State Agency dated 07/15/2025. On that report it documents that R8 returned from the hospital to facility on 07/13/2025. The hospital records include an imaging (CT scan) fracture of the right acetabulum (near hip/pelvis) and compression fracture to vertebral bodies (support of the spine). Facility submitted final report of investigation dated 07/21/2025, without definite conclusion as to how R8 sustained those fractures. Per Minimum Data Set (MDS) assessment dated [DATE], R8 does not walk, uses wheelchair for locomotion and dependent for functional abilities including bed mobility. R8 was care planned as substantial assist on bed mobility, dependent on transfers that needs mechanical (Hoyer) lift, non-weight bearing on right lower extremity and non-ambulatory. On 12/31/2025, at 10:23 AM, V6 (Assistant Director of Nursing) stated R8 went to the hospital because he was difficult to arouse. At that time there was no concern with fall or trauma. R8 went back to the facility on [DATE], that was when facility knew about the fracture based on hospital records. V6 stated that R8's fracture was reported on 07/15/2025, per facility's procedure on timely reporting of resident's injury is within 24-hours when facility knew about the fracture. V6 stated that it should have been reported on 07/14/2025. After checking the calendar, 07/14/2025 falls on Monday. V6 stated there was no determination on how exactly R8 sustained fracture. Abuse Prevention Policy dated 01/2019: Injuries of unknown origin procedure on reporting requires facility as follows: Report shall be made immediately, but no later than two hours after allegation is made. If the event that cause the allegation involve abuse or resulted to serious injury, or not less than 24-hours if the event that cause the allegation do not involve abuse and did not result in serious bodily injury.

Based on review of records and interviews the facility failed to timely and accurately assess 1 out of 3 residents (R8) on identifying pressure injuries and update R8's care plan after the identification. These failures are not in accordance with facility's pressure injury prevention policy guidelines that affected 1 resident (R8) who sustained bilateral heel deep pressure injuries (deep tissue injuries). Finding includes: R8 is [AGE] years old, initially admitted in the facility on 04/10/2018. Medical diagnoses dated 07/13/2025 includes metabolic encephalopathy, displaced fracture of anterior wall of right acetabulum, wedge compression fracture of first lumbar vertebra. R8 has impaired cognition unable to perform brief interview of mental status assessment (BIMS) dated 07/28/2025. On 12/30/2025, at 12:08 PM, V18 (Wound Coordinator / Registered Nurse) stated that R8 was admitted in the facility from the hospital on [DATE], with right and left heel deep tissue injury which is considered as pressure injuries. R8's right and left heels pressure injuries were treated with skin prep and foam dressing to help with the friction. R8 was to use heel protector but was not placed as a physician order and was not placed as an intervention on the care plan. Per V28 (Registered Nurse) dated 07/08/2025, nursing notes documents that R8 was transferred to hospital due to weak, pale, difficult to arouse and minimal respond to call. Hospital records dated 07/08/2025 the same day R8 was transferred from facility to the hospital, R8 was assessed with bilateral heel pressure injury (deep tissue injuries) when admitted to the hospital. R8 returned in the facility per census history on 07/13/2025. On 12/31/2025, at 10:23 AM, V6 (Assistant Director of Nursing) stated that residents need intervention to prevent pressure ulcer. V6 stated that it includes turn every two (2) hours or as needed, barrier cream for skin protection, heel protection, cushion while on the wheelchair, vitamins or supplements, and low air loss mattress. Multiple assessments were reviewed with V6. V6 reviewed R8's BRADEN assessment dated [DATE] (BRADEN assessment is use as a tool to identify risk on predicting pressure injury) it documents that R8 walks occasionally and with slightly limited on bed mobility. V6 said, I know R8, and he is dependent, he does not walk at all. BRADEN assessment is inconsistent with MDS assessment dated [DATE] and care plan of R8. Per Minimum Data Set (MDS) assessment R8 does not walk, uses wheelchair for locomotion and dependent for functional abilities including bed mobility. Per care plan R8 needs substantial assist on bed mobility, dependent on transfers that needs mechanical (Hoyer) lift, non-weight bearing on right lower extremity and non-ambulatory. R8's care plan failed to address right and left pressure injuries (deep tissue injuries). V6 stated that facility does weekly skin assessments as part of preventive measure for all residents to prevent from pressure injuries. V6 said, the purpose of that if the resident has any problem with skin integrity so that we can catch it on time. V6 stated that weekly skin assessment is done for all residents, while weekly wound assessments are done to residents that have wounds. Weekly skin assessment is part of preventive measure for pressure ulcer while we are doing it, we can see if resident has skin problem that we can prevent. V6 reviewed R8's weekly skin assessment of R8 that documents as follows: R8's weekly skin assessments dated 06/06/2025, 06/13/2025, 06/2025, 06/20/2025, 07/02/2025, 07/09/2025, 07/15/2025, 07/23/2025 documents no loss of skin integrity existing or new for all assessment. R8 was assessed by V18 (Wound Coordinator/Registered Nurse) on 07/09/2025 although R8 was not in the facility (on that date). At that time R8 right and left pressure injuries were already identified by hospital on [DATE], which was the date of transfer. After R8 was re-admitted in the facility from the hospital on [DATE]. R8's weekly skin assessments dated 07/15/2025 and 07/23/2025 documents no concern with skin integrity although hospital and facility records document that R8 have left and right pressure injuries. V6 stated, I do not know how they assess R8 on 07/09/2025 when resident was not here, they do not do assessment when resident is not here. That may be an error. As to assessments dated 07/15/2025 and 07/23/2025 I have to ask V18 (Wound Coordinator) about this. Per facility's guidelines for prevention / treatment of pressure injuries dated 10/09/2023: If upon assessment an actual pressure injury is found appropriate treatment and intervention will be added on residents' care plan. Skin assessments will identify other risk factors including existing pressure injuries. Assessments will repeat at least weekly. The Braden Scale will be performed in addition to weekly skin assessments being completed as per policy and regulation. Ensure all assessments are timely and accurate.

Based on observation, interview and records review, the facility failed to provide a safe mechanical lift transfer for one dependent resident (R9), of 5 residents reviewed for transfers out of a total sample of 10 residents. Findings Include:R9's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Cerebral palsy, chronic obstructive pulmonary disease, obesity, muscle wasting and atrophy, hypertensive heart disease without heart failure. Minimum Data Set Section (MDS) section C (dated [DATE]) documents that R9 has an Interview for Mental Status (BIMS) score of 10, indicating that R9 has moderate cognitive impairment. Minimum Data Set Section (MDS) section GG (dated [DATE]) documents that R9 is dependent on staff for transfers. Care plan (dated 12/23/2025) documents that R9 is dependent on staff for transfers and requires a mechanical lift. On 12/30/2025 at 10:21AM, surveyor conducted an interview with R9, a bed-bound dependent resident, pertaining to a fall incident that R9 had on 10/04/2025. R9 stated, On 10/04/2025, V19 (certified nursing assistant) and V26 (licensed practical nurse) were attempting to transfer me from the wheelchair to my bed. The mechanical lift was in front of me, while I was sitting in the wheelchair. All of a sudden, the mechanical lift machine tipped over and fell on my wheelchair, causing my wheelchair to completely tip over and I fell to the ground together with the wheelchair. They did not spread the legs of the mechanical lift appropriately and that's why the fall happened. I did not have any injuries. They sent me to the hospital for evaluation, and everything was fine, no injuries. I don't have any pain. On 12/30/2025 at 10:17AM, V3 (restorative nurse) stated, R9 transfers with a mechanical lift. At least 2 staff members have to be present during the transfer for R9. R9 had a fall 10/04/2025. While staff were transferring the resident from the wheelchair to the bed with a mechanical lift, the mechanical lift tilted while the resident was in the wheelchair and the wheelchair tipped over and fell to the floor. R9 was sitting in the chair when the chair tilted and fell to the floor. R9 did not obtain any injuries. R9 was sent to the hospital for evaluation via 911. R9 had a CT scan in the hospital, and it was negative. When the mechanical lift is being used, the legs must be opened wide, if it is not opened wide and properly, the mechanical lift can tilt. The nurse and the certified nursing assistant were performing the transfer. After the fall, I did an educational training with the nurses and the certified nursing assistants for proper techniques of mechanical lift transfers. I performed a complete fall risk assessment, call light within reach, free of clutter, clean environment. The machine tilting is the reason why R9 had a fall. R9 is dependent on staff for all ADLs. The mechanical lift was inspected after the fall occurred and there was nothing wrong with the machine. On 12/30/2025 at 1:56PM, V19 (certified nursing assistant) stated, On 10/04/2025, V26 (licensed practical nurse) and I were transferring R9 from her wheelchair back to bed with a mechanical lift. I was assisting the nurse. The mechanical lift was being used. The resident was sitting in the wheelchair, and I was holding the mechanical lift, and the nurse was fixing the ears of the sling. I am not sure what happened or what caused the mechanical lift to tilt. During the preparation before the transfer, the wheelchair flipped, and the resident fell together with the wheelchair to the floor. R9 was still sitting inside the wheelchair when the wheelchair flipped. I did not notice any injury on R9. R9's Progress Note (dated 10/04/2025) documents, While staff were transferring the resident from the wheelchair to her bed VIA Hoyer Lift, the Hoyer lift tripped/tilted the wheelchair and the resident's wheelchair fell while the resident was on the wheelchair. Head to toe assessment was completed. The resident is A/O x3, and able to express her needs. Vitals as follows: BP-128/84, P- 84, Temp- 97.5F, Resp 18, oximetry 98% VIA R/A, and no visible bruises or injury noted from the fall. A 72-hours neurological assessment initiated, ROM within the resident's baseline, PERRLA was noted, no C/O pain. Physician group was called and an order to transfer the resident to the nearest hospital VIA 911 for CT-Scan was obtained and carried out. The writer spoke with the nurse practitioner and the director of nursing was made aware of the incident. R9's Progress Note (dated 10/05/2025) documents, The resident was brought back into the facility by 2 paramedics on a stretcher, the resident was transferred to bed and was made comfortable. A/Ox3, vital signs were BP-124/84, P-80, R-16,02-95%RA. No complaints of pain or discomfort. Director of nursing and State Guardian office made aware. Guidelines for Mechanical Lift Transfer/Usage Policy (dated 07/08/2024) states in part: Many residents who require a two-person transfer- will need to be transferred using a mechanical lift. The type of transfer must be the safest method based on the resident's assessed ability to safely assist in their own transfer. Two staff members are required when a mechanical lift is used. Position the lift around the resident's bed/chair/surface. Base legs are usually more stable in full open position. The mechanical lift legs open and close to accommodate wheelchairs.

Based on observation, interview, and record review, the facility failed to record the daily refrigerator temperature log on a personal refrigerator for one (R1) in a total sample of 3 residents reviewed. Findings include: On 12/30/2025 at 11:14 AM, Surveyor observed R1 laying down in his bed while watching television, there were no signs of discomfort or pain. R1 is alert and oriented to person, place and time. Surveyor observed R1's personal refrigerator temperature set to 40 degrees Fahrenheit. Surveyor observed the daily refrigerator temperature log was did not have a temperature or initial documented for several dates on the month of December. Surveyor observed the refrigerator was attached to the wall outlet. Surveyor observed the refrigerator was clean, organized, and there were no odors at this time. On 12/30/2025 at 11:15 AM, R1 stated in the past a complaint was filed about the refrigerator not being attached to the wall outlet, causing the food to get spoiled. R1 stated the staff always says the temperature is at 39 degrees Fahrenheit, but it is never recorded. R1 stated housekeeping should come every day to check the temperature in the refrigerator to prevent the food getting spoiled. On 12/30/2025 at 11:41 AM, V10 (Registered Nurse) stated housekeeping is responsible for ensuring that the refrigerator temperature is approximately 39-40 degrees Fahrenheit. V10 stated there is a log attached to the refrigerator, and it is expected to be recorded every day. Surveyor asked V10 what can potentially happen to the food inside the refrigerator if the temperature log is not being recorded per facility policy. V10 stated the temperature should be checked and documented daily. On 12/30/2025 at 2:05 PM, V21 (Housekeeping Director) stated housekeeping staff is responsible for making sure the refrigerator is clean, sanitized, organized, and temperature is documented every day. V21 stated the refrigerator should be at approximately 35-40 degrees Fahrenheit. Surveyor asked V21 what can potentially happen to the food inside the refrigerator if the temperature log is not being recorded per facility policy. V21 stated the food can get contaminated if the temperature is not at the expected temperature range. V21 stated the temperature should be recorded daily to avoid exposure to residents getting sick for eating potential spoiled food. On 12/31/2025 at 10:15 AM, surveyor observed R1's refrigerator temperature thermostat, it was at 39 degrees Fahrenheit. Survey observed inside R1's refrigerator, it was clean and organized and there were no odors noted. There was no refrigerator temperature recorded on the daily refrigerator temperature log. On 12/31/2025 at 10:19 AM, V25 (Housekeeping) stated she is responsible for making sure residents' personal refrigerator is kept clean. V25 stated she makes sure to monitor the temperature, and document it on the refrigerator temperature logs every day. V25 stated the temperature should be set to approximately 39- 40 degrees Fahrenheit. Surveyor asked V25 what can potentially happen to the food if the temperature is not being recorded daily. V25 stated the food will get contaminated causing the resident to get sick. Policy titled Unit (Resident Room) Refrigerators with no review date documents in part It is the policy of the facility to assure that perishable food requiring refrigeration is stored at the proper temperature. Each refrigerator will be provided with a thermometer to ensure that the refrigerator is maintained between 35 degrees and 40 degrees Fahrenheit. Refrigerator temps will be checked and documented daily. Policy titled Food Brought into the Facility by Friends/Family/Others (Outside Sources)For Residents Policy with review date 11/28/2016 documents in part Facility staff will monitor resident rooms, resident personal refrigerators, unit pantries as well as facility refrigerators and freezers for food and beverage disposal needs for safety.

Based on interview and record review, the facility failed to ensure that menus are followed when staff did not use the appropriate utensil to serve/plate the food. This deficient practice has the potential to affect all residents that receive meals from the kitchen.Findings include:On 9/28/2025 at 11:16 AM, V15 (Traveling Chef Manager) said, yesterday I observed kitchen staff not following the menu. They were not using the appropriate utensils to plate food. I told them that they must follow the menu and use the appropriate utensils to plate food.On 9/28/2025 at 12:08 PM, R14 said, a lot of the times, the portions are small like what you would feed to a toddler.On 9/28/2025 at 11:58 AM, R4 said food portions are small.On 9/28/2025 at 2:28 PM, R12 said food portions are small.On 9/28/2025 at 4:15 PM via telephone, V4 (Psychiatric Rehabilitation Service Coordinator/PRSC) said, they (the residents) always complain about the food. There's new staff in the kitchen. The portions look small, but I don't know.On 9/29/2025 at 12:25 PM via telephone, V22 (Registered Dietitian) said, I have heard from residents that portions are small. It could be a problem (if the appropriate utensils are not used to plate food). Residents may not get the proper nutrition or protein. That could lead to residents not getting the right amount of calories and protein which could lead to weight loss. 8/27/2025, Resident Council Meeting Minutes documents: residents requested larger portion sizes.Policy related to plating of food requested, not received at time of survey.

Based on observation, interview, and record review, the facility failed to a.) monitor the call light system and answer call lights within a timely manner for two residents (R1, R5), b.) provide incontinence care for two (R5, R8) residents, and c.) ensure one (R1) resident have access to their personal belongings. These failures affect three residents in a sample of six residents reviewed. Findings include:1.) On 09/26/2025 at 1:20PM, R1 states when he pulls his call light string, it is connected to a light switch and the switch remains in the same position when he activates his call light. R1 states it takes staff a long time to answer his call light, and he's waited up to 30 minutes for someone to answer his call light. R1 states he was recently transferred to his current room and his heart monitor was left in his old room. R1 states he informed V4 (Psychiatric Rehabilitation Service Coordinator/PRSC) that he was missing his heart monitor, which looks like a cell phone, and is black in color. R1 states V4 told him that she would go and look for his heart monitor, but V4 never returned or followed up with him about this matter.On 09/27/2025 at 11:16AM, V4 (Psychiatric Rehabilitation Service Coordinator/PRSC) states she remembers R1 telling her about his missing heart monitor about one to two days ago. V4 states she spoke to the nurse and CNA (Certified Nursing Assistant) staff on the (XXX) floor and asked them the location of R1's belongings. V4 states she does not recall which nurse or CNA she spoke with, but they were unaware of where R1's belongings were. V4 states she never asked staff on the (YYY) floor the location of R1's belongings because she wanted the staff on the (XXX) floor to go and find R1's belongings. V4 states when R1 experienced a room change, she expected the staff to take all R1's belongings to his new room. V4 states she did not know that R1 had a heart monitor and does not know what it looks like. V4 states she has not followed up with the matter of R1's missing heart monitor. Record review documents that R1 was transferred to his new room on 08/22/2025.R1's progress note dated 08/30/2025 at 2:33AM documents Received a [AGE] year-old African American male, readmitted from hospital with Dx: of bradycardia. R1 arrived on the stretcher accompanied with two EMTs at approximately 8:40 pm. R1 is A&OX3 (alert and orientated), able to make needs known. Head to toe assessment was completed, Skin is intact. Vitals sign are as follows BP 117/78 P 69 T 97.7 R 16 SPO2 97% room air. No s/s (signs and symptoms) of discomfort or distress noted. Denied pain at this time. R1 has a left-side implantable Loop Recorder for one year now. ER (Emergency Room) nurse reported that the loop recorder interrogation was completed by the device company, no abnormality or blockage were noted. R1 is advised to avoid Beta Blockers. All medications were verified and confirmed with Dr (doctor). and order received to continue with medications from the hospital. Noted and carried out. R1 on regular heart diet. DON/ADON (Director of Nursing/Assistant Director of Nursing) made aware. R1 is lying comfortably in bed, fall precautions are maintained per facility policy, call light placed within reach. plan of care ongoing.During record review, R1's inventory list dated 09/10/2025 does not document that R1's heart monitor was inventoried in the facility. There is no documentation to show that R1's personal items and clothing were inventoried upon admission on [DATE] or when R1 was hospitalized on [DATE].During record review of R1's inventory sheet on 09/27/2025 at 10:42AM, the CNA and nurse's name is not legible to read. Surveyor then asks V2 (DON) if he is aware of who completed and signed R1's inventory sheet. V2 states the form is also not legible for him to read.2.) On 09/26/2025 at 1:05PM, R5 states about two weeks ago, he pressed his call because he was soiled and needed to have his incontinence briefs changed. R5 states this incident occurred at approximately 4:00PM and facility is terrible at answering the call lights during the 3:00PM to 11:00PM shift. R5 states he waited approximately 1.5 hours to have his incontinence briefs changed. R5 states by the time V5 (CNA) came to change his incontinence briefs, he was already on the phone with the state agency reporting the incident.On 09/26/2025 at 2:04PM, surveyor exits the elevator and is located on the (YYY) floor of the facility and hears an audible call light sound. At 2:06PM, surveyor located at the (YYY) floor nurses' station and observes that R5's call light is illuminated. Surveyor observes V10 (CNA) sitting in a chair at the nurses' station facing the call light system. V10 has her cell phone in her hand and observed looking down and scrolling on her phone. Once V10 observes surveyor, V10 puts her phone away, gets up out of the chair, and begin walking away from the nurses' station.On 09/27/2025 at 12:44PM, V5 (CNA) states about two weeks ago, he was assigned to care for R5 during the 3:00PM to 11:00PM shift. V5 states R5 pressed his call light, and he went to R5's room to see what R5 needed. V5 states R5 informed him that he was soiled and needed to be changed. V5 states he told R5 he would be back to assist him soon. V5 states when he left R5's room, the was approached by another colleague who informed him that it was his turn to monitor another resident for 1:1 monitoring. V5 states he made a mistake by not updating R5 because he forgot. V5 states after performing his 1:1 monitoring for the other resident, he saw that R5's call light was illuminated. V5 states when he went inside of R5's room, R5 was on the phone with the state agency and complained that he had to wait 4 hours to be changed. V5 states R5 did not wait 4 hours to be changed and instead, only waited 1 hour to be changed. V5 states he apologized to R5 and then changed R5's incontinence briefs. 3.) On 09/26/2025 at 2:09PM, R8 observed sitting in a wheelchair in the (YYY) floor hallway wearing a gown. R8 states he has been asking staff to take him to the bathroom for the past 30 minutes and no one has taken him yet. On 09/26/2025 at 2:11PM, V8 (Licensed Practical Nurse/LPN) states it is unacceptable for a CNA staff member to be using their cell phone and ignoring a resident's call light. V8 states even if a resident is not assigned to a particular CNA, it is still everyone's responsibility to answer all resident's call lights. V8 states it's important to answer resident call light due to the potential of there being an emergency. V8 states she was just made aware of R8 needing to use the restroom. Surveyor observes V8 (LPN) instruct V10 (CNA) to assist R8 to use the restroom. V10 is observed transporting R8 via wheelchair away from the nurses' station. On 09/26/2025 at 2:19PM, V10 observed transporting R8 back to the nurse's station. R8 then states V10 never took him to the restroom and brought him right back to the nurse's station. R8 states he still needs to use the restroom, otherwise he will urinate on himself.Facility policy undated, titled Call Lights documents in part, It is the policy of the facility to have a system in place to allow the staff to respond promptly to a resident's call for assistance. Procedure: 2. Call lights are to be answered promptly by staff who see that the call light has been activated. 6. Answer the call light in a prompt, courteous manner; turning off the call light upon entrance to the room. 7. NEVER TURN OFF A CALL LIGHT THEN FAIL TO SEE THAT THE RESIDENT'S REQUEST WAS ADDRESSED.Facility policy undated, titled Incontinence Care documents in part, It is the policy of the facility to ensure that residents receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with routine daily care.Facility policy undated, titled Resident Personal Clothes and Belongings Handling documents in part, Procedure: upon admission and annually the following will be done: Personal belongings are to be listed as well.When a resident is transferred to another room, nursing staff and housekeeping staff will transfer the resident's clothing and belongings.

Based on observation, interview, and record review the facility failed to follow their policy to ensure a safe and healthy living environment for the 59 residents residing on the third floor.Findings include:8/21/25 at 12:36 PM, Survey team smelled cigarette smoke inside a resident room. Survey team had recently left the room less than five minutes prior. R1 had just gone into the room from talking to surveyors in the hallway and did not smell of cigarette smoke. 8/21/25 at 12:38 PM, while observing R11s room, survey team observed cigarette butts on the floor next to R11s bed. 8/26/25 at 11:48 AM, V9 (Assistant Director of Nursing) stated smoking is not allowed in the building. I have been here four months. I have not witnessed residents smoking in the facility. No staff has notified me of seeing residents smoking. If a resident is caught smoking, they would be put on pass restriction, we notify the physician, family, social service, Administrator, Interdisciplinary team. Incase smoke is smelled in the room; we check where the smell is coming from. Two staff, including social service search resident pockets and room for cigarettes and lighter, any smoking material. R11 allowed us to search his pockets and room. No smoking material was found. If staff witness smoking in the facility, they immediately notify management so smoking materials are taken away and we educate the resident. 8/26/25 at 1:33 PM, V15 (Social Service Director) stated smoking is not allowed in the building. It creates an unsafe atmosphere. It's an Illinois law that prohibits smoking in and 15 feet from the doorway of a public building. We have oxygen in the building. Smoking in the facility is not allowed to keep residents and staff safe. R11 is a smoker. We observed old cigarette butts under R11s bed, at least two. R11 claimed they did not smoke in the building, that the butts must have fallen from their pockets. If staff catch a resident actively smoking inside the building, they should make supervisor, Administrator, Social Service aware and call a code for help. 8/26/25 at 2:10 PM, Observed R11 in the hallway headed to the front area of the facility in his wheelchair. R11 said R11 does smoke. R11 said R11 used to smoke inside the facility until the facility told R11 not to.R11 care plan reads in part: R11 is a smoker and have been non-compliant with smoking policy and use of substances while a resident of the facility. R11 violated the smoking agreement by being found and witnessed to smoke marijuana at facility premises on multiple occasions.Facility Smoking Safety Policy, 10/5/2015, reads in part: Policy Objective, To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. It is also the objective of this policy to communicate to each resident that they are responsible for following each rule and on-going compliance with this policy. Guidelines, 1. Smoking is only allowed in designated areas established by management. If indoor smoking is prohibited by state or local law the interior of the facility will remain smoke-free at all times. The designated area(s) will be outside in accordance with state/local standards.

Based on observation, interview and record review the facility failed to ensure the resident the right to free of abuse for one (R2) of three residents included in a sample of 8 who was physically assaulted by R1, resulting in R2 sustaining a laceration to the top of head requiring 8 staples. Findings include: R1 is a [AGE] year old male with a diagnosis including Pulmonary Disease , Diabetes 2 , Heart Failure and Low Back Pain. R1 was first admitted to the facility on [DATE] and was discharged from the facility on 7/1/25. R1 has a BIMS ( Brief Interview Of Mental Status ) Score of 15/15 . R1 is care planned for including abuse potential resulting from 6/30/25 incident where R1 and R2 got into an argument with no physical contact, and on 7/1/25 where there was an altercation between R1 and R2 with physical injury to R2 . R1 was first admitted to the facility on [DATE]. R2 is a [AGE] year old male with a diagnosis including Parkinsons Disease , Dementia , Bi Polar Disorder and Repeated Falls . R2 was first admitted to the facility on [DATE] R2's BIMS ( Brief Interview Of Mental Status ) score of 15/15. R2 is care planned for abuse potential based on 6/30/25 and 7/1/25 incident. On 7/3/25 at 9AM R2's head was observed with V2 (DON). A 3.2 CM (centimeter) laceration with 8 staples was observed on top of head. On 7/2/25 at 10:45AM R2 stated, I was out smoking and R1 came up and sprayed me. I fell down and hit my head on the metal side of bench. I couldn't see. There was 15-people out there when this happened. I got 8 staples at the hospital. I don't know where he got the [NAME] from. We also had an altercation in the dining room that happened the night before on 6/30/25. The nurse stopped the altercation right away in the dining room the day before the smoking patio incident. R1 accused me of wearing his shoes. I never touched his shoes. I found them under his bed. I am ok and feel safe now since the incident. I don't see R1 here and heard he isn't coming back. On 7/2/25 at 10:54AM V1 (Administrator) stated, I am the abuse prevention coordinator. R1 and R2 got in altercation in the dining room on 6/30/25. They had an argument and were separated. V5 (Nurse) was there. On 6/30/25, R2 was moved to another room upon agreement of R2. We increased monitoring of both residents. Yesterday (7/1/25) there was a code gray called. I went out to smoking patio. I saw R2 was by edge of patio. R1 was on the bench 5 feet away. R2 had blood on head. R1 had no injury and was sitting on bench. I called the nurse to take care of R2. Nurses applied first aid while I stayed there with R1. R1 said he was having trouble breathing because he has COPD. Am ambulance was called for both of them per doctors order. R1 was presented with an IVD (Involuntary Transfer or Discharge) for emergency discharge. I went to the hospital to have R1 sign Notice of Involuntary Transfer or Discharge and Opportunity for Hearing. He requested his belongings. I went back to facility and got those belongings. I brought the belongings the same day. R2 was just readmitted to facility. R2 has stitches on his head. R1 sprayed [NAME] and pushed R2. R1 went out on pass on 7/1/25 and I think that is how he got the [NAME]. On 7/2/25 at 1:10PM V8 (RN) stated, I was on floor Code gray (Fight) was called on patio. Everybody rushed out. R2 was bleeding on head we assisted him. First aid was given, 911 called. Both were alert and oriented. R1 stated he couldn't breath, we gave oxygen. 911 arrived. On 7/2/25 at 1:13PM V9 (LPN) stated, I went to patio after a code gray was called out on patio. I cleaned out the cut approximately 1.5 inches. We put a steri strip on it and covered with clean gauze. I am not aware that he was sprayed with [NAME]. I didn't treat his eyes. I helped the other nurse tend to the cut on top of R2's head. On 7/2/25 at 1:30PM V10 (Physician) stated, yes I was the doctor that the facility contacted on the R1, R2 incident. R2's injury to the top of the head is consistent with hitting the head on a metal part of the bench after being pushed. I am not aware of the [NAME] being sprayed into R2's eyes by R1. I saw R2 yesterday after he came back from the hospital and he didn't complain of any eye discomfort. His eyes were clear and had no visible sign of injury. On 7/3/25 at 1:0PM R9 stated, I was out on smoking patio on 7/1/25 when R1 started an argument with R2 . R1 stood up and got in R2's face . R2 went to push R1 back away and R1 then sprayed R2 with [NAME] in the face. R2 covered his eyes and fell hitting his head on the bench. The staff came to the area and cleared everyone out. That is all I know. R2 hospital record dated 7/1/25 shows diagnosis of laceration of scalp , initial encounter. Facility policy titled Abuse Prevention Program Revised 3/1/21 shows It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility.

Based on interview and record review, the facility failed to administer intravenous (IV) antibiotic medication as ordered by Physician for one (R3) resident with diagnosis of Osteomyelitis. This failure affected one (R3) of three residents reviewed for pharmaceutical services. The findings include: R3's admission record showed admit date on 6/12/2025 with diagnoses not limited to Osteomyelitis, Paraplegia, Depression, Bipolar disorder, Anxiety disorder, Essential (primary) hypertension, Neuromuscular dysfunction of bladder, Neurogenic bowel, Contact with and (suspected) exposure to other viral communicable diseases. MDS (Minimum Data Set) dated 6/19/2025 showed R3's cognition was intact. On 6/25/25 at 11:58AM Observed R3 sitting up on bed, alert and oriented x 3, verbally responsive, appears comfortable, with multiple wounds on both lower legs. He said he was admitted to the facility on [DATE] between 4-5pm for IV antibiotic treatment due to wound infection on sacral area. R3 stated he was on IV Meropenem 3 times per day and IV Vancomycin 3 times per day. He said he was supposed to get IV Vancomycin on the day he came to the facility on 6/12/25 and the following day 6/13/25 but he did not get it, and he missed a total of 4 doses. R3 said IV Vancomycin was started on 6/14/25 and he completed IV antibiotic treatment on 6/20/25. On 6/26/25 at 11:40 AM, V2 (DON / Director of Nursing) stated he has been in the facility for about nine years. He said R3 should continue the IV ABT (antibiotic) Vancomycin as ordered by the physician upon admission. V2 stated it is important to administer the medication, the potential effect is that the cycle will be incomplete and the ABT (antiboitic treatment) may not treat the infection as prescribed by the physician. V2 stated that the IV Vancomycin was available in the (automated medication and supply management system) and it should have been administered or a call to the pharmacy could have taken place for a STAT (emergency) order to be delivered. V2 said per MAR (Medication Administration Record) Vancomycin IV was not administered on 6/12/25 and 6/13/25, it was started on 6/14/25. R3's hospital records (summary of discharge medications) dated 6/12/25 showed order not limited to: Vancomycin 1gm inject into the vein every 8 hours for 7 days. End of treatment 6/17/25. Schedule: 12AM, 8AM, and 4PM. Last dose given on 6/12/25 at 10:37AM. R3's order summary report dated 6/25/25 showed order not limited to: Vancomycin HCl Intravenous Solution Reconstituted 1 GM (gram) (Vancomycin HCl) Use 1000 mg (milligrams) intravenously every 8 hours for antibiotic for 7 Days 1000mg into vein every 8 hours. Order date 6/13/25. R3's MAR (Medication Administration Record) showed Vancomycin HCl Intravenous Solution Reconstituted 1 GM (Vancomycin HCl) Use 1000 mg intravenously every 8 hours for antibiotic for 7 Days 1000 mg into vein every 8 hours. Schedule time at 6AM, 2PM and 10PM. IV Vancomycin was signed as given or started on 6/14/25 and was completed on 6/20/25. R3's Nursing Progress Note by V6 (Licensed Practical Nurse / LPN) dated 6/12/2025 showed in part: R3 admitted to facility in stable condition with Contact Isolation, wound all over his body and big wound in the sacral area. R3 came with a PICC line one lumen in the right arm for IV antibiotic. R3's progress notes reviewed and did not reflect that IV Vancomycin was given on 6/12/25 and 6/13/25. R3's care plan dated 6/13/25 showed in part: IV meds (medications). R3 has PICC (peripherally inserted central catheter) line on right arm related to wound infection. Administer medication as ordered. Facility's pharmacy delivery schedule and cut off times information (an automated medication and supply management system) showed in part: STAT as requested 2-4 hour turn around. Facility's list of medications available in the cubex showed but not limited to: Vancomycin 1gm, Vancomycin 500mg, Vancomycin 750mg, Vancomycin 125mg, Meropenem 500mg. Facility's Drug Administration - general guidelines policy (undated) showed in part: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by personas legally authorized to do so. Medications are prepared, administered, and recorded only licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations. Medications are administered in accordance with written orders of the attending physician. The resident's MAR is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose administration. Facility's physician order policy (undated) showed in part: It is the policy of the facility to follow the orders of the physician.

