Every finding on record at Forest City Rehab & NRSG CTR

Based on interview and record review the facility failed to ensure a resident's safety while providing cares which applies to 1 of 3 residents (R1) reviewed for falls in a sample of 7. This failure resulted in R1 falling out of bed, while receiving care, and sustaining a leg fracture.The findings include:R1's Facility assessment dated [DATE] showed R1 was a cognitively impaired resident with admitting diagnoses which included dementia, bipolar disorder, and obesity. This assessment showed R1 was dependent on staff with functional abilities (activities of daily living-ADLs) which included toileting hygiene, lower body dressing, personal hygiene, rolling in bed, sitting up in bed, and bed to chair transfers.R1's Fall assessment dated [DATE] showed R1 was a high fall risk.R1's Care plan dated 5/16/26 showed R1 was at risk for falls. An intervention for R1 was to use 2 person assists for all bed mobility related ADL's or wound care. This intervention was initiated on 2/13/23.On 8/10/26 at 12:20 PM, V11 (Licensed Practical Nurse) stated V10 reported to her R1 had fallen out of bed. V11 stated when she got to R1's room R1 was on the floor between the bed and the wall (3-4-foot space). R1 was complaining of pain. V11 contacted 911 and sent R1 to the hospital.On 8/10/26 at 12:35 PM, V10 (Certified Nursing Assistant/CNA) stated R1 was incontinent and needed to be cleaned up. V10 stated she was the only one in the room to perform care at that time. V10 stated she turned R1 on her side away from her. V10 stated she turned around to get R1's positioning wedge. When she turned back R1 was falling away from her on the other side of the bed. V10 stated R1 stated complaining of knee pain after she fell on the floor.On 8/10/26 at 2:15 PM, V15 (R1's Hospice CNA) stated 2 people were needed for R1's bed baths or showers. V15 stated R1 could not turn herself in bed. R1 could help by holding onto the rail, but could not hold herself there for any long periods of time. R1's Hospital X-Rays and CT-scan dated 7/3/26 showed R1 had sustained a comminuted (multiple breaks) right femur fracture on the distal end of the bone (near knee).On 8/10/26 at 1:35 PM, V2 (Director of Nursing/DON) stated if a person's care plan showed the resident is a 2 person assist there should be 2 people providing cares.The facility's Fall Policy dated 1/2026 showed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on interview and record review the facility failed to protect a resident's dignity during an activity. This applies to one of four residents (R1) reviewed for dignity in the sample of four.The findings include:The facility face sheet for R1 shows she was admitted to the facility with diagnoses to include anxiety, conversion disorder with seizures, encephalopathy and alcohol dependence. The facility assessment dated [DATE] shows her to be cognitively intact and requires supervision for her activities of daily living.On 5/14/26 at 10:04 AM, R3 said he was playing cards with some of his peers and R1 had left the game to go shower. R3 said R2 then came and joined the game but later left to go use the bathroom. R3 said while R2 was in the bathroom, R1 came back to the game to play and sat in the chair R2 was in. R3 said when R2 came back he told R1 to move, and she refused. R3 said R2 picked up the back of R1's chair and forced her to stand up.On 5/14/26 at 10:14 AM, R2 said he had joined a game of cards in the dayroom that night, but he had to use the bathroom after playing for a while. R2 said when he came back, R1 was in his chair. R2 said he asked R1 to get up, but she refused. R2 said he lost his patience with R1 and forced her to get off the chair by picking up the back legs of the chair.On 5/14/26 at 10:24 AM, R4 said he was playing cards with some peers. R4 said R1 was playing cards with them but then left to go take a shower. R4 said R2 came and joined the game but left for a short time to use the bathroom. R4 said while R2 was in the bathroom, R1 came back and sat in the chair. R4 said when R2 came back and saw R1 in his chair he got mad and forced R1 to get out of the chair by picking up the back legs of the chair.On 5/14/26 at 10:36 AM, R1 said she was playing cards with some of her peers and another resident came to join the game and said she was in his seat. R1 said she refused to get up and this other resident (R2) picked up the back of her chair, forcing her to stand up. R1 said she was so mad and felt embarrassed about it. R1 said she nearly fell to the floor.On 5/14/26 at 11:12 AM, V4 (Registered Nurse) said she was working the night R2 forced R1 to get off a chair. V4 said the residents play cards nearly every night. V4 said she heard yelling between the group of residents, and she told them to settle down. V4 said she then saw R2 pick up the back of the chair R1 was sitting in and forced R1 to stand up. On 5/14/26 at 9:25 AM, V1 (Administrator) said an incident happened during a card game between some residents on 5/3/26 around 10:00 PM. V1 said he completed an investigation into the incident, and it was proven that R2 did pick up the back of R1's chair and forced her to stand up and get out of a chair. V1 said these residents play cards nightly and residents will come and go from the game. V1 said R1 had left the game to go shower and R2 joined the game. V1 said R2 left the game to go to use the bathroom and when he got back to the game R1 was in his chair.The facility final investigation into the incident shows after review of the video footage, it was observed that R2 picked up the back of the chair R1 was sitting in and forced her to stand up. The findings of the incident shows confirmation of inappropriate behavior by tipping the chair forward during a verbal dispute. The conclusion shows that a verbal disagreement escalated and R2 inappropriately tipped R1's chair during the dispute. No injuries resulted from the incident. Facility staff were reminded to promptly intervene during escalating resident disagreements to prevent further incident.The facility face sheet for R2 shows he was admitted to the facility with diagnoses to include low back pain, myopia and lipoma. The facility assessments dated 2/9/26 shows him to be cognitively intact and requires supervision for his activities of daily living.The facility policy with a revision date of 1/2025 for dignity shows the purpose is to protect the residents right to be treated with dignity and respect. 1. Residents should be treated with dignity and respect. 2. Residents will be assisted in maintaining and enhancing his/her self-esteem and self-worth.

Based on interview and record review the facility failed to schedule a urology appointment for 1 of 3 residents (R1) reviewed for quality of care in the sample of 3.The findings include:R1's prostate specific antigen (PSA) lab results dated 5/14/25 indicated a high value. V6 (Nurse Practitioner) wrote on the lab result form to refer R1 to urology. R1's Order Summary Report with active orders as of 5/19/25 showed an order for a referral to urology related to a high PSA lab result. The order was dated 5/16/25.On 03/09/2026 at 10:44 AM, V2 (Director of Nursing) confirmed V6 wrote on the PSA lab result form for R1 to see a urologist. V2 said the referral should have been placed in V8's (Medical Appointment Scheduler) mailbox so V8 could schedule the urology appointment.On 03/09/2026 at 10:22 AM, V8 said R1 did not have a urology appointment scheduled. V8 said there were no appointments in the appointment schedule book for R1 to see a urologist. V8 said he believed the appointment was not made because he was not notified of the order/referral.On 03/09/2026 at 2:04 PM, V2 said she looked at R1's electronic medical record and there was no indication R1 saw a urologist.

Based on interview and record review the facility failed to protect a resident's right to be free from misappropriation of property by staff. This failure resulted in money being removed from a residents bank account after the resident expired and staff having a resident's cell phone at home. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include:R1's Face Sheet printed on [DATE] listed schizoaffective disorder as a diagnosis.R1's Progress notes dated [DATE] showed R1 expired on [DATE]. On [DATE] 11:36 AM, V11 (R1's Sister In-Law) said charges were made to R1's bank account after he expired and the charges were made by V5 (Licensed Practical Nurse-LPN). V11 said there were about 34 charges made to R1's bank account after he expired including a PayPal charge for $1,000 to V5. V11 added that V5 had R1's cell phone at her home. V11 said she came to the facility on [DATE] and talked with the police and V1 (Administrator) regarding the situation.On [DATE] at 8:50 AM, V1 said he became aware of the situation with R1 and V5 on [DATE] when the police arrived. V1 said the police reported to him that V5 alleged R1 said on his death, V5 could have the money in his bank account after V5 paid for his cremation. V1 said the facility was not aware of any such agreement between V5 and R1. V1 said staff should not be taking any money from residents. On [DATE] at 1:38 PM, V16 (Police Officer) said V5 admitted to making purchases using R1's bank account after R1 expired. V5 had R1's bank information saved on a phone and that was how she was making purchases using R1's bank account. V5 also admitted to having R1's cell phone at her home. V5 alleged R1 told her on his death, V5 could have the money in his bank account after she pays for his cremation. V16 added that V5 said no one was aware of the agreement.A Police Department Incident report dated [DATE] showed V5 alleged R1 said on his death V5 was to pay for his cremation and V5 could have the remainder of his money. There was no documentation for this agreement and there were no witnesses to the statement. The document showed V5 admitted to transferring $1,000 of R1's money into her PayPal account and, .spending a couple thousand dollars. from R1's bank account. The document showed V5 had R1's cell phone at her residence and V5 alleged R1 said for V5 to keep the phone as the phone would ping when deliveries were made. R1's Bank Statement showed starting on [DATE] (one day after R1 expired) to [DATE], 34 charges were made including a $1,000.00 charge to V5's PayPal account. The total of the 34 charged was $4,910.79.The facility's Policy and Procedure Abuse and Retaliation Preventions policy date 1/2026 showed the facility affirms the right of their residents to be free from misappropriation of property. The same policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. On [DATE] at 1:58 PM, V1 said consent to use resident's money/belonging is done by making the facility aware of the resident's wishes and having a witness.The facility's Employee Handbook (undated) showed staff should not violate resident rights. The same document showed staff should never borrow or take money or other personal belongings from residents.

Based on interview and record review the facility failed to identify, document, and update dietary interventions for a resident with a history of weight loss and a recent change in food intake for 1 of 3 residents (R1) reviewed for weight loss in the sample of 5. These failures resulted in a severe weight loss of 29% for R1 from 1/6/26 until 1/16/26.The findings include:R1's Face sheet dated 2/5/26 showed diagnoses to include, but not limited to diabetes, atherosclerosis (hardening and narrowing) of the aorta, asthma, hypothyroidism, gastro-esophageal reflux disease (GERD), cataracts, dysphagia (difficulty swallowing), lack of coordination, and abnormalities of gait/mobility. R1's facility assessment dated [DATE] showed she had moderate cognitive impairment and required supervision to eat. R1's Care Plan initiated 7/9/25 showed R1 was at risk for weight gain/loss related to diabetes and hypothyroidism. The interventions included monitor and document % (percentage of food) consumed at all three meals and make referral to doctor/dietician if there is a 5 % weight loss over 30 days or 10% loss over 180 days. R1's Weight Summary showed on 7/8/25 her weight was 128 pounds. This document showed the last weight documented by the facility on 1/6/26 was 113.6 pounds. R1's Hospitalist Initial admission Note dated 1/16/26 showed R1 was admitted to the hospital for acute cystitis, hyponatremia and metabolic acidosis. This note showed R1 had severe protein-calorie malnutrition and her weight was 80 pounds (demonstrates a severe weight loss of 29% since the facility's most recent weight on 1/6/26). The hospital record showed R1 appeared frail and cachectic.R1's Nutrition Support dated 1/17/26 showed she was referred for unintentional weight loss. This document showed on 1/17/26 R1 weighed 87 pounds. This document showed she had severe protein-malnutrition in the context of chronic disease. This document showed R1 appears thin and frail. R1's son at bedside and provided most of the information. R1's son stated her intake has steadily declined over the past 6 months and she's somewhat of a picky eater. R1's Facility Amount Eaten showed 1/6/26 R1 consumed 0-25% for breakfast and lunch, but there was no entry for the evening meal. There was no amount eaten documented for R1 1/7-1/10/26. This document showed R1 refused to eat 1/11, 1/13, and 1/15. This document showed R1 ate 0-25% on 1/12 at the breakfast and lunch meals, but there was no entry for the evening meal. R1's Psychiatry Note dated 1/15/26 showed, Per staff, patient has not been eating. This note showed that staff reported the resident was spending approximately $600/week on [a food delivery app], and after her family placed a spending limit on her card, she had reportedly not been eating. R1's Dietary Progress Note dated 1/15/26 showed R1's intakes had been poor, and she does require 1:1 supervision with meals. This note showed R1 continued on an appetite stimulating medication and had multiple interventions in place to aid weight maintenance, including super cereal at breakfast, ice cream twice a day and health shakes three times a day. This note showed R1 used to order food (on a food delivery app) a lot but has been unable to order as much as she used to and may have contributed to some weight loss. This note included R1's weight from 1/6/26. The facility did not obtain a new weight for R1 related to her changes in appetite. (During interview with V5 (Dietician) she said this note was based on a chart review and she did not see R1 in person).R1's progress notes do not show that the nursing staff notified R1's Provider or the Dietician of her change in intake from 1/6/26 to 1/15/26. These notes did not show that weight frequency was increased, or nutritional interventions were updated between 1/6/26 and 1/15/26. On 2/4/26 at 1:34 PM, V6 (Certified Nursing Assistant - CNA) said she was regularly assigned to R1. V6 said R1 didn't like the food at the facility. V6 said she would offer a substitute and usually she'd refuse it. V6 said R1 liked the health shakes, milk and occasionally she could get her to eat grilled cheese. V6 said R1's POA provided her with a card to order from a food delivery app. V6 said R1 ordered a lot of food, but when the amount she could spend on the food delivery app was decreased R1 stopped eating. V6 said she told the nurse that R1 wasn't eating. V6 said she wouldn't know about R1's weight and said to ask the nurse. V6 said the CNAs should document amount eaten after each meal. On 2/4/26 at 1:49 PM, V7 (CNA) said R1 was a little one. V7 said R1 ordered food out because she didn't like the facility's food. V7 said she ordered a lot of food, but then the family stopped the ordering, and she stopped eating. V7 said it looked like she was losing weight after she stopped getting the food delivered. V7 said we reported it to the nurse. On 2/4/26 at 1:54 PM V8 (Licensed Practical Nurse - LPN) said if a resident stops eating, then the facility should obtain a weight to see where they are at. V8 said she remembered R1 had a lot of food delivered. V8 stated, Food was coming in every day, all day. She was eating well when she ordered the food. V8 said if there is a concern with weight loss and lack of intake then the nurse should notify the provider and the dietician.On 2/4/26 at 2:05 PM, V9 (Registered Nurse - RN) said she was familiar with R1 and assigned to R1's hall. V9 said R1 stopped eating when R1's family cut off her card for ordering food deliveries. V9 said R1 didn't completely stop ordering, but it was very decreased. V9 said R1 would eat the delivery food, but not the facility's food. V9 said R1 would take health shakes and eat anything brought from outside. V9 said when R1 stopped eating, she did notice that R1 had lost some weight, but R1 was always pretty tiny. V9 said when R1 stopped eating regularly, the facility probably should have obtained a weight to establish a baseline and/or compare to her previous weights. V9 said she did not see a facility weight entered after 1/6/26. The surveyor asked if R1 weighed 80 pounds at the hospital would that be concerning? V9 replied, Yes, that would be a very significant weight loss. V9 said the CNAs should be documenting meal intakes at every meal. This surveyor reviewed R1's intakes for the last 30 days with V9. V9 said R1 had no documented intakes from the evening of 1/7/26 to 1/11/26. V9 said the purpose of documenting intakes is to ensure the residents are eating enough. V9 said R1 was definitely at risk for weight loss. On 2/4/26 at 2:25 PM, V4 (Dietary Manager) said she the facility has a Nutritional at Risk meeting weekly. V4 said they discuss residents that triggered for weight loss and any new concerns that she becomes aware of. V4 said R1 hadn't been discussed in the meetings held between 1/6/26 and 1/16/26. V4 said she had met with R1 but she was refusing the facility meals and ordering a lot of food delivery. V4 said R1 was non-compliant with her modified diet and was provided education but continued to refuse. V4 said towards the end of R1's stay at the facility she wasn't able to purchase as much from the food delivery app. V4 said the CNAs are usually pretty good about reporting any food issues. V4 said they did tell me that she wasn't getting the food delivery as much and was eating 26-50%. The surveyor asked V4 to review R1's meal intakes. V4 replied there isn't much charted. V4 said there should be a documented food intake for each meal and R1's records did not reflect that. V4 said based on no meal intake documented 1/6/26 evening meal to 1/11/26 she should have requested a weight and notified the dietician. V4 said she would have expected the staff to report that R1 wasn't eating or was minimally eating for several days. On 2/4/26 at 2:45 PM, V5 (Dietician) said she had seen R1, and she had history of weight loss during her stay at the facility. V5 said R1 had gained 1.6 pounds between 12/4/25 and 1/6/26 weights. V5 said she performed a chart review on 1/15/26 but did not physically see R1. V5 said she knew R1 was ordering a lot from a food delivery app, but her family had decreased the amount she could spend. V5 said she was not aware that R1's meal intakes were not documented or were 0-25%. V5 said she was not notified that the resident was refusing to eat or had low intakes. V5 said if she had known, then she would have had the facility to obtain a weight. V5 said if the weight showed weight loss, then she would have talked to the Dietary Manager to discuss food preferences with the resident and review additional interventions to prevent further weight loss. V5 said she believed some of the weight loss was attributed to eating less fast food. V5 said if the resident weighed 80 pounds at the hospital, that would be a significant change. On 2/4/26 at 3:22 PM, V2 (Director of Nursing) reviewed R1's amount eaten for the last 30 days. V2 said this charting was completely unacceptable. V2 said the CNAs know that are supposed to document every meal. V2 said it's a standard of care to document meal intakes. V2 said this documentation is important to monitor if a resident is eating enough and getting their nutritional needs met. V2 said if a resident was not eating or had decreased intakes, then I would expect the staff to obtain a weight and call the Provider or Dietician. V2 said the weight frequency should be increased until the weight stabilized. V2 said that R1's last weight obtained by the facility was 1/6/26.On 2/6/26 at 9:39 PM, V15 (Nurse Practitioner - NP) said she was familiar with R1. V15 said R1 had been admitted to the facility for failure to thrive and had a slow decline in her health throughout her stay. V15 said she saw R1 in November 2025 and again on 1/5/26. V15 said R1 did appear thinner to her on the 1/5/26 visit, but R1 had experienced a weight loss since November. V15 said R1 was on a medication to stimulate her appetite and had nutritional supplements in place. V15 said R1 had a poor appetite and didn't like the facility food. V15 said R1 was ordering out a lot but thought that had decreased. V15 said she didn't know R1 was refusing to eat or that her intakes were less than 25%. V15 said she would expect the facility to notify her of that. V15 said if she was aware of refusal to eat and/or low intake then she would order a weight to see where she was and increase the frequency of the weights. V15 said if R1 continued to lose weight then she would talk to R1's family about other alternatives and possible placement of a feeding tube or hospice referral. V15 said she didn't think R1 was neglected, but the facility could have done weekly weights for better tracking. V15 said she doesn't see how R1 could have gone from 113.6 on 1/6/26 to 80 on 1/16/26. V15 stated, That doesn't seem right. V15 said R1 likely did lose weight, but that seemed drastic. V15 said R1 had been slowly losing weight and her co-morbidities likely contributed to the slow decline in weight and overall health. The facility's Weight Policy dated 9/2018 showed the facility will have a systematic interdisciplinary effort to identify, track, intervene, and monitor residents that are at high risk for weight loss, dehydration and pressure ulcers. Residents reviewed are based on criteria including significant change in appetite and decreased oral intake in the last 7 days.

Based on interview and record review the facility failed complete a thorough, initial skin assessment and ongoing skin assessments for a resident at risk for skin breakdown with redness to her buttocks and peri-area for 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 5.The findings include:R1's Face sheet dated 2/5/26 showed diagnoses to include, but not limited to diabetes, atherosclerosis (hardening and narrowing) of the aorta, asthma, hypothyroidism, gastro-esophageal reflux disease (GERD), cataracts, dysphagia (difficulty swallowing), lack of coordination, and abnormalities of gait/mobility. R1's facility assessment dated [DATE] showed she had moderate cognitive impairment; was dependent on staff for toilet hygiene; required substantial to maximal assistance for personal hygiene; and required supervision for bed mobility. R1's Physician Order Sheet showed on 12/16/25 there was an order for Zinc Barrier Cream to buttocks twice a day for incontinence and as needed.R1's Care Plan initiated 12/16/25 showed R1 had impaired skin integrity related to exposure to moisture and irritants secondary to incontinence as evidenced by erythema, excoriation, and skin breakdown to peri-area and buttocks. R1's Electronic Medical Record did not contain an assessment of R1's buttocks from 12/16/25 until she was transferred on 1/16/26. R1's Progress Note dated 12/25/25 showed Zinc barrier cream to buttocks and perineal area continues as part of incontinence care. Area remains stable. Will continue treatment and monitor for changes. R1's Shower Sheet dated 1/6/26 showed she had redness to her buttocks. R1's Electronic Medical Record did not include a skin assessment (including wound classification, size, description of tissue, and presence of drainage) performed by a nurse related to R1's redness (skin issue). R1's Hospital Emergency Department Encounter dated 1/16/26 showed R1 had a sacral ulcer.On 2/4/26 at 1:34 PM, V6 (Certified Nursing Assistant - CNA) said she was familiar with R1 and was regularly assigned to R1's hall. V6 said R1 had a real red area on her butt and they were putting barrier cream on it after providing care. V6 said she didn't remember R1 having an open area or dressing to her butt. V6 said she wasn't working 1/16/26 (when R1 was sent to the hospital). V6 said the CNAs report any skin issues to the nurse.On 2/4/26 at 1:54 PM, V9 (Registered Nure - RN) said she was the nurse that sent R1 to the hospital on 1/16/25 for abnormal labs. V9 said R1 was stable when she was sent to the hospital. V9 said she didn't inspect R1's skin before sending her to the hospital. V9 said the last time she saw R1's bottom was 3-4 days prior to her transfer to the hospital. V9 said R1 did have redness and irritation to her buttocks. V9 said they were putting barrier cream on the area and just monitoring the redness. V9 said she didn't document any skin assessments. V9 said the nurse just documents the barrier cream on the Treatment Administration Record, but did not chart the size or description of the wound. The surveyor asked how the nurses track the progress of R1's wound if there are no assessments with size, appearance, and location of the wound. V9 replied, I can see what you're saying. V9 said she saw R1's redness when she moved to V9's hall. V9 said R1 was at risk for skin breakdown because she stopped eating as much, was very thin, and didn't like to get out of bed. The surveyor asked V9 to review R1's record for a Skin Assessment. V9 said the only skin assessment she saw was R1's Initial Skin Assessment (done on admission 7/8/25). On 2/4/26 at 3:22 PM, V2 (Director of Nursing - DON) said she didn't see any skin/wound assessments for R1 since 12/16/25, except a skin/wound note dated 12/25/25 that showed Area remains stable. The surveyor asked V2 what stable means. V2 replied, I'm going to assume not open. I'm guessing just redness and not open. The surveyor asked what V2 would expect to be charted. V2 said she would expect the location of the area, appearance, and size would be included in an assessment. V2 said wound assessments are important to track the progress or decline in a wound. On 2/5/26 at 8:56 AM, V11 (Wound Care Nurse) said this was her first role as a Wound Care Nurse and she had been at the facility since July 2025. The surveyor asked V11 what she does when a resident has a new skin issue. V11 replied it depends on the wound. V11 said for certain things she knows what the wound doctor will want her to do. V11 said if she is unsure then she will call the wound doctor. V11 said if it's redness for incontinence she knows to order zinc barrier cream and leave it open to air. The surveyor asked V11 what kind of assessment she would document. V11 replied just what I saw visually, if I received orders and that I will continue to monitor. V11 said she thinks she documented an assessment for R1. The surveyor asked how the facility monitors a wound without wound assessment documentation. V11 replied, I know what it looks like and I'll go in every other day to see what it looks like and see if there are any new interventions that need to be placed. The surveyor asked how often a skin assessment should be documented. V11 replied, It just kind of depends. Sometimes weekly, sometimes every other. V11 said wound assessments allow us to track the progress or decline of a wound and prevent deterioration of a wound. V11 said R1 had redness to her peri-area and buttocks. V11 said the facility was trying zinc to clear it up, but nothing was really working. V11 said R1 stopped eating as much before she went to the hospital. V11 said lack of proper nutrition and R1 not getting out of bed can contribute to skin breakdown. V11 said the last time she saw R1's buttocks was a couple days before she went to the hospital. V11 said it's possible that R1's wound opened up. On 2/6/26 at 9:39 AM, V15 (Nurse Practitioner) said R1 was admitted to the facility with a failure to thrive and experienced a gradual decline throughout her stay at the facility. V15 said R1 was at risk for pressure ulcer development due to her thin body habitus and decreased nutritional intake. V15 said if R1 had redness it could deteriorate over the bony prominences like the butt into a pressure ulcer. The facility's Wound Policy revised 11/2022 showed the purpose was to identify factors that place the resident at risk for development of pressure ulcers and to implement appropriate interventions to prevent the development of clinically avoidable wounds; promote a systemic approach and monitoring process for the care of residents with existing wounds and those who are at risk for skin breakdown; and to promote healing of existing pressure and non-pressure ulcers. The policy showed any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc, should be assessed and documented weekly by the Wound Nurse or designee.

Based on observation, interview and record review the facility failed to follow the menus for residents on regular, mechanical and pureed diets. This failure has the potential to affect all 166 residents residing in the facility. The findings include: The CMS-671, Long- Term Care Facility Application for Medicare and Medicaid form that was completed by the facility on 11/17/25 shows there were 166 residents residing in the facility. A list of resident diet orders shows all 166 residents receive food prepared by the facility. Facility provided menus show on 11/17/25 during the noon meal a biscuit should be served to residents receiving a regular diet, a soft biscuit served to residents receiving mechanical soft diets and pureed bread should be given to residents on pureed diets. On 11/17/25 the noon meal food service line on the first floor was continuously observed from 11:35 AM until 12:15 PM. Resident meals trays were prepared by V22 (Cook/Dietary Aide) which included BBQ chicken, mashed potatoes, vegetable, oven roasted potatoes, and dessert. There were no biscuits, or bread on the serving line and residents were not served any during the meal service. On 11/17/25 at 12:09 AM, V22 said that she did not make biscuits for the residents because it is too much for their oven space. V22 also said she did not make or give bread to any residents on a pureed diet. On 11/18/25 at 9:55 AM, V14 (Dietary Manager) said the facility menus should be followed and she was not aware that biscuits/bread was not served to the residents on 11/17/25. On 11/18/25 at 1:37 PM, V15 (Dietician) said the menus should be followed and if they do not give what is on the menus or give a replacement item the caloric intake would be less then planned. The facility provided Cycle Menu policy dated 9/26/23 shows that the menus are planned out ahead using national guidelines and will meet the nutritional needs of the residents.

Based on observation, interview and record review the facility failed to ensure beard coverings were worn when preparing resident meals. This failure has the potential to affect all 166 residents residing in the facility. The findings include:On 11/18/2025 at 9:35 AM, V24 [NAME] was observed in the kitchen making pureed bread and vegetables. V24 has a beard and was not wearing a beard covering. V14 Dietary Manager was present in the kitchen while V24 was observed making the pureed food for the noon meal. At 9:54 AM, V24 said he needed about 20 minutes for the turkey to finish cooking so this surveyor and V14 left the kitchen together. On 11/18/25 at 10:08 AM, V14 said that V24 should have a beard covering on while he was preparing food. At 10:16 AM, the surveyor and V14 finished the interview V14 left and did not go into the kitchen. At 10:16 AM, this surveyor returned to watch V24 make the remaining pureed entrees. At no time did he put a beard cover on and continued to puree turkey to serve with the noon meal. On 11/18/25 at 10:22 AM, V24 said the facility policy is beard covers should be worn when preparing food in the kitchen and he should have had one on. The facility provided Food Safety and Sanitation policy dated 9/17/23 shows that beard restraints should be worn at all times.

Based on observation, interview, and record review the facility failed to have pressure treatments and pressure reducing interventions in place which applies to 4 of 9 residents (R117, R129, R51, R73) reviewed for pressure wounds in a sample of 33. The findings include:1) R117's Medical Record showed R117's is a [AGE] year-old female resident readmitted to the facility on [DATE] with diagnoses which includes Stage 4 pressure ulcer of the sacral (tailbone) region. On 11/17/25 at 12:30 PM, V5 and V6 Certified Nursing Assistants (CNAs) were performing peri-care for R117. R117's incontinence brief had urine in it. R117's sacral pressure wound had no coverage dressing in place. V5 stated V34 Hospice CNA told them R117's dressing came off after their shower. V5 stated they should have let the nurse know the dressing was missing. On 11/17/25 at 12:55 PM, V34 stated when they cleaned up R117 the dressing on R117's wound came off. V34 stated they cleaned up R117 around 11:15 AM to make sure she would be up for lunch. V34 stated they let V5 know. On 11/17/25 at 2:00 PM, V31 Wound Nurse stated no one had come to let them know R117's dressing had come off earlier in the day. V31 stated someone should have come to let them know about the dressing not being in place. R117's wound is being treated for an infection and needs to be covered. Dressing should be in place per order. R117's Physician Orders printed on 11/17/25 showed a wound care order for the sacral area to apply crushed Cipro (antibiotic) and gauze soaked with antibacterial solution to the wound bed and cover with border dressing. On 11/17/25 at 2:30 PM, V2 Director of Nursing stated wounds should have their dressings in place. CNAs need to let a nurse know it is missing so it can be replaced. 2. R129's Wound and Skin Alteration Review dated 11/13/25 showed R129 had a Stage 4 pressure injury to her right heel that measured 0.2 cm (centimeters) x 1.2 cm x 0.5 cm. R129's Order Summary Report dated 10/30/25 showed R129's right heel pressure injury was to be covered with a gauze dressing at all times. On 11/17/25 at 10:30 AM, R129 was observed propelling her wheelchair around the facility. R129 wore only socks, no shoes. It appeared there was no dressing to R129's right heel. R129 was asked if she had a dressing to the wound on her right foot. R129 shook her head no. On 11/17/25 at 2:35 PM, R129 was seated in her wheelchair on the second floor of the facility. R129 again stated she had a wound to her heel. When R129 was asked if she had a dressing covering the wound on her right heel, R129 shook her head no and pulled down the sock on her right foot. No dressing was noted to R129's right heel pressure wound. On 11/18/25 at 9:26 AM, V7 Licensed Practical Nurse (LPN) stated R129 had a boggy pressure wound to her right heel. V7 LPN stated staff provide treatment and a dressing change to R129's pressure injury every Monday, Wednesday, and Friday. V7 stated, She is supposed to have a dressing covering her wound at all times to protect it. 3. R51's Care Plan with a completed date of 10/15/25 showed R51 was at risk for breakdown in skin integrity as evidenced by pressure over boney prominences. Listed under interventions was for a low air loss mattress. On 11/17/2025 at 8:41 AM, R51 was in bed. Hanging on the foot of the bed was an air mattress pump. There was a black tube coming from the pump that was disconnected from the mattress resting on the floor. The green power switch was in the off position. On 11/17/2025 at 11:22 AM and on 11/18/25 at 8:01 AM, R51 was in bed and there was no change in R51's air mattress pump. 4. R73's Care Plan with a completed date of 10/1/25 showed R73 was at risk for breakdown in skin integrity as evidenced by pressure over bony prominences. On 11/17/2025 at 10:23 AM, R73 was in bed. Hanging on the foot of the bed was an air mattress pump. The green power switch was in the off position and not lit up. On 11/18/2025 at 8:00 AM, R73 was in bed and the air mattress pump remained off. On 11/18/2025 at 11:36 AM, V7 (Licensed Practical Nurse) said an air mattress is a preventative intervention for residents at risk for pressure injuries and if a resident has an air mattress it should be working/on.

Based on observation, interview, and record review the facility failed to manage a resident's indwelling urinary drainage bag in a dignified manner for 1 of 33 residents (R131) reviewed for dignity in the sample of 33. The findings include:R131's Order Summary Report printed on 11/17/25 showed R131 had a suprapubic indwelling urinary catheter. On 11/17/2025 at 11:42 AM, R131 was in the dining room eating lunch with other residents. R131 was in a reclining wheelchair with the indwelling urinary drainage bag hanging on the reclining wheelchair. The urinary drainage bag was not in a privacy bag. Urine was visible in the collection bag. On 11/17/2025 at 1:17 PM, R131 was in bed. The indwelling urinary drainage bag could be seen from the hallway. Urine was visible in the collection bag. On 11/18/2025 at 8:03 AM and at 11:40 AM R131 was in the dining room eating with other residents. R131 was in a reclining wheelchair with the indwelling urinary drainage bag hanging on the reclining wheelchair. The urinary drainage bag was not in a privacy bag. Urine was visible in the collection bag. On 11/18/2025 at 12:35 PM, V2 (Director of Nursing) said indwelling urinary drainage bags should be in a privacy bag and privacy bags are used to provide dignity. The facility's Dignity policy with a revision date 1/25 showed examples of promoting dignity and respect include the use of privacy covering for urinary catheter bags.

Based on observation, interview and record review the facility failed to provide adaptive utensils to a resident at meals for 1 of 3 residents (R147) reviewed for resident accommodation of needs/preferences in the sample of 33.The findings include:R147's current care plan showed R147 required the use of built up silverware at meals to aid in his ability to feed himself due to his diagnosis of a cerebrovascular accident (CVA) and bilateral carotid stenosis. R147's breakfast meal tickets dated 11/17/25 and 11/18/25 showed R147 was to use built up silverware when eating his meals. On 11/17/25 at 8:36 AM, R147 was seated in his room with his breakfast tray in front of him. R147 was attempting to feed himself, using regular, standard utensils. No weighted utensils or utensils with rubber grips on the handles were noted on R147's meal tray. On 11/18/25 at 8:05 AM, V11 Certified Nursing Assistant (CNA) delivered R147's breakfast tray to R147 in his room. The only utensils on R147's tray were a plastic fork and a plastic spoon. On 11/18/25 at 8:41 AM, R147 was seated in his room, attempting to eat his breakfast with a plastic fork. R147 was able to spear scrambled eggs with the fork but a small amount of egg would fall off the fork as he brought the fork to his mouth. On 11/18/25 at 9:26 AM, V7 Licensed Practical Nurse (LPN) stated R147 required the use of weighted (built up) utensils to eat because he has had a stroke. The weighted silverware helps him eat using his affected hand from the stroke. Those utensils allow him to build up strength in his affected hand when he uses that silverware. He should use weighted silverware at every meal.The facility's Adaptive Eating Devices policy dated 10/11/23 showed, Adaptive eating equipment, such as plate guards, sip cups, and built-up utensils, are provided for residents who need them to promote feeding independence.

Based on interview and record review the facility failed to ensure psychotropic and anti-psychotic medications that were ordered as needed had a stop/duration date for 3 of 8 residents (R127, R13, and R10) reviewed for pharmacy services in the sample of 33. The findings include:1. R127's Order Summary Report printed on 11/17/25 showed an order for haloperidol (anti-psychotic medication) as needed every 8 hours. The order had a start date of 11/12/25. There was no stop/duration date for the order.2. R13's Order Summary Report printed on 11/17/25 showed an order for lorazepam (psychotropic antianxiety medication) as needed every 3 hours. The order had a start date of 10/6/25. There was no stop/duration date for the order.3. R10's Order Summary Report printed on 11/17/25 showed an order for lorazepam as needed every 8 hours. The order had a start date of 10/15/25. There was no stop/duration date for the order.On 11/18/2025 at 12:35 PM, V2 (Director of Nursing) said as needed psychotropic and anti-psychotic medications need a stop date.The facility's Psychotropic Medication Policy with a reviewed date of 7/1/25 showed as needed psychotropic and anti-psychotic medication are limited to 14 days.

Based on observation, interview and record review the facility failed to provide incontinence care to and reposition a resident dependent on staff for these cares for 1 of 33 residents (R27) reviewed for activities of daily living (ADLs) in the sample of 33.The findings include:R27's current care plan showed R27 was nonverbal and cognitively impaired due to his diagnoses of intellectual disability and paralytic syndrome. The plan showed R27 is dependent on staff for toileting/incontinence care, transfers and repositioning. R27 was incontinent of bowel and bladder. The plan showed staff will reposition R27 as per facility protocol and keep R27's skin clean and dry. On 11/17/25 at 10:21 AM, R27 was seated in a high-back wheelchair in his room. R97 (R27's roommate) was also in the room. R97 looked at this surveyor and stated, He (R27) doesn't talk. When R97 was asked how long R27 had been up in his wheelchair that morning, R97 stated, He's been up in the wheelchair since around 5 AM. They (staff) don't lay him down much during the day. On 11/17/25 at 11:36 AM, R27 remained seated in his high-back wheelchair in the dining room of the facility.On 11/17/25 at 12:15 PM, V5 and V6 Certified Nursing Assistants (CNA) transferred R27, from his wheelchair to bed, via a mechanical lift. V5 and V6 CNAs removed R27's incontinence brief. A large amount of dried out, hard stool was stuck to the crease between R27's buttocks. R27's brief contained a large amount of dark yellow urine. Redness was noted to the skin of R27's buttocks, groin and scrotum. Skin creases, caused by exposure to R27's wet incontinence brief, were noted to R27's buttocks. V6 CNA stated R27's incontinence brief was last changed sometime between 5 AM-6 AM when staff had gotten him up and out of bed for the day. On 11/18/25 at 9:26 AM, when V7 Licensed Practical Nurse (LPN) stated residents are to be repositioned every 2 hours to help prevent skin breakdown. V7 stated residents should be checked every 2 hours for incontinence and changed if soiled.The facility's Repositioning and Turning policy dated June 2014 showed, It is the policy of the Nursing Department that residents, unable to reposition themselves, will be turned and repositioned every two hours, in accordance with their needs.

Based on observation, interview, and record review the facility failed to ensure electrical wiring was appropriately insulated and stowed out of reach in one resident's room (R149) and failed to ensure a resident was transferred in a safe manner for 2 of 6 residents (R149, R147) reviewed for safety in the sample of 33. The findings include: 1. On 11/18/25 at 12:53PM, R149 showed the surveyor two wires sticking out of the wall in the resident's room. R149's room has a black and a white electrical wire hanging out of a conduit tube under the window. The electrical wires were wrapped with black electrical tape. On 11/18/25 at 1:25PM, V12 Maintenance used a voltage tester to check the electrical wires. The voltage tester started flashing and emitted a tone signifying electrical current was present in the wires. V12 Maintenance said, there is 120 volts of electrical power coming through the wires. The wires should be enclosed with wire caps (rather than electrical tape). The facility's Preventative Maintenance Program dated 02/19 shows all electrical equipment is checked for safety. 2. R147's Restorative assessment dated [DATE] showed he required partial to moderate assistance of staff for transfers and toileting due to his diagnoses of frequent falls, cerebrovascular accident (CVA) and bilateral carotid stenosis. On 11/17/25 at 9:01 AM, V8 and V9 Certified Nursing Assistants (CNA) entered R147's room to provide cares. V9 CNA wheeled R147 into the bathroom via his wheelchair. V9 then transferred R147, from his wheelchair to the toilet, by placing her arm under R147's left arm and guiding R147's buttocks onto the toilet. V9 did not use a gait belt when transferring R147. V8 CNA stood in the doorway of the bathroom and watched as V9 CNA transferred R147. On 11/18/25 at 1:03 PM, V10 Restorative Nurse stated R147 required partial to moderate assistance of one staff for all transfers which included the use of a gait belt to ensure R147's safety. V10 stated R147 was at risk for falls due to his previous falls in the facility. The facility's Gait Belt policy dated January 2025 showed, Purpose: To provide support and safety during ambulation, lifting, or transferring residents. Place the gait belt around the resident's waist. Make certain that the belt fits snugly. Grasp belt webbing securely at resident's back and resident's right or left side to support resident balance during transfers.

Based on observation, interview and record review the facility failed to maintain a residents urinary catheter bag below the level of the bladder and off the floor for 2 of 7 residents (R82, R3) reviewed for urinary catheters in the sample of 33.The findings include:1.R82's current care plan showed R82 had a urinary catheter in place due to his diagnoses of prostate cancer and obstructive and reflux uropathy. The plan showed R82 is at risk for infection or complications related to catheter use.Observe position of drainage bag and keep below waist to ensure proper drainage. R82's progress note dated 11/5/25 showed R82 developed blood in his urine. R82's physician/nurse practitioner was notified. A urinalysis of R82's urine was ordered. R82's urinalysis result dated 11/11/25 showed R82 was diagnosed with a urinary tract infection (UTI) and started on antibiotics for treatment of the UTI. On 11/17/25 at 8:53 AM, R82 was in bed, lying on his right side. The catheter bag, connected to R82's urinary catheter, rested on the seat of a wheelchair that was located directly next to the left side of R82's bed. Because R82's bed was positioned lower than the seat of the wheelchair, R82's catheter bag rested below the level of R82's bladder. R82's urine was unable to drain into the urinary catheter bag. On 11/17/25 at 1:27 PM, R82 remained asleep in bed. R82's urinary catheter bag remained on the seat of the wheelchair next to R82's bed. Because R82's bed was positioned lower than the seat of the wheelchair, R82's catheter bag rested below the level of R82's bladder. R82's urine was unable to drain into the urinary catheter bag. On 11/18/25 at 7:28 AM, R82 was asleep in bed, R82's urinary catheter bag rested on the seat of the wheelchair next to R82's bed. Because R82's bed was positioned lower than the seat of the wheelchair, R82's catheter bag rested below the level of R82's bladder. R82's urine was unable to drain into the urinary catheter bag. On 11/18/25 at 9:26 AM, V7 Licensed Practical Nurse (LPN) stated a resident's urinary catheter bag should be positioned below the level of a resident's bladder so urine can drain out of the resident into the bag. V7 stated if a resident's urine can't drain into the catheter bag, it can cause an infection and/or discomfort to a resident. The facility's Catheter Care policy dated January 2025 showed, Catheters shall be positioned to maintain a downhill flow of urine to prevent a back flow of urine into the bladder or tubing, during transfer, ambulation, and body positioning. 2. R3's medical records showed R3 is a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses which include type 2 diabetes mellitus, obstructive and reflux uropathy, and benign prostatic hyperplasia with lower urinary tract symptoms. On 11/17/25 at 10:40 AM, 11/17/25 at 12:45 PM, and 11/18/25 at 9:30 AM R3's urinary catheter bag was not in a dignity bag. The lower half of the urinary collection bag was laying on the floor. On 11/18/25 at 8:00 AM, V26 Certified Nursing Assistant (CNA) stated catheter bags should not be touching the floor. On 11/18/25 at 2:45 PM, V4 Infection Control Preventionist (ICP) stated urinary catheter bag should not be hung low enough to touch the floor or be placed directly on the floor which can increase the chance of an infection. The facility's Catheter Care Policy dated 10/13/18 showed urinary drainage bags and tubing shall be positioned to prevent them from touching the floor.