Based on observation, interview, and review of records, the facility failed to ensure that smoking was done in required designated area. These practices are not in accordance with their policy and State laws and can affect all 144 residents living in the facility as it pertains to their safety and comfort related to smoking effects. Findings include: On 06/17/2025, at 11:18 AM, R3 stated that residents are smoking inside their rooms, common restrooms, shower rooms and other areas not designated for smoking. R3 stated that it is a continuing problem that affects other residents when inhaling cigarettes strong odor. Inside another resident's room, R5 stated that he smelled strong cigarettes odor upon entering the common restroom on the floor. R6 who was outside of R5's room, stated that it is a continuing problem that needs to be addressed. R3 accompanied writer to the common restroom and showed the writer the wall filed with cigarettes marking. When R3 opened the door, a strong odor of cigarettes was smelled. Just outside of the restroom was a crash cart with an oxygen tank attached to the cart. R3 stated that residents are affected by other smoking and he is experiencing breathing problems due to inhaling cigarette smoke. At the nurse station, V3 (Certified Nursing Assistant) was requested to go to the restroom. Upon opening V3 stated Yes, I can smell cigarettes. V3 Went back to the nurse's station and informed V4 (Licensed Practical Nurse) who went to the restroom. Upon opening the door of the restroom, V4 stated, You are right, someone smokes in here. V4 stated that he will notify his supervisor and an investigation will be done about the incident. V2 (Assistant Director of Nursing) who was at the nurse's station was notified. V2 went to the restroom, opened the door, with a strong cigarette odor. V3 pointed to V2 and observed the wall filled with cigarettes marks. After seeing the cigarettes marks on the wall ,V2 said, It is there, I cannot deny that. V3 pointed to V2 and observed an oxygen tank near the restroom. V2 stated, Yes, they should not smoke near oxygen tank. Residents are not allowed to smoke inside the restroom. V1 (Administrator) was made aware about residents smoking in the restroom with an oxygen tank located near the restroom. V1 stated that residents are not allowed to smoke in the restroom and they (residents) are only allowed to smoke in designated areas. Facility Smoking Safety Policy dated 10/05/2015, notes the facility must provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff members, and visitors. It is also the objective of this policy to communicate to each resident that they are responsible for following each rule and on-going compliance with this policy. Smoking is only allowed in designated areas established by management. If indoor smoking is prohibited by State or local law, the interior of the facility will remain smoke-free at all times. The designated area(s) will be outside in accordance with State/local standards. Public Act [PHONE NUMBER] and Smoke Free Illinois Act both prohibits indoor smoking or similar acts. Smoke Free Illinois Act dated 01/01/2008 reads: The General Assembly finds that tobacco smoke is a harmful and dangerous carcinogen to human beings and a hazard to public health. Secondhand tobacco smoke causes at least 65,000 deaths each year from heart disease and lung cancer according to the National Cancer Institute. Secondhand tobacco smoke causes heart disease, stroke, cancer, sudden infant death syndrome, low birthweight in infants, asthma and exacerbation of asthma, bronchitis and pneumonia in children and adults. Secondhand tobacco smoke is the third leading cause of preventable death in the United States. Illinois workers exposed to secondhand tobacco smoke are at increased risk of premature death. An estimated 2,900 Illinois citizens die each year from exposure to secondhand tobacco smoke. Also finds that the United States Surgeon General's 2006 report has determined that there is no risk-free level of exposure to secondhand smoke; the scientific evidence that secondhand smoke causes serious diseases, including lung cancer, heart disease, and respiratory illnesses such as bronchitis and asthma, is massive and conclusive; separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate secondhand smoke exposure; smoke-free workplace policies are effective in reducing secondhand smoke exposure; and smoke-free workplace policies do not have an adverse economic impact on the hospitality industry. Further finds that the Environmental Protection Agency has determined that secondhand smoke cannot be reduced to safe levels in businesses by high rates of ventilation. Air cleaners, which are capable only of filtering the particulate matter and odors in smoke, do not eliminate the known toxins in secondhand smoke. The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) bases its ventilation standards on totally smoke-free environments because it cannot determine a safe level of exposure to secondhand smoke, which contains cancer-causing chemicals, and ASHRAE acknowledges that technology does not exist that can remove chemicals that cause cancer from the air. A June 30, 2005, ASHRAE position document on secondhand smoke concludes that, at present, the only means of eliminating health risks associated with indoor exposure is to eliminate all smoking activity indoors. (Source: P.A. 95-17, eff. 1-1-08.) Healthcare Facility means an office or institution providing care or treatment of diseases, whether physical, mental, or emotional, or other medical, physiological, or psychological conditions, including, but not limited to, hospitals, rehabilitation hospitals, weight control clinics, nursing homes, homes for the aging or chronically ill, laboratories, and offices of surgeons, chiropractors, physical therapists, physicians, dentists, and all specialists within these professions. Healthcare facility includes all waiting rooms, hallways, private rooms, semiprivate rooms, and wards within healthcare facilities. The act prohibits smoking including a minimum distance of 15 feet from entrances, exits, windows that open, and ventilation intakes that serve an enclosed area where smoking is prohibited.

Based on observation, interviews and review of record the facility failed to re-ordered medication on a timely manner for 1 out of 3 residents (R2) reviewed for pharmaceutical services. This practice is not in accordance with their policy and may affect 1 resident (R2) in ensuring pharmaceutical supplies are available to meet the needs of resident. Findings include: R2 is [AGE] years old, initially admitted on [DATE], with medical diagnosis of diabetes mellitus, multiple sclerosis and cerebral infarct. On 06/17/2025, at 10:52 AM, R2 was seen in her room alert and verbally able to express her thoughts well. R2 stated that she does not receive all her medications including eye drops and medication for diabetes. At the nurse's station with V5 (Registered Nurse) all of the medication for R2 in the medication cart was reviewed. After review, there were three (3) medicines that are not available: Glipizide (for diabetes), Metformin (for diabetes) and Trazodone (antidepressant). V5 stated that she just re-ordered Glipizide and Metformin medicines today to the pharmacy. V5 stated that when medication in the bingo card reaches dark colored area it needs to be re-ordered. V5 showed the bingo card that dark blue color once it reaches eight (8) medicines left. V5 re-stated that it needs to be re-ordered to the pharmacy once eight (8) medication left. On 06/17/2025, at 10:50 AM, V2 (Assistant Director of Nursing) stated that nursing staff need to re-order medication on time to ensure medications are available to meet their needs. V2 stated that dark blue area on the bingo card is an indicator that medicine needs to be re-ordered. R2's medication administration record (MAR) on blood sugar monitoring document that R2 have elevated results in certain days. Ordering Medications Policy without a date reads that medications are ordered from the pharmacy on a timely basis. And instructs facility staff to requests for a refill to the pharmacy 72 hours prior to the last dose.

Based on interview and record review, the facility failed to follow the facility policy for smoking safety and failed to ensure that residents are not smoking inside a shared residents' room near oxygen equipment where oxygen is in use which affected 5 residents (R2, R7, R8, R9 and R10) of 12 residents reviewed for odors from smoking within the facility. This failure resulted in R10, who uses nasal cannula oxygen from an oxygen tank, experiencing psychosocial harm from sharing a room with R4 who was found on 5/31/25 by staff with a lit, half smoked cigarette in their shared room with visible smoke in the air and on 6/1/25 when R10 smelled cigarette smoke in their shared room, alerted staff, and staff confiscated a box of 14 cigarettes from R4's dresser drawer. Subsequently, R10 was transferred to a different room on the floor. Findings include: On 6/4/25 at 11:00 AM, R10 observed laying in bed with oxygen infusing at 3 liters/minute (L/min) via nasal cannula from an oxygen tank positioned upright in a holder on the side of R10's bed. R10 stated that R10 was admitted from another long-term care facility on 5/30/25 wearing the nasal cannula oxygen and that R10 wears continuous oxygen due to respiratory failure. R10 stated that R10 was admitted to the room at the end of the hallway where R10 resided with R4, R5 and R6. R10 stated that R10 witnessed R4 and R5 smoking in their shared room and also smelled smoke coming from their shared bathroom. R10 stated, Yes, I saw them smoking. I can smell it. I am a non-smoker. R10 stated that R10 cannot be around people smoking due to being on oxygen. R10 stated, That's why they (staff) moved me out of the room, but it was the next day (6/1/25). R10 stated that being close to R4 who was smoking cigarettes and R10 who uses continuous oxygen, R10 stated, I felt terrible. It was definitely hard on me. It's dangerous. They could have blew me up. R10 stated that staff didn't move me when I told them (5/31/25) and that the staff moved R10 away from R4 on 6/1/25 after R4 did it (smoked in their room) again. R10's admission Record documents, in part, diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, sequala of cerebral infarction, polyosteoarthritis, atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation, peripheral vascular disease, chronic systolic (congestive) heart failure, ischemic cardiomyopathy, hyperlipidemia, occlusion and stenosis of bilateral carotid arteries, chronic kidney disease stage 3, chronic obstructive pulmonary disease, type 2 diabetes mellitus, Chron's disease, and intestinal obstruction. R10's Census List documents, in part, that on 5/30/25 at 3:30 PM, R10 was active status as actual admission to the shared room with R4, R5 and R6. R10's Room Change to a different room on the same floor was effective on 6/1/25 at 12:00 PM. In R10's Progress Notes, dated 5/30/25 at 4:46 PM, V21 (LPN) documents, in part, Writer received a new resident from (another long term care facility) via stretcher, escorted by 3 EMT (emergency medical technician) staff, the resident is A/Ox3 (alert and oriented times three), able to express (R10's) needs . MD (medical diagnoses): acute respiratory failure with hypoxia . oxygen 98% (saturation percentage) via nasal cannula 2L (liters). Medication was confirmed by NP (V29, Nurse Practitioner). In reviewing R10's Order Summary Reports, an order (dated active on 5/31/25 and discontinued on 6/4/25) is noted to apply oxygen per nasal cannula whenever needed (PRN) and check for oxygen saturation every shift; and an order (dated active on 6/4/25) is noted to apply oxygen 3 L/min PRN and check for oxygen saturation every shift, as needed for shortness of breath. R10's Smoking Evaluation, dated 6/2/25, documents, in part, that R10 does not use smoking, tobacco or nicotine products. On 6/3/25 at 11:28 AM, R4 observed in room in R4's assigned bed which is closest to the outer wall with windows. R4 stated that R4 is a smoker and that R4 now has to go outside to smoke during the scheduled smoking breaks on the smoking outdoor patio. R4 stated that the facility staff provide R4 with cigarettes and the staff will light the cigarette on the patio. R4 stated that R4 used to go out by R4's self with no staff when R4 had a green pass. R4 stated that R4 doesn't know how R4 lost the green pass privileges but is currently on red pass. R4 stated that a nurse or CNA will take R4 out to smoke, usually in the morning around 8 am, and later in the evening, besides smoking during the 3 designated smoke breaks. When asked if R4 smokes inside R4's shared room, there was a long pause from R4 as R4 is looking at this surveyor. This surveyor then asked the question again, and R4 stated, Yes, I do. I'm not gonna lie. I know I'm not supposed to. R4 stated that when R4 does smoke cigarettes inside the shared room, R4 will blow the exhaled cigarette smoke out of the open window. R4 stated that R4 uses a water cup to put out the cigarette to stop from continuing to burn. R4 pointed to the ½ filled water cup (clear, plastic) observed in the room on R4's table, and R4 stated Safety first with the water. When asked if any other residents have smoked with R4 in the shared room with R4, R4 stated, Yes, but (R4) is not gonna name any names. R4 stated that R4 also smokes inside the shared bathroom because, it's safe in there. R4's admission Record documents, in part, diagnoses of nicotine dependence, chronic obstructive pulmonary disease, hypertensive heart disease without heart failure, type 2 diabetes mellitus, glaucoma, hyperlipidemia, hypertension, schizoaffective disorder bipolar type, pure hyperglyceridemia, weakness, need for assistance with personal care, abnormalities of gait and mobility, unsteadiness on feet, major depressive disorder recurrent, violent behavior, and schizophrenia. R4's Census List documents, in part, that on 4/15/25 at 4:04 PM, R4 was active status as actual admission to R4's current shared room, and R4 has not been moved to a different room since admission. In R4's Smoking Evaluation, on 4/18/25, V4 (Social Services Director, SSD) documents, in part, that R4 uses smoking, tobacco, and nicotine products and that R4 does not have a desire to stop smoking. In R4's Smoking Evaluation, on 5/2/25, V4 documents, in part, that R4 engaged in unsafe smoking behaviors. No Smoking Evaluation is noted for R4 on 5/31/25 or 6/1/25. In R4's Community Survival Skills Assessments, dated 5/2/25, V4 documents, in part, that R4's green pass was revoked for a 14 day restriction, and on 5/16/25, V4 documents, in part that R4's green pass in reinstated. In R4's Community Survival Skills Assessments, dated 5/28/25, V9 (Psychiatric Rehabilitation Services Coordinator, PRSC) documents, in part, that R4 violated the facility's smoking policy and that R4's pass level was changed from green to red for the next 14 days. R4's Order Summary Report documents, in part, an active physician order for RED pass for 14 days dated 5/29/25. R4's Resident Behavior Contract, signed by R4 and dated 5/28/25, documents, in part, that R4 agrees to allow staff to check/search R4's room for contraband, such as hidden cigarettes, lighters, or matches, at the staff's discretion; that R4 agrees to only smoke in the designated area at the designated times; and that R4 will immediately turn over all smoking materials if so requested. R4's Care Plan, date initiated on 5/2/25 and revision date on 6/2/25, documents, in part, a focus of R4 expressing the desire to smoke with R4 demonstrating non-compliance with safe smoking regulations evidenced by smoking in resident rooms, bathrooms and other non-designated areas with an intervention of remind the resident that staff will be observing & supervising smoking-related behavior. Non-compliance is to be documented in the medical record (initiated 5/28/25). On 6/3/25 at 1:40 PM, during the scheduled outdoor smoking break outside on the smoking patio, V6 (Activity Aide) observed with the locked cart containing the cigarettes for residents and holding the lighter to light resident cigarettes. R4 observed sitting smoking a gray colored cigarette. V6 stated that V6 provided R4 and other attending residents with one gray cigarette and lit the cigarette for R4. Upon R4 finishing smoking the gray cigarette, R4 lifts up R4's left pant leg and retrieves a ½ smoked, white colored cigarette from inside R4's sock. V6 observed watching R4, and R4 asks V6 to light this second (1/2 smoked, white) cigarette. V6 walks up to R4 and says that V6 cannot light it, asking where R4 got this cigarette, saying You (R4) are only supposed to smoke one cigarette. R4 observed turning sideways towards R14 (another resident sitting next to R4 who is currently smoking a lit gray cigarette). R4 then observed lowering the ½ smoked, white cigarette with R4 bending head down towards R14's lit cigarette, inhales and ignites this cigarette in contact with R14's cigarette. Surveyor asked both R4 and R14 if they had a lighter in their possession, and both denied it. R4 stated that R4 lit that cigarette that R4 took out of R4's ankle sock, and R4 said, I (R4) put it up to (R14's) cigarette to light it. Am I in trouble? This surveyor then walked back over to V6 and asked about residents lighting another residence cigarette using a pre lit cigarette, and she said that sometimes he does that, is that not allowed? On 6/3/25 at 2:30 PM, V10 (LPN) observed at nurse's station on R4 and R10's floor and stated that R4 is currently on a red pass for only supervised smoking. V10 stated, Residents cannot smoke in their room. It's a fire hazard. This surveyor informed V10 about this surveyor's observation of seeing R4 on the smoking patio removing a 1/2 smoked, white cigarette from R4's ankle sock, and V10 stated that V10 will call and notify social services staff. On 6/3/25 at 2:37 PM, V10 and this surveyor walked down to R4's shared room (with the red and white oxygen in use sign posted on the door), and R4 is observed in the bathroom. V10 knocked on the bathroom door, and R4 opened the bathroom door. V10 asked R4 if R4 had any smoking materials like a cigarette or a lighter on R4's person and explaining to R4 that R4 is on a red pass and hopes that R4 does not have a lighter on R4's person. R4 stated that R4 did not have any lighter on R4's person, but stated, I (R4) got one (a lighter). R4 observed walking out of the bathroom and over to R4's dresser drawers where R4 opens the top drawer and removes a blue, small sized gas lighter but R4 states that the lighter fluid chamber is empty. R4 stated, I used up my fluid. R4 hands this blue lighter to V10 with V10 saying that it's not allowed for R4 to have this in R4's possession. In R4's electronic health record (EHR), on 5/31/25 at 12:56 PM, V8's (Registered Nurse, RN) authored progress note is stricken out for incomplete documentation with a line through the documentation; however, this surveyor is able to read V8's following nurse's note: The resident (R4) was found to have smoked in a shared room occupied by four residents, including a newly admitted resident on oxygen therapy (R10). No active smoking was observed at the time, but there was a strong smell of cigarette smoke, and a used cigarette was found with (R4), with cigarette smoke visible in his space. The resident (R4) denied smoking in the room. (R4) was educated on the facility's no-smoking policy in the room and the serious safety hazard posed by smoking near oxygen equipment and other residents. The social worker (V25) was notified of the incident and plans to speak with the resident regarding safety concerns. Ongoing care continues. On 6/4/25 at 2:29 PM, V8 (RN) stated that R4 is irrational when talking to R4, is hyperverbal and is a smoker. V8 stated that on 5/31/25, R10 told V8 about other residents smoking in R10's shared room. V8 stated that when V8 entered R4, R5, R6 and R10's room on 5/31/25, V8 observed R4 with a smoked cigarette but did not see R4 lighting the smoked cigarette or smoking the cigarette. V8 initially stated that their room was smoky, but then changed R8's statement saying that V8 was only documenting R10's verbal account of what R10 reported. V8 stated that R10 was using nasal cannula oxygen on 5/31/25. V8 stated that R5 and R6 (R4 and R10's fellow roommates) were in the room at the time, and R4, R5 and R6 all denied smoking cigarettes in the shared room. When asked if V8 smelled cigarette smoke upon entering their shared room, V8 stated that V8 uses a face mask, and V8 again repeating that R10 said that it was a strong smoke smell in the room. V8 stated that V8 the partially used, white cigarette in R4's space, on the bedside table with R4 laying on R4's bed. V8 stated that V8 notified V25 (PRSC) of this incident with R4 and confiscating the used cigarette, and that V25 will speak to R4. On 6/10/25 at 2:46 PM, V25 (PRSC) stated that V25 works Tuesdays through Saturdays in the facility. When asked on 5/31/25, which was a Saturday, was it reported to V25 that there was an alleged smoking incident in the facility with R4, V25 asked which residents were residing in that shared room at that time, and this surveyor informed V25 that it was R4, R5, R6 and R10. V25 stated, I (V25) may have been (notified), but I didn't go. I was busy. When asked did V25 follow up with the allegation of R4 smoking in the shared room before the end of V25's shift on 5/31/25, V25 stated, Nope. I didn't. If it would have been at the end of my shift, then nope. V25 stated that V25 has smelled cigarette smoke wafting down that hallway, and when V25 smells it, V25 will go investigate the smell. In R4's EHR, on 6/1/25 at 8:06 PM, V7's (LPN) authored progress note is stricken out for incomplete chart with a line through the documentation; however, this surveyor is able to read V7's following behavior note, Resident (R4) awake/responsive verbally, alert/oriented X4 on stable condition. Compliant with meds but have behavioral issues. At 5pm resident (R4) caught smoking in the room. Cigarettes were confiscated but could not find the lighter. When nurse caught the residents one of them were flushing the toilet. When nurse ask residents if staff could see their pockets they strongly refused. Administrator, DON (Director of Nursing), and Primary MD (medical doctor) made aware. Unfortunately, Social Worker could not be reach. Will continue to monitor. On 6/9/25 at 2:07 PM, V26 (Certified Nursing Assistant, CNA) stated that on 6/1/25, while working the evening shift, I (V26) caught them (3 residents) smoking and let them (nurses) know. V26 stated that V26 caught smell of smoke (coming from R4, R5, R6 and R10's room). I opened their divider. I saw smoke in the air, and they had it (cigarette) lit. It was resting on windowsill. They were all together behind the curtain. V26 stated that it was R4's side of the room, and V26 identified the 2 remaining residents by their ethnicity, not names. V26 stated that R4 was standing next to the lit cigarette on the windowsill and that smoke was coming from the lit cigarette which was wafting out towards the open window. V26 stated that V26 told R4 to put out the cigarette and that R4 did. V26 stated that immediately informed V10 (RN) who informed R4's assigned nurse, V7 (LPN). On 6/4/25 at 1:26 PM, V7 (LPN) stated that on 6/1/25, R10 reported that smoking was happening in R10's shared room with R4, R5 and R6 present. V7 stated that R10 was wearing and using 2 L/min oxygen via nasal cannula from an oxygen tank at R10's bedside. V7 stated, At that time, I didn't smell smoke. I don't know what happened. V7 stated that R4 was the resident who was seen flushing the toilet upon entering the room. V7 stated that V7 questioned R4 and R5 about smoking in the shared room, and they denied it. V7 stated that R4 and R5 refused searches of their persons. V7 stated that V7 confiscated 14 cigarettes in a box that V7 observed in R4's dresser drawer (which was open that V7 could see into). V7 stated that V7 did not search the remainder of R4's room or R5's side of their shared room because V7 knows that V7 has to have 2 staff members present to conduct a room search for paraphernalia. V7 stated that V10 (RN) who was the other nurse on the floor was on break and that social services staff is not in the facility on Sundays. V7 stated that V7 did not perform a room search for R4 and R5 later on 6/1/25. V7 stated that V7 stated that R10 said that R10 was bed bound, was on oxygen and was asking to move to a different room, and V7 informed R10 that V7 has to check with V1 (Administrator) first. V7 stated, I move (R10) right away. (R10) was thanking us. V7 stated that V7 struck out V7's original documentation in R4's EHR due to V7 not actually witnessing the act of R4 smoking the cigarette. V7 stated that it's a dangerous risk to smoke cigarettes near an oxygen source, and that it is a fire hazard that can blow up the room. On 6/3/25 at 11:26 AM, R5 observed walking with a cane and standing near doorway in R5's shared room (with R4 and R5). R5 wrote R5's name on surveyor's paper with no clear verbalization noted when R5 attempts to speak. R5 denied ever smoking in R5's shared room on 5/31/25 or 6/1/25 by nodding no, and R5 nodded yes to being a smoker. When asked if other residents have smoking inside R5's room, R5 pointed to R4's curtain, which is closed, with R4 behind the curtain. R5's admission Record, documents, in part, diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, encounter for prophylactic measures, hypertension, type 2 diabetes mellitus with hyperglycemia, hyperlipidemia, aphasia following cerebral infarction, tobacco use, abnormalities of gait and mobility, weakness, and need for assistance with personal care. On 6/3/25 at 12:00 PM, R2 stated that R2 is a nonsmoker and keeps R2's door closed to prevent smelling the cigarette smoke in the hallway that is coming from R4's shared room. R2 stated that R4 was caught smoking in R4's shared room on 5/31/25 and 6/1/25 by staff. R2 stated that R2 smelled the cigarette smoke coming from the room and reported it to staff. R2 stated that R2 witnessed the staff addressing R4's smoking incidents on 5/31/25 and 6/1/25, and R10 being moved out of the shared room on 6/1/25, after the smoking incident. R2 stated, I (R2) heard the whole thing on Saturday and Sunday. (R10) had oxygen and (R10) had to be moved. It's an open secret that (R4) does it (smoke inside the room). R2's admission Record, documents, in part, diagnoses type 2 diabetes mellitus, obstructive and reflux uropathy, schizoaffective disorder, hypertension, abnormalities of gait and mobility, suicidal ideations, delusional disorder, polyosteoarthritis, peptic ulcer, and nasal congestion. R2's MDS, dated [DATE], documents, in part, that R2's BIMS score is a 10 which indicates that R2 has moderate cognitive impairment. R2's Smoking Evaluation, dated 12/20/24, documents, in part, that R2 does not use smoking, tobacco or nicotine products. On 6/3/25 at 11:46 AM, R7, R8 and R9's shared room door observed closed and is the neighboring room (same side) to R4, R5 and R6's room. Upon opening R7, R8 and R9's room, R7 stated that the door is closed so R7 does no smell the cigarette smoke coming from the hallway. R7 stated that R7 is a non-smoker. R7's admission Record, documents, in part, diagnoses of end stage renal disease, heart failure, type 2 diabetes mellitus, schizophrenia, anemia, asthma, hypertension, hyperlipidemia, cardiomegaly, vitamin D, chronic duodenal ulcer without hemorrhage or perforation, unsteadiness on feet, difficulty in walking, weakness, need for assistance with personal care, chronic kidney disease stage 4, acute pulmonary edema, and pleural effusion. R7's MDS, dated [DATE], documents, in part, that R7's BIMS score is a 15 which indicates that R7 is cognitively intact. R7's Smoking Evaluation, dated 1/11/25, documents, in part, that R7 does not use smoking, tobacco or nicotine products. On 6/3/25 at 11:49 AM, R8 that R8 is not a smoker and that R8 smells smoke from the hallway and from blowing in their room when the window is open. R8 stated that R8 cannot be near secondhand smoke. R8 stated that the facility staff caught R4 smoking inside R4's room last weekend and that during this last same weekend (5/30/25 to 6/1/25), the cigarette smoke was coming into R7, R8 and R9's room via their open window. R8 stated that the window is on R9's side of the room, and R9 likes to have the fresh air breeze come in their room from outside. R8 stated that R8 has reported smelling cigarette smoke coming from R4's room to multiple staff and that R8 told R4 to stop smoking in R4's room with R4 telling R8 to mind my own business. On 6/3/25 at 2:36 PM, R8 stated that R4 has no respect that (R4) keeps smoking in (R4's) room. With the way the wind blows, the smoke comes directly into our room. R8's admission Record, documents, in part, diagnoses cerebral infarction, asthma, transient cerebral ischemic attack, hypertensive heart disease without heart failure, bipolar disorder, hyperlipidemia, prediabetes, Parkinson's disease without dyskinesia, and chronic pancreatitis. R8's MDS, dated [DATE], documents, in part, that R8's BIMS score is a 15 which indicates that R8 is cognitively intact. R8's Smoking Evaluation, dated 5/17/25, documents, in part, that R8 does not use smoking, tobacco or nicotine products. On 6/3/25 at 11:51 AM, R9 observed laying in a bariatric bed positioned closest to the wall with the windows. R9's two windows are open approximately 6 inches with a breeze from outside felt blowing through. R9 stated that R9 sometimes smells the cigarette smoke coming from the outside air into the room. R9 stated that R9 is a non-smoker. R9 stated that R9 has not witnessed any resident smoking, but R9 is bedbound and doesn't go out of the room. R9 stated that smelling the cigarette smoke coming blowing in from the open window has increased R9's coughing, and R9 has asthma and has had to use R9's inhaler more often. R9 stated that R9 chokes on the smoke. R9 stated that R9 told the CNA but could not provide the name. On 6/5/25 at 11:11 AM, R9 stated that R9 administers a short-acting inhaler, Albuterol, when R9 feels short of breath due to coughing. R9 stated that R9 has R9's own Albuterol inhaler at R9's bedside to use and shows this surveyor the Albuterol inhaler held in a red key chain device. R9 stated that R9 did not tell the nursing staff when R9 has administers the extra doses of Albuterol to R9's self, and if I (R9) have to wait for them (nurses) to bring me the inhaler (Albuterol), I would be here choking. R9's admission Record, documents, in part, diagnoses of asthma, type 2 diabetes mellitus, personal history of other venous thrombosis and embolism, morbid (severe) obesity due to excess calories, anemia, body mass index (BMI) 70 or greater, adult, neuralgia and neuritis, and constipation. R9's MDS, dated [DATE], documents, in part, that R9's BIMS score is a 15 which indicates that R9 is cognitively intact. R9's Smoking Evaluation, dated 3/17/25, documents, in part, that R9 does not use smoking, tobacco or nicotine products. R9's May and June 2025 Medication Administration Record indicate R9's Albuterol Sulfate HFA (Hydrofluoroalkane) Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (micrograms per actuation), 2 puffs inhale orally every 4 hours as needed for asthma. Upon R9's EHR review, no self-administration assessment was noted for R9. On 6/9/25 at 11:54 AM, this surveyor requested from V1 the medication self-administration assessment for R9 and was not provided with one by end of the survey. On 6/4/25 at 11:18 AM and on 6/5/25 at 11:08 AM, R2 and R7, R8 and R9's rooms observed with the doors closed. On R7, R8 and R9's door, a handwritten sign is posted indicating to close the door behind whoever is entering or leaving the room. On 6/3/25 at 11:44 AM, R6's privacy curtains are closed all the way, separating R6 from the shared room open space. R6 stated that R6 is a nonsmoker; can't smell anything due to having a chronic plugged up nose; and keeps R6's privacy curtains closed at all time. R6 stated that there is a sign on the door that oxygen is in use and that no one can be smoking when there's oxygen in use. R6 stating that would be dangerous. R6's admission Record documents, in part, diagnoses of hyperlipidemia, bipolar disorder, hypertension, acquired absence of left and right toes, regular astigmatism bilateral, right eye secondary cataract, insomnia, right eye injury of conjunctiva and corneal abrasion, weakness, need for assistance with personal care, conjunctival hyperemia right eye, unsteadiness on feet, bipolar disorder, optic atrophy, myopia bilateral and presbyopia. On 6/4/25 at 3:12 PM, V4 (SSD) stated that V4 oversees the social services staff (V9 and V25) which is responsible for the assessing residents for safe smoking practices. V4 stated that community pass privileges are coded as red, yellow and green, and safe smokers are able to have a green pass to go outside (after nurse signs each daily pass) between 8 am and 8 PM to smoke. V4 stated that no residents are permitted to hold and possess their own smoking materials (cigarettes and lighters) in the facility, even the safe smokers on a green pass. V4 stated that a resident on a green pass will retrieve the cigarette and a lighter from the receptionist and will walk outside to a designated area at least 15 feet away from the door. V4 stated that residents who are on a red pass are deemed unsafe to smoke unsupervised and smoke during the designated smoke breaks on the patio or are taken outside with staff supervision to smoke in between scheduled smoke breaks. V4 stated that for R4's 5/2/25 smoking assessment, V4 stated that R4 did not follow the smoking safety rules and had smoked inside the facility. V4 stated that R4 had a red pass for 14 days until 5/16/25 when R4 obtained green pass privileges again (in conjunction with a physician's order). V4 stated that on 5/28/25, R4 was observed retrieving R4's cigarette and lighter from the receptionist, and as R4 was walking out the front door, R4 lit the cigarette and was not in the designated area at least 15 feet from the front door. V4 stated that R4 then went back to red pass status for breaking the facility smoking policy. On 6/5/25 at 3:58 PM, V2 (Director of Nursing, DON) stated that whenever there is an allegation of residents smoking inside the facility, the staff must check and investigate it. V2 stated, We want people to be safe. V2 stated that residents can't be smoking in the facility near oxygen and that it is a fire hazard. V2 stated that on 6/1/25, V7 (LPN) informed V1 and V2 of the allegation of R4 smoking in the shared room with R10, and that R10 was moved to a different room for safety since R10 was using oxygen. On 6/9/25 at 2:57 PM, V1 (Administrator) stated that R10 was a newer admission to the facility and was admitted with oxygen therapy. V1 stated that on 6/1/25, V7 notified V1 of a concern from R10 of R4 smoking; that V7 did not see R4 smoking; that V7 confiscated cigarettes from R4's room; and that R10 was not happy in this shared room with R4. V1 stated that V1 instructed V7 to move R10 to a different room and to search R4 and room for additional smoking materials. V1 stated, We don't want smoking on or around oxygen. We are taking every precaution to make sure everyone is safe. Nurse (V7) did mention (R10) is on oxygen, then I said to please move (R10) away from the situation. V1 stated that if smoking occurs near oxygen, a fire can start which could burn R10's face (since R10 wears nasal cannula oxygen), and adding, Oxygen can explode. When asked if V1 was notified on 5/31/25 of R10's allegation of R4 smoking in their shared room with V8 confiscating a partially smoked cigarette, V1 stated, No, I found out about on Monday (6/2/25). V1 stated that V2 (DON) met with V7 and V8 on 6/2/25 about being careful with documenting in the resident's medical record, ensuring that the nurse knows for sure that smoking occurred with actual proof of smoking. V1 stated that for proper follow up protocol, nurses are to document clinical information, and social services staff is to document on behaviors such as smoking inside the facility. V1 stated that there are no social services staff working on-site in the facility on Sundays. On 6/10/25 at 12:19 PM, V27 (Medical Director) confirmed that V27 is the medical director for the facility. When asked about V27's expectations staff to ensure safe smoking practices so residents are not smoking within the facility, V27 stated that residents receive information on day one of being admitted to the facility about smoking inside the facility being prohibited. When asked what effects could happen if a resident is smoking in the same room with another resident who is using oxygen, V27 stated, So that is a concern then. That's why the resident (R10) was removed, but it is a big concern with this smoking and oxygen. They don't mix well, we all know. V27 stated that smoking cigarettes in close proximity to an oxygen source is a combustible hazard. Facility Smokers List dated 6/3/25 documents, in part, that R4 and R5 are current smokers. Facility policy titled Facility Smoking Safety Policy dated 10/5/2015 documents, in part, Policy Objective: to provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. It is also the objective of this policy to communicate to each resident that they are responsible for following each rule and ongoing compliance with this policy. Guidelines: 1. Smoking is only allowed in designated areas established by management . The designated area(s) will be outside in accordance with state/local standards. The organization has the right to enforce a policy prohibiting residents from keeping any smoking materials in his/her possession for health, safety and security reasons . 3. Smokers will be evaluated to determine their ability to comply with safety rules and their ability to carry smoking materials. Residents requiring supervision shall receive this monitoring consistent with their assessment and plan care . 5. Individuals who are non-compliant, potentially dangerous, exercise poor judgment and show a lack of concern for the welfare of others will be counseled accordingly. The facility maintains the right to limit and restrict access to smoking products, matches and lighters for persons deemed unsafe. Smoking privileges will be revoked if there is a pattern of persistent, careless and hazardous behavior. 6. Oxygen use is prohibited in smoking areas for the safety of all parties (reference NFPA 101, 2000 ed., 19.7.4.). No resident may smoke near/around oxygen. 7. It is against facility policy to give away, sell, share and trade smoking materials or light another resident's cigarette . 9. All persons interested in retaining smoking privileges must follow the guidelines set forth in this policy. The following behaviors and or conditions will be considered when assessing residents. Independent privileges will not be granted if any of these behaviors are displayed. These behaviors will jeopardize and cause revocation of the person's independent privileges: 1. Smoking in any non-designated area, such as resident rooms, bathrooms, hallways, elevators, stairways and/or smoke-free courtyard . 4. poor safety awareness . making smoking dangerous f[TRUNCATED]

Based on observation, interview, and record review the facility failed to follow their dental policy to meet the need for dental services and to address negative dental findings immediately for one [R61] resident out of a sample of 28 reviewed for dental services. This failure resulted in a delay of a recommended dental procedure resulting in ongoing dental pain. Findings include: R61 medical diagnosis not limited to; paraplegia, type II diabetic, absence of right leg below the knee, need for assistance with personal care, and open left foot wound. R61 's Dental Consults [Facility Dentist] Recommendations documented in part: 10/18/23: R61 root tips in all four quadrants to be extracted referral made. 11/8/23: R61 still waiting for extractions. Facility needs to make arrangements for transportation. 12/12/23: Facility states R61 missed two appointments for extraction, due to blood thinner was not discontinued. 4/9/24: Several referrals have been made for extractions. He has been to V42 [Dentist] office and was recommended 11 extractions. Arrangements for transportation need to be made. These teeth are difficult to do in facility. 9/16/24: R61 still need extractions, will update referral. On 5/28/25 at 12:09 PM, V39 [Ombudsman] stated, I been communicating with V1 [Administrator] and V2 [Director of Nursing] regarding R61's tooth ache since last year around September 2024, nothing has been done. R61 has seen the facility's dentist, and he recommended several teeth extractions, this has been going on for a long time and still is not resolved. On 5/28/25 at 1PM, R61 stated, I been having a toothache for over a year. The facility's dentist told me I needed some extractions, but he was unable to pull my teeth here in the facility. I have been asking for an appointment, and nothing has been done. The physician ordered me pain medication for my tooth ache and body pains as well. On 5/29/25 at 1:14 PM, V40 [Licensed Practical Nurse] stated, R61 has been complaining about his toothache since last year around September. I remember the facility dentist assessed him last year and recommended a tooth extraction but could not be done here at the facility. R61 complains of his toothache all the time. R61 receives scheduled pain medication of Morphine Sulfate 15mg (milligrams) every eight hours, and Tylenol Extra Strength 500mg every eight hours for his toothache and body pains. I am not sure why R61 has not been to a dentist, I do not schedule appointments. On 5/29/25 at 2:30 PM, V41 [Appointment Scheduler/Escort/Certified Nurse Assistant] stated, I went back in my books to September 2024 to present, and R61 has not seen a dentist. I was made aware on 5/28/25, that R61 needed a dental appointment. I been calling around to a few places, but none of the offices accepts R61's health insurance. I called R61's health insurance company, but I have not gotten anywhere with them. I will let the director of nursing know. On 5/29/25 at 11:27 AM, V2 [Director of Nursing] stated, The nursing staff placed in an order for dental consult on 5/28/25. I cannot remember if I was made aware of R61's tooth ache before 5/28/25. We will work on getting R61 a dental appointment. On 5/30/25 12:46 PM, V1 [Administrator] stated, I started working here on 4/22/24. I do not recall if V39 told me if R61 need to see a dentist. The facility dentist has seen him, several times since last year. Policy document in part: Guidelines For Dental Services: [6/18/23] It is the policy of the facility to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This includes meeting any need for dental, denture care to include routine as well as emergency indicated services. Assessments of dental will be conducted upon admission, quarterly, annually, and significant change that affects the oral cavity. Negative findings will be immediately addressed.

Based on observations, interviews, and record reviews, the facility failed to a.) maintain sanitary kitchen conditions, b.) ensure proper working order of freezer, c.) ensure food items were properly labeled and dated, d.) maintain cleanliness of kitchen equipment. These failures have the potential to affect all 139 residents who receive food prepared in the kitchen. Findings include: On 05/27/25 at 9:28 AM, during initial kitchen tour observed a large amount of garbage and debris on the floor in tray line and food preparation area. Used discarded hairnets, empty plastic cups and particles of food were seen on the floor, the floor tiles had a greasy residue quality to them, the wall behind the oven had yellow/brown color splattered on the wall tile, and the oven had yellow colored food substance dried along the side of the oven. A large mop bucket filled with dirty gray colored water with a dirty looking mop head was observed. Next to the hand sink there was a very large gallon trash barrel with wheels. The lid of the trash barrel was propped open from all the garbage inside and had a used, empty 1-gallon mayonnaise balancing on the outside top of the lid. The lid on the large trash can could not be closed. A large collection of black flies were seen flying around the trash can and even more appeared when the lid of the trash can was moved. On the other side of the hand sink a large, uncovered cardboard box on top of a smaller closed garbage can was filled with kitchen trash. There was also another uncovered cardboard box underneath the hand sink on the floor overfilled with garbage. Next to the walk-in refrigerator there were other uncovered, cardboard boxes and on top was a large empty egg carton with a pile of cooked eggs on top of it falling toward the floor. The freezer door was partially opened. On 05/27/25 at 9:30 AM, V15 (Cook) stated when he came to work this morning the trash was like that, and it should have been emptied last night by the evening shift. V15 stated he dumped the scrambled eggs on top of the empty egg carton because there was no where else to put it. V15 stated the garbage cans should not be overfilled and the lid of the garbage can should be able to shut tightly to keep out pests and bugs. V15 stated the garbage smells which attracts gnats and fruit flies. V15 stated he could see the black flies flying all around the trash bin. V15 stated that dirty mop water is from last night and it was like that when V15 came to work this morning. V15 stated the floor has not been swept or mopped yet today. On 05/27/25 at 9:43 AM, V15 observed partially opened freezer door. V15 attempted to close the freezer door but when he pressed against the door it sprung back open and would not fully close. Inside the freezer observed standing water on the floor tiles, and water that had dripped from under the fans to form a pile of dripped ice on a box of food. Portable thermometer located inside the freezer read 25 degrees F (Fahrenheit). Inside freezer observed the following products: 1.) Fully defrosted 64-ounce bag of a vegetable blend full of water inside the bag and the vegetables were discolored. 2.) Defrosted two unopened 10-pound bags of pork loin. Able to easily press fingers into the pork loin. 3.) Fully defrosted Frozen Supplement Treat with liquid that had dripped and leaked out of the containers into the storage box. 4.) Fully defrosted liquid oral supplement shakes. V15 stated all the products in the freezer should be frozen solid. V15 stated the temperature inside the freezer should be zero degrees F or less. V15 stated the freezer door should be closed tightly to keep the cold air inside. V15 stated there must be something wrong with the freezer because it is not working correctly. V15 stated all the food inside the freezer is compromised and could potentially be in the temperature danger zone which could lead to food borne illness if served to the residents. On 05/27/25 at 9:52 AM, V15 stated all food items stored in the refrigerator should be labeled with an open or prepared date and a use by date. The following items were observed in the refrigerator: 1.) Opened package of hotdogs not labeled or dated. 2.) Large pan of hamburger patties covered in plastic wrap not labeled or dated. 3.) Cooked spinach labeled with a prepared date of 05/21/25. 4.) [NAME] pepper wrapped in plastic wrap dated 05/14/25. [NAME] pepper skin was very soft and mushy. 5.) Two opened packages of sliced American Cheese wrapped in plastic but not labeled or dated. On 05/27/25 at 10:07 AM, the table mounted can opener on the prep table was dirty with an accumulation of thick pink and black residue on the inside and outside of the spike of the can opener and inside the holding bracket for the can opener. V15 stated that can opener looks dirty, and it should be washed daily after each use to prevent cross contamination. V15 stated since the can opener is not clean all the bacteria and dirt on the spike of the can opener gets pushed into the can of the product he is opening. V17 (Dietary Aide/Pot Washer) stated no one told her that the can opener needed to be cleaned and she has never washed it before. On 05/27/25 at 10:12 AM, V16 (Maintenance Director) stated there is something wrong with the door locking mechanism on the freezer door which is why the freezer door is not shutting all the way. V16 stated no one told him there was a problem with the freezer. V16 stated the temperature inside the freezer is too high which is causing everything to defrost which is why the drain pan is overflowing with too much water and then leaking onto the food racks. On 05/27/25 at 10:38 AM, V14 (Dietary Manager) stated all items in the freezer should be frozen solid and yesterday there was no problem with the freezer, items were frozen solid. V14 stated no one told her anything about the freezer not working properly today and that the kitchen staff document the temperature of the freezer twice a day. V14 stated they will have to pull all the food out of the freezer and discard defrosted product. V14 stated the garbage was not thrown out yesterday because the trash bag was too heavy for the staff to pick up and that all garbage should be in a trash bag and the lid of the trash can should be closed, not propped open with garbage because this is unsanitary. V14 stated that dirty mop bucket is from last night and the staff should be sweeping and mopping the floor three times per day with clean soapy water, not dirty water. V14 stated all items in the refrigerator need to be labeled with a prepared/opened date and a use by date. V14 stated this is important for accuracy so the staff knows when to discard a food product, so it is not served to the residents. On 05/27/25 at 4:04 PM, V29 (Regional Director of Kitchen Operations) stated bacteria starts to grow once frozen items are defrosted and defrosted food needs to be used within three days. V29 stated she cannot tell when the freezer started not functioning properly or how long the items have been defrosted so she is going to have to throw out the items inside the freezer because it has the potential to cause food-borne illness. On 05/27/25, facility provided list of diet orders for all residents in the facility. The diet order list indicates there are two residents receiving nothing by mouth (NPO). Facility provided policy titled Freezer and Refrigerators undated which documents in part. This facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation and will observe food expiration guidelines. Acceptable temperature should be 35 degrees to 41 degrees F for refrigerators and less than 0 degrees for freezers. Facility provided copy of policy titled Sanitation revised 08/01/23 which documents in part, the food service area shall be maintained in a clean and sanitary manner, all kitchen areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. Facility provided copy of policy titled, Garbage and Rubbish Disposal undated which documents in part, all garbage and rubbish containing food wastes shall be kept in containers, all containers shall be provided with tight-fitting lids or covers and such containers must be kept covered when stored or not in continuous use and all garbage and rubbish shall be disposed of daily. Facility provided copy of policy titled Basic Cleaning Equipment undated which documents in part, basic cleaning equipment will be maintained in a clean and sanitary condition after every use to ensure food safety and the food service manager will be in charge of a visual inspection of all equipment. Facility provided policy titled Labeling and Dating reviewed date 07/30/23 which document in part, leftovers and opened foods shall be clearly labeled with date food item is to be discarded and food items to be labeled and dated include items prepared in house and food items that are opened and stored for later use. Facility provided policy titled Can Opener undated which documents in part can opener will be cleaned after each use.

Based on observation, interview and record review, the facility (a) failed to properly discard multi-dose insulin pen on expiration date and to properly store unopened insulin pen for 1 resident (R10), (b) failed to label and date opened multi-dose inhalers for 2 residents (R121, R95), and (c) failed to discard house stock medication on expiration date from two of three medication carts inspected for medication storage and labeling. This failure had the potential to affect all 28 residents receiving medications from third floor medication cart one. Findings Include: On 5/27/25 at 9:29 AM, third floor team one medication cart was inspected with V10 (Licensed Practical Nurse) and found R121's opened Trelegy Ellipta inhaler without the date opened written on the label (label reads to discard 6 weeks), R10's opened Fiasp Flextouch (insulin aspart) with date opened 4/28/25 written on the label, R10's unopened Fiasp insulin pen with refrigerate until opened written on the label, and a bottle of house stock Zinc 50 mg medication with best by date 4/25 written on the label. V10 stated insulin and inhalers are dated upon opening. V10 stated insulins are discarded after 28 days of opening and unopened insulin vials and pens should be stored inside the refrigerator. V10 further stated that expired medications should be discarded and not be stored inside the medication cart. On 5/27/25 at 11:40 AM, second floor 2-East medication cart was inspected with V12 (Licensed Practical Nurse) and found R95's Breo Ellipta inhaler without the date opened written on the label (label reads to discard 6 weeks). On 5/27/25 at 3:36 PM, V2 (Director of Nursing) stated that insulin pens and vials are dated upon opening and should be discarded after the 28 days. The last day would be the 28th day. V2 stated unopened insulin pens and vials should be refrigerated when they receive from pharmacy. V2 stated that inhalers should also be dated upon opening so nurses would know when to discard it. V2 further stated that all expired medications should not be stored inside the medication cart to prevent giving them to the resident. The facility's 3.1: MEDICATION STORAGE IN THE FACILITY policy and procedures dated 5/24 documents in part: Medications and biologicals are stored safety, securely, and properly following the manufacture or supplier recommendations. Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled or without secure closures will be immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures, and reordered from the pharmacy if a current order exists. The facility's Insulin Reference Chart (no date) documents in part: 28 days expiration for opened Fiasp insulin. The facility's EXPIRATION GUIDELINES FOR INHALATION PRODUCTS (7/2013) documents in part: Once these products are opened, they must be used within a specific timeframe to avoid reduced potency and, potentially, reduced efficacy.

Based on observation, interview, and record review the facility failed to ensure on multiple occasions medications were administered as scheduled per physician orders for one (R109) of four residents reviewed for medication administration. Findings Include: On 5/27/25 at 10:29 AM, R109 stated he does not get his Amlodipine on time on certain days. R109 stated for five days in the last twenty days, R109 did not receive his Amlodipine as scheduled in the morning. R109 remembers not getting it on time yesterday, Sunday, and other days but R109 does not remember exact days. R109 stated Amlodipine is ordered once a day to take in the morning. R109 stated some days the nurses don't give the medication to him until evening time. On 5/27/25 at 9:25 AM, V10 (Licensed Practical Nurse) stated that R109's Amlodipine is scheduled to be administered at 9:00 AM and nurses have two hours before and two hours after the scheduled time to administer medications to residents. V10 stated medications should be administered according to the doctors' orders. On 5/27/25 at 3:19 PM, a phone interview conducted with V26 (Licensed Practical Nurse) and stated [V26] does not remember if he gave R109's Amlodipine yesterday or not. V26 stated, Probably I offered it to [R109] and maybe he refused. I forgot to document. I don't remember if I gave the Amlodipine to him or not. If I administer the medication I would document as given in the MAR [Medication Administration Record]. Usually, I would put see progress notes if the resident refuses or does not take it. Sometimes [R109] has moods that he does not take his medications. If they refuse medications I would call the doctor. I would also document. V26 stated that the standard nursing practice is that if it's not documented, that means it did not happen. On 5/27/25 at 3:36 PM, V2 (Director of Nursing) stated that medication administration is done one hour before and one after the scheduled administration times. V2 stated that if the nurses give the medications late or if resident refused, they must call the doctor. V2 stated that after a resident takes their medications, the Nurses are documenting the time they administered the medications in the EMAR (Electronic Medication Administration). R109's face sheet included diagnoses but not limited to Essential Hypertension and Atherosclerotic Heart Disease. Minimum Data Set (MDS) dated [DATE] shows R109 is cognitively intact with BIMS (Brief Interview for Mental Status) of 15. R109's Medication Admin Audit Report reviewed from 5/1/25 to 5/27/25 and it revealed R109's physician's order for Amlodipine 5 mg tablet to be given one time a day for Hypertension to be administered at 9:00 AM (Hold if systolic blood pressure is less than 110, diastolic blood pressure less than 60, and heart rate less than 60 beats per minute). This audit report revealed on 5/1/25 R109's Amlodipine was administered at 9:30 PM, on 5/2/25 it was administered at 12:51 PM, on 5/5/25 it was administered at 12:26 PM, on 5/6/25 it was administered at 11:24 AM, on 5/10/25 it was administered at 10:40 AM, on 5/16/25 it was administered at 11:56 AM, on 5/18/25 it was administered at 2:13 PM, on 5/19/25 there was no documentation it was administered, and on 5/26/25 it was administered at 1:09 PM. Review of R109's progress notes from 5/1/25 to 5/16/25 do not show any documentation the reason why R109's Amlodipine was administered late and if R109's physician was notified. Facility provided surveyor R109's progress notes for 5/18/25, 5/19/25, and 5/26/25 documented on 5/27/25 as late entries for R109's Amlodipine being refused. R109's May vitals summary revealed no morning shift blood pressure and heart rate readings on 5/18/25 and 5/19/25. No readings of systolic blood pressure (BP) below 110, diastolic BP of below 60, and heart rate of below 60 beats per minutes. The facility's MEDICATION ADMINISTRATION policy (no date) documents in part: Review the resident's Medication Administration Record (MAR). Read each order entirely. The facility's PHYSICIAN ORDERS--(FOLLOWING PHYSICIAN ORDERS) (no date) documents in part: It is the policy of the facility to follow the orders of the physician. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission.

Based on observations, interviews, and records review the facility failed to protect the rights of a resident to be free of resident to resident abuse for one (R5) out of three residents reviewed for abuse. These failures were not in accordance with abuse policy of facility and resulted to one resident (R5) with cognitive impairment sustaining injuries in two separate incidents with (R6 and R9). R5 sustained scratches and abrasion on the neck on 01/13/2025 and right eye swelling and redness on 11/18/2024 which resulted in R5 being sent to the hospital. Findings include: On 02/11/2025 at 11:10 AM, R5 was initially seen in his room sleeping. R5 was unable to respond by calling his name multiple times. On 02/14/2025 at 09:44 AM, R5 was with V19 (Certified Nursing Assistant) was seen doing bedside care. R5 was on his bed awake but does not respond when his first name was called. R5 stares to the wall without reaction to any conversation. V19 stated that R5 does not talk and only respond to his name. V19 stated that R5 can walk if he wants to, and that R5 declines because he is now on hospice. V19 said, He does not understand and only respond to his name. R5 is [AGE] years old, initially admitted in facility on 12/28/2020. R5 medical diagnosis includes dementia / Alzheimer's disease, cognition deficit, brain disorder, behavioral disturbance. R5 has severe impairment on his cognition. Per brief interview of mental status (BIMS) dated 02/07/2025, R5 never or rarely understood. On 02/11/2025 at 11:16 AM, R6 was seen at dining room sitting on his wheelchair near the window with view overlooking the street. R6 is alert and able to express his thoughts within topic during conversation. R6 stated that he knows R5 and remember very well the incident or conflict that happened between him (R6) and R5. R6 stated that R5 was blocking the way so he punched R5 on his face. R6 said, I punch him in his face. I just hit him twice both in his face. R6 stated that he told R5 four (4) times to move but R5 did not move. R6 stated that R5 did not hit him back because R5 cannot fight. R6 said, R5 is an old timer, you know what I mean, he (R5) lost his memories. R6 was asked instead of hitting R5, why not inform the staff to move R5 if he was blocking the way? R6 replied, But I did, they were busy talking. I asked the nurse, but he won't stop it. I have to do what I have to do. On 02/14/2025 at 09:50 AM, R6 was seen at dining room same place near the window. R6 was able to make conversation with staff. R6 then wheeled himself moving his wheelchair to the hallway. On 02/18/2025 at 11:21 AM, R6 was seen at dining room same location. R6 stated that incident between him and R5 happened in the dining room. R6 said, I asked him many times, three (3) times to move. But he refused to move. So, I punched him on the face. R6 is [AGE] years old, initially admitted in facility on 03/23/2021. R6 medical diagnosis includes hypertension. R6 has intact cognition, per brief interview of mental status (BIMS) dated 01/13/2025, R6 scored 14. Documentation between R6 and R5 incident dated 01/13/2025 are as follows: V4 (Registered Nurse) clinical notes dated 01/13/2025 documents: It was reported by the Certified Nursing Assistant on duty that during her rounds, R5 and R6 had interaction. R5 sustained scratches on left side of the neck and face. Upon assessment of R5 abrasion noted on left side of the neck and face. V8 (Certified Nursing Assistant) written confidential witness statement dated 01/15/2025 reads: I saw them arguing and I separated them. On 02/18/2025 at 10:02 AM, V8 stated that while she was passing trays for dinner. She (V8) heard something on the dining room. V8 said, Shout, shout, shout. V8 stated that when she went to dining room, she saw R5 and R6 fighting. R6 was waving his hands on the air. R6 was on his wheelchair and R5 standing because he walks everywhere in the hallway and room to room. V8 stated that R5 needs to be monitored because R5 walks around. V8 stated that there was no staff in the dining room because they were passing trays, and she (V8) was on the hallway passing trays when she heard commotion in the dining room. It happened between 05:45 PM to 6:00 PM during dinner time. V8 stated that after separating R5 and R6, R5 has scratches and abrasions. V8 stated that she was going to tell the nurse (V4) but was not able to see or find him. V8 stated that she looked for V4 but nowhere to be found. V8 said, Maybe he (V4) was on a break. When V9 (Registered Nurse) came in for the next shift (from 7:00 PM to 7:00 AM), and during endorsement with V4, V8 stated that V9 inquired about R5's scratches during endorsement with V4, and that was the time she (V8) informed V4 and V9 what happened in the dining room. Per V8 during incident V4 was her nurse working from 7:00 AM to 7:00 PM, then V9 came in to work from 7:00 PM to 7:00 AM. V9 (Registered Nurse) written confidential witness statement dated 1/15/2025 reads: I saw R5 had a superficial scratch. I assessed him and started to evaluate what happened. I didn't see what happened, but I treated the scratch, and everything was fine. Signed by V1 (Administrator) only, signature of witness left blank. On 02/18/2025 at 10:33 AM, V9 stated that she came to work for 7:00 PM to 7:00 AM shift. Upon making her rounds at the beginning of her shift, R5 was seen with scratch and bruise on his neck. V9 said, I know it was fresh because it was a bit bleeding. V9 stated that because R5 was confused and cannot tell what happened, she (V9) asked around all CNA (Certified Nursing Assistant). Called V4 (Registered Nurse) and asked him about R5's neck abrasion. V4 came, stated he does not see anything. V8 (Certified Nursing Assistant) informed them about the incident that happened in the dining room between R5 and R6. V4 then made a report about the incident. Clinical Notes by V4 dated 01/13/2025 (late entry) documents: V8 reported to him (V4) that R5 and R6 had interaction, and that V8 noticed scratches on R5's left side of neck and face. Injury site was cleaned with normal saline and dried. On 02/18/2025 at 10:48 AM, V4 stated that he was on break at the time of the incident. When I came back from break, I was informed by V8 and V9 about the incident contact between R5 and R6. On 02/19/2025 at 10:44 AM, V4 clarified that it was V9 who informed him that something happened with R5 and R6. When he (V4) came to the floor, V8 told him that something happened to R5 and R6. That R6 made physical contact to R5. R6 touched R5 but V8 was not sure if it was done on purpose. Another incident that happened on 11/18/2024. In this incident, R5 was also the victim and sustained swelling and redness into his right eye when another resident R9 hit R5's face. V10 (Registered Nurse) clinical notes dated 11/18/2024, documents that on the hallway R5 bumps into R9. R9 then proceeded to tap R5's face. R5 was observed with slight swelling, redness in right eye area. Ice pack was applied, and neuro check was initiated to R5. R5 was transferred to the hospital for medical intervention including CT scan. Per hospital records, R5 was considered a victim of assault. V10 (Registered Nurse) written confidential witness statement dated 11/18/2024 reads: I observed from the nurse station the resident (R5) moved towards another resident (R9) and got tapped in the face. Resident was separated and moved away. Signed by V1 (Administrator) only, signature of witness left blank. On 02/14/2025 at 11:41 AM, V10 stated that R9 was sitting on wheelchair near the nurse station. Because R5 likes to wander, he accidentally bump to R9. R9 tapped face of R5 that resulted to slight redness. Then she (V10) applied ice pack to R5's right eye area. V10 was asked to elaborate more on R5's right eye after R9's tapped. V10 stated there were redness, erythema and swelling with skin irritation. V10 stated a soft tap will not result to redness or swelling. Yes, it needs to be force enough. V10 stated that R5 is not very much alert and wanders a lot. R5 is not able to make conversation, uses jumbles speech or incoherent speech. V10 stated that if what happened to R5, happened to any of his family or friends she will really feel bad. And would not want that to happened to any of her family members. V10 stated that she does not want resident that does not work well with other residents on the same floor. V10 stated that R5 likes to get up at times. And the incident happened around breakfast time. Nursing staff were busy, and she was busy with her computer. R5 may have been getting out for breakfast. Clinical notes of V11 (Registered Nurse) dated 11/18/2024, documents that she asked R9 why did he did that? R9 replied, Shut up you b***h! I wanna spill this coffee on your face. On 02/18/2025 at 02:50 PM, R9 was seen in front of nurse station sitting on his wheelchair. R9 was alert and able to express his thoughts within topic during conversation. R9 agreed to go to his room for an interview. When asked about R5, R9 a bit evasive with the question. R9 replied, R5 cannot talk to me, he is mad. He is here for murder. R9 was asked if he can elaborate more about his statement. R9 a bit uncomfortable, stated he cannot elaborate or cannot remember about the incident. R9 is [AGE] years old, initially admitted in the facility on 03/21/2011 with medical diagnosis that includes dementia, schizoaffective disorder, cognitive communication deficit. R9 assessment dated [DATE], documents that R9 has intact cognition to slight impairment with BIMS (Brief Interview of Mental Status) score of 13. And that R9 is non-ambulatory and uses motorize wheelchair per functional abilities assessment with the same date. On 02/19/2025 at 09:21 AM, V1 (Administrator) stated that on the incident dated 11/18/2025, R5 has dementia that likes to wander around. R9 tapped R5's face and staff immediately remove R5 and R9. V1 was asked how R9 able to tap R5's face? V1 stated that R9 cannot walk but can stand. R5 on the other hand cannot understand. V1 said, What happened was not intentional. It happened to two dementia residents. V1 was asked about the incident dated 01/13/2025. V1 stated that there was a concern between two individuals (R5 and R6). V1 stated that after investigation there was no proof that superficial scratch was done by R6. V1 said, I think R5 done it to himself. V1 was asked what did R6 said about the incident? V1 took written statement of R6 and read: He said R5 was in his way, and he asked him to move. V1 was asked how did she first learn about the incident? Who was the facility staff who contacted her? V1 replied that the person contacted her was V9 (Registered Nurse). V1 was made aware that V9 was not in the facility during the incident because she started working 7:00 PM. V1 then stated that V8 (Certified Nursing Assistant) was the only staff that saw what happened. And V8 did not see that scratches was done by R6. V1 was made aware that R6 stated that he punched R5 on the face because he told R5 to move multiple times but R5 did not move. Abuse policy dated 03/01/2021 reads: Policy It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends, or other individuals. For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Identification of Allegations/ Internal Reporting Requirements The nursing staff is additionally responsible for reporting on a facility Incident Report the appearance of bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the Nursing Supervisor is responsible for assessing the resident, reviewing the documentation, and reporting to the Administrator or in the absence of the Administrator, the Director of Nursing.

Based on interview and record review, the facility failed to prevent and protect one resident (R8) from resident-to-resident physical abuse by (R9) for two of three residents reviewed for physical abuse. This failure resulted in R8 being beaten with a walking cane while in the facility and sustaining a left hip fracture. Findings include: On 01/19/2025, at 1:40 PM, V12 (Licensed Practical Nurse/LPN) states he was the nurse assigned to care for R8 when R8 was sent out to the hospital. V12 states on 01/16/2025, R8 was involved in a verbal and physical altercation with his roommate (identified as R9). V12 states he was at the nurses' station someone informed him that R8 and R9 were in an altercation. V12 states he did not witness the altercation but was informed that the aggressor was R9. V12 states R8 told him that R9 used R9s' walking cane to strike R8, which is why R8 was sent out to the hospital. V12 states R8s' other roommate (identified as R3) witnessed the altercation between R8 and R9 and brought it to V12s' attention. V12 states he documented the altercation in the electronic health records and informed V1 (Administrator) of what happened. V12 states he also notified R8 and R9s' doctors and received orders to send both residents out to the hospital. V12 states R8 complained of pain to his left hip, and he administered pain medications to R8 while R8 waited for the ambulance to arrive. Nursing progress note dated 01/16/2025, written by V12 documents in part 6:40 PM, there was an alleged altercation between R8 and R9. Investigation initiated. R8 stated that he had complained to his roommate that the room was cool. R8 wanted to have R9 close the window but R9 refused and chose to come on his side to turn off the heater. That is when R8 and R9 got into a verbal altercation. R9 used his cane on R8s' left leg. A head to toe assessment was completed. R8 complained of pain on the left hip to lower extremity. Pain medication was given to R8. R8's skin intact, vitals were stable, the ADON (Assistant Director of Nursing) was notified and the administrator was made aware. Physician order for R8 to be sent to hospital for medical evaluation and no family member listed as a contact. Nursing progress note dated 01/16/2025, documents in part 6:40 PM there was an alleged altercation between R9 and R8. R9 stated R8 wanted the window closed and feels comfortable stating the room is cold. R9 then switched off the heater that was close to R8 which led to shouting and screaming against each other and knocking down R8's food. Staff did a head to toe assessment. R8 had no skin openings or cuts. Staff notified the physician. The psychiatrist ordered R9 to the hospital. The ADON and the administrator were made aware. On 01/19/2025, at 2:11 PM, V13 (LPN) states he did not witness the altercation that occurred between R8 and R9. V13 states R8 and R9s' altercation took place on the previous shift prior to his scheduled shift. V13 states he was the oncoming nurse on 01/16/2025, and was informed by V12 during shift change about R8 and R9s' altercation. V13 states he was given report by V12 that R8 was complaining of leg pain and awaiting the arrival of the ambulance. V13 states he was also informed by V12 that R9 struck R8 with a walking cane. V13 states later in his shift, he followed up and called the hospital to check the status of both R8 and R9. V13 states a hospital nurse informed him that R8 was admitted to the hospital with a femoral fracture. Nursing progress note dated 01/17/2025, written by V13 documents Followed up on R8 status at the hospital. Per floor nurse RN, R8 is admitted to the hospital with a diagnosis of Left Femoral Fracture. Unable to reach Primary care at this time. Will follow up to notify. ADON made aware. R8 is self-responsible. Nursing progress note dated 01/17/2025, written by V13 documents Writer called hospital to follow up on R9. R9 is admitted . admitting diagnosis is bipolar disorder and insomnia. On 01/19/2025, at 2:20 PM, V1 (Administrator) states she has been working at the facility since April 2024 and she is the abuse coordinator. V1 states she is currently working on and investigating the facility reported incident involving R8 and R9. V1 states R8 and R9 were roommates and allegedly something happened. R8 was sent to the hospital for medical evaluation and R9 was sent to the hospital for agitation. V1 states she submitted an initial report to the state agency on 01/16/2025, and is still in the process of investigating the incident. V1 states she has not spoken to any of the other residents residing in the room with R8 and R9. V1 states she has not received a definitive report of R8s's hip being fractured. V1 states R8 and R9 are still hospitalized and has not returned to the facility. V1 states she plans to contact the hospital liaison for more information regarding R8. On 01/19/2025, at 3:55 PM, R3 states he witnessed the altercation between R8 and R9. R3 states he resides in the same room as R8 and R9 and walked in on the altercation. R3 states R8 wanted the window closed in their room. R9 opened the window instead and then R8 began yelling at R9 to close the window. R3 states R8 uses a wheelchair to ambulate. R3 states when he walked in his room, he observed R9 beating R8 with R9s' walking cane. R3 states R8 was lying on the floor bleeding from the head while R9 beat R8 with a cane. R3 states he broke the fight up and informed the nurse (identified as V12) of the altercation between R8 and R9. R3 then goes to R9s' bed and points to a cane hanging on R9s' bed. R3 states to surveyor that the cane is the same cane that R9 used to beat R8 with. Surveyor observes a cane with a grey, rubber, hook handle with a single metal pole frame. R3 states no one has inquired about the altercation between R8 and R9 other than surveyor. R3 states this is not the first time that R8 and R9 have gotten into a physical altercation. R3 states approximately one month ago, R8 and R9 were involved in another physical altercation and R3 reported this to a CNA/Certified Nursing Assistant staff member. R3 states the altercations between R8 and R9 have been getting worse. Upon reviewing medical records for R8, R8 reported to hospital staff that he was in a physical altercation with another resident and was hit in the left thigh with a cane. R8 also reported to hospital staff that he fell and hit his head with no loss of consciousness. R3s' MDS/Minimum Data Set, dated dated dated [DATE] documents that R3 has a BIMS of 15/15, indicating that R3 is cognitively intact. R8s' Facesheet documents that R8 has diagnoses not limited to: Osteoarthritis of hip, epilepsy, abnormalities of gait and mobility, unsteadiness on feet, vitamin D deficiency, weakness, and myocardial infarction. R8's MDS/Minimum Data Set, dated dated dated [DATE] documents that R8 has a BIMS of 12/15, indicating that R8 is cognitively intact. R8 requires partial/moderate assistance with ADL/Activities of Daily Living care and ambulates via wheelchair. R8s' Trauma Screening dated 01/17/25 documents that R8 had an alleged disagreement with his peer. R9s' Facesheet documents that R9 has diagnoses not limited to: Cardiomyopathy, major depressive disorder, insomnia, essential hypertension, weakness, abnormalities of gait and mobility. R9's MDS/Minimum Data Set, dated dated dated [DATE] documents that R9 has a BIMS of 13/15, indicating that R9 is cognitively intact. R9 requires supervision with ADL/Activities of Daily Living care. R9s' Trauma Screening dated 01/17/2025 documents that R9 had an alleged occurrence with his peer. Facility initial reported incident dated 01/16/2025 documents that R8 and R9 had a disagreement and were separated. Ombudsman Residents' Rights for People in Long-Term Care Facilities dated 11/2028 documents in part, You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually. Facility policy dated 03/01/2021 titled Abuse Prevention Program documents in part, It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility.

Based on interview and record review the facility failed to ensure that one resident (R2) was free from staff to resident mental abuse. This failure affected one resident (R2) in a total sample of three reviewed for abuse. This failure resulted in (R2) experiencing mental anguish. Findings include: On 10/22/24 at 11:28am R2 stated on 10/11/24 V12 (Psych tech) came to her room and threatened to have R2's green pass privileges removed if R2's family member continued to call the facility with complaints. On 10/23/24 at 10:30am R2 stated, The facility threatening to take my pass away made me feel threatened and abused. All me and my family did was advocate for them not picking me up. The mental abuse here is terrible. I don't feel safe here. V12 eyeballs me now but he doesn't say anything to me. On 10/22/24 at 12:15pm V12 stated that he only informed R2 that V13 (social service coordinator/SSC) wanted to speak with R2 regarding pass privileges. On 10/23/24 at 11:03am V12 read aloud V12's witness statement, Early a message was relayed to me that by the actions of her (R2's) sister calling the facility calling on her behalf saying there's no transportation for her, by the actions could get her pass took. On 10/22/24 at 12:40pm V13 stated that she never requested R2 to come to speak with her. V13's witness statement documents in part, R2 came to front office to discuss possible green pass issues. Resident was agitated with the news .she (R2) felt he (V12) disrespected her (R2) by letting her know I (V13) would have to speak with her about her pass. R1's witness statement documents in part, I (R1) heard V12 say to R2 your green pass is in jeopardy. On 10/23/24 at 1:46pm V2 (Assistant Director of Nursing/ADON) stated that on 10/11/24 R2 came to his office and told him that she (R2) was threatened to have her green pass privileges removed by V12 and V13. V2 stated that R2 informed him that she did not feel safe with V12 and V13. V2 stated that he asked R2 to calm down and have a seat in his office. V2 stated that he spoke to R2's roommate who witnessed V12 make the statement regarding the pass. V2 stated that R2's roommate R1 stated that V12 told R2 that her green pass was in jeopardy. V2 stated, A threat to take something away from someone is verbal abuse. On 10/23/24 at 2:58pm V1(Administrator) stated, Threatening to remove someone's privileges could be a form of abuse but in this situation, I don't believe that it was. Out of all the residents that reside here, I've completed the most abuse allegations for R2. R2's care plan dated 10/16/24 titled Abuse, Neglect, Trauma Factors documents in part, The resident will be treated with respect, dignity and reside in the facility free of mistreatment. R2's medical diagnoses include chronic obstructive pulmonary disease, unspecified sequela of cerebral infarction, anxiety disorder, grastro-esophageal reflux disease without esophagitis, major depressive disorder, post-traumatic stress disorder. R2's Minimum Data Set (MDS) dated [DATE] has a brief interview for mental status (BIMS) score of 14 which indicates R2's cognition is intact. R2's active physician order dated 8/12/24 documents, Resident may go out on green pass. Facility's job description titled Psychiatric Technician documents in part, Essential Position Functions .Intervenes with clients in a manner that offers dignity and support. Facility's policy revised 3/1/21 titled Abuse Prevention Program documents in part, It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. Facility's undated policy titled Your Rights and Protection as a Nursing Home Resident documents in part, You have the right to be free from abuse and neglect: You have the right to be free from verbal, sexual, physical, and mental abuse.