Based on interview and record review the facility failed to consistently document meal intakes and monthly weights and failed to ensure a resident (R40) was assessed by the dietician following a significant weight loss. This failure resulted in additional interventions not being implemented and R40 experiencing on going weight loss. The facility failed to ensure nutritional interventions were implemented for 4 residents (R9, R14, R153, R160) and failed to ensure weekly weights were obtained for a resident (R153). The findings include:1. On 11/19/2025 at 10:26AM, V14 Dietary Manager said, I perform admission and quarterly nutritional assessment on the residents. The dietitian uses my assessments and performs their own assessment. The dietitian only assesses residents if the computerized medical record triggers the resident for weight loss. The problem with R40's weight loss is the computer did not trigger the weight loss because no weights were documented. I was not made aware R40's weights were not being documented. From January 2025 through July 2025 R40's Medication Administration Record shows, R40 refused being weighed. If I would have known R40 was refusing to be weighed I would have requested an assessment by a Registered Dietitian. Then we would have been aware of R40's weight loss. Now we have a process. If a resident refuses to be weighed twice we have the resident assessed by the Registered Dietitian. Weight loss can be identified through observation. I monitor the resident's weight in the computerized medical record. On 11/19/2025 at 1:17PM, V15 Dietitian said, November 17, 2025, is the first time I assessed R40. I do not see any progress notes addressing R40's weight loss by the previous dietitian. R40 is high risk for weight loss. R40 has a history of anorexia and a new diagnosis of dementia. These diagnoses increase the effects of the weight loss on R40. On 08/07/2025 the prior dietitian recommended a supplement; this recommendation should have been paired with a progress note by the Registered Dietitian. I assess residents in multiple facilities. I am not in R40's facility daily. I only assess the residents that trigger in the electronic medical record for significant weight loss or when the facility requests me to assess a resident. The most effective way to identify significant weight changes is by weighing the resident. R40 refused to be weighed for eight months. It is more difficult, but weight loss can be identified by reviewing Meal Intake Records and through daily observation of the resident during the meal. When R40's weight loss was identified in August (08/06/2025), a Registered Dietitian should have assessed R40 immediately. Significant weight loss is defined as a 5% gain/loss in one month, 7.5% gain/loss in three months, or 10% gain/loss in six months. R40's Weight Record shows, the resident weighed 114.3 pounds on 12/30/2024. On 08/06/2025 R40's weight was 98.6 pounds, which is 13.7 percent weight loss. R40's Weight Record shows on 11/07/2025, the resident's weight was 90.8 pounds, which was a further is a 7.9% loss in three months. R40's Dietary Progress Note dated 11/17/2025 by V15 Dietitian shows, Registered Dietitian Weight Assessment. Weight Changes: Significant weight loss in three months. 7.8-pound loss with 7.9% weight loss. R40's Meal Intake Record shows, nine categories to document R40's intake. The categories include 0-25%, 26-50%, 51-75%,78-100%, Nothing by Mouth, Tube Feeding, Resident Not available, Resident Refused, Not Applicable. The Meal Intake Record from 10/21/2025 through 11/17/2025, shows there were 45 meals with no entries of the intake percentages. R40's care plan included a Focus initiated on 03/22/2016 and revised on 07/10/2025, that shows, (R40) . is known to deny meals and only eat her supplements. Will work on encouraging oral intake. The goal, initiated on 06/22/2022 and revised on 10/25/2025 shows, (R40) will not lose any weight through next review. The interventions included, Chart % consumed at each meal and offer substitutes for refused item and Nurse alert MD (Medical Doctor) and guardian of significant weight loss and assure that dietician is made aware so a consult can take place. Both had an initiation date of: 09/01/2024. A second Focus initiated and revised on 10/25/2025, shows, (R40) is at risk for elevated blood pressure related to hypertension. The interventions included, Assess (R40's) weight monthly or as ordered. Date initiated and revised: 10/25/2025. The facility undated Food Service Supervisor-Job Description shows, Main Duties: Make recommendations for changes in diet based on observations. Implement any plan of correction as required by State and Federal surveys in the dietary department. 2. On 11/17/2025 the noon meal food serving line on first floor was observed continuously by this surveyor from 11:35 AM-12:15 PM. Staff were heard asking V22 (Cook) for magic cups and ice cream for the resident who have those items on their meal tickets. V22 would inform them that they do not have any. At 12:09 PM, V22 said that the facility ran out of magic cups and ice cream on Friday 11/14/2025, and V8 (Certified Nursing Assistant) added that the facility runs out of things a lot. On 11/17/2025 at 12:25 PM, R14 did not have a magic cup on his lunch meal tray. R14's Physician Orders dated 3/12/2025 Magic cup in the afternoon for Magic cup with lunch. Magic Cup in the evening for Magic cup with dinner. On 11/18/2025 at 9:55 AM, V14 (Dietary Manager) said she was not aware the facility had run out of magic cups and ice cream last Friday. V14 said they should have let her know so she could go get some. V14 also said other nutritional supplements should have been given to the residents. On 11/18/2025 at 10:10 AM, R160 said she did not get her magic cup or ice cream at lunch yesterday and she likes that. R160's Dietary Progress Note dated 10/31/2025 shows her current weight as 95.8 pounds (lbs.) and she has had a history of significant weight loss of 10.2# (lbs) or 13.7% in 3 months from July to October 2025. R160's Dietary note shows she should receive nutritional supplements including magic cup and ice cream with lunch and dinner. R160 has a physician order for both Magic Cup ordered on 7/17/2023 and ice cream ordered on 6/23/2025 both to be given with lunch and dinner. On 11/18/2025 at 12:25 PM, R153 said she did not get her magic cup for the past few days, and they often do not give it to her. R153's weight summary shows she had a prior significant weight loss of 10.3% 12.4 lbs. in August of 2025. R153's order summary shows she has a physician order dated 3/16/2025 for magic cup with breakfast and dinner. On 11/18/2025 at 1:05 PM, R9 said he got the magic cup today, but didn't get it this weekend or yesterday. R9 said he eats it when he gets it. R9's Physician Orders dated 8/5/2025 Serve magic cup with lunch for weight management. On 11/18/2025 at 1:39 PM, V15 (Dietician) said all the residents who have orders to receive magic cup are either at risk for weight loss or have had weight loss and the magic cup is an intervention to prevent weight loss. V15 said she was not aware the facility had run out of the magic cup and ice cream, but they should have given a substitute. The facility provided Supplementation policy dated 8/5/2023 shows supplements are given to meet resident nutritional needs and to maintain weight. 3. R153's Order Summary Report printed on 11/17/2025 showed an order for weekly weights to be done every Tuesday. The order had a start date of 4/1/2025. On 11/17/2025 at 10:10 AM, R153 said she was not being weighed every week and she was not sure why. R153's October Medication Administration Record (MAR) and Weight and Vital Summary document for October showed a weekly weight recorded for two out of four weeks in October. The October MAR had not applicable documented for 10/7/2025, 10/21/2025, and 10/28/2025. R153's November MAR printed on 11/19/2025 and Weight and Vital Summary document for November showed weekly weights were done for one of two weeks. The November MAR had not applicable documented for 11/4/2025, 11/11/2025, and 11/18/2025. On 11/18/2025 1:37 PM, V15 (Dietitian) stated weekly weights are done to closely monitor a resident's weight to see of interventions are working or if interventions need to be added. The facility's Weight Assessment and Interventions policy with reviewed date of 1/24 showed ensure that residents are monitored for undesirable weight loss or gain so appropriate interventions can be put in place in a timely manner.

Based on observation, interview and record review the facility failed to administer medications as ordered by the physician. There were 28 opportunities with 2 errors resulting in a 7.14% error rate. This applies to 2 of 4 residents (R17, R70) observed in the medication pass. The findings include:1.R17's Order Summary Report shows he was admitted to the facility on [DATE], with a diagnosis of type two diabetes mellitus with diabetic neuropathic arthropathy. R17 has an order for humalog tempo pen inject 15 units subcutaneously three times a day for diabetes.On November 17, 2025, at 11:00 AM, V19 Licensed Practical Nurse (LPN) prepared R17's insulin pen by placing a needle on the end. V19 turned the dial on R17's pen to 15 units. V19 then administered the insulin to R17's abdomen. V19 did not prime the insulin pen and needle by wasting two units of insulin prior to administering the insulin to R17. V19 said she only primes the insulin pen when she opens a new pen, not with each administration.On November 18, 2025, at 12:30 PM, V2 Director of Nursing (DON) said insulin pens should be primed with two units of insulin each time the pen is used in order to ensure the residents get the full amount of insulin. The facility's Insulin Pen Injection Administration Policy not dated shows, Always use a new needle for each injection. Remove protective tab from needle and screw it into the pen device. To prime: turn the dose selector to two units. Hold pen with the needle pointing up and tap the cartridge gently to move air bubbles to the top. Press the button all the way in. A drop of insulin should appear at the tip of the needle. Selecting the dose: turn the dose selector to the number of units needed to inject. The device will not allow you to select a dose greater than the number of units left in the pen. 2. R70's Order Summary Report shows she was admitted to the facility on [DATE]. There is an order for zyrtec allergy (cetirizine) oral tablet 10 mg (milligrams), give 10 mg by mouth daily for allergies. On November 17, 2025, at 9:20 AM, V7 Licensed Practical Nurse (LPN) administered loratadine 10 mg instead of cetirizine 10 mg. On November 18, 2025, at 12:30 PM, V2 DON said cetirizine and loratadine are different allergy medications. The facility's Policy and Procedure on Administering Medications dated January 1, 2020, shows, Medications shall be administered in physician's written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified and the medication is labeled according to accepted standards.

Based on interview and record review the facility failed to provide R125 a snack outside of the scheduled meal service times for 1 of 5 residents (R125) reviewed nutrition in the sample of 33.The Findings Include:On 11/18/25 at 9:08AM, R125 said, I do not get snacks. I would like a bedtime snack. When I request a bedtime snack, V14 Dietary Manager tells me, only the diabetics get snacks. On 11/18/25 at 9:35AM, V13 LPN-Licensed Practical Nurse said, the facility only provides diabetic residents and residents with weight loss a snack at night.On 11/18/25 at 10:20AM, V14 Dietary Manager, we do not offer snacks to anyone. Diabetic residents are the only residents the snacks are set up for in the evening.On 11/18/25 at 1:38PM, V15 Dietitian said, we only provide snacks to diabetics.R125's Diet Order dated 10/02/2017 shows, regular texture, thin liquids, consistency for general diet.On 11/18/25 R125's Care Plan show, no intervention forbidding R125 from having a snack outside of scheduled meal service times.On 11/18/25 R125's Physician's Orders show, no Physician Order forbidding R125 from having a snack outside of scheduled meal service times.

Based on observation, interview, and record review the facility failed to ensure staff wear personal protective equipment (PPE) and have signs posted for residents on enhanced barrier precautions (EBP) isolation which applies to 2 of 33 residents (R117, R82) reviewed for infection control in a sample of 33.The findings include: 1) R117's Medical Record showed R117's is a [AGE] year-old female resident readmitted to the facility on [DATE] with diagnoses which includes Stage 4 pressure ulcer of the sacral (tailbone) region. On 11/17/25 at 12:30 PM V5 and V6 Certified Nursing Assistants (CNAs) entered R117's room, performed a mechanical lift transfer, and peri-care without placing a blue gown on prior to entering the room. R117 has a sign on the door for EBP isolation precautions to be used. R1's Physician Orders printed on 11/17/25 showed R117 has dressing change orders which include using a crushed antibiotic and antibacterial solution to be applied to R117's wound. On 11/18/25 at 2:45 PM V4 Infection Control Preventionist (ICP) stated R117 is on EBP for a chronic wound which is currently being treated for an infection. Gowns and gloves should be worn during high contact care. On 11/19/25 at 9:35 AM, V5 stated if someone is on EBP then a gown and gloves need to be used during cares. V5 stated they should have worn a gown during R117's care. The facility's EBP policy dated 11/28/22 showed EBP require the use of gown and gloves during high contact care activities which includes changing briefs or assisting with toileting. EBP applies to resident with a chronic wound. 2. R82's current care plan showed R82 had a urinary catheter in place due to his diagnoses of prostate cancer and obstructive and reflux uropathy. R82's Order Summary Report dated 7/16/25 showed a physician order for R82 to have Enhanced Barrier Precautions (EBP) in place due to having a urinary catheter. On 11/17/25 at 8:53 AM and 1:27 PM, R82 was in bed with a urinary catheter in place. No Enhanced Barrier Precautions (EBP) signage was noted on or by the door to R82's room. On 11/18/25 at 9:26 AM, R82 was in bed with a urinary catheter in place. No Enhanced Barrier Precautions (EBP) signage was noted on or by the door to R82's room. On 11/18/25 at 9:26 AM, when V7 Licensed Practical Nurse (LPN) was asked how staff identify if a resident is on EBP or any type of isolation precautions, V7 stated, There is a sign posted on the resident's door which identifies what type of isolation the resident is on and what PPE (personal protective equipment) staff are required to wear when providing cares. The facility's Enhanced Barrier Precautions policy dated 4/28/25 showed, Enhanced Barrier Precautions apply to residents with a wound (chronic wounds, not shorter-lasting wounds, such as skin breaks or tears covered with an adhesive dressing) or similar dressing and indwelling medical device (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) .

Based on interview and record review the facility failed to ensure residents pressure injury treatments were being completed for 2 of 3 residents (R2 & R3) reviewed for pressure injury in the sample of 4.The findings include:The findings include:1. Face Sheet dated 10/21/25 for R2 showed diagnoses including stage 4 pressure ulcer to the left lower back, type 2 diabetes mellitus, chronic obstructive pulmonary disease, adult failure to thrive, gastroesophageal reflux disease, anxiety, falls, and peripheral vascular disease.The Wound Care Physician Note dated 10/16/25 for R2 showed a stage 4 pressure wound to the left lower back with the objective of treatment to prevent deterioration. The October 2025 Treatment Administration Record (TAR) for R2 showed, collagen matrix silver external sheet - apply to wound topically one time a day every Saturday and Sunday for wound care and it was not signed off as being completed on 10/4/25 and 10/5/25. Wound care: left lower back - cleanse with wound cleanser, skin prep to peri wound, pack with collagen with silver and cover with gauze island dressing one time a day every Saturday and Sunday that was not signed off as being completed on 10/4/25 and 10/5/25. Wound Care: left lower back: cleanse with wound cleanser, skin prep peri wound, pack with antiseptic soaked kerlix and cover with gauze island dressing one time a day every Saturday and Sunday that was not signed off as being completed on 10/18/25. On 10/21/25 at 4:00 PM, V8 Wound Care Nurse stated the day the treatment order is put into the computer is the start date for the treatment. If the order was entered on 10/4/25 then the treatment would start on 10/5/25. V8 stated the treatments should be marked off on the Treatment Administration Record (TAR) after it is completed by the nurse. V8 stated she does wound treatments Monday - Friday and the floor nurses do the treatments on the weekends. V8 stated if it is not documented then it is not done. V8 stated it is important that residents receive their wound treatments as ordered so they don't get worse or become infected. V8 reviewed the October 2025 TAR for R2 and confirmed that some of the weekend treatments were not signed off as being completed and should have been.R2's Care Plan dated 9/22/25 showed wound management of left lower back. Provide wound care per treatment order. The facility's Pressure Ulcer and Skin Condition Assessment Policy (10/17/20) showed, physician ordered treatments shall be initialed by the staff on the Treatment Administration Record after each administration.2. The Face Sheet dated 10/21/25 for R3 showed diagnoses including right sided hemiplegia, obesity, asthma, traumatic brain injury, stage 3 pressure ulcer of right ankle, schizoaffective disorder, and edema. The October 2025 Treatment Administration Record (TAR) for R3 showed right lateral ankle - cleanse with wound cleanser, skin prep to peri-wound bed and cover with gauze island dressing one time a day every Saturday and Sunday for wound care that was not signed off as being completed on 10/4/25, 10/5/25, and 10/18/25.On 10/21/25 at 4:00 PM, V8 Wound Care Nurse stated the day the treatment order is put into the computer is the start date for the treatment. If the order was entered on 10/4/25 then the treatment would start on 10/5/25. V8 stated the treatments should be marked off on the Treatment Administration Record (TAR) after it is completed by the nurse. V8 stated she does wound treatments Monday - Friday and the floor nurses do the treatments on the weekends. V8 stated if it is not documented then it is not done. V8 stated it is important that residents receive their wound treatments as ordered so they don't get worse or become infected. V8 reviewed the October 2025 TAR for R3 and confirmed that some of the weekend treatments were not signed off as being completed and should have been.R3's Care Plan dated 9/10/25 showed, pressure ulcer to right lateral ankle related to pressure over bony prominences, mechanical factors, and alteration in sensation manifested by hemiplegia affecting right dominant side. Followed by a sound care provider. Provide wound care per treatment order.The facility's Pressure Ulcer and Skin Condition Assessment Policy (10/17/20) showed, physician ordered treatments shall be initialed by the staff on the Treatment Administration Record after each administration.

Based on interview and record review, the facility failed to assess a resident's pressure injuries in a timely manner and failed to implement pressure injury treatment interventions for 1 of 3 residents (R1) reviewed for pressure injuries. These failures resulted in R1's pressure injuries deteriorating from two Stage 2 pressure injuries into one unstageable pressure injury. The findings include: R1's Admission Record dated 1/27/25 shows R1 was admitted to the facility on [DATE] with the following diagnoses: sepsis, diabetes mellitus type 2, pressure ulcer of right buttock, stage 2, pressure ulcer of left buttock, stage 2, high cholesterol (hyperlipidemia), a right below knee amputation, congestive heart failure, methicillin resistant staphylococcus aureus infection, gastroesophageal reflux disease (GERD), osteomyelitis, hyperglycemia, and bacteremia (blood stream infection). R1's After Hospital Care Plan (printed 12/20/24) shows orders for R1's Stage II pressure injuries of his right and left buttocks which were to be treated twice a day. R1's Order Recap Report dated 1/27/25 shows orders dated 12/20/24 for R1 to receive wound treatment to his left and right buttocks twice a day, every day beginning 12/20/24. R1's Wounds record (printed 1/27/25) for 12/1/24-12/31/24 shows R1 did not receive 16 of 19 treatments between 12/20/24 and 12/30/24. No documentation was provided showing R1 had refused any of those wound treatments. The facility's Pressure Wound Report provided by the facility on the morning of 1/27/25 with a reporting date of 1/21/25, shows R1 has an unstageable pressure ulcer of his sacrum (upper buttocks area) and does not have a statement signed by the physician to indicate it is unavoidable. As of 1/28/25 at 10:26 AM, there was no Unavoidable Disruption in Skin Integrity statement for R1, nor were there any documented refusals of wound care treatment for R1. R1's current care plan provided by the facility marked care plan closed date 1/27/25 reason for close: discharge, shows R1 has a self care deficit related to weakness, impaired balance, limited range of motion, pain, and physical inactivity and requires extensive to total assistance with mobility related tasks and dressing. R1 needs two staff assistance with turning/repositioning and transferring with a mechanical lift, he is non-ambulatory, and his primary mode of locomotion is via a wheelchair. The same care plan shows a focus that R1 (as of initiation date of 12/22/24) is at increased risk for alteration in skin integrity as evidenced by mechanical factors, pressure over bony prominences, moisture, impaired circulation, and alteration in sensation. R1's Admission/Readmission Screener dated 12/20/24 at 4:55 PM, under the question, Does the resident currently have any skin abnormalities (i.e. bruising, skin tears, pressure injuries, etc)? There is no pressure injury listed. R1's Wound and Skin Alteration Review (Wound Nurse) dated 12/27/24 at 10:59 AM shows R1 has a nonstageable (NS) sacral (upper buttocks area) pressure injury measuring 7.2 by 8 by 0.1 centimeters with 90 percent slough. Under number 7. Healing Process, New Wound is marked. This same document shows a Stage 2 Pressure Injury is partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough and an Unstageable Pressure Injury is full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown, and/or eschar (tan, brown, or black) in the wound bed. On 1/27/25 at 11:50 AM, V3, Wound Care Nurse, said residents' wounds are supposed to be assessed within 24 hours of being admitted . V3 said R1's initial wound assessment was not done until 12/27/24; the admitting nurse did not identify R1's buttock wounds upon admission (on 12/20/24). V3 said R1's admitting diagnoses show R1 was admitted with Stage 2 pressure wounds of his right and left buttock, but when he assessed R1's wounds he saw overlapping wounds and classified the wound as an unstageable pressure wound of the sacrum. V3 said R1 was admitted with wound treatment orders on 12/20/24 to be done twice a day, every day of the week to the right and left buttocks. V3 said R1's wounds should have been assessed upon admission and treatments completed as ordered. V3 said the purpose of wound treatment is to try to help heal the wound, prevent infection, and to prevent it from deteriorating and getting worse. V3 said without wound treatment, wounds can deteriorate and get worse. On 1/27/25 at 12:46 PM, V2, Director of Nursing (DON), said R1 was admitted to the facility on [DATE] and she entered R1's wound treatment orders from his discharge orders from the hospital which should have been started that same day, as per physician orders. V2 said if the wound care nurse is in facility, when a resident is admitted , they do the admission skin/wound assessment, otherwise the admitting nurse does it. They should measure open wounds, but, some floor nurses are not comfortable staging them, a full wound assessment should be done optimally within 24 hours of admission. V2 said V4, Licensed Practical Nurse (LPN), was covering the wound care position on 12/18/24, 12/19/24, and 12/20/24 while V3 was on vacation. On 1/28/25 at 8:33 AM, V4 LPN said she was covering the wound care position on 12/18/24, 12/19/24, and 12/20/24 while V3 was on vacation. V4 said her responsibilities as wound care nurse included everything the wound nurse would do, such as wound treatments and (skin/wound) assessments of any new admissions. V4 said new admission assessments are done within the first hour or two after residents arrive. If the wound care nurse is not in the facility, he/she would do it the following day, but the admitting nurse would do a skin assessment, although they would probably not stage a pressure ulcer (pressure injury), they would document it and some nurses would measure and document the wound characteristics. V4 said the wound nurse would do the full assessment which includes identifying the type of wound, measurements, what the wound/peri wound looks like, any odor, any drainage, any characteristics, any pain, location, and she would stage a pressure ulcer. V4 said R1 was admitted on a Friday after she had already left, so she never saw him or his wound. V4 said the admitting nurse needs to look at the orders and put them in the computer as the floor nurses are responsible for wounds on the weekends. V4 said it would not be ok to do the initial wound assessment a week after a resident was admitted . V4 said a wound could deteriorate during that time. V4 said wound treatments are done per physician orders. The nurse looks at the TAR (treatment administration record), the MAR (medication administration record), and the Wound tabs to see what treatments need to be administered. If a day(s) was crossed out on those tabs, the nurse would not do the treatment. The responsible nurse signs off the day once the treatment is done. V4 said she does not know if R1's primary care provider (PCP) would have seen R1's wound but said if the PCP is giving the treatment orders for a wound, she would think they are evaluating or have evaluated the wound. On 1/28/25 at 9:04 AM, V5, Nurse Practitioner (NP), said the facility needs to do wound treatments as ordered. If a resident refuses, they need to document that. V5 said R1 should have been seeing the wound care doctor and she did not look at his pressure wounds when she saw him in the facility. V5 said a wound can deteriorate in a week and lack of wound treatments could contribute to a wound deteriorating. On 1/27/25 at 11:01 AM, V6, LPN, said the wound care nurse does the wound care treatments except for on the weekends. The floor nurse would look under the Wound tab to see if there are any wounds requiring treatment and carry out the orders. Once the treatment is completed, the treatment is signed off as being done; if the treatment is not signed off, it was not done. V6 said the purpose of wound care treatment is to keep wounds clean and healing. The facility's Wound Policy (reviewed 11/2022) shows the purpose is to promote a systematic approach and monitoring process for the care of residents with existing wounds and to promote healing of existing pressure ulcers. The goals of wound treatment include protecting the ulcer from contamination and promoting healing. The policy shows that current standards of Clinical Practice will be utilized.

Based on interview, and record review the facility failed to ensure a resident with a history of embolic strokes (R167) received physician ordered anticoagulants. This failure resulted in R167 requiring emergency transport to the hospital for an acute embolic stroke. R167 was hospitalized until [DATE], when he passed away. The facility also failed to ensure an anticoagulant medication was administered as ordered for R116 for 2 of 8 residents (R167 & R116) reviewed for significant medication error in the sample of 33. The Immediate Jeopardy began on [DATE] when R167 was readmitted to the facility and the facility failed to ensure the physician prescribed anticoagulant medication was obtained from pharmacy. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 1:02 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the process changes and in-service training. The findings include: 1. R167's Facesheet dated [DATE] showed diagnoses to include, but not limited to: stroke due to embolism, nicotine dependence, encephalopathy, hypertension, deep vein thrombosis, chronic obstructive pulmonary disease, unsteadiness on feet, repeated falls, weakness, and long-term use of anticoagulants and antithrombotics/antiplatelets. This document showed R167's original admission to the facility was [DATE]. R167's Physician Order Sheet printed [DATE] showed an order for Xarelto 15 mg (milligrams) twice a day for stroke due to embolism. This order was entered on [DATE]. R167's MAR (Medication Administration Record) showed he R167's was scheduled to received Xarelto 15 mg in the morning and the evening, starting [DATE]. R167's MAR showed there were entries for [DATE], [DATE] and [DATE] that showed the medication was on order from pharmacy or a progress note was entered. (According to pharmacy, R167's Xarelto was delivered to the facility on [DATE]. R167's should have received 6 doses of the medication during that time.) R167's Progress Note dated [DATE] at 4:02 PM, showed R167 had returned to the facility from a facility initiated transfer. R167's Progress Note [DATE] at 11:05 PM, showed This writer just spoke with [consulting pharmacist] regarding the status of atorvastatin and xarelto. Atorvastatin will be delivered tonight. Xarelto is not covered by resident's insurance. Asked pharmacist what would be covered as an alternative and he reports it is not in the notes, billing department will know that and they will be in tomorrow morning at 0600. [V12-NP] informed. R167's Progress Note dated [DATE] showed he lost his balance, pushing his wheelchair and fell on the dining room floor. There were no injuries noted. R167's Progress Notes dated [DATE] at 9:15 PM, showed, Residents family have been here with resident most of the PM shift. Resident has had no changes in baseline mental status. Resident's niece states at 9:10 PM, I'm scared my uncle might have had a stroke earlier when we were taking to him, but I really don't know. CNA [Certified Nursing Assistant] reports she just assisted resident back to bed and that his behavior was fine, he was speaking to her, and had no abnormalities. This RN [Registered Nurse] did neuro assessment and no signs that resident had a stroke . R167's Progress Notes dated [DATE] at 5:50 PM, showed At approximately 5:50 PM resident started having seizure in the dining room that lasted 2 minutes. Staff immediately notified nursing - accucheck 168. Pulse oximetry 73% on room air . 911 called while nursing helped resident in the dining room . 23:00PM resident admitted with stroke diagnosis. R167's Xarelto prescription dated [DATE] showed the medication was to be administered twice a day. R167's Xarelto Manifest showed it was delivered to the facility on [DATE] at 8:00 PM. R167's emergency room records dated [DATE] showed he had a history of strokes, had a seizure prior to arrival. The facility reported the patient had a two minute seizure in the dining room. The records showed the family reported an episode of aphasia yesterday, which as resolved. These notes showed R167's was admitted to the hospital on [DATE] for an embolic stroke. R167's Neurology Progress Note dated [DATE] showed R167 had recurrent bi-hemispheric embolic strokes. R167's Hospital Discharge Summary dated [DATE] showed R167 died . R167's Death Certificate showed he died on [DATE] and the primary cause was recurrent emobilic strokes. On [DATE] at 2:15 PM V2 (Director of Nursing/DON) said when a resident is admitted from the hospital the discharge medication list is used to order the resident's medications at the facility. V2 said the nurse will enter the orders when the resident is admitted . V2 said when the order is entered, the order is sent to pharmacy to fill the medication. V2 said sometimes there is an issue with the insurance and pharmacy will send an authorization notice. V2 said if the medication isn't available for more than a shift and a half, then I get involved. V2 said she expects the nurses to report any medication that has not been received from pharmacy to her. V2 stated, I know I was in contact with the pharmacy about [R167's Xarelto]. I told them to send it. V2 said she isn't sure if Xarelto is in the automated medication dispensing system, but stated, It should be. V2 said she thought the issue was taken care of because the nurses hadn't reported any issues to her. V2 said she doesn't know if R167 received his scheduled Xarelto prior to [DATE]. V2 said she doesn't know why the Xarelto was documented as administered by some nurses. V2 said she had no idea how a nurse would give a medication that wasn't available because they aren't supposed to borrow medications from another resident. (R167's Xarelto was delivered on [DATE] at 8:00 PM.) V2 said the automated medication dispensing system was changed six months ago and there are a few nurses that still don't have access to it. V2 said Xarelto is a blood thinner and is used to prevent clot formation and decrease the risk for stroke. V2 said she wasn't sure what happened to R167. V2 reviewed R167's Electronic Medical Record (EMR) and said it looked like he had seizure activity and was sent to the emergency room . At 3:28 PM, V2 accessed the automated medication dispensing system. The automated medication dispensing system was small, the size of a mini-refrigerator and across the room there was a plastic storage container, with a padlock affixed to it. V2 said if the medication isn't inside the smaller automated medication dispensing system, then a key will be obtained to open the lock on the plastic container. V2 checked for Xarelto and was unable to obtain it from the automatic dispensing system. V2 stated, I'll have to sign out the key and check over there. V2 signed out the key and opened the plastic storage container to expose multiple small, divided containers. V2 picked up a small plastic container and stated, Look at this. There isn't even a label on this to tell me what is inside. I just have to look at each separate medication. This system is ridiculous. I hate it. V2 stopped and stated, This will take forever. Do we have to go through each one? Can I just get the list from pharmacy that shows what medications are available. V2 locked the cabinet and returned the keys to the automated dispensing system. On [DATE] at 1:10 PM, V6 (Licensed Practical Nurse/LPN) said she wasn't sure if Xarelto was available in the automated medication dispensing system. V6 said she didn't have access to the system. V6 said the system was changed about 6 months ago and there were still nurses that didn't have access. On [DATE] at 4:03 PM, V9 (LPN) said she doesn't remember R167 or any specific information regarding him. V9 said she does not have access to the facility's automated medication dispensing system. V9 said she would have to ask another nurse to access, but stated, She hasn't come across anyone that had access to it while I was working. On [DATE] at 7:59 AM, V12 (Nurse Practitioner/NP) said R167 was admitted from the hospital after he had a stroke. V12 said the nurse reviews the medications and enters the orders into the EMR. V12 said she expects the medications to be administered as ordered. V12 said R167 was on Xarelto because he had a stroke caused by a blood clot. V12 said it was important R167 received the medication as it was ordered to prevent blood clot development and reduce the risk of stroke. V12 said missing 6 doses of the Xarelto could have contributed to R167 having an acute embolic stroke on [DATE]. V12 said she didn't order an alternative blood thinner because she was under the understanding that insurance issue was addressed promptly. V12 said she would expect the facility to obtain R167's medications in a timely manner. On [DATE] at 9:08 AM, V11 (Pharmacy Consultant) said Xarelto is an anticoagulant medication that is prescribed to prevent blood clots and strokes. V11 said R167 could be at an increased risk of stroke if multiple doses were missed. V11 said Xarelto was not a medication stocked in the automated medication dispensing system. V11 stated, Today [V2-DON] called and we will be adding Xarelto to the stock. At 10:34 AM, V11 said R167's Xarelto order was entered on [DATE] at 11:48 PM; the pharmacy sent a message to the facility that authorization was needed on [DATE] at 7:49 AM; the facility responded to the authorization message on [DATE] at 8:17 AM; and the medication was delivered to the facility on [DATE] (at 8:00 PM). 2. R116's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include chronic systolic congestive heart failure, atrial flutter, stage 3 chronic kidney disease, cardiomyopathy, anemia in chronic kidney disease, and cirrhosis of liver. R116's [DATE] Physician Order Sheet showed an order for an anticoagulant dated [DATE] for Rivaroxaban (Xarelto) 20 mg daily for atrial flutter. R116's [DATE] eMAR (electronic Medication Administration Record) showed an order for warfarin (anticoagulant) was discontinued [DATE] and a new order for Rivaroxaban (anticoagulant) was started [DATE]. R116's eMAR showed his warfarin was not administered [DATE] or [DATE] due to being on order with pharmacy. The same eMAR showed R116's Rivaroxaban was not administered [DATE], [DATE], and [DATE] due to not being delivered by pharmacy. R116 went without an anticoagulant for a 5 days. R116's Late Entry Nursing Note entered on [DATE] at 1:18 PM (after an Immediate Jeopardy was declared related to anticoagulant therapy not being administered) but dated for [DATE] at 5:15 PM showed, Received new order from [R116's Physician]. New order processed for Xarelto (Rivaroxaban) d/t abnormal EKG for Atrial flutter. Ok to start when arrives from pharmacy. The facility provided a list of medications available in the automated medication dispensing system on [DATE]. Xarelto was not a medication listed. There was a handwritten note attached to the list that stated, Have already requested that Xarelto be stocked in the cubex. The facility's Administering Medications Policy and Procedure dated [DATE] showed, To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Procedure: .3. Medications shall be administered in physician's written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity 6. Medications should be administered within one hour of the prescribed times . The facility's Physician's Order Policy dated ,d+[DATE] showed, All resident medications and treatments must be ordered by a licensed physician or nurse practitioner . The facility's undated Ordering Medications Policy showed, Policy: Medications and related products are ordered from [contracted pharmacy] on a timely basis. Procedure: New medication order requests can be faxed to the pharmacy's main fax number, sent via electronic health records, EHR system, electronically prescribed by the prescriber, and/or called in by the appropriate personnel according to State laws and regulations . The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. R167 no longer resides in the facility; expired in the hospital All licensed nursing staff have been re-educated to ensure residents admitted have medications available, are aware of the process in place to ensure commonly prescribed medications are readily available, are aware of the steps to take when medications are not available. Education includes an emphasis on the importance of securing medications, such as blood thinners/anticoagulants. Education conducted by Administrator/DON/MDS/or clinical management directors. The Administrator re-educated licensed clinical management nursing staff on the process to follow-up with pharmacy when authorization is required. This was completed on 10.23.2024 via in person education. - A system is in place to ensure commonly available medications are available through pharmacy, back up pharmacy and the backup medication dispensing system. - Education initiated 10.23.2024 and completed on 10.23.2024 - Re-education is completed by Administrator/DON/MDS/clinical management directors. All licensed nursing staff have been contacted via phone by the Administrator/DON/MDS/or clinical management directors and prior to the beginning of the next shift worked and will sign education sheets ensuring the licensed nursing staff was re-educated to ensure residents admitted have medications available, are aware of the process in place to ensure commonly prescribed medications are readily available, are aware of the steps to take when medications are not available. Education includes an emphasis on the importance of securing medications, such as blood thinners/anticoagulants. On 10.23.2024 a house audit was completed which consisted of the Director of Nursing ensuring that all residents prescribed blood thinners are receiving the prescribed medications, per physician orders. New licensed nursing staff hired on or after 10.23.2024 are educated to ensure residents admitted to the facility have medications available, are aware of the process in place to ensure commonly prescribed medications are readily available, are aware of the steps to take when medications are not available. Education includes an emphasis on the importance of securing medications, such as blood thinners/anticoagulants medication administration, medication availability and steps to take when medications are not available. The newly hired licensed nursing staff will sign that the education was completed. The Administrator/DON/MDS/or clinical management directors are conducting the education on hire, prior to the new licensed nursing staff member working the floor. On the spot education for licensed nursing staff is being conducted to ensure residents admitted have medications available, are aware of the process in place to ensure commonly prescribed medications are readily available, are aware of the steps to take when medications are not available. Education includes an emphasis on the importance of securing medications, such as blood thinners/anticoagulants. Education conducted by Administrator/DON/MDS/or clinical management directors. Education to be completed by the start of next scheduled shift. A weekly audit of 5 residents will continue for four months to ensure residents have all medications are available, including blood thinners and all medications are received in a timely manner, per physician orders. The DON or designee perform QAPI audits of 5 residents a week for 4 months to ensure medications are administered as prescribed. An analysis of the audits are presented through QAPI quarterly QAPI Audits are completed using direct observation, resident interview and medical record review . A root cause analysis was completed on [DATE] to determine process breakdown, barriers and process improvement. The root cause analysis was completed by the IDT which included the Administrator, clinical management licensed staff, pharmacy representation, corporate clinical staff and the medical director. All QAPI audits will be analyzed and reviewed in quarterly QAPI. This is overseen by the medical director and administrator. QAPI will determine if further audits will continue after the completion of 4 months. 38488

Based on observation, interview and record review the facility failed to follow up a report of a stage 1 pressure injury resulting in the progression of the injury,and not being identified and treated until it became a stage 3, and failed to implement interventions to prevent the development of a pressure injury for 2 of 3 residents (R90, R122) reviewed for pressure injuries in the sample of 33. The findings include: 1. R90's admission record shows he was admitted to the facility on [DATE]. The 9/30/24 resident assessment and care screening documents R90 to have severe cognitive impairment and is dependant on staff for his personal hygiene needs and mobility. The same assessment shows he is at risk of developing pressure ulcers/injuries and had one stage 4 pressure injury present. The bowel and bladder assessment shows he is always incontinent. The October 2024 bath and shower sheet shows on 10/10/24 a reddened area was noted by V31 (CNA/Certified Nursing Assistant) during his bed bath. The nursing progress notes were reviewed for skin check and assessment related to the reddened area and none were found. On 10/23/24 at 9:30 AM, R90 was observed in bed, he had a dressing to his right hip. The wound on his right hip was noted to be irregular in shape and just larger than a quarter. The surface of the wound was covered with white tissue and the edges were slightly reddened. R90 was not able to provide any information or voice concerns due to his cognitive status. On 10/23/24 at 10:00 AM, V25 (RN/Registered Nurse) said (R90) acquired the pressure wound to the right hip in the facility. He said the new wound was initially identified at a stage 3 after it was reported by a CNA about 2 weeks ago. V25 said it is ideal to find wounds prior to becoming stage 3. He said he completed an assessment after it was reported to him. The wound and skin alteration reviews for October 2024 show on 10/9/24, R90 had wounds to his sacrum and right buttocks. The 10/16/24 weekly skin assessment completed by V25, shows a stage 3 pressure injury measuring 3.0 x 2.0 x 0.2 cm (centimeters) on the right hip. The area was documented as a new wound. The actions taken were orders received and carried out. The family notification was not marked and not documented in the comments of the report or in the nursing progress notes. On 10/24/24 at 10:29 AM, V30 (CNA) said residents get showers twice a week and if they refuse it is reported to the nurse. When residents are incontinent they are changed and care is provided every 2 hours, and skin is checked at that time. V30 said (R90) does refuse his showers and gets bed baths. He is also incontinent of bowel and bladder so staff has to change him every 2 hours and do his skin checks. If there is any reddened areas or spots, they are reported to the nurse and V25. If found during a bath, it is marked on the shower sheet by circling the area. V30 said the shower sheets are then turned into the Director of Nursing. On 10/24/24 at 9:39 AM, V16 (LPN/Licensed Practical Nurse) and former wound nurse said skin checks done with showers twice weekly. If they refuse showers we will just ask to see their skin. It is important to make sure there is no skin breakdown if any skin breakdown is starting it is important to get interventions started to prevent any further breakdown. If a CNA finds reddened areas, it should be reported to the floor nurse and the wound nurse. Nurses should be documenting in the progress notes when any skin issue is identified or reported. The initial assessment should be completed by whoever finds it and include measurements and location of the skin issue. She said notifications are done to the wound physician, V2 (DON/Director of Nursing), V25, and the POA (Power of Attorney)/Guardian. and NP (Nurse Practitioner). V16 said skin breakdown/wounds should be identified prior to becoming a stage 3. She said there would be signs such as redness before it becomes a stage 3. The facility 7/2022 policy for wounds shows 3. Upon identification of the development of a wound, the wound assessment will be documented. 5. Residents should be examined thoroughly at least weekly by a licensed nurse to identify existing pressure ulcers. 6. Nurse Aides should complete a shower sheet on all residents when they are bathed or showered and given to the charge nurse. b. After review by the charge nurse, the shower sheet should be given to the wound nurse, or designee for appropriate follow up. The 2/1/22 policy for change in resident's condition documents it is the policy of the facility, except in a medical emergency, to alert the resident's physician/NP (Nurse Practitioner) and resident's responsible party of a change in condition. 20042 2. On 10/23/24 at 9:13 AM, V25 (RN/Registered Nurse/Wound Care Nurse) and V22 (LPN/Licensed Practical Nurse) went into R122's room to provide care and dressing change for her pressure injuries. R122 was laying on her back in bed. V25 removed the blanket from R122's legs and feet. R122's off loading boot was not in place to her right foot. V25 stated he did not remove R122's offloading boot before coming in to provide wound care. V25 stated R122 has a deep tissue injury to her right heel and came back from the hospital with the wounds. V25 had gloves on and applied skin prep to R122's right heel. The right heel had a large dark purple/black area present. The Wound Care Physician's Initial Wound Evaluation & Management Summary dated 10/15/24 for R122 showed, deep tissue injury of the right heel. Float heels in bed; off-load wound; reposition per facility protocol; turn side to side every 1-2 hours if able. The Care Plan dated 10/18/24 for R122 showed, documented pressure ulcer to right heel and left lateral foot, unstageable deep tissue injuries related to mechanical forces, pressure over bony prominence's, impaired circulation, and psychogenetic factors manifested by being dependent for activities of daily living/mobility, generalized weakness, diagnoses of dementia, epilepsy, and subdural hemorrhage. Right heel measures 3.5 x 5.7 cm. Maintain off-loading heel boots. The Face Sheet dated 10/23/24 for R122 showed diagnoses including transient cerebral ischemic attack, dementia, cardiac arrhythmia, hypertension, traumatic subdural hemorrhage, hyperlipidemia, and epilepsy. The Pressure Ulcer and Skin Condition Assessment policy (10/2011) showed, the resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches, and goals for care. The policy did not address pressure ulcer prevention.

Based on observation, interview, and record review, the facility failed to ensure a resident with their last known weight of 1/2024 showing a significant weight loss, failed to conduct, monitor weights and record, failed to ensure a resident with significant weight loss had a quarterly nutritional assessment by a dietician, and failed to ensure a resident with significant weight loss had interventions implemented to prevent further weight loss for 1 of 6 residents (R103) reviewed for nutrition in the sample of 33. These failures resulted in R103 not being weighed or seen by a dietician for 9 months after a significant weight loss occurred. The findings include: R103's face sheet showed a [AGE] year-old male with diagnosis of schizophrenia, major depressive disorder, and anxiety disorder. On 10/23/24 at 9:30 AM, R103 was in his bed supine. R103 was pale, cachectic and lying on an unmade bed (no linens or pillows). R103 had clear speech and said he eats his meals in his room. R103 was calm and not interviewable. At 12:23 PM, R103's lunch tray was untouched on a bedside table in his room. The table was not within reach of the resident. R103 was in bed covered with a coat. The room was dark. The lights were off, and the window coverings were closed. At 10:00 AM, V19 (Licensed Practical Nurse/LPN) said meal intakes for R103 are hit or miss. Sometimes he will throw his tray into hallway. It's just however he feels. V19 said restorative monitors resident weights. They do monthly weights. Maybe dietary does it too. At 10:50 AM, V16 (Assistant Director of Nursing/ADON) was asked what nutritional approach performed meant on R103's physician order sheet and medication administration record (MAR). V16 said she wasn't sure and would find out. At 11:08 AM, V16 said it meant it was verified that the resident was served the correct diet. At 12:25 PM, V19 (LPN) was asked what nutritional approach provided meant. V19 said she didn't know. V19 was asked if she monitored that the residents received the correct diet ordered and she said The kitchen should be serving the correct diet and if not the CNA (Certified Nursing Assistant) will let me know if the wrong diet is served. I do not go around checking each residents tray. At 12:31 PM, V38 (Restorative Nurse) said, We do monthly weights. Some refuse and if they refuse, I try to remember to document that. V38 said, We seldom catch (R103) 'in a good mood'.The other day he was receptive to me. (R103's) last recorded weight was in January and was 138.8 pounds. The dietitian looks at the weights after we record them. On 10/24/24 at 8:54 AM, V32 (Dietary Manager) said R103 is on Med Pass (nutritional shake). V32 confirmed after reviewing R103's record with this surveyor that no nutritional dietary assessment was done by a dietitian since January 2024. V32 said a nutritional assessment should be done quarterly. If weights and dietitian assessments are not done weight loss can continue. V32 said there was no documentation or care plan interventions to increase calorie intake, diet compliance or encourage PO (oral) intakes. V32 said, Any interventions would be implemented after a discussion between the Dietician and me and there is no documentation that occurred. Any new interventions should be care planned. Evidence of dietary interventions was requested, and none were received. At 9:39 AM, V21 (Dietitian) said she had been at the facility for 2 to 3 months and was not aware of any concerns regarding R103. V21 said it was concerning he hasn't had any weights done. V21 said she speaks to the facility weekly and looks at everyone with a significant weight loss. V21 said, If a resident refuses to be weighed they should be reapproached when they're having a good day and should be followed up. If there isn't a monthly weight documented, they should do a re-weigh. Residents are weighed monthly to make sure they're on track. A weight loss or gain would trigger us to see and assess them. Residents whose weights are not monitored could continue to lose weight. Interventions might include extra portions, supplements, add foods based on their preferences and snacks. I do think more could have been done. Due to behaviors, if a resident refused weights or interventions, I would request staff to reapproach on another day the resident was more receptive. R103's 8/15/24 showed severe cognitive impairment. R103's nutritional risk reviews (done by V32 Dietary Manager) dated 2/23/24, 5/20/24, and 8/15/24 showed current weights of 138.8 pounds. All three reviews showed meal intakes of 26-75% independently with in-direct supervision. R103's weight record showed his 12/6/23 weight was 151.2 pounds. R103's last recorded weight was on 1/18/24 at 138.8 pounds (an 8.20% weight loss in one month). R103's physician order sheet showed a general diet order with mechanical soft texture, regular thin liquid consistency, and a room tray. A 7/23/24 order showed nutritional approach performed every day and evening shift for monitoring. There were no current orders for nutritional supplements (Med Pass) or appetite stimulants. There were no orders for a snack, pudding, or double portions. R103's 10/22/2020 care plan interventions included to weigh the resident monthly and make a referral to the doctor/Registered Dietician if there is a 5% weight loss over 30 days. There have been no care plan interventions in 2024 to increase caloric intake, improve diet compliance, increase appetite, or encourage oral intake. R103's medication administration record (MAR) showed V19 (Licensed Practical Nurse/LPN) provided nutritional approach 18 times (as indicated by her initials). R103's restorative notes showed monthly weights were refused in May, June, August, and September 2024. There were no documented refusals for February, March, April, July, or October 2024. R103's 1/15/24 dietitian note showed to add resident to weekly weights and perform a medication review for appropriateness of an appetite stimulant. This note showed a 7.8-pound weight loss in one month and recent significant weight loss months prior. The facility's 1/2024 Weight Assessment and Interventions Policy showed the purpose was to ensure that residents are monitored for undesirable weight loss or gain so appropriate interventions can be put in place in a timely manner. Weigh the resident upon admission and weekly for a total of four weeks. Monthly weights will be done thereafter if no issues are identified. Weights will be entered in the resident's medical record. The dietician will review the weight record to identify and address weight issues. Significant weight changes are defined as 5% weight gain/loss in 30 days. The dietician will document desirable and undesirable weight changes and will discuss with the interdisciplinary team to identify possible approaches/interventions. If a resident refuses to participate in weight interventions, the dietician will document the resident's wishes.