Based on observation, interviews, and record reviews the facility failed to follow their wound prevention policy to ensure one [R9] of three residents did not develop pressure wounds. This failure resulted in R9 developing a stage three pressure ulcer to R9's left hip. Findings Include: R9 clinical record indicates in part: R9 is a [AGE] year-old, with the following medical diagnosis includes but not limited to need for assistance with personal care, dementia, essential (primary) hypertension, weakness, legal blindness, cognitive communication deficit, and unsteadiness on feet. R9's Minimum Data Set (MDS) section [C] dated 7/2/24 score of [6] indicates R9 is moderately impaired. R9s' MDS section [GG] indicates R9 is total dependent for all his activities of daily living such eating, oral hygiene, shower, bathing, upper and lower body dressing, putting on and off footwear, personal hygiene, rolling left and right, toileting, sit to stand, and transfers. R9's care plan documents in part: 7/14/24: R9 is incontinent of bladder and bowel. R9 will be cleaned, dry and odor free daily. Administer appropriate cleansing and peri care after each incontinent episode. Initiated on 4/21/23 [ Revised on 7/10/24]: Precautions for prevention of pressure ulcers are good pericare, and drying of the skin, apply protective barrier cream, reposition R9 frequently when in bed, or wheelchair, off load heels, pressure reducing relieving mattress and wheelchair cushion. On 8/13/24 at 11:22 AM, V41 [R9's Family Member] waved surveyor into the R9's room. Entering R9's room, noted strong offensive odors. R9 was resting in bed lying on his left side. V41 stated, Please help me, R9 smells like feces and urine, I need someone to check him to see if R9 needs changing. On 8/13/24 at 11:30 AM, V41 and R9 gave surveyor permission to observe incontinence care. V9 [Registered Nurse] detached R9's under brief, surveyor, V9, and V41 observed and half of the under brief was inside R9's buttock crease with three rings [circles] yellow and red tinge in color, dried and wet stool in the under brief, outside the brief and on the pad. V41 requested for nursing administration to see the condition of R9's under brief. V3 [Assistant Director of Nursing] entered R9 room and observed R9's under brief half of the under brief was inside R9's buttock crease with three rings [circles] yellow and red tinge in color, dried and wet stool in the under brief, outside the brief and on the pad. On 8/13/24 at 11:45 AM, V20 [Certified Nurse Assistant] came in the room and stated to surveyor, V41, V9 and V3 I am R9's certified nurse assistant. I have not checked his under brief today. I was not able to provide ADL care to R9. I started work today at 7AM. I have a heavy assignment and cannot provide care timely. I will clean R9 up now. V20 and V9 turned R9 onto his right side and removed the under brief and noted an open red area with yellowish drainage on his left hip. The incontinent pad was removed, there was dried dark brown substance with several yellow circle on the fitted sheet. V20 stated, There is feces and urine underneath the incontinence pad, whoever changed R9 last only replace the incontinence pad and did not change the linen. R9's Wound Evaluation dated 8/13/24 indicate in part: In-house facility acquired pressure injury wound noted on 8/13/24. Wound measurements were 0.5 x 0.6 x 0.2cm [centimeters]. Current wound status -R9 likes to lay on left side, offloaded with pillows. R9 complained of pain when cleansing the wound. On 8/14/24 at 9:44 AM, V45 [Wound Care Nurse] and surveyor observed R9's wound assessment and treatment. V45 stated, R9 has a facility acquired stage three pressure ulcer on his left hip that measures 0.5 x 0.6 x 0.2cm [centimeters]. I'm placing on a medihoney treatment with dressing. I will initiate wound care interventions of air loss mattress, and off load with pillows. If a resident does not receive incontinent care timely, and reposition, the resident could potentially develop pressure ulcers, skin issues and infection. On 8/15/24 at 10:13 AM V2 [Director of Nursing] stated, Recently the second and fourth floor decreased from four certified nurse assistants to three, due to the facility low census. The decision comes from corporate during our staffing meeting. Corporate look at the numbers and use a staffing grid for the facility. On the second floor there are approximately [14] residents, and [16] residents on the fourth floor that need mechanical lift transfers, extensive assistance with ADL (activies of daily living) care, incontinent care, bed mobility, and transfers. I received complaints from staff regarding the heavy workload, I asked the staff to give the facility a chance to make their assignments better. V1 (Administrator) was made aware last week there were ADL concerns and staffing concerns. I expect that all staff including nurses to assist the certified nurse assistants with provided ADL incontinent care to meet the needs of all the residents. If a resident is not provided incontinent care and repositioning at least every two hours, it could potentially cause skin issues and pressure ulcers. Policy document in part: Guidelines for Prevention/Treatment of Pressure Injuries The facility will ensure a resident received care, consistent with the profession standards of practice: to prevent pressure ulcers and does not develop pressure ulcers. Pressure injuries can interfere with the resident's functions and recovery, especially if complicated by pain and or infection. Pressure injury can occur as a result of prolonged pressure.

Based on interviews and records review, the facility failed to supervise one (R1) resident while on outside physician appointment of three residents reviewed for supervision. This failure resulted in R1 missing for approximately six hours. Findings include: R1's current face sheet documents R1 is a [AGE] year-old individual with medical diagnosis that include but not limited to: Wernicke's encephalopathy, unspecified dementia, unspecified severity, with other behavioral disturbance, other amnesia, other lack of coordination needs for assistance with personal care, cognitive communication deficit, dementia in other diseases classified elsewhere, moderate, with mood/ psychotic disturbance. R1's MDS (minimum data set) section c-cognitive functions dated 4/20/2024 documents R1's BIMS (Brief Interview for Mental Status as 6/15, indicating R1 indicating R1 has severe cognitive impairment. R1's MDS Section GG- Section GG - Functional Abilities and Goals document R1 needs substantial/maximal assistance with oral hygiene, shower/bathing self, lower/upper body dressing, putting on/off footwear, personal hygiene, rolling left and right, sit to lying, sit to stand, and R1 needs supervision or touching assistance with eating, walking 10, 50, 100 feet. On 06/20/2024 at 2:44pm, V16 (Physician) stated R1 should not have been left alone while R1 was out of the facility for an outside physician appointment because R1 has diagnosis such as Wernicke's encephalopathy, Dementia which causes memory loss. V16 stated the only time R1 could have been left alone is when R1 was in the examination room with the physician and nurses. during R1's appointment. On 5/18/2024 at 1:33pm, R1 was observed laying in his bed watching TV. R1 was able to answer some questions but was confused at times. R1 stated he has an appointment Last week Monday, and they left me(R1) there, and I (R1) was scared. R1 stated he does not remember what the appointment was for does not remember where he went or how he got back to the facility on [DATE]. R1 was observed wearing a wander guard on his right-hand wrist. On 06/18/2024 at 4:21pm, V1(Administrator) stated R1 went out on appointment with (V5) Escort on 6/10/2024, R1 attended the appointment, and V5 was in the lobby of the hospital where R1 had an appointment and V5 had to use the rest room. V1 stated V5 asked the security guard to watch R1 while V5 used the washroom and when V5 come back from the washroom, V5 found R1 had walked off. V1 said V5 asked the security guard what happened, and the security guard told V5 that it was not the security guard's job to watch R1. V1 stated she found out R1 had disappeared at about 11:30am. V1 stated V5 then called V4(Memory Care Coordinator/Transportation Trainer) to let V4 know R1 had disappeared and V4 went to the hospital to help V5 look for R1. V1 stated the hospital is located about14 miles from the facility. V1 stated V4 notified the police and the security at the hospital so that they could assist in looking for R1. V1 stated she(V1) received a call from the police at approximately 3pm on 6/10/2024 letting her know R1 was located 10 miles away from the hospital where R1 had gone for him appointment escorted by V5. V1 stated V5 should have gone to the bathroom while R1 was in his appointment, because it would have been safer because R1 was in the hands of medical personnel. V1 said V5 was given a write up and a suspension for leaving R1 with the security guard, who was not responsible for R1. V1 stated R1 needed an escort because he is not capable of taking care of himself and it is the responsibility of the facility to make sure R1 was safe during his outing to the appointment. V1 further stated during the period R1 was lost, he could have gotten hurt, lost, and not found, and there could have been many other negative outcomes related to R1 getting lost. V1 stated her expectation was that V5 should have always remained with R1 during the outing to the appointment. V1 said V5 was suspended for three days for leaving R1 alone and R1 getting lost after walking away alone from the hospital. On 06/20/2024 at 12:05pm, V5 (Escort) stated on 6/10/2024, V5 escorted R1 to an outside physician appointment and left the facility about 9:30am via taxi, and the appointment was completed at about 11:45am. V5 stated there was a security guard by washroom and there was a seat, so V5 asked the security guard to keep an eye on R1 as V5 went to the restroom. V5 stated the security guard agreed, so V5 went to the bathroom, and when V5 come back from the bathroom, V5 did not see R1. V5 asked the security guard where R1 was, the security guard told V5 that it was not his job to watch R1. V5 stated V5 called facility front desk and spoke to V17 (Transportation) who was at the reception and informed V17 that R1 was lost, and to let V1 and V2 know. V5 stated V17 called V5 back and stated V4(Memory Care Coordinator/Transportation Trainer) would go to the hospital and assist V5 in looking for R1, and other management staff were also on the way. V5 stated the hospital security cameras showed R1 had walked outside the facility through the main door and was heading on the East side of the building. V5 stated she does not know the exact time R1 was found, but it was after 4:00pm. V5 stated she is not supposed to leave a resident without supervision, but V5 stated she had to go to the bathroom really badly, so she(V5) asked the security guard to watch R1. V5 stated the security guard was not responsible for R1, but she (V5) couldn't pee (sic) on herself, therefore V5 left R1 with the security guard. V5 stated she had been told never to leave a resident while escorting the resident to an appointment, but V5 stated she could not pee (sic) on herself, so she asked the hospital security guard to watch R1. V5 stated she was trained/in-services on safety and how to take care of the resident while out on escort about three months ago. V5 stated R1 could been hit by a car, R1 might not have been found, or R1 could have consumed something he is not supposed to, which could have affected R1 heath. On 06/20/2024 at 11:26am, V2 (Director of Nursing-DON) stated R1 went to an outside appointment with V5 (Escort) because he has dementia and confusion and R1 needs supervision because of his mental status. V2 stated she received a call from V4 who informed V2 that V5 had told her that R1 had wandered away from V5. V2 stated she informed V1 and V1 told all management staff to go to the hospital where R1 had the appointment and start looking for R1. V2 stated she went to the hospital and was driving around the building trying to see if she could locate R1. V2 further stated that V7(Housekeeping supervisor) informed V2 that the campus/hospital security had looked at the cameras and R1 was observed on the cameras walking out the exit doors. V2 stated she kept driving around looking for R1 until she received a call from one of the facility's search team (V2 cannot remember who) informing V2 that R1 had been located at R1's old address. V2 stated she drove to the police station to see R1 and stay with R1 and brought R1 something to eat. V2 stated V2 and R1 waited for transportation from the facility. together to come pick R1 up. V2 stated R1 told V2 that (R1) was going home and told V2 that he took the bus. V2 stated R1's family no longer lives in address R1 went to. V2 stated V5 was supposed to always stay with R1 because R1 is confused and the purpose of V5 accompanying R1 to outside appointment was to watch R1 and keep him safe. V2 stated R1 could have been lost and not found, R1 could have been hurt by someone, or R1 could have walked into traffic and got hit by a car. V2 stated so many bad things could have happened to R1 when R1 was left unaccompanied. On 05/20/2024 at 10:40am, V4 (Memory Care Coordinator/Transportation Trainer) said residents who have low cognitive abilities with diagnosis of diseases such as Dementia , Alzheimer's, residents at risk for elopement, residents who wander and residents who are on yellow and red community pass need an escort when leaving the facility so that the escort can assist the residents and keep them safe while out of the facility. V4 stated the escort cannot leave the resident alone, and if the escort needs to use the restroom, the escort can only leave the resident when the resident is in the care of doctors/nursers during the appointment. V4 stated the escort cannot leave a resident with a security guard at a community hospital because it is not the responsibility of the security guard at an outside facility to watch facility residents. V4 said she would not expect an escort to leave a resident with an outside security guard because that is neglect. V4 stated she was off on 6/10/2024 when R1 was left with a security guard by V5 (Escort) during an outside appointment. V4 sated she received a call from the facility front desk letting her know V5 just called the facility stating R1 was not in V5's view at a community hospital. V4 stated she called V1(Administrator) and V2 (Director of Nursing-DON) and told them that V5 did not know where R1 was. V4 stated she was off duty and was eight minutes away from the community hospital, so she went to the hospital to help V5 look for R1. V4 stated when she got the hospital, she called 911 to report R1 was missing. On 06/20/2024 at 12:32pm, V8 (Director of Social Services) said R1 disappeared during R1's outside the facility medical appointment. V8 said she heard V5 (Escort) had gone to the bathroom and left R1 with the hospital security guard, and when V5 come back, R1 was gone. V8 stated it is not the responsibility of the hospital security guard to keep R1 safe because R1 is not the hospital's resident. V8 further stated it would have been different if V5 had left R1 with someone providing care for the R1 such as the doctors, nurses, Certified Nursing Assistants -CNAs or anyone who was involved with R1's appointment at that time, because that person would have been responsible for R1's safety. V8 stated if a person has memory loss, diagnosis such as Dementia, Alzheimer's, extreme behaviors such and promiscuous related to mental health issues, they will need an escort while going out of the facility for outside services. V8 stated social services does the Community Survival Assessment to determine the eligibility for community access and assess if the resident is are independent, supervision or is restricted for community pass privileges, even when going to appointments. V8 stated the Community Survival Assessment is completed quarterly, and if a resident is on supervision or restricted pass, they cannot leave the facility without being accompanied by a family member of a staff member for safety and to ensure the resident is provided with the support they need such as monitoring their baseline and making sure the resident can function while out in the community. V8 stated R1 should not have been left alone because of his diagnosis. V8 stated R1 could have wondered into traffic and got hurt, could have been harmed or harmed someone else. V8 stated it was not acceptable for V5 to leave R1 alone unattended while outside the facility. On 06/20/2024 at 2:09pm, V9 (Psychiatric Rehabilitation Services Coordinator) said she has worked with R1 for a short period of time and completed R1's Community Survival Skills Assessment after R1 had disappeared at the hospital during his appointment on 6/10/2024. V9 stated R1 wears a wander guard because R1 had diagnosis of dementia, Wernicke's encephalopathy, depression and, and R1 is confused at sometimes to time and place and is often looking for his family. V9 stated R1 should be supervised at all times when out in the community because R1 can get lost, and R1 if R1 walks around the block he would not know where he is, and R1 can wander to unsafe areas. V9 further stated that R1 is not aware he lives in a long-term care facility and does not remember the address of the facility and does not know he(R1) is in a long-term care facility. V9 stated R1 is on a yellow pass, which means R1 cannot leave the building alone because R1 always needs supervision. V9 stated the community survival skills assessments documents the resident's recommendation for being in the community and notifies the nursing staff the level of care a resident need while out in the community. On 06/20/2024 at 2:52pm, V17 (transportation) stated on 6/10/2024 at 11:45am, V5 (Escort) called V17 while V17 was at the reception filling in for the receptionist and V5 stated she (V5) did not know where R1 had gone to after R1's appointment at the hospital. V17 stated V5 told V17 that she (V5) had asked the security guard at the hospital to watch R1 as V5 went to the bathroom, but when V5 come back, R1 was not there. V17 stated she called V2 and V4 and let them know that V5 had called V17 stating R1 was missing. V17 stated she volunteered to go assist in looking for R1 and V17 called the hospital while en-route to the hospital and spoke to a nurse (No Name) who stated they would notify the campus police that R1 was missing from the hospital. V17 stated after a while the nurse called V17 back and stated the campus/hospital security were looking for R1. V17 stated she drove around the hospital looking for R1 and could not find him, therefore V17 come back to the facility and found all the department heads in a meeting discussing R1 missing, and there after the department heads left to go look for R1 at the hospital. V17 stated approximately 5:55pm V17 was informed R1 had been found, but she does not remember who informed her. V17 stated when transporting a resident to appointments, the resident cannot be left alone because they can wonder off, they can get hurt, and when R1 was lost, there was a lot of construction going on in the hospital and R1 could have fallen in one of the open holes and got hurt. V17 stated R1 has a wander guard for a safety, but it only works when R1 is in the facility, and the wander guard does not work outside of the facility. V17 stated for residents with memory loss, the staff must always keep them within eyesight for safety, especially while outside the facility. R1's nursing progress notes dated 06/10/2024 documents: -R1 went to R1's regular appointment at a nearby hospital and was accompanied by an escort (V5). -R1 wandered off his scheduled doctor's appointment. R1's facility summary dated 6/10/2024 documents: -R1 left facility with V5 for appointment at a community hospital at 9:30am -V5 asked the hospital security guard to watch R1 and V5 went to the bathroom. At 11:30am, V5 come out of the bathroom and R1 had walked off. The hospital security guard told V1 that he (Security guard) was not responsible for R1. -At 3:30pm, police called the facility and stated R1 was found 10 miles from the hospital. -At 5:30pm, V2 picked up R1 from the police station and took R1 back to the facility. R1's Physician order Sheet (POS) documents: 10/31/2022 -Wander guard- Check for placement and functioning every day and night shift 3/6/2024-Appointment on the June 10th Monday 9.30am {arrived by 9.15 am} (liver center) 6/22/2023-Yellow Pass-May have community pass with supervision. Policy titled Physician Visits for Medical Specialties Outside of the facility dated 06/16/12 documents: -The scheduler makes transportation and escort arrangements as necessary. Policy titled Missing Resident/Elopement dated 4/5/2023 documents: -It is the policy of the facility to provide a safe and secure environment for all residents. Purpose: -To ensure the safety and security of all residents -to educate and maintain staff awareness of the importance of resident safety and security. R1's Community Survival Skills assessment dated [DATE] and 9/27/2023 documents: -R1 is currently assessed as appropriate for YELLOW PASS privileges d/t (due to) dx (Diagnosis) of dementia and medical dx. -R1 incapable of caring for self independently in the community and requires accompaniment at all times.

Based on interview and record review the facility failed to follow their change of condition policy and assess one resident [R2] with an acute change in condition and failed to call 911 when the resident's condition worsened. This failure resulted in R2 experiencing an acute change in condition, and a delay in receiving a higher level of care. This was identified as an Immediate Jeopardy which began on [DATE]. On [DATE] at 10:09 AM, the administrator was notified of the immediate jeopardy. The immediate jeopardy was removed on [DATE]. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. Findings include, R2's clinical record indicates but not limited to; R2 was a [AGE] year-old with medical diagnosis of asthma, cerebral infarction, type 2 diabetes, dysphagia, oropharyngeal phase, dementia, unsteadiness on feet, dependence on renal dialysis, essential (primary) hypertension, bipolar disorder, anemia, insomnia, acute myocardial infarction, and weakness. R2's Emergency Department History and Physical Note dated [DATE] at 2:14AM, documents in part: R2 presents to the emergency room from nursing home for three days of hiccoughs as well as appearing lethargic and having oxygen desaturations. Final Disposition: R2 full admission to ACU [Acute Care Unit. Diagnosis: Acute respiratory failure with hypoxemia [low blood oxygen levels], AMS [Altered Mental Status], Hiccups [involuntary spasms of the diaphragm], SIRS [Systemic inflammatory response syndrome- life threatening medical emergency], Elevated lactic acid [decrease oxygen delivery]. R2's EMS (emergency medical systems) report documents in part: Narrative: RN (registered nurse) reported patient having prolonged hiccups, lethargic, hypotension (not baseline) and oxygen saturation being low Vitals in transit, patient oxygen levels rapidly declining. R2's progress notes document in part: Nursing Progress Note, Effective Date: [DATE] 21:30:00, Department: Nursing, Created By: V7 [Registered Nurse], Created Date: [DATE] 00:36:49 [DATE] 21:30-Nursing Progress Note: Note Text: NOD [nurse on duty V7] observed that the patient is lethargic but arousable @ times, continuous hiccup. Assessed right away, Vital signs taken & recorded, T [temperature]98.4 , P [pulse] 100, R [respirations] 18 , B/P [blood pressure] ,d+[DATE] , O2 sat.[oxygen saturation] ranging from 82 % to 90 % , Oxygen @ 4 L [liters] / nasal cannula administered ,increased to 96 % with O2 [oxygen] , on close monitoring , color is not good , skin slightly moist Referred to V22 [R2's Physician] with tel. (telephone) order to send the patient out to hospital for ER evaluation ,order carried out right away . All paper works were made, DON [V2] notified, message left to R2's family member [V11], facility's contracted ambulance company called with an ETA [estimate time of arrival] of ,d+[DATE] hours, report given to ER [emergency room ] nurse. Nursing Progress Note, Effective Date: [DATE] 21:45:00, Department: Nursing, Position: Registered Nurse, Created By: V7 [Registered Nurse], Created Date: [DATE] 17:58:29 Late Entry: Note Text, Note Text: @ 2145 hrs.[hours], writer [V7] checked on patient [R2}, A/O x ,d+[DATE], verbally responsive, on continuous pulse oximeter @ bedside saturating @ ,d+[DATE] percent with oxygen. Denies any chest pain nor chest discomfort. & 2200 hrs. vital signs as follows T 98.0 tympanic P 83, R20, B/P ,d+[DATE] Right arm lying, O2 saturation of 97 percent. Offered a carton of Nepro & he took 90 percent. @ this time patient is stable & able to sleep fairly. @ 2300 hrs. patient O2 Saturation remains 97 percent, PR 80, RR 20 B/P ,d+[DATE]. (RA) lying, @ 2430 hrs. patient is awake & able to move his upper & lower extremities within normal limits. [R2's change of condition was on [DATE]. R2 expired on [DATE]. V7's progress note was entered 4-days later ([DATE])] [DATE] 06:37 V7's Nursing Progress Note: Note Text: NOD [V7] called Hospital & the patient [R2] is being admitted with an admitting diagnosis of acute respiratory failure with hypoxemia [ low oxygen] and elevated troponin per nurse. R2's SBAR [Situation, background, assessment and recommendation] dated [DATE], documented by V7 [Registered Nurse] documents in part: -Change of condition symptoms: lethargy, continuous hiccup and desaturation, since this started it has stayed the same. -Mental status: Altered level of consciousness -Code Status: Full Code On [DATE] at 9:59 AM, V11 [R2's Family Member] stated, On [DATE] at 6:30 PM, I received a call from the hospital acute care unit nurse. She said R2 arrived on [DATE] around 1:30 AM, in respiratory failure, and low blood pressure. I was informed R2 arrived at the emergency department very sick. I stayed at the hospital with him, and on [DATE], R2 passed away. I left the hospital and went to the nursing facility for answers. I spoke with V1 [Administrator] and V2 [Director of Nursing], they told me on [DATE] around 9:30 PM, the nurse noted R2 with low oxygen levels, started on oxygen, R2 was stable and sent to the hospital emergency department. V1 and V2 said V22 [R2's Physician] gave an order to send R2 to that specific hospital emergency room and the nurse[V7] and ambulance service company followed the physician order. I expressed to V1 and V2, they made no common sense to me. If R2 was stable, then why did the physician give the order to send a stable resident to the hospital emergency department. From the nursing home facility which is located on the north side of Chicago and transported R2 to a south side of Chicago hospital which was 19 miles away from each other, bypassing several closer hospitals that was terrible. R2 arrived at the hospital over 4 hours later in respiratory failure. V1 and V2 seems not to understand, a delay in transport means a delay in R2 receiving medical treatment, just maybe R2 would still be alive, all V7 had to do, was call 911. On [DATE] at 12:36 PM, V7 [Registered Nurse] stated, I have been a registered nurse for twelve years. I am familiar with R2. Some of R2's medical diagnosis was asthma, high blood pressure and on renal dialysis due to kidney failure. I was R2's nurse on [DATE]. Around 8:30 PM, I noted R2 was lethargic but arousable sometimes, like he was sleeping and hard to wake him up, and R2 would not stay woke for long. R2 had continuous hiccups sound like making gasping air sounds. R2's oxygen level was around 80 to 83% on room air, I started oxygen at 4 liters per nasal cannula and R2's oxygen level increased to 96%. However, R2's skin was gray in color, wet and sweaty. At 9:15PM, I called V22 [R2's Facility Physician] and received an order to send R2 to the hospital for an emergency room evaluation. I completed all R2's needed paperwork and then I phoned V2 [Director of Nursing], V11 [R2's Family Member] there was no answer, so I left a voice mail. Next, I phoned the facility's contracted ambulance company around 9:20 PM, for R2's transport to the emergency room . The ambulance company told me there would be a two-to-three-hour estimate time of arrival. I phoned the hospital emergency department and gave report to the registered nurse. I did not call V22 or V2 to notify them that transport was not available for at least two-to three hours. I monitored R2 closely to make sure he was okay. [Surveyor asked V7 why she [V7] noted R2's vital signs and monitoring noted in the chart four days later (dated [DATE] at 17:58), and how did she remember the exact times and vital signs readings that was documented in R2's chart] V7 stated, I did not place the note in on [DATE], I completed the note on [DATE]. Surveyor explained the late entry was shown effective date was [DATE] at 21:45 [9:45 PM], but the note create date was [DATE] at 17:58 [5:58PM]. V7 stated, Oh Wow, I did not know you could see the note was typed on [DATE], this is too much. I don't know why I placed the note in four days later, you need to ask V2 [Director of Nursing] why I placed in the note four days later and where I got the vital signs from, I have nothing else to say. On [DATE] at 11:06 AM, V7 [Register Nurse] stated, I observed R2 with a change in condition around 8:30PM. R2 was making continuous hiccups sounds, skin was looking greyish and moist, heart rate was elevated, oxygen saturation levels were between ,d+[DATE]%. R2 was not stable, he was in respiratory distress, that's why I administered [R2] 3 liters of oxygen per nasal canal and completed a change in condition assessment. R2's oxygen level went up to 96% while on 3 Liters of oxygen, he looked better, but his hiccup sounds continued. I received the physician order to send R2 out the hospital emergency department around 9:15 PM and called the ambulance company right away for transport. I don't why the ambulance report sheet documents I called at 10:26 PM, I'm pretty sure I called right away, I don't remember the time I called. The ambulance company told me it would be a 2-to-3-hours estimate time of arrival. I did not notify the physician [V22] or director of nursing [V2] of the estimated time of arrival from the ambulance, because I felt that R2 was okay to wait 2 to 3 hours to be transported. I monitored R2 closely, about every hour. My late entry progress effective date of [DATE] at 21:45:00 [9:45 PM], was placed in R2 clinical record on [DATE] 17:58:29, the oxygen saturation levels were charted, I forgot to put the amount of oxygen R2 was receiving. R2 was receiving 3 Liters of oxygen. When any resident has a change of condition it is up to the individual nurse how often the resident is monitored. I had to check on my other residents as well and I was busy providing care to other residents. On [DATE] at 1:27 PM V24 [Basic Emergency Medical Technician (BEMT)] stated, Upon arrival to facility V7 gave me report on R2 and said R2's oxygen had dropped down to 92% and administered oxygen per nasal cannula, and R2 had excessive hiccups for a few days. Upon my assessment R2 was in bed sitting up, R2 was lethargic, incoherent, unable to speak clearly, increase in heart rate and wheezing in bilateral lungs. V7 told me that was R2's base line orientation and vital signs, but the oxygen was new. V7 did not tell me in report that R2's oxygen earlier had dropped to 82%. If I would have received that information in report, I would have called our advance life support, if they were too far out the I would have called 911 and stayed with R2 until 911 arrived. V23 [Basic Emergency Medical Technician (BEMT)] and I are not trained to provide advanced life support. R2 needed to be placed on a cardiac monitor, and intravenous line accessed. Once a person oxygen drops down that low, they are in respiratory distress even if the oxygen came back up with supplemental oxygen. On [DATE] at 1:01 PM, V23 [Basic Emergency Medical Technician (BEMT)] stated, V24 [Basic Emergency Medical Technician] and I arrived at the facility. R2 was alert and oriented x,d+[DATE], V7 said R2's normal orientation was x,d+[DATE], he had a decrease in alertness. R2 was trying to communicate but was not coherent. R2 was receiving ,d+[DATE] liters of oxygen per nasal cannula upon our arrival. R2's blood pressure was reading low, and V7 said R2 usually have a low blood pressure and that was his baseline. Due to V7 telling V24 and I that R2 was at his baseline, we felt comfortable transporting R2. V24 and I are BEMT, meaning we provide basic support, such as oxygen, and to monitor the residents' basic vital signs. On [DATE] at 11:32 AM, V12 [ Contracted Ambulance Company-Assistant General Manager] stated, According to R2's Patient Care Report dated [DATE]. The facility staff nurse phone dispatch on [DATE] at 22:26 [10:26 PM] and requested ambulance service to a specific emergency room department per physician order. Facility nurse was made aware there would be a two-to-three hour wait for transport. The ambulance arrived at the facility on [DATE] at 00:25 [12:25 AM]. The ambulance crew was in direct contact with the resident at 00:30 [12:30 AM. The ambulance left the facility at 01:02 AM. R2 arrived at the hospital emergency room at 1:38 AM. [V22 gave physician order to send R2 to the hospital at 9:15 PM, V7 phoned the Contract ambulance company at 10:26 PM, noted a one-hour delay to call for ambulance transport. At 1:38 AM, R2 arrived at the hospital 4-hours later diagnosed with acute respiratory failure.] On [DATE] at 12:22 PM V26 [Register Nurse (In house Contracted Dialysis Unit)] stated, I am very familiar with R2. He [R2] receive dialysis five times per week, Monday thru Friday. On [DATE] was on a Saturday, R2 did not receive dialysis on that day. R2 last day he received dialysis was on [DATE], and he tolerated dialysis well, and all vital signs were stable before and after dialysis. According to R2 clinical dialysis record, there is no documentation that R2 has ever needed oxygen during dialysis treatments. Vital signs such as blood pressure, heart rate, respirations, oxygen saturations, and temperature are monitored before, during treatment every fifteen minutes and after dialysis treatment. All of R2's vital signs were stable on the last day he received dialysis [DATE]. On [DATE] at 1:43 PM, V2 [Director of Nursing] stated, On [DATE] R2's family member V11 came into the facility yelling, crying, and very upset that R2 had expired. I calmed her and we sat down in the conference room to talk. V11 was upset that R2 was transported so far away from the facility bypassing several other near hospitals. I explained nurses follow the physician orders and send the resident where the physician request the resident to be sent unless it is a 911 situation. When any resident is at their baseline that means they are at their normal status, they are stable. R2 was not on oxygen according to his chart. On [DATE] R2 was given 4Liters of oxygen because he was noted with a low oxygen level. Once R2 received oxygen, is became stable. No, it was not R2's baseline to receive oxygen, but I asked V7 twice, was R2 stable and she told me yes. I have not spoken to V22, I do not know why he did not order the mobile services, since R2 was stable. If R2 had a change in condition, then V7 knew to call 911. I am not sure why V7 said to ask me why she [V7] placed in a progress note on [DATE], with times and vital signs for [DATE]. I did not tell V7 to place in a progress note four days later after the event, nurses have 72-hours to place in a late entry. V7 should have documented at the times she [V7] assessed and monitored R2 with the times and vital signs readings. V7 did not notify me that there was a three hour wait before the ambulance could transport R2. On [DATE] at 2:52 PM, [Telephone Interview] V2 stated, On [DATE], V7 called me after all measures was in place. V7 told me R2's assessment, and after applying the oxygen R2 was stable, so I did not recommend V7 to call 911. During an acute change of condition, R2's vital signs should've been taken a few times within each hour, even if he [R2] became stable, to ensure R2 remained stable. R2'S vital signs should have been documented soon as possible in the resident's progress notes. [Surveyor read the policy to V2-The change of condition policy reads in part; a significant change in condition is a decline, that will not normally resolve itself without interventions by staff or clinical interventions and during medical emergencies such as unstable vital signs, or respiratory distress 911 will be notified for transport.] V2 stated, I understand the policy, however, once R2 was receiving 4 liters of oxygen he became stable, and V7 should not have phoned 911. The change of condition policy was not followed in terms of calling 911, that was because R2 became stable, there was no reason to call 911. The ambulance company said it was going to be a 2 to 3hour wait, but V7 knew to call 911 if R2 was not stable. On [DATE] at 12:23 PM, V22 [R2's Facility Physician] stated, Baseline means any resident is at their highest level of functioning, residents are stable at their baseline. On [DATE], V7 phoned me and said R2's oxygen level dropped a little like 91 to 92%, V7 administered oxygen, and R2 was now stable. I gave an order to send R2 to a specific hospital emergency room because that is the hospital where R2's primary care physician is on staff, and I told V7, if R2's condition changes to call 911. I did not order the facility's mobile services, because due to R2's medical history with asthma, I felt he needed to assess by a physician sooner than later. Some residents with low oxygen levels may require intubation. [Surveyor read V7's progress note dated [DATE] at 21:30 to V22.] V22 stated, Oh my goodness, V7 absolutely did not tell me that R2 was lethargic, continues hiccups, elevated heart rate, oxygen saturation in the 80's, skin color was not good, and skin was moist. I would have called 911 myself. I would have told V7 to call 911 for immediate care, treatment, and transport. V7 did not notify me that the ambulance service was going to be two-to-three hours getting to the facility. V7 should have called 911 for R2, he was not stable. I am so sorry that R2 expired. V7 did not tell me all the information stated in her [V7] progress note ([DATE] at 21:30), V7 should have called 911. On [DATE] at 11:18 AM, V1 [Administrator] stated, On [DATE] V11[ R2's Family Member] came into the facility very upset. Requesting information regarding the ambulance run sheet. I called V12 [Contracted Ambulance Company-Assistant General Manager] and went over the details. V12 emailed me a copy of the report. Corporate told me I could not give V11 a copy, she had to obtain her own copy from the ambulance company. I don't understand what the problem is, the ambulance sheet stated, that R2 was stable on the first sentence, that says it all. Facility Policy: Change in Resident's Condition or Status [No Date]. Document in part: -A significant change in condition is a decline that will not normally resolve itself without intervention by staff or clinical interventions -The Nurse will notify the resident's attending physician when there is a significant change in the resident's physical, mental or psychological status. Except: In medical emergencies, notifications will be made within 24-hours of a change occurring in the resident's condition or status. During medical emergencies such as unstable vital signs, respiratory distress, uncontrolled bleeding, and unresponsiveness 911 will be notified for transport to the hospital. Facility Registered Nurse Job Description: documents in part: -The registered nurse provides direct nursing care to the residents, carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations -Chart nurse notes in an informative and descriptive manner that reflects the care provided to the resident -Notifies the resident attending physician when there is a change in the resident's condition -Must be able to relate information concerning resident's condition The immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: All residents are at risk for a change in condition were assessed for an acute change in condition. V2 and V27 initiated education on [DATE]. All licensed and registered nurses will be in-serviced on the following topics: When a resident experiences an acute change in condition, the nurse will assess the resident utilizing the SBAR per policy and procedure & If resident is observed with an unstable or worsening vital sign and/or shows respiratory distress, 911 will be notified immediately. Newly hired nurses will be in-serviced prior to working on the floor. Agency nurses will not be permitted to work until they have completed such in-services. A QAPI meeting was held by V1 [Administrator] for the IDT and the medical director on [DATE]th, 2024, to discuss the points of the POC (plan of correction). Audit tools were created on [DATE] to monitor that licensed and registered nurse properly assess residents during an acute change in condition per policy and procedure and if resident is observed with unstable or worsening vital sign and/or respiratory distress, 911 will be notified immediately. Beginning [DATE] audit tools to monitor that will be reviewed 3 times a week for 2 weeks, then beginning [DATE] for 2 times a week for 2 weeks, then beginning [DATE] monthly for 3 months. QAPI committee which meets monthly will review for compliance and determine that compliance has been met. Any concerns will have been addressed. However, any patterns will be identified. If indicated, an Action Plan will be written by the QAPI Committee. Any Action Plan will be monitored weekly by the V1 [Administrator] until resolved.

Based on observation, interview and record review, the facility failed to manage R2's pain by not following physician orders to schedule a consultation at the pain clinic. This failure resulted in R2 experiencing dental pain rated as 10 out of 10 on a numerical rating pain scale, resulting in the pain radiating and R2 experiencing headache. Findings include: R2's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: paraplegia, type 2 diabetes mellitus with unspecified complications, local infection of the skin and subcutaneous tissue, neuromuscular dysfunction of bladder, gastro-esophageal reflux disease without esophagitis, anxiety due to known physiological condition, acute kidney failure. MDS section C (09/04/2023) documents that R2 has a BIMS score of 15, indicating that R2's cognition is intact. Care plan (dated 08/23/2023) documents that R2 is at increased risk for alteration in pain/discomfort related to skin or tissue impairment, other generalized pain, wound chronic disease process, neuropathic pain, circulatory impairment, musculoskeletal impairment, chronic physical or psychosocial disability. On 11/28/2023 at 10:30am, R2 stated, I am not getting my pain medication. I was admitted to the facility in August, and since August I have not been receiving the Oxycodone. I have pain that is severe. My pain is 10/10 due to my teeth, and when I ask for the Oxycodone, they tell me that the doctor did not write the script for the Oxycodone, and the only thing they offer me for pain management is Tylenol. The Tylenol brings down my pain from 10/10 to 9/10. I asked the doctor on many occasions for the pain medication, and he did not write the script since August. I have been telling the doctor that I am in a lot of pain due to my teeth, and since I am not getting the pain medication, the pain radiates to my head, resulting in headaches. The pain is so bad, that I get headaches from not getting the Oxycodone. I kept asking the nurses for the Oxycodone, and the nurses reached out to the physician and either the physician does not call back or ignores the request for the pain medication. I was ignored by my physician many times when I requested the Oxycodone. Since August, I have been ignored and my pain has not been managed and it got to the point that I am experiencing headaches from the severe pain. I have not been referred to the pain clinic. During medication administration on 11/28/2023 at 11:02, surveyor observed R2 complaining of pain on a scale of 10/10. Surveyor observed V3 (licensed practical nurse) administering Tylenol to R2 for pain management of 10/10. On 11/28/2023 at 11:03am, V3 (licensed practical nurse) stated, R2 has been complaining of severe pain and the only medication I can give R2 is Tylenol. R2 has an active order for Oxycodone since 08/21/2023, but the doctor did not write the script. I called the doctor's office on several occasions, and I did not receive a call back. When I saw the doctor during rounds, I informed the doctor that R2 is having severe pain and the pharmacy will not fill the Oxycodone without a script. The physician did not want to write the script despite me asking several times. I am not sure why the doctor did not write the script, but I asked several times and R2 asked the doctor several times as well. R2 complains of pain due to his teeth and eventually causing headaches. R2 states that the pain is 10/10 and I can only give him Tylenol because that is the only pain medication that I can give R2 without a script for the Oxycodone. On 11/28/2023 at 11:20am, V4 (assistant director of nursing) stated, R2 has a PRN order for Oxycodone and R2 has not been receiving this medication. The Oxycodone was ordered on 08/21/2023, and the doctor did not write a script for it and that is why R2 is not receiving the medication. If a resident has an active order for the PRN Oxycodone, the resident must have an active script from the physician which the pharmacy needs. R2 does not have an active script for the prn Oxycodone. Nobody informed me that R2 needs a script for the pain medication. I was not aware that R2 is experiencing severe pain and that he is not receiving the Oxycodone because the physician did not write a script for it. I was not aware that R2 was not receiving the Oxycodone since his admission in August, and I was not aware that R2 needed a script. If I knew, I would have taken care of this matter immediately. I was also not aware that V3 (licensed practical nurse) attempted to call the doctor's office to obtain the script and that V3 did not receive a call back. The doctor may not have written a script for the Oxycodone because the doctor may want R2 to go to see a pain specialist. R2 has not been seen by a pain specialist since he admitted . On 11/28/2023 at 1:22pm, V6 (social services coordinator) stated, When R2 was first admitted , he complained about not receiving his pain medication. R2 was specifically complaining of tooth pain and mentioned that R2 is not receiving his pain medication. On 11/28/2023 at 2:52pm, V7 (R2's physician) stated, Oxycodone is a controlled medication and we have to get a pain specialist to see the resident and write the script for this medication. Oxycodone is a medication that is controlled and should be ordered by the pain specialist. Oxycodone is a scheduled C2 class of medications, and it has to be prescribed by a pain specialist due to the opioid overdose pandemic. R2 should have been scheduled to see the pain specialist, so that R2 could receive the Oxycodone, but he was not scheduled. This medication is very addictive, and a pain specialist should write this script. On 11/30/2023 at 12:55pm, V11 (transportation) stated, I did not schedule R2 for a pain consultation. The order must not have been on our dashboard. For the physician order to appear on the dashboard, the nurse must write a note on the dashboard, and I will see it and schedule the resident for the appointment. R2 was never scheduled for the pain consultation because I did not see the order. The order for R2's pain consultation was placed on 09/09/2023, but I made a mistake and overlooked the order, and R2 was never scheduled. R2's Order (dated 08/21/2023) states: Oxycodone-Acetaminophen Oral Tablet 5-325 MG (Oxycodone with Acetaminophen) (milligrams) *Controlled Drug*. Give 0.5 tablet by mouth every 6 hours as needed for pain. Review of R2's Medication Administration Record (08/21/2023 to 11/28/2023) indicated that R2 did not receive a single dose of Oxycodone-Acetaminophen Oral Tablet 5-325 MG. R2's Physician Order (dated 09/09/2023) states: Refer for pain consult. R2's Progress Note (dated 10/3/2023) documents, The writer was informed that he complain of headache staff gave the pt. Tylenol 2 tabs and staff page the np (nurse practitioner), the operator pick up number and promised to call back to the writer, which never happened. Endorsed to the incoming nurse. R2's Progress Note (dated 10/16/2023) documents, Resident has been complaining of Dental pain, appointment scheduled for today 10/16/23 at (dental office) at 1030. Resident declined to go, stating he was up all night unable to sleep and does not feel up to an appointment at his time. Transportation notified; she will reschedule the dental appointment. Progress Note (dated 11/28/2023) documents, The resident was seen today at the bedside by (Physician), and these following orders were given Lantus 15 units HS (evening), Pain consultation with (pain clinic physician), and Cardiology consult with (cardiac physician). Orders were carried out. Guidelines for Pain Management (09/01/2023) states: It is the intent of the facility to promote resident independency, comfort, and to preserve resident dignity in an ongoing effort to promote the highest level of quality for their lives. One aspect of this commitment is to maintain an effective pain management plan to provide residents the means to receive necessary comfort, exercise greater independence, and therefore enhance their overall welfare and well-being.

Based on observations, interviews and records review, the facility failed to (a) ensure resident safety by allowing a medically compromised resident (R1) out on a community pass without a medical provider authorization/order, (b) notify the police of missing resident (R1), and (c) thoroughly investigate the location of R1 after R1 did not return to the facility. Resident (R1) of 3 residents reviewed for community pass supervision. This failure resulted in R1 being hospitalized in the intensive care unit (ICU). According to medical records dated [DATE], R1 remained in a coma for 14 days. R1's family made the decision to discontinue life support for R1 and R1 expired 2 days later. Facility observed to have secured front door entry/exit-electronically controlled by front desk staff. This was identified as an Immediate Jeopardy which began on [DATE]. On [DATE] the administrator (V1) was notified of the immediate jeopardy. The immediacy was removed on [DATE]. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. Findings Include: Face sheet dated [DATE], documents that R1 is a [AGE] year-old female with diagnoses not limited to: Bipolar disorder, End-Stage Renal Disease (ESRD), dependence on renal dialysis, cognitive communication deficit, opioid dependence, unspecified atrial flutter, anemia, cardiomegaly, unsteadiness on feet, weakness, and anxiety disorder. R1's MDS (Minimum Data Set) dated [DATE], documents that R1 has a BIMS (Brief Interview for Mental Status) of ,d+[DATE] indicating that R1 is alert and oriented x2 and moderately cognitively impaired. R1's Activities of Daily Living (ADL) Assistance documents that R1 requires extensive assistance with bed mobility and transfer, requiring two+ persons' physical assist. R1's ADL Assistance also documents that R1 requires extensive assistance with locomotion on/off the unit, dressing, toilet use, and personal hygiene, requiring one-person physical assist. R1 is frequently incontinent of bowel and bladder. R1's MDS dated [DATE] documents that walking activity for R1 did not occur. R1 is not steady, only able to stabilize with staff assistance with moving from a seated to standing position, moving on and off the toilet, and surface-to-surface transfer (transfer between bed and chair or wheelchair). The activity of walking 10 feet, car transfer, and going up/down a curb was not attempted due to R1's medical condition or safety concerns. R1 utilized a manual wheelchair and required substantial/maximal assistance with [NAME] 50 feet with two turns and [NAME] 150 feet. R1 has a history of recent hospitalization s within recent months since being admitted to the facility. R1's admitting diagnoses while hospitalized includes, but not limited to chest pain, shortness of breath, fluid volume overload, and hypertensive urgency. R1 is power of attorney (POA) for herself and makes her own decisions. R1's Physician order sheet (POS) documents Hemodialysis 5 times per week on MON-TUE-WED-THUR-FRI Venous Access Site: Left Chest Perma Cath Venous Access Site care and dressing change during dialysis days and as needed (per dialysis). R1's physician order sheet (POS) does not document a physician order for R1's community pass. On [DATE] at 2:23pm during a telephone interview, V5 (R1's family member #1) stated I received a call from the facility/nurse on [DATE] informing me that R1 went out on pass and did not return. R1 could not walk and was on dialysis. The facility asked me if I knew where R1 was. V5 stated that he was annoyed that the facility allowed R1 out on pass. V5 stated that R1 had a drug abuse problem and that he was trying his best to get R1 back on the right track. V5 stated that he commented to the nurse I did not even know that R1 had left the facility at all. V5 stated The facility/nurse told me that R1 left with my family member (V8-/R1' family member #2) but I spoke with V8 and V8 informed me that he did not pick R1 up from the facility. V8 told me that R1 left with an old friend (identified as R1's friend/V10) who also has a history of drug abuse. I received a call from Hospital C the next day on [DATE]. Hospital C informed me that R1 had a heart attack, needed cardiopulmonary resuscitation (CPR), and was in the intensive care unit (ICU) in a coma, on life support, unable to breathe on her own and in a vegetative state. V5 stated, after 2 weeks, our family made the decision to pull the plug and take R1 off life support on [DATE]. R1 expired on [DATE]. Death certificate documents R1's date of death [DATE]. Cause of death: Non-Traumatic Respiratory Failure, Non-Traumatic Anoxic Brain Injury, and Cardiac Arrest. R1's care plan dated [DATE] states in part, Obtain a physician's order for outside pass privilege. R1's care plan documents that R1 is care planned for: refusing to attend dialysis, risk for cardiac distress, substance abuse, impaired decision making, signs/symptoms of delirium, requiring psychotropic medication, impaired mobility, risk for falls, and risk for abuse. On [DATE] at 2:17pm during a telephone interview, V3 (R1's Physician) stated that he cannot recall if R1 had an order to go out on pass. V3 stated that he could not give surveyor information that he did not know and referred surveyor to speak with V4 (R1's Nurse Practitioner) instead since V4 visited/assessed R1 more often than he did. On [DATE] at 2:51pm during a telephone interview, V4 stated Yes, I am the one who visits/assess R1 at the facility. R1 has end-stage renal disease and requires dialysis. R1 also has a history of heroin abuse and frequently asks for pain medication. I was not made aware that R1 had gone out on pass. I don't know who gave R1 a pass to go out in the community. V3 and I did not give any orders for R1 to go out on pass. We were not informed that R1 had left the facility against medical advice (AMA). I never knew R1 had a community pass. I visit the facility every week on Wednesdays and was not informed of R1 being out of the facility until I visited the facility the following Wednesday on [DATE]. That is when I was made aware that R1 went out on [DATE] and never returned to this day. On [DATE] at 3:13pm during a telephone interview, V8 (R1's family member #2) stated I spoke to R1 on the phone that day and R1 told me that a photo ID was needed to provide it to the facility to take R1 out on pass. I spoke with V10 (R1's friend) on the phone on [DATE] after V10 picked R1 up from the facility. V10 told me that he picked up R1 from the facility on [DATE] and did not provide any form of identification to the facility. V10 is an old roommate of R1. An attempt to contact V10 via telephone was made on [DATE] at 3:20pm. Surveyor left voicemail with contact information, awaiting call back. On [DATE] at 1:58pm, V7 (Dementia Care Coordinator) stated I've been in this role as the Dementia Care Coordinator since [DATE]. I work alongside social services and help in that area. Green passes are guided by physician recommendations, and the doctor let us know if it is reasonable for the resident to go out into the community. If a doctor approves a resident to go out on pass, then either the nurse or the doctor will put the order in the physician order sheet (POS). This is how everyone knows if a resident can go out on pass or not. Before a resident goes out on pass, the protocol is for the resident to obtain the pass from the nurse, then take the pass down to the receptionist to show them, then that resident can leave the facility. I assessed R1 for a yellow supervised community pass. R1 was in a wheelchair and on dialysis and the yellow pass was for R1's safety. A yellow pass indicates that a resident is allowed out on community pass with either a loved one or a friend. R1 was not allowed out overnight. If residents show up before 8pm the same day or by the final in/outs rounding at about 6pm, then it is okay for the residents to be back at the facility by 8pm the same day. V7 stated Overall, R1 was alert and oriented X2. R1 could not recall the facility address, phone number, or who to contact in case of an emergency. This is why R1 was assessed for a yellow pass. When a resident does not return from out on pass, the protocol is for the nurse on duty (NOD) to reach out to the doctor, Director of Nursing (DON), and the family to alert them. As of today, I do not know where R1 is located. V7 stated V5 (R1's family member #1) came to the facility to pick up R1's medical records and belongings at the beginning of this month. V5 did not state where R1 was located at that time. V5 only requested R1's medical records and R1's belongings. V5 picked up R1's belongings but not R1's medical records because V5 needed to fill out a form first. I have R1's medical records in my possession and available for V5. When someone comes to pick up a resident to take them out on pass, they check in with the receptionist, they state who they are to the resident and based on the resident's pass level, we allow the resident to get a pass from the nurse, and the resident can leave the facility. The nurses are the ones who gives out the community passes to the residents and the residents are required to show the pass to the receptionist prior to leaving the facility. Before a resident leave, they or the person picking them up, must sign out on the sign-out sheet kept at the receptionist desk. The person picking the resident up usually state who they are to the resident. To my knowledge, it was R1's brother-in-law who signed R1 out of the facility on [DATE] but I was not here that day on [DATE]. There is no identification or contact information for R1's brother-in-law. On [DATE] at approximately 3:45pm, Surveyor verified with V7, a copy of R1's community pass dated [DATE], titled Release of Responsibility for out on Pass Green. V7 stated I was here that day on [DATE] and that is my signature, I signed R1's community pass that day on [DATE], but I was not in the building when R1 left the facility, I left before R1 on [DATE]. Surveyor verified with V1 (Administrator) that V7 was on duty at the time that R1 left the facility. Surveyor asks V7 to read the name of the person who signed R1 out, which was signed on R1's community pass on [DATE]. V7 stated I am not sure of what the name reads for the person who picked R1 up that day on [DATE]. On [DATE] at approximately 3:45pm, V2 (Director of Nursing/DON) stated The nurses and the social workers are allowed to give out the community passes. As of today, I do not know where R1 is located. On [DATE] at 9:36am, V2 stated There must be a physician order for all residents, for all levels of the community passes, including red, yellow, and green. If a resident has a Red pass, they cannot go out into the community. A Green pass indicates that a resident can go out in the community unsupervised and come back by curfew time to maintain pass privileges. A Yellow pass indicates that a resident can go out in the community with supervision, they are expected back at curfew time unless they call and say they are running late. If a resident wants to go out on an overnight pass, then we require a 24-hour notice. To my knowledge, this was the first time that R1 has ever went out on pass into the community. The physician should be notified of a resident's AMA status within 12 hours or by the next day. At least, by that next morning, someone should have informed R1's physician that R1 had went out on pass and never returned. Due to a previous knee injury, R1 ambulates via wheelchair and does not walk. V2 stated that V7 (Dementia Care Coordinator) was authorized to give R1 a community pass because V7 works in the social services department. I am not sure if V7 asked R1's physician for an order for R1 to go out on pass but V7 knows that she must obtain an order for R1 to go out and that has always been V7's process prior to letting residents out on pass. We do keep a list of residents who are on Green passes at the front desk in the receptionist office. This list is reviewed and updated on a weekly basis. On [DATE] at approximately 3:45pm, V1 (Administrator) stated Once R1 did not return to the facility, R1 was considered to have left against medical advice (AMA). We do not have video footage of R1 leaving the facility that day. Our camera footage only lasts 7 days. As of today, I do not know where R1 is located. Per AMA policy dated [DATE], Titled Unplanned Discharge documents in part, The MD, NP or Nurse will: Advise resident of the risks to their health and well-being if they choose to leave with an unstable medical condition. Obtain and witness resident's signature on AMA form. Provide referrals for medical, psychiatric, or other services as needed. On [DATE] at 4:07pm, V6 (Social Services Director) stated I was informed that R1 did not return to the facility when I came into work the morning of [DATE]. I was informed by V7 that R1's brother-in-law picked R1 up on [DATE]. On [DATE], I called Hospital A, Hospital B, Hospital C, and Hospital D to see if R1 was located at their facility. All hospitals stated that R1 was not located at any of the hospitals. I did not document that I called any of the hospitals and I do not remember who I spoke with at any of the hospitals that I called. We do not ask for identification of the person picking up the residents to go out on pass. On [DATE] at 4:13pm during a telephone interview, V9 (Former Receptionist) stated The residents are required to have a pass before they leave the facility. I no longer work there but I would usually keep a list of the residents who are on a green pass taped to the desk located at the receptionist desk. This would make the list easy to check if staff needed to know who is allowed out independently. On [DATE], R1 came to the receptionist desk and showed me a green community pass. R1 was not listed on my list that I kept at the receptionist desk, so I called up to the 2nd floor (2 East) and spoke to R1's nurse. R1 was upset that I was doing this and kept asking What's the problem? I cannot remember the name of the nurse, but I told the nurse that R1 had a green community pass, and I asked the nurse was it okay for R1 to go out on pass. The nurse told me If R1 has a pass, then let R1 go out. I did not feel that I had the right to question the nurse, so I let R1 leave the facility. I was thinking to myself, why would they let R1 leave knowing R1's condition of having a drug problem. Before R1 left, I saw the man who picked R1 up to take R1 out on pass. I do not remember his name, but the man was a short man about 5'2 or 5'3 tall, he was Hispanic, he had black hair, he was wearing glasses and a baseball cap. I asked the man who he was, but the man never spoke a word. R1 became upset again by this and spoke for him saying that the man was R1's brother-in-law and that he was taking her out for a Mother's Day meal. I asked the man to sign R1 out and he did. R1 then said, come on, let's go and they both left the facility. V5 called the facility saying R1 died because of you guys, R1 was not supposed to go out with that man. V5 would call wanting to speak to someone in administration. Often, administration was in meetings so I told V5 that I would take a name and number and have someone from administration to give a call back. The nurse on duty assigned to care for R1 on [DATE] from 7am-7:30pm has been identified as V18/Agency Licensed Practical Nurse. An attempt to contact V18 via telephone was made on [DATE]. Surveyor left voicemail with contact information, awaiting call back. R1 ambulates via wheelchair. Facility is unaware of R1's mode of transportation once leaving the facility, which is located on a busy street with heavy traffic. Per R1's medical record dated [DATE], R1 was found on the floor in a bathroom at an unknown residence and transported to a community hospital approximately 6 miles from the facility. R1 was transported to the community hospital on [DATE], the same day that R1 did not return to the facility. On [DATE] at approximately 5:30pm, V1 (Administrator) stated When R1 did not return to the facility, we did not contact the local police to inform them of this. Per R1's medical record review, shows that R1 was medically compromised or vulnerable while residing at the facility: R1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. R1 has a history of recent hospitalization s within the recent months. R1's hospitalization records documents that R1 was hospitalized at Hospital A from [DATE]-[DATE] for chest pain, shortness of breath, deep vein thrombosis (DVT), abnormal electrocardiography (EKG), acute chronic congestive heart failure, hypertensive urgency, and End-Stage Renal Disease (ESRD) on hemodialysis. R1's hospitalization records documents that R1 was hospitalized at Hospital A from [DATE]-[DATE] for hypertensive emergency, End-Stage Renal Disease (ESRD) on hemodialysis, hyperkalemia, and right upper extremity abscess with new medication for antibiotics and antihypertensives. R1's hospitalization records documents that R1 was hospitalized at Hospital A from [DATE]-[DATE] for chest pain, shortness of breath, elevated brain natriuretic peptide (BNP) level, End-Stage Renal Disease (ESRD) on hemodialysis, hypertension, anemia, and pulmonary congestion. R1's hospitalization records documents that R1 was hospitalized at Hospital B on [DATE] for right arm arteriovenous (AV) graft excision and repair of brachial artery, shortness of breath, and mild volume overload. R1's hospitalization records documents that R1 was hospitalized at Hospital A from [DATE]-[DATE] for chest pain, pulmonary edema, shortness of breath, hypertensive urgency, hyperkalemia, End-Stage Renal Disease (ESRD) on hemodialysis, and anemia. On [DATE], staff/ V9 (Former Receptionist) allowed, R1 to leave the facility on a yellow community pass and due to return to the facility by 8pm on [DATE] and R1 failed to return the facility to date. On [DATE] at 3:50pm, V9 allowed R1 to go out on a community pass with an unidentified male who presented as R1's brother-in-law and R1 never returned to the facility. Per V1 (Administrator), local police were never called and R1 was considered to have left the facility (AMA) on [DATE] which contradicts the facility's AMA policy. R1s' community survival skills assessment dated [DATE] and signed by V7 (Dementia Care Coordinator), documents that R1 is unable to be out in the community w/o supervision or an escort d/t R1 physical and mental disabilities. R1 must be accompanied at all times by staff or a family member. Release of Responsibility for Community Pass (dated [DATE]) documents, R1 was released out on community pass on [DATE] to go out to eat with R1's brother-in-law. However, R1 did not return to the facility. Pass indicates that R1 was released on a Green pass, which indicates that a resident may go out on community pass independently. Facility policy dated ,d+[DATE] titled Outside Community Pass Privileges Policy documents in part, Green Pass- Resident who may go out in the community independently and return within curfew hours. Yellow Pass-Resident who may go out in the community with a co-resident or responsible party and return within the designated time limit- residents will be given 2-hour yellow pass initially. Concern logs reviewed for the past 3 months and documents a concern dated [DATE] for R1 going out into the community unauthorized. Facility policy, undated, titled Physician orders, documents in part, It is the policy of the facility to follow the orders of the physician. Social Service Progress Note written by V6 (Social Services Director) dated [DATE] at 4:40pm, documents On [DATE], R1 was requesting to go out on pass with her brother-in-law. R1 stated that she was going to have Mother's Day dinner. Educated that R1 will need to have her family member signed her out. Also spoke to R1 about her safety while in the community and what is expected from her. At around 3:50 pm, her family member signed her out and she left in stable conditions. Progress note written by V2 (DON) dated [DATE] at 4:38pm documents Spoke to R1's son in reference to his mother not returning to the facility from pass with brother in law. Son stated he was called on Friday night by the nurse on duty asking if he had seen her because she did not return to facility after being signed out by brother-in-law. Son states that he informed staff that he will call his brother and uncle to see if the resident is with them. Son reported to writer that when he called the family he was told they saw R1 earlier and she was going to the Humboldt Park area. Multiple calls were made to her cell number, but no answer. MD was notified of the resident's failure to return for out on pass. Social Service Progress Note written by V7 (Dementia Care Coordinator) dated [DATE] at 1:45pm documents Hard copy of the State ID arrived; writer gave the R1 hard copy; R1 thanked writer & asked if R1 may now go out on an out into the community. Writer explained just because R1 had an ID now didn't mean R1 could go out into the community. Writer reminded R1 that the GREEN PASS / YELLOW PASS policy was discussed with her son & R1 - both present & both agreed to understand the policy. R1 asked for a clarification; writer clarified her that since R1 is her own responsible party & does not have a current POA over her health & based on her hx. attending MD recommended her to not be out in the community by herself but that R1 was able to go out into the community w/a responsibly party as long as they signed her in & out upon departure / arrival. Resident then agreed to not go out on her own & wait until R1 has a family member come take her out to go shopping, for a stroll & bring her right back. Resident left w/no additional questions / concerns. The survey team on site at the facility on [DATE] to review the facility's abatement plan. The facility has taken the following action concerning the IJ component: [DATE] Submission of this abatement for Continental Nursing and Rehabilitation Center is not a legal admission that a deficiency exists or that this immediate jeopardy was correctly cited. In addition, preparation and submission of this abatement does not constitute an admission or agreement of any kind by the facility of the truth of any facts set forth in this allegation by the surveyor's agency. 1. The facility has taken the following actions concerning the alleged deficiency identified in the immediate jeopardy: a. R1 is no longer a resident at the facility. 2. How other residents having the potential to be affected by the same deficient practice will be identified and what corrective action(s) will be taken. a. Beginning on [DATE], residents that are medically compromised (Yellow) will be reviewed to ensure a medical provider authorization has been given for a community pass. Will be completed [DATE]. There is a total number of 125 medically compromised residents that have been assessed for a yellow pass. b. The facility will follow the Unplanned Discharge Policy and Procedure c. Beginning on [DATE], the facility will review community risk assessments for residents that are medically compromised (yellow). Will be completed [DATE]. d. On [DATE], the resident pass tracking log has been revised to include a check box which verifies if the resident has a green or yellow pass. And a note that if the resident does not return from pass, the floor nurse will be notified and will follow the Unplanned Discharge Policy and Procedure. Will be completed [DATE]. e. On [DATE] the Resident Community Pass Approval form has been updated to include the following i. Resident contact information in case of emergency. ii. Whom resident was escorted by (Name/relationship/contact number iii. Resident status iv. Medical condition review at time of pass v. Any medication needed at time of pass Will be completed [DATE] 3. The following measures have been taken by the facility to ensure that proper practices continue: a. Beginning on [DATE], the Administrator will educate social services and receptionists on the Unplanned Discharge Policy and Procedure and the facility pass policy and procedure. Will be completed [DATE]. Any newly hired the social services, and receptionists will be educated at orientation. b. Beginning on [DATE], per the pass policy, the receptionists will receive a daily updated pass list that has the type of pass granted per the assessment and physician order. Will be completed [DATE]. Any newly hired receptionists will be educated at orientation. c. Beginning on [DATE], the Administrator will educate the nursing staff (to include weekend and agency) on the Unplanned Discharge Policy and Procedure and the facility pass policy and procedure. Will be completed [DATE]. Any newly hired the nursing staff (to include weekend and agency) will be educated at orientation. d. Beginning on [DATE], the Administrator will educate the nurses, social services and receptionists on the Resident Community Pass Approval form that has been revised to include resident contact information in case of emergency, whom resident was escorted by, resident status, medical condition review at time of pass and any medication needed at time of pass. Will be completed [DATE]. Any newly hired the nurses, social services, and receptionists will be educated at orientation. e. Beginning on [DATE], the Administrator will educate the nurses, social services, and receptionists on the revised resident pass tracking log to include a check box which verifies if the resident has a green or yellow pass. And a note that if the resident does not return from pass, the floor nurse will be notified and will follow the Unplanned Discharge Policy and Procedure. Will be completed [DATE]. Any newly hired the nurses, social services, and receptionists will be educated at orientation. 4. The Administrator or designees will monitor continued compliance via the following Quality Improvement programs: a. Beginning on [DATE], upon a resident request for pass, the Administrator, or designee, will ensure that an order has been given from the physician and the Resident Community Pass Approval has been completed. The facility will continue the QA for 90 days and then discuss at the QA/QI meeting. b. Beginning on [DATE], daily the administrator or designee will ensure the update pass list is at the reception area for guidance. The facility will continue the QA for 90 days and then discuss at the QA/QI meeting. Beginning on [DATE], upon a resident failing to return from pass, the Administrator, or designee will follow the Unplanned Discharge Policy and Procedure. The facility will continue the QA for 90 days and then discuss at the QA/QI meeting. c. The results of the monitoring completed under this POC are submitted to the QA/QI Committee for review and follow-up.

Based on record review and interview, the facility failed to ensure the resident received adequate supervision and assistance to prevent accidents. This failure affected 1 (R1) of three residents reviewed for adequate supervision resulting in Left hip fracture that required surgical repair. Findings include: R1 is a [AGE] year-old female with a diagnosis including Displaced Intertrochanteric Fracture of Left Femur, Hemiplegia and Hemiparesis Affecting Left Dominant Side, Vascular Dementia, Type II Diabetes, and Absence of left leg above the knee. R1 has a BIMS (Brief Interview of Mental Status) score of 15/15. 11/16/2022 Minimum Data Set shows R1 is a two plus persons for transfer from bed, chair, and wheelchair. R1 Fall Risk Review Dated 11/8/22 shows high risk for falls. On 12/9/22 at 1PM, R1 stated I fell in the shower. I was assisted by V7 (CNA) from my bed to the shower stall. I was rinsing off in my shower chair. I sent the CNA (V7) to my room to make my bed. She left out of the shower room. As I went to rinse myself, I grabbed the rail on the wall. My hand slipped from the soap on my hand. I started to fall, and my shower chair tipped. I fell on my left leg which is partially amputated. I heard a loud crack. I was by myself in the shower room. I could not reach the nurse call cord. I was in severe pain. About 5 minutes later V7 came back and found me on the floor. I was brought back to my room. I got an Xray in the nursing home. They sent me to the hospital the next night. I had to get surgery. I have stitches in my leg now. On 12/10/22 at 11:25AM, V7 (CNA) stated I am a certified nurse's aide. I take care of R1. I gave her a shower once. On the Friday of the incident, I picked up the shower activity for R1. R1 requires extensive assistance with showers. R1 is totally dependent. You must put R1 in the chair and do everything for her. I told her I had not given her a shower before and asked her how it is done for her by the other CNAs. R1 only had one foot and I was wanting to give her a bed bath. R1 wanted a shower. I took her to shower room. The shower room is identified as room [ROOM NUMBER]. R1 was put in a shower chair in her room. I held her from around her trunk and put her in the shower chair next to her bed. It was a one-person transfer. I brought her into the shower. We finished the shower. I needed to grab more towels because there was water on the floor. I had towels in the shower room but not in the shower stall. I left the shower stall to get the towels. I was on the other side of curtain. R1 was still rinsing. By the time I got back to her she was sitting on the floor in a water puddle. R1 said she was just trying to grab the soap and she slid from the chair. She didn't really need the soap because she was done but she tried getting the bar. I did leave her alone in the shower stall by herself before the shower started. R1 asked me to make her bed and to go do it. I left her in the chair in the shower stall and went to go make her bed. I returned and gave her the shower. I am aware that I shouldn't have left R1 unattended in the shower stall by herself. Above interview shows R1 was not transferred to shower chair according to 11/16/22 MDS, two plus persons for transfer from bed, chair, and wheelchair. On 12/9/22 at 11:55AM V4 (Physician) stated I am R1's doctor. R1 is a 1 person assist with showers. I talked to V7 (CNA) who was the CNA responsible. V7 told me that she had full visual control of R1. V7 turned to get a towel and at the same time R1 went to grab soap on ledge. R1 slid from the chair to fall in sitting position. Portable Xray showed an Acute intertrochanteric hip fracture. R1 was sent to the hospital for surgery of internal fixation of the hip. She is now back in the facility recovering. On 12/10/22 at 10:53AM, V8 (MDS Coordinator) stated R1 requires extensive assistance when taking a shower because of her diagnosis. There is supposed to be a staff with R1 at all times during shower. Hospital record dated 11/5/22 shows R1 sustained a closed displaced intertrochanteric fracture of left femur from a fall at nursing home. Facility Reported Incident dated 11/5/22 included statement, Investigation was conducted as per nursing staff, she was assisting resident in the shower room and as she turned to get towel to assist resident with drying her, resident appeared to slide from the shower chair and landed on her butt. As per CNA, resident was trying to reach for the soap dispenser that is on the wall and that is how she slid from the shower chair. Facility Policy Titled Fall Prevention and Management includes statement. This facility is committed to safety and maximizing each resident's physical, mental, and psychosocial well-being. The purpose of our Fall Prevention and Management Program is to: Provide our residents with an interdisciplinary approach to assess risk of falls. Provide appropriate interventions to prevent falls. Ensure that in the event a fall occurs, the fall will be investigated, appropriate emergency treatment will be provided, and additional interventions will be implemented to prevent another fall from occurring as much as possible.