Based on observation, interview and record review the facility failed to ensure residents were free from physical and sexual abuse from R1 who has a history of physical and sexual behaviors that escalated to staff then to residents. This failure resulted in R1 punching R2 in the face, pushing R3's chair over and causing him to fall to the floor and exposing himself to R4. The facility failed to ensure residents were free from physical abuse. This applies to 6 of 10 residents (R2, R3,R4, R6, R8, R10) reviewed for abuse in the sample of 10. The findings include: The Immediate Jeopardy began on 4/13/24 when R1's behaviors escalated. R1 punched R2 in the face. On 4/16/24, R1 flipped R3 out of the chair causing him to fall to the floor. On 4/18/24 R1 exposed himself to R4. V1 Administrator was notified of the Immediate Jeopardy on 5/1/ 24 at 8:48 AM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 4/18/24, when R1 was placed on 1:1 supervision until he was discharged with the local police department on 4/20/24. 1. R1's face sheet shows he is a [AGE] year-old male admitted to the facility on [DATE] from a long-term care facility. His diagnoses include hemiplegia and hemiparesis following cerebral infarct affecting left non-dominant side, unspecified dementia with other behavioral disturbance, cognitive communication deficit and metabolic encephalopathy. R1's Minimum Data Set assessment dated [DATE] shows his cognition is moderately impaired has poor decision-making skills and requires cues/supervision. R1 has physical, verbal behaviors directed towards other including (hitting, kicking, pushing, grabbing, abusing others sexually) and puts others at significant risk for physical injury. R1 has wandering behaviors and there was no assessment of daily and activity preferences completed. R1's Criminal History Background Check dated 3/29/24 shows result: HIT with Felony convictions including armed robbery/discharge of firearm in 1980, 1984, attempted murder in 1987. R1 was sentenced to [AGE] years of imprisonment at the Department of Corrections. R1 was released for parole in November 1996. R1 was charged with resisting a peace officer in 2002, attempt to resist peace officer 2011, resisting a peace officer 2013, and driving reckless, suspected DUI in 2019 sentenced to 24 months probation and 30 days periodic imprisonment. R1's Social Service note dated 3/20/24 documents, R1 arrived at the facility, he is alert/disoriented with diagnoses including but not limited to Dementia, Type 2 diabetes and hypertension. R1 has never been married, he completed the 5th grade and worked .for over [AGE] years retiring 5 years ago. R1 states he has three children and in his free time likes to watch sports. R1 admits he has a history of abusing alcohol and has never been arrested. R1's community access was determined to be supervised. R1's nurse's note dated 3/21/24 documents R1 became agitated during casual conversation. R1 lunged towards staff yelling F*** You. R1 is unable to be redirected. R1's nurse's note dated 3/23/24 documents social services was notified R1 was following a CNA (Certified Nursing Assistant) and trapped her in his room masturbating in front of her. R1 was displaying physically aggressive behaviors following her around the nurse's station. R1 began pushing on the front door trying to leave. R1's nurse's note dated 4/1/24, R1 got upset and displayed aggressive behaviors towards staff. R1 was not able to receive redirection. V3's (Psychiatrist) Progress note dated 4/3/24 documents staff report physical aggression and (R1) placed a choke hold on staff. Staff report abrupt and random behaviors are often unpredictable without notable triggers .social history POA reports substance abuse history and inappropriate sexual behaviors and advance towards others .mental status examination: speech: aphasic and rarely speaks per staff report, insight: lack of insight concerning matters of self; judgement lacks judgement regarding everyday activities. R1's nurse's note dated 4/9/24, R1 was displaying aggressive behaviors after family visit. Staff report this is a recurrent behavior and he is unable to receive redirection. R1's nurse's note dated 4/13/24, R1 hit a male peer (R2) while passing each other on the 400 halls. R1's social service note dated 4/14/24, R1 displaying aggressive behaviors. R1's social service note dated 4/15/24, due to R1's physically aggressive behaviors, attempting to send him out for psychiatric hospitalization . R1's social service note dated 4/15/24, Investigator visited today regarding background check. R1 given reminders from the Investigator about appropriate conduct with staff and peers. R1's social service note dated 4/16/24, R1 educated about respecting all the residents and their privacy. R1's nurse's note dated 4/16/24 documents, R1 flipped peer (R3) out of his chair in the dining room. This appeared unprovoked. R1's nurse's note dated 4/16/24 documents, R1 was observed walking down the wrong hall heading toward another resident's room. When CNA attempted to redirect R1, he ran toward CNA with fists raised and CNA went into nurses' station and R1 threw a full can of pop at the CNA. R1's nurse's note dated 4/18/24, R1 attempted to kick a peer, he missed the chair. The facility's Initial Report dated 4/15/24 documents on 4/13/24 staff reported R1 and R2 were passing each other in the 400-wing hall, when R1 hit R2 on the left cheek. On 4/29/24 at 9:23 AM, R2 was observed on the 2nd floor sitting in his wheelchair. He was alert to person and confused to time and date. On 4/29/24 at 9:59 AM, V13 (Certified Nursing Assistant-CNA) said on 4/13/24 she was passing meal trays on the 400-wing. R2 was in the hallway self-propelling in his wheelchair. R1 stopped R2 and was punching him on his left cheek really fast three to five times. I told R1 to stop. R1 gets paranoid and thinks people are going to come in his room. R2 had a bruise to his left cheek. R1 had a history of being aggressive with staff, but this was the first time he was going after another resident. R2's Incident Report dated 4/13/24 documents staff reported witnessing being struck in the left facial cheek; injury type: bruise on the face. 2. On 4/29/24 at 10:38 AM, R3 said R1 got mad at me and pushed me over in my chair and I fell on my side. It hurt. On 4/29/24 at 2:21 PM, V10 (Licensed Practical Nurse-LPN) said she was R1's nurse on 4/16/24 when she had the incident with R3. R1 has dementia and a stroke and could not communicate well. Around dinner time she was at the nurse's cart, and she heard the staff yell out for help, she went to the dining room and R3 was on the floor. R1 flipped R3 out of his chair. V10 said she had an incident with R1 one day. R1 got his coat and was trying to leave the facility. She called out his name to come back and he turned around and came at me with his fists in the air. There was another incident when he threw a can of pop at another staff member. He had unprovoked behaviors. On 4/29/24 at 2:33 PM, V14 (CNA) said she was in the dining room on 4/16/24 the day of the incident with R1 and R3. My back was turned and she heard R3 yell and saw him on the floor. R1 came up to R3 and kicked his chair over to the floor. R3's Incident Report dated 4/16/24 documents (R1) pushed the chair onto the floor in the dining room. R3 was very scared afterwards. Resident description: (R1) threw me over in my chair. The facility's Final Abuse Report dated 4/21/24 documents on 4/16/24 at 5:00 PM, staff reported R3 was sitting in a chair that R1 was sitting in. R1 tipped the chair over and R3 fell to the floor. 3. On 4/29/24 at 9:08 AM, R4 said I got molested. A man (R1) came to my doorway he was playing with himself, and he grabbed my breast. I told him to stop. R4 was visibly upset and said, I can't do this right now. On 4/29/24 at 1:12 PM, V28 (R4's POA) said he went to visit R4 on 4/19/24 and she told me a guy was masturbating in front of her and touched her. When she told me that I looked at the camera that is in her room. When I reviewed the camera, I saw him (R1) walking into her room and kept trying to touch her, he was reaching out for (R4), and she was backing away in the wheelchair. She told him to put it away, put it away and eventually he left the room. The facility called me about the room change, but did not tell me why, then we found out what happened. I was not expecting something like this to happen. After talking to my siblings, we decided to call the police and press charges. We sent the police the video of the incident. On 4/30/24 at 8:54 AM, V15 (CNA) said on 4/18/24 she heard a female resident yelling out for help she saw R1 outside of R4's room and pulling up his pants. R4 said he's touched me and exposed himself to her. R4 was crying and distressed. She was so scared she urinated through her pants. V15 said she reported the incident to V1. V15 had heard of previous incidents of R1 being physical and sexually inappropriate with staff. On 4/30/24 at 8:01 AM, V11 (LPN) said he was R1's nurse on 4/18/24 when the incident happened with R4. He came in at 3:00 PM and started passing medications and saw management run down the 400 hall. R1 had sexually assaulted R4. R1 had behaviors of physical and sexual aggressions towards others, he could not express himself verbally. On 4/29/24 at 2:05 PM, V2 (DON) said she interviewed R4 after the incident. R4 said that crazy guy (R1) showed me his privates and tried to touch my right breast. R1 was a transfer from another facility, he had erratic behaviors. We were concerned about the safety of our residents. We did not want R1 to be aggressive towards a resident who could retaliate back. I'm not sure why he was transferred from another local long term care facility, but there is a reason they did not want him back. On 4/29/24 at 12:42 PM, V4 (Social Service Director) said she was R1's primary case manager. R1 had a history of aggression and an identified offender. He had a history of physical aggression towards staff and physically attacked a staff member. He then became physical towards residents and was sexually inappropriate with a resident, R4. R1 was at risk for abusing others, and it was hard to know what triggered him. R4 reported the incident to her family, and they decided to press charges. R4 has a camera in her room and the police had enough evidence to arrest R1 and R1 went to jail. On 4/29/24 at 12:19 PM, V8 (Social Services) said she is in charge of the background checks and fingerprints. R1 had a HIT on his criminal background check and the officer came to do R1's fingerprints. I was in the room with the officer and R1 reached his hand down his pants rubbing his privates and starring at me. R1 had a history of being sexually inappropriate with staff. On 4/30/24 at 9:46 AM, V19 (LPN) said when R1 was first admitted to the facility he would roam around the facility. R1 had exposed himself prior to staff, he choked up another staff and she witnessed R1 follow another female staff around the nurses station. On 4/30/24 at 12:35 PM, V1 (Administrator) said R1 had poor impulse control, we did have some knowledge of some behaviors. We sent a representative out to evaluate him and we decided we would admit him. This facility tries to take care of the more difficult patients. We knew he would be in a private room and I'm sure he had some behaviors but there was nothing major at first. The first red flag was when he exposed himself to a staff member. The first resident incident was with R2. R1 was in the hallway, and he stopped R2 and made direct contact with him. R1 then flipped R3 out of his chair and he landed on the floor. R1 approached R4's doorway he grabbed her the wheelchair arms and pushed her back he reached out his arm and touched her right chest and turned around and walked away and exposed himself to her. R4's family decided to press charged and the police came and arrested R1 on 4/20/24. The facility's Final Report dated 4/23/24 documents on 4/18/24 at 3:30 PM, R4 stated R1 came to her room and exposed himself. R1 does not recall and denies doing this R1 was placed on 1:1 supervision until his discharge on 4/21/24. The final report does not include R1 was arrested and taken into custody with police. R1's Police Incident Information dated 4/20/24 shows incident/reason for stop aggravated criminal sexual abuse. R1's nurse's note dated 4/20/24 documents R1 exited the building with Police escort. R1's current care plan initiated on 4/1/24 shows R1 is at risk for abuse for and/or neglect due to history of dementia and history of aggressive behaviors with interventions include to follow facility policy for all suspected instance of abuse. Remind R1 that the staff at the facility has an open-door policy and patient is safe to report any concerns to staff anytime. R1 exhibits behaviors that include targeting staff following staff being sexually inappropriate with interventions include to keep distance between residents and others if resident becomes physically aggressive, make sure resident is safe and allow time to calm self, intervene if inappropriate behavior is observed. Communicate to the resident must exercise self-control. R1 is alert but with short term memory deficits due to dementia. R1 needs cues and reminders for safety awareness and judgement. R1 has exhibited movement behavior that may be interpreted as wandering or roaming as evidenced by attempting to bang his walker against the door. Interventions include to intervene and re-direct, limit number of staff that re-direct, use distraction to try to distract resident away from current situation. R1 has a history of aggressive, inappropriate, attention-seeking, and/or maladaptive behaviors .the history includes threatening behavior, verbal or physical aggression, acting impulsively, erratically, disrespectful, insulting, demeaning behavior. Interventions include conduct a review of past behaviors and evaluate the likelihood for aggressive/inappropriate behaviors during initial assessment, intervene, communicate R1 must have self control over impulse behaviors, refer to mental health professional, give psycho-active medications and record behavioral symptoms. R1 has a history of criminal behavior. R1 has demonstrated stability during the admission process, does not appear to present an unusual risk and is there for considered appropriate for admission. According to the available history he has been arrested and convicted of a crime(s) and has served jail time or correctional facility. Risk assessment is still waiting to be received. (The care plan does not list the crimes R1 committed). Interventions include conduct a review of past behavior & evaluate potential for aggressive/high risk behavior. Screen the state police and DOC data base .evaluate ability to control impulses. Document the information learned about the criminal behavior, provide supportive group, 1:1 or as needed intervention, teach impulse control strategies, follow appropriate standards when considering room assignments. R1's Screening Assessment for indicators of aggression and/or harmful behaviors dated 3/27/24 shows he scored a 0 for history of recent episode of aggressive/agitated behaviors, 0 for history of substance abuse, 0 for history of criminal behavior. Total score of 2. The assessment documents R1 has no history of abuse prior to admission, no history of presence of dysfunctional behavior (including provoking, aggressive, disrespectful, inappropriate behaviors), no history of mistreating others. Total Abuse Score of 2.0. Indicating potentially to integrate into the peer community and minimal risk for aggression. R1's assessment does not show an accurate risk or abuse assessment was performed. The facility's Abuse Prevention Program Facility Policy and Procedure states, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting in physical harm, pain or mental anguish .It includes verbal abuse, sexual abuse, physical abuse and mental abuse .This facility desires to prevent abuse .this will be accomplished by a comprehensive quality management approach involving the following .resident assessment, pattern assessment and staff supervision. Immediate Jeopardy and deficient practice corrected by exit. The Immediate Jeopardy that began on 4/13/24 was removed and the deficient practice corrected on 4/18/24 when the facility took the following actions to remove the Immediacy and correct the noncompliance. Abatement plan provided on 5/1/24. R1 no longer resides in the facility. R2 is at baseline and continues to reside safely in the facility. R3 is at baseline and continues to reside safely in the facility. R4 is at baseline and continues to reside safely in the facility. All staff are in the process of being re-educated on the abuse policy to ensure residents are free from physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place. Education initiated 4.18.2024; education completed 5.1.2024. The Administrator/DON/MDS/management directors will complete the education. All staff will be educated via phone prior to the beginning of the next shift worked and will sign education sheets on keeping from physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place. A list of identified offenders was reviewed by Social Service staff to ensure a safety plan is in place, per the plan of care. New hires will be educated on ensuring residents are kept free from physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place during orientation. On the spot education on abuse training knowledge is completed to ensure compliance System: Education to be completed by the start of next scheduled shift. A weekly audit of 10 residents will continue for four months to ensure residents free of physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place. Audits will be completed by Social Services Director or designee and an analysis presented through QAPI quarterly. Audits are completed using direct observation, resident interview and medical record review. A root cause analysis was conducted to identify barriers and further education needed. Completed 4.19.2024 All audits will be analyzed and reviewed in quarterly QAPI. This is overseen by the medical director and administrator. QAPI will determine if the audits will continue at that time. 35178 4. The facility Abuse/Incident investigation dated 11/05/23 at 8:30AM, shows, R5 hit R6 in the chest. R5 did not like R6 being a friend and visiting with another residents. R5 has a diagnosis of anxiety disorder. R6 has a diagnosis of schizoaffective with major depressive disorder. 5 .The facility Abuse/Incident investigation dated 3/27/24 at 10:15AM, shows, R7 hit R8 in the arm. R7 was standing in the hallway, R8 passed by and was hit in the shoulder by R7. 6. The facility Abuse/Incident investigation dated 3/06/24 at 12:05PM, shows, R9 hit R10 on the left leg as R9 passed R10 at the nurse's station.

Based on interview and record review the facility failed to supervise a resident with escalating behaviors of physical and sexual aggressions with known behaviors. This failure resulted in R1 not being supervised after exhibiting physical behaviors towards residents (R2, R3) and sexually assaulting R4. This applies to 1of 10 residents (R1) reviewed for safety in the sample of 10. The findings include: The Immediate Jeopardy began on 4/13/24 when R1's behaviors escalated, R1 punched R2 in the face. On 4/16/24, R1 flipped R3 out of the chair causing him to fall to the floor, he was sent out to the local hospital for his behaviors and returned to the facility on [DATE]. On 4/18/24, R1 was found unsupervised in the hallway and exposed himself to R4. V1 Administrator was notified of the Immediate Jeopardy on 5/1/2024 at 8:55 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed when R1 was placed on 1:1 supervision on 4/18/24, until he was discharged with the local police department on 4/20/24. 1. R1's face sheet shows he is a [AGE] year-old male admitted to the facility on [DATE] from a long-term care facility. His diagnoses include hemiplegia and hemiparesis following cerebral infarct affecting left non-dominant side, unspecified dementia with other behavioral disturbance, cognitive communication deficit and metabolic encephalopathy. R1's Minimum Data Set assessment dated [DATE] shows his cognition is moderately impaired has poor decision-making skills and requires cues/supervision. R1 has physical, verbal behaviors directed towards other including (hitting, kicking, pushing, grabbing, abusing others sexually) and puts others at significant risk for physical injury. R1 has wandering behaviors and there was no assessment of daily and activity preferences completed. R1's Criminal History Background Check dated 3/29/24 shows result: HIT with Felony convictions including armed robbery/discharge of firearm in 1980, 1984, attempted murder in 1987. R1 was sentenced to [AGE] years of imprisonment at the Department of Corrections. R1 was released for parole in November 1996. R1 was charged with resisting a peace officer in 2002, attempt to resist peace officer 2011, resisting a peace officer 2013, and driving reckless, suspected DUI in 2019 sentenced to 24 months probation and 30 days periodic imprisonment. R1's Social Service note dated 3/20/24 documents, R1 arrived at the facility, he is alert/disoriented with diagnoses including but not limited to Dementia, Type 2 diabetes and hypertension. R1 has never been married he completed the 5th grade and worked .for over [AGE] years retiring 5 years ago. R1 states he has three children and in his free time likes to watch sports. R1 admits he has a history of abusing alcohol and has never been arrested. R1's community access was determined to be supervised. R1's nurse's note dated 3/21/24 documents R1 became agitated during casual conversation. R1 lunged towards staff yelling F*** You. R1 is unable to be redirected. R1's nurse's note dated 3/23/24 documents social services was notified R1 was following a CNA (Certified Nursing Assistant) and trapped her in his room masturbating in front of her. R1 was displaying physically aggressive behaviors following her around the nurse's station. R1 began pushing on the front door trying to leave. R1's nurse's note dated 4/1/24, R1 got upset and displayed aggressive behaviors towards staff. R1 was not able to receive redirection. V3's (Psychiatrist) Progress note dated 4/3/24 documents staff report physical aggression and (R1) placed a choke hold on staff. Staff report abrupt and random behaviors are often unpredictable without notable triggers .social history POA reports substance abuse history and inappropriate sexual behaviors and advance towards others .mental status examination: speech: aphasic and rarely speaks per staff report, insight: lack of insight concerning matters of self; judgement lacks judgement regarding everyday activities. R1's nurse's note dated 4/9/24, R1 was displaying aggressive behaviors after family visit. Staff report this is a recurrent behavior and he is unable to receive redirection. R1's nurse's note dated 4/13/24, R1 hit a male peer (R2) while passing each other on the 400 halls .R1 is on 15 minutes checks for safety precautions. R1's nurse's note dated 4/14/24, R1 remains on observation monitoring post physical aggression initiated towards male peer. R1's social service note dated 4/14/24, R1 displaying aggressive behaviors and the police called. R1's social service note dated 4/15/24, due to R1's physically aggressive behaviors, attempting to send him out for psychiatric hospitalization . R1's social service note dated 4/15/24, Investigator visited today regarding background check. R1 given reminders from the Investigator about appropriate conduct with staff and peers. R1's social service note dated 4/16/24, R1 educated about respecting all the residents and their privacy .will continue to monitor. R1's social service note dated 4/16/24, R1's neurologist suggested a new medication. After discussion with the IDT team, the referral process has been put on hold .social service will continue to monitor R1 for behaviors. R1's nurse's note dated 4/16/24 documents, R1 flipped peer (R3) out of his chair in the dining room. This appeared unprovoked. R1's nurse's note dated 4/16/24 documents, at 9:02 PM, R1 was observed walking down the wrong hall heading toward another resident's room. When CNA attempted to redirect R1, he ran toward CNA with fists raised and CNA went into nurses' station and R1 threw a full can of pop at the CNA. R1 continued to pace and agitated. R1 sent out to the local hospital. R1's nurse's note dated 4/17/24, received call from local hospital does not meet criteria in patient admission. R1's nurse's note dated 4/17/24 at 4:03 AM, R1 returned to the facility. ER Dx: Aggressive behavior due to dementia .nursing will continue to monitor for behaviors .15-minute observation monitoring in place. R1's nurse's note dated 4/18/24 at 7:38 AM, R1 remains on observation monitoring 15-minute checks post physical aggression. R1's nurse's note dated 4/18/24 at 11:48 AM, R1 attempted to kick a peer, he missed the chair. R1's nurse's note dated 4/18/24 at 4:18 PM, R1 will be a 1:1 until further notice. The facility's Final Report dated 4/23/24 documents on 4/18/24 at 3:30 PM, R4 stated R1 came to her room and exposed himself. R1 does not recall and denies doing this R1 was placed on 1:1 supervision until his discharge on 4/21/24. The final report does not include R1 was arrested and taken into custody with police. R1's Police Incident Information dated 4/20/24 shows incident/reason for stop: aggravated criminal sexual abuse. R1's nurse's note dated 4/20/24 documents R1 exited the building with Police escort. On 4/30/24 at 12:35 PM, V1 (Administrator) said R1 was admitted from another local long term care facility. We did have some knowledge of some behaviors. We sent a representative to evaluate him, and we decided to admit him. This facility tries to take the more difficult patients. The first red flag was the incident of him exposing himself to a female staff, R1 also became physically aggressive with the housekeeper. On 4/13/24, R1 made contact with R2 in the hallway, he was placed on supervised checks. On 4/16/24, R1 flipped R3 out his chair and R3 landed on the floor. On 4/18/24, R1 was in the hallway outside of R4's room. R1 exposed himself to R4 and tried to touch her. We've had residents like this before. R1 was being supervised, supervised checks anybody and everybody can have eyes on him there is no assigned person to monitor him. After the incident R1 was placed on a 1:1 on 4/18/24. On 4/20/24 he received a call from his staff, the police were in the building for R1. R1 was arrested and escorted with the police. On 5/1/24 at 9:55 AM, V3 (R1's Psychiatrist) said he heard of R1 causing lots of behaviors. We would recommend supervision checks every 15 minutes and if behaviors continues, he should have been placed on a 1:1 supervision. I would have recommended not to admit this resident. On 4/29/24 at 10:28 AM, V5 (Psych Rehab Social Services) said she was not aware of R1's history of behaviors. We were trying to send R1 due to physical aggression and attempted to find placement. Residents with behaviors should be placed on 15-minute checks or 1:1 supervision. Someone should be assigned to the checks, it's typically the CNAs or the nurse doing the checks. On 4/29/24 at 12:42 PM, V4 (Social Service Director) said once we receive a referred from another nursing home, management decided if they are appropriate to be admitted . She is not part of the admission process and was not aware of his behaviors. R1 had physical behaviors shortly after being admitted to the facility towards staff then became physical aggressive towards residents and sexually inappropriate to R4. R1 was supposed to be on 15-minute checks before the incident with R4 due to his behaviors. We communicate to the nurses and CNAs when a resident is on supervised checks. Nursing does the documentation of the checks. R1 was an identified offender, we usually place them in groups to manage behaviors/coping skills but due to his diagnosis of dementia he could not retain the information. Behavior monitoring should be done as well. We were aware of the potential situation, that's why he was supposed to be supervised. I don't know what else we could have done, we tried to send him out. R1 went to jail from here, after the incident with R4. On 4/29/24 at 2:21 PM, V10 (RN) said R1 had dementia and could not communicate well. On 4/16/24, she was R1's nurse. R1 flipped R3 out of his chair and threw a can of pop at one of the CNA's. He was sent out to the local hospital and returned. After that incident he was supposed to be on 15-minute checks. There is paper sheet to sign. Usually, the CNAs sign off the sheets because they are the ones on the floor. The nurses are too busy to sign off the sheets. On 4/29/24 at 2:33 PM, V14 (CNA) said R1 was very combative, usually towards the staff. On 4/16/24, she was R1's CNA when he flipped R3 out of his chair. I don't know if was on 15-minute checks. The CNAs are responsible for signing off the checks, there's a sheet of paper we have to initial the time and location of the resident. On 4/30/24 at 8:20 AM, V12 (LPN) said R1 was confused and aggressive at times. R1 was supposed to be on supervised checks, the form is at the nurse's station, and we all sign it off. We all participate on signing of the checks. R1 was then placed on 1:1 supervision after several incident towards residents. On 4/30/24 at 9:46 AM, V19 (LPN) said she had been R1's nurse on several occasions. There was an incident when R1 was being sexually inappropriate to a CNA, there was an incident when a staff member got choked up, and another time when R1 was following a CNA around the nurse's station. On 4/18/24 she was R1's day nurse. We were short CNAs; we were supposed to keep an eye out for him. R1 was supposed to be supervised after he attacked other residents, but we were short staffed. Not sure who was signing off the sheets, the 15-minute check sheet is at the nurse's station, anybody can sign it. On 4/30/24 at 8:01 AM, V11 (LPN) said on 4/18/24, he was R1's nurse during PM shift. Sometime after 3:00 PM, I was starting to pass resident medications. I noticed management running down the 400 hall. It was reported to me R1 had sexually assaulted another resident (R4). Prior to the incident R1 was allowed to walk around freely. He was not on supervision prior to the incident only 1:1 after the incident. On 4/30/24 at 8:54 AM, V15 (CNA) said on 4/18/24 she heard a female resident yelling out for help she saw R1 in the hallway outside of R4's room pulling up his pants. R4 said R1 touched me and exposed himself to her. R4 was crying and distressed. She was so scared she urinated through her pants. V15 said she was not R1's CNA, that day she just happened to respond to R4 yelling for help. V15 said she had heard of some of the incidents he had with other staff and residents. R1's behaviors were unpredictable. On 4/30/24 at 9:19 AM, V16 (CNA) said R1 was very combative and irate he was not really redirectable. On 4/18/24 she worked the PM shift; he was supposed to be on 15-minute checks prior to the incident with R4. She was not his assigned CNA and was not doing the supervision checks. On 4/30/24 at 9:25 AM, V17 (CNA) said R1 would walk around the facility, he used to fight with other residents then walk off and start another fight. I saw him start fights unprovoked. On 4/18/24, she worked the PM shift on the 300 hall. The 400 hall where R1's room was, split between staff. If a resident is on 15 checks it depends on who is available to monitor the resident. She was not assigned to R1 that day and was not supervising him. On 4/30/24 at 9:33 AM, V18 (CNA) said on 4/18/24 she worked the PM shift, we split the rooms on the 400 hall, I do not recall having him that day. If a resident is on 15-minute checks the nurse will notify you and the CNA is responsible for doing the checks. On 4/30/24 at 11:15 AM, V20 (CNA) said R1 wound wander a lot, he was on 15-minute checks on 4/18/24 from the start of my shift at 12:00 PM. I did not have him that day and was not doing his checks. V21 (Activity Aide) was supposed to be assigned to him. On 4/30/24 at 11:41 AM, V21 (Activity Aide) said she worked on 4/18/24 from 11:00 AM to 8:43 PM. She did activities from 1:00 PM to 4:15 PM including happy hour and bingo. She started one to one monitoring with R1 about 4:45 PM until she left that night. R1 was being monitored due to his behaviors. She was not monitoring R1 prior to 4:45 PM, she was doing resident activities. On 4/29/24 at 2:05 PM, V2 (DON) said R1 started having behaviors, erratic behaviors, all of sudden he was fine then not fine. R1 was on 15-minute checks prior to the incident when went off of the checks. R1 was doing great and walks down the hallway and does that. R1 exposed himself to R4 and tried to touch her right breast. I want to say he was off the checks prior to the incident. If a resident is on supervised checks who every is assigned to him should be documenting the location of the resident. R1's 72 hour 15-minute check form dated 4/13/24 to 4/15/24 shows there were no checks signed off on 4/15/24. R1's 72-hour 15-minute check form dated 4/16/24 to 4/18/24 shows on 4/16/24 at 9:15 PM to 4:45 AM, R1 was in the facility. (R1's nurse note dated 4/16/24 showed R1 was not in the facility at 9:15 PM, R1 left the facility at 9:02 PM and returned on 4/17/24 at 4:03 AM.) The same form shows on 4/17/24 at 5:00 AM to 11:45 AM, R1's location is listed as hospital/ER. (R1's nurses note dated 4/17/24 showed R1 was in the facility at 5:00 AM to 11:45 AM, not in the ER). R1's care plan initiated on 4/1/24 shows he has a history of aggressive, inappropriate, attention-seeking, and/or maladaptive behaviors .the history includes threatening behavior, verbal or physical aggression, acting impulsively, erratically, disrespectful, insulting, demeaning behavior. Interventions include conduct a review of past behaviors and evaluate the likelihood for aggressive/inappropriate behaviors during initial assessment, intervene, communicate R1 must have self-control over impulse behaviors, refer to mental health professional, give psycho-active medications and record behavioral symptoms, refer to mental health professional including consulting psychiatrist for evaluation of the resident's symptoms warrant further assessment or on-going management. R1 exhibits behaviors that include targeting staff following staff being sexually inappropriate with interventions include to keep distance between residents and others if resident becomes physically aggressive, make sure resident is safe and allow time to calm self, intervene if inappropriate behavior is observed. Communicate to the resident must exercise self-control. R1 has a history of criminal behavior. R1 has demonstrated stability during the admission process, does not appear to present an unusual risk and is there for considered appropriate for admission. According to the available history he has been arrested and convicted of a crime(s) and has served jail time or correctional facility. Risk assessment is still waiting to be received. (The care plan does not list the crimes R1 committed). Interventions include conduct a review of past behavior & evaluate potential for aggressive/high risk behavior. Screen the state police and DOC data base .evaluate ability to control impulses. Document the information learned about the criminal behavior, provide supportive group, 1:1 or as needed intervention, teach impulse control strategies, follow appropriate standards when considering room assignments. R1's Screening Assessment for indicators of aggression and/or harmful behaviors dated 3/27/24 shows he scored a 0 for history of recent episode of aggressive/agitated behaviors, 0 for history of substance abuse, 0 for history of criminal behavior. Total score of 2. The assessment documents R1 has no history of abuse prior to admission, no history of presence of dysfunctional behavior (including provoking, aggressive, disrespectful, inappropriate behaviors), no history of mistreating others. Total Abuse Score of 2.0. Indicating potentially to integrate into the peer community and minimal risk for aggression. R1's assessment does not show an accurate risk or abuse assessment was performed. R1's Behavior Monitoring and Interventions Report dated 3/20/24 to 4/17/24 shows no results found. The facility's Safety and Supervision of Residents Policy & Procedure dated 9/22, states, Resident safety and supervision and assistance to prevent accidents are facility wide priorities .resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs .the type and frequency of resident supervision may vary among residents . Immediate Jeopardy and deficient practice corrected by exit. The Immediate Jeopardy that began on 4/13/24 was removed and the deficient practice corrected on 4/18/24 when the facility took the following actions to remove the Immediacy and correct the noncompliance. Abatement plan provided on 5/1/24. R1 no longer resides in the facility. R2 is at baseline and continues to reside safely in the facility. R3 is at baseline and continues to reside safely in the facility. R4 is at baseline and continues to reside safely in the facility. All staff are in the process of being re-educated on the abuse policy to ensure residents are free from physical and sexual abuse and behavior management for residents with a safety plan in place. Education includes supervising residents with escalating behaviors, monitoring and placing interventions in place. A system is in place to ensure supervision checks are completed as identified by the facility. The form is reviewed daily by clinical management to ensure it is completed and accurate. Education initiated 4.18.2024; education completed 5.1.2024. The Administrator/DON/MDS/management directors will complete the education. All staff will be educated via phone prior to the beginning of the next shift worked and will sign education sheets on ensuring residents are free from physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place. Education includes supervising residents with escalating behaviors, monitoring and placing intervention in place. A system is in place to ensure supervision checks are completed as identified by the facility. The form is reviewed daily by clinical management to ensure it is completed and accurate. A list of identified offenders was reviewed by Social Service staff to ensure a safety plan is in place, per the plan of care. New hires will be educated on ensuring residents are kept free from physical and sexual abuse, identifying abusive behaviors and behavior management for residents with a safety plan in place during orientation residents are free from physical and sexual abuse and behavior management for residents with a safety plan in place. Education includes supervising residents with escalating behaviors, monitoring and placing interventions in place. A system is in place to ensure supervision checks are completed as identified by the facility. The form is reviewed daily by clinical management to ensure it is completed and accurate. On the spot education on abuse training, identifying escalating behaviors, monitoring and placing interventions in place. A knowledge check is completed to ensure compliance. A system is in place to ensure supervision checks are completed. System: Education to be completed by the start of next scheduled shift. A weekly audit of 10 residents will continue for four months to ensure residents free of physical and sexual abuse, staff identifying escalating behaviors, monitoring and placing interventions in place and a system is in place to ensure supervision checks are completed. Audits will be completed by Social Services Director or designee and an analysis presented through QAPI quarterly. Audits are completed using direct observation, resident interview and medical record review. A root cause analysis was conducted to identify barriers and further education needed. Completed 4.19.2024 All audits will be analyzed and reviewed in quarterly QAPI. This is overseen by the medical director and administrator. QAPI will determine if the audits will continue at that time.

Based on interview and record review, the facility failed to identify, assess, and implement pressure wound treatment and prevention interventions for 1 of 3 residents (R1) reviewed for pressure wounds in the sample of 3. These failures contributed to R1 developing an additional Stage 2 pressure wound and worsening of his other wounds. The findings include: R1's hospital Nursing Discharge/Transfer Communication dated 12/5/23 shows R1 has wounds on his coccyx and heels. R1's Census List dated 4/9/24 shows R1 was admitted to the facility on [DATE]. R1's current Care Plan (Review last completed on 12/18/23) provided by the facility shows R1 is at increased risk for alteration in skin integrity and was admitted on [DATE] with a stage 3 pressure wound to the left heel and a wound to the sacrum. The same care plan shows no treatment or prevention interventions for R1's increased risk for alteration in skin integrity and only shows nursing staff are to check R1's skin during routine care and during his weekly bath/shower. No new interventions were ever added to R1's care plan. R1's Order Summary Report dated 4/9/24 shows R1 never had any wound treatment orders until 12/13/23. R1's Wounds Treatment Administration Record for 12/1/23-12/31/23 show R1 did not receive any wound care treatments to his sacrum and left heel from his admitted [DATE] until 12/27/23. R1's Census List dated 4/9/24 shows R1 left the faciity on [DATE] and returned on 1/16/24. R1's Order Summary Report dated 4/9/24 shows R1 did not have treatment orders for his left heel and sacral wounds until 1/24/24. R1's Wounds Treatment Administration Record for 1/1/24 to 1/31/24 show R1 did not receive any wound care from his return to the facility, on 1/16/24, and 1/24/24. The facility was unable to provide any documentation which shows a complete wound assessment was completed by the facility for R1's wounds, between 12/5/23 and 12/26/23, including the type of wound, site, size, stage, odor, drainage, description, and date and the name/credentials of the person performing the assessment. V6's, Wound Care Physician, Wound Evaluation & Management Summary for R1 dated 12/19/23 shows R1 has a Stage 3 pressure wound of the left heel, a Stage 4 pressure wound of the sacrum, and a Stage 2 pressure wound of the left, medial buttock. R1's left heel and sacral wound were both exacerbated or worse and the buttock wound was new as indicated by a duration of greater than three days with no documentation under Wound Progress as is included with the two other wounds referenced above. The facility was unable to provide a Wound Care Physician, Wound Evaluation & Management Summary for R1 for the prior week (12/12/23). V6's Wound Evaluation & Management Summary for R1 dated 12/26/23 shows R1's sacral pressure wound was worse compared to the prior evaluation. V6's Wound Evaluation & Management Summary for R1 dated 1/2/24 shows R1's left heel and sacral pressure wounds were worse compared to the prior evaluation. V6's Wound Evaluation & Management Summary for R1 dated 1/23/24 shows R1's sacral wound was worse compared to the prior assessment. On 4/9/24 at 10:30 AM, V4, Wound Care Nurse, said the admitting nurse does an initial skin assessment when a resident is admitted to the facility. If there are any skin issues, she does her own assessment, and consults the wound doctor to see the resident. V4 said she will contact the wound doctor and get wound treatment orders which begin right away. V4 said she charts when she completes the wound treatment on the Wound Administration tab. V4 said she does all the wound care treatments Monday through Friday, unless she is not at work, and on the weekends. V4 said the floor nurses do the wound treatments when she is gone, on the weekends, and if the dressing comes off or becomes soiled. V4 said if a resident refuses treatments or treatment interventions, such as wound care or repositioning, the nurses should chart the refusals. On 4/11/24 at 11:09 AM, V4 said she was not doing the wound assessments on the resident's EMR (electronic medical record). V4 said her weekly wound assessment is V6's wound assessment. On 4/9/24 at 1:41 PM, V2, Director of Nursing (DON), said when a resident is admitted , the wound nurse does the initial skin assessment if she is in the facility, otherwise, the admitting nurse does it. If skin issues are found, then they have standing orders for the resident to see the wound care physician. V2 said some residents come with wound treatment orders which they follow until the wound care physician sees them. If there are no wound care orders, they will call the physician to get them. The nurse will put the orders in and act on them right away. The nurses chart on the Nurse's Notes or the Admission/Readmission screening. V2 said every time they do a treatment, they chart it on the Wound TAR (treatment administration record). V2 said if residents refuse care, it should be documented. V2 said if a resident refused a wound treatment, a box opens up where narrative can be typed to explain what happened. On 4/9/24 at 4:08 PM, V2 said she cannot account for the lack of wound care on R1's Wound TAR. V2 said she would have to assume if it's not documented, it's not done. V2 said she cannot explain why R1 does not have wound treatment orders upon admission and readmission. On 4/11/24 at 9:30 AM, V2, Director of Nursing (DON), said the resident's wound assessment notes are supposed to be a part of their record, it should not be done on shower sheets. On 4/9/24 at 2:58 PM, V5, Licensed Practical Nurse, said R1 never refused wound care. V5 said R1 could be a bit resistive at first, but once you eased into his care and explained what you were going to do, he was cooperative. V5 said R1 did not have behaviors (of refusing care). On 4/9/24 at 5:40 PM, V6, Wound Care Physician, said R1 did not refuse wound care when he saw R1 in the facility. V6 said it is important to do the wound care treatments, especially for R1's sacral wound. V6 said a lack of wound care treatments and non-compliance with the wound treatment plan is the perfect recipe for wounds to deteriorate. On 4/11/24 at 12:12 PM, V7, Care Plan Coordinator, said the purpose of the care plan is so everyone knows the care the resident requires. V7 for a resident with pressure wounds, there should be more interventions to treat and prevent new and/or worsening wounds. V7 said the care plan should include seeing the wound care physician, wound care treatment, a turning/repositioning schedule, if appropriate, and probably a special mattress. V7 said only checking the resident's skin weekly and with daily care is not adequate for someone with pressure wounds. The facility's Pressure Ulcer and Skin Condition Assessment Policy (revised 10/17/2020) shows pressure ulcers will be assessed and measured at least every seven days by a licensed nurse and recorded on the facility approved Wound Assessment Form. The purpose of the policy is to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure and other ulcers and assuring interventions are implemented. An individual Wound Assessment Form will be initiated when pressure and/or other ulcers are identified by the wound nurse or licensed nurse. This form is a permanent clinical record. The Wound Care Nurse will measure and stage pressure ulcers. Wound assessments will be documented in the medical record for each identified ulcer area and will include: site, size (length by width by depth), stage of pressure ulcer, odor, drainage, description, date and initials of the individual performing the assessment per electronic record. A notation will be made in the nurse notes, TAR, or on weekly bath sheet when NO skin problems are observed. The resident's care plan will be revised to reflect alteration of skin integrity, approaches and goals for care. Physician ordered treatments shall be initialed by the staff on the TAR AFTER each administration. Other nursing measures not involving medications shall be documented in the progress notes. The treatment nurse is responsible for completing the Director of Nursing's Weekly Pressure Ulcer Report on the day assigned by facility.

Based on observation, interview and record review the facility failed to ensure fall prevention interventions were implemented for 1 of 2 residents (R5) reviewed for safety in the sample of 32. This failure resulted in R5 falling out of bed while being provided personal care and recieving a laceration requiring stitches to his head. The findings include: R5's Face Sheet shows diagnoses of: hemiplegia affecting the left side, schizoaffective disorder, dementia, epilepsy, osteoporosis and traumatic brain injury. R5's Minimum Data Set assessment dated [DATE] shows that he is dependent on staff to roll from left to right. On 12/5/23 at 9:43 AM, R5 was sitting in his room in a high back wheelchair. R5 had a laceration above his right eyebrow. On 12/6/23 at 10:39 AM, R5 was provided incontinence care. R5's body was contracted and rigid with spastic movements at times. No fall mats were observed in R5's area of the room. R5's Final Fall Incident Report dated 11/28/23 shows R5 fell out of bed on 11/24/23 at 8:30 PM. The report shows, Resident rolled out of bed during hygiene care. Blood noted to right eyebrow area. An order was obtained from [Nurse Practitioner] to send resident to [local emergency room ] for evaluation and treatment Resident returned with 8 sutures CNA (Certified Nursing Assistant) were educated to always perform care with [R5] with 2 staff members to ensure safety. R5's Nursing Notes dated 11/24/23 at 8:30 PM shows, Resident rolled out of bed while CNA were cleaning him up during bed check rolled off bed has a gash above his right eye .called 911 D/T (due to) resident getting head injury . resident transported 8:45 PM to [local hospital]. On 12/6/23 at 3:05 PM, V24 (Certified Nursing Assistant/CNA) said that she provided care to R5 on 11/24/23. V24 said that she provided care to R5 by herself. V24 said that she was located on R5's left side of the bed during the care. V24 said that she turned R5 to his right side and all of a sudden, he just fell on to the floor. V24 said that he fell directly onto the floor and there was no floor mats on the floor. V24 said that he was bleeding from his head. On 12/6/23 at 11:06 AM, V23 (CNA) said that she had asked V24 (CNA) to help her provide care to R5 since she was not familiar with him and staff had told her that he needed two people for cares. V23 said that when she entered R5's room, V24 was already providing care to R5 so she started providing care to his room mate. V23 said that R5 was turned to his right side and V24 was putting his brief on when he fell . V23 said that R5 was fidgeting and all of a sudden she saw him fall to the floor and hit his head on the floor. V23 said that she was standing on the roommate's right side of the bed so she was not close to R5 when he fell . On 12/7/23 at 11:59 AM, V2 (Director of Nursing) said that R5 needs two persons for cares and should have had two people providing care on the day that he fell out of bed. V2 said that R5 requires the use of fall mats as well. V2 verified that R5's area of the room did not have fall mats in it. V2 said that pair care means that the staff should always do care with 2 staff member for resident and/or staff safety. On 12/6/23 at 2:52 PM, V25 (Nurse Practitioner) said that she received a call that R5 had fallen out of bed and sustained an injury and was being sent to the emergency room . V25 said that the injury was directly related to his fall. R5's emergency room After Visit Summary dated 11/24/23 shows diagnoses of: closed head injury and forehead laceration. R5's emergency room notes dated 11/24/23 shows, Patient reportedly rolled out of bed. He did strike his head .laceration length: 4 cm (centimeters) Number of sutures: 8 R5's CT of the Head dated 11/24/23 shows, Right frontal scalp hematoma. R5's Fall Care Plan shows, Always provide pair care with resident with an initiation date of 10/2/23. The Fall Care Plan also shows, Floor mats on both side of the bed with an initiation date of 3/30/16.

Based on interview and record review, the facility failed to ensure a resident was free from abuse for one of six residents (R1) reviewed for abuse in the sample of six. This failure resulted in R1 experiencing a fractured nose. The findings include: R1's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including heart failure, generalized anxiety disorder, major depressive disorder, emotional lability, and history of falling. R2's Admission Record shows he was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, generalized anxiety disorder, and morbid obesity. The facility's Initial Incident Report dated August 13, 2023 shows, Staff reported that they heard resident [R1] yelling at resident [R2] in the back of the dining room. Staff reports that's resident [R2] then stood up and hit resident [R1] in the face. Residents separated immediately. [R1] was assessed for injuries. A small amount of bleeding from bridge of nose and bleeding from nose noted. [R1] did not want the police notified and initially refused to go to the hospital. After education and encouragement, [R1] did agree to be seen at the hospital for evaluation. [R2] placed on 15 minute checks. Both residents were educated to seek out staff assistance when needed. R1's After Visit Summary dated August 13, 2023 shows R1 had a diagnoses of nasal fracture. On August 22, 2023 at 9:54 AM, V1 Administrator said the incident between R1 and R2 occurred at dinner time. V1 said that R1 was calling R2 an ogre. V1 said that R1 pushes other residents' buttons at times. V1 said according to the video, R1 began to wheel away from R2, but then turned around and pointed at R2's face. That is when R2 hit R1 in R1's face. V1 said that R2 has never had any altercations with other residents in the past. V1 said that R2 has never been angry towards another resident before. V1 said that R2 went to the hospital and had a fractured nose. At 10:13 AM, V11 CNA (Certified Nursing Assistant) said he was fixing supper trays when he heard R1 yelling and screaming at R2. When V11 turned around to look, he saw R2 hit R1. V11 said R1 and R2 always sit with each other at the same table. V11 said that R1 has behaviors of bullying people at times. V11 said R2 never has any behaviors and that R2 is quiet. V11 said he has never seen R2 get aggressive. At 10:34 AM V9 CNA said she had stayed over her scheduled shift to help with dinner. V9 said she was getting dinner trays ready when another resident yelled V9's name. V9 said she turned around and saw R2 hit R1 in his face. V9 said nothing was happening prior to the incident. V9 said she was shocked when she saw R2 hit R1. V9 said R2 has never had behaviors before and that R1 and R2 have sat at the same table for a long time. V9 said that R2 was crying and R2 said he felt bad for hitting R1. At 10:57 AM, V10 CNA said she was setting up hallway trays for dinner when she heard another resident telling R1 to stop and leave R2 alone. V10 said when she came around the corner to see what was going on, R1's nose was bleeding. V10 said she pulled R2 out and sat him by the nurses station. V10 said that R2 was crying because he didn't want to hit R1 but R2 told V10 that R1 kept calling R2 a big fat ogre. V10 said this was the first time that she saw R1 be aggressive. V10 said that R2 is very sweet. At 12:43 PM, R2 said that he feels safe in the facility. R2 said that R1 was calling R2 an ogre. R2 said he asked R1 to stop and R1 did not stop so R2 hit R1 in the face. R2 was calm during this interview. At 2:00 PM, R1 said that he feels safe in the facility and has no pain. R1 said that R2 hit him in the nose, but R2 apologized and they are friends. At 2:21 PM, V8 CNA said she heard a scream and turned to see what was going on. V8 said R2 had hit R1 in the face. V8 said that V7 CNA directed R2 out of the dining room. V8 said she does not remember seeing or hearing any arguing prior to R2 hitting R1. V8 said that R2 has never had behaviors before and R2 hitting R1 is out of R2's norm. At 2:46 PM, V7 CNA said she did not see the incident between R2 and R1 occur. V7 said after the incident, she took R2 and walked with him. R2 told her that R1 kept calling R2 an ogre. V7 said R2 felt bad and asked R1 if he was ok. V7 said that R2 was calm and that she felt safe with R2. V7 said that R2 has no behaviors and is a really sweet resident. V7 said she was surprised that R2 hit R1. The facility's Abuse Prevention Program policy January 4, 2019 shows, This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment.

Based on interview and record review, the facility failed to ensure a resident with [CONDITION(S)] (R3) received [CONDITION(S)] treatments, failed to document the missed [CONDITION(S)] treatments, failed to get orders for [CONDITION(S)], and failed to develop a [CONDITION(S)] care plan. The facility also failed to notify the resident's physician and family of missed [CONDITION(S)] appointments and failed to monitor 2 of 2 residents (R3 and R6) reviewed for [CONDITION(S)] in the sample of 8. This failure resulted in R3 being sent to a local hospital on 6/8/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: 1. R3's Admission Record showed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/18/22 at 3:26 PM, V18 (R3's Power of Attorney-POA) said R3 missed [CONDITION(S)] appointments on 6/3/22, 6/6/22 and 6/8/22. V18 said he did not find out about the missed [CONDITION(S)] appointments until 6/8/22 when R3 was sent out to the hospital. On 7/19/22 at 2:21 PM, V6 (Scheduler) said she has been scheduling transportation for about four and a half to five months for the facility. V6 said R3 was scheduled to go to [CONDITION(S)] every Monday, Wednesday and Friday. V6 said R3's appointments and transportation was already set up. V6 said she set these back up when R3 returned from the hospital on 6/2/22. V6 said she believed R3 declined the [CONDITION(S)] on 6/3/22 and the transport company did not show up for some of the appointments. On 7/20/22 at 9:31 AM, V8 ((Licensed Practical Nurse-LPN) said she had not taken care of R3 prior to 6/3/22. V8 said she was was not sure which days R3 was scheduled for [CONDITION(S)] because R3's paperwork and orders did not show anything about her [CONDITION(S)]. V8 said she got her information from other nurses and V2 (Director of Nursing-DON). V8 said she was the nurse for R3 on 6/3/22, 6/6/22 and 6/8/22. V8 said R3 did not refuse to go to [CONDITION(S)] on any of these three dates. V8 said R3 was dressed and ready to go. V8 said she believes all three missed appointments were due to transportation issues. V8 said on 6/8/22, she noticed R3 getting puffier and she was not as alert as she usually was. V8 said she called V19 ( Nurse Practitioner). V8 said V19 informed her that they cannot wait for transportation and gave orders to send R3 to the hospital for [CONDITION(S)]. V8 said she did not document the missed [CONDITION(S)] appointments for R3. V8 said she thinks she spoke with V12 (R3's Mother) about transportation. V8 said she did not document in R3's chart about speaking with V12. V8 said she knows she spoke with V12 on 6/8/22, when the facility sent R3 to the hospital for [CONDITION(S)]. There was no evidence in R3's medical record showing V8 notified V2 (DON) or V19 (Nurse Practitioner) until 6/8/22, when R3 was sent to a local hospital. On 7/20/22 at 11:51 AM, V12 (R3's Mother) said she did not receive any calls from the facility informing her about any missed [CONDITION(S)] appointments on 6/3/22, 6/6/22 or 6/8/22. V12 said she received a call saying they were sending R3 to the hospital. On 7/20/22 at 10:08 AM, V2 said she believes one of R3's missed [CONDITION(S)] appointments was due to R3 refusing and the other two were due to transportation issues. V2 said the residents on [CONDITION(S)], should have orders showing when and where the resident receives [CONDITION(S)], as well as where the [CONDITION(S)] access site is on the resident, and what staff need to monitor the resident for. On 7/20/22 at 11:04 AM, V11 (Manager for local [CONDITION(S)] center) said R3 was scheduled for 6 treatments in June of 2022. V11 said the [CONDITION(S)] center did not treat R3 at all for the month of June 2022. V11 said the only time we receive a call from the facility is if there are concerns. V11 said there was nothing documented in R3's [CONDITION(S)] charting showing the facility calling to cancel missed appointments. V11 said [CONDITION(S)] is very important for someone with kidney disease. One missed treatment increases their chance of death. V11 said most patients receive [CONDITION(S)] for 12 hours a week whereas normal kidneys function 24 hours, 7 days a week. V11 said without the needed [CONDITION(S)] it will increase the patient's potassium levels and increase their risk of death. On 7/20/22 at 4:28 PM, V2 (Director of Nursing) said when a resident misses a [CONDITION(S)] treatment, the doctor and the residents family should be notified and it should be documented in the resident's progress notes that the doctor and the resident's family was notified about the missed [CONDITION(S)] treatment. When asked if the facility had a communicaton binder for [CONDITION(S)] communications, V2 said the facility does not have a [CONDITION(S)] communication binder. V2 said the [CONDITION(S)] communication information could be found in the miscellaneous tab of the resident's electronic charting. R3's miscellaneous tab did not contain any communication documentation between the facility and the [CONDITION(S)] center. V2 said she does not recall seeing any [CONDITION(S)] communication forms for R3. R3's Order Summary Report, printed by the facility on 7/19/22 showed orders on 5/5/22 of [CONDITION(S)] access site care done at [CONDITION(S)] center. [CONDITION(S)] access site: Shunt right arm. [CONDITION(S)] days and times M/W/F 11:15 to 3:15. [CONDITION(S)] location: no location listed. [CONDITION(S)]: Check access site for bruit and thrill daily on return shift. The Order Summary Report showed these orders were discontinued. R3's Physician Order Sheet from her readmission on 6/2/22 showed no orders for [CONDITION(S)], no shunt access site location, no location of [CONDITION(S)] center, the orders did not show the type of [CONDITION(S)] R3 received, or what staff should monitor for. R3's progress note dated 6/8/22 at 10:53 AM, showed Resident to be sent to (local hospital) for possible [CONDITION(S)] per (V19). vitals within normal limit although resident is not as alert as previous day .ambulance to transport. Emergency contact notified (Mother). R3's Progress note of 6/8/22 at 2:00 PM showed Writer called (local hospital) to follow up status of resident's [CONDITION(S)]. (Local hospital) nurse informed writer that resident was just moved to critical care to initiate [CONDITION(S)] . Critical care nurse informed this writer that the resident's potassium level is high, but will still initiate [CONDITION(S)]. R3's Progress note dated 6/9/22 at 12:12 AM showed the Critical Care Nurse at the local hospital was called and informed the facility nurse that they had to stop the [CONDITION(S)] early. The same note showed they were only able to do 233 milliliters of fluid due to R3's high potassium level. The Critical Care Nurse also informed the facility nurse that they will perform another [CONDITION(S)] in the hospital later that morning. R3's progress notes showed no documentation of the missed [CONDITION(S)] treatments on 6/3/22 or 6/6/22. R3's progress notes did not show V19 (Nurse Practitioner) or R3's physician being notified of the missed [CONDITION(S)] treatments until 6/8/22 when V8 (Licensed Practical Nurse-LPN) received orders to send R3 out to the hospital. On 7/20/22 at 9:07 AM, a message was left on V19's voice mail to please call this surveyor. Another call was placed to V19 at 2:57 PM. At 3:00 PM the facility was asked to assist with obtaining an interview with V19. No return call was received prior to exiting the facility on 7/21/22. R3's lab results dated 6/8/22 showed a critical high potassium level of 6.8 mg/dl (milligrams per deciliter), the normal range is between 3.6-5.0 mg/dl. The lab results showed R3 had a critical low sodium level of 104 mg/dl (normal range 138-147 mg/dl), and a critical creatinine level of 7.25 mg/dl (normal range 0.44-1.32 mg/dl). R3's care plans reviewed showing no [CONDITION(S)] care plan in place during her stay at the facility. The facility's Nursing Home [CONDITION(S)] Transfer Agreement, provided by the facility on 7?20/22, showed 4. Transportation of Designated Resident. Facility shall have the responsibility for arranging suitable transportation of the designated resident to and from center, including the selection of the mode of transportation, qualified personnel to accompany the designated resident and transportation equipment usually associated with this type of transfer including the use of appropriate life support measures in accordance with the applicable federal and state laws and regulations. The agreement showed the facility shall be responsible for all costs of transportation associated with the transfer of the designated resident to and from the center and the facility. R3's June 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's acute care hospital paperwork dated 6/8/22 showed, history of present illness: . Presenting from (the facility) due to missed HD (hemodialysis) .I spoke with her nurse and as per her, patient has missed a total of three HD sessions .At baseline she is alert, oriented x 1-2, screams with all care, but this morning, patient was obtunded and was difficult to arouse with sternal rub .I saw her in the emergency department and she is still currently obtunded but wakes up to sternal rub and starts moaning . 1. Principle problem: [CONDITION(S)]-due to missed hemodialysis. Plan: 1. Admit to medical ICU (intensive care unit). 2/ Patient already received [CONDITION(S)] cocktail in the ED (emergency department) .3. Nephrology on board from ED. 4. Plan for stat (immediate) HD (hemodialysis). The hospital paperwork showed R3 was admitted on [DATE] and discharged on [DATE]. The facility's policy and procedure titles [CONDITION(S)] Care, with a revision date of 12/2021 showed, 5. An individual care plan should be developed and followed in coordination with the comprehensive assessment. 2. R6's face sheet showed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's July 2022 physician order sheet showed, [CONDITION(S)] M/W/F. R6's physician orders did not include the type of [CONDITION(S)] access, the location of the [CONDITION(S)] access, monitoring of the [CONDITION(S)] site, or where she would go to receive [CONDITION(S)] treatment. R6's July 2022 eMAR (electronic Medication Administration Record) and eTAR (electronic Treatment Administration Record) showed no documentation regarding [CONDITION(S)]. R6's Care Plan initiated on 3/5/2020 showed, [R6] has renal insufficiency related to stage 5 kidney disease. [R6] has [CONDITION(S)] on Monday, Wednesday, Friday. She goes to [[CONDITION(S)] facility]. R6's care plan did not include what type of [CONDITION(S)] access she has, the location of the access site, monitoring of the access site, or communication with the [CONDITION(S)] facility. R6's medical record did not show any communication with the [CONDITION(S)] facility since February 2022. On 7/20/22 at 1:07 PM, V10 ADON (Assistant Director of Nursing) said she was currently working on R6's hall. V10 said she does not know where R6 goes for [CONDITION(S)] treatment. V10 said she is not aware of any communication forms or paperwork that would go with R6 to [CONDITION(S)] and R6 does not bring anything back from [CONDITION(S)]. V10 said after [CONDITION(S)] it would be important to monitor the [CONDITION(S)] site for bleeding, leave the bandage in place for 24 hours, monitor the thrill and bruit at the [CONDITION(S)] access, and monitor for other signs and symptoms such as swelling and puffiness.

Based on observation, interview, and record review, the facility failed to ensure a resident wasn't too close to the side of the bed when providing incontinence care. This failure resulted in R1 being turned onto her side in bed next to a side rail that fell off the bed. R1 fell out of bed and sustained an orbital fracture. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 6. The findings include: The Nursing Progress notes for R1 showed, On 5/31/22 at 4:30 PM, Writer was informed by the CNA (Certified Nursing Assistant) cleaning the resident that she fell out of the bed when she rolled over and the bed rail broke. Resident landed in a prone position. Writer assessed the resident and she was alert and oriented. Writer also noticed that there is a mild bleeding on the resident's right side of the face near her eye and her right nostril too. With the approval of the NP (Nurse Practitioner), resident was sent to the ER (emergency room ) for further evaluation. At 10:38 PM, Writer called the ER and the ER nurse said R1 had an orbital floor fracture. [MEDICATION(S)]-Clavulanate 875-125 mg tab, twice a day for 5 days was prescribed. Resident is to be discharged (back to facility) awaiting transportation. The hospital Emergency Department Physician's Note dated 5/31/22 for R1 showed, Patient with a mechanical fall. Patient is on [MEDICATION(S)] and reports that her pain is not managed with that alone as she has been on [MEDICATION(S)] for a long time. She was subsequently given [MEDICATION(S)] and odanestron and removed reports of significant improvement. Patient is found to have a fracture of the inferior orbital floor, without any signs of entrapment both on physical exam or on CT (computerized tomography). Treatment plan is discussed with the patient and she is discharged back home to the nursing facility. On 6/21/22 at 10:13 AM, V3 ADON (Assistant Director of Nursing) stated, I was gone when that (R1 falling out of bed) happened. I heard about it. The CNA (Certified Nursing Assistant) was doing a bed change and the side rail on R1's bed broke. R1 fell out of bed. I am going to assume she fell because the side rail broke. I think we were going to see about a bigger bed. I don't believe they know why it broke. On 6/21/22 at 10:55 AM, V4 LPN (Licensed Practical Nurse) stated, When I came in they said the CNA was rolling R1 and the side rail on R1's bed that was closest to the door came off. R1 fell out of bed onto the floor. R1 had a black eye and she fractured the orbital floor. R1 is alert and oriented. R1 is paranoid now about it. On 6/21/22 at 12:25 PM, V5 CNA stated, I was changing R1 and she had two side rails on her bed that were already loose. I rolled R1 towards the wall. I rolled R1 so she could put her arm over the rail. R1 was near the side of the bed. I was changing her cloth pad and the side rail just fell off. R1 went face first onto the floor. R1 was really scared and is still scared when you turn her. R1 can tell you what happened. I talked to some other CNA's and they told me the railing had been broken and no one ever fixed it. On 6/21/22 at 12:59 PM, R1 was laying in bed and had a purple mark under her right eye. R1 had bilateral upper side rails on her bed. R1 stated, V5 CNA was changing me and turned me towards the door. V5 had me close to the side of the bed and bam there I went. I fell on my face and front. I hit my face on the floor first. Since the fall, I am scared to death, I am afraid of falling again. It hurt like hell. The side rail came off, just like that. This side rail on the right side fell before too and they fixed it. I went to the hospital and they said I broke my cheek bone. They fixed the railing while I was at the hospital. On 6/21/22 at 2:21 PM, V8 LPN stated, I was starting my shift and was at the nurse's station. The CNA called me and I went to R1's room. R1 was laying on the floor. The CNA was in the room, said she was changing R1 and R1's whole body went into the bed rail. R1 cannot move her hands because of all of her neurological changes. R1 put her weight on the bed rail and it fell off. R1 was in a prone position on the floor. I told R1 not to move and I called 911. R1 was getting progressively worse before the fall and couldn't do anything herself anymore. R1 used to use the side rails for repositioning but couldn't anymore. On 6/21/22 at 2:30 PM, V9 CNA stated, One time before R1's bed rail was loose on one side. I know they fixed a side rail before because it was loose and came off. R1 can't grab onto the side rails anymore or reposition herself. It takes two people to reposition R1 in bed and that was before this fall. On 6/22/22 at 9:56 AM, V16 CNA and V17 CNA were in R1's room to transfer her from her wheelchair to her bed and provide incontinence care. V3 ADON (Assistant Director of Nursing) was in the room to observe the transfer and care. R1 was transferred to her bed that had bilateral upper side rails. V17 turned R1 onto her left side near the side rail and side of her bed. R1 was not able to grab onto the side rail. V16 provided incontinence care and then turned R1 onto her right side. R1's body was pressed against the side rail and near the side of the bed. V3 stated, We talked about getting R1 a bigger bed. R1 shouldn't be leaning into the side rails. They are not meant to prevent falls. V16 and V17 stated R1 needed a bigger bed because there was no room in her current bed to turn her without going near the side of the bed and into the railing. R1 stated she felt her body going into the railing and didn't like it. The facility's Repositioning & Turning policy (6/21) showed, A turning/repositioning program is used by the nursing staff. The MDS (Minimum Data Set) nurse or Wound Care Nurse is responsible for incorporating the plan, approaches and goal into the care plan. Positioning plans will be revised and approaches altered, on a timely basis, to address changes in the resident's condition. Prior to repositioning the resident the assignment for specific directions will be checked. The MDS dated [DATE] for R1 showed for bed mobility, transfers, dressing, toilet use and personal hygiene the resident was totally dependent and required the assistance of two plus persons. The Care Plan dated 5/25/22 for R1 showed, R1 requires extensive assistance of 2 (people) with bed mobility, toileting, and transfer. The Fall Risk Review dated 5/31/22 for R1 showed, high fall risk. On 6/22/22 at 10:19 AM, V17 CNA stated, I know before R1 fell out of bed I had talked to V3 ADON about getting R1 a new bed. The one she has is too small. R1 was a 1 person assist at first and then she started gaining weight and declined. R1 is not able to grab the side rails anymore. R1 needs two people to do her care. R1's side rails should have been taken off. I noticed the side rails were bending out and were not straight up. It looked like they had weight against them. I wasn't in the room when it (R1's fall out of bed). V5 CNA was by herself when it happened. V5 came out to the nurse's station. I was at the nurse's station and we all went down there (R1's room). R1 was laying on her face. I asked the nurse if we could get R1 off her face and roll R1 onto her back. We stayed until the ambulance came. The facility's Supervision and Safety policy (8/20) showed, Safety risks and environmental hazards are identified on an ongoing basis through employee training conducted upon hire, annually and as needed. Resident supervision is the core component of resident safety. Staff to decrease safety risk factors as much as possible. The facility's Fall Prevention Program policy (12/20) showed, It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Care plan incorporates: identification of all risk/issue; preventative measures. All staff will be oriented and trained on fall prevention. Malfunctioning equipment will be immediately reported to maintenance for repair or removed from service, i.e. bed locks, side rails, and grab bars. The Diagnosis Information dated 6/21/22 for R1 showed she has diagnoses including [CONDITION(S)], abnormalities of gait and mobility, diabetes mellitus, depression, [CONDITION(S)], [CONDITION(S)] disorder, persistent mood disorder, anxiety disorder, hypertension and [CONDITION(S)].

Based on observation, interview and record review the facility failed to provide adequate supervision for a resident with a history of falls and failed to implement fall prevention measures for a resident for one of three residents (R82) reviewed for falls in the sample of 34. This failure resulted in R82 sustaining a right humerus fracture from a fall. The findings include: On 5/25/21 at 10:46 AM, R82 was in bed, sleeping soundly. There was no scoop mattress, nor were any fall mats noted. At 10:59 AM, this surveyor was standing outside R82's room and observed him attempting to pull the blankets off himself. R82 sat up on the side of his bed, with his blanket still stuck on his right foot. R82 stood up, his right foot slipping on the blanket, walked out of the blanket and proceeded to pace around his room. R82 was not wearing shoes and had a shuffling gait. R82's Facesheet printed 5/27/21, showed he had diagnoses to include, but not limited to: nondisplaced fracture of the right humerus; abnormalities of gait and mobility; lack of coordination; unsteadiness on feet; chronic obstructive pulmonary disease; diabetes, obesity; and dementia. R82's facility assessment dated [DATE], showed R82 had short and long term memory problems; required extensive assistance of two or more staff members for bed mobility, transfers, toilet use, and personal hygiene; not steady and only able to stabilize with staff assist for moving from seated to standing position, walking, and turning around; had an impairment on one side of his upper extremity; was frequently incontinent of urine and bowel; and had fallen since admission. R82's Fall Care Plan (initiated 5/19/16) was reviewed on 5/26/21. This care plan showed, [R82] is at risk for falls r/t (related to) use of [CONDITION(S)] medications, use of antihypertensives, use of hypoglycemics, history of falls, he has not been wearing shoes and/or socks . This care plan included interventions of fall mats (initiated 4/24/21) and scoop mattress (initiated 4/24/21). The copy of the care plan provided by the facility was edited and these interventions were not printed. R82's fall list dated 11/26/20 to 5/26/21 showed 15 falls incidents. Handwritten on this note was, March 13th Moved Downstairs. This list showed R82 fell on [DATE], 1/4/21, twice on 3/11/21 (once at 2:05 PM and a second time at 5:45 PM), and 11 more times. (The second fall on 3/11/21 resulted in R82 fracturing his right arm.) R82's Progress Note dated 3/11/21 at 2:05 PM showed, This writer was called to resident room [by staff]. Resident observed lying on the floor on left side with head near back of toilet, back to the wall, legs in the front of the toilet. The call light was not in use, light was on, resident had urinated on the floor. Resident had shoes on. Resident stated, I fell . Resident inspected for injuries, red area noted to back of head. No other injuries notes . Resident ambulated to bed with weakness and unsteady gait noted . R82's Progress Note dated 3/11/21 at 5:45 PM showed, This writer observed staff attempting to redirect resident due to resident attempting to walk to room with tray. Staff told resident they would bring his tray to his room due to res weakness and unsteady gait while ambulating. Resident started cussing at staff and attempting to take tray. Resident spilled his juice on his tray, resident then gave his tray to staff. Resident did not have shoes on and staff was attempting to warn res that there was juice on the floor when resident slipped in juice, resulting in fall. Resident did not hit his head but attempted to catch him self with his right arm. Resident fall was witnessed by this writer and CNA. This writer inspected resident for injuries, abrasion noted to right knee, right shin. This writer assessed ROM when resident c/o (complained of) pain to right arm near shoulder. Resident was guarded and would not move shoulder, right elbow ROM WNL and all other ROM WNL . Notified [R82's physician], order for multiple x-rays to right arm . R82's Progress Note dated 3/11/21 at 11:00 PM showed R82 was transferred to the emergency room . R82's Progress Note dated 3/12/21 at 8:20 AM, showed R82 returned from the local emergency room with a prescription for pain medication related to a right humerus fracture from a recent fall. R82's Physician Progress Note dated 3/26/21 at 1:57 PM showed, .Rehabilitation follow-up for impaired ADLs and mobility related to right upper extremity [CONDITION(S)] and physical deconditioning related to right humeral neck fracture and recent hospitalization . On 5/27/21 at 11:05 PM, V11 (Restorative Nurse) said she is responsible for reviewing all the falls at the facility. V11 said the falls are discussed at the daily interdisciplinary meetings, the team brainstorms appropriate interventions, and those interventions are entered into the record. V11 reviewed R82's record during this interview and verified that R82 had interventions entered for a scoop mattress and fall mats. V11 said any interventions on R82's care plan should be in place. V11 stated, The team decided not to go with scoop mattress, but I forgot to take it out of the care plan. Thanks for catching that; I just deleted it. V11 said that V1 (Administrator) said he was going to order R82 fall mats at the IDT meeting on 4/24/21. V11 said she wasn't sure why R82 did not have the fall mats yet. V11 said fall interventions are put in place to prevent further falls and possible injuries to residents. V11 said preventative measures would include fall mats and a scoop mattress. V11 said R82 is not supposed to ambulate by himself, but she saw him doing so yesterday. On 05/27/21 at 12:05 PM, V4 (Certified Nursing Assistant - CNA) said we encourage R82 to stay in his wheelchair because he's unsteady on his feet. V4 said R82 is not supposed to be up walking alone. V4 said she wasn't sure what R82's fall interventions are because she has been too busy to look. V4 said she would refer to R82's care plan or ask the nurse if she wasn't sure. V4 said R82 is hard-headed and won't always ask for help. V4 stated, We try to keep an eye on him, but it's not always possible. On 5/27/21 at 12:20 PM, R82 was in his room, lying in bed. There was no scoop mattress or fall mats in his room. R82's call light was hanging off the bed, out of reach of the resident. As the surveyor exit the room, R82 started yelling out, light,light. The surveyor returned to R82's room and he was sitting on the edge of his bed. R82 was unsteady and had his blanket wrapped around his foot. R82's wheelchair was parked at the foot of the bed, away from the resident. The resident was instructed to wait for staff to assist him with the transfer and he said he would wait. On 5/27/21 at 12:46 PM, V1 (Administrator) stated, I can't recall ordering a scoop mattress for him. I know he's fallen a bunch and we've done a bunch of things. V1 stated, I can't clearly give you an answer as to why he keeps falling, he has no safety awareness. Earlier today he was in my office walking around, asking me to buy him a pizza. V1 said R82 did fall and break his arm in March and he did report it. V1 stated, I don't have an excuse as to why the fall interventions are not in place. On 5/27/21 at 1:08 PM, this surveyor left a message for V13 (local Emergency Medicine Physician), but did not receive a return phone call. On 5/27/21 at 1:41 PM, V12 (Registered Nurse - RN) said she was working on the second floor the night R82 fell and broke his arm (3/11/21). V12 said R82 had fallen in his room earlier in the day and he was having weakness. V12 said later that night R82 walked to the dining room to get his dinner tray. V12 stated, He was unsteady so we were trying to get him back to his room to lay down. He's very hard of hearing and was having weakness. The CNA and I were trying to tell him we would bring him is tray and he was getting agitated. The CNA was carrying the tray, he turned to grab the tray from her, and he fell . When he fell he landed on his arm. When I assessed him, he said his arm was hurting. I called the doctor and we sent him to the emergency room . When he came back from the hospital they moved him downstairs. I guess he broke his arm and was in a sling. He had COVID and it seemed like for a while he was just declining. He was unsteady on his feet, weak, and short of breath with ambulation. The facility's Fall Prevention Program (2/28/2014) showed, Policy: It is the policy of the facility to have a Fall Prevention Program to assure the safety of all residents in the facility . The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistance devices are utilized .

Based on observation, interview, and record review the facility failed to ensure a resident with severe sleep apnea received continuous positive airway pressure ([CONDITION(S)]) treatment; failed to ensure transcribe a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R225 being transferred to the hospital via ambulance on 5/27/21 in respiratory distress. The findings include: On 5/25/21 at 12:45 PM, R225 walked from her bathroom, across her room, and sat on the edge of her bed. R225 was wearing oxygen via nasal cannula. R225 was short of breath and unable to answer more than one word without having difficulty breathing. R225 stated, I need a minute. After several minutes, R225 was able to answer questions with short phrases. R225 had a [CONDITION(S)] machine with a hose lying on the floor of her room, near the head of the bed. R225's [CONDITION(S)] hose did not have a mask attached to it. R225 said she is supposed to wear the [CONDITION(S)] at night, but hasn't been able to because she hasn't had a mask. R225 said she hasn't been wearing the mask since she got to the facility. R225 said she needs the part that she puts on her face and she gets anxious with the full face mask. R225 said she needs the mask that only covers her nose. R225 said she's told the staff about it, but no one has brought me a mask. R225 said she was admitted to the facility after being in the hospital, on a ventilator, in a medically induced coma for 28 days. R225 stated, I'm not sure who takes care of the masks here, but it would be nice if they would. R225 said she has just been wearing the oxygen all the time. During this interview, several short breaks had to be taken to allow resident time to calm her breathing. On 5/26/21 at 9:20 AM, R225 was sitting up on the side of her bed with her oxygen on. The [CONDITION(S)] machine and hose remained on R225's floor and there was no mask visible in her room. On 5/27/21 at 09:26 AM, V14 (Licensed Practical Nurse - LPN) said she was the nurse for R225. V14 said she heard R225 snoring this morning and wondered why she wasn't using her [CONDITION(S)], that was sitting on the floor. V14 stated, I didn't even know she needed a [CONDITION(S)] until this morning. V14 said when I asked her why she wasn't using it, she pointed down and said, I didn't have a mask for it. V14 said when a resident is admitted the nurse receiving the resident will review the orders and enter them into the computer. At 9:30 AM, V15 (Admissions Director) approached V14 and stated, [R225] was trying to come out of her room, she's short of breath, on the phone with her doctor's office, and says she wants to go to the hospital. V15 stated, She is on the phone with someone that wants to talk to the nurse, [R225] said she was talking to her doctor. V14 went to R225's room. At 9:35 AM, V14 (LPN) returned to the nurses station and said R225 was talking to V18's office (R225's Pulmonologist). V14 said R225 was up walking and is short of breath and V18's office wants R225 sent to the emergency room for evaluation. At 9:49 AM, V14 (LPN) called 911 and reported R225 needed transport to the hospital for an exacerbation of [CONDITION(S)] (Chronic Obstructive Pulmonary Disease). V14 said R225's oxygen saturation was 80% on 3 liters of oxygen, via nasal cannula. At 9:59 AM, R225 was transported via ambulance stretcher. R225 had visible intercostal retractions, was short of breath, pale, and wearing a non-rebreather oxygen mask. The [CONDITION(S)] machine was not transported with the resident to the hospital. R225's Facesheet printed 5/27/21 showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This document showed R225 was admitted to the facility on [DATE]. R225's Hospital Records dated 5/13/21 showed R225 was admitted to the hospital on 4/4/21 and discharged on [DATE]. This document showed R225's Plan was, .3. Ref (referral) to Pulmonary Rehab .6. Pulmonary/sleep appointment . Visit Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R225's Pulmonary Medicine Clinic Department of [a local hospital] order dated 5/17/21 showed R225 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This document showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . autopap 8-12 cmh20 ([CONDITION(S)] settings) with 2 lpm oxygen while sleeping. There are handwritten notes on the bottom of this document that stated, See prog (progress) note. She requires a [CONDITION(S)] not [CONDITION(S)]! Will need to call . R225's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R225's Progress Notes were reviewed from admission (5/17/21) to 5/26/21. There were no entries related to R225 needing, using, or refusing to use the [CONDITION(S)]. R225's Care Plan was reviewed on 5/26/21 and there was no mention R225 requiring a [CONDITION(S)]. On 5/27/21 at 09:32 AM, V2 (Director of Nursing - DON) reviewed R225's Electronic Medical Record (EMR) with this surveyor. V2 said I saw the order for R225 to have the [CONDITION(S)], scanned under the Miscellaneous tab, but I don't see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 said V19 (Assistant Director of Nursing - ADON) is supposed to audit new admissions and should have caught this. V2 said the admission audits are a double check to make sure we have everything done correctly. V2 said R225 not having the [CONDITION(S)] in place could lead to respiratory distress. V2 said R225 should have a face attachment. V2 said V16 (LPN) would have ordered it. On 5/27/21 at 9:44 AM, V16 (LPN) stated, I do not order [CONDITION(S)] supplies. [V17, Housekeeping Director] does that, he places the orders. I haven't heard anything about [R225] needing supplies for a [CONDITION(S)]. The [CONDITION(S)] shouldn't be on the floor. I don't know where the facial attachment (mask) is. On 5/27/21 9:57 AM, V17 (Housekeeping Director) stated, I'm not sure where we got [R225's] [CONDITION(S)]. Usually I order the mask and tubing when V16 (LPN) tells me. I have not ordered any masks for her. I wasn't aware that she needed one. On 5/27/21 at 10:19 AM, V19 (ADON) stated, I just searched the room and didn't find a mask. It was just the box ([CONDITION(S)]) and the hose. On 5/27/21 at 11:48 PM, V20 (V18's Office Nurse) said she was familiar with R225. V20 said she talked to R225 this morning and she was very short of breath. V20 stated, [R225] was so short of breath she couldn't finish her sentences. V20 said she asked to speak with the nurse at the facility and told the nurse to send R225 to the emergency room . V20 stated, I believe [R225] is admitted to the hospital now. On 5/27/21 at 12:04 PM, V18 (R225's Pulmonogist) said the last time R225 was in the office was September 2020, but she had recently been hospitalized and he provided the facility with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V18 said R225 should be using the [CONDITION(S)] every night, as ordered. V18 said R225 has several co-morbidities that contribute to her breathing difficulties including: obesity, smoking, [CONDITION(S)], and severe sleep apnea. V18 stated, Not using her [CONDITION(S)] every night would have contributed to her breathing difficulties that caused her to have to go to the hospital today. The facility's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Policy: .2. Orders must be recorded in the medical record by a licensed nurse authorized to transcribe such orders . 5. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's [CONDITION(S)]/[CONDITION(S)] Use Policy (1/1/20) showed, Policy: To provide guidelines for use of [CONDITION(S)]/[CONDITION(S)] therapy for treatment of the following conditions: Obstructive sleep apnea . history of respiratory failure. Procedure 1. Resident using [CONDITION(S)]/[CONDITION(S)] will require a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review the facility failed to prevent resident to resident abuse, this failure led to the strangulation and subsequent death of R1 by R2. This applies to 1 of 6 residents (R1) reviewed for abuse in the sample of 6. This failure resulted in an immediate jeopardy. The immediate jeopardy began on [DATE] when facility staff first became aware that R1 began complaining about his roommate. The immediate jeopardy was identified on [DATE]. V1 (Administrator) was informed of the Immediate Jeopardy on [DATE]. The surveyor confirmed by observation, interview and record review that the immediate jeopardy was removed on [DATE] but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's Face Sheet showed an original admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Face Sheet showed an original admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Amended Incident Report from the event on [DATE] at 11:31 PM showed, there was a physical altercation between R1 and R2; R2 grabbed (R1) around the neck. At some point, (R1) passed out. (R2) then came to the nurse's station to report the incident. (R1) remains in the neuro intensive care unit at (a local hospital). The Police Report dated [DATE] showed an interview between police and R2. The report showed R2 and R1 had argued for the last week regarding R1 breaking the toilet and R1 breaking the window that morning. The report continued, R1 approached R2 and he (R2) said he does not like when people larger than him get close to him because he was raped in the past. The report showed R1 punched R2 and R2 put him in a headlock until (R1) he became unconscious. On [DATE] at 10:30 AM, V22 R1's Attending Physician stated, there has been little change in R1's condition and there is little hope for any neurological recovery .There is no etiology (cause) to explain his condition other than the strangulation. The CT was negative for fractures or subluxation. (dislocation) On [DATE] at 3:50 PM V26 Social Worker at local hospital stated R1 had passed away the afternoon of [DATE]. R1's Incident Note from [DATE] at 1:25 AM showed, At approximately (11:25 PM), client's roommate [R2] said to staff, 'I think I killed my roommate.' Staff rushed to client's room and observed him unresponsive lying face down on the bedroom floor. The 1st bed (roommate's) was pushed diagonally toward the 2nd bed (client's). A code blue and 911 was called. CPR was initiated . On [DATE] at 3:07 PM, V11 Licensed Practical Nurse stated, R2 approached the second-floor nursing station at approximately 11:30 PM on [DATE]. V11 stated, .(R2) goes by the phone and asks to use the phone and I told him it's kind of late thinking he wanted to call his Mom. V11 said, as R2 was walking away he said, You need to call 911 .my roommate jumped on me and punched me in the nose, and I think I killed my roommate. V11 stated, she ran to R1/R2's room and found R1 lying face down, unresponsive, pulseless, and not breathing. On [DATE] at 10:30 AM, V7 R1 and R2's emergency room physician on [DATE] said, (R2) admitted to doing the choking but he didn't know how long he choked him for. (R2) said, he punched me so I choked him. V7 stated .Strangulation could have caused the condition he came in with if it was long enough. V7 said, He (R2) said they were fighting over the light in the room, one wanted it on and the other wanted it off. (R2) got up to turn it off and the other guy (R1) got up and punched him and that's when (R2) choked him. On [DATE] at 1:53 PM, R1 and R2's room had a broken window and the wall adjacent to the window had an approximate inch hole. On [DATE] at 1:55 PM, V24 Housekeeping stated the broken window was a new issue and had occurred the night before. On [DATE] at 8:56 AM, R1 was observed in the Neuro Intensive Care Unit (ICU) at a local area hospital where he was on a ventilator. R1 had bruising to his bilateral knuckles and two quarter sized scabs to his left knee. V21 R1's ICU nurse suctioned R1's throat and no gag reflex was seen. V21 attempted painful stimuli and there was no response. On [DATE] at 9:05 AM, V21 stated R1's sedative had been turned off for approximately 30 minutes and R1 was not gagging despite having a breathing tube in place. R2's Notice of Room Transfer showed R2 was moved in with R1 on [DATE]. On [DATE] at 12:35 PM, V5 Social Services stated she was called to see R1 and R2 regarding an incident on [DATE]. V5 said, When I walked in, (R2) was telling me that (R1) said he smelled. So, (R2) asked about deodorant. I said, 'Do you want a room move?' He (R2) said if there was room he would like to move rooms; but I told him at that time we don't have a room available but when one comes available we will move him. He (R2) said he would like to move in the future when available .It's not like there wasn't room for him to move, but I didn't feel like it was necessary at the time. I did communicate that with (V4 SS Director) . On [DATE] at 12:19 PM, V20 R2's Legal Guardian stated, (R2) told me, and (V4 SS Director) knows this, that he didn't really like his roommate. (R2) said (R1) talks about me under his breath and I told him he has to get along. I told him (V4) and I had a conversation; that (R2) had requested another roommate. She called me about it and I never heard any more about it . I felt like that she was going to move him to another room, but she was trying to find him a match. V20 said, His (R2) impulse control is bad. The facility's Abuse Prevention Program Facility Policy and Procedure reviewed on [DATE] showed Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm .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. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1. On [DATE] the police were called at 11:30 PM. R2 was 1:1 supervision by staff until the police arrived and took over. 2. On [DATE] the facility educated staff on prevention of resident to resident abuse. 3. On [DATE] the facility educated staff on early recognition of escalating behaviors. 4. On [DATE] the facility educated staff on crisis prevention. 5. On [DATE] the facility completed a facility wide audit of roommate compatibility and developed policies for a 72-hour follow-up when roommates are changed. 9. On [DATE] the facility audited its residents to determine appropriate level of supervision per the CHAR report. Based on the audit, residents were assigned to the appropriate group therapy. This audit has been added to the facility's QAPI to ensure residents are receiving appropriate therapy. 10. On [DATE] the facility implemented a policy for weekly rounding on Moderate Risk residents to specifically ensure roommate compatibility. 11. On [DATE] staff were educated to report any resident to resident conflict to the administrator, educated to separate the residents, educated to stay with the residents for safety, and educated to contact psych social. 12. On [DATE] the facility trained staff on both verbal and non-verbal signs of increasing aggression and how to react to those signs.