Based on interview and record review, the facility failed to have a system in place to prevent one resident (R1) with a history of confusion, behaviors, and known to tamper with [CONDITION(S)] catheter from removing the [CONDITION(S)] catheter cap. This failure affected 1 of 9 residents (R1) reviewed for supervision/monitoring. This failure resulted in R1 removing the [CONDITION(S)] catheter access cap, bleeding out, and being admitted to the ICU (Intensive Care Unit) with a diagnosis of [CONDITION(S)]. Findings include: R1's was admitted to facility on [DATE] around 6:30pm according to V18 (RN) admission record dated [DATE], documents diagnoses of: [CONDITION(S)], Hypertension, Chronic Kidney Disease, [CONDITION(S)], [CONDITION(S)], Gastro- [CONDITION(S)] reflux Disease, Restlessness and Agitation. R1 transferred to local hospital on [DATE] at 2:40am by EMS (Emergency Medical Service) in [CONDITION(S)]. Progress noted dated [DATE] at 2:30AM states V13 (CNA) alerted nurses on duty that R1 observed on the floor immediately rushed to the room noted resident bleeding from her [CONDITION(S)] catheter port. 911 called, oxygen placed via non rebreather(type of oxygen mask) mask, pressure applied to the site firmly with a clean bandage. Assessment revealed that resident had opened the [CONDITION(S)] catheter port and the cup was found on the dining room table. Cup replaced to the opened catheter. 911 transferred resident to the nearest hospital. NP (Nurse Practioner) (V16) made aware. R1's Local fire department run sheet, dated [DATE] at approximately 2:17am documents in part, Called for a bleeding victim in NH (Nursing Home) found pt (R1) on the floor of dining room on several bloody sheets and towels. There's much blood on the floor. She's (R1) agonal (gasping) breathing and crew couldn't detect a pulse. CPR (Cardiopulmonary Resuscitation) initiated and ventilation by BVM (Bag Value Mask), RN said he found pt (R1) alone on the floor bleeding from the [CONDITION(S)] chest access. He capped it off and called 911. It's unknown how long she's (R1) been down. Removed pt (R1) to the ambulance with ongoing CPR and ventilated by BVM, O2 (oxygen) 15L(liters). Initial rhythm was PEA (Pulseless Electrical Activity) After 3rd epi([MEDICATION(S)]) pt (R1) was in vfib (ventricular fibrillation). Crew defibrillated pt (R1) at 200j (Joules). She (R1) went back to PEA. Crew continued CPR. OLMC (Online Medical Command) ordered transport to ED (Emergency Department) with continuing efforts. Release pt (R1) to ED staff without change or incident. All treatment times were estimated. Late Entry Nursing Progress Note [DATE] at 19:05 documents in part, Note Text: Alert and oriented x 2, Resident mood is pleasant, no behavior noted, not in any type of distress, able to makes needs known, resident denied any pain at this time. Upon assessment vital sign within normal range B/P - ,d+[DATE], P-70, R-18, Temp-97.6, Spo,d+[DATE]% room air, Blood glucose level-90. All due medication administered and well tolerated. Author of note V12 Nursing Progress Note [DATE] at 19:01 documents in part, Note Text: Received this [AGE] years old black African American female from Local Hospital with admitting diagnosis of subarachnoid with history of [CONDITION(S)], hypertension, stage renal disease, [CONDITION(S)], right artery aneurysm and right external ventricular drain. Resident arrived to the unit on a stretcher accompanied by two paramedics staff. Resident noted in stable condition. AOx,d+[DATE]. Vital signs taken BP ,d+[DATE], Pulse 66, temp 97, RR 18, O2sat 99%RA (room air-amount of oxygen in blood). Head to Assessment completed. Resident is ambulatory with an assistance. Resident is a [CONDITION(S)] patient. All medications verified by NP (V16) and reconciled with and an order. 72 Hours new admission monitoring initiated per facility protocols. DON made aware. Author of note V18 R1's Admission/Readmission screener dated [DATE] documents under section E. Neurological R1 is orientated to person under section K. Teaching/Education Skilled Care Daily Progress Note resident is extensive for ADL's (Activities of Daily Living), Uses bed side commode, Right side facial and eye dropping. Resident on pureed low sodium diet. R1's Daily Skilled Nursing Note dated [DATE] documents under mental status documents R1 is alert, disoriented, forgetful and confused. R1's Hospital discharge summary record dated [DATE] at 3:22pm by discharging hospital Present Illness states, in part, [AGE] year-old female who was admitted to local hospital for [CONDITION(S)] ([CONDITION(S)]) exacerbation. Developed R-facial droop and weakness. Imaging revealed SAH (Subarachnoid Hemorrhage) and transferred to name (Another Local Hospital) for neurosurgical intervention. CTA (Computed Tomography [MEDICATION(S)]: a type of medical test that combines a CT scan with an injection of a special dye to produce pictures of blood vessels and tissues in a part of your body) head showed [NAME]/PCOM (Right Internal Carotid Artery/Posterior Communicating Artery Aneurysm) artery aneurysm measuring 4.5 x 2 mm in size. Underwent coiling and EVD (External Ventricular Drain) placement. EVD eventually removed but patient remained confused and agitated. Assessment/Plan: needing restraints and will try to discontinue. Preadmission Screening and Resident Review dated [DATE] documents, in part, Patient (R1) intermittently confused. R1's Hospital discharge summary record dated [DATE] at 7:55 progress notes: documents in part, Patient's restraints were discontinued around 20:30. Instructed patient not to remove the perma-cath, (Catheter) if she will, we will put the soft restraints back. R1's hospital discharge [DATE] documents in part, Critical Care Initial Evaluation Note ER (emergency room ) staff called nursing home and RN notes that R1 is known to play with her [CONDITION(S)] catheter and for it to become uncapped. On [DATE] at 10:07am V2 DON (Director of Nursing) stated that V12 LPN (Licensed Practical Nurse) called and stated that R1 was in the dining room and wanted to watch TV. V2 stated, I (V2) told V12 to let R1 stay in the dining room because R1 was in there by R1's self. V2 (DON) stated, V13 (CNA) was making rounds and saw R1 in the dining room on the floor. V2 stated, V13 told me that V13 saw blood. V2 stated, V12 (LPN) told me that the blood was coming out of the R1's [CONDITION(S)] catheter site and V12 saw the cap off the [CONDITION(S)] catheter and the cap was on the dining room table. V2 stated, The nurse did not describe if blood was on the floor. V2 stated, There was no CPR initiated at the facility, R1 did not need CPR because R1 was breathing and talking. V2 stated, If something is not documented, I (V2) will not say it's not done. V2 stated, The nurse's chart by exception and that the nurse did not do vital signs because she was holding pressure to R1's [CONDITION(S)] catheter and holding pressure on a [CONDITION(S)] catheter is more important because R1 was bleeding out. On [DATE] at 12:14 PM surveyor asked V12 (LPN) to tell surveyor what happened to R1 on [DATE] to [DATE]. V12 stated that she (V12) was R1's nurse and at midnight V12 could not find R1 when V12 was doing rounds. V12 stated that I (V12) went to R1's room and R1 was not there so I (V12) went to R1's bathroom and R1 was not there. V12 stated that I (V12) went to the dining room and saw R1 in the dining room. V12 stated that I (V12) told R1 to stay in her (R1's) room. R1 stated that I (R1) want to stay in the dining room. V12 stated that I (V12) called V2 (DON), and V2 said R1 can stay in the dining room since no one is in there. V12 stated that I (V12) continued to make rounds. V12 stated about ten minutes later I (V12) saw R1 again in the dining room watching TV. V12 stated that V12 asked R1 was she ready go to R1's room. R1 said let me stay here please. V12 stated that I (V12) said I (V12) will be back. V12 stated that I (V12) asked V13 (Certified Nursing Assistant, CNA) to watch R1 because R1 was in the dining room. V13 was in the hallway when I (V12) talked to V13. Surveyor asked V12 what time this occurred. V12 stated, I do not know. On [DATE] at 12:17pm V12 stated that V13 called me (V12) and said blood was coming from R1's chest in the dining room. V12 stated she (V12) went there (referring to dining room) and saw R1 bleeding from chest and called out to V14 RN (Registered Nurse) to call 911. Surveyor asked V12 what time this occurred. V12 stated, I (V12) do not know. V14 (Registered Nurse, RN) called 911. V12 stated that R1 was in the dining room alone. V12 stated, R1 was sitting in the chair, and I (V12) lowered R1 to the floor because I (V12) did not want R1 to fall out of chair. V12 stated that I (V12) put sheets under R1 while lying on floor so R1 was not lying on a dirty floor. V12 stated that I (V12) put a pressure dressing to the catheter site and then I (V12) saw the caps were off R1's [CONDITION(S)] catheter. V12 stated, The caps were on the dining room table. V12 stated, I (V12) put the cap back on. V12 stated, I (V12) asked R1 why you (R1) pull your (R1) caps off your (R1's) [CONDITION(S)] catheter. V12 stated, R1 looked like R1 didn't know R1 had done something wrong and R1 stated, I (R1) did not know why. V12 stated that I (V12) took Vital Signs at the beginning of my (V12's) shift. V12 stated that V12s' shift is 7:00pm to 7:00am. V12 stated, I (V12) did not take R1's vital signs when I (V12) responded to R1 in the dining room bleeding because I already took them. On [DATE] at 12:55 PM V13 (CNA) stated that R1 was walking around in the hallway when V13 came in at 11:00 pm. V13 stated, I (V13) tried to redirect R1 at that time but R1 kept on walking. V13 stated that V12 asked me (V13) to keep an eye on R1. R1 was in the dining room. V13 stated, I (V13) do not know what time it was that I (V13) observed R1 in the dining room. V13 stated, it was less than every two hours. V13 stated, I couldn't watch R1 continuously, because I (V13) have other residents. V13 stated, When making rounds I (V13) noticed R1's shirt with blood on it and both nurses came and assisted R1. On [DATE] at 4:40 PM surveyor asked V14 (Registered Nurse, RN) what happened to R1 on [DATE]. V14 stated, V12 yelled out and said R1 had removed R1's cap from the [CONDITION(S)] catheter. On [DATE] at 1:28pm V2 stated, V13 was monitoring R1, he (V13) is making sure that another resident does not come into the dining room and that R1 does not leave the dining room. V2 stated, V13 would be in the hallway and can observe the resident through the windows of the dining room. R1 did not display any behaviors according to the head-to-toe assessment after we (Staff) spoke to the resident. V2 stated, V12 will keep an eye on R1 and if anything is noticed then V12 would notify me (V2), and it would be recommended for her to be monitored more closely and possibly moved. If she (R1) was in her room then R1 would have been monitored every two hours, but since she was in the dining room, she was being monitored from the hallway to prevent the spread of Covid-19. Surveyor asked V2 if V13 could monitor R1 closely and care for other residents. V2 stated, No, he (V13) would not be able to look after other residents because she (V2) told the CNA to monitor R1 closely to prevent her from wandering out of the room or someone from wandering into the room. Monitoring means the resident should be in his line of sight, at all times, so that he (V13) could redirect her (R1) if she tries to leave the dining room. On [DATE] at 1:54pm V14 (RN) stated, I saw R1 in the hallway interacting with V12 and I supposed V12 was telling R1 to go back to the blue zone. V14 said, I don't remember what time, but it was late at night, and it was before the incident occurred and the incident occurred around 2:30am. The nurse (V12) had a call, and she (V12) came to answer the call and then she (V12) went back to talk to R1. On [DATE] at 2:44pm V18 (RN) stated, Yes, I (V18) completed the admission for R1 and received report from the hospital prior to receiving the resident (R1). I (V18) can't remember much about this resident (R1). Surveyor asked if the sending hospital nurse told you (V18) that R1 had any behaviors or tampered with her [CONDITION(S)] catheter. V18 stated, No, they didn't tell me (V18) about any behaviors while R1 was in the hospital and R1 was not having any behaviors when I (V18) received her (R1). V18 stated, The hospital nurse giving me (V18) report on R1 didn't tell me anything about restraints and I (V18) don't think I saw anything in the discharge papers about restraints. V18 stated that R1's orientation status was alert & oriented x ,d+[DATE] because she (R1) was able to tell me her name and where she was. Again, V18 stated, No, I (V18) didn't get anything about the hospital staff having to use restraints on R1 verbally or in the written documentation and no, I (V18) am not sure about anyone telling me or reading about the resident (R1) tampering with her (R1) catheter. V18 stated, we don't do training about managing a cognitively impaired resident with a [CONDITION(S)] catheter and it depends on the mental status of the resident. We have to educate the resident about safety concerning the catheter. Most of the time we would have a one to one for 24 hours with a cognitively impaired resident. We always educate them about not touching or tampering with the catheter or any part of that area. Surveyor inquired regarding orders to manage the [CONDITION(S)] catheter. V18 replied, I don't really have a specific answer, but we always educate the resident, and we sometimes involved the [CONDITION(S)] department of the condition of the resident. On [DATE] at approximately 8:04am surveyor asked V18 were you made aware in report (verbal or written) that R1 had behaviors. V18 stated, I didn't see any behaviors in the report that stated the resident had any behaviors. No, I did not review that the hospital had to use soft restraints on R1. Surveyor asked V18 was she aware that the soft restraints had been discontinued on the 26th or 27th of May. V18 said, Yes, that they had discontinued the use soft restraints. Surveyor asked V18 if she informed the V16 (NP) about the discontinued use of the soft restraints. V18 said, No, I did not tell him (V16) about the restraints. I (V18) told him (V16) about the medications and that R1 had a [CONDITION(S)] catheter and V16 told me to continue the orders. V18 stated that the NP visits with the resident the next day and will review the medications again. Surveyor asked V18 again about informing the doctor about the discontinued use of the restraints. V18 said, No, I didn't inform the NP about the restraints. On [DATE] at 8:45am surveyor asked V2, what are the steps for completing a new admission for a resident. V2 stated, nurse will have to do head to toe assessment (LOC(level of consciousness) and alertness and for behaviors). If any notice of any behaviors, then the nurse will notify me and then we will talk about it. If there are behaviors, then we will put interventions in place to deal with the issues. Nurses are to verify medications and other orders such as behaviors with the doctor, than they would have to put the medications in the system so that pharmacy can bring to them facility. Document in PCC your admission notes, the assessments, any abnormalities noted and any interventions that was recommended. Notify the family, and DON. Surveyor asked V2 what would be done for a resident with a [CONDITION(S)] catheter. V2 stated, Normal admission is done, but they would have to assess to see if the resident is ok. They are looking for any behaviors such as tampering or playing with the [CONDITION(S)] catheter. On [DATE] at 9:27am Surveyor asked V12 what steps were taken when you admitted R1. V12 stated, when you receive the resident, you go with the paramedics as they transfer the resident into her (R1) bed so you can do a quick assessment as far as how's she breathing and looking before you sign the release paperwork. After that you would complete your head-to-toe assessment. After head-to-toe assessment then you would notify the doctor of any wounds, bed sores and or if the resident has a [CONDITION(S)] catheter and any abnormalities of your head-to-toe assessment. V18 stated that you would also verify the meds with the doctor, receive new orders from the doctor in regard to meds and labs. The next step should be is that you to instruct the CNA to inventory the residents' belongings, provide water, and determine if the resident has eaten. Overall goal is to make sure the resident is comfortable. The next thing is you have to start your admission which is to do your assessments and write your notes, then you have to monitor every two hours until the next shift comes in and takes over. V12 clarified that she would let the doctor know that the resident is in the building and if there are any abnormalities with the head-to-toe assessment such as wounds, bed sores and [CONDITION(S)] catheter. Then you would verify the medications and receive new orders for medications and labs. Surveyor asked, V12 how do you provide care for residents with [CONDITION(S)] catheter? V12 stated, You educate them on the [CONDITION(S)] catheter and safety, meaning not to bother with the [CONDITION(S)] catheter. Surveyor asked, who gave you report the night R1 was admitted ? I received report from V17 (RN). V17 told me (V12) I would have a new admission and that R1 has a [CONDITION(S)] catheter. I started the admission on R1. No one told me, anything other than R1 has a [CONDITION(S)] port. I don't remember if the resident was in the building when my shift began or came after. V12 stated, No, I didn't receive the report from the hospital nurse. I received report from V17 that I was going to have an admission and he didn't provide any additional information. Yes, I reviewed the hospital discharge papers that came with the resident and don't recall any orders for the [CONDITION(S)] catheter. Surveyor asked if she received in report information regarding R1 playing with her [CONDITION(S)] catheter. V12 said, No, she was so nice and did not have any behaviors. No, I didn't see her playing with or tampering with the [CONDITION(S)] catheter. V12 stated that if I would have saw this behavior I would have contacted the DON immediately and monitored R1 more frequently. V12 stated that more frequently would mean more than every two hours. Surveyor asked, how do you provide care for a resident that has a [CONDITION(S)] catheter. V12 stated, We always monitor them to make sure they don't mess with the catheter. We monitor the resident with a [CONDITION(S)] catheter for safety and we monitor them every two hours unless. We monitor them not to touch it and we monitor the site to make sure it is not bleeding. The site is always covered but you can see if it is bleeding or not. We don't touch it and we monitor if it is bleeding. [CONDITION(S)] staff will change the dressing unless it is bleeding than we would apply pressure and send the resident to the hospital. Surveyor asked did you perform a head-to-toe assessment on R1. V12 stated, Yes, I did, and her mental status was alert & oriented times two. V12 stated that she called the DON between midnight and one o'clock to inform her about the resident not wanting to leave the dining room. V12 stated, she V12 can't force her to leave the dining room. Because she was responding to her questions normally and did not show any behaviors to make me think it would be unsafe to leave her in the dining room, I did not think R1's behaviors were abnormal. V12 stated, I did not call the receiving hospital and the receiving hospital will not call. V12 further stated, I can't recall if I called the hospital to get an update. On [DATE] at 9:53am surveyor asked V2, if there are notes in the discharge paperwork regarding restraint usage what is the expectation of your nurses. V2 stated, I mean, first of all, they send the packet and we review it and if it states that the restraint usage we won't take the patient and we tell them that the resident has to be off of the restraints for a least 5 days before we take the resident. V2 further stated, Soft restraints, yes that is what was in use, and we denied the patient because we don't use restraints in the facility. Days later they called back and stated that she wasn't agitated anymore, and she wasn't using the restraints for a few days. I requested the paperwork that stated she was off the restraints. V2 stated that we have an admission person here in the facility who communicates with the social worker at the hospital. The soft restraints were discontinued on the 26th of May. V2 stated, I was aware that R1 had behaviors while in the hospital regarding her [CONDITION(S)] catheter and I was aware that soft restraints had been used on the resident while in the hospital. Surveyor inquired, did V12 call you to tell you that R1 wanted to stay in the dining room. V2 stated, It was in the middle of the night, and I was sleep and it was late night and was woken up from sleep. She (V12) told me that R1 is in the blue zone, and she went to the dining room and she's refusing to get out. I said OK and asked if she (V12) tried to convince her (R1) and she said yes. She (V12) said she could not force her, and I asked her to monitor her and make sure no one else goes into the dining room. Surveyor asked what does monitoring mean. V2 stated, Monitoring means that it is not like a one on one and if she displayed any kind of behaviors than it would be a one on one and they would be at arm's length. In this situation it was not a one on one and she could be observed through the window. V12 did not inform her V2 that R1 was having any type of behaviors that would lead her to an assessment of close or one to one monitoring. V2 told her that she tried to convince her and that R1 told her in a nice way to leave her alone and just let her watch TV. V12 asked if she had a TV in her room and she said yes, but she just wanted to watch TV in the dining room. Surveyor inquired, what assessment did you use to determine if R1 was safe being in the dining room? V2 stated, I saw her (R1) myself and the nurse called me (V2) about R1 having staples. V2 stated, there were no orders for these staples. V2 stated that she (V2) and the NP (V16) went to look at the resident and tried to find out more information about the surgical wound and the resident stated that she didn't remember. V2 stated, V16 said that the staples were mature, and we can't just leave them there. He (V16) requested a staple remover, but I (V2) couldn't find one, so he said to make sure the wound care nurse removed the staples the next day and the wound care nurse had left for the day. V2 stated that it was between 6:30p and 7:00 pm when we saw the resident. V2 stated that R1 came late, and I (V2) don't really remember the exact time, but it was after 5:30pm. Surveyor asked, did you ask V12 whether R1 had any behaviors and what her diagnoses were. They (nurses) will tell you if there are behaviors and they would let us know because we have those two rooms on the 4th floor, so I (V2) didn't ask her (V12). Criteria for the resident are for people that have a urinary catheter, and they are tugging or pulling it or if they are a fall risk. V2 stated that a resident who is trying to pull, tamper or play with the catheter would be a candidate for those rooms. Those monitoring rooms are on the fourth floor and those rooms are for those residents who are a safety hazard to themselves or others. V2 stated that R1 was not a candidate to be moved to that floor based the behaviors she had displayed. Surveyor asked V2 if in verbal report or if the paperwork states the resident had previous behaviors what is done. V2 stated, It depends on the verbal report coming from the hospital and what the paperwork states. If they are telling us that she was not displaying any behaviors and our assessment confirms that she has no behaviors than there is no reason to have placed that resident in the monitoring rooms. The monitoring rooms are 408 and 418 and a psych tech would sit there ,d+[DATE]. If someone gets better and have no behaviors than they would be moved to the regular room. Surveyor asked V2, if R1 had behaviors with tampering with her [CONDITION(S)] catheter is this someone you would leave alone in the dining room. V2 stated, No, if she showed any behaviors of tampering with the [CONDITION(S)] catheter, she (R1) would have been moved to the 4th floor and provided with frequent monitoring which means a one to one is at arm's length, at all times with Psych tech. V2 stated, there was nothing in report or discharge orders about the staples in her right or left hip and that is why the nurse called me (V2) to inform me of these staples. V2 stated she was still at the facility. V2 stated that she waited for the NP (V16) so she could see the wound herself. At that time V2 did not see any behaviors from R1. On [DATE] at 4:37pm surveyor asked V16 (NP) if it is okay to leave a new resident (R1) that had behaviors of tampering with their [CONDITION(S)] catheter in the dining room alone. V16 stated, No, I would not leave that type of patient (R1) in the dining room alone. V16 further stated, V18 did not tell me R1 had a history of tampering with her [CONDITION(S)] catheter when V18 called to verify orders. To be honest, the nurses do not sit down to read the resident's chart. It is hard for the nurse to know what happened to R1 from the hospital. They (referring to the nurses) do not read the papers. Sometimes the facility (hospital) will tell them that but sometimes the facility (hospital) will hide that information. To come to a nursing home the resident has to be 3 days with no restraints. In the nursing home they have LPN's. This resident (R1) did not come till about 6pm so one nurse had the resident then another nurse came and had the resident for only 7 hours. They do not know the resident (R1) that would come with time. The mindset of a LPN in the nursing home is totally different than a practitioner or nurse in the hospital. The nurses don't read the papers, they just don't. Surveyor stated R1's diagnosis included restlessness and agitation, is that someone you would leave alone in the dining room. V16 stated, Again like I said, no this resident (R1) should not have been left alone in the dining room. This resident (R1) should have had someone always able to see her. I did not think residents were left alone in the dining room. A new patient coming to the facility can develop sundowning and [CONDITION(S)] generally on admission and is at risk for almost anything for the first 72 hours. You don't know them; you have to be close to them. They should not be left in the dining room. When the nurse called me, she did not tell me the resident (R1) had any behaviors and we did not discuss the [CONDITION(S)] catheter and there were no orders regarding the [CONDITION(S)] catheter given. Surveyor asked what is the harm that can occur to someone who has known behaviors of tampering (i.e., removing the cap) with their [CONDITION(S)] catheter. V16 stated, What is the harm?, dangerous they can bleed to death in the blink of an eye. The resident (R1) had a high shunt catheter and fortunately she is still alive. By the time they (EMS) took her she was still alive. This is a teachable moment. The curriculum of the nurse in the nursing home has not changed, the need to upgrade their level of care to take care of these residents. It is difficult for these nurses to care for a central or [CONDITION(S)] catheter, most of these nurses do not know what your are talking about. We have to figure out how to help these nurses. Someone needs to take report and help the nurse know what to do. The care and acuity of this patient is far from the care in the hospital. On [DATE] at 1:41pm Surveyor asked V18 what does head to toe assessment mean. V18 stated, That you have to assess every part of the patient. You would state the system you would state what you saw on the head-to-toe assessment. I was not informed that the resident was any restraint order for resident. Neuro assessment for R1 was able to move her hands; can't really remember too much about this patient (R1). She (R1) was walking. She (R1) was not confused. On [DATE] at approximately 3:04pm Surveyor asked V2 if a resident is in the dining room alone, how will the resident call for help. V2 stated, The dining room is close to the nurses station. We usually do not put resident there because they cannot call for help, but R1 walked to the dining room. We would not put residents that can't call for help in the dining room. Surveyor asked V2 again, even if a resident can walk into the dining room but then needed help and were not able to walk to get help, how would the resident call for help. V2 stated, we had the CNA (V13) monitor her (R1) to make sure one will go in room and R1 will not go out. The residents on this floor are independent and the dining room is close to the nursing station so someone could help them. During the day, there is always someone in the dining room. We will not leave people unattended in the dining room and will not let them sit in the dining room without any supervision. We do not let residents go into the dining room at night we try to redirect the resident, but V12 tried to redirect R1. V12 called me and I directed them to stand there and monitor her. V2 stated the dining room has glass windows so V13 was able to watch the resident. V2 stated R1 was not being watched constantly. V13 walked back and forth V13 had to stay right there where he could see her (R1). V13 was not sitting in front outside the room. R1 was sitting in a chair. V13 was just monitoring her. Surveyor asked V2 if V13 was monitoring R1, would V13 be able to see R1 trying to remove the cap from the catheter. V2 stated monitoring is not 1:1, R1 had supervision there is not a timeframe just have to be where resident is visible. 1:1 is always constant observation. This is not necessary for monitoring. V13 was outside the room watching R1. V13 was not continuously watching R1 like a 1:1. Any resident we do not know we just monitor. R1 did not display any behaviors. I was aware R1 was in restraints, we don't restrain in our facility, R1 had restraints off for 5 days. R1 was stable, no restraints needed and 1:1 not needed. During this survey, V2 (DON) did not provide any policy regarding resident supervisor or resident safety, or baseline care plan as requested by the surveyors. Undated Facility Registered Nurse Job Description states, in part, Position Summary: The Registered Nurse provides direct nursing care to the residents. The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times. E. Role Responsibilities- Nursing Care: 8. Implement and maintains establish nursing objectives and standards. Undated Facility Certified Nursing Assistant Job Description states, in part, the primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors and ensure that residents who are unable to call for help are checked frequently. Undated Facility Licensed Practical Nurse Job Description documents in part, Position Summary: The Licensed Practical Nurse provides direct nursing care to the residents. The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times and monitors seriously ill residents as necessary. Undated Facility Assessment Tool states, in part, Management of Medical Conditions: Assessment, early identification of problems/deterioration,

Based on interview and record review, the facility failed to identify, assess and provide emergency care for one of one resident (R1) reviewed for bleeding from [CONDITION(S)] access catheter in the sample of 9. This failure resulted in R1 bleeding out of R1's right [MEDICATION(S)] [CONDITION(S)] catheter and delayed cardiopulmonary resuscitation (CPR). R1 was admitted to ICU (Intensive Care Unit) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Include: R1's was admitted to facility on [DATE] around 6:30pm according to V18 (RN) admission record dated [DATE], documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 transferred to local hospital on [DATE] at 2:40am by EMS (Emergency Medical Service) in [CONDITION(S)]. R1's Local fire department run sheet, dated [DATE] at approximately 2:17am documents in part, Called for a bleeding victim in NH (Nursing Home) found pt (R1) on the floor of dining room on several bloody sheets and towels. There's much blood on the floor. She's (R1) agonal (gasping) breathing and crew couldn't detect a pulse. CPR (Cardiopulmonary Resuscitation) initiated and ventilation by BVM (Bag Value Mask), RN said he found pt (R1) alone on the floor bleeding from the [CONDITION(S)] chest access. He capped it off and called 911. It's unknown how long she's (R1) been down. Removed pt (R1) to the ambulance with ongoing CPR and ventilate by BVM, O2 (oxygen) 15L(liters). Initial rhythm was PEA (Pulseless Electrical Activity) After 3rd epi([MEDICATION(S)]) pt (R1) was in vfib (ventricular fibrillation). Crew defibrillated pt at 200j (Joules). She (R1) went back to PEA. Crew continued CPR. OLMC (Online Medical Command) ordered transport to ED (Emergency Department) with continuing efforts. Release pt (R1) to ED staff without change or incident. All treatment times were estimated. Late Entry Nursing Progress Note [DATE] at 19:05 documents in part, Note Text: Alert and oriented x 2, Resident mood is pleasant, no behavior noted, not in any type of distress, able to makes needs known, resident denied any pain at this time. Upon assessment vital sign within normal range B/P - ,d+[DATE], P-70, R-18, Temp-97.6, Spo,d+[DATE]% room air, Blood glucose level-90. All due medication administered and well tolerated. Author of note V12 Nursing Progress Note [DATE] at 19:01 documents in part, Note Text: Received this [AGE] years old black African American female from Local Hospital with admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident arrived to the unit on a stretcher accompanied by two paramedics staff. Resident noted in stable condition. AOx,d+[DATE]. Vital signs taken BP ,d+[DATE], Pulse 66, temp 97, RR 18, O2sat 99%RA. Head to Assessment completed. Resident is ambulatory with an assistance. Resident is a [CONDITION(S)] patient. All medications verified by NP (V16) and reconciled with and an order. 72 Hours new admission monitoring initiated per facility protocols. DON made aware. Author of note V18 Progress Notes dated ([DATE]) at 2:30 am documents Type: Nursing Progress Note: At 2:30am CNA alert Nurses on duty that resident observed on the floor, immediately rushed to the room noted resident bleeding from her [CONDITION(S)] catheter port, 911 called, oxygen placed via nonrebreather mask, pressure applied to the site firmly with a clean bandage. Assessment revealed that resident had opened the [CONDITION(S)] catheter port and the cup (cap) was found on the dining room table. Cup (cap) replaced to the opened catheter, 911 transferred resident to the nearest hospital. V16 (Nurse Practitioner, NP) made aware. R1's Risk Management report dated [DATE] at 3:33 AM document in part, Type/Nature of Incident: Fall, Nursing Description: NOD (Nurse on Duty, V12) was made aware by CNA (V13) that while walking on the hallway, he (V13) saw resident on the floor in the dining room. Description of Action Taken: Nurse went to the dining room, observed resident on the floor bleeding from her [CONDITION(S)] access site, pressure dressing applied, 911 called. Resident transferred to the nearest hospital. MD (Medical Doctor) and family notified. R1's Risk Management dated [DATE] no time documented Note Text shows: NOD (Nurse on Duty) was made aware by CNA (V13) that while walking on the hallway he saw resident on the floor in the dining room. Nurse went to the dining room, observed resident on the floor bleeding from her [CONDITION(S)] access site, pressure dressing applied, 911 called, VS ,d+[DATE]-[DATE].4. Resident transferred to the nearest hospital. MD and family notified, DON also notified. Facility unable to identify who documented note. R1's Hospital discharge summary lab results dated [DATE] at 5:01 am indicates R1's Hemoglobin is 9.6 R1's emergency room Provider Notes Chief Complaint: Patient presents with [CONDITION(S)]. HPI (history of present illness) in part shows R1 presented to ED via EMS in [CONDITION(S)]. R1 apparently found down in pool of blood with source seemingly port site in R chest wall. En(sic) route, R1 received in total x5 epi ([MEDICATION(S)]). Presenting rhythm PEA (Pulseless Electrical Activity (no heart rate), in total R1 received x3 Epi, x1 bicarbx1, Ca, 10u insulin with ROSC. R1 initial rhythm s/p ROSC sinus tach degenerated to slow Afib (irregular heart rhythm). No evidence of trauma on primary survey pt subsequently intubated sedated and [MEDICATION(S)] gtt (IV drip, which helps elevate blood pressure) started via R fem (femoral) central line. R1's emergency room Records dated [DATE] at 3:58 am, documents in part, page 17 of hospital records indicates hemoglobin 7.4, RBC 2.28 Pulmonary/Critical Care ICU consultation Physician note document [DATE] at 0542 (5:42am) in part shows R1 presents s/p(status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 unfortunately had a prolonged period of pulselessness. She had apparently suffered blood loss from her HD (hemodialysis) catheter, so hypovolemia (low blood volume) is the suspected cause. Critical Care Initial Evaluation Note date of admission [DATE] at 0542 (5:42am) Physician Note, Chief Complaint: Presented [CONDITION(S)], HPI/ED Course in part shows R1 with PMH (past medical history) of hypertension and [CONDITION(S)] (end stage renal disease) who was found on floor of her dining room at the nursing home coupious (large amount) blood with multiple bloody sheets. EMS called and noted a significant amount of blood and no pulse felt and ACLS initiated. Per RN at nursing home, he noted that he found patient with [CONDITION(S)] catheter uncapped and laying on the floor and that's when he called EMS. Unknown downtime. ACLS (advanced cardiac life support) was continued with 3 more rounds of [MEDICATION(S)] given, V. Fib and defibrillated (electric shock with goal to restore a heart rythmn) at 200J. En Route had received a total of 5 rounds of [MEDICATION(S)]. R1 presented to ER in PEA and received another 3 rounds of [MEDICATION(S)], [MEDICATION(S)] and calcium with 10 units of insulin and [NAME] (resumption of care achieved) achieved. Post arrest rhythm ST which [NAME] (degenerated) to slow afib. Intubated without issues and right femoral central line in place. Head CT(computerized tomography scan) without any acute bleeding and chest CT without any focal changes. ER staff called nursing home and RN notes that R1 notes that patient is known to play with her [CONDITION(S)] catheter and for it to become uncapped. Assessment/Recommendations: R1's hospital emergency room record dated [DATE] at 05:42am (5:42am) documents in part, Cardiovascular: [CONDITION(S)] at nursing home with unknown downtime. Received a total of 8 rounds of [MEDICATION(S)] and had one shock delivered for V fib (Ventricular Fibrillation). ROSC (Return of Spontaneous Circulation) obtained and post arrest EKG (Electrocardiogram) with sinus rhythm. Cause of [CONDITION(S)] unclear at this moment but suspect from significant blood volume loss. Nephrology Physician Note dated [DATE] at 0959 (9:59am) documents in part, R1 found in [CONDITION(S)] at the nursing home. Per nursing home documentation patient was playing with her [CONDITION(S)] catheter and she uncapped it. R1 likely profusely exsanguinated (large blood loss). R1 had unknown down time. ACLS was performed after Total of 5 round of [MEDICATION(S)] ROSC was achieved. R1 is given blood transfusion. Impression & Plan: 2. [CONDITION(S)]-on pressors postcardiac arrest 3. Hypervolemia - UF as tolerated 4. Acute blood loss [CONDITION(S)] on top of [CONDITION(S)] of chronic disease-status post [MEDICAL RECORD OR PHYSICIAN ORDER] General Surgery Consult Physician note dated [DATE] at 1222pm documents in part, HPI: currently hospitalized for [CONDITION(S)]. R1 was found down in nursing home, with [CONDITION(S)] catheter uncapped and bleeding from this. R1 was pulseless at time of discovery, achieved ROSC in ER. R1 remains intubated, CT demonstrating [CONDITION(S)] (oxygen deprivation) [CONDITION(S)]. At bedside, R1 is not responsive to verbal or physical stimuli. On [DATE] at 10:07am V2 DON (Director of Nursing) stated that V12 LPN (Licensed Practical Nurse) called and stated that R1 was in the dining room and wanted to watch TV. V2 stated, I (V2) told V12 to let R1 stay in the dining room because R1 was in there by R1's self. V2 (DON) stated, V13 (CNA) was making rounds and saw R1 in the dining room on the floor. V2 stated, V13 stated that V13 saw blood. V2 stated, V12 (LPN) stated that the blood was coming out of the R1's [CONDITION(S)] catheter site and V12 saw the cap off the [CONDITION(S)] catheter and the cap was on the dining room table. V2 stated, The nurse did not describe if blood was on the floor. V2 stated, There was no CPR initiated at the facility. R1 did not need CPR because R1 was breathing and talking. V2 stated, If something is not documented, I (V2) will not say it's not done. V2 stated, The nurse's chart by exception and that the nurse did not do vital signs because she was holding pressure to R1's [CONDITION(S)] catheter and holding pressure on a [CONDITION(S)] catheter is more important because R1 was bleeding out. On [DATE] at approximately 12:17pm V12 stated that V13 called me (V12) and said blood was coming from R1's chest in the dining room. V12 stated she (V12) went there (referring to dining room) and saw R1 bleeding from chest and called out to V14 RN (Registered Nurse) to call 911. Surveyor asked V12 what time this occurred. V12 stated, I (V12) do not know. V14 (Registered Nurse, RN) called 911. V12 stated that R1 was in the dining room alone. V12 stated, R1 was sitting in the chair, and I (V12) lowered R1 to the floor because I (V12) did not want R1 to fall out of chair. V12 stated that I (V12) put sheets under R1 while lying on floor so R1 was not laying on a dirty floor. V12 stated that I (V12) put a pressure dressing to the catheter site and then I (V12) saw the caps were off R1's [CONDITION(S)] catheter. V12 stated, The caps were on the dining room table. V12 stated, I (V12) put the cap back on. V12 stated that I (V12) asked R1 why did you (R1) pull your caps off your (R1's) [CONDITION(S)] catheter. V12 stated, R1 looked like R1 didn't know R1 had done something wrong and R1 stated, I (R1) did not know why. V12 stated that I (V12) took Vital Signs at the beginning of my (V12's) shift. V12 stated that V12's shift is 7:00pm to 7:00am. V12 stated, I (V12) did not take R1's vital signs when I responded to R1 in the dining room bleeding because I already took them. On [DATE] at 12:55 PM V13 (CNA) stated that R1 was walking around in the hallway when V13 came in at 11:00 pm. V13 stated, I (V13) tried to redirect R1 at that time but R1 kept on walking. V13 stated that V12 asked me to keep an eye on R1. R1 was in the dining room. V13 stated, I (V13) do not know what time it was that I observed R1 in the dining room. V13 stated, That it was less than every two hours. V13 stated, I couldn't watch R1 continuously, because I (V13) have other residents. V13 stated, When making rounds I noticed R1's shirt with blood on it and both nurses came and assisted R1. V13 stated, There was no blood on the floor just on R1's shirt. V13 stated, R1 was sitting in a chair and R1 did not say anything. The nurses then took her (R1) off the chair and sat her down on the floor then one of nurses call 911. V13 was not able to state which nurse called 911. V13 stated that the paramedics came around five or ten minutes later and took R1 away and no CPR (Cardiopulmonary Resuscitation) was started on R1 at that time. On [DATE] at 3:13 PM V12 stated, 911 was called because every time there is a bleed you don't know what is going to happen. V12 stated that R1's skin was warm to touch and R1's skin color was within normal limits. V12 stated that the paramedics saw the blood and V12 told them V12 had just closed the cap on the [CONDITION(S)] catheter. V12 stated, R1's gown was changed before R1 left the facility with the paramedics. Surveyor asked V12, with a change of condition with R1 bleeding from the [CONDITION(S)] catheter, should R1's vital signs been taken? V12 said, Yes the vitals should have been taken, I do know that. V12 stated, There was no indication of R1's condition declining. R1's breathing was normal. R1's mental status was not changing. V12 stated that R1 didn't know R1 had done something wrong when R1 took the cap off. On [DATE] at 3:19pm surveyor asked V12 regarding the progress note dated [DATE] at 2:30am by V12 that documents that V13 alerted Nurses on duty that resident observed on the floor, immediately rushed to the room noted resident bleeding from her [CONDITION(S)] catheter port, 911 called, oxygen placed via nonrebreather mask, pressure applied to the site firmly with a clean bandage. Assessment revealed that R1 had opened the [CONDITION(S)] catheter port and the cap was found on the dining room table. cap replaced to the opened catheter. V12 stated, She (R1) was not on the floor I (V12) lowered R1 onto the floor; I put a sheet on the floor and lowered her (R1) to the floor. Again, V12 stated, She (V12) put R1 on floor. V12 stated, I (V12) documented wrong, and it was not that much blood. V12 stated, Blood was dripping from catheter on her (R1) clothes, but there was no blood on floor. On [DATE] at 4:40 PM surveyor asked V14 (Registered Nurse, RN) what happened to R1 on [DATE]. V14 stated, V12 called and said R1 had removed R1's cap from the [CONDITION(S)] catheter. V14 stated that V12 called out orders to call 911. V14 stated, It was a minimal amount of blood on R1's dress. V14 stated, The [CONDITION(S)] cath was open and the cap was put back on the [CONDITION(S)] catheter. I (V14) did not notice or see any more blood after the cap was put back on the [CONDITION(S)] catheter. R1 was no longer bleeding from the [CONDITION(S)] catheter. V14 stated that after I (V14) called 911, I (V14) went back into the dining room to assist V12. V14 stated, I (V14) cannot not remember if vital signs were done. V14 stated that V12 was in the room also. V14 stated, R1 was verbally responsive even when R1 was leaving for the hospital. V14 stated, When the paramedics came, I (V14) don't remember what the paramedics did. V14 stated that when there is a change in condition, standard nursing is to assess the resident, call the doctor, get recommendation from the doctor, and get labs. V14 further stated that getting vital signs is included in the assessment. Surveyor asked V14, what is the professional standard for charting? V14 stated that professional standard for charting is objective information, document what happened, orientation of resident, what care was provided to the resident and every interaction with the resident. V14 stated, If not charted it's not done. On [DATE] at 12:30pm V16 (Nurse Practitioner, NP) stated, The nurse (V12) called and said that R1 was full of blood and believed the [CONDITION(S)] catheter was pulled out. V16 stated, the nurse (referring to V12) just said that R1 was full of blood. V16 stated, I (V16) asked V12 how R1 was doing and V12 said R1 was alert. V16 stated that I (V16) told V12 to send R1 out to the hospital. Surveyor asked V16, V16's professional opinion regarding a bleeding [CONDITION(S)] catheter. V16 stated, A pressure dressing is definitely needed to the area and vital signs are needed when there is a change of condition. Surveyor asked V16 the importance of obtaining vital signs when a resident is bleeding out from a [CONDITION(S)] catheter. V16 replied, Absolutely, vital signs are very important. Surveyor inquired about the volume of blood coming from a [CONDITION(S)] catheter. V16 stated, A [CONDITION(S)] catheter is a high-pressure catheter, and it would take ,d+[DATE] minutes for a resident to be full of blood with a high-volume catheter and it would depend on when they found R1. It definitely will not be drops or a [NAME] of blood, because of the type of [CONDITION(S)] catheter it is. V16 stated, With a high-volume catheter, in ,d+[DATE] minutes R1 could be gone (deceased ). It is not a good sight, and it is not an ambulance call it is a 911 call. On [DATE] at 1:54pm V14 (RN) stated, I saw R1 in the hallway interacting with V12 and I supposed V12 was telling R1 to go back to the blue zone. V14 said, I don't remember what time, but it was late at night, and it was before the incident occurred and the incident occurred around 2:30pm. The nurse (V12) had a call, and she (V12) came to answer the call and then she (V12) went back to talk to R1. Surveyor inquired about who made the 911 call. V14 replied, I think I did; the call was made within minutes of the other nurse (V12) asking me (V14) to call 911. Surveyor inquired about what was told to the 911 responder. V14 stated, I don't recall, but no vitals were given. V14 stated, after making the call I (V14) printed the transfer papers and then went into the dining room and we (V12, V13 and V14) were helping the patient (R1). We (V12, V13, V14) stayed with the patient (R1); we changed the gown because there was blood from the [CONDITION(S)] cath. It didn't take 911 long to arrive it took about ,d+[DATE] minutes. Surveyor asked if there was blood on the floor. V14 stated, No, there was no blood on the floor. There was a sheet on the floor that the nurse (V12) had put on the floor and the resident (R1) was sitting on the flat sheet. I (V14) don't recall if there were any towels, but she (R1) was not on the bare floor. I (V13) don't know if it was a white sheet or blanket. I (V14) didn't take vitals and I (V14) don't know if V12 had taken vitals. V13 was in the dining room with us (V12 and V14) while we (V12 and V14) were taking care of the resident (R1). V13 was the one who brought the gown and was there interacting with the resident (R1) during this time. On [DATE] at approximately 2:57pm surveyor asked V2 if a resident is found bleeding with agonal (irregular gasping) respirations and no pulse, what is the expectation of staff. V2 (DON) stated, The nurse will do CPR (cardio pulmonary resuscitation) and call a code so lots of people can come to help with crash cart, but in this particular case, the resident (R1) was breathing with a pulse and alert. On [DATE] at 4:10pm surveyor asked V19 (Paramedic) to describe what V19 saw upon arrive to the dining room where R1 was located. V19 stated, when we (referring to paramedics and firefighters) got there a male nurse (V14 RN) was just leaving the room (referring to dining room) and stated he (V14) had capped the port. V19 was asked if anyone else was in the dining room and if CPR or any type of care was being done for R1. V19 stated, No there was no one in the room with R1. She (R1) was laying on the floor alone in the dining room. No staff were there, no one was doing CPR, no crash cart was present, I (V19) cannot remember if R1 had any oxygen on. We (referring to paramedics) went over to R1, and she was having agonal (gasping) respirations and no pulse was felt so CPR was immediately started, and we put pads on the patient (R1). V19's narrative stated his patient care report narrative was accurate. V19 also stated, The facility did not call the right information in regarding the patient so all of the right equipment was not brought up immediately, this should have been an ACLS (Advanced Cardiac Life Support) call, and it was not, but we had equipment to take care of the patient. V19 stated, I am not sure what happened to the patient (R1) but I believe she was given blood when we got her to the hospital. During the course of this survey V2 (DON) did not provide a baseline care plan or 72-hour admission as requested from surveyors. Facility Registered Nurse Job Description undated documents, in part, Position Summary: The Registered Nurse provides direct nursing care to the residents. The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times. E. Role Responsibilities- Nursing Care: 8. Implement and maintains establish nursing objectives and standards. Facility Licensed Practical Nurse Job Description undated documents in part, Position Summary: The Licensed Practical Nurse provides direct nursing care to the residents. The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times. E. Role Responsibilities- Nursing Care: 8. Implement and maintains establish nursing objectives and standards. 18. Takes and records TPRs (Temperature, Pulse, Respirations), blood pressure, etc., as necessary. Facility Certified Nursing Assistant Job Description undated documents in part, the primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors and ensure that residents who are unable to call for help are checked frequently. Facility's Policy dated [DATE] and titled, Change in Resident's Condition or Status, documents, in part, 3. A significant change of condition is a decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. 4. During medical emergencies such as unstable vital signs, respiratory distress, uncontrolled bleeding and unresponsiveness 911 will be notified for transport to the hospital. Facility's Policy revised dated [DATE] and titled, Accident Incident Reporting Policy, documents, in part, Procedure: 1. If a resident is involved in an accident/incident an immediate assessment of the resident will be completed. First aid will be provided as necessary. Facility Assessment tool dated [DATE], document, in part, Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies. Staff type: Nursing Services (DON, RN, LPN, or CNA)