Based on observation, interview, and record review the facility failed to ensure the safety of one resident (R1) by not separating two incompatible roommates; the facility failed to properly implement increased supervision for a resident (R2); and the facility failed to identify a resident with a history of violence towards roommates. These failures resulted in a physical altercation between R1 and R2 and the subsequent strangulation and death of R1. This applies to 2 of 6 residents (R1, R2) reviewed for safety/supervision in the sample 6. This failure resulted in an immediate jeopardy. The immediate jeopardy began on [DATE] when facility staff first became aware that R1 began complaining about his roommate. The immediate jeopardy was identified on [DATE]. V1 (Administrator) was informed of the Immediate Jeopardy on [DATE]. The surveyor confirmed by observation, and record review that the immediate jeopardy was removed on [DATE] but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's Face Sheet showed an original admitted [DATE] with diagnoses to include: Type II diabetes, [CONDITION(S)] Disorder, and Major Depressive Disorder. R2's Face Sheet showed an original admitted [DATE] with diagnoses to include: [CONDITION(S)] disorder, [CONDITION(S)], Anxiety, and [CONDITION(S)] not due to a substance or known physical condition. The Police Report dated [DATE] showed an interview between police and R2. The report showed R2 and R1 had argued for the last week regarding R1 breaking the toilet and R1 breaking the window that morning. The report continued, R1 approached R2 and he (R2) said he does not like when people larger than him get close to him because he was raped in the past. The report showed R1 punched R2 and R2 put him in a headlock until he became unconscious. The facility's Amended Incident Report from the event on [DATE] at 11:31 PM showed, there was a physical altercation between R1 and R2; R2 grabbed (R1) around the neck. At some point, (R1) passed out. (R2) then came to the nurse's station to report the incident. (R1) remains in the neuro intensive care unit at (a local hospital). On [DATE] at 10:30 AM, V22 R1's Attending Physician stated, there has been little change in R1's condition and there is little hope for any neurological recovery. He has no real neurological activity .There is no etiology (cause) to explain his condition other than the strangulation. The CT was negative for fractures or subluxation. (dislocation) On [DATE] at 3:50 PM, V26 Social Worker at local hospital stated R1 had passed away this afternoon. On [DATE] at 1:53 PM, R1 and R2's room had a broken window and the wall adjacent to the window had an approximate inch hole. On [DATE] at 1:55 PM, V24 Housekeeping stated the broken window was a new issue and had occurred the night before. On [DATE] at 8:56 AM, R1 was observed in the Neuro Intensive Care Unit (ICU) at a local area hospital where he was on a ventilator. R1 had bruising to his bilateral knuckles and two quarter sized scabs to his left knee. V21 R1's ICU nurse suctioned R1's throat and no gag reflex was seen. V21 attempted painful stimulus and there was no response. On [DATE] at 9:05 AM, V21 stated his sedative had been turned off for approximately 30 minutes and R1 was not gagging despite having a breathing tube in place. R1's Incident Note from [DATE] at 1:25 AM showed, At approximately (11:25 PM), client's roommate [R2] said to staff, 'I think I killed my roommate.' Staff rushed to client's room and observed him unresponsive lying face down on the bedroom floor. The 1st bed (roommate's) was pushed diagonally toward the 2nd bed (client's). A code blue and 911 was called. CPR was initiated . On [DATE] at 3:07 PM, V11 Licensed Practical Nurse stated, R2 approached the second floor nursing station at approximately 11:30 PM on [DATE]. V11 stated, .(R2) goes by the phone and asks to use the phone and I told him it's kind of late thinking he wanted to call his Mom. V11 said, as R2 was walking away he said, You need to call 911 .my roommate jumped on me and punched me in the nose and I think I killed my roommate. V11 stated, she ran to R1/R2's room and found R1 lying face down, unresponsive, pulseless, and not breathing. On [DATE] at 10:30 AM, V7 R1 and R2's emergency room physician on [DATE] said, (R2) admitted to doing the choking but he didn't know how long he choked him for. (R2) said, he punched me, so I choked him. V7 stated .Strangulation could have caused the condition he came in with if it was long enough. V7 said, He (R2) said they were fighting over the light in the room, one wanted it on and the other wanted it off. (R2) got up to turn it off and the other guy (R1) got up and punched him and that's when (R2) choked him. R2's Notice of Room Transfer showed R2 was moved in with R1 on [DATE]. R1's Social Service note from [DATE] at 10:21 AM showed, SS (Social Services) approached resident in his room following a report that resident was not getting along with roommate. Staff inquired what the issue was, and (R1) replied, He smells, take your mask off and you can smell him. The CNA responded that resident's roommate had just showered but resident continued to state that the roommate had body odor. Staff suggested a room move but resident denied and continued to ignore .(Incident occurred within 5 days or residents becoming roommates.) R2's Social Service Note from [DATE] at 11:03 AM showed, SS (Social Services) met with (R2) regarding an issue with roommate. It was reported that resident and roommate were not getting along .reminded him that if he still wants to transfer rooms, staff will assist him to move once a room became available . Note signed by V5 Social Services (SS). On [DATE] at 12:35 PM, V5 Social Services stated, in regard to the [DATE] SS note, When I walked in, (R2) was telling me that (R1) said he smelled. So, (R2) asked about deodorant. I said Do you want a room move? He (R2) said if there was room he would like to move rooms; but I told him at that time we don't have a room available but when one comes available we will move him. He (R2) said he would like to move in the future when available .It's not like there wasn't room for him to move, but I didn't feel like it was necessary at the time. I did communicate that with (V4 SS Director) . On [DATE] at 12:19 PM, V20 R2's Legal Guardian stated, (R2) told me, and (V4 SS Director) knows this, that he didn't really like his roommate. (R2) said (R1) talks about me under his breath and I told him he has to get along. I told him (V4) and I had a conversation; that (R2) had requested another roommate. She called me about it and I never heard any more about it . I felt like that she was going to move him to another room, but she was trying to find him a match. V20 said, His (R2) impulse control is bad. On [DATE] at 3:08 PM, the facility received medical records from R1's previous Long-Term Care facility. The following documents were contained in that packet. R1's Nurse Practitioner note from [DATE] showed, .He had gotten angry at his roommate and they got into an altercation. He states that this was a long time coming and they have had issues . R1's physician note from [DATE] showed, .His behaviors have been a bit off lately. He had an argument with a roommate and has since had to change rooms . R1's physician note from [DATE] showed, .His behaviors continue to be a bit of a problem. Recently he had some issues with roommates as well . On [DATE] at 1:30 PM, V9 Director of Nursing at R1's previous long-term care facility, was contacted in regard to these roommate issues and R1's behavior. V9 stated, R1 was in a physical altercation with his roommate. V9 said, After the roommate incident, we changed roommates and put him on 15-minute checks and we also did some anger management therapy with the two of them. (R1) was the instigator in that incident with the roommate. He (R1) was complaining that his roommate smelled, and he didn't want to live with him anymore; he was picking a fight. On [DATE] at 2:47 PM, V4 SS Director stated, she was not aware of the roommate issues described in the medical records from R1's previous long-term care facility. V4 stated, If I had known about the incident at (R1's previous long-term care facility) I would have looked at putting him (R1) in a single room by himself. R1's Care Plan showed, Pt (patient) exhibits behaviors that include but are not limited to verbal and physical aggression towards other. On [DATE] Pt displayed verbal aggression towards staff. R2's [DATE] Background Check showed Multiple Hits regarding criminal past. R2's [DATE] Discharge Order and Transition Record from a local Behavioral Hospital showed, Reason for Admission: Danger to self with [CONDITION(S)], Lack of impulse control, Danger to others with [CONDITION(S)] The record continued, Triggers and Stressors (Behaviors, situations and circumstances that put at emotional risk) are: Certain environments, People touching your stuff, and Like things to be a certain way. R2's Nursing Facility Placement Assessment Summary Information dated [DATE] showed, ,d+[DATE] prior arrests (dates unknown) According to hospital staff, the patient has been arrested three times for stealing cars .and a few times for purchasing guns. In [DATE] he stole his grandfather's car. He was driving to Indiana and was stopped because he was driving on the wrong side of the road. It is unclear, but the patient may have a restraining order against him from his family .The patient has a tendency to start fires at his home or in hotels .He continues to exhibit poor reality contact with no insight or judgment to the severity of his MI (Mental Illness) .The patient was hospitalized on [DATE] (for) worsening [CONDITION(S)], inability to care for self, being kicked out of family homes and hotels for destructive behaviors, and paranoia with no regard to his own well-being. His mother has legal guardianship of the patient due to his inability to care for himself. He is rather impulsive with no regard for himself or others (i.e. his paranoia was so intense he tried to jump out of a moving car with his mother driving just before being hospitalized ) .He has gone to Indiana on several occasions to purchase firearms because he does not need a FOID (Firearms Owner Identification) card. He has been court ordered to treatment multiple times . R2's Identified Offenders Program (commonly referred to as CHAR report) shows him to be a Moderate Risk-This resident requires closer supervision and more frequent observation than standard or routine for most resident in an open facility . R1 and R2's room was the second to last room (end) of their hallway. On [DATE] at 11:34 AM, V19 Certified Nursing Assistant stated, I was not aware of their (R1, R2) backgrounds or histories. We were not doing any special supervision for them (R1, R2). We are supposed to do rounds on everyone, every 2 hours. We only do 15-minute checks when warranted; (R1 or R2) were not on 15 minute checks whenever I worked with them. On [DATE] at 8:45 AM, V15 Licensed Practical Nurse stated, there are some residents that are monitored more frequently; however, (R1) and (R2) were not on any increased monitoring. On [DATE] at 11:50 AM, V4 Social Service Director stated the only increased supervision R2 received was 1 to 1 group therapy twice a week and usually a daily visit by social services. R2's [DATE] Care Plan Conference Participation Log showed there was no staff, family, or guardian participation. On [DATE] at 12:19 PM, V20 R2's Legal Guardian stated she was not contacted for a care plan meeting. V20 stated she had to contact the facility to set up the meeting and it was not done until a week before the incident. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. 1. On [DATE] the police were called at 11:30 PM. R2 was 1:1 supervision by staff until the police arrived and took over. 2. On [DATE] the facility educated staff on prevention of resident to resident abuse. 3. On [DATE] the facility educated staff on early recognition of escalating behaviors. 4. On [DATE] the facility educated staff on crisis prevention. 5. On [DATE] the facility completed a facility wide audit of roommate compatibility and developed policies for a 72-hour follow-up when roommates are changed. 9. On [DATE] the facility audited it residents to determine appropriate level of supervision per the CHAR report. Based on the, audit residents were assigned to the appropriate group therapy. This audit has been added to the facility's QAPI to ensure residents are receiving appropriate therapy. 10. On [DATE] the facility implemented a policy for weekly rounding on Moderate Risk residents to specifically ensure roommate compatibility. 11. On [DATE] staff were educated to report any resident to resident conflict to the administrator, educated to separate the residents, educated to stay with the residents for safety, and educated to contact psych social. 12. On [DATE] the facility trained staff on both verbal and non-verbal signs of increasing aggression and how to react to those signs

Based on observation, interview, and record review the facility failed to identify a resident with a history of violent behaviors (R8) and failed to prevent a resident (R7) from sustaining physical abuse and psychosocial harm for 4 of 9 residents (R6, R7, R9, R12) reviewed for abuse in the sample of 15. These failures resulted in R8 hitting R7 in the face and pushing R7 to the ground on 12/26/19. R7 suffered broken ribs and a broken left hip which required surgical intervention. These failures resulted in an immediate jeopardy. The immediate jeopardy began on 11/21/19 when facility staff first became aware that R8 had assaulted someone prior to entering the facility. The immediate jeopardy was identified on 1/8/2020. V1 (Administrator) was informed of the Immediate Jeopardy on 1/8/2020 at 12:20 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was: removed on 1/9/20 but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R8's Admission Record shows he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R8's Social History and assessment dated [DATE] shows, Discuss any psychiatric history/treatment, psychiatric illness in the family, substance abuse in the family, and any problems with the law/legal system, arrest, incarceration (Is there a criminal history?) R8 said he was unsure. This assessment also asks if there are adjustment/mental health behavior issues. Conflictual relationships and adjustment issues are marked as yes. V4 Social Service Director said that the social service department conducted this assessment. R8's electronic name based background check dated 11/14/19 shows R8's name with a birthdate of 3/22/88. This background check came back with No record on file. R8's electronic name based background check dated 12/28/19 (two days after the incident with R7) with his correct date of birth (3/20/88) shows Multiple hits-fee fingerprints requested. On 1/2/2020 at 8:33 AM, V1 (Administrator) said, We found out we ran it without the right birthdate and then we ran a new one. At 8:45 AM via telephone V8 (Social Services Assistant) said a background check for R8 was not ran again until 12/28/19. The original background check dated 11/14/19 came back clean because they had the wrong birthdate. We did not know the incorrect date of birth was on there. The County 17th Judicial Circuit Court Record shows R8 had previous charges for battery/makes physical contact, aggravated battery/pregnant/handicapped, and aggravated battery/victim 60+ on 11/27/2018. Aggravated battery/victim 60+ class 3 felony and battery/pregnant/handicapped class 3 felony on 1/23/19. Assault/deadly weapon on 5/18/2009, with knowingly damage to property <$300 two times on 5/31/2006. Disorderly conduct on 11/9/2005. Aggravated battery/school employee class 3 felony on 11/9/2005, and with battery on 4/27/2005. R8's physician progress notes [REDACTED]. On 12/31/19, V10 LPN (Licensed Practical Nurse) said she remembers R8 telling her he had to go to court for something he did prior to being admitted to the facility. At 3:40 PM, V18 RN (Registered Nurse) said R8 has said he has been to jail before and V18 thought it involved an altercation in the past because that is what R8 told him. On 1/9/2020 at 9:47 AM, V23 CNA (Certified Nursing Assistant) said she was not aware that R8 had a history of [REDACTED]. V10 said that R8 ambulated on his own throughout the facility and she was not told about the need to monitor R8. R8 did not need any special interventions for aggression. R8's Mood/Behavior note dated 12/14/19 at 4:48 AM documents, Staff personnel (CNA) informed writer that resident (R8) was slightly agitated due to peer (two doors down had awakened this resident), resident (R8) observed per writer (V5 Charge Nurse) throwing personal items, suitcase against wall, clothes on floor, and talking to self, 'I'm going to kick his as*. Extensive attempts per writer to re-direct, de-escalate present aggressive behaviors, resident threw stationary chair into wall, ambulating down hallway, stated, I'm kicking his as*, you're going to see why I got two felonies, I'm tired of hearing that sh*t, I don't want to calm down. Interventions included temporary bedroom/medication and/or conversing with staff regarding appropriate coping skills, resident replied, I'm not going to another room, I'm not taking no dam* medicine and I don't have to talk to nobody, all I need to do is find him. Resident (R8) then attempted to enter bedrooms [ROOM NUMBERS], writer intervened/redirected, resident replied, That's alright, I'll get him at breakfast. Nurse practitioner notified and order received to transport to emergency room involuntary for evaluation and treatment if needed. Resident stated, Good get me the hel* out of here. Dispatch notified, will bring police for back up .5:15 AM two attendants (Emergency medical technicians-EMTs) and two police personnel here, resident continued with disruptive behaviors towards police/technicians stated, Bunch of punk bit**es, all racists. Resident left via stretcher with extremities restrained. Accompanied per EMTs and police personnel . R8's local emergency room notes dated 12/14/19 documents, Patient brought by emergency medical services (EMS) for aggressive behavior at nursing home, per nursing home staff patient was woken up by another resident and was angry and started threatening nursing home staff, patient on arrival was restrained with soft restraints. R8's Nursing Progress Noted dated 12/14/19 at 8:11 AM shows, Resident arrived from the hospital after being sent out for aggression .resident stated he would stay away from the peer and would not be aggressive towards anyone. On 12/31/19 at 10:30 AM, V2 Regional Quality Assurance/previous Director of Nursing said there was an incident with R8 when another resident (R13) was yelling in the middle of the night and R8 got up to shut him (R13) up. R8 left his room and headed towards R13's room and staff redirected R8. On 1/2/2020 at 2:45 PM, V15 CNA said, one day R8 got woken up because another resident was screaming (R13). R8 said he better shut up and he was going to get out of the bed. R8 wanted to hit him (R13) because (R13) was screaming. R8 came out of his room and V15 got two male CNAs because V5 Charge Nurse felt R8 was going to get out of control. The police came and they strapped (R8) down. R8 was not nice to the police and ambulance personnel. On 1/2/2020 at 9:00 AM, V5 (LPN) said, there was an incident with R8 about two weeks ago. R8 was upset that another resident (R13) was having a behavior (yelling out). I tried to calm him down (R8). I called 911 before things escalated. He (R8) was saying that he was going to find the resident and he (R8) said he may have to do something but he didn't know what. He said if I didn't take care of it he was going to punch him (R13). I wanted to get him (R8) out before he inflicted bodily harm. The chair he threw, was the one in his room. He (R8) told me, Hey you are going to find out why I have two felonies.' On 12/31/19 at 4:13 PM, V1 (Administrator) said he wasn't sure how long ago R8 got mad at the nurses station because a resident was loud and woke him up. V1 stated the staff was able to redirect him. V1 did not recall R8 being sent out to the hospital for behaviors. When V1 was asked if R8 had a history of [REDACTED]. A lot of people have a history of aggression before coming here. In regards to R8, V1 said staff were working on how to handle situations as they came along. To me something would go on and we would notice that he would begin getting more agitated more rapidly. R8's Care Plan initiated 12/14/19 shows, Patient exhibits behaviors that include but are not limited to verbal and physical aggression towards peers . (V24 psychiatrist) to evaluate and treat as indicated and as needed. On 1/8/2020 at 1:58 PM, V4 Social Services Director said, V24 sees residents upon admission and comes to the facility every two weeks. If someone is having a behavior V4 puts the resident on V24's list of visits. V4 could not recall if R8 was added to V24's list but verbal or physical behaviors would warrant a resident to be added to V24's list. R8's Progress Notes show R8 was last seen by V24 on 11/19/19. On 12/31/19 at 3:52 PM, V3 DON (Director of Nursing) said she was not aware of an aggressive history with R8 in the past. V3 was not aware of any incidents that R8 had with others residents while in the facility. V3 said if there is an incident that happens on the floor, staff report it to V1 directly. The facility has a meeting every morning or afternoon that goes over anything that is in risk management. V2 also said she was not aware of any aggressive history with R8. I just assume everyone has a history. R8's Screening Assessment for Indicator of aggressive and/or harmful behaviors dated 12/15/19 shows, R8 is a moderate risk. The assessment's inaccurate due to the history of criminal behavior is marked 0. R8's Incident Note dated 12/26/19 shows, Resident (R8) involved in an altercation with a peer in first floor dining room at approximately 7:35 AM while preparing for breakfast. Staff reported to writer (V10 LPN) that the two residents were heard arguing over a seat at the dining room table. Both had hands on the chair. Resident (R8) became angry and pushed peer (R7) to the floor before staff could intervene, while staff yelled for resident to stop, he (R8) was able to shove resident to the floor again before staff arrival. Resident (R8) walked from the dining room while staff assisted peer (R7). Writer observed resident (R8) at the first floor nursing station cursing, That motherfu**er hit me first, I'm not scared of the fuc*ing police, take me to jail. Resident (R8) kicked the Christmas decoration over and knocked over the trash can, punched the phlebotomy case sending it crashing to the floor. Police in facility at this time following situation. At 12:21 PM, R8's Social Service Note shows, Social Services staff was informed about this morning incident with (R8) displayed physical aggression towards a male peer. Police at the facility and took (R8) to jail where he will need to talk to a judge before he can return to the facility. R8's hospital discharge paperwork dated 12/14/19 shows he is [AGE] years old and 6 feet 1 inch tall and weighs 260 pounds. R7's electronic medical record of 12/29/19 shows R7 is [AGE] years old and he weighs 169.4 pounds (almost 100 pounds less than R8) and is 73 inches (6 feet 1 inch). The facility's surveillance video was observed on 12/31/19 with V1. R7 was sitting at the dining table in the dining room. There was an empty chair with pillows in it next to R7 that V1 stated is where R10 sits. R10 walked to exit the dining room and walked passed R8. R8 walked to the empty chair, took the pillow out and set them on the table. R8 proceeded to take the chair and R7 took hold of the right arm of the chair. R7 and R8 were both holding the chair and struggling to pull it in opposite directions. R8 then hit the front of R7's head with a closed right fist. R7 touched his head with his right hand, and then took his glasses off and set them on the table. R7 stood up and R7 and R8 had a hold of each others hands pushing against each other. V17 CNA started to walk over to R7 and R8. R8 looked at V17 and then pushed R7 down. R7 hit another chair and landed on the floor on his left side. V17 attended to R7 while R8 walked out of the dining room. On 12/31/19 at 12:20 PM, V17 said, while in the dining room, she heard R14 yelling something and she went over to R7 and R8. R8 pushed R7 down. She saw a red mark on the middle and left side of R7's forehead. She helped R7 get up into the chair. R7 stated to V17 that he was saving the seat for R10. R7 said his hip hurt. V17 went to the nursing station and yelled to call psych social. R8 was knocking stuff off of the counter. V10 LPN was at the nurses' station trying to calm R8 down. Shortly after the ambulance came and got R7. V17 said that R7 and R10 sit by each other in the dining room all the time and R8 sits at various places in the dining room. V17 stated that R7 is a really sweet guy. At 1:50 PM, V10 said she didn't see the incident happen, but R8 was upset and said to her Mother fu**er hit me and I hit his as* down. R8 kicked the Christmas decorations and kicked the garbage can. V10 attempted to calm R8 down. R8 went upstairs with V18 RN and stayed with him until police got there. At 3:40 PM, V18 said he didn't see the altercation but he brought R8 upstairs to remove him from the situation. R8 told V18 that he hit R7 and pushed him down. V18 brought R8 downstairs when the police arrived. The County 17th Judicial Circuit Court Records show R8 was charged with 2 counts of aggravated battery/great bodily harm class 3 felonies on 12/27/2019. R7's hospital paper work dated 12/26/19 shows he was admitted to the hospital from 12/26/19-12/29/19 with left hip and rib fractures. On 12/31/19 at 4:13 PM, V1 Administrator said he received a call from V17 and she said that R8 hit and pushed R7. V1 said that he could hear R8 yelling in the background. R7 got sent to the hospital because he complained of hip pain. R7 had broken ribs and a broken hip. The police were called and reviewed the video surveillance. V1 said he knows that R8 was charged with a felony for this incident. On 1/2/2020 at 1:10 PM R7 had a walker next to his bed. R7 said, I was saving a chair in the dining room and a man beat me up. R7 said he had surgery on his hip and now after this incident his pain is rated a 9/10. Before the incident occurred, R7 said his pain was a 5/10 but was general pain. R7 said his head hurt after the incident occurred. R7 said, (R8) acted like he was the boss around here. I feel safe now that R8 is not here anymore. The police pressed charges against him (R8). I wouldn't feel safe if R8 was back in here. Now I am paranoid to think that he (R8) could do that. Before this happened I was able to walk by myself really well, and now I have to walk with a walker. And look, now I am a fall risk. On 12/31/19 at 3:11 PM, V2 Regional Quality Assurance/previous Director of Nursing said R8 is still in jail, the police were pressing felony charges against R8 because R7's age is greater than 65. On 12/31/19 at 11:20 AM, R6 stated she feels so sorry for R7. She had heard that R8 did this at another place. R6 stated she does not feel safe in the facility and feels like some of the residents need 24 hour psychiatric care. On 1/2/19 at 1:45 PM, R9 said, Everything is edgy here. I feel nervous. There's a lot of disruptions from residents here. One man broke my friends hip. I don't feel safe here. At 1:50 PM, R12 stated she does not feel safe from other residents in this facility. On 1/2/19 at 10:30 AM, V4 Social Services Director said, We do our best, but we can't have eyes on people 24/7 365 days. All residents are treated the same, behaviors can happen whether it is a person with a history or a little old lady. V2 former director of nursing and current quality assurance said, Even if the background check was done correctly, it wouldn't have changed anything. We would not have done anything different for him (R8) anyway. We don't base our admissions on background checks. R7's Admission Record shows he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R7's MDS dated [DATE] shows he is cognitively intact. Prior to this incident, R7 walked and transferred independently and required no mobility devices like a walker. R7's screening assessment for indicators of aggressive and/or harmful behaviors dated 12/6/19 shows he is minimal risk for aggression. The facility's Abuse Prevention Program Facility Policy and Procedure dated 1/4/19 shows, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. The Immediate Jeopardy that began on 11/21/19 was removed on 1/9/2020 when the facility took the following actions to remove the immediacy. 1. On 12/26/19 the police were called at 9:40am. R8 was 1:1 supervision by staff until the police arrived and took over. 2. Background check for R8 was completed by Social Services on 12/28/19. 3. An audit of all residents back ground checks were completed by Social Services to ensure accuracy on 1/8/20. 4. Social Services initiated a double check process to ensure accuracy for pre-screening residents on background checks. 5. Re-education for all staff prior to start of their shift initiated on 1/8/20 for: A double check system for background checks on admission (pre-screening), per abuse policy and procedure is being completed to ensure accuracy, Education provided to Social Services by the Administrator on 1/8/20. The double check system on admission background checks is being conducted by Social Services. Every new admission will be audited for 4 months. All staff education on abuse will be provided by Department Managers and will be competed by 1/9/20. All staff re-education on identifying high risk residents was initiated on 1/8/20, and completed on 1/9/20. 6. Care plans were reviewed to ensure interventions were individualized based on risk assessments for known violent behaviors. Education completed by Department Managers on 1/9/20 to ensure accuracy and individualized interventions are in place. The audit revealed no discrepancies. 7. Social Services will continue to educate all staff on crises and behavior intervention techniques during orientation and annually. 8. Abuse education remains on-going and is completed monthly by the Administrator or designee. 9. The Facility abuse assessment audit was initiated on 1/8/20. The audit was completed on 1/9/20 to ensure accuracy and individualized interventions are in place. The audit revealed no discrepancies.

Based on observation, interview, and record review the facility failed to ensure the safety of a resident with a known history of suicide attempts and failed to accurately assess a resident at risk for self harm for 1 of 3 residents (R1) reviewed for safety with suicidal ideation. This failure resulted in R1 attempting to commit suicide by cutting her left wrist with broken glass. The findings include: R1's face sheet showed R1 was a [AGE] year old female who was admitted to the facility on (MONTH) 20, 2019 with [DIAGNOSES REDACTED]. R1's Admission History and Physical report dated (MONTH) 17, 2019 showed, (R1) . tried to overdose on a number of pills . has been hospitalized for [REDACTED]. attempted suicide twice, once by cutting herself . R1's progress note dated (MONTH) 17, 2019 at 11:28 AM by V4 (Social Services Director) showed, CNA (Certified Nursing Assistant) came to SS (Social Service) office and asked SS to come to patient's room right away. When SS arrived, SS witnessed patient lying in her bed with blood all over her pillow, sheets, both hands, hair, on the floor next to her bed, and on the top drawer of her nightstand. Nursing staff was in the process of wrapping (R1's) left wrist and SS was informed (R1) cut her wrist vertically with a sharp piece of glass she got after breaking a picture frame . R1's nursing note entered by V10 LPN (Licensed Practical Nurse) dated (MONTH) 17, 2019 at 10:45AM showed, Resident noted by Rehab NP (Nurse Practitioner) at approximately 10:25 AM in resident's bedroom bleeding profusely, blood on the floor and bed, resident sitting in bed, writer called to room. Upon entering room writer noted (R1) to be semi sitting/lying in bed which was soiled with bright red blood, resident's hands, hair and arms also covered in blood along with gown. Writer did a quick body check . a deep, vertical jagged laceration approximately 2 inches to the left pedal pulse area was noted, fresh red blood was trickling at this time with some coagulation noted at perimeters, 911 called . blood trail was followed to bedside table where a big piece of broken glass from picture frame was found with blood smears and bloody fingerprints were noted . (Resident was bleeding from left wrist area, nursing note showing pedal pulse area is not accurate.) R1's acute care hospital records showed R1 was admitted to the acute care hospital on (MONTH) 17, 2019 at 10:58 AM for a suicide attempt. R1's care plan for history of suicide attempts and self-harm was initiated on (MONTH) 20, 2019 and last revised on (MONTH) 5, 2019 with interventions to include, (1) as warranted conduct a room check/search and remove any sharp objects or similar contraband (razor blades, razors, knives, scissors, etc, alcohol/drugs, including over-the-counter medications, cleaning supplies, any other objects that (in the opinion of the health care professionals) may pose a threat to safety, (2 )as warranted conduct random room safety checks, personal wellness check, mouth check during medication pass, behavior monitoring of the resident, evaluation of mental status, mood state, thought content, (3)assure the resident that staff members are available to help and that staff has an open door policy if resident has a concern resident wants to discuss, (4) educate on the importance of reporting such issues in order to keep self safe. Offer support and reassurance as needed for agitation and anxiety and (5) enroll (R1) in the Symptom Education Group and encourage her to participate in the 1:1 sessions if needed, (6) evaluate potential indicators of depression and evaluate potential signs/symptoms of [MEDICAL CONDITION], (7) intervene if any self-injurous behavior is observed On (MONTH) 27, 2019 at 2:10 PM, V10 LPN (Licensed Practical Nurse) said R1 had a stay at a psychiatric hospital prior to this suicide attempt. V10 said when R1 came back from the psychiatric hospital she was still delusional. V10 said she was not aware of R1 trying to harm herself in the past. On (MONTH) 31, 2019 at 3:27 PM, V2 RN (Registered Nurse, Former Director of Nursing, Current Quality Assurance Nurse) said R1 was refusing everything when she came back from the hospital. V2 said she is not aware of any interventions that were in place for R1's suicidal ideation. V2 said if a resident would be admitted to the facility with previous suicidal attempts she would expect that they would figure out what kind of an attempt was made and put interventions into place specific to the type of attempt. V2 said for example if someone cut themselves we would want to make sure that we are taking away those sharp objects. V2 said the psych-social department would be the ones who would determine if a resident's room should be checked. The facility's room check logs for (MONTH) 2019 through (MONTH) 2019 were reviewed and showed R1's room had not be checked for the length of her stay. R1's Screening Assessment for Evaluation Self Harm/Suicide Risk completed by V7 PRSC (Psychiatric Rehabilitation Services Coordinator) dated (MONTH) 20, 2019 showed R1 to be a moderate risk for self-harm and reflected that R1 had a history of [REDACTED]. is a moderate risk for self- harm. She has a long history of mental illness and suicidal ideation. R1's Screening Assessment for Evaluation Self Harm/Suicide Risk completed by V8 (Social Services Assistant) on (MONTH) 27, 2019 and (MONTH) 27, 2019 erroneously showed R1 did NOT have any previous suicide attempts and V8 entered a note which showed R1 to be a low to moderate risk. R1's medical record showed she was sent to an acute care psychiatric hospital on (MONTH) 23, 2019 and was readmitted to the facility on (MONTH) 12, 2019. R1's progress notes from (MONTH) 12, 2019 through (MONTH) 17, 2019 showed R1 continued to display delusions and reported auditory hallucinations in addition to refusing assessments and medications. R1's (MONTH) eMAR (electronic medication administration record) showed R1 refused her bedtime medications on (MONTH) 15 and (MONTH) 16. On (MONTH) 27, 2019 at 10:30 AM, V4 (Social Services Director) said she knows R1 well. V4 said R1 has severe mental illness and has had this for a long time. V4 said R1 is paranoid and suspicious at her baseline. V4 said R1 will do well for a period of time and then she will start to get more paranoid and delusional and start to refuse medications. V4 said when R1 starts to refuse her medications her symptoms get worse, and she is sent for an inpatient psych stay. V4 said this is R1's cycle. V4 said R1 is involved in psych-social groups and see the facility psychiatrist. V4 said if R1 does not attend the group meetings they do a 1:1 meeting with her to discuss what was talked about in the group. On (MONTH) 31, 2019 at 12:47 PM, V6 (PRSC) said R1 was in two groups with psych-social, Symptom Education Group and Social Skills Group. V6 said R1 did not once participate in group or participate in 1:1's. V6 said all refusals are documented on the group sheets regardless if it is a group or a 1:1 refusal. V6 said there is no other scheduled interactions with residents besides the two groups. R1's Group Record of Participation for (MONTH) 2019 through (MONTH) 2019 was reviewed and showed R1 did not participate in group or 1 on 1 sessions. On (MONTH) 31, 2019 at 3:52 PM, V3 DON (Director of Nursing) said she does not really know anything about care plans and what interventions are in place for residents with a history of suicide attempts. V3 said she is not aware of any specific interventions in place for R1's suicidal ideation.

Based on observation, interview, and record review the facility failed to assess, identify and prevent pressure ulcers from developing. This facility failure resulted in R172 developing three unstageable pressure ulcers. This applies to 2 of 3 residents (R28, R172) reviewed for pressure in the sample of 35. The findings include: 1. The physician's orders [REDACTED]. The Minimum Data Set assessment (MDS) dated (MONTH) 12, (YEAR) showed R172 needs extensive assistance of one for bed mobility and he had no pressure ulcers. The Braden Scale (pressure ulcer risk assessment) dated (MONTH) 5, (YEAR) showed R172 to be at high risk for pressure ulcer development. The admission skin integrity review dated (MONTH) 15, (YEAR) showed R172 had no skin issues. The nursing progress note dated (MONTH) 24, (YEAR) showed R172 was assessed by the doctor due to [MEDICAL CONDITION] and the beginning of pressure ulcers to ankle areas. No further documentation was found about the pressure ulcers until (MONTH) 7, (YEAR). R172's weekly skin alteration review dated (MONTH) 7, (YEAR) (13 days after initial physician assessment) shows a deep tissue pressure injury, to the right lateral foot and an unstageable pressure injury to the right lateral ankle. R172's weekly skin alteration review dated (MONTH) 14, (YEAR) shows an unstageable pressure injury to the left hip. R172's wound care specialist initial evaluation dated (MONTH) 7, (YEAR) shows an unstageable necrotic pressure ulcer to the right lateral ankle measuring .9 by 1.3 centimeter (CM). The area was covered with 100% necrotic (dead tissue) tissue. The recommendation for staff was to off load the area and wear bunny boots. The same report also shows an unstageable deep tissue injury to the right lateral foot measuring 7.5 by 0.6 CM caused by pressure. The recommendation for this wound is to off load the area. R172's wound care specialist evaluation dated (MONTH) 14, (YEAR) shows an unstageable necrotic pressure injury to the left hip. The wound measures 1.7 by 1.1 CM and was covered by 100% necrotic tissue. The wound was debrided by the physician. The post debridement wound was staged as a four. R172's POS dated (MONTH) 6, (YEAR) shows an order to ensure off loading boots are on daily three times a day was started on (MONTH) 13, (YEAR). On (MONTH) 5, (YEAR) at 9:15 AM, V19 (wound care nurse) was observed changing the dressing to R172's left hip and right ankle. The wounds have red wound beds with minimal drainage and pink skin surrounding the wound. On (MONTH) 4, (YEAR) at 11:04 AM, V15 (R172's father) said his son developed the pressure ulcers after coming to the facility. On (MONTH) 5, (YEAR) at 2:30 PM, V16 Assistant Director of Nurses (ADON) said R172 was admitted to the facility with no pressure ulcers. On (MONTH) 6, (YEAR) at 10:52 AM, V6 LPN said when a new wound is found the nurse is do an assessment, give the information to the wound care nurse and that person will obtain orders for treatment. V6 said frequent repositioning and off loading pressure areas are important to prevent pressure sores. On (MONTH) 6, (YEAR) at 10:36 AM, V9 CNA said to prevent pressure sores you have to reposition the residents frequently and use pillows to off load pressure to certain areas. On (MONTH) 6, (YEAR) at 1:04PM, V20 Licensed Practical Nurse (LPN) said she thinks the bunny boots were started a few weeks after coming to the facility. On (MONTH) 6, (YEAR) at 1:11 PM, V21 Certified Nursing Assistant (CNA) said the bunny boots were started after the pressure ulcers started to his foot. On (MONTH) 6, (YEAR) at 9:38 AM, V2 Director of Nurses (DON) said the wounds should have been found and treated before they became unstageable. R172's care plan shows the increased risk for alteration in skin integrity was initiated on (MONTH) 20, (YEAR). The interventions are to reposition frequently and off load heels as needed. The facility policy for pressure ulcer and skin condition assessment dated ,[DATE] shows the purpose is to establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure and other ulcers and assuring interventions are implemented. #4 shows each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the initial assessment. #7 at the earliest sign of a pressure ulcer . a skin assessment form will be initiated. The initial observation of the ulcer or skin breakdown will also be described in the clinical record. 2. On 12/04/18 at 9:32 AM, R28 states she has wound on left foot and has been going to the wound care doctor for 6-8 weeks. R28 states she thinks the wound was caused by the strap on footrest of her wheelchair. R28 stated she is taking an antibiotic for infection of wound. A strap was in place at the back of the left foot rest on her wheelchair. R28 was not wearing any offloading boots or shoes. A gauze bandage was observed on R28 left foot. The physician notes for R28 dated 10/16/18, shows R28 had a superficial left heel ulcer and increased [MEDICAL CONDITION] to lower extremity. No measurement or additional wound description is recorded. The initial wound note by nursing dated 10/22/18 shows the wound is on the left heel, stages as a deep tissue injury, measured 2.8 x 3.0 CM, with a moderate drainage. The treatment includes use of an off loading boot and foam dressing. The assessment did not include a description of the wound bed. On 12/06/18 at 10:25 AM, V18 (Licensed practical nurse/wound care nurse) stated, I think R28 self reported the heel wound to me on 10/22/18. She is not on scheduled skin checks. I referred her to the wound doctor on the same day because he was here making wound rounds. R28 does her own shower. V18 stated she was not sure, but the wound could have been caused from the strap on the foot rest of her wheelchair and she doesn't wear shoes. V18 confirmed there were no nursing notes of the new wound for R28 before 10/22/18. V18 stated the treatment included off loading the wound on 10/22/18. V18 stated R28 uses a sponge boot at times. She does not use the correct one but she is free to choose which boot to wear. R28's legs are swollen. V18 has not observed R28 walking, but thought she could transfer herself to the toilet. V18 described R28's wound as a deep purple color, and drainage was leaking from the wound, but it was not open. V18's initial wound assessment did not contain any information regarding the precipitating factors that may have caused the deep tissue injury of R28's heel or measures used to alleviate the pressure. R28's care plan states she requires assistance with ADL's to maintain the highest possible level of functioning AEB the following limitations and potential contributing factors: General weakness, use of [MEDICAL CONDITION] medications, [MEDICAL CONDITION], Anxiety, [MEDICAL CONDITION], Type II diabetes, and [MEDICAL CONDITION]. She is mostly independent but needs some assistance with dressing and transfers. The care plan shows R28 has an alteration in skin integrity and is at risk for additional and or worsening of skin integrity issues related to Type II diabetes, [MEDICAL CONDITION] and allergic rhinitis. Deep tissue injury 10/22/18 Interventions include to skin check during routine care on a daily basis and during the weekly/biweekly bath or shower schedule. Other interventions related to deep tissue injury of the left heel were to administer wound care treatments per physician orders. No interventions to relieve pressure to the left heel are identified in the care plan for R28. The (MONTH) (YEAR) physician order [REDACTED]. [MEDICATION NAME] every 72 hours for pain. On 11/28/18 an antibiotic order was started for treatment of [REDACTED]. The wound physician note on (MONTH) 3, (YEAR) measured the wound size 1.7 cm x 3.0 cm x 0.3 cm with moderate serous drainage and 40% cover with thick adherent devitalized necrotic tissue. The wound was surgically excised of devitalized tissue. R28's [DIAGNOSES REDACTED]. [MEDICAL CONDITION] of right lower limb, [MEDICAL CONDITION], chronic embolism and [MEDICAL CONDITION] of deep veins of lower extremity, GERD, alcoholic [MEDICAL CONDITION] of liver without ascites, heart failure, [MEDICAL CONDITION], spondylosis without [DIAGNOSES REDACTED] or radiculopathy, [MEDICAL CONDITIONS], anxiety, OA, HTN, idiopathic peripheral autonomic [MEDICAL CONDITION]. R28's Minimum data set of 09/17/18 shows R28 has brief interview of mental status score of 15 (cognitively intact) and she does not walk, uses a wheelchair for mobility. R28 is at risk for pressure ulcer and had no unhealed pressure ulcer, or other wound or skin problem.

Based on interview and record review, the facility failed to provide the necessary care and services by not assessing, documenting vital signs, and monitoring for a decline in condition for a resident that received multiple opioid medications in error. This failure contributed to the resident becoming unresponsive and required an emergent opioid reversal medication. This applies to 1 of 3 residents (R1) reviewed for status changes in the sample of 8. The findings include: R1's Electronic Medical Record shows R1 was admitted to the facility on [DATE]. R1 had [DIAGNOSES REDACTED]. R1's progress notes show a late entry was created on July 3, 2017 at 5:43 PM (7 days after incident occurred) by E5 LPN (Licensed Practical Nurse) that on June 26, 2017 E5 LPN mistakenly gave R1 [MEDICATION NAME] 90mg and [MEDICATION NAME] 5/325 two tablets, at approximately 7:45 PM. On July 6, 2017 at 1:00 PM, Z1 NP (Nurse Practitioner) stated she received a phone call notification from E5 LPN in regards to the medication error that occurred with R1. Z1 NP stated she gave orders to monitor the resident's vital signs every hour, to monitor for respiratory depression or increased lethargy, and to administer [MEDICATION NAME] (medication used for opioid overdose) if there were any changes in her vital signs. On July 17, 2017 at 3:23 PM, E2 DON (Director of Nursing) stated the facility staff did not take any vital signs from May, 2017-June 2017 but hospice care took weekly vital signs. The hospice clinical note provided by the facility shows on May 18, 2017 R1 vital signs were: Blood Pressure 118/72, Pulse 70, respirations 18, and oxygen 94% on room air. R1's vital signs on June 22, 2017 were blood pressure 118/72, pulse 70, respirations 18, and oxygen 94% on room air. According to R1's Electronic Medication Record, R1's vital signs were created into the progress notes between July 3, 2017-July 6, 2017 with the exception of two entries. This is 7-10 days after the medication error incident occurred on June 26, 2017. On July 6, 2017 at 2:53 PM, E2 DON (Director of Nursing) stated the facility staff was documenting vital signs on paper and that is why there is late documentation. She expects the staff to document right away in the computer. R1's vital signs on June 26, 2017 at 7:50 PM were entered into her progress notes on July 5, 2017 (9 days after the incident) by E5 LPN: Blood pressure (BP)=105/68, pulse(P) 89, respirations(R) 18, oxygen level(02) 95% on room air(RA) and resident was alert and oriented. R1's vital signs on June 26, 2017 at 8:48 PM that were entered into her progress notes on July 5, 2017 (9 days aftger the incident) also entered by E5 LPN: Blood Pressure 116/82, pulse 75, respirations 18, oxygen level 96% on room air, and resident remained alert, oriented, and verbally responsive. R1's vital signs on June 26, 2017 at 9:45 PM that were entered into her progress notes on July 5, 2017 (9 days after the incident) entered by E5 LPN: Blood Pressure 110/82, pulse 87, respirations 16, oxygen level 94% on room air, resident remains verbally responsive. R1's vital signs on June 26, 2017 at 10:52 PM that were entered into her progress notes on July 5, 2017 (9 days after the incident) entered by E5 LPN: Blood Pressure 119/80, pulse 79, respirations 18, oxygen level 95% on room air, no changes in mental status, verbally responsive. The next progress note was entered on July 6, 2017 (10 days after the incident) by E10 RN (Registered Nurse) and only reflects R1's respiratory rate on June 27, 2017 at 12:25 AM: Respirations: 20 R1's vital signs on June 27, 2017 at 3:17 AM that were entered into her progress notes on July 6, 2017 (10 days after the incident) entered by E10 RN: Blood Pressure 100/66, pulse 74, respirations 22, oxygen level 91%. R1's vital signs on June 27, 2017 at 5:38 AM that were entered into her progress notes on June 27, 2017 by E10 LPN: Blood Pressure 104/68, pulse 64, respirations 16, oxygen 91%. Resident very lethargic this am. To remain in bed at this time. R1's progress note entered by E4 LPN on June 27, 2017 shows at 7:31 AM, R1 was not responsive to a sternal rub. Her pupils were pinpoint/fixed. Blood pressure was 86/65, respirations were 12, and oxygen level was 62%. Orders were received from Z1 NP at this time. E3 ADON entered a progress note on July 3, 2017 (7 days after the incident) at 9:53 PM to reflect on June 27, 2017 at 8:47 AM E3 was alerted that there may have been a medication error on June 26, 2017 during the night. E3 was asked to assess R1 around 7:00 AM. Upon R1's assessment, R1's blood pressure was 103/45, pulse 123, respirations 26 and shallow, and oxygen level was 73% on 2 liters of oxygen via nasal cannula. R1's pupils were pin point and fixed, non reactive to light. New order received from Z1 NP for [MEDICATION NAME] administration. [MEDICATION NAME] was administered and within 10 minutes, R1 began to wake up. R1's oxygen level increased to the upper 80, lower 90% on 5 liters of oxygen via nasal cannula. Vital Signs Chart documented as the following: June 26, 2017 7:50 PM=BP 105/68 P89 R18 O2 95% RA-note created on July 5, 2017 at 6:14 PM 8:48 PM=BP 116/82 P75 R18 O2 96% RA-created on July 5, 2017 at 6:22 PM 9:45 PM=BP 110/82 P87 R18 O2 94% RA-created on July 5, 2017 at 6:26 PM 10:52 PM=BP 119/80 P79 R18 O2 95% RA Res alert-created on July 5, 2017 at 6:37 PM June 27, 2017 12:25 AM=No vital signs. R20-Resident sleeping. Created on July 6, 2017 at 9:12 AM 3:17 AM=BP 100/66 P74 R22 O2 91% RA-created on July 6, 2017 at 9:24 AM 5:38 AM=BP 104/68 P64 R16 O2 91% RA-Resident very lethargic. Created on June 27, 2017 at 5:43 AM. 7:00 AM=BP103/45 P123 R26 O2 73% 2 liters of oxygen. Pupils pinpoint and non reactive. Created on July 3, 2017 at 9:53 PM. 7:31 AM=BP 86/65 No pulse documented R12 O2 62%. Res not responsive. [MEDICATION NAME] given. On July 6, 2017 at 3:20 PM, E5 LPN stated, Z1 NP said to call Z1 NP back if there were changes in her condition. We were monitoring for lethargy or respiratory depression. On July 6, 2017 at 2:10 PM, E4 LPN stated, E10 RN reported to me that there may have been a medication error. He said to monitor her vital signs. On July 10, 2017 at 1:45 PM, E3 ADON stated, A change in condition could include sedation, lethargy, changes in alertness, a decrease in blood pressure, increase in pulse, and decrease in oxygen level, or respiratory rate could increase or decrease. E10 RN should have notified Z1 NP at 3:17 AM. On July 10, 2017 at 2:55 PM, E2 DON (Director of Nursing) stated, The physician should be notified with changes in vital signs, altered mental status, or lethargy. Physician should have been notified if R1's blood pressure went down or she became lethargic. I would have called Z1 NP with R1's vital signs at 3:17 AM. On July 10, 2017 at 3:23 PM, E9 CNA (Certified Nursing Assistant) stated, My shift started at 10:00 PM on June 26, 2017. At the beginning of my shift, R1 was coherent. At about 4/4:30 AM, R1 wouldn't wake up and wouldn't move, so I told E10 RN. E10 RN assessed R1 and said that we would monitor her. Her eyes weren't open and she wasn't speaking. I think E10 RN was going to notify the doctor. On July 10, 2017 at 3:33 PM, E10 RN stated, E5 LPN told me R1 received an overdose of medications but I don't remember which ones. E5 LPN did not tell me how often to monitor R1. I think I took her vital signs twice. I let R1 sleep. R1 was lethargic in the morning of June 27, 2017, I figured she was ok. The CNA came and got me about 5:30 AM. I told the CNA that R1 had too many medications and needed to sleep it off. I would notify the NP with changes in respirations or if their vital signs changed. On July 11, 2017 at 9:48 AM, Z2 (one of the facility's pharmacy pharmacist) stated, The peak (time it takes for the drug to reach its highest effective action) of [MEDICATION NAME] extended release is approximately 10 hours. The patient could be extremely drowsy. The medication error could have made a difference in her condition since R1 needed the [MEDICATION NAME]. On July 13, 2017 at 4:32 PM, Z10 (Medical Doctor) stated, The peak time of [MEDICATION NAME] extended release is 8-12 hours. [MEDICATION NAME] is used for opiate reversal. The first sign of toxicity would be drowsiness. Pin point pupils would also signify opiate toxicity. The facility's policy on Change in Condition Physician Notification dated April 2014, shows all significant changes in resident status are thoroughly assessed .

Based on observation, interview, and record review the facility failed to transfer a resident who needs extensive assist, and history of falls, in a safe manor by not using a gait belt and 2 persons. This failure contributed to R7 experiencing a fall following a spontaneous fracture, and sustaining three additional fractures. R7 fractured both arms and both legs. This applies to 1 of 3 residents (R7) reviewed for falls in the sample of 8. The findings include: R7's most recent Face Sheet shows R7 has [DIAGNOSES REDACTED]. R7's Minimum Data Set (MDS) dated [DATE] shows R7 is cognitively intact, requires extensive assistance of 2 for transfers, and is not steady moving on and off the toilet (only able to stabilize with staff assist). R7 is independent with locomotion once in wheelchair and requires only setup help for eating. R7's Incident Report for July 4, 2017 shows R7 sustained a fall resulting in injury. R7 was in the bathroom, with an aide, transferring from the toilet to the wheelchair with assist of a walker when resident's leg popped and buckled at the knee. Resident was lowered to the floor per Certified Nursing Assistants (CNA). Laceration approximately 3 inches received to upper shin just below knee and right lower extremity exhibiting a visible outward rotation, not in alignment with knee. Resident able to move upper right extremity though pain expressed along with guarding. Resident alert and oriented throughout and Nurse Practitioner notified. 911 were contacted .Resident was transported to hospital emergency per ambulance. On July 11, 2017 at 4:00 PM, R7 was at the local hospital, laying flat on his back in bed, both arms and legs propped up on pillows. R7's arms were wrapped in bandages with only his fingers visible. R7 was pale and edematous. R7 was alert and stated where he was, the date, and the last holiday. R7 stated he was transferring from the toilet to the wheelchair when his legs gave out and he fell down on both knees. There was just one girl helping me and I told her my legs weren't working and then down I came. There was no belt around by waist, they don't usually use one. I don't recall hitting anything on my way down I was just weak that day. I broke both of my arms and legs. On July 11, 2017 at 4:15 PM, Z7 Registered Nurse (RN) at the hospital stated R7 has an open fracture to his tibula/fibula of the right leg, a closed fracture to his tibula/fibula of the left leg, and fractures to the humerus of both arms. All 4 of R7's extremities are splinted. R7 is a high risk for surgery and there are no plans for surgery. On July 12, 2017 at 2:00 PM, Z8 RN at the hospital stated R7 can't do anything, not even feed himself. He can only move his fingers and he is splinted everywhere else. R7's Hospital emergency room History and Physical dated July 4, 2017 at 11:11 AM, shows R7 had a spontaneous open fracture of his right proximal tibia and fibula. He then fell breaking his other 3 extremities. Principal Problem: open fracture of proximal end of right tibia and fibula (lower leg) Active Problems: Closed fracture of proximal end of tibia and fibula(lower leg) , Closed supracondylar fracture of left humerus( upper arm by elbow), and Closed supracondylar fracture of right humerus (upper arm by elbow). R7's Hospital Orthopedic Surgery Consultation Note dated July 4, 2017 at 3:49 PM shows R7 right proximal tib-fib resulted in a laceration to the right leg anteriorly over the fracture site. The right proximal tib-fib fracture site is exposed to the external environment. On July 18, 2017 at 12:12 PM, Z11 Orthopedic Physician stated R7 had a spontaneous fracture to the right leg, fell and then broke other 3 extremities. R7's weight from falling from a standing height would have been enough for the other three fractures. R7's arm fractures were the same type of break and in the same location on both arms. The combination of velocity of the fall and the torque from R7's arms going over his head could break the humerus bones. Based on simple physics if R7 was lowered to the ground slowly there would have been less injury. My guess is that R7 needs 2 people to transfer. R7's Nurses Note dated July 3, 2017 at 1:33 PM shows resident requests to remain in bed today, confusion noted. Unable to answer questions appropriately. Current loss of appetite noted. Orders received for STAT CBC. R7's Nurses Note dated July 3, 2017 at 8:21 PM shows R7 res had been in bed throughout shift .res is lethargic and has episodes of confusion. Res usually wakes up, responds to name when called upon, talks to writers and will go back to sleep. O2 sat is 90% at 4 liters oxygen .Res bilateral lower extremities warm to touch and red. Nurse Practitioner notified and orders received for an antibiotic. R7's Nurses Note dated July 4, 2017 at 7:00 AM, shows R7 alert and responsive to verbal/tactile stimuli .antibiotic therapy in progress for cellulitis to bilateral lower extremities (reddened, warm to touch and slightly swollen). R7's Nurses Noted dated July 4, 2017 at 11:20 AM (after R7's fall) shows resident in bathroom with aide transferring from toilet to wheelchair with assist of walker when resident's leg popped and buckled at the knee, resident lowered to floor per CNA. Laceration approximately 3 inches across received to upper shin just below the knee, bleeding profusely .Area stabilized due to right lower extremity exhibiting a visible outward rotation, not in alignment with knee. Resident able to move upper extremity although pain expressed along with resident guarding .Resident alert and oriented throughout ordeal. Resident noted to be lethargic this am heavy smoker although resident could only take 3 puffs this am. Oxygen delivered per nasal cannula at 4 liters, oxygen saturation 88%. Face flushed, skin clammy, lips slightly blue in color .Resident transported to emergency via ambulance. On July 12, 2017 at 12:30 PM, E15 Licensed Practical Nurse (LPN) stated she was taking care of R7 the day of the incident. E15 stated R7 was not his normal self that day, he was off a little and a little weak. R7 was alert and oriented but his face was flushed and his oxygen saturation was 89-90% on 4 liters oxygen via nasal cannula. E15 stated I told him I hope I don't have to send you out this morning. R7 is a heavy smoker and had only smoked half a cigarette and came back in and requested his nebulizer treatment which was very uncommon. E15 stated I normally have to talk him into taking his treatment. R7 needed to go to the bathroom and I assisted him to the toilet and went on lunch. R7 usually sits in the bathroom a good 30 minutes. When I came back from lunch, I went to the room and R7 was already on the floor and 911 had been called. R7 was able to tell me everything that happened he was alert and oriented. R7 was guarding his right arm and his right leg didn't look right it was bowed out to the right. E15 stated she helped paramedics load R7 up. On July 12, 2017 at 9:40 AM, E14 CNA stated she answered R7's bathroom call light and R7 stated he was ready. E14 stated R7 stood up from the toilet, while holding his walker. E14 wiped R7 and fastened the incontinence brief on the right and reached over to fasten the left side of the brief when R7 stated I can't do it. E14 stated she felt he was going down and told him to go down R7 go down. While R7 was going down he held onto the walker the entire time. R7 landed on his knees and stated I think I broke my leg and was holding one arm. On July 13, 2017 at 1:35 PM, E15 stated prior to R7's fall, R7 was acting strange that day. R7 went outside to smoke (without his oxygen) and came back in and requested his oxygen and breathing treatment. R7 only had half of his breathing treatment and then wanted to go to the bathroom. R7 did not have oxygen on in the bathroom. R7 must not have been feeling the greatest to ask for oxygen and his breathing treatment. On July 12, 2017 at 3:20 PM, E17 RN stated R7 transfers with a walker, a gait belt, and 1 or 2 staff to assist depending on if he is compliant with his oxygen. If R7 is noncompliant with his oxygen it makes him weak and lethargic and then 2 staff members are needed for transfers. On July 12, 2017 at 12:40 PM, E12 Restorative Nurse stated she was paged to R7's room when R7 fell . E3 saw R7 on his knees still holding onto walker with blood on the floor. E3 left R7's room to go call the doctor and 911 and did not see if R7 had a gait belt on. R7 has weakness in his legs and requires a gait belt, a walker, and one person assist for transfers, but if R7 is having an off day that staff should go to the next step of 2 person assist or a mechanical lift. E12 stated she does the transfer and fall risk section of care plans and prints the Kardex MDS book for the CNAs. The Kardex book is updated and is the most current. When this surveyor inquired about R7's Look Back Charting and Transfer & Bed Mobility Assessment (completed by her) showing R7 requires extensive assistance of 2 for transfers E12 was not sure of the discrepancy and stated R7 fluctuates. On July 12, 2017 at 12:50 PM, E2 Director of Nursing stated staff is expected to follow the residents care plan. E2 stated she did not know how R7 transferred and could not explain why current charting shows R7 transfers with extensive assist of 2 and the staff were using one person for transfers. On July 12, 2017 at 1:00 PM, E3 Assistant Director of Nursing (ADON) stated R7 transfers with 1 assist and a gait belt. E3 stated a change in condition could change a residents needs for assistance and could explain why the recent charting shows R7 needs 2 assist. On July 12, 2017 at 11:55 AM, Z5 Occupational Therapist stated R7's last Physical Therapy and Occupational Therapy assessments were done (June 20, 2017) 2 weeks before his fall on July 4, 2017, when his therapy ended. At 12:12 PM, Z5 stated R7's therapy report dated June 20, 2017 shows R7 requires moderate assistance (26-75%) to transfer to the toilet because on a good day R7 needs less help but if R7 is lethargic he needs more help thus the range. R7's Minimum Data Set (MDS) dated [DATE] (which is incomplete-still in progress) shows R7 requires extensive assist of 2 staff for toileting and is not steady moving on and off the toilet. R7's Look Back Charting Forms for July 2-3, 2017 show R7 was alert and oriented, transfers with extensive assist of 2, has shortness of breath with exertion and at rest, is a fall risk, and was on acute monitoring for infection. R7's Transfer & Bed Mobility/Limited Lift Review Form dated June 27, 2017 completed by E12, shows R7 is an extensive assist of 2 persons for transfer, has poor ability to stand and maintain balance, is not steady moving on and off toilet, and has a recommendation resident will be designated for a Sit to Stand Transfer Device with a Standard Sling as the resident requires Extensive Assist for transfer abilities with staff assistance at over 26% weight bearing assistance for transfers. R7's MDS Kardex Report in the CNA book at the Nurses station dated June 13, 2017 shows R7 requires extensive assistance of 2 person physical assist for transfers and is not steady moving on and off the toilet. R7's Fall Risk Review dated June 27, 2017 shows R7 is a high fall risk due to history of falls (bilateral femur fractures in October 2016), R7 exhibits loss of balance while standing, and has [DIAGNOSES REDACTED]. R7's Care Plan (not updated since April 29, 2016) shows R7 is at risk for falls, has general weakness, moderate to severe range of motion loss to all extremities, bilateral femur fractures, and requires extensive assistance with most activities of daily living. R7's interventions shows gait belt for all transfers and if resident appears to have declined staff will get more assistance and/or use mechanical lift for transfer. The facility's Lifting/Transfer Policy dated February 2017 shows the purpose To promote comfort . and decrease the possibility of injury to the resident and/or nursing personnel. The facility's Gait Belt Policy dated February 2017 shows the purpose of gait belts To provide support and safety during ambulation, lifting, or transferring residents.

Based on interview and record review, the facility failed to administer medications in a manner to avoid a significant medication error. This failure resulted in R1 receiving R3, R4, R5, and R6's opioid medications, which contributed to R1 becoming unresponsive and requiring an emergency opioid reversal medication. This applies to 1 of 3 residents (R1) reviewed for medications in the sample of 8. The findings include: R1's Progress Notes created on July 3, 2017 by E5 LPN (Licensed Practical Nurse) (7 days after the incident) shows on June 26, 2017 at approximately 7:45 PM, E5 LPN mistakenly gave R1 [MEDICATION NAME] 90 mg and [MEDICATION NAME] 5/325 two tablets. Upon realizing the medication error, the DON (Director of Nursing) and NP (Nurse Practitioner) was notified. Orders received to monitor resident closely for now and inform Nurse Practioner for any changes in resident's condition. Resident resting in bed at this time, alert and verbally responsive. On July 6, 2017 at 3:20 PM, E5 LPN stated, I was preparing medication pass when a CNA (Certified Nursing Assistant) called for my help with another resident. I placed a medication cup that had [MEDICATION NAME] 60mg, [MEDICATION NAME] 30mg, and two [MEDICATION NAME] 5/325 tablets into the top drawer in the medication cart. On July 10, 2017 at 2:50 PM, E5 LPN stated the [MEDICATION NAME] 60mg tablet came from R5's medication card, the [MEDICATION NAME] 30 mg came from R3's medication card, one [MEDICATION NAME] 5/325 mg tablet came from R4's medication card, and one [MEDICATION NAME] 5/325 mg tablet came from R6's medication card. E5 LPN stated R3, R4, R5, and R6 were all asking for pain medications so she put them all in the same medication cup to be able to get to the faster before the CNA requested her help in another room. R1's Progress Notes that were created on July 5, 2017 (9 days after incident) by E5 LPN, show on June 26, 2017 at 8:48 PM, R1 remained alert and oriented and verbally responsive. R1's blood pressure was 116/82, pulse 75, respirations 18, and oxygen level was 96% on room air. R1's progress note created on July 6, 2017 (10 days after incident) by E10 RN (Registered Nurse) shows on June 27, 2017 at 12:25 AM, R1 appeared to be sleeping and her respirations were 20. No other vital signs were documented at this time. R1's progress noted created on July 6, 2017 (10 days after incident) by E10 RN shows on June 27, 2017 at 3:17 AM, R1's blood pressure was 100/66, pulse was 74, respirations 22, and oxygen level was 91% on room air. The next progress note was created on June 27, 2017 (day after event) and showed at 5:38 AM, R1 was very lethargic. Blood pressure 104/68, pulse 64, respirations 16, oxygen 91% on room air. E4 LPN created a progress note that shows on June 27, 2017 at 7:31 AM, R1 was not responsive to sternal rub. Her pupils were pinpoint/fixed. Blood pressure 86/65, respirations were 12, and oxygen level was 62%. Orders received from Z1 NP to give 1CC (cubic centimeters) of [MEDICATION NAME] (medication used to reverse opioid overdose) immediately. E3 ADON (Assistant Director of Nurses) created a note on July 3, 2017 (7 days after the incident) that shows on June 27, 2017 around 7:00 AM, R1's blood pressure was 103/45, pulse 123, respirations shallow 26, oxygen level 73% on 2 liters of oxygen. R1's pupils were pinpoint, fixed, and not reactive to light. Z1 NP (Nurse Practitioner) was notified and an order for [REDACTED]. R1 stated she felt tired. Oxygen level increased to upper 80 to lower 90% on 5 liters of oxygen. E4 LPN entered a progress note dated June 27, 2017 that shows at 7:40 AM, R1 was alert and verbally responsive. Blood pressure 89/68, no pulse documented, respirations 18, and oxygen level 98 % with 2 liters of oxygen. On July 10, 2017 at 3:23 PM, E9 CNA stated, At the beginning of my night shift on June 26, 2017 at about 10:00 PM, R1 was coherent. At about 4/4:30 AM, R1 wouldn't wake up and she wouldn't move or speak or open her eyes. I told E10 RN and he assessed her and said we were going to monitor her. I think E10 RN was going to notify the doctor. On July 10, 2017 at 3:33 PM, E10 RN stated, E5 LPN told me that R1 received an overdose of medications, but I don't remember which ones. E5 LPN didn't tell me how often to monitor R1. I took R1's vital signs twice that shift. At about 5:30 AM (June 27, 2017), the CNA came and got me. R1 was lethargic. I told the CNA that R1 had too many medications and needed to sleep it off. When the day nurse came in at 7:00 AM, she felt R1 was more lethargic. On July 6, 2017 at 1:00 PM, Z1 NP stated she was notified of the medication error on Monday night (June 26, 2017). Orders were given to monitor vital signs every hour. Watch for respiratory depression and increased lethargy. [MEDICATION NAME] 90 mg is a large dose. Give [MEDICATION NAME] if there is any change in R1's vital signs. R1 responded to the [MEDICATION NAME]. On July 6, 2017 at 2:10 PM, E4 LPN stated, On the morning of June 26, 2017, R1 was her normal self. (When questioned regarding the medication error that occurred on June 26, 2017) During change of shift report, E10 RN reported to me that there may have been a medication error and to monitor R1's vital signs. At about 7:10AM, R1 was not responsive. Z1 NP gave an order to give [MEDICATION NAME]. R1 was alert and responsive within a few minutes after the [MEDICATION NAME]. [MEDICATION NAME] reverses the effects of opiates. On July 6, 2017 at 2:30 PM, E3 ADON stated, At about 7:00 AM, E10 RN reported that there was a possible medication error. E4 LPN and I went into R1's room to assess her. Her pupils were pinpoint and she wasn't responding to a sterna rub. E4 LPN administered [MEDICATION NAME] and within approximately 5-10 minutes later R1 came around. R1's Medication Review Report shows an order for [REDACTED]. R3's Medication Administration Record [REDACTED]. R4's Medication Administration Record [REDACTED]. R5's Medication Administration Record [REDACTED]. R6's Medication Administration Record [REDACTED]. On July 6, 2017 at 8:08 AM, Z9 RN stated R1 was her normal baseline self prior to the medication error. R1 was eating, propelling herself in her wheel chair, smoking, and socializing. On July 14, 2017 at 8:45 AM, Z9 stated R1 passed away on July 3, 2017. Z9 informed the coroner of the medication error that occurred at the facility on June 26, 2017 because there were concerns. Z9 stated the medication error occurred on June 26, 2017, R1 possibly aspirated on June 29th, then passed away on July 3, 2017. On July 13, 2017 at 4:32 PM, Z10 MD (Medical Doctor) stated [MEDICATION NAME] is used for opiate reversal. One of the first signs of opiate toxicity would be drowsiness. Pinpoint pupils would signify opiate toxicity. On July 12, 2017 at 10:15 AM, E12 RN stated [MEDICATION NAME] is used for someone that overdoses. If R1 did not receive [MEDICATION NAME], she could've stopped breathing or not gotten enough oxygen. On July 11, 2017 at 9:48 AM, Z2 (Pharmacist) stated, If a resident received [MEDICATION NAME] 90 mg and [MEDICATION NAME] 5/325 two tablets, the resident could be extremely drowsy. The medication error could have made a difference in her condition, since R1 needed the [MEDICATION NAME]. On July 10, 2017 at 2:55 PM, E2 DON (Director of Nursing) stated, It is not at all ok to put multiple medications for different residents together because a medication error can occur. The facility's undated Medication Administration Policy shows medications must be administered in accordance with a physician's orders [REDACTED].medications may not be pre-poured .only prepare and administer medications for one resident at a time.

Based on observation, interview and record review, the facility failed to ensure the requirements for involuntary discharge were met. These failures resulted in residents being displaced to facilities that could not meet their specialized needs such as attending activities/groups to promote independance and peer socialization. This applies to 4 of 6 residents (R1, R3, R4 and R6) reviewed for involuntary discharges in the sample of 13. The findings include: 1. On May 17, 2017 at 1:00 PM, R1 was observed lying in a small room in the local hospital emergency department. R1 was lying on a bed watching television. R1 would get out of the bed and ambulate in the emergency department hallways while squeezing a foam star (used for stress relief.) R1 ambulated on the balls of his feet with a limp to his gait. R1 would begin walking towards the exit doors and was easily redirected by the hospital staff. R1 was dressed in a hospital gown and gripper socks rather than his regular clothing. R1 was calm and cooperative but spoke in a child like manner. R1 said (facility name) put me in a police car and brought me here (hospital). R1 said he hit someone at (facility name). R1 said It was morning about 9:30-10:00 (AM) just before the coffee time. E17 (physical therapy) was getting on my nerves because they were trying to make me do exercises and I refused. She (E17) said she would put on my chart that I refused and I got angry because I didn't want it to be there (on the chart). R1 said he doesn't really like it at the facility because they yell at me, steal from me and are mean to me. R1 said That morning (May 9, 2017) I gave the middle finger to a staff member when I was going to get coffee. She pi**ed me off and I told her to leave me alone. I went to (E4's - Psychosocial Rehabilitation Services Director - PRSD) office and talked awhile. E4 was pi**ing me off so I told her to leave me alone I was going to my room. R1 said I told those a**holes to leave me alone. R1 said I kicked (E11 Psychosocial Rehabilitation Services Counselor - PRSC) in the knee. Sometimes I have hit staff in the past. My dad came to see me that day (May 9, 2017) and told me they didn't want me back. I don't feel good about that. R1 had no furniture other than the bed and hospital overbed table. R1's lunch meal was on the overbed table. R1 stated he ate in this room while at the hospital and not in the dining room as he had done at the facility. On May 17, 2017 at 1:15 PM, Z10 (Center for Mental Health Manager) stated the facility has brought residents to the hospital emergency department before using the involuntary discharge. Z10 said placement is difficult and they don't qualify for acute care of the hospital and it can become a prolonged process. Z10 said R6 was brought to the hospital a year ago in the same manner as R1. Z10 said R6 was housed in the acute setting for 315 days before placement could be found. Z10 stated it has been her experience working in long term care facilities that discharges seem to depend on who is hit at the facility. Z10 said if administrative staff get hit, the residents are involuntarily discharged on an emergency basis. On May 17, 2017 at 1:30 PM, Z8 (emergency room Physician) said the sending facility reported R1 was aggressive. Z8 said the facility immediately told the Hospital emergency room staff they would not accept R1 back to the facility. The facility then sent staff back to the emergency department to serve R1 with a notice that said R1 had 24 hours to find somewhere else to live. Z8 said R1 is mentally unable to care for himself. Z8 said the facility did not express to the hospital what needs the facility could no longer provide. Z8 said We (hospital) ruled out any medical conditions that could be affecting (R1's) behavior, such as a UTI (urinary tract infection). Everything came back fine medically so we called the facility to inform them we were sending him back. They refused to take him. Z8 said sometimes long term care facilities will bring residents to the emergency department and say they won't take them back but when the facilities are reminded it is illegal to dump residents, the facility will usually come back and pick up the residents. Z8 said since R1's arrival, R1 had exhibited no aggressive behaviors. Z8 said since R1's mother is his POA (power of attorney) the hospital called her to come get R1 as he was being discharged . Z8 said R1's POA became upset and said he could not come home and she would file a restraining order to prevent this from occurring. Z8 said R1 is too intellectually disabled to be discharged to the streets so he has been kept in the emergency room . Z8 said she is not aware of any needs R1 requires that could not be met by the long term facility. Z8 said R1 has no ability to obtain housing, has self care deficits, can't hold a job, can't be responsible for finances and has [DIAGNOSES REDACTED] which affects intellectual development. Z8 said An emergency department is to rule out life threatening and emergent conditions that need to be addressed within 24 hours. We can not meet long term care needs. Z8 said R1 has not exhibited any aggressive behaviors since his being brought to the emergency department 8 days ago. On May 17, 2017 at 2:00 PM, E6 (Activity Aide) said the facility has a daily Coffee Clutch at 10:00 AM and 2:00 PM. E6 stated R1 typically attends both groups as well as the 1:30 PM library activity. E6 said R1 was the first in line for the 10:00 AM group on May 9, 2017 and was not exhibiting any unusual behavior. E6 said R1 asked her if she wanted to see something funny and then flipped me off. E6 said I took it as a joke because he was not aggravated at all. E6 said about 10:15 AM, R1 came up to her and apologized repeatedly saying I'm sorry. E6 said after R1 repeated his apology several times he asked her to remove his name from the 1:30 PM library time. E6 said she thought his asking to be removed was a little strange because he always attends. E6 said she looked at the list and R1's name had already been removed. E6 said R1 then began to repeat, take me off the list! E6 said at that point she realized R1 was becoming agitated and so she walked him over to E4's PRSD (Psychosocial Rehabilitation Services Director) office to deal with his escalating behavior. On May 17, 2017 at 11:20 AM, E4 said on May 9, 2017, R1 was seated in her office because he was upset with something that happened in the morning activities. E4 stated R1 was rocking back and forth and shaking his head which is what he does when his behavior is escalating. E4 stated she attempted to get R1 to discuss what was upsetting him but he refused to speak. E4 said she let R1 sit in her office, as it was a calm environment, as she continued to work. E4 said eventually R1 stood up and punched a bookcase in her office and left to go to his room. E4 said she followed R1 to his room and asked R8 (R1's roommate) to go tell the nurse to bring R1 his PRN medication to decrease R1's chance of exploding. On May 18, 2017 at 10:00 AM, E7 LPN (Licensed Practical Nurse) said she was not R1's nurse on May 9, 2017 but went down the hallway to the room where R1 was residing because she heard loud voices. E7 said E4 and R1 were in his room, alone. E7 said R1 was lying on his bed shaking his head from side to side but easily redirectable. E7 said E4 was sitting on R1's bed. E7 said R1 was calm at that time but E4 told E7 to get R1 his PRN medication ([MEDICATION NAME].) E7 said she left to obtain the medication and could not locate it. E7 said she checked the convenience box medications and no [MEDICATION NAME] was available. E7 said she was gone less than 5 minutes and then she returned to the room to inform E4 the medication was not available. E7 said by the time she returned to R1's room, E4 and R1 were in the hallway and E4 said R1 hit her. E7 said R1 was still easily redirectable as she locked arms with him and lead him back into his room. E7 said about that time a couple of PRSC's (Psychosocial Rehabilitation Services Counselors) had arrived to R1's room so E7 left. E7 said she couldn't imagine what happened in the 5 minutes she was gone. E7 said perhaps E4 and R1 had words. E7 said if E4 told R1 she was sending him out (to hospital or elsewhere), that would have set him off. E7 said I am guessing that is what happened, that she (E4) escalated (R1). On May 18, 2017 at 10:15 AM, E10 PRSC (Psychosocial Rehabilitation Services Counselor) stated he was not aware of any issues on May 9, 2017 until E11 (PRSC) came to him and told him R1 was having an episode by his room. E10 said he went to the hallway where R1 lives and saw E4 and E5 LPN (Licensed Practical Nurse - MDS (Minimum Data Set) Coordinator) standing in the hallway with R1. E10 said R1 was yelling and swinging his arms but he did not witness R1 hit anyone. E10 said E5 left and R1 walked into his room and laid on his bed. E10 said at that point, E4 called out for someone to call 911. E10 said R1 got up out of bed and began repeatedly yelling No don't call! I don't want to go! E10 said R1 was arrested when he was about [AGE] years old so he knows what 911 means. E10 said, I feel if (E4) had not said she was calling 911 in front of (R1), he would not have escalated to that point. E10 said R1 began yelling at E4 to get out of his room. E10 said then R1 threw a water bottle at E4 and tried to run out of the room. E10 said at that point, he and E11 used a bear hug technique to put R1 on the bed. On May 18, 2017 at 10:15 AM, E10 said he quit working at the facility a few days after R1's event of May 9, 2016 because he felt the management staff were unprofessional and did not handle R1's situation correctly. E10 said R1 has a history of physically abusive behavior and has even hit E10 in the past. E10 said he felt the only reason R1 was involuntarily discharged was because this time R1 hit E4 (management) instead of line staff. On May 18, 2017 at 1:15 PM, E11 (PRSC) stated she was in the dining room for lunch when she was approached by a CNA (certified nursing assistant) who told her there was a problem in the hallway. E11 said she stepped into the hallway and saw E4 and R1. E11 said she did not notice any hitting or swinging or arms but knew R1 was upset because he was rocking back and forth. E11 explained that is a self soothing behavior exhibited by R1 when he becomes upset. E11 said E4 was yelling down the hall for someone to call 911. E11 said R1 is afraid of the police and he definitely heard E4 yell call 911. This is when R1 threw a water bottle at E4. E11 said she never saw R1 hit E4. E11 said R1 stomped on her foot and kicked her shin during the side body hug take down on May 9, 2017. E11 said the first time R1 hit her was approximately 2 years ago. E11 said R1's behavior cycles. E11 said R1 escalates then calms down. E11 said his escalating behavior [MEDICAL CONDITION] in 30-45 minutes. E11 said R1 has been sent to the hospital many times for behaviors but returns the the facility calm and no interventions were done. E11 said R1 is afraid of going to the hospital but more afraid of the police so typically if he is sent to the hospital for evaluation, he is calmed down by the time he arrives to the emergency room . E11 said she saw no difference in this episode as compared to any of his past behaviors. E11 said E9 (Housekeeping Director) was called to assist after she and E10 placed R1 on the bed because E9 gets along very well with R1. E11 said E9 was able to calm R1 enough that by the time the police arrived, R1 would have been fine to stay in the facility. E11 said at that point, he probably would have even take an oral PRN medication if the nurse wanted him too. E11's account of the events involving R1 on May 9, 2017 were consistent with E10's interview. On May 18, 2017 at 2:40 PM, E9 stated he was paged to assist with R1 on May 9, 2017. E9 said he has a good rapport with R1. E9 stated R1 has exhibited these behaviors in the past but he calms down quickly. E9 said I have dealt with him a lot when he is like this. E9 said he and E10 sat on the bed with R1 for between 2-4 minutes and he was calm. E9 said R1 asked if he could go to the bathroom and E9 said he could and if R1 stayed calm he would sit on the bed across from him instead of next to him. R9 said he returned calm and they sat across from each other talking for about 7-10 minutes before the police arrived. R9 said R1 was calm and quiet the entire 9-14 minutes and left with the police quietly. E9 said I felt his escalating behavior was over. On May 19, 2017 at 4:35 PM, Z9 (Hospital Psychiatrist) stated the events of May 9, 2017 at the facility will have permanent psychosocial harm for R1. Z9 said anyone kicked out of their home of 6 years and threatened to be arrested is detrimental especially with (R1's) mental and emotional developmental delay. Z9 stated R1 has the mentality of approximately a 4 year old. Z9 said early signs of R1 becoming agitated include him talking about superhero's and bad guys (good vs evil), his tone will become louder and he will begin to pace and increase self-talking. Z9 said had staff intervened at the facility when R1 was at this point, he likely never would have become physically aggressive. Z9 said R1's PRN [MEDICATION NAME] should have been given prior to him getting to the point of having rocking back and forth behaviors. Z9 stated R1 has not exhibited any aggressive behaviors since his arrival to the hospital 10 days ago. On May 19, 2017 at 9:56 AM, an interview was conducted with Z7 (Facility Psychiatrist). Z7 stated he has never witnessed one of R1's episodes. Z7 states he based his decision to have R1 involuntarily discharged on the reports given to him by the facility staff that R1's behavior was escalating. Z7 stated giving R1 the ordered dose of PRN [MEDICATION NAME] (antipsychotic) theoretically would of minimized his aggression but it hasn't been working. Z7 then stated he was not made aware R1 had missed 2 consecutive doses of [MEDICATION NAME] prior to the episode of May 9, 2017 and was not aware that the PRN medication was not being offered, given nor even available at the facility. Z7 said the IM [MEDICATION NAME] would have been appropriate to be administered even if R1 was actively exhibiting aggressive behaviors. On May 23, 2017 at 8:40 AM, Z4 (Long Term Care Ombudsman) said she has many concerns regarding this facility and the involuntary discharges. Z4 said, They are dumping people at hospitals. It's pretty clear. Z4 stated R1 was eventually admitted to a room on the hospital's 4th floor because placement could not be found and he could no longer remain in the emergency room . Z4 said R1 had developmental disabilities in addition to his mental health [DIAGNOSES REDACTED]. A hospital consultation note written by Z9 on May 12, 2017 showed review of the medical record indicates patient (R1) presenting to the emergency department multiple times with similar complaints from (facility name) .At this time, (R1) does not meet criteria for acute psychiatric hospitalization . Hospital/Emergency Department progress notes since R1's arrival May 9, 2016 showed R1 has exhibited no aggressive behaviors. The notes showed R1 is cooperative and easily redirectable. The May 9, 2017 note at 4:49 PM showed R1 told the hospital staff he was not going to hurt anyone, that he was just mad (earlier) because (E4) told him he was going to jail. The facility census sheet showed R1 was initially admitted to the facility on [DATE] making him a resident of the facility for almost 6 years. The August 16, 2016 social service note of 10:26 AM, showed R1 was placed on a 1:1 (one staff member to care for R1 only) and an involuntary petition was completed and R1 was sent out to the local hospital to be evaluated for exhibiting aggressive behaviors to include throwing chairs, attempting to hit staff, and making threats to himself and his parents. The Nursing progress note dated August 16, 2016 at 10:30 PM showed R1 returned from the hospital emergency department and was accepted back into the facility with no behaviors being exhibited. The November 16, 2016 at 4:18 PM and February 13, 2017 at 3:50 PM social service notes showed R1 hasn't exhibit(ed) any incidents of aggressive behaviors during this quarter and his mood status remains stable. The January 3, 2017 Psychiatry Note timed 8:02 PM showed R1 is stable. On March 7, 2017 at 11:24 AM, a social service note showed R1 was very agitated and aggressive .threw a table .an involuntary petition was completed and (R1) will be sent to the ER (emergency room ) for a psych evaluation. The nursing note dated March 7, 2017 at 6:27 PM showed R1 was again returned and accepted back to the facility with no new orders and displaying appropriate behaviors. Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors are completed quarterly on all residents by the social services department. R1's assessments completed between February 22, 2016 and February 13, 2017 showed no changes in R1's risk level. All assessments identified R1 as Potentially able to integrate with structure, direction, and supportive counseling. All progress notes to include physician, nurse practitioner, psychiatrist and psychologist for R1 for the past year were requested. All records/notes provided were reviewed with no mention made of difficulties or changes in mood/behavior documented until May 9, 2017. R1's care plan for a history of exhibiting physically and verbally aggressive behavioral symptoms when he is agitated as evidenced by hitting staff ., initiated September 15, 2014 lists interventions to include: avoid over-stimulation (e.g. noise, crowding); avoid power struggles with resident; identify maladaptive behaviors before they become aggressive and encourage the use of PRN medications; try not to reason with or confront the resident; and when resident becomes physically abusive, keep distance between resident an others (e.g. staff, other residents, visitors). The facility's policy dated March 2017 titled Behavior Crisis showed protocol is to diffuse crisis through calming communication and assess the need for chemical restraint. 2. R6 was a resident at the facility from March 23, 2010 to May 19, 2016 according to the facility census sheet. The facility provided a prescreening assessment for R6 dated June 26, 2008. The prescreening assessment lists the following: Physical Violence towards others = moderate. Recently twisted his father's arm and hit another client in January 2007; Poor Judgement placing self or others at risk = High. Poor self care, no insight into his delusions, may be putting others at risk; Serious wandering elopement risk = Moderate; and Sexual Aggression = High. R6 has expressed sexually inappropriate behaviors. A nursing note dated May 20, 2016 at 4:20 PM, describes R6 exhibiting inappropriate sexual behaviors with peers. At 7:47 PM, the nursing note showed R6 was sent to the local hospital emergency department for a psychiatric evaluation. At 10:00 PM, the nursing notes showed a call was received from the local hospital emergency room stating that R6 was medically cleared and needed to return to the facility. Facility social service progress notes document attempts to locate alternative placement was being sought. A nursing note dated May 22, 2017 at 1:33 AM, (over 2 days after R6 was cleared to return to the facility), the emergency department again contacted the facility and stated R6 was cleared and needed to return to the facility. The progress note (authored by E18 Registered Nurse), showed E18 stated he would not accept R6 back to the facility. On May 30, 2017 at 11:30 AM E4 said R6 was sent to the local hospital emergency department due to inappropriate sexual behaviors. E4 said R6 was not involuntarily discharged . E4 said she had made arrangements for R6 to be transferred to (another facility). E4 said the new facility was supposed to work with the hospital for a direct admit from the emergency room to their location. E4 said the hospital called their facility at 1:00 AM and the nurse said he wouldn't take R6 back due to the time of the day/night. E4 said I don't know why our nurse didn't explain R6 was set to go to (another facility). E4 said the local hospital never relayed to her or their facility that the (other facility) was no longer an option for R6. On May 19, 2017 at 4:35 PM. Z9 (Hospital Psychiatrist) stated this local long term care facility sent R6 to their hospital with severe to profound mental disabilities, a PEG (Percutaneous Endoscopic Gastrostomy) tube and incontinence of stool. Z9 said R6 had lived at the facility for 4 years and came to the hospital in the same way as R1. Z9 said R6 was listed as his own guardian and could not make his own decisions. Z9 said R6 needed Mental Health services not psychiatric services. Z9 said R6 was eventually admitted to the hospital acute psychiatric facility and was a patient for just shy of 1 year. Z9 said due to the hospital being an acute psychiatric facility, they (the hospital) did not have the resources available to obtain mental health placement for R6. Z9 said R6 is now in a Group Type home and functioning much more independantly with the services that were not available to him at the hospital. 3. R3 was admitted to the facility on [DATE] according to the facility census sheet. R3's psychiatric progress note dated July 12, 2016 showed staff report stable mood and psychotic symptoms. The September 5, 2016 psychiatric progress note showed R3 has exhibited no aggressive episodes since admission to the facility. The January 3, 2017 psychiatric progress note showed R3 with continued stable mood symptoms, no acute changes. A December 5, 2016 social service note showed R3 had (an) altercation with staff during lunch .(R3) became agitated and began swearing at staff .was redirected. The January 10, 2017 social service note showed R3 has verbal confrontations with others. A January 13, 2017 social service note showed R3 took a full cup of water and threw it on a peer as he was angry that the peer spilled (R3's) apple juice. A January 30, 2017 social services note showed R3 had been asking to have homicidal ideation removed from his [DIAGNOSES REDACTED]. physical and verbal aggressive behaviors since his admission to this facility, she does not feel it's appropriate to remove the [DIAGNOSES REDACTED]. There was no documentation provided that R3 had ever been involuntarily discharged for these documented behaviors. The nursing progress note dated March 3, 2017 at 10:16 AM showed housekeeping staff alerted the nurse that R3 was on the floor. The note showed R3 stated he stumbled over his wheelchair and fell . Attempts to assess R3's right hip were unsuccessful and R3 was sent to the local hospital for a medical evaluation. The March 3, 2017 progress note of 10:18 AM showed a hospital nurse called the facility to make them aware R3 expressed having thoughts of hurting another resident at the facility. The nursing note of March 3, 2017 at 12:24 PM showed R3 was being admitted to the local hospital with a [DIAGNOSES REDACTED]. A hospital emergency department note dated March 3, 2017 at 12:28 PM showed E13 RN (Registered Nurse - long term care facility) told the emergency department RN the facility won't take (R3) back due to (his) threats against roommate. R3 was served with a notice of involuntary discharge on March 3, 2017, 3 days after sustaining a [MEDICAL CONDITION]. The reason listed on the discharge papers was the safety of individuals in this facility is endangered. R3's care plan initiated October 7, 2016 showed a focus area of manipulative behavior as evidenced by making statement of wanting to blow peers up, stating he has a plan to act 'crazy' so he can get kicked out of this facility, threatening to call IDPH (Illinois Department of Public Health), his insurance caseworker and local news stations to report the facility, etc. The interventions included educate R3 on the importance of using appropriate skills vs. making threats towards others and towards the facility; redirect; remind R3 inappropriate behavior will not be tolerated; and set clear limits for expected behavior. On May 30, 2017 at 11:05 AM, E4 stated R3 was transferred out due to a fall. E4 said the facility made the decision the day R3 was sent out for the fall not to accept him back to the facility. E4 said R3 was given the written notice of Involuntary Discharge 1-2 days after he was sent to the hospital. E4 said no alternative living arrangements were offered prior to R3's discharge. On May 30, 2017 at 12:10 AM, E13 stated R3 was never physically aggressive while at the facility. E13 said R3 was easy to redirect and the only time he threatened to kill someone was at the hospital. 4. R4's computerized [DIAGNOSES REDACTED]. R4's MDS (Minimum Data Set) dated January 9, 2017 shows behaviors including physically aggressive to others, verbally aggressive to others, and other behavioral symptoms not directed towards others. The same MDS under the Change in Behavior or Other Symptoms section (E1100) states: How does the resident's current behavior status compare to prior assessment? Same R4's computerized census sheet shows she has been a resident in the facility since March 2013 (almost 4 years). R4's care plans were reviewed and showed a focus area initiated dated October 9, 2014 which stated: (R4) has a history of physical aggression, which probably stems from her dementia and confusion. At times, (R4) becomes confused and delusional as a side effect of her ammonia levels. The care plan focus area also listed dates of R4's aggressive behaviors which included: November 5, 2015 (R4) pushed another pt (patient) to the floor February 23, 2016 (R4) displayed physical aggressive behaviors towards two residents February 28, 2016 (R4) threw a chair in the dining room July 13, 2016 (R4) attempted to hit a peer with wet floor sign July 15, 2016 (R4) pushed and hit staff August 16, 2016 (R4) pushed peer August 18, 2016 R4) hit a female peer on the back of the head September 2, 2016 (R4) hit a female peer in the back R4's social service progress notes show additional incidents of aggressive behavior including: January 9, 2017 Patient (Pt) agitated today which she always is on money management days. Pt came behind staff trying to grab and hit staff November 13, 2016 hit a housekeeper October 27, 2016 hit roommate July 29, 2016 staff witnessed R4 throwing a chair in the upstairs dining room which struck a peer in the lower legs R4's care plans also showed a focus area initiated May 6, 2015 which stated: (R4) has complications with controlling mood swings. She needs reminders for interacting appropriately when agitated. R4's social service progress note dated January 21, 2017 at 9:27 AM states: This writer was informed that Pt. pushed a water cooler off of the first floor nurses's station, causing it to strike a female peer in the face .nursing staff inspected (R4) for injury. None were noted. R4's social service progress note dated January 21, 2017 at 11:49 AM states: Pt had an aggressive incident this morning with a peer. Her peer called the police, the police came to the facility, gathered information, and arrested Pt for battery. Pt was taken via police to the (local county jail). Due to Pt's aggressive behavior, she will be given an Emergency Involuntary Discharge. R4's police report narrative dated January 21, 2017 stated: (resident hit by water cooler) advised she is sore, but does not have any visible marks and (R4) did not make any statements towards her prior to the incident or afterwards. (Police officer) did not observe injuries. She advised she would like to pursue charges. The police reports shows E10 (PSRC) stated resident had not been spoken to by social service staff before she had contacted the police. The report also shows police viewed the surveillance footage of the incident and stated R4 did push the water cooler off the counter, which did hit a resident. The report stated R4 was not stopped by staff and continued walking through the hallway. The police report stated he observed a CNA turn around to see what had happened, and then she turned back around to her desk. Police stated it was a short time before the CNA assisted the resident to another chair in the area. The report also states staff informed police R4 can be irrational in the morning if she has not received her medication. The report states the cooler incident occurred at 7:37 AM. The progress notes of the female peer struck with the water cooler was reviewed and showed a nursing progress noted dated January 21, 2017 stating: Resident assessed for injury after resident stated being hit in the face by a water jug. This writer saw no injuries on resident face. ROM (range of motion) extremities with no pain. A social service note of the same date states: She claimed that her nose was a bit sore, but did not wish for further attention. On May 16, 2017 at 9:17 AM, Z4 (Ombudsman) stated she was notified on January 21, 2017 of R4's involuntary discharge to the local county jail and was concerned with the fact E4 (PSRD) had relayed to her that jail protocol prohibits the dispensing of medications and R4 was locked up in a cell with 3 other people. Z4 stated R4's daughter bailed her out of jail the same day and took her to the local hospital. Z4 stated the facility was using the pressed charges as a reason for an immediate discharge rather than a 30 day notice of discharge. Z4 said she spoke with the Public Defender's Office and R4's charges had been dropped the day of the incident. On June 2, 2017 at 1:10 PM, Z13 (R4's daughter/POA) stated she bailed R4 out of jail around noon on January 21, 2017. Z13 said R4 was smiling, totally calm, not psychotic, and not aggressive. Z13 said she took R4 to (the local hospital) because she had nowhere else to go. Z13 state R4 needs 24 hour care and had no other choice but the hospital. Z13 stated the hospital called the facility repeatedly requesting R4 be admitted back in and the facility continued to refuse. Z13 said the hospital told the facility R4 was stable and able to be returned yet the facility still said no. Z13 said, Yes, I did want her to go back. I had no other place to put her. Z13 said R4 sat at the local hospital from approximately noon until 11:00 PM and was calm the entire length of time. Z13 stated she was told by three separate staff members, E1 (Administrator), E4 (PSRD) and an Adapt staff member, that R4 was not allowed to return to the facility. R4's involuntary discharge records show R4's daughter did file an Involuntary Discharge Hearing Request on January 21, 2017 (day of discharge). R4's medical record does not show any readmission to the facility after January 21, 2017. On May 30, 2017 at 11:15 AM, E4 (PSRD/Discharge Planner) stated R4 was arrested because she pushed a water cooler onto another resident. E4 stated the police insisted R4 be arrested and she was charged with assault, therefore was involuntarily discharged because she was in jail. E4 stated R4 was bailed out of jail the same day (January 21, 2017) by family and taken to the local psychiatric hospital. E4 stated R4 was not allowed to return to the facility after the water cooler incident because she was a danger to residents. E4 stated R4 was not readmitted to the faculty after being released from jail or after stabilization at the local hospital. E4 said there were n(TRUNCATED)