Based on interviews and record reviews, the facility failed to provide medication and care services to address the psychosocial needs of a resident who exhibited depressive behaviors. This failure affected one of three residents (R1) reviewed for behaviors and social service needs in a sample of 10. R1 experienced periods of depression and negative behaviors that was not treated which caused an acute exacerbation of illness. R1 had to be hospitalized for [REDACTED]. Findings include: According to R1's medical records, R1 was admitted to the facility on [DATE] and diagnosed with [REDACTED]. R1's (MONTH) (YEAR) progress notes were reviewed and documented: 9/2/16 Medical Practitioner Note: History of Present Illness . (R1) has a significant psychiatric history with multiple psychiatric admissions per medical record. 9/3/16 Nursing Progress Note: (R1) noted with bizarre behavior, does not want anything for self and when asked (R1) stated, I'm scared R1's Electronic Medication Administration Record [REDACTED] On 9/4/16 [MEDICATION NAME] tablet 0.25 mg, give 1 tablet by mouth every 12 hours as needed for anxiety, not available yet On 9/6/16 [MEDICATION NAME] tablet 0.25 mg, give 1 tablet by mouth two times a day for anxiety, (Z1) to call order in to pharmacy for delivery, will give when available On 9/7/16 time 16:13, Depressed was documented on the Daily skilled nursing note: Record any mood behavioral issues. 9/7/16 16 R1's Electronic Medication Administration Record: [REDACTED] On 9/7/16 time 21:57, Calm all shift but depressed was documented on the Daily skilled nursing note: Record any mood behavioral issues. On 9/9/16 time 15:56, Daily skilled nursing note: Record any mood behavioral issues: Depressed On 9/10/16 time 19:41, Quiet was documented on the Daily skilled nursing note: Record any mood behavioral issues. On 9/16/16, 16:36, Behavior charting: Describe Behavior/Mood: sitting on the floor On 9/16/16, 16:45, Daily skilled nursing note: Record any mood behavioral issues: Depressed On 9/16/16, 16:46, Daily skilled nursing note: Record any mood behavioral issues: Depressed, anxious and agitation Record any teaching/education: (R1) to stop sitting on the floor Additional comments: (R1) to comply with medication orders On 9/23/16, 11:38, Behavior note: Behavioral issues noted. Always going to the floor and lay down crying. Stated that (R1) wants to go to hospital or (R1) will kill self. When asked why and how (R1) plans to do it, (R1) was unable to answer and just start crying again. (R1) was put on 1:1 9/23/16, 14:04, Behavior note: (R1) continues to have behavioral issues (Crying and trying to throw self on the floor. 1:1 monitoring until paramedics came and took (R1) to (local hospital) 9/23/16, 18:35, Nurse Progress note: Received a call from (hospital), (R1) admitted with [DIAGNOSES REDACTED]. R1's 9/29/16 Hospital note (Z6's progress notes) document in part: (R1) states that (R1) has been feeling severely depressed and having suicidal thoughts. (R1) states that (R1) keeps hearing voices and the voices inside head are getting louder each day, makes (R1) nervous, restless and scared, but at nursing facility, (R1) was reportedly being very agitated and expressing suicidal thoughts. Indications for hospitalization : Severe depression, suicidal ideation, auditory hallucinations, paranoia, increasing agitation, violent potential and impaired judgment. Modalities of Treatment: Psycho-pharmacological treatment, psychotherapy including individual, group milieu and all other therapeutic activity. R1's 9/5/16 Comprehensive Care Plans document: Physical and Psychosocial needs - New admission, diagnosis, [MEDICAL CONDITION] disorder, major [MEDICAL CONDITION], long term care new (was in intermediate care facility previously) Symptoms are manifested by: -Feelings of helplessness, mood distress, anxiety, sadness, communication through behavioral symptoms Comments and specific observations: Easily upset, cries when spoken to by staff, unable to manage emotions, observed lability Approaches: One to one as needed, alleviate anxiety and assist in adjustment to facility Use group therapy to alleviate anger/depression, reduce loneliness, isolation Intervene on an incidental or episodic basis to re-direct behavior symptoms. Complete objective documentation showing an increase in functional ability and or a decrease in maladaptive behavior. -The resident demonstrates significant mood distress related to a [DIAGNOSES REDACTED]. Problems are manifested by: Remaining in room Angry, tearful outbursts . They don't like me. Paranoia that staff, residents think I'm a baby, don't like me. -The resident has a history of self harmful ideations and behaviors This appears related to evidence of severe mental illness, poor impulse control, lack of awareness, feelings of hopelessness, helplessness Problems are manifested by: [MEDICAL CONDITION], tearful at times Approaches/Interventions: Conduct an initial psychiatric evaluation -The resident displays behavioral symptoms related to Severe Mental illness, a difficult time adjusting to life in the long term facility, poor or ineffective coping skills, noted to drop to floor when upset, crying uncontrollably but unable to express why Approaches/Interventions Conduct an evaluation of behavioral symptoms Provide supportive group, 1:1 or as needed intervention Intervene when any appropriate behavior is observed Refer resident to the consulting psychiatrist for psychiatric evaluation as warranted Give psychoactive medication as ordered, record behavioral symptoms R1's medical record did not document any individual counseling or group therapy for the month of (MONTH) (YEAR). Z1 (R1's Primary Physician) documented on R1's medical records on 9/1/16: Plan/Comment: [MEDICAL CONDITION] disorder, on ([MEDICATION NAME]) 15 mg 1 tablet by mouth daily, psychiatric consultation R1's medical record did not document any psychiatric evaluation and consultation at the facility for the month of (MONTH) (YEAR). R1 was interviewed on 10/19/16 at 3:46 pm. During the interview, R1 was noted to to be oriented to person and place and appropriately answered questions. In the middle of the interview, R1 started crying for 30 seconds and when R1 stopped, R1 stated, Can I go to my room? Staff interviews were conducted. E8 (Restorative Aide) was interviewed on 10/20/16 at 1:29 pm. E9 stated that R1 is alert and oriented to person and place, and has behaviors and at times is more confused and anxious. Z2 (Nurse Practitioner) was interviewed on 10/19/16 at 1:06 pm. Z2 stated that R1 has behaviors, which has a pattern of crying loudly, then (R1) will lie on the ground, and cry. Z2 stated that R1 is alert to self and place and has a background of [MEDICAL CONDITION]. E4 (Licensed Practical Nurse) was interviewed on 10/19/16 at 3:12 pm. E4 stated that R1 is alert but confused, hallucinates and has anxiety. E4 stated that R1 has behaviors, R1 cries, laughs, sits and sleeps on the floor. E4 stated that R1 has psychiatric needs and uses [MEDICAL CONDITION] medications. E3 was interviewed on 10/24/16 at 5:00 pm. E3 stated that R1 is alert and oriented but that (R1)'s mood is very labile, for example, cries and sits on the floor. E3 stated that R1 has some adjustment issues because (R1) came from intermediate care facility and transferred to a skilled nursing facility. E3 stated that R1's psychosocial needs have been addressed in R1's care plans. E2 was interviewed on 10/26/16 at 3:00 pm. E2 confirmed that all social services encounters are documented in the social services progress notes and confirmed that R1 did not have any psychosocial groups, 1:1 or individual counseling sessions or psychiatric evaluation and consultation at the facility until R1 returned from latest hospitalization . Z6 (Psychiatrist) was interviewed via telephone on 10/26/16 at 1:39 pm. Z6 stated that R1 was admitted to the hospital due to [DIAGNOSES REDACTED]. Z6 stated that during the examination, R1 was depressed, talking to self, talking non-sense, and affected was [MEDICATION NAME]. Z6 stated that hospitalization could have been prevented if R1 was compliant with medications. Z6 stated also that R1 would benefit from psychotherapy milieu including groups and individual counseling, medication management and being managed by psychiatry professional. Z6 added that because of psychotherapies that were provided at the hospital and medication evaluation and management, R1 became more stable and was discharged back to the facility.

Based on interview and record review the facility failed to have a system in place to monitor a resident's alcohol consumption while in the facility and have a mechanical device in place to effectively prevent a resident from exiting the building from a window on the 4th floor. As a result, R1 climbed out of a fourth floor window and sustained multiple fractures. Findings Include: R1's face sheet indicates R1 was admitted to the facility on [DATE]. R1's face sheet [DIAGNOSES REDACTED]. R1's incident report dated 5/20/2014 indicates that R1 climbed out of the window and was observed on the ground moaning. R1's incident report conclusion indicates that R1 attempted to escape the facility between 8:30 - 8:40 pm by going through a window by tying sheets together. R1's incident report indicates that R1 fell to the ground and was immediately transferred and admitted to a local hospital with right and left femur fractures, rib fractures, left pneumothorax and a 4 centimeter laceration to the right hand. On 9/26/16 at 10:31 am, E2 (Director of Nursing / DON) stated that R1 tied six bed sheets together and used them to climb out of a window. E2 (DON) stated a passerby saw R1 climbing out of the window and falling in the process. E2 stated the passerby notified the facility and emergency responders were called immediately. E2 stated R1 was a new admission and was on a red (restricted) pass. E2 stated a restricted means that the resident cannot go out of the facility unsupervised (for medical care only). On 9/26/16 at 1:01 pm E3 (Maintenance Director) stated R1 used a metal cane as a leverage tool to bend a middle stopper allowing the window to be forced up. E3 stated there was a metal cane, eyeglasses, a bag of clothes and a beer can observed on the ground on the outside of the facility near R1. On 9/26/16 at 1:47 pm E4 (Registered Nurse / RN) stated R1 did not express a desire to leave the facility before he jumped from the window. E4 stated that R1 asked for his night medication early stating that he wanted to go to bed early. E4 stated that she notified R1's physician on the medication request and medicated R1 at 8:15 pm with Librium. On 9/26/16 at 3:50 pm E7 (Certified Nursing Assistant /CNA) stated that she was not R1's CNA the night that he jumped from the window. E7 stated that E7 provided R1 with a snack in the 8:00 pm hour, asked R1 if he needed anything and he replied no he was okay. E7 stated that she did not notice any unusual behavior and did not smell any alcohol on R1. E7 stated that R1 did not express a desire to leave the facility. On 9/27/16 at 3:08 pm E6 (CNA) stated that she was R1's CNA on the night that he jumped from the window. E6 stated R1 was independent and kept to himself. E6 stated on the evening of 5/20/2014 while providing care for R1's roommate R1 made a request from the nurse but she is unsure what he requested. E6 stated R1 did not appear intoxicated and she does not recall smelling alcohol. E6 stated she does not know where R1 got the sheets from. E6 stated the linen were kept in the hall but she did not see R1 taking any linen. E6 stated while in the room caring for R1's roommate she did not hear or see R1 tampering with the window. E6 stated she was not in the room when R1 jumped out of the window. R1's emergency room hospital record dated 5/20/2014 at 9:20 pm indicates that R1 had a blood alcohol level of 37 milligram/deciliter (mg/dl) with a normal range of 0 - 10 mg/dl. R1's emergency room hospital record dated 5/20/2014 indicates that R1 had been consuming alcohol prior to the events and had a bottle of alcohol with him at the scene which had broken during the fall and caused a laceration to the right hand. R1's emergency room hospital records indicates that R1 suffered bilateral trochanteric fractures, displaced fractures involving the fifth through twelfth ribs with an associated small pneumothorax, non-displaced fractures to the right sixth through ninth ribs, right talus fracture and left pubic rami fracture. On 9/29/16 at 9:25 am Z4 (Addiction Nurse) stated if the blood alcohol levels are elevated then there has been recent alcohol consumption. On 9/29/16 at 11:15 am Z3 (Medical Director) stated if the blood alcohol level is elevated then there is alcohol in the patient's system. Z3 stated when there is no alcohol consumption the level will go down to the normal range. R1's care plan dated 5/08, 5/09 and 5/14/2014 did not address in what manner staff will monitor R1's alcohol use, when it indicated R1 had a substance abuse disorder, history of alcohol abuse, drunkenness and alcohol withdrawal. The facility's policy on room/bag searches, contraband items and removal of contraband dated 5/17/2010 indicates the alcoholic beverages are not allowed in a resident's possession.

Based on observation, interview, and record review the facility failed to implement adequate resident monitoring and observation per physician orders, failed to follow their fifteen-minute monitoring policy, and failed to identify suspicious behaviors for five of five residents (R1, R2, R3, R4 and R5) reviewed for supervision in the sample of five. The facility's failures resulted in an immediate jeopardy due to lack of supervision and monitoring on 2/27/16, between 2:30pm and 3:10pm, when five residents (R1,R2,R3,R4,R5) were found unresponsive on the second floor of the facility and were sent to the hospital where heroin overdose was confirmed. The facility also failed to consistently implement 15-minute monitoring per doctor's order and facility policy, when four of the five residents (R2, R3, R4 and R5) returned to the facility in the evening of 2/27/16. As a result, R5 had access to and ingested heroin for the second time on 2/28/16 between 9:05am and 10:09am. The immediate jeopardy was determined to have begun on 2/27/16, at 6:30PM, when the first (of the five residents) returned to the facility after being diagnosed with [REDACTED]. On 3/9/16, at 2:15 PM, E1 (Administrator) was notified of the immediate jeopardy. The immediate jeopardy was removed on 3/10/16, at 4:10 PM. While the immediacy was removed, the facility remains out of compliance at level two as the facility continues to implement their abatement plan interventions. Findings include: Facility's incident reports dated 2/27/16 of five residents (R1, R2, R3, R4 and R5) document that the five residents were found unresponsive on the second floor of the facility within the duration of approximately 40-minute period. The five residents were sent to the hospital where heroin overdose was confirmed. Upon return to the facility of the four residents (R2, R3, R4 and R5) on 2/27/16, the facility failed to provide supervision and monitoring that resulted in R5's subsequent heroin overdose on 2/28/16. 1. Face Sheet documents R5 is a [AGE] year old resident admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Hospital Transfer form dated 12/31/15 documents a history of substance abuse. (MDS) Minimum (MDS) data set [DATE] Section C- Cognitive Patterns scores R5 as 15 indicating no cognitive impairment or signs of delirium; Section G Functional Status documents R5 is independent with activities of daily living and ambulation. Interview for Substance Abuse Disorder dated 1/7/16 documents R5 has used heroin in the past. Physician order [REDACTED]. Hospital Record dated 2/27/16 documents the reason for emergency room visit is heroin overdose, 2/28/16 documents the reason for emergency room visit is probable heroin overdose. R5's care plan for substance abuse/chemical dependency dated 1/23/16 does not have evidence that it was updated with additional or new interventions to address the heroin overdose on 2/27/16 or 2/28/16. Progress Note 2/27/16, 6:47pm, R5 was found unresponsive in R6's room, along with R4. Upon their arrival, paramedics administered Narcan to R5; R5 started to wake up and R5 was transferred to the hospital. Ambulance Run Sheet dated 2/27/16, 3:05pm, documents R5's symptoms were overdose, confusion, vomiting; R5 received two doses of Narcan to treat a suspected opiate overdose. Progress Note 2/27/16, R5 returned from the hospital. Progress Note 2/28/16, 11:23am, documents a second episode of non-responsiveness within 12 hours from returning from the hospital on [DATE]. R5 was found unresponsive on the floor in R4's room. Upon arrival, paramedics administered Narcan and R5 began to wake up. Ambulance Run Sheet 2/28/16 10:17am documents R5 was given Narcan for a suspected opiate overdose; Impression is documented as heroin overdose. On 3/2/16 at 9am, by phone, Z3 (Police Detective) stated that on both 2/27/16 and 2/28/16, R5 was found with rolled up paper money next to her, which is used as a way to inhale heroin through the nose. Plan of Care 2/28/16, documents 15-minute monitoring started 2/28/16 at 8:28am; On 2/29/16 at 3:45pm, E2(Director of Nursing) stated in the Daily Status Meeting that all documents regarding 15-minute monitoring of R5 have been presented. Medical record presented by the facility staff does not show evidence that R5 was being monitored every 15 minutes as stated. R5 was not available to interview during the survey. On 3/2/16 from 11am-12pm, video recorded footage from the second floor was reviewed. The video recording shows staff walking through the entire second floor, checking in each room from 2am - 2:10am on 2/28/16. This staff activity was repeated again at 5:05am, three hours later. In between 2:10am and 5:05am, staff intermittently walked up and down the halls, but did not go into R5 ' s room in regular 15-minute intervals. Video footage 2/28/16, at 9:05am shows R5 walking from the dining room into R4's room; 9:42am E21(Nurse Aide) walks to R4's doorway (unable to determine if E21 goes into the room); at 10:09am, E21 walks into R4's room, then comes out of the room, staff at the nurse's station get up and go to R4's room; at 10:12am, the emergency crash cart is brought down to R4's room; at 10:13am, R3 walks out of R4's room. On 2/28/16 at 10:30am, R3 stated R4 and R5 got high again this morning (2/28/16). R3 stated that R3 knew this because R3 was in the room with them (R4 and R5). R3 stated R5 was taken back to the hospital because she (R5) was found on the floor of his (R3) room. On 3/2/16 at 3:15pm, E21 stated R5 was in R4's room on 2/28/16 when E21 checked on them around 9:30am after breakfast. The door to R4's room was half way closed; R4 and R5 were told to keep the door open. E21 stated that was the last time he saw R4 and R5 until E21 found R5 on the floor of R4's room after 10am. 2. Face sheet documents R3 is a [AGE] year old resident admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Hospital Note 9/24/15 documents R3 has a history of opiate abuse, bipolar disorder, poly substance abuse, and suicide attempts. MDS (Minimum Data Set) dated 12/30/15 Section C - Cognitive Patterns scores R3 as 15, indicating no cognitive impairment and no symptoms of delirium; Section G - Functional Status documents R3 is independent or only needs supervision with activities of daily living and ambulation. Substance Abuse Screen dated 10/14/15 documents R3 denies using street drugs or a history of drug abuse. Assessment for Suicidal or Self Harm dated 10/7/15 documents R3 has had suicidal thoughts and actions. Progress Note dated, 2/19/16 10:47pm, R3 came back to the facility late from pass, staff smelled alcohol on R3, R3 denied drinking alcohol. Social Service Progress Note 2/23/16 R3 had a self-harm incident on 2/19/16. Progress Note 2/24/16 documents a lab result was positive for substance abuse. Drug Screen 2/21/16 was positive for amphetamines and marijuana. Physician order [REDACTED]. Progress Note 2/27/16 documents that at approximately 2:40pm, R3 was found on the floor of his room, unresponsive. Upon their arrival, paramedics administered Narcan to R3; R3 began to wake up, and was sent to the hospital. Ambulance Run Sheet 2/27/16 2:54pm documents Narcan was given to R3 for a suspected opiate overdose; upon waking up R3 stated to paramedics that, (R3) did a dime bag of heroin. Hospital emergency room Record dated, 2/27/16 documents R3 was diagnosed with [REDACTED]. R3 has a past history of heroin and marijuana use. Review of clinical record does not show evidence that R3 received increased supervision to monitor for behaviors when R3 returned from the hospital on [DATE]. On 2/28/16 at 10:30am, R3 stated that a few weeks ago R3 tried to kill himself by overdosing on heroin because he (R3) was upset. R3 also stated that his roommate, R4, heard that Z2 (family member) is a heroin user and wants to get some. Then on 2/27/16 after lunch, R1 and Z2 came into R3's room and gave him (R3) drugs. R3 stated R1 and Z2 were hoping R3 liked the drugs and would buy more. R3 described the drugs as, white powder in a small zippered baggie. R3 stated he thought the powder was either cocaine or heroin, he inhaled it through his nose, and stated, I don't remember much after that until I woke up and saw the paramedics standing over me. During the same interview, R3 also stated that the facility staff did not check on him (R3) more often after coming back from the hospital. R3 stated that R4 and R5, got high again this morning (2/28/16) Plan of Care monitoring for R3 starts on 2/27/16 at 9:15pm; the next entry is on 2/28/16 at 3pm. On 2/29/16 at 2pm, E9 (Nurse) stated R3 was on regular two-hour well-being checks on 2/27/16 for the 7am-3pm shift. E9 stated R3 ate lunch in the dining room on 2/27/16 but does not remember when R3 was seen after that. On 3/2/16 at 2:33pm, E5 (Social Service) stated R3 had a suicide attempt while out in the community on 2/19/16, R3 overdosed on heroin. On 2/29/16 at 3:45pm, E2 (Director of Nursing) stated in the Daily Status Meeting that all documents regarding 15-minute monitoring of R3 have been presented. On 3/2/16 from 11am-12pm, video recorded footage from the second floor was reviewed for 2/27/16 11pm through 2/28/16 10:15am. Staff walked through the entire second floor, checking in each room from 2am-2:10am on 2/28/16. This was repeated again at 5:05am, three hours later. In between 2:10am and 5:05am, staff intermittently walked up and down the halls, but did not go into R3's room in regular 15-minute intervals as ordered. After 5:05am, there is no video evidence that staff monitored R3 in regular 15-minute intervals. Video footage 2/28/16, 10:13am, R3 walks out of R4's room. R3's care plan for substance abuse/chemical dependency dated 1/23/16 does not have evidence that it was updated with additional or new interventions to address the heroin overdose on 2/19/16 or 2/27/16. On 3/2/16 at 2pm, E2 presented new substance abuse care plans for R2 and R3 dated 2/28/16. E2 stated the care plans were updated after the concern was brought to their attention on 3/1/16 by the surveyor. 3. Face Sheet documents R4 is a [AGE] year old resident admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Minimum (MDS) data set [DATE] Section C- Cognitive Patterns scores at 14, indicating no cognitive impairment and no signs of delirium; Section G Functional Status documents R4 needs supervision only for activities of daily living and ambulation. Community Survival Skills assessment dated [DATE] documents R4 has a history of substance abuse. Interview for Substance Abuse Disorder dated, 1/5/16 documents R4 has used heroin and alcohol in the past; last used heroin three weeks ago, and substance abuse is currently a problem for R4 now. Progress Note 2/27/16 12:16pm (late entry) documents R4 was noted on the bed, unresponsive. 911 paramedics were called and upon arrival took over the care of R4 and R4 was transported to the hospital. Ambulance Run Sheet 2/27/16 3:10pm documents suspected substance abuse, impression heroin overdose. In this report, R4 admits to drinking vodka and doing heroin. Physician order [REDACTED]. Plan of Care documentation of 15-minute monitoring starts 2/16/16 and ends 2/25/16. On 2/29/16 at 3:45pm, E2 (Director of Nursing) stated in the Daily Status Meeting that all documents regarding 15- minute monitoring of R4 have been presented. Medical record does not show evidence that R4 was being monitored every 15 minutes as stated upon returning from the hospital on [DATE] after a heroin overdose. On 2/28/16 at 11:30am, R4 sat in the conference room for an interview. R4 had slurred speech and the conversation was incoherent at times. R4 would fall asleep sitting at the table, wake up and not know where he was or where the conversation was going. R4 stated that on 2/27/16, he spoke with Z2 (family member of R1) about drugs. R4 said Z2 could, get some good s**t for R4, so R4 paid Z2 $25 for drugs. R4 told Z2 that if the drugs were good, R4 could triple Z2's money in three days at the facility. R4 stated he (R4) controlled the drugs both times so R5 would not overdose again. R4 was not able to specify what that meant. During the same interview, R4 stated the staff is not watching him more closely since coming back from the hospital on [DATE]. At the time of this interview, R5 was already transferred to the hospital but R4 was not aware of this fact. R4's interview is validated with Z3 (Police Detective)'s interview, review of the video, portions of R3's interview, and ambulance run sheet documentation. On 3/2/16 from 11am-12pm, video recorded footage from the second floor was reviewed. Staff walked through the entire second floor, checking in each room from 2am-2:10am on 2/28/16. This was repeated again at 5:05am, three hours later. In between 2:10am and 5:05am, staff intermittently walked up and down the halls, but did not go into R4's room in regular 15-minute intervals as ordered. Substance Abuse care plan does not document any new or updated interventions upon R4's return from the hospital after the heroin overdose on 2/27/16. On 3/2/16 at 2pm, E2 presented new substance abuse care plans for R2 and R3 dated 2/28/16. E2 stated the care plans were updated after the concern was brought to their attention on 3/1/16. R4's care plan was not updated because he is no longer in the facility. 4. Face Sheet documents R2 is a [AGE] year old resident admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Minimum (MDS) data set [DATE] Section C- Cognitive Patterns score is 15, indicating R2 is cognitively intact and without signs of delirium; Section G - Functional Status R2 requires supervision with activities of daily living. Facility document titled Indicators of Aggressive and/or Harmful Behaviors 1/22/16 documents R2 has a history of substance abuse with recent relapse (unknown date). Interview for Substance Abuse Disorder dated 8/19/15 documents R2 has used heroin and marijuana, last using heroin on 4/11/15. Social service note dated 3/1/16 addresses the incident of 2/27/16. Nurse Progress Note dated 2/27/16 2:50pm (late entry) documents R2 was found on the floor in the room behind the door. Nurse Progress Note 2/27/16 10:33pm, R2 returned from the hospital with the [DIAGNOSES REDACTED]. Plan of Care documentation starts on 2/27/16 at 9:27pm; the next entry is 2/28/16 at 8:13am. Ambulance Run Sheet dated 2/27/16, 3:01pm, documents present history is substance abuse, overdose, and pinpoint pupils; R2 admits to using heroin this day; Narcan is administered at 3:24pm for the indication of opiate overdose. Impression is overdose. Hospital Record 2/27/16 documents R2's [DIAGNOSES REDACTED]. On 2/28/16 at 10:20am, R2 stated that after lunch on 2/27/16 he found a baggie of white powder in the corridor, snorted it, and doesn't remember anything after that until the paramedics woke him. R2 stated that he (R2) knew it was cocaine or heroin. R2 also stated no one checked on him (R2) more often after coming back from hospital on [DATE]. On 2/29/16 at 3:45pm, E2 (Director of Nursing) stated in the Daily Status Meeting that all documents regarding 15-minute monitoring of R2 have been presented. On 3/2/16 from 11am-12pm, video recorded footage from the second floor was reviewed with E1 (Administrator) and E2 for 2/27/16 11pm through 2/28/16 10:15am. The video shows the facility staff walked through the entire 2nd floor, checking in each room from 2am-2:10am on 2/28/16. This was repeated again at 5:05am, three (3) hours later; Staff did not go into R2's room. From 3:44am to 7:28am, the door to R2 ' s room remained closed and no one entered the room to perform 15-minute checks on R2. R2's care plan for substance abuse/chemical dependency 2/12/16 does not have evidence that it was updated with additional or new interventions regarding the heroin overdose on 2/27/16. On 3/2/16 at 2pm, E2 presented new substance abuse care plans for R2 and R3 dated 2/28/16. E2 stated the care plans were updated after the concern was brought to their attention on 3/1/16. 5. Face Sheet documents R1 is a [AGE] year old resident admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Hospital records dated 2/10/16 documents that R2 has a history of alcohol and recreational drug use. Minimum (MDS) data set [DATE] Section C - Cognitive Patterns documents R1 is cognitively intact, scores 14 out of 15 on the Brief Interview for Mental Status, and does not have any signs of delirium; Section G - Functional Status R1 is independent with walking in the halls and using the bathroom. Community Survival Skills assessment dated [DATE] documents it cannot be determined if R1 can refrain from alcohol and drug use in the community. Interview for Substance Abuse Disorder dated 2/17/16 documents that R1 used alcohol every day, with the last drink being three months ago, and denies the desire to use alcohol at this time. Physician order [REDACTED]. The facility did not present a policy regarding the routine monitoring of residents on the second floor even after surveyor's request. Substance Abuse Care Plan dated 2/17/16 documents that R1's history of alcohol abuse and drug seeking behaviors, no interventions are documented for the history of recreational drug use as documented in the hospital records 2/10/16 prior to admission into the facility. Progress Notes dated 2/27/16, 2:45pm R1 was found unresponsive in the common bathroom on the second floor. The facility called 911; staff started cardiopulmonary resuscitation on R1. Paramedics arrived and administered Narcan (to counteract heroin) to R1, and R1 began to wake up. Ambulance Run Sheet dated 2/27/16, 2:31pm documents R1 was unresponsive in the bathroom, Narcan was administered at 2:40pm for a suspected opiate overdose, and R1 began to respond. Impression is documented as overdose. Both the facility Progress Note 2/27/16, 11:32pm and the hospital drug screen 2/27/16 document R1 is positive for opiates and benzodiazepines. Hospital History dated 2/27/16, documents that R1, denies taking drugs in her life. There are other residents here with similar symptoms. Supposedly, there was or were individuals passing out heroin at the nursing home. Progress Note dated 2/27/16, 9:39pm, R1 signed out of the hospital AMA (against medical advice) and returned to the facility. R1's physician was notified and R1 was petitioned out to the psychiatric hospital. On 2/29/16 at 10:20am, E9 (Nurse) stated R1 was introducing Z2 (R1's daugther) to all of the residents on 2/27/16 before lunch. R4 asked R1 for Z2's phone number and R1 gave it to him. E9 stated R1 is drug-seeking and has a history of substance abuse. R1 was asking for more medications during the day on 2/27/16. E9 did not have any information regarding R4's behaviors on 2/27/16. On 2/28/16 at 9:45am, E1 (Administrator) stated five Emergency Code Blues were called within 40 minutes on 2/27/16 involving R1-R5. The facility knows that Z2 brought in a substance which is unconfirmed as heroin. On 2/29/16 at 10:45am, E10 (Nurse Aide) stated R1 and Z2 were speaking with R4, and E9 said she, didn't like what was going on between them. R4 and R5 went into R1's room with Z2 after lunchtime on 2/27/16. E10 stated she saw R2 begging R1 for Z2's phone number. E10 did not tell anyone or other members of the staff about this encounter. On 2/29/16 at 11am, R6 stated he found R4 and R5 in his (R6) room and doesn't know how they (R4, R5) got there. R4 was asleep on the bed and R5 was asleep on the floor. R6 did not tell anyone that he couldn't wake up R4 and R5 to get them out of his room. R6 stated that he heard some people were doing drugs on 2/27/16, but does not know where R4 and R5 got the drugs. On 2/29/16 at 11:50am, E11 (Nurse) stated R1 has a history of drug abuse and E11 only saw R1 with Z2. After the code blues on 2/27/16, E9 and E10 told E11 that R1 was acting suspicious with Z2 and they both went into a resident room with R4 and R5. On 2/29/16 at 3:15pm, E2 (Director of Nursing) stated R2, R3, R4, and R5 were all on 15-minute monitoring when they returned from the hospital on [DATE]. On 3/1/16 at 11:05am, E17 (Nurse Aide) stated he saw R1 introduce Z2 to R4 in the 2nd floor hallway. On 3/2/16 at 2:20pm, E19(Nurse) stated that on 2/28/16, the night shift (unknown nurse) told her that R5 was on 15-minute monitoring due to a heroin overdose 2/27/16. E19 last saw R5 between 8-9am on 2/27/16. E21 reported to E19 that R5 was nonresponsive on the floor on 2/28/16 around 10am. Per 11/25/11 facility policy titled, fifteen-minute monitoring, the facility uses this guideline to emphasize a proactive intervention promoting enhance physical and psychosocial well-being. The procedures documents in part, (2) a staff member that has been assigned to care for the resident will visualize the resident every 15 minutes, (4) if the resident cannot be guided or redirected during the 15minute monitoring, one to one monitoring will be instituted, (5) The physician/psychiatrist will be notified for further evaluation and treatment. The facility does not have a policy for standard two (2)-hour monitoring of residents. The facility submitted the following plan to remove the immediate jeopardy: Corrective action for residents affected: · (R1, R2, R3, R4 and R5) were immediately sent to the hospital via 911 for further evaluation and treatment on 02/27/16 by the licensed nurse. · R1, R2, R3, R4 and R5 returned to the facility and were assessed and placed on every 15 minute monitoring on 02/27/16 which was placed on a 1:1 supervision by activity aide on 02/28/16. · R1 on 02/27/2016, after being transferred 911 to a local hospital, R1 left hospital, Against Medical Advice at 7:15pm and walked to the facility and arrived, approximately 8:00pm to the front lobby of the facility. R1 was immediately placed on 1:1 supervision and until transferred to a local hospital at 10:00pm via ambulance for Agitation and Non-compliance with care and ultimately admitted to the hospital for suicidal ideation. Currently there is no information regarding status of R1. · R4 returned from the hospital on [DATE] at 6:30pm. On 02/28/2016 at 6:30pm, resident was noted hypertensive with minimal response to blood pressure medication. Physician was notified with new orders to transfer resident to the hospital for further evaluation, at 6:50pm. R4 was admitted at the hospital for behavior, depression and heroin abuse. R4 was eventually discharged from Jackson Park hospital to community. · R3 returned to facility from the hospital at 7:30pm on 02/27/2016 with [DIAGNOSES REDACTED]. Physician ordered to send patient to the hospital. R3 was admitted to the hospital with [REDACTED]. Currently still in the hospital. · R2 returned to the facility from the hospital at 7:30pm on 02/27/2016 with [DIAGNOSES REDACTED]. Physician was notified with orders to send to the hospital and was transferred there at 11:38pm. R2 was admitted to with [DIAGNOSES REDACTED]. · R5 returned on 02/27/2016 to facility from the hospital at 11:30pm. Diagnosis; substance abuse. On 02/28/2016, physician was notified regarding patient ' s highly irrational and volatile response, relating to the fact that R4, aka, ' her husband ' was being sent out for evaluation to the hospital. Physician ordered to transfer R5 to the hospital. · R5 was transferred on 02/28/2016 at 6:50pm, to hospital and admitted for behavior, depression and heroin abuse. Resident was eventually discharged from the hospital to community. How other residents will continue to be identified: · All residents currently in the facility were assessed for SMI (severe mental illness) /Substance abuse history in conjunction with the current substance abuse assessment and care plans that were updated by Social Service Department on March 1, 2016. System revision: · The facility has immediately ceased any admission in which patients have active substance abuse. Any resident determined to have been admitted / readmitted or returned from pass with active substance abuse, will be placed on 1:1 (one-to-one) supervision by facility staff and reassessed (Social Service Initial Interview for substance abuse / SMI) by the facility to provide interventions relating to substance abuse to the resident. The facility will make a determination, regarding substance abuse rehabilitation services. Referrals to facilities specializing in drug abuse rehabilitation services will be completed, as indicated. · There are currently no residents identified with active substance abuse. · Residents admitted /readmitted or who returned from pass will be assessed by Nurses, to include a physical assessment, vital signs with completion of nursing assessments, within 24 hours, and Social Services Assessments, will be completed within 24 hours to identify risk level as Minimal, Moderate or High risk for substance abuse. If it ' s determined, that the resident needs to be placed in other facility, 1:1 ' s will continue, no Passes will be issued and a new behavioral contract will be initiated. All residents with an active substance abuse history will be subject to a random drug screen, to detect for active or suspected substance abuse. Failure to provide a urine sample is an admission of guilt and a violation of facility policy. Physician will be notified for further orders. If patient has POA (power of attorney) or Guardian, they will be notified of any new orders. · All residents and visitors entering the facility will be subject to inspections of their person and associated bags, back pack, and purses by security personnel (Security Corporation), located at the front door as 02/27/16 and before entering the residential areas. Inspections include opening bags, emptying pockets, etc. Any contraband will be immediately confiscated. Contraband include but not limited to: 1. Alcohol, illegal drugs and substances 2. Cigarettes, tobacco, cigarette papers, cigarette lighters, match, etc. 3. Guns, BB Guns, knives of any kind, fireworks 4. Any article that the member of staff reasonably suspects has been, or is likely to be, used to commit an offence, or to cause personal injury to, or damage to property. · One security guard has been provided on the second floor for supervision and security and for monitoring any suspicious activity for the protection of the residents as of 03/02/16. Suspicious activity includes but not limited visitors wandering in and out of rooms, nervousness, keeping hands in pockets, carrying packages. · Visitors will be allowed to only enter the resident room they are visiting or a common area (dining room, hallway, TV room & visitor lounge). No visitors are allowed to wander into other residents rooms. Any Staff member has the right to ask them to leave if they are not compliant and may be escorted out of the building. · Security searches were conducted throughout the facility by interdisciplinary team members on 02/27/2016 and daily thereafter by interdisciplinary team members. Random Security searches are being completed by Interdisciplinary team members (IDT) and other designated staff that includes, nurses, C.N.A. ' s (nursing assistants), housekeepers and Social Services. IDT (interdisciplinary team) members consist of facility managers. · The facility created a policy and procedure for residents with active substance abuse (positive drug screen or resident admission of actively using) on 03/09/16. · Facility staff has been in-serviced regarding Q15 min monitoring, Search and Confiscation, and protocol for residents utilizing illicit drugs/alcohol on 02/28/16. Staff is currently being in-serviced on the revised policies (Visitation, Fifteen Minute Monitoring, Residents with active substance abuse and added new policy for Recognizing and Dealing with Suspicious Activity), and subsequent staff during the next shift. Revisions are as follows: Visitation; added, no visitors are allowed to wonder into other resident rooms; Fifteen Minute Monitoring; added a Q15 tool to include resident behavior; Created new policies with active substance abuse and recognizing and dealing with suspicious activity. · Facility staff (Department Managers, Nursing, housekeeping, escorts, and Dietary) has been in-serviced by ADON (assistant director of nursing) and PM (afternoon-evening) Nurse Supervisor, on the Search and Confiscation policy procedure, on 02/28/16 and subsequent staff during the next shift. · Any new employees, as part of their orientation, will be in-serviced on the changes regarding, Search and Confiscation, Visitation, Fifteen Minute Monitoring, Suspicious behaviors and residents with active substance abuse. How the facility will monitor system: · The Administrator/DON will monitor and in-service that all employees continue to be educated on recognizing residents with active substance abuse, Search and Confiscation, Visitation, Fifteen Minute Monitoring, and Suspicious behaviors. · The Administrator/DON will monitor that all residents have been assessed for history of and current substance abuse and associated care plans have been put into place. · All allegations of the substance abuse and confiscation of drug paraphernalia will be reported to the Administrator and DON. · Any staff who is not scheduled to work will be in-serviced on the new aforementioned policies by being called in or if unable to return to facility, in-servicing will take place via telephone. · To ensure compliance with new policies, Administrator /DON will question staff ' s knowledge, regarding aspects of the new aforementioned policies. · All identified trends will be reviewed by the QA committee and a plan will be discussed and implemented until resolution.