Based on observation, interview and record review, the facility failed to provide and/or implement effective interventions for known behaviors to maintain residents highest mental and psychosocial well being. These failures contributed to residents exhibiting adverse behaviors towards others. These failures also resulted in residents being displaced for varing periods of time to more restrictive environments. This applies to 4 of 6 residents (R1, R3, R4 & R6) reviewed for discharges in the sample of 13. The findings include: 1. R1 has [DIAGNOSES REDACTED]. The facility census sheet showed R1 was initially admitted to the facility on [DATE] (a resident for almost 6 years.) During an interview with E4 PRSD (Psychosocial Rehabilitative Services Director), the Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors are completed quarterly on all residents by the social services department. R1's assessments completed between February 22, 2016 and February 13, 2017 showed no changes in R1's risk level. All assessments identified R1 as Potentially able to integrate with structure, direction, and supportive counseling. On May 17, 2017 at 1:00 PM, R1 was observed lying in a small room in the local hospital emergency department. R1 had no furniture available other than the bed and overbed table. R1's lunch tray was on his overbed table. R1 said he eats in his room at the hospital not in a dining room as he did at the facility. R1 would get out of the bed and ambulate in the emergency department hallways while squeezing a foam star (used for stress relief.) R1 would begin walking towards the exit doors and was easily redirected by the hospital staff. R1 was calm and cooperative, R1 was wearing a hospital gown and socks with grippers instead of his daily clothing attire. On May 17, 2017 at 2:00 PM, E6 (Activity Aide) said the facility has a daily Coffee Clutch at 10:00 AM and 2:00 PM. E6 stated R1 typically attends both groups as well as the 1:30 PM library activity. E6 said R1 was the first in line for the 10:00 AM group on May 9, 2017 and was not exhibiting any unusual behavior. On May 17, 2017 at 1:15 PM, Z10 (Center for Mental Health Manager) stated the facility has brought residents to the hospital emergency department before as involuntary discharges. Z10 said placement is difficult because once the residents are medically cleared, they don't qualify for acute care of the hospital. Z10 said an acute hospital does not have access to the same resources as a long term care facilities so finding placement for these residents can become a prolonged process. Z10 said R6 was brought to the hospital a year ago in the same manner as R1. Z10 said R6 was housed in the acute setting for more than 350 days before placement could be found. On May 17, 2017 at 1:30 PM, Z8 (emergency room Physician) said the sending facility reported R1 was aggressive. Z8 said the facility immediately told the Hospital emergency room staff they would not accept R1 back to the facility. The facility then sent staff back to the emergency department to serve R1 with a notice that said R1 had 24 hours to find somewhere else to live. Z8 said R1 is mentally unable to care for himself. Z8 said the facility did not express to the hospital what needs the facility could no longer provide. Z8 said We (hospital) ruled out any medical conditions that could be affecting (R1's) behavior, such as a UTI (urinary tract infection). Everything came back fine medically so we called the facility to inform them we were sending him back. They refused to take him. Z8 said since R1's arrival, R1 had exhibited no aggressive behaviors. Z8 said since R1's mother is his POA (power of attorney) the hospital called her to come get R1 as he was being discharged . Z8 said R1's POA became upset and said he could not come home and she would file a restraining order to prevent this from occurring. Z8 said R1 is too intellectually disabled to be discharged to the streets so he has been kept in the emergency room . Z8 said she is not aware of any needs R1 requires that could not be met by the long term facility. Z8 said R1 has no ability to obtain housing, has self care deficits, can't hold a job, can't be responsible for finances and has [DIAGNOSES REDACTED] which affects intellectual development. Z8 said An emergency department is to rule out life threatening and emergent conditions that need to be addressed within 24 hours. We can not meet long term care needs. Z8 said R1 has not exhibited any aggressive behaviors since his being brought to the emergency department 8 days ago. On May 18, 2017 at 10:00 AM, E7 LPN (Licensed Practical Nurse) said she was not R1's nurse on May 9, 2017 but went down the hallway to the room where R1 was residing because she heard loud voices. E7 said E4 PRSD (Psychosocial Rehabilitation Services Director) and R1 were in his room, alone. E7 said R1 was lying on his bed shaking his head from side to side but easily redirectable. E7 said E4 was sitting on R1's bed. E7 said R1 was calm at that time but E4 told E7 to get R1 his PRN medication ([MEDICATION NAME].) E7 said by the time she returned to R1's room, E4 and R1 were in the hallway and E4 said R1 hit her. E7 said R1 was still easily redirectable as she locked arms with him and lead him back into his room. E7 said about that time a couple of PRSC's (Psychosocial Rehabilitation Services Counselors) had arrived to R1's room so E7 left. E7 said she couldn't imagine what happened in the 5 minutes she was gone. On May 18, 2017 at 10:15 AM, E10 PRSC (Psychosocial Rehabilitation Services Counselor) stated he was not aware of any issues on May 9, 2017 until E11 (PRSC) came to him and told him R1 was having an episode by his room. E10 said he went to the hallway where R1 lives and saw E4 and E5 LPN (Licensed Practical Nurse - MDS (Minimum Data Set) Coordinator) standing in the hallway with R1. E10 said R1 was yelling and swinging his arms but he did not witness R1 hit anyone. E10 said E5 left and R1 walked into his room and laid on his bed. E10 said at that point, E4 called out for someone to call 911. E10 said R1 got up out of bed and began repeatedly yelling No don't call! I don't want to go! E10 said R1 was arrested when he was about [AGE] years old so he knows what 911 means. E10 said, I feel if (E4) had not said she was calling 911 in front of (R1), he would not have escalated to that point. E10 said R1 began yelling at E4 to get out of his room. E10 said R1 has a history of physically abusive behavior and has even hit him in the past. E10 said he felt the only reason R1 was involuntarily discharged was because this time R1 hit E4 (management) instead of line staff. E10 said many other residents in the facility hit people and never get sent out. E10 said R1 probably would never have escalated to this level had he been left alone as that is an intervention that has worked for him in the past. On May 18, 2017 at 1:15 PM, E11 (PRSC) stated she was in the dining room for lunch when she was approached by a CNA (certified nursing assistant) who told her there was a problem in the hallway. E11 said she stepped into the hallway and saw E4 and R1. E11 said she did not notice any hitting or swinging of arms but knew R1 was upset because he was rocking back and forth. E11 explained that is a self soothing behavior exhibited by R1 when he becomes upset. E11 said E4 was yelling down the hall for someone to call 911. E11 said R1 is afraid of the police and he definitely heard E4 yell call 911. This is when R1 threw a water bottle at E4. E11 said she never saw R1 hit E4. E11 said the first time R1 hit her was approximately 2 years ago. E11 said R1's behavior cycles. E11 said R1 escalates then calms down. E11 said his escalating behavior [MEDICAL CONDITION] in 30-45 minutes. E11 said R1 has been sent to the hospital many times for behaviors but returns the the facility calm and no additional interventions done while R1 was at the hospital. E11 said R1 is afraid of going to the hospital but more afraid of the police so typically if he is sent to the hospital for evaluation, he is calmed down by the time he arrives to the emergency room . E11 said she saw no difference in this episode as compared to any of his past behaviors. E11 said she has no idea why R1 was involuntarily discharged after this event. E11 said that was E4's decision. E11 said E9 (Housekeeping Director) was called to assist after she and E10 placed R1 on the bed because E9 gets along very well with R1. E11 said E9 was able to calm R1 enough that by the time the police arrived, R1 would have been fine to stay in the facility. E11 said at that point, he probably would have even take an oral PRN medication if the nurse wanted him too. E11 said due to R1's intellectual disability, it is hard for him to manage and process anger. E11 said this event was typical for him so she isn't aware of E4 is just unfamiliar with actual hands-on dealing with R1 and these episodes because the rest of the social service team usually deals with the residents with behaviors, E4 doesn't usually deal with them directly. R1's care plan for a history of exhibiting physically and verbally aggressive behavioral symptoms when he is agitated as evidenced by hitting staff ., initiated September 15, 2014 lists interventions to include: avoid over-stimulation (e.g. noise, crowding); avoid power struggles with resident; identify maladaptive behaviors before they become aggressive and encourage the use of PRN medications; try not to reason with or confront the resident; and when resident becomes physically abusive, keep distance between resident an others (e.g. staff, other residents, visitors). On May 18, 2017 at 2:40 PM, E9 stated he was paged to assist with R1 on May 9, 2017. E9 said he has a good rapport with R1. E9 stated R1 has exhibited these behaviors in the past but he calms down quickly. E9 said I have dealt with him a lot when he is like this. E9 said he and E10 sat on the bed with R1 for between 2-4 minutes and he was calm. E9 said R1 asked if he could go to the bathroom and E9 said he could and if R1 stayed calm he would sit on the bed across from him instead of next to him. E9 said he returned calm and they sat across from each other talking for about 7-10 minutes before the police arrived. E9 said R1 was calm and quiet the entire 9-14 minutes and left with the police quietly. E9 said I felt his escalating behavior was over. On May 19, 2017 at 4:35 PM, Z9 (Hospital Psychiatrist) stated the events of May 9, 2017 at the facility will have permanent psychosocial harm for R1. Z9 said anyone kicked out of their home of 6 years and threatened to be arrested is detrimental especially with (R1's) mental and emotional developmental delay. Z9 stated R1 has the mentality of approximately a 4 year old. Z9 said early signs of R1 becoming agitated include him talking about superhero's and bad guys (good vs evil), his tone will become louder and he will begin to pace and increase self-talking. Z9 said had staff intervened at the facility when R1 was at this point, he likely never would have become physically aggressive. Z9 stated R1 has not exhibited any aggressive behaviors since his arrival to the hospital 10 days ago. On May 19, 2017 at 9:56 AM, an interview was conducted with Z7 (Facility Psychiatrist). Z7 stated he has never witnessed one of R1's episodes. Z7 states he based his decision to have R1 involuntarily discharged on the reports given to him by the facility staff that R1's behavior was escalating. Z7 stated giving R1 the ordered dose of PRN [MEDICATION NAME] (antipsychotic) theoretically would of minimized his aggression but it hasn't been working. Z7 then stated he was not made aware R1 had missed 2 consecutive doses of [MEDICATION NAME] prior to the episode of May 9, 2017 and was not aware that the PRN medication was not being offered, given nor even available at the facility. Z7 said the IM [MEDICATION NAME] would have been appropriate to be administered even if R1 was actively exhibiting aggressive behaviors. On May 23, 2017 at 8:40 AM, Z4 (Long Term Care Ombudsman) said she has many concerns regarding involuntary discharges. Z4 said, They are dumping people at hospitals. It's pretty clear. Z4 stated R1 was eventually admitted to a room on the hospital's 4th floor because placement could not be found and he could no longer remain in the emergency room . Z4 said R1 had developmental disabilities in addition to his mental health [DIAGNOSES REDACTED]. A hospital consultation note written by Z9 on May 12, 2017 showed review of the medical record indicates patient (R1) presenting to the emergency department multiple times with similar complaints from (facility name) .At this time, (R1) does not meet criteria for acute psychiatric hospitalization . Hospital/Emergency Department progress notes since R1's arrival May 9, 2016 showed R1 has exhibited no aggressive behaviors. The notes showed R1 is cooperative and easily redirectable. The May 9, 2017 note at 4:49 PM showed R1 told the hospital staff he was not going to hurt anyone, that he was just mad (earlier) because (E4) told him he was going to jail. During the daily status meeting on May 19, 2017 at 3:30 PM, E1 (Administrator), E3 ADON (Assistant Director of Nursing), E4 (PRSD), E5 LPN (MDS Coordinator), E19 & E20 (Corporate Nurses) were asked why R1 was not returned to the facility on ce he was stabilized at the hospital and a 30 day discharge notice initiated. There was no explanation/response as to why R1 was not allowed to return to the facility. The facility's policy dated March 2017 titled Behavior Crisis showed protocol is to diffuse crisis through calming communication and assess the need for chemical restraint. 2. R6 was a resident at the facility from March 23, 2010 to May 19, 2016 according to the facility census sheet. The facility provided a prescreening assessment for R6 dated June 26, 2008. The prescreening assessment lists the following: Physical Violence towards others = moderate. Recently twisted his father's arm and hit another client in January 2007; Poor Judgement placing self or others at risk = High. Poor self care, no insight into his delusions, may be putting others at risk; Serious wandering elopement risk = Moderate; and Sexual Aggression = High. R6 has expressed sexually inappropriate behaviors. These documents showed the facility were aware of R6's specialized needs and accepted R6 as a resident. A nursing note dated May 20, 2016 at 4:20 PM, describes R6 exhibiting inappropriate sexual behaviors with peers. At 7:47 PM, the nursing note showed R6 was sent to the local hospital emergency department for a psychiatric evaluation. At 10:00 PM, the nursing notes showed a call was received from the local hospital emergency room stating that R6 was medically cleared and needed to return to the facility. Facility social service progress notes document attempts to locate alternative placement was being sought. A nursing note dated May 22, 2017 at 1:33 AM, (over 2 days after R6 was cleared to return to the facility), the emergency department again contacted the facility and stated R6 was cleared and needed to return to the facility. The progress note (authored by E18 Registered Nurse), showed E18 stated he would not accept R6 back to the facility. On May 30, 2017 at 11:30 AM, E4 said R6 was sent to the local hospital emergency department due to inappropriate sexual behaviors. E4 said R6 was not involuntarily discharged . E4 said she had made arrangements for R6 to be transferred to (another facility). E4 said the new facility was supposed to work with the hospital for a direct admit from the emergency room to their location. E4 said the hospital called their facility at 1:00 AM and the nurse said he wouldn't take R6 back due to the time of the day/night. E4 said I don't know why our nurse didn't explain R6 was set to go to (another facility). E4 said the local hospital never relayed to her or their facility that the (other facility) was no longer an option for R6. On May 19, 2017 at 4:35 PM, Z9 (Hospital Psychiatrist) stated this local long term care facility sent R6 to their hospital with severe to profound mental disabilities, a PEG (Percutaneous Endoscopic Gastrostomy) tube and incontinence of stool. Z9 said R6 had lived at the facility for 4 years and came to the hospital in the same way as R1. Z9 said R6 was listed as his own guardian could not make his own decisions. Z9 said R6 needed Mental Health services not psychiatric services. Z9 said R6 was eventually admitted to the hospital acute psychiatric facility and was a patient for almost a year. Z9 said due to the hospital being an acute psychiatric facility, they (the hospital) did not have the resources available to obtain mental health placement for R6. Z9 said R6 was eventually placed in a group type home and has progressed in his independant living skills. 3. The facility census sheet showed R4 resided in the facility from [DATE] to January 21, 2017 (almost 4 years.) R4's [DIAGNOSES REDACTED]. R4's care plans were reviewed and showed a focus area initiated dated October 9, 2014 which stated: (R4) has a history of physical aggression, which probably stems from her dementia and confusion. R4's care plans showed a focus area initiated May 6, 2015 which stated: (R4) has complications with controlling mood swings. She needs reminders for interacting appropriately when agitated. On June 2, 2017 at 1:10 PM, Z13 (R4's daughter/POA) stated R4 was involunatarily discharged from the facility on January 21, 2017 and sent to the local jail. Z13 stated she was given the involuntary discharge papers by E4 (PSRD) and E10 (PSRC) while R4 was in the jail. Z13 stated facility staff did not speak with her at all when the involuntary discharge papers were delivered. Z13 stated R3 was calm, smiling, not psychotic or aggressive at the jail. Z13 stated she bailed R4 out of jail (as soon as she was processed) and took her to the local hospital because she (Z13) had no other place to take her. Z13 stated she felt like she was doing the job the facility should be doing. Z13 stated R4 sat in the hospital from approximatley noon until 11:00 PM when she was finally transfered to a second facility. Z13 stated the hospital located, organized, and orchestrated the entire transfer process (to an acute psychiatric facility.) Z13 stated the facility did nothing to assist the hospital with placement. Z13 stated she never stopped trying to get R4 back into the facility. Z13 said she had a meeting with R4's discharging facility sometime in February 2017 in an effort to have R4 readmitted . Z13 stated E4 (PSRD) was present during that meeting and was laughing, rolling her eyes, making huffing noises and had an attitude. Z13 stated E4 was playing on her phone the entire time and was showing no interest in discussing R4's return. On May 18, 2017, E10 (PSRC) stated during meetings related to resident behaviorial issues, upper management would disregard his concerns. E10 stated they (upper managment) would always keep doing paperwork when he came in to discuss resident incidents and he felt like his concerns were not being addressed. On May 23, 2017 at 8:40 AM, Z4 (Long Term Care Ombudsman) said R4's charges were dropped but the facility still would not take her back. 4. R3 was admitted to the facility on [DATE] according to the facility census sheet. R3's [DIAGNOSES REDACTED]. The nursing progress note dated March 3, 2017 at 10:16 AM showed housekeeping staff alerted the nurse that R3 was on the floor. The note showed R3 stated he stumbled over his wheelchair and fell . Attempts to assess R3's right hip were unsuccessful and R3 was sent to the local hospital for a medical evaluation. The March 3, 2017 progress note of 10:18 AM showed a hospital nurse called the facility to make them aware R3 expressed having thoughts of hurting another resident at the facility. The nursing note of March 3, 2017 at 12:24 PM showed R3 was being admitted to the local hospital with a [DIAGNOSES REDACTED]. A hospital emergency department note dated March 3, 2017 at 12:28 PM showed E13 RN (Registered Nurse - long term care facility) told the emergency department RN the facility won't take (R3) back due to (his) threats against roommate. R3 was served with a notice of involuntary discharge on March 3, 2017, 3 days after sustaining a [MEDICAL CONDITION]. The reason listed on the discharge papers was the safety of individuals in this facility is endangered. R3's care plan initiated October 7, 2016 showed a focus area of manipulative behavior as evidenced by making statement of wanting to blow peers up, stating he has a plan to act 'crazy' so he can get kicked out of this facility, threatening to call IDPH (Illinois Department of Public Health), his insurance caseworker and local news stations to report the facility, etc. The interventions included educate R3 on the importance of using appropriate skills vs. making threats towards others and towards the facility; redirect; remind R3 inappropriate behavior will not be tolerated; and set clear limits for expected behavior. On May 30, 2017 at 11:05 AM, E4 stated R3 was transferred out due to a fall. E4 said the facility made the decision that day (March 3, 2017), R3 was not to return to the facility. E4 said R3 was given the written notice of Involuntary Discharge 1-2 days after he was sent to the hospital. E4 said no alternative living arrangements were offered prior to R3's discharge. On May 30, 2017 at 12:10 AM, E13 stated R3 was never physically aggressive while at the facility. E13 said R3 was easy to redirect and the only time he threatened to kill someone was at the hospital.

Based on interview and record review, the facility failed to have available and administer as needed medication for a resident exhibiting escalating behaviors. This failure contributed to R1 physically assaulting staff, being involuntarily discharged from his home and having criminal charges filed. This applies to 1 of 6 residents (R1) reviewed for medication administration in the sample of 13. The findings include: R1 has [DIAGNOSES REDACTED]. These orders were obtained and implemented on November 27, 2104 and May 26, 2015 (respectively) according to the electronic Medication Review Report printed May 17, 2017. On May 17, 2017 at 11:20 AM, E4 PRSD (Psychosocial Rehabilitation Services Director) said on May 9, 2017, R1 was seated in her office because he was upset with something that happened in the morning activities. E4 stated she tried for awhile to get R1 to express what was wrong but he wouldn't talk to her. E4 said R1 was rocking back and forth and shaking his head which is what he does when his behavior is escalating. E4 stated she let R1 sit in her office as she continued to work. E4 said eventually R1 stood up and punched a bookcase in her office and left to go to his room. E4 said she followed R1 to his room and asked R8 (R1's roommate) to go tell the nurse to bring R1 his PRN medication to decrease R1's chance of exploding. E4 said, E7 LPN (Licensed Practical Nurse) returned to the room without the medication and E4 did not know why. On May 18, 2017 at 10:15 AM, R9 stated he was roommates with R1 for a long time. R9 said he was not in the room when R1 became upset about a week ago. R9 said he was not allowed down the wing during the event. R9 said I heard that he hit someone. R9's MDS dated [DATE] showed R9 as having no cognitive deficits. On May 18, 2017 at 10:00 AM, E7 said she was not R1's nurse on May 9, 2017 but went down the hallway to the room where R1 was residing because she heard loud voices. E7 said E4 and R1 were in his room, alone. E7 said R1 was lying on his bed shaking his head from side to side. E7 said E4 was sitting on R1's bed. E7 said E4 told E7 to get R1 his PRN medication (Chlorpromazine.) E7 said she left to obtain the medication and could not locate it. E7 said she checked the convenience box medications and no Chlorpromazine was available. E7 said she returned to the room to inform E4 the medication was not available. E7 said by the time she returned to R1's room, E4 and R1 were in the hallway and E4 said R1 hit her. E7 said about that time a couple of PRSC's (Psychosocial Rehabilitation Services Counselors) had arrived to R1's room so E7 left. E7 said she went to E8 LPN (R1's nurse May 9, 2017) to inform her of the situation and the lack of medication availability. E7 said she and E8 searched for the Chlorpromazine and E8 validated there was none available in the facility. The nursing progress notes dated May 7 and May 8, 2017 showed R1 refused his Olanzapine for both days. No notes notifying the physician of the missed doses was documented until May 8, 2017. The nursing progress note read, Note left for (ANP - Advanced Nurse Practitioner) in regards to (R1) refusing his HS (bedtime) Olanzapine. R1's care plan for a history of exhibiting physically and verbally aggressive behavioral symptoms when he is agitated as evidenced by hitting staff ., initiated September 15, 2014 lists the intervention of identifying maladaptive behaviors before they become aggressive and encourage the use of PRN medications. On May 18, 2017 at 10:15 AM, E10 PRSC (Psychosocial Rehabilitation Services Counselor) stated he was not aware of any issues on May 9, 2017 until E11 PRSC came to him and told him R1 was having an episode by his room. E10 said he went to the hallway where R1 lives and saw E4 and E5 LPN (Licensed Practical Nurse - MDS (Minimum Data Set) Coordinator) standing in the hallway with R1. E10 said R1 was yelling and swinging his arms. E10 said he and E11 were able to get R1 back into his room when E4 began calling out for someone to call 911. E10 said R1 began repeatedly yelling No don't call! I don't want to go! E10 said R1 was arrested when he was about [AGE] years old so he knows what 911 means. E10 said R1 began yelling at E4 to get out of his room. E10 said then R1 then threw a water bottle at E4 and tried to run out of the room. E10 said at that point, he and E11 used a bear hug technique to put R1 on the bed. On May 18, 2017 at 1:15 PM, E11 stated she was in the dining room for lunch when she was approached by a CNA (certified nursing assistant) who told her there was a problem in the hallway. E11 said she stepped into the hallway and saw E4, E5 and R1. E11 said she knew R1 was upset because he was rocking back and forth and E5 was holding him back. E11 explained that is a self soothing behavior exhibited by R1 when he becomes upset. E11 said E4 was yelling down the hall for someone to call 911. E11 said R1 is afraid of the police and he definitely hear her yell call 911. This is when R1 threw a water bottle at E4. E11 said R1 stomped on her foot and kicked her shin during the side body hug take down on May 9, 2017 as R1 attempted to run out of his room . E11 said the first time R1 hit her was approximately 2 years ago. E11 said R1's behavior cycles. E11 said in the past, R1 has calmed rapidly when his PRN medication is given. E11 said many times R1 will take it orally if offered because he would rather take it than have a shot. On May 19, 2017 at 4:35 PM, an interview was conducted with Z9 (R1's current Hospital Psychiatrist). Z9 said he would expect staff to notify the physician if a resident misses 1 dose of an antipsychotic. Z9 said that if 2-3 doses of Olanzapine are missed, there is an increased potential for a resident to exhibit increased behaviors. Z9 said an IM medication would have been appropriate to use, without question even if the resident was agitated. Z9 said if PRN medications are ordered it is expected they would be used when needed. Z9 said an IM Chlorpromazine would have been effective in 30 minutes or less as it is very sedating. Z9 said the medication in the IM form works rapidly. On May 19, 2017 at 9:56 AM, an interview was conducted with Z7 (Facility Psychiatrist). Z7 stated he has never witnessed one of R1's episodes. Z7 stated he based his decision to have R1 involuntarily discharged on the reports given to him by the facility staff that R1's behavior was escalating. Z7 explained (R1) used to take Clozaril (antipsychotic) as a PRN medication because it is most effective for treating psychotic aggression. Z7 said R1 had a partial colon re-section and side effects of Clozaril is mega-colon so I had to discontinue the Clozaril and start him on something else. Z7 said the Clozaril was discontinued about 2 years ago and Chlorpromazine was ordered as the second best solution. Z7 stated giving R1 the ordered dose of PRN Chlorpromazine theoretically would of minimized his aggression but it hasn't been working. Z7 then stated he was not made aware R1 had missed 2 doses of Olanzapine prior to the episode of May 9, 2017 and was not aware that the PRN medications were not being offered nor available at the facility. Z7 said the IM Chlorpromazine would have been appropriate to be administered even if R1 was actively exhibiting aggressive behaviors. On May 19, 2017 at 11:30 AM, E3 ADON (Assistant Director of Nursing) stated the facility is linked to the pharmacy electronically. E3 said the pharmacy delivers medications to the facility 2 or more times daily during the week and at least daily on the weekends. E3 stated if a resident has an active PRN order, the medication should be available at all times. E3 stated the facility has no specific policy for obtaining Emergency Medications. The care plan for R1 with the focus area listed as Resident [DIAGNOSES REDACTED]. In the focus section, the care plan showed R1 as exhibiting delusions regularly and lists an intervention of Administration of psychoactive medications as ordered by physician. This care plan had no intervention revision dates since the initiation of the care plan. The care plan for R1 with the focus area listed as R1 has a history of exhibiting physically and verbally aggressive behavioral symptoms as evidenced by hitting staff was initiated on September 15, 2014. Interventions listed for this behavior includes identify maladaptive behaviors before they become aggressive and encourage the use of PRN medication to help (R1) to calm down. Review of the discharge paperwork titled Notice of Involuntary Transfer or Discharge showed R1 was sent to the local hospital emergency room and was not returning to the facility because the safety of individuals in this facility is endangered. E3 and E4 stated during interviews on May 19, 2017 and May 17, 2017 (respectively) that they delivered R1's involuntary discharge paperwork to the hospital emergency department after R1 had been removed from the facility. The facility produced a letter from the (local) County State's Attorney dated May 17, 2017 stating a warrant was being prepared for the arrest of R1. On May 19, 2017 at 4:35 PM, Z9 stated the events of May 9, 2017 at the facility will have permanent psychosocial harm for R1. Z9 said anyone kicked out of their home of 6 years and threatened to be arrested is detrimental especially with (R1's) mental and emotional developmental delay. Z9 stated R1 has the mentality of approximately a 4 year old. Z9 said early signs of R1 becoming agitated include him talking about superhero's and bad guys (good vs evil), his tone will become louder and he will begin to pace and increase self-talking. Z9 said had staff intervened at the facility when R1 was at this point, he likely never would have become physically aggressive. Z9 said R1's PRN Chlorpromazine should have been given prior to him getting to the point of having rocking back and forth behaviors. The facility's Medication Administration Policy dated February 2017 showed Medications must be administered in accordance with a physician's orders [REDACTED]. The facility's policy titled Refill Orders updated December 31, 2014 showed A supply of medications as ordered by the physician will be available to residents at all times.

Based on observation, interview, and record review the facility failed to have an effective pest control program to identify and prevent re-infestation, and failed to manage and treat an ongoing infestation of bed bugs. This failure had a psychosocial impact on R2, R8, R14, R15, R16, R17, R18, resulting in anxiety, aggression, behaviors, depression, bed bug bites, and emotional upset. This applies to 9 of 9 residents (R2, R7, R8, R12, R14, R15, R16, R17, R18) reviewed for bed bugs in the sample of 22. The findings include: 1. On April 5, 2017 at 11:30 AM, Z9 entomologist with one of the facility's pest management providers said it is very important to have a systematic approach and process in place which would include tracking which rooms and residents have been affected by bed bugs and the movement of the effected residents and furnishings. This approach would lessen the spread of the bed bugs. On March 31, 2017 at 9:50 AM, E1 Administrator said E4 (Environmental Services Director) is in charge of the bed bug situation and its management. The facility's November 2014 Pest Control Policy shows the E4 will be responsible for coordinating the pest control program. On April 5, 2017 at 9:50 AM, E4 said he does not do any tracking of bed bug infestations in the facility. E4 said there is no policy in place that provides screening of items brought in the facility by new admissions or by residents that have community access. E4 said he has no record of treatments and was not aware that a pest control company treated the following rooms for bed bugs on these dates: February 13, 2016 for room 2211; May 26, 2016 for room 2211. On April 4, 2017 at 11:00 AM, E21 Maintenance Director said the Psych Social Department tracks furniture inventory and where things are moved. On April 4, 2017 at 10:15 AM, E15 PRSD (Psychiatric Rehabilitation Services Director) said furniture is not inventoried as far as moving in and out of different rooms According to the facility's bed bug elimination timeline and March 2017 Room Move form, R2 and R8's room was sprayed for bed bugs by the facility on March 17, 20, 21, and 22, 2017. On March 22, 2017, R2 and R8's room was inspected by E4. On March 23, 2017, R2 was moved back into the room. On March 24, 2017, the facility again found a live bed bug in R2's. The facility sprayed this room for bed bugs again on March 24, and 25. On March 28, 2017, R2 and R8's room was sprayed by the facility for bed bugs and then inspected by E4. On March 29, 2017, R2 and R8 were moved back into the room. On March 30, 2017, it was reported to E4 that a live bed bug was outside of the room, and E4 found live bed bugs again in the room. E4 then sprayed the room for bed bugs (the eighth time in 13 days). On March 31, 2017 at 11:35 AM, three dead bed bugs (verified by E4), were found on the floor of R2 and R8's room. On March 31, 2017, at 10:10 AM, E18 CNA (Certified Nursing Assistant) said she saw live bed bugs in the room when R2 was in there and reported it to E5 LPN (Licensed Practical Nurse). E18 said she was told this morning (March 31, 2017) there are bed bugs in the room again and R2 and R8 were just moved back in there Tuesday or Wednesday (March 28 or 29, 2017). At 1:50 PM, E15 PRSD (Psychiatric Rehabilitation Services Director) said R2 and R8 had to move three times in one week due to bed bugs. E15 said change causes extra distress and anxiety. R8 was concerned and thought she was covered in bed bugs and we had to calm her. R2 just returned from an inpatient psychiatric hospitalization . E15 said she stayed late on March 29, 2017 because the anxiety was high in the building and we had to calm the residents. E15 said on March 30, 2017 we had to move 17 or 18 residents and it was a madhouse. We had to split up a husband and wife and she is still upset today. At 11:15 AM, E17 CNA said she saw a live bed bug crawling up the door frame of R2 and R8's room around 6:30 AM. At 1:00 PM, E13 Housekeeping Assistant Supervisor said he was told about a bed bug crawling down the hall that came out of a room this morning by E5. E13 said he sprayed outside R2 and R8's room and adjacent rooms on either side. At 2:15 PM, E6 CNA (Certified Nursing Assistant) said he saw bed bugs in R2 and R8's both times they had them on March 24, 2017 and March 29, 2017. At 2:30 PM, E5 LPN said around 6:30 this morning she saw a live bed bug on the outside door frame of R2 and R8's, and she put it in a baggie to give to E4. E5 said she notified E2 DON (Director of Nursing) and E4 of the findings and was told by E4 a guy from an outside company is coming in to handle it. On April 4, 2017 at 9:35 AM, E22 said when they found bed bugs in R2 and R8's room again on March 29, 2017, R2 was highly irate and you could see on her face she was upset. She just got back from the hospital and wanted to be home and she wasn't with these bugs again. E22 said R8 does not usually display upset behaviors and she seemed more annoyed now. The bed bugs have caused fear and hampered the resident's lifestyle. We have had this bed bug issue for nine months to a year now and they keep telling us it's resolved. On March 31, 2017 at 11:30 AM, R2 said the first day she was back from the hospital (from an inpatient psychiatric stay) I saw a bug crawling on me. It's depressing me to talk or hear talk about it. R2 then asked her roommate (R8) and this surveyor to stop talking about it and left the room. R2's MDS (Minimum Data Set) dated March 9, 2017 shows a BIMS (Brief Interview for Mental Status) score of 15 which indicates she is cognitively intact. R2's March 21, 2017 Social Service note shows R2 said she has hemorrhoids that were made worse by bed bugs. On March 31, 2017, at 2:00 PM, E7 housekeeper said that on March 29, 2017 around 8:00 PM he was with E22 PSA (Psych/social Aide) and R2. E7 said R2 was listening to music and was calm after returning from an inpatient psych hospitalization . R8 (R2's roommate) came to him and said she saw a bed bug again. E7 went to R2 and R8's room and found a few bed bugs on a blanket on R8's bed, and E22 found some bed bugs on a blanket R8 had put on the floor. E7 housekeeper said R2's speech became frantic and R2 was obviously overwhelmed and upset by this. E7 said you could just tell R2 felt back-stabbed and a hurt feeling came over her. It negatively affected her. E7 said this all could have been prevented a while ago as R2 and R8's room had been treated for [REDACTED]. On March 31, 2017 at 11:35 AM, R8 said they treated my room three times. I told E4 and a couple of other people I had bed bugs in my room and nobody did anything about it for weeks, maybe a month. I'm mad, nobody did anything about it. I went to bed with a bed bug crawling down my back. R8's Social Service Progress Note for March 29, 2017 at 7:08 PM, shows R8 was upset and agitated after room move due to bed bugs. R8's MDS (Minimum Data Set) dated February 21, 2017 shows a BIMS (Brief Interview for Mental Status) score of 15 which indicates she is cognitively intact. 2. According to the facility's bed bug elimination timeline, on March 24, 2017, live bed bugs were found in R7 and R12's room. R7 and R12 were moved from the room. The facility sprayed R7 and R12's room on March 24 and 25, 2017. There is no indication an inspection was performed before R7 and R12 were moved back into the room on March 29, 2017. Later the same day, bed bugs were seen by the residents and E4 sprayed the room. On March 30, 2017, E4 found live bed bugs in R7 and R12's room. On March 31, 2017 at 11:38 AM, at least six dead bed bugs (verified by E4, Environmental Services Director) were on the floor, and along the connecting wall in R7 and R12's room. On March 31, 2017 at 12:40 PM, E19 housekeeper said on March 29, 2017 there were live bed bugs on the mattress (after treatment) while she was cleaning in R7 and R12's room. E19 said they were going to move the residents back in the room. The facility's March 2017 Room Move List shows R7 and R12 were moved back into the room on March 29, 2017 (after housekeeping had identified live bed bugs). This list shows R7 and R12 were moved out of their room on March 30, 2017 due to bed bugs (one day after treatment). On April 3, 2017 at 9:50 AM, R12 said there were live bed bugs in his cigarette pack and on his bed. On March 31, 2017 at 10:00 AM, E4 said on March 30, 2017 he found blood markings in the cracks and crevices of R12's headboard. E4 said the night stand and dresser also had dead bed bugs and bed bug secretion markings on them. On March 31, 2017 at 2:30 PM, E5 LPN (Licensed Practical Nurse) said on March 30, 2017 around 4:30 AM, I pulled up the sheets at the foot of R7's bed and saw a live bed bug. E5 said there was one on R7's pillow and one on the fitted sheet behind his back. I called for E6 CNA to come to the room and he found bed bugs on R12's (R7's roommate) bed as well. E5 said she reported this to E2 DON (Director of Nursing). On March 31, 2017 at 2:15 PM, E6 said that on March 30, 2017 at around 3:00 AM, he was called to R7 and R12's room by E5 LPN (Licensed Practical Nurse). E6 said he saw four bed bugs on R7's fitted sheet as R7 lay in the bed. E6 said when he pulled the sheets back there were about eight more bed bugs present in R7's bed. E6 said R12's (R7's roommate) bed was checked and there was a nest of 12 or more bed bugs in and around the headboard area. 3. According to the facility's bed bug elimination timeline, bed bug activity was found in R17's room. E4 sprayed the room. The facility's March 2017 Room Move form shows R17 was moved from this room on April 1, 2017 due to bed bugs. On April 4, 2017 at 8:40 AM, R17 said she moved into the room about four months ago and has been telling them she has had bed bugs since the first day. It's almost like they were ignoring me. I had a housekeeper catch one and put it in a baggie and we showed E1. They finally saw them (bed bugs) and moved me out of the room on Saturday (April 1, 2017). It's causing me lots of distress. I am angry and am having mental, emotional, and physical pain because of it. I can't get at my toiletries or underwear. I even have bites on my legs from them. R17 showed this surveyor both lower legs. There were numerous raised and non-raised, unopened, reddened areas in varying shapes and sizes to both lower legs. At 8:50 AM, E2 DON and E3 ADON (Assistant Director of Nursing) were shown the [MEDICAL CONDITION] to R17's lower legs and both said they were probably bed bug bites. E2 and E3 said they were not aware of these bites as they did not perform skin checks on any residents on the 2300 or 2400 hallways. On March 31, 2017 at 11:15 AM, E17 CNA said she saw a bed bug crawling up the curtain in R17's about a month ago. On April 3, 2017 at 2:17 PM, Z3 pest control company manager, said he treated R17's room for bed bugs on January 26, 2017. The facility's pest management services invoice dated April 3, 2017 shows room R17's room was found to have bed bug activity in the head board (two months after bed bugs were previously found). On April 4, 2017 at 9:00 AM, R14 was crying and said she is very, very, very depressed and sad. I hardly feel like eating. R14 said she and her husband have been together for [AGE] years and are now in separate rooms because of the bed bugs. R14 and R15 were in the room directly next to R7 and R12, which had active bed bugs. R14 said she took her anger out physically; pinched a CNA, and kicked another staff person. At 8:55 AM, R15 (R14's spouse) said the least they could have done is give us a room together. I'm bored, down in the dumps, and it bothers me. R15 said I don't like being separated from my wife. We've been married [AGE] years. On April 4, 2017 at 9:05 AM, R16 said I feel like I've been moved three times for bed bugs. It affects my mental attitude, I have OCD ([MEDICAL CONDITION]) and when I get anxious it aggravates my symptoms. This moving and bed bugs has brought my symptoms back again after being gone for so long. I don't have underwear and I don't want to wear anyone else's. E4 told my husband he was bringing in bed bugs so now he is mad and doesn't come to visit as often. At 9:15 AM, R18 said he doesn't like change and initially he was yelling, cussing, and throwing stuff. R18 said he hasn't been eating and has not showered since he moved. The facility Room Move form shows R18 was moved on March 30, 2017. On March 31, 2017, E1 was asked to provide any and all information the facility had in regards to incidents, complaints, and resident room involvement with bed bugs. No tracking information was received. On March 31, 2017 at 10:00 AM, E4 Environmental Director (with E1 Administrator present) said R2 and R8's, and R7 and R12's rooms are the only rooms involved with bed bugs and are considered to be isolated incidents. On March 31, 2017 at 11:15 AM, E17 said she saw a bed bug crawling up the wall in the staff bathroom (in 2500 hall) about three weeks ago. At 11:20 AM, Z1 Assistant Program Director of Psych Rehabilitation Program, said she saw a bed bug in a staff bathroom a few weeks ago and reported it to both a nurse (E7) and E2 DON (Director of Nursing). At 12:50 PM, E18 CNA said there have been bed bugs on all four halls on the second floor but recently the problem is on the 2200 and 2500 halls. At 1:00 PM, E13 said residents and staff are anxious about the bed bugs and the exterminating company's treatments were not effective. E13 said a week or two ago he saw a bed bug in a box in the 2200 hallway. At 2:15 PM, E6 said the room next to R7 and R12 had bed bugs about four or five months ago. On April 3, 2017 at 2:17 PM, Z3 facility pest control company manager, said he has been at the facility and treated for [REDACTED]. (did not document room numbers). The facility provided a room move summary for September 2016 that shows R7 and R12 were moved out of their room on September 30, 2016. The facility invoice for a Zapp Bug Oven 2 shows it was ordered on November 18, 2016 and shipped to the facility on [DATE]. The owner's manual shows it is used to exterminate bed bugs. On April 4, 2017 at 11:00 AM, E21 Maintenance Director said the facility purchased a hot box last year because there was a problem with bed bugs. On April 5, 2017 at 1:30 PM, Z2 said this is the room (R7 and R12's) treated for [REDACTED]. They were unable to show what room was treated in October 2016. Z2 said she is unsure if the facility controls or tracks facility furniture movement. On April 4, 2017 Z2 provided a timeline of the March 2017- April 3, 2017 bed bug situation. This timeline shows a third wing (2300 - 3 of 4 on the second floor) had bed bug activity since entrance on March 31, 2017. The facility's March 2017 Room Move form shows 11 residents were moved out of their rooms on March 30, 2017 due to bed bug activity. The facility's pest control company's invoice dated April 1, 2017 shows six resident rooms were treated for [REDACTED]. The facility's February 2015 Bed Bug Policy shows the purpose is to adequately treat cases of bed bugs and prevent infestation. There is no procedure to monitor, track and trend bed bug occurrences, resident movement or involved furnishings and correlate this information to adequately treat and prevent bed bug infestations.