Based on interview and record review, the facility failed to ensure residents were provided with psychosocial services to address the identified substance abuse needs for 5 of 5 sampled residents (R1, R2, R3, R4, R5), identified with a history of substance abuse. This failure resulted in 5 residents (R1, R2, R3, R4, R5) overdosing on heroin within the facility. The findings include: On review of the facility's incident reports dated 2/27/16, R1, R2, R3, R4 and R5 were found in the facility between the hours of 2:30 PM and 3:10 PM, unresponsive due to overdose of heroin. When the emergency responders entered the facility, Narcan (Opiate antidote) was administered to all 5 residents and all 5 regained consciousness. All 5 residents were transferred out to the hospital for further evaluation and stabilization. On 2/28/16 at 10:20 AM, R2 stated that he has been a resident for 5 months in the facility. R2 stated on 2/27/16 he saw a bag on the floor in the hallway. R2 stated the plastic bag contained a white powdered substance. R2 further stated, he took the bag back to his room, where he sniffed it (the white powder). R2 stated he had not used any drugs since 4/29/15 and says he did a stupid thing because I was out of it. R2 stated he thought it was cocaine or heroin. R2 stated that initially he did not feel anything but then I must have passed out. R2 required the assistance of emergency medical services and was given a dose of Narcan (Opiate antidote) for for the treatment of [REDACTED]. R2 stated that he does not know how the drugs got into the facility. R2 stated he has done drugs but would not specify. R2 stated during the interview, that he does not attend any psychosocial programming. On 2/28/16 at 10:30 AM, R3 stated that R4 got wind of Z2 (R1's daughter) being a heroin user. R3 sampled a brownish powder that R1 had brought in and knew it to be heroin. R3 stated he had never done heroin before. R3 stated that Z2 had brought in a jab of heroin. A jab is slang terminology used to describe approximately 2.0 grams of heroin, which is equally divided into quantities of 12-13, with a cost of approximately $100. R3 stated this was the first time that he knows of the heroin being brought in to the facility. R3 stated that R4 still had some bags of heroin because R4 wanted to be in control of it. E3 stated that R5 was just sent out again this morning. R3 stated that R4 is in his room and is not coherent upstairs because R4 seemed to be high or under the influence of drugs. R3 stated the facility has a substance abuse group, but he is not required to attend any of the groups, because he does not have a problem with chemical dependency. During the interview on 2/28/16, R3 stated that he tried to commit suicide a few weeks ago and the facility let him back in and never did anything about it. R3 would not say how he tried to commit suicide. On 2/28/16 at 10:45 AM, R4 stated that himself, R1, Z2 (R1's daughter) and Z3 (visitor) added their money together and came up with $100 on 2/27/16. During the interview, R4 was observed nodding for short periods of time. As R4 was talking, he appeared incoherent at times and often changed his story of his account of the events of 2/27/16. R4 was asked if he still had any of the heroin and R4 replied, that was some good s**t! which he repeated over and over. R4 added, I want to sell and triple her money in here. R4 asked this is just between me and you, right? R4 stated that Z2 came in on 2/27/16 and gave him 3 to 4 baggies of heroin and stated it's the good stuff. Prior to obtaining the heroin, R4 stated Z2 came into the facility and talked about getting the heroin and then returned with it. R4 would not answer if he had used the heroin this morning or if he had any heroin left. R4 stated the heroin was snorted with a rolled up (money) bill. During the interview, R4 stated he is keeping control of the drug so R5 does not overdose again. R4 verbalized his concerns regarding R5, as she was identified as his girlfriend. R4 was asked if he knew the whereabouts of R5 and R4 responded that she was up in her room. R4 was not aware that R5 was not in the facility at the time of interview. On 2/28/16, R4 stated that the staff were not watching him anymore then than they had been prior to the overdose on 2/27/16. R4 stated he does what he wants. Throughout the interview, R4 was extremely lethargic, drifting asleep then the next moment he would be up and pacing. At 11:30 AM, E2 (director of nursing) stated that this was probably due to the heroin residual, not his usual demeanor. The clinical record lacked evidence of psychosocial programming for R4. During interviews on 2/28/16, statements were not obtained from R1 or R5, as neither was in the facility. R1 was not in the facility as a result of the heroin overdose on 2/27/16; and R5 was sent back out to the hospial for a subsequent heoin overdose earlier on 2/28/16. During an interview on 2/29/16 at 10:45am, E10 (Nurse Aide) stated R1 and Z2 were observed having a conversation with R4. E10 stated E9 (Nurse) made a comment that she didn ' t ' t like what was going on between them. After lunch on 2/27/16, R4 and R5 were observed to go into R1's room with Z2. E10 stated she saw R2 begging R1 for Z2's phone number. E10 did not tell anyone about this encounter, which appeared to be suspicious behavior. On 2/29/16 at 11 AM, R6 stated he found R4 and R5 in his room getting high after lunch on 2/27/16. R6 stated he saw bags of drugs and some empty bags. R6 stated he tried to get the residents to get out of his room because he was trying to get a community apartment and drugs would ruin his chances. R6 stated he does not know where or from whom R4 and R5 got the drugs. R6 stated that the staff tried to put the blame on him by saying R6 brought in the drugs. R6 stated he did not report to any staff that he found R4 and R5 in his room using drugs. R1, R2, R3, R4 and R5 all required emergency medical services for a heroin overdose. The residents who were admitted to the facility between 12/26/15 and 2/16/16, were not provided with psychosocial services to address their identified substance abuse needs. R1's hospital note dated 2/27/16 documented R1 was positive for opioids. This hospital note is after R1 was taken to the hospital after being found unconscious in the facility. R1 is a [AGE] year old resident who was admitted to the facility on [DATE]. The Minimum Data Set (MDS) completed by facility staff and dated 2/23/16, documented R1 is independent with all activities of daily living, ambulatory and orient times three. The comprehensive assessment did not include any documented diagnoses. R1's hospital face sheet dated 2/10/16 documents R1 was in the psychiatric department for schizophrenia. R1 was evaluated by the emergency department for suicide ideation, delusions and auditory hallucinations. R1 admitted to hearing voices and being depressed. R1 denied alcohol and substance abuse. R1 did not have a Preadmission Screening and Annual Resident Review (PASSAR) completed, prior to her admission to the facility on [DATE]. R1's Social Service Interview for SMI (severe mentally ill)/Substance Abuse Disorder, completed by E5 on 2/17/16, documented she has abused alcohol, street drugs and painkillers. R1 stated she had received treatment for [REDACTED]. On admission to the facility, R1 denied using drugs or alcohol. R1 stated at the time of interview, she had no interest to engage in substance abuse. On review of the Substance Abuse/Chemical Dependency care plan dated 2/17/16, facility staff documented that R1 had a history of [REDACTED]. The care plan approaches/intervention: to establish a verbal or written behavioral contract specifying what is or is not allowed. Implement increasingly restrictive interventions in effort to break the addictive cycle. Interventions may include: supervision while in the community, restrictive independent pass privileges, implementation of money guidance and budget control to reduce/prevent access to substances. The clinical record lacked documentation that R1 was provided with any substance abuse programs. R2's ambulance run sheet dated 2/27/16 documented R2 who admitted to using heroin in the facility, was lethargic with pinpoint pupils. After the Narcan was administered, R2 was alert and orient times three. R2 is a [AGE] year old resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On review of the quarterly MDS dated [DATE], facility staff documented the resident was ambulatory, independent with all activities of daily living and orient times three. R2 did not have a current PASSAR completed prior to his admission to the facility. R2's Social Service Interview for SMI/Substance Abuse Disorder dated 8/19/15 documents use of street and prescription drugs, such as, marijuana and heroin. It was documented that the resident used heroin daily. R2 also admitted to being convicted of substance possession. R2's admission social service note dated 8/12/15 documents R2 having a history of heroin and marijuana abuse, and suicide ideation. R2 stated that he checked himself into the hospital prior to his nursing home admission due to being homeless and overwhelmed with his situation. R2's 2/12/16 care plan documents substance abuse/chemical dependency. The approaches/intervention included:to establish a verbal or written behavioral contract specifying what is or is not allowed. Implement increasingly restrictive interventions in effort to break the addictive cycle. Interventions may include: supervision while in the community, restrictive independent pass privileges, implementation of money guidance and budget control to reduce/prevent access to substances. The clinical record lacked documentation that R2 was provided with any substance abuse programs. R2's hospital noted dated 2/27/16 documented R2 admitted he used heroin while in the facility. The hospital record indicated the resident was being treated for [REDACTED]. R3 is a [AGE] year old resident who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's most recent quarterly MDS completed by facility staff on 12/30/15, documented the resident was ambulatory, independent with all activities of daily living and orient times three. R3's hospital inpatient admission form dated 9/24/15 documents he has depressive disorder. The hospital initial psychiatric evaluation dated 9/24/15 documents R3 has bipolar disorder along with opioid and marijuana abuse. R3 came to the hospital with complaints of being depressed and having a plan of injecting himself with air to cause air embolism and kill himself. R3 has been homeless and living on the streets and in shelters. R3 stated he has been self-medicating with cannabis as evidenced by the positive urine drug screen. The drug test also showed R3 being positive for amphetamines. R3 claimed the positive amphetamines results are from his Adderall medication for his Attention Deficit Hyperactivity Disorder (ADHD). R3 admitted to severe mood swings, racing thoughts, irritability and vacillating with depressive disorder and crying spells. The evaluation also documented that R3 has been a resident in other nursing facilities for individuals with mentally illness R3 reported that he has attempted suicide in the past by overdosing on pills. R3's PASSAR assessment dated [DATE] was sent to this facility on 10/6/15 per fax from R3's previous nursing home placement. This was 6 days after R3 was admitted to this facility. This PASSAR documented R3 being hospitalized due to being non-compliant with treatment and a history of suicide attempts. R3 stated he wanted to hang himself and had run out of his medications. The assessment documented R3's anti-social behavior, physical violence toward others, his subsequent arrest and getting probation for aggravated battery and his non-compliance with treatment and his suicide attempts. R3 stated he tried to hang himself while in a nursing home and plans on trying it again. The assessment documents that R3 requires medication monitoring along with stabilization and adjustments, mental health rehabilitation services, incentive program to improve participation in treatment and substance use/abuse management. R3's Social Service Interview for SMI/Substance Abuse Disorder dated 10/14/15 documents he denied ever abusing alcohol or street or prescription drugs. R3's substance abuse care plan dated 1/23/16 documented the approaches of implementing increasingly restrictive interventions in an effort to break the addictive cycle. Interventions may include: supervision while in the community, restrictive independent pass privileges, implementation of money guidance and budget control to reduce/prevent access to substances. This was not done per lack of documentation. R3's social service note completed by E6 (PRSC) on 2/22/16, documented that R3 was having thoughts of suicide. R3 was educated on not letting difficult times from his past affect all the progression he has made since his admission. There is no psychosocial programming presented or seen on how R3 is assisted with his issues with the exception of being counseled. On review of the social service note for R3 dated 2/23/16, E5 documented the self-harm incident on Friday (2/19/16). E5 and R3 discussed what triggered the event which was a past trauma from his childhood. It documents that they came up with a safety plan which includes regular counseling with E5. There is no documentation to support what the safety plan entails. The note documents that E5 will work with R3 on finding forms of leisure to enhance his coping abilities. On 3/2/16 at 2:33 PM, E5 stated the safety plan consists of R3 coming to E5 whenever he feels suicidal. R4's ambulance run sheet dated 2/27/16 documented R4 admitting to drinking vodka and doing heroin while in the facility. R4 is a [AGE] year old resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On review of the 30 day MDS dated [DATE], facility staff documented the resident was ambulatory, independent with all activities of daily living and orient times three. R4's PASARR dated 12/29/15 documented R4 required services with mental health rehabilitation activities, illness self-management, community re-integration and substance use/abuse management. The assessment documents a long history of opiate abuse and being in and out of mental hospitals since age 7. R4's Social Service Interview for SMI/ Substance Abuse Disorder dated 1/5/16 documented R4 has used heroin and alcohol daily. R4 has been in treatment for [REDACTED]. R4's Patient Information and Transfer Form dated 12/26/15 documented R4 as having depression, suicidal ideation, being paranoid and having a history of substance abuse. Along with the transfer sheet, there was a toxicology report on alcohol which was negative. There were no other toxicology reports for R4. However, the resident reported a history of substance abuse. On review of R4 ' s Substance Abuse care plan dated 1/23/16, facility staff documented the approaches would include increasingly restrictive interventions in an effort to break the addictive cycle. Interventions may include supervision while in the community, restrictive independent pass privileges, implementation of money guidance and budget control to reduce/prevent access to substances. The care plan also documented R4 would be placed on RED pass (no community pass) to avoid triggers and for R4 to attend addiction group consistently. R4 was not attending his addiction group and the clinical record did not include any documentation the resident was provided with substance abuse programs. R5's ambulance run sheet dated 2/27/16, documented suspected opioid overdose with R5 being lethargic and having pinpoint pupils. It was also documented that after Narcan was administered, R5 was alert and looking around and saying nothing. R5 is a [AGE] year old resident who was admitted to the facility on [DATE]. The MDS completed by facility staff on 1/7/16, documented the resident was ambulatory, independent with all activities of daily living and orient times three. R5's PASARR dated 12/31/15 documented R5 self -medicates with drugs (alcohol, heroin, marijuana) to cope with her auditory hallucinations. R5 reported she used heroin a day before the hospital admission. R5's [DIAGNOSES REDACTED]. R5 requires services in mental health rehabilitation, self- illness management, community re-integration and substance use/abuse management. R5's Social Service Interview for SMI/Substance Abuse Disorder dated 1/7/16 documented R5 as having a heroin addiction and having used as recently as 3 weeks ago prior to her admission to the nursing facility. R5 expressed a desire to get sober and not be an addict anymore. R5's care plan dated 1/8/16 on Substance Abuse/Chemical Dependency documents resident reports use of heroin along with her [DIAGNOSES REDACTED]. The care plan approaches/intervention were to establish a verbal or written behavioral contract specifying what is or is not allowed. Implement increasingly restrictive interventions in an effort to break the addictive cycle. Interventions may include: supervision while in the community, restrictive independent pass privileges, implementation of money guidance and budget control to reduce/prevent access to substances. The clinical record lacked documentation that R5 was provided with any substance abuse programs. R1's through R5 's social service progress notes are lacking what area are being addressed, the progress or lack of, details of measurable goals and interventions, the techniques that will be utilized on the maintaining or ensuring their sobriety. The progress notes fail to determine why the residents are not attending and implement interventions that will assist resident in attending addiction groups. On 3/3/16 at 4:30 PM, E2 (Director of Nursing) stated that it has been a challenge with staffing the psychosocial department. E3 (PRSD) has been here 2 months and the longest employed PRSC is E6 who has been here for 6 months. The hire dates for E3, E4, E5, E6 and E7 (all are PRSC with the exception of E3 who is the director) were confirmed per documentation provided by E2. E3 was hired on 12/21/15, E4 hired 12/21/16, E5 hired 1/12/16, E6 hired 6/29/15 and E7 hired 2/10/16. The facility's policy on Admission/Readmission documents a history and physical must be made within 5 days of potential admit and interview of prospective resident, the facility's ability to care for resident/continuity of care and a determination of need/PASARR screen to be completed prior to admission for appropriateness of the resident to nursing home. The facility's policy on addressing the drug abuse is that if staff suspect the use of illicit drugs or alcohol the resident will be assessed by the nurse, the physician notified, residents' medications will be withheld if the physician indicates it and the resident will be drug screened either by urine or blood sample. This was not done. The facility's policy titled Community Pass Policy documents random bag checks and/or room checks may be performed when a resident comes back from the community with following reasons : a) If the staff have suspicions that the resident has paraphernalia on their possession that compromise the safety of others and b) If the resident appears intoxicated or under the influence of any type of substance. There is no evidence this was followed for R3's 2/19/16 incident nor the 2/27/16 suspicious behavior between R1 and Z2 with R4 and R5. The facility's Program Policy documents it is the philosophy of this organization to offer mentally ill resident consistent and therapeutic intervention designed to help each resident acquire the behaviors necessary to function with as much self-determination as possible in the least restrictive environment. The program centers on 4 main pillars, resident assessment/treatment, environmental control, programming and staff training. The resident assessment/treatment involves point of referral/admission screening, taking a detailed history and formulating a realistic and meaningful care plan. Screening should investigate success or failure in previous environments and history of violence (including substance abuse). The environmental control involves taking steps to create a safe and secure living area. This may include granting pass privileges to persons who demonstrate responsibility. Programming addresses medication compliance, in-house support groups and outside programs and living skills. Staff training involves teaching personnel appropriate psychiatric and mental health interventions. Some topics may include intervention skills, such as, setting and enforcing limits and rules. Persons with concomitant substance abuse disorders are appropriate admission if the person expresses a desire to address their problem, seeks assistance in achieving sobriety and acknowledge the importance of following the rules. The facility failed to follow their own program policy. On 3/1/16 at 1:25 PM, E3 (Psychiatric Rehabilitation Service Director/PRSD) stated that he came in on 2/27/16 at 3:30 PM to the facility and R1 through R5 had already been sent out to the hospital. E3 stated the residents are given choices as to what groups to attend. It is an open format for psych-social groups. The residents are not assigned to any specific groups. E3 stated it is the resident's decision to attend groups or not. E3 stated there is not a strong attendance tracking policy because the residents were not required to go to groups. E3 stated if a need is identified to attend a certain groups and the resident does not attend the group, pass privileges are revoked. E3 stated the residents are counseled on the need to attend groups and will try to determine why a resident does not want to attend groups and work with that individual. E3 stated that the residents' needs along with their [DIAGNOSES REDACTED]. This is done on admission and a quarterly basis. E3 stated that there have been no changes in behaviors for R1 through R5 and E3 is not aware of any current drug abuses by R1 through R5. E3 stated that newly admitted residents with a history of substance abuse are placed on a 30 day wait period for a pass privilege to ensure the resident is clean and sober. E3 stated there are 3 levels of pass privileges. Red pass is no outside pass. Yellow pass is a supervised pass with staff or family and green pass is unsupervised for a set period of time. E3 stated R1, R4, R5 are on Red Pass and R3 is on a green pass. E3 was not sure about R2's pass privileges. On 3/2/16 at 2:33 PM, E5 (Psychiatric Rehabilitation Service Counselor/PRSC) stated she is the assigned PRSC for R1, R2, R3, R4 since her start date of 1/19/16 with the facility. E5 stated E24 (PRSC) use to be their counselor, but she only works as needed now. E5 stated R3 was temporarily on a Green Pass so he could attend classes at a local university. E5 stated R3 attends everyday to every other day. During the interview on 3/2/16, E5 was questioned about the social service entry dated 2/22/16 that documented R3 was having thoughts of suicidal ideation, E5 stated she did not write that entry. It was written by E6 (PRSC). However, E5 stated R3 left the faciity on [DATE] and attempted suicide by heroin overdose, while out in the community. E5 stated she was not sure if a toxicological test was done for R3, upon his return to the facility. E5 stated the hospital probably did a tox screen. E3 stated that drug testing is done when there is a suspicion of drug use, but it is not routinely done. The clinical record lacked evidence that a toxicology urine screen was collected for R3, after his report of an attempted suicide. E5 continued with the interview and stated she returned back to work on 2/22/16 and spoke to R3 about the 2/19/16 incident and informed him to come to her if he has any suicidal ideations. E5 stated that upon admission, R3 denied use of drugs. E5 stated the 2/19/16 incident was his first attempt of overdosing and using heroin as far as she knows. E5 stated that R3 informed her that he usually attempts suicide 1 to 2 times a year since he can remember. E5 stated she does not know if or when R3 attends psychosocial groups but knows he sees a psychologist 2 times a week. E5 stated that the heroin overdose on 2/27/16, was not an intended suicide per R3. R3 told E5 that the heroin was dropped in front of him and he was enticed to use it. E5 stated the staff believe R3 snorted it because no needles or devices were found. On 3/3/16 at 12:16 PM, E2 stated that she looked into the 2/19/16 incident, of the report of an attempted suicide for R3. E2 presented a nurses' note dated 2/19/16, which E25 (Licensed Practical Nurse) documented smelling alcohol on R3 after he returned from a community pass on 2/19/16 at 9 PM. R3 denied drinking when asked by E25. E25 asked R3 why he was late returning back from his pass and R3 claimed his money had been stolen. R3 requested his 9 PM medication which were given. E2 stated that R3 did not report the 2/19/16 suicide attempt to the nurse, as he had reported to the social service department. E2 stated that R3 informed staff that he just walked out of the hospital without the hospital staff knowing. The clinical record lacked documentation of a hospital visit for R3 on 2/19/16. In addition, the record also lacked a toxicology report for the R3's reports of an attempted heroin overdose on 2/19/16. However, E2 was able to provide a toxicology report dated 2/22/16 that documented R3 was positive for amphetamines and marijuana, two days after the 2/19/16 incident. The toxicology report of 2/22/16, was the only toxicology report the facility had a record for R3, since his admission of 9/30/15. On 3/2/16 at 3:15 PM, E5 stated that R4 is inconsistent with his attendance in the addiction day group. E5 stated the resident is on a RED pass, which means he is not able to leave the facility. E5 was not able to provide any documentation on why R5 is not attending his addiction group; or what other interventions or approaches the facility had implemented to assist R4 in attending the addiction group. On 3/2/16 at 3:20 PM, E5 stated that R2 does not receive regular drug testing. E5 stated that R2's psychologist note dated 3/1/16 documents R2 never having any drug rehabilitation except when in the hospital for short term. E5 stated R2 has not been to any addiction group since admission. On 3/2/16 at 3:50 PM, E5 stated that R1 is very new to the facility. E5 stated that R1 was sent here for depression symptoms. Since R1's admission, E5 stated that R1 has complained of pain and has been drug seeking. E5 stated R1 only reported having a problem with alcohol for 1 year following partner's death and everything going down hill since then which has been 3 years. E5 stated R1 has not attended any groups or substance abuse or alcohol On 3/3/16 at 3:33 PM, E4 (PRSC) stated that she has worked for the facility since 12/21/15. E4 stated that R5 has been on her caseload since mid January 2016. E4 stated R5 was admitted to the facility, as a result of her substance abuse problem. E4 stated R5 should attend Relapse Prevention groups, but she is not sure if she has attended any of the groups.