Based on observation, interview and record review the facility failed to ensure that resident was transferred in a safe manner to avoid injury. This failure resulted in R3 sustaining a fractured right foot on October 31, 2015. The facility failed to maintain mechanical lifts in good repair. This applies to 2 of 3 residents (R3, R7) reviewed for safety in the sample of 7. The findings include: 1. The Physician order [REDACTED]. The Minimum Data Set (MDS) dated [DATE] shows R3 is total dependence of physical assist of two or more staff with transfers. The Nurses Notes dated October 31, 2015 documented that E8 (Certified Nursing Assistant (CNA) called E3, License Practical Nurse (LPN) to R3's room. R3 was in bed, in supine position. R3's right foot was caught between the bed frame and the mattress. According to E8, he transferred R3 to bed per mechanical lift by himself. On December 12, 2015 at 12:00 PM, R3 was by the nurse's station sitting up in his wheelchair. His right foot was resting on his leg rest. R3 said his right foot got caught in his mattress while being transferred to bed. R3 said his right foot is broken. On December 12, 2015 at 11:55 AM, E2 Director of Nursing said, E8, Certified Nursing Assistant (CNA) was fired because E8 ' s stories were not matching up. E2 stated we were investigating and reinvestigating this incident. When R3 was being put to bed, E8 was by himself. (R3 is a two person assist and Mechanical Lift) E2 said R3's Mattress moved in the process of the transfer. R3's foot got stuck between the bed frame and mattress. When R3 was rolled over in bed, it twisted R3's foot and R3 sustained a fracture. On December 14, 2015 at 9:20 AM E3 Licensed Practical Nurse (LPN) said he was the nurse when this incident happened. E3 said he was informed by E8 (CNA) to go to R3's room. E3 said when he got to the room, R3 was in bed. E3 said he did not remember seeing a mechanical lift in the room. E3 said he was more concerned about R3 ' s foot being stuck between the mattress and the bed frame. E3 said E8 told him he transferred R3 by himself. On December 14, 2015 at 10:00AM, surveyor and E1 went to R3's room. E1 (administrator) showed the surveyor R3 's mattress. E1 said the investigation revealed that R3 was transferred from the shower cart to bed. E8 performed a one person transfer to R3 from the shower cart to the bed. E1 said the air mattress was not fastened to the bed, the air mattress slid off partially from the bed. E1 said R3's right foot was trapped between bed frame and mattress, E8 rolled R3 to his side. R3's right foot was twisted and caused R3's right foot fracture. Z1 stated she does not understand how it happened. Z1 said she was told R3's foot caught in the bed. Z1 stated I ordered an x-ray. R3 has a right foot fracture. R3 has been under the care of an orthopedic Doctor. The Final Radiology Report dated October 31, 2015 showed an Acute Right foot fracture. The Facility Policy Entitled Mechanical Lift states 1. A Mechanical lift should be used . two staff members required for the procedure. 2. On December 14, 1915 at 9:30AM, E5 & E6 Certified Nursing Assistants (CNA) transferred R7 using a mechanical lift and with a full body sling. The mechanical lift used by E5 and E6 was missing a hanger bar latch. E6 stated, we have two lifts, I know one was missing the hanger bar latch. On December 14, 2015 at 2:08 PM, E1 said, mechanical lifts should not be used without the hanger bar latch, the mechanical lift should be repaired. On December 15, 2015 at 10:56 AM, Z2 mechanical sling lift manufacturer stated, the hanger bar latch is part of the bar to attach the sling, it should be used when transferring a resident.

Based on observation, interview and record review, the facility failed to supervise a resident at risk for fall during a shower. This failure contributed to R1 falling and sustaining a left hip fracture on May 27, 2015 that required surgical repair. This applies to 1 of 2 residents (R1) reviewed for safety and supervision in the sample of 3. The findings include: R1 ' s Physician order [REDACTED]. R1 ' s Minimum Data Set-MDS dated [DATE] shows that R1 is severely cognitively impaired. The same MDS shows R1 needs limited assist of 1 staff for transfers and ambulation. R1 ' s incident report dated May 27, 2015 documents R1 was getting a shower. R1 was sitting on a shower chair when she stood up, crossed her feet, turned around and fell . On June 1, 2015 at 11:00 AM, E5 (CNA-Certified Nurse Aid) said, she gave R1 a shower. E5 (CNA) said she turned her back and walked towards her supply to get a towel to dry R1. When she turned around, R1 was already on the floor. E5 said it happened so fast. At 11:30 AM, E1 (Administrator) and E5 (CNA) were asked to accompany surveyor to the 2nd floor shower room where R1 fell . The shower stall is enclosed with a shower curtain. E5 showed the location of her supply bench that contained her towels. The bench was outside of the shower stall, behind the curtain, approximately 5 feet from where R1 was seated. On 2:25 PM E6 (LPN- License Practical Nurse) said R1 was being given a shower by E5 (CNA). E5 walked away to get her a towel. R1 got up, R1 has an unsteady and shuffling gait. R1 slipped and fell on the wet floor in the shower. E6 (LPN) said R1 was complaining of pain in her Left leg so she got an order to send R1 to the hospital. E2 (Director of Nursing) stated R1 had a previous fall on May 22, 2015. R1 Slipped and fell on a wet floor sign. E2 said R1 is impulsive and will not follow direction from staff. The Incident Report dated May 22, 2015 shows R1 slipped and fell over the cone that was on the floor for wet floor notification. R1 ' s care plan initiated on October 2014 shows R1 has potential for injury related to falls. R1 is unaware of safety measures, angers easily and displays impulsive behavior. R1 requires frequent cues and reminders from staff for safety awareness and judgment due to her dementia and memory impairment. R1's Fall risk assessment dated [DATE] shows R1 is a high risk for falls. The same document shows that R1 has a lurching, swaying, and slapping gait. The Hospital record dated May 27, 2015 shows R1 ' s X-ray of the left leg revealed a left intertrochanteric hip fracture. R1 underwent surgery for [REDACTED]. (Open Reduction/ Internal Fixation) On June 1, 2015 at 3:00 PM, E2 said no new interventions were added to R1 ' s care plan after she fell on [DATE] to prevent additional falls. On June 2, 2015 at 10:30 AM, Z1( Physician) was asked if R1 ' s fall could have been prevented. Z1 said the Director of Nursing or nursing staff should know the residents history and put appropriate interventions in place. Any questions should be directed to the nursing staff. At 11:20 AM, Z2 said R1 is high risk for falls. R1 should be closely monitored especially in the shower room. It is in those brief moments when things happen.

Based on interview and record review the facility failed to provide supervision for a resident at high risk for aspiration and choking while eating. This failure resulted in R2 choking, losing consciousness and expiring on [DATE] from a cardiac arrest. This failure resulted in an Immediate Jeopardy. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was determined to have begun on [DATE] when the facility failed to supervise R2 while eating. While the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a severity level two. Additional time is needed to monitor and evaluate the effectiveness of revised policies and/or procedures. This applies to 1 of 16 (R2) residents reviewed with swallowing precautions for aspiration on the second floor. The findings include: R2 is a [AGE] year old resident with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] shows R2 eats independently with supervision and assistance with meal set up. The Care Plan for R2 dated [DATE] shows a physician order [REDACTED]. The care plan does not show eating or swallowing interventions in place for potential choking. The care plan dated [DATE] for R2 shows she has a memory problem that causes her to have a great deal of difficulty remembering even the most basic of information. She often needs reminders of where she is and what she is doing here. The hospital Emergency Department Record dated [DATE] documents, "R2 presents from the nursing facility. R2 was found choking at her meal. EMS (Emergency Medical Service) arrived and was unable to intubate so the patient was bagged (ambu) ... A large amount of food debris was found in the airway, suctioned and then the patient was intubated ... The patient was difficult to bag, suctioned a lot of food debris from the tube, oral pharynx and from the airway ....The patient was asystolic the entire time. R2 was pronounced dead at 1800 (6 PM)." A previous Hospital Emergency Department Record from [DATE] states, "R2 was sent in secondary to choking. R2 reportedly has her food pureed, however, her pizza puffs were not pureed today and she has been having swallowing issues for quite some time. R2 comes in today in obvious respiratory distress, unable to speak". The Hospital Emergency Department Record on [DATE] states, "R2 who has a history of developmental delay and lives in a nursing home comes to the Emergency Department by ambulance after a choking episode. R2 states that she 'ate her burrito too fast'." During interview on [DATE] at 3:25 PM, R6 stated she ate in the same dining room as R2 on the evening of [DATE]. R6 stated, "I was not seated at her table, but had a direct view of her (R2). R2 has choked several times before while eating so I always kept an eye on her. R2 usually gets pureed foods but that night I noticed she received the same food as I did. It was a chicken and noodle dish, it was very thick and sticky, like peanut butter. She was eating, and then I noticed the panic in her eyes, I knew she was choking. I got up and went to her and called out loudly to E16 (Licensed Practical Nurse - LPN), he was at the nurses ' station. The CNA staff was not in the dining room. No one was around to help except E16 at the desk. E16 came into the dining room and started giving R2 the Heimlich." On [DATE] at 3:00 PM, E16 (LPN) stated, "R2 has a history of choking. That evening I was seated at the nursing station working on the computer filling out an incident report from a previous event". E16 stated, "I heard screaming from the resident in the dining room". E16 stated he responded and tried to get R2 to cough, and she could not speak. E16 stated he tried the Heimlich maneuver several times before she became unconscious. E16 stated he was not monitoring the residents eating, and was unsure where the CNA staff were at the time of R2's choking. E16 stated, "On Wednesday, [DATE], it was decided to put R2 back on pureed foods because she had choked on Monday [DATE]". E16 stated, "I delivered the diet change slip to the kitchen staff and was sure she received a pureed diet on the 23rd". On [DATE] at 2:05 PM, E12 (Speech Therapist) stated, "R2 has dysphagia because she gets very anxious, it ' s part of her behaviors. When she is anxious, she can start shoveling her food in very fast." E12 reviewed R2's choking history. E12 stated after a choking incident in [DATE], her diet was changed to mechanical soft. Then she had a second choking incident in [DATE] and they changed her diet to puree. R2 was very unhappy about the pureed diet, so a swallow evaluation was conducted in [DATE]. On [DATE], the recommendation was for R2 to have a mechanical soft diet. E12 stated in a controlled situation when she is coached frequently to take small bites and slow down she could do well. E12 stated, "R2 choked on [DATE] after the mechanical soft diet was restarted. On [DATE], the staff and physician agreed it was in R2's best interest to change her diet back to puree with thin liquids." E12 stated R2 ate in a supervised dining area along with several other residents. On [DATE] at 11:20 AM, E19 (CNA) stated she was assigned to the second floor the evening of [DATE]. E19 stated R2 always ate fast and needed to be encouraged to slow down and take small bites. E19 stated she served the tray to R2 that included chicken and noodles, vegetable, dessert, water and milk. E19 stated the beans were whole so it was not a puree diet. E19 stated R2 was served what the diet card said she should have. E19 stated she gave R2 the tray and left the room to go get another tray for the other residents at her table. E19 stated she thought E18 (CNA) was in the dining room when she left because someone was always to be in the dining room. E19 stated when she returned E16 (LPN) was in the room doing the Heimlich on R2. E19 stated R2 was on aspiration precautions because she had choked on her food before. E19 stated aspiration precautions included to monitor how they are eating and swallowing and to not let them put too much food in their mouth at one time. On [DATE] at 9:35 AM, E18 (CNA) stated supervising the dining room meant to ensure there were no problems during the meal such as stealing other ' s food or inappropriate behaviors. E18 stated he was aware R2 had had problems with swallowing in previous months. E18 stated if he noticed someone choking he would encourage them to cough harder and get the nurse. E18 stated when he entered the assisted dining room with a meal tray; R2 was on the floor. E16 (LPN) and E5 (Registered Nurse - RN) were doing CPR for R2. On [DATE] at 10:00 AM, E15 (Dietary Supervisor) stated nursing completes a "pink slip" for resident diet changes and sends it to dietary. The dietary staff will make the changes in the computer and a new meal card is printed. When the resident is ready to eat the CNA gives the resident their meal card and they hold it up for the dietary staff to fill their tray. E15 stated she did not know who or when the diet change was entered in the computer for R2 on [DATE] because she was on vacation. E15 stated, "The diet clerk or the cook should make the changes when I ' m not here ". E15 stated she could not verify if the correct diet was on R2's meal card because she was taken out of the computer system by the time she returned from vacation. On [DATE] at 12:20 PM, E2 (Director of Nurses - DON) explained her expectation of CNA staff monitoring the residents in the assisted dining room. E2 stated, "I am very rigid (with the staff) about monitoring residents. I expect the CNA staff to remain in the room at all times, and monitor how the residents are eating. Also to be watchful of what food the resident was served; they should be circulating in the room." On [DATE] at 12:45 PM, Z5 (R2' s physician) stated, "The choking incident was the cause of her death; R2 did not have any underlying health conditions that would have caused her sudden demise." The facility policy, "Supervision of Resident Nutrition" (undated) states,"Nursing personnel are responsible for assuring that residents are served the correct food tray. Prior to serving the food tray, the nurse aide must check the diet card to assure that the correct food tray is being served to the resident. Residents needing assistance in eating must be promptly assisted upon being served. Food and fluid intake must be observed by nursing personnel at each meal." E1 (Administrator) was notified of the Immediate Jeopardy on [DATE] related to the facility's failure to supervise R2 on [DATE] while she was eating her evening meal. R2 choked, lost her ability to cough, or breathe, and became unconscious with asystole (no heart beat). She expired at 6:00 PM on [DATE]. Based on observation, interview and record review the surveyor confirmed the facility took the following steps to remove the immediacy of the situation: 1. Completed on [DATE] - A way to identify residents at risk for swallowing difficulties in the dining room was put in place. All residents with aspiration precautions, interventions, or swallowing difficulty have a large " A " handwritten on their diet card. Any resident with an A on their diet card is given a paper placemat. This provides a visual cue to staff of residents with interventions. 2. " A " = Standard Aspiration Interventions for all residents are to take small bites, eat at a slow pace, and alternate solids and liquids. Other specific recommended interventions will be written on the resident ' s diet card. A poster is in each dining room, informing staff of what an - " A " means on the diet card, standard aspiration interventions, and signs/symptoms of aspiration. In-service training of the ,[DATE] staff started on [DATE]. Prior to each meal, supervising staff will be in-serviced on A = aspiration interventions until 100% completion. 3. Completed on [DATE] - All resident dietary orders have been checked against the dietary pink slips and the diet cards to ensure they all match. All staff have access to the resident ' s current diet via Matrix and or Point of Care computer system. The dietary department has policy regarding updating of diet cards. 4. Completed on [DATE] - Second floor dining plan was reviewed and revised. Assisted residents are now served early in the main dining room with constant supervision in place during meal service. 5. Completed on [DATE] - The list of residents with swallowing precautions was reviewed to ensure accuracy. The care plans of these residents were audited and updated. 6. Completed on [DATE] - List of residents with swallowing precautions was reviewed to ensure accuracy. Audited and updated care plans of these residents. 7. Completed [DATE] - Policies put in place to ensure diet cards are updated and accurate. 8. Completed [DATE] - Reviewed and revised processes for speech therapy recommendations so needed information gets to all disciplines including dietary, care plans, ect.. 9. Completed [DATE] - Binder of residents at risk for swallowing difficulties will be kept at each nurses ' station. Nursing staff in-service on new binder. 10. Completed [DATE]`3 - An emergency QA meeting with the Administrator, the DON, the MDS/CP coordinator, and the nurse consultant was help to develop the plan. Plan reviewed with Medical Director. 11. Completed [DATE] - In-servicing has been completed on the change of meal time and moving the assisted residents to the main dining room, and monitoring and interventions for residents with aspiration precautions. 12. Completed [DATE] - Dietary staff in-served on proper method of preparing puree, mechanical soft diets and processing diet cards. 13. Completed on [DATE] - Individualized interventions for each resident with swallowing problems or aspiration risk are included on the resident ' s diet card.

Based on interview and record review the facility failed to ensure a resident at high risk for aspiration and choking received the prescribed puree diet. This failure resulted in R2 receiving a mechanical soft diet. R2 choked while eating a chicken and noodle casserole entree during the evening meal on 10/26/13. R2 lost her ability to cough or breathe, lost consciousness and expired on 10/26/13 from a [MEDICAL CONDITION]. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy situation was identified on 11/4/13. The Immediate Jeopardy was determined to have begun on 10/26/13 when the facility failed to supervise R2 while eating.While the Immediate Jeopardy was removed on 11/4/13, the facility remains out of compliance at a severity level tow. Additional time is needed to monitor and evaluate the effectiveness of any revised policies and/or procedures. This applies to 1 of 7 (R2) residents reviewed that require a pureed diet in the sample of 26. The findings include: R2 is a [AGE] year old resident with [DIAGNOSES REDACTED]. The Care Plan for R2 dated 10/23/13 shows R2's diet change to puree related to the recent choking episode (no date listed). The hospital Emergency Department Record dated 10/26/13 documents, "R2 presents from the nursing facility. R2 was found choking at her meal. EMS (Emergency Medical Service) arrived and was unable to intubate so the patient was bagged (ambu) ... A large amount of food debris was found in the airway, suctioned and then the patient was intubated ... The patient was difficult to bag, suctioned a lot of food debris from the tube, oral pharynx and from the airway ....The patient was asystolic the entire time. R2 was pronounced dead at 1800 (6 PM)." R2 had a history of [REDACTED]. R2 reportedly has her food pureed, however, her pizza puffs were not pureed today and she has been having swallowing issues for quite some time. R2 comes in today in obvious respiratory distress, unable to speak." The Hospital Emergency Department Record on 4/10/13 states, "R2 who has a history of developmental delay and lives in a nursing home comes to the Emergency Department by ambulance after a choking episode. R2 states that she 'ate her burrito too fast'." During interview on 10/30/13 at 3:25 PM, R6 stated she ate in the same dining room as R2 on the evening of 10/26/13. R6 stated, "I was not seated at her table, but had a direct view of her (R2). R2 has choked several times before while eating so I always kept an eye on her. R2 usually gets pureed foods but that night I noticed she received the same food as I did. It was a chicken and noodle dish, it was very thick and sticky, like peanut butter. She was eating, and then I noticed the panic in her eyes, I knew she was choking." On 10/30/13 at 3:00 PM, E16 (LPN) stated, "R2 has a history of choking. That evening I was seated at the nursing station working on the computer filling out an incident report from a previous event." E16 stated he was not monitoring the residents eating, and was unsure where the CNA staff were at the time of R2 choking. E16 stated, "On Wednesday, 10/23/13, it was decided to put R2 back on pureed foods because she had choked on Monday 10/21/13". E16 stated, "I delivered the diet change slip to the kitchen staff and was sure she received a pureed diet on the 23rd". On 10/29/13 at 2:05 PM, E12 (Speech Therapist) stated, "R2 has dysphagia because she gets very anxious, it's part of her behaviors. When she is anxious, she can start shoveling her food in very fast." E12 reviewed R2's choking history. E12 stated after a choking incident in April 2013, her diet was changed to mechanical soft. Then she had a second choking incident in May 2013 and they changed her diet to puree. On 10/7/13, the recommendation was for R2 to have a mechanical soft diet. E12 stated, "R2 choked on 10/21/13 while eating a mechanical soft diet. On 10/23/13, the staff and physician agreed it was in R2's best interest to change her diet back to puree with thin liquids." On 10/30/13 at 11:20 AM, E19 (CNA) stated she was assigned to the second floor the evening of 10/26/13. E19 stated she served the tray to R2 that included chicken and noodles, vegetable, dessert, water and milk. E19 stated the beans were whole so it was not a puree diet. E19 stated R2 was served what the diet card said she should have. E19 stated when she returned E16 (LPN) was in the room doing the [MEDICATION NAME] on R2. E19 stated R2 was on aspiration precautions because she had choked on her food before. E19 stated aspiration precautions included to monitor how they are eating and swallowing and to not let them put too much food in their mouth at one time. On 10/30/13 at 10:00 AM, E15 (Dietary Supervisor) stated nursing completes a "pink slip" for a resident diet change and sends it to dietary. The dietary staff will make the changes in the computer and a new meal card is printed. When the resident is ready to eat the CNA gives the resident their meal card and they hold it up for the dietary staff to fill their tray. E15 stated she did not know who or when the diet change was entered in the computer for R2 on 10/23/13 because she was on vacation. E15 stated, "The diet clerk or the cook should make the changes when I'm not here". E15 stated she could not verify if the correct diet was on R2's meal card because she was taken out of the computer system by the time she returned from vacation. On 10/30/13 at 12:45 PM, Z5 (R2's physician) stated "The choking incident was the cause of her death; R2 did not have any underlying health conditions that would have caused her sudden demise." E1 (Administrator) was notified of the Immediate Jeopardy on 11/4/13 related to the facility ' s failure to supervise R2 on 10/26/13 while she was eating her evening meal. R2 choked, lost her ability to cough, or breathe, and became unconscious with asystole (no heart beat). She expired at 6:00 PM on 10/26/13. Based on observation, interview and record review the surveyor confirmed the facility took the following steps to remove the immediacy of the situation: 1. Completed on 10/27/13 - A way to identify residents at risk for swallowing difficulties in the dining room was put in place. All residents with aspiration precautions, interventions, or swallowing difficulty have a large " A " handwritten on their diet card. Any resident with an A on their diet card is given a paper placemat. This provides a visual cue to staff of residents with interventions. 2. " A " = Standard Aspiration Interventions for all residents are to take small bites, eat at a slow pace, and alternate solids and liquids. Other specific recommended interventions will be written on the resident ' s diet card. A poster is in each dining room, informing staff of what an " A " means on the diet card, standard aspiration interventions, and signs/symptoms of aspiration. Inservice training of the 3-11 staff started on 11/4/13. Prior to each meal, supervising staff will be inserviced on A = aspiration interventions until 100% completion. 3. Completed on 10/26/13 - All resident dietary orders have been checked against the dietary pink slips and the diet cards to ensure they all match. All staff have access to the resident ' s current diet via Matrix and or Point of Care computer system. The dietary department has policy regarding updating of diet cards. 4. Completed on 10/26/13 - Second floor dining plan was reviewed and revised. Assisted residents are now served early in the main dining room with constant supervision in place during meal service. 5. Completed on 10/26/13 - The list of residents with swallowing precautions was reviewed to ensure accuracy. The care plans of these residents were audited and updated. 6. Completed on 10/29/13 - List of residents with swallowing precautions was reviewed to ensure accuracy. Audited and updated care plans of these residents. 7. Completed 10/27/13 - Policies put in place to ensure diet cards are updated and accurate. 8. Completed 10/27/13 - Reviewed and revised processes for speech therapy recommendations so needed information gets to all disciplines including dietary, care plans, ect.. 9. Completed 10/27/13 - Binder of residents at risk for swallowing difficulties will be kept at each nurses ' station. Nursing staff in-service on new binder. 10. Completed 10/27/1`3 - An emergency QA meeting with the Administrator, the DON, the MDS/CP coordinator, and the nurse consultant was help to develop the plan. Plan reviewed with Medical Director. 11. Completed 10/30/13 - In-servicing has been completed on the change of meal time and moving the assisted residents to the main dining room, and monitoring and interventions for residents with aspiration precautions. 12. Completed 10/30/13 - Dietary staff in-served on proper method of preparing puree, mechanical soft diets and processing diet cards. 13. Completed on 11/4/13 - Individualized interventions for each resident with swallowing problems or aspiration risk are included on the resident ' s diet card.

Based on observation, record review, and interview, the facility neglected to have a wound management system in place to ensure that nursing staff were knowledgeable in the prevention of pressure ulcers. The facility neglected to identify resident risk factors for skin breakdown. The facility neglected to systematically inspect the skin of residents at risk for skin breakdown. The facility neglected to re-assess a residents risk for skin breakdown when the resident had a known decline in condition. The facility neglected to identify the residents current skin condition and develop and individualized plan to prevent worsening. The facility had no policy for re-assessing resident risk factors when the resident experiences a change in condition. There was no evidence of oversight and supervision to ensure that the facility was implementing its policies and procedures for prevention and treatment of [REDACTED]. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on 10/27/10. The Immediate Jeopardy began on 6/10/10 when R14's condition began to decline significantly. The facility did not re-assess R14's risk for pressure ulcer development. R14 developed a stage III pressure ulcer to his sacrum. R14 developed a pressure ulcer to his right ear that was first identified at a stage IV. This applies to 1 of 5 residents with facility acquired pressure ulcers. The Immediacy was removed on 10/28/10. The facility remains out of compliance at a level 2 due to the need to evaluate the effectiveness of the corrective measures put into place, the need to complete the inservicing plan, and to monitor and evaluate the effectiveness of the wound and skin care program changes. The examples include: R14's October, 2010 physician's orders [REDACTED]. R14's Admission Nursing Assessment (Body Sheet) dated 2/19/10 showed no identified areas of breakdown on R14's skin. R14's Minimum Data Set (MDS) reference assessment date of 5/28/10 (quarterly) documented that R14 had a short and long term memory problem. R14 had moderately impaired cognitive skills for daily decision making. The same assessment showed that R14 required extensive assistance of two persons for bed mobility and transfer. R14 required supervision and set up help for eating. R14 had range of motion limitations with partial loss of voluntary movement that affected his arm, hand leg, and foot. R14 was incontinent of bowel and bladder. The assessment showed no weight loss or weight gain, and that R14 had one stage II pressure ulcer. R14's Braden Scale for Predicting Pressure Sore Risk dated 6/3/10 (no further assessments after this date) showed a score of 19. (Not at risk) The same document shows that scores are 15-18 at risk, 13-14 moderate risk, 10-12 high risk, and 9 or below as very high risk.The same document showed; when other major risk factors are present (advanced age, fever, poor dietary intake of protein, etc...advance to the next level of risk.) R14's Nursing Note for 6/3/10 documented that R14 complained of sacral pain and the wound care nurse was notified. R14's physician's orders [REDACTED]." ( No previous order to check the coccyx daily was documented) On the same day an order for [REDACTED]. coccyx for 7 more days then discontinue." R14's Nursing Notes for 6/10/10 documented that R14 experienced a decline in condition. On 7/29/10 , R14's physician's orders [REDACTED]. R14's physician's orders [REDACTED]. A physician's orders [REDACTED]. and TAO (triple antibiotic ointment) dressing to the right ear daily. A Physician's Consult note dated 9/29/10 showed that R14 had a stage IV pressure ulcer to the right ear. The initial assessment of R14's ear was documented as a stage IV pressure ulcer. A Physician's Consult note dated 10/6/10 showed a stage III pressure ulcer to the upper sacrum. The initial staging and documentation of the wound showed a Stage III pressure ulcer. The next Consultation Note on 10/13/10 documented that R14's sacral ulcer was unstageable, and R14's ear wound was a stage IV. A Skin Check Sheet completed on 10/19/10 documented that R14 had only skin breakdown to the Sacrum. ( There was no documentation regarding his ear) R14 was not identified on the August, 2010 Weekly Pressure Ulcer Surveillance Report. The September, 8, 2010 report documented a resolved left knee ulcer, and a sacral ulcer that is 25% necrotic and 25% slough, with serous drainage. (devitalized tissue) The stage of the wound is not documented. The surveillance sheet dated 9/15/10 documented that R14 acquired the sacral wound in the hospital with an onset date of 9/16/10. (No documentation concerning a prior hospitalization was found in R14's medical records.) R14's Skin Risk Care Plan dated 9/3/02 shows the following : Potential for skin breakdown due to skin desensitized to pain/pressure/discomfort due to severe [MEDICAL CONDITION] in the lower extremities, compromised health and limited mobility. The goal is that R14 will have no skin breakdown through 9/3/10. The care plan does not address R14's gradual decline in condition beginning in June, 2010. The care plan does not identify any current pressure areas that R14 has. The interventions include daily multivitamin (discontinued on physician's orders [REDACTED]. The approaches also include to give R14 cues, supervision and set up with meals to assure good nutrition. (R14's MDS of 9/1/10 showed R14 required extensive assistance of 1 to eat). R14's weight record showed a weight of 171 pounds in February, 2010 (no reweigh done). R14 gradually lost weight each month until October, 2010. R14's weight was documented as 133 pounds in May 2010, and 109 pounds in October, 2010) One, undated, daily skin check sheet was provided for R14 on 10/27/10. On 10/21/10 at 10:00 AM, E2 (Director of Nursing) said that R14 had recently become hospice because he was weaker. E2 said that R14 was getting help to maintain his weight and nutritional status. On 10/27/10 at 10:00 AM, R14 was observed with E7 Licensed Practical Nurse, and Z1. R14 was lying on his left side. R14 had an open area on the right, anterior aspect of the upper ear. R14 had a pressure ulcer on the sacrum. R14's appearance was cachetic. No pillow supports were used to position R14. The facility failed to recognize the need to re-assess a residents risk for pressure ulcer development after the resident experienced a significant decline in condition. The facility failed to perform systematic skin inspections for a resident at risk. The facility failed to develop a plan of care that identified residents current skin status and individualized approaches to prevent further pressure ulcer development and pressure ulcer worsening. The facility policy for Pressure Ulcer Prevention shows: Residents will be assessed to determine their risk factors for pressure ulcer development. The Guidelines include: All residents will be assessed to determine their risk factors for pressure ulcer development, upon admission and at least quarterly thereafter. The policy does not address re-assessment when the resident experiences a change in condition. Residents who are assessed as being at High Risk will have a plan of care that will include: A) Daily skin checks conducted by either the CNA (Certified Nursing Assistant) or the Licensed Nurse to ensure early identification of potential problem areas. B) Plan of care to address mobility status and ability to reposition self. C) Use of pressure reducing devices, such as pressure reducing mattresses, mattress overlays, wheel chair cushioning devices. E) Any other factor identified on the risk assessment including but not limited to nutritional support, positioning/ support devices, or medication review. 4. The resident's care plan will indicate the resident's care plan will indicate the resident's risk factors and include individualized interventions as needed for a comprehensive pressure ulcer prevention program. 5. All residents will have their skin checked and documented utilizing the CNA skin Attention Form. The facility policy for Pressure Ulcer Treatment and Management showed the following: 5. The clinical record will indicate whether the resident was admitted with a pressure ulcer or the ulcer was acquired in the facility. 6. The plan of care will include the presence of the pressure ulcer and include the individual description of the treatment plan including: pressure relief, turning and repositioning, addition nutritional measures, need for assistance with mobility, and range of motion. 8. Residents with pressure ulcers will be determined to be high risk for pressure ulcer prevention and all components of the High Risk protocol include: pressure relieving devices, nutritional support, assistance with mobility including repositioning and range of motion as outlined in the High Risk Protocol. E2 Director of Nursing was informed of the Immediate Jeopardy on 10/27/10 at 3:55 PM The survey team confirmed that the facility took the following actions to remove the immediacy: 1. The facility has reviewed its Policy and Procedure for the prevention and treatment of [REDACTED]. Completed 10/27/10 2. The facility has inserviced the Nursing staff on the facility's Policy and Procedure for the prevention and treatment of [REDACTED]. Completed: 10/28/10 3. All residents on the skilled floor will have full body skin assessments by licensed nurse to ensure no further skin abnormalities have occurred. Any abnormalities found will have their Physician notified and a treatment order obtained. Completed: 10/19/10 4. All residents on the skilled floor will have their Braden scale assessment re-done to ensure all residents at high risk for developing pressure ulcers have been identified. This was completed by Licensed nurses and monitored by the Director of Nursing-DON. Completed: 10/27/10 5. All residents identified as being at high risk will have daily skin assessments initialed and maintained on an ongoing basis. This will be maintained by the treatment nurse and monitored by the Assistant Director of Nursing-ADON. Completed: 10/27/10 6. All residents identified as being at high risk will have their care plans regarding skin care reviewed and updated and maintained on an ongoing basis. This will be maintained by the care plan nurses and monitored by the ADON. Completed: 10/27/10 7. All resident identified with wounds or identified as having high risk for developing pressure ulcers will have their MDS reviewed for accuracy. This will be done by the MDS nurse and monitored by the DON. Completed 10/28/10. 8. The protocol for identifying residents at risk for developing pressure ulcers as well as managing and monitoring wound healing has been revised to identify staff members responsible for task completion. Task include: Braden assessment, wound and skin assessment, care plan development, and ensuring preventative devices are in place. Review of protocol was completed by the Nursing Management Team, including the DON, ADON, Treatment Nurse, Restorative Nurse, MDS and Care Plan Nurse. Completed: 10/27/10

I. Based on observation, record review, and interview, the facility failed to prevent residents from developing pressure ulcers and to prevent wounds from worsening. The facility failed to re-assess a residents gradual decline in condition for increased risk factors for pressure ulcer development. The facility failed to monitor and document a residents skin condition daily. The facility failed to develop an individualized care plan to address R14's risk factors for developing pressure ulcers. The facility failed to implement a plan to decrease R14's risk of developing pressure ulcers. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on 10/27/10. It began on 6/10/10 when R14 began to decline. The facility failed to monitor and document R14's skin status, reassess R14 for skin breakdown, and develop a prevention plan to prevent pressure ulcer development. The Immediacy was removed on 10/28/10. The facility remains out of compliance at a level 2 due to the need to evaluate the effectiveness of corrective measures put in place, the need to complete the inservicing plan, and to monitor and evaluate the effectiveness of the wound and skin care program changes. This is for 1 resident of 5 with facility acquired pressure ulcers. (R14) The examples include: R14's October, 2010 physician's orders [REDACTED]. R14's Admission Nursing Assessment (Body Sheet) dated 2/19/10 showed no identified areas of breakdown on R14's skin. R14's Minimum Data Set (MDS) reference assessment date of 5/28/10 (quarterly) documented that R14 had a short and long term memory problem. R14 had moderately impaired cognitive skills for daily decision making. The same assessment showed that R14 required extensive assistance of two persons for bed mobility and transfer. R14 required supervision and set up help for eating. R14 had range of motion limitations with partial loss of voluntary movement that affected his arm, hand leg, and foot. R14 was incontinent of bowel and bladder. The assessment showed no weight loss or weight gain, and that R14 had one stage II pressure ulcer. R14's Braden Scale for Predicting Pressure Sore Risk dated 6/3/10 (no further assessments after this date) showed a score of 19. (Not at risk) The same document shows that scores are 15-18 at risk, 13-14 moderate risk, 10-12 high risk, and 9 or below as very high risk. The same document showed; when other major risk factors are present (advanced age, fever, poor dietary intake of protein, etc...advance to the next level of risk.) R14's Nursing Note for 6/3/10 documented that R14 complained of sacral pain and the wound care nurse was notified. R14's physician's orders [REDACTED]." ( No previous order to check the coccyx daily was documented) On the same day an order for [REDACTED]. coccyx for 7 more days then discontinue." R14's Nursing Notes for 6/10/10 documented that R14 experienced a decline in condition. an order for [REDACTED]." A pharmacy Consult Report dated 8/5/10 showed to discontinue R14's [MEDICATION NAME] as R14 had not experienced a significant gain since the start of the therapy. On 7/29/10 , R14's physician's orders [REDACTED]. R14's physician's orders [REDACTED]. physician's orders [REDACTED]. R14's MDS reference assessment date of 8/28/10 showed that R14 required extensive assistance of one person to eat. No pressure ulcers were identified on this assessment. R14's diet order for 9/20/10, showed Pureed diet with nectar thick liquids. R14's dietary care plan dated 9/20/10 showed the following " resident on a planned weight gain program related to leaving 25% of meals uneaten." A physician's orders [REDACTED]. and TAO (triple antibiotic ointment) dressing to the right ear daily. A Physician's Consult note dated 9/29/10 showed that R14 had a stage IV pressure ulcer to the right ear. The initial assessment of R14's ear was documented as a stage IV pressure ulcer. A Physician's Consult note dated 10/6/10 showed a stage III pressure ulcer to the upper sacrum. The initial staging and documentation of the wound showed a Stage III pressure ulcer. The next Consultation Note on 10/13/10 documented that R14's sacral ulcer was unstageable, and R14's ear wound was a stage IV. A Skin Check Sheet completed on 10/19/10 documented that R14 had only skin breakdown to the Sacrum. (There was no documentation regarding his ear) R14's physician's orders [REDACTED]. R14 was not identified on the August, 2010 Weekly Pressure Ulcer Surveillance Report. The September, 8, 2010 report documented a resolved left knee ulcer, and a sacral ulcer that is 25% necrotic and 25% slough, with serous drainage. (devitalized tissue) The stage of the wound is not documented. The surveillance sheet dated 9/15/10 documented that R14 acquired the sacral wound in the hospital with an onset date of 9/16/10. (No documentation concerning a prior hospitalization was found in R14's medical records.) R14's Skin Risk Care Plan dated 9/3/02 shows the following : Potential for skin breakdown due to skin desensitized to pain/pressure/discomfort due to severe [MEDICAL CONDITION] in the lower extremities, compromised health and limited mobility. The goal is that R14 will have no skin breakdown through 9/3/10. The care plan does not address R14's gradual decline in condition beginning in June, 2010. The care plan does not identify any current pressure areas that R14 has. The interventions include daily multivitamin ( discontinued on physician's orders [REDACTED]. The approaches also include to give R14 cues, supervision and set up with meals to assure good nutrition. (R14's MDS of 9/1/10 showed R14 required extensive assistance of 1 to eat). R14's weight record showed a weight of 171 pounds in February, 2010 (no reweigh done). R14 gradually lost weight each month until October, 2010. R14's weight was documented as 133 pounds in May 2010, and 109 pounds in October, 2010) One, undated, daily skin check sheet was provided for R14 on 10/27/10. On 10/21/10 at 10:00 AM, E2 (Director of Nursing) said that R14 had recently become hospice because he was weaker. E2 said that R14 was getting help to maintain his weight and nutritional status. On 10/27/10 at 10:00 AM, R14 was observed with E7 Licensed Practical Nurse, and Z1. R14 was lying on his left side. R14 had an open area on the right, anterior aspect of the upper ear. R14 had a pressure ulcer on the sacrum. R14's appearance was cachetic. No pillow supports were used to position R14. According to Acello, Barbara, 2009, The Long Term Care Nursing Desk Reference, pg.76, " All at-risk residents should have a systematic skin inspection at least once per day. In most cases this can be done by a nursing assistant who reports his or her findings to the nurse. Licensed nurses should check high risk residents' skin weekly or according to facility policy. Keep in mind that the conditions for residents admitted to a healthcare facility is not static, so pressure ulcer risk requires routine reexamination. Accurate and complete documentation of all risk assessments ensures continuity of care and may be used as a foundation for the skin care plan. According to Bryant, Ruth, 2007, Acute and Chronic Wounds, Current Management Concepts, page 212, In hospitals and long-term care facilities, impaired nutritional intake,lower dietary protein intake, impaired ability to self-feed, and recent weight loss have been identified as independent predictors of pressure ulcer development. ( Allman et al, 1995; Bergstrom and Braden, 1992, Brandeis et al, 1990, Berelowitz and Wilking, 1989, Chernoff 1996) E2 Director of Nursing was informed of the Immediate Jeopardy on 10/27/10 at 3:55 PM. The survey team confirmed that the facility took the following actions to remove the Immediacy. 1. All residents on the skilled floor will have full body skin assessments by licensed nurse to ensure no further skin abnormalities have occurred. Any abnormalities found will have their Physician notified and a treatment order obtained. Completed: 10/19/10 2. All residents on the skilled floor will have their Braden scale assessment re-done to ensure all residents at high risk for developing pressure ulcers have been identified. This was completed by Licensed nurses and monitored by the Director of Nursing-DON. Completed: 10/27/10 3. All residents identified as being at high risk will have daily skin assessments initiated and maintained on an ongoing basis. This will be maintained by the treatment nurse and monitored by the Assistant Director of Nursing-ADON. Completed: 10/27/10 4. All residents identified as being at high risk will have their care plans regarding skin care reviewed and updated and maintained on an ongoing basis. This will be maintained by the care plan nurses and monitored by the ADON. Completed: 10/27/10 5. All resident identified with wounds or identified as having high risk for developing pressure ulcers will have their MDS reviewed for accuracy. This will be done by the MDS nurse and monitored by the DON. Completed 10/28/10. 6. The protocol for identifying residents at risk for developing pressure ulcers as well as managing and monitoring wound healing has been revised to identify staff members responsible for task completion. Task include: Braden assessment, wound and skin assessment, care plan development, and ensuring preventative devices are in place. Review of protocol was completed by the Nursing Management Team, including the DON, ADON, Treatment Nurse, Restorative Nurse, MDS and Care Plan Nurse. Completed: 10/27/10 7. Nursing staff will be inserviced by Dr. Gogia, wound care specialist on the prevention, assessment and treatment of [REDACTED]. Nursing staff will be removed from duty until they complete this inservice. This will be monitored by the DON. Completed: 10/28/10 II. Based on observation, record review, and interview the facility failed to perform routine skin checks on residents at risk for skin breakdown. The facility failed to re-assess a residents risk for skin breakdown following a hospitalization for skin grafting. These failures contributed to R16 developing an unstageable right heel ulcer and R4 developing a stage III pressure ulcer on the sacrum. This applies to two residents with skin breakdown (R4, R16) The facility failed to ensure that residents at risk for skin breakdown had pressure redistribution cushions on their wheel chairs (R17, R21). The examples include: 1. R16's October, 2010 physician's orders [REDACTED]. An undated physician's orders [REDACTED]. Xeroform over skin grafts followed by 4 x 4 gauze then Kerlix , then splint with ACE wrap." R16's Minimum Data Set (MDS) Assessment (Significant Change of Condition) of 9/24/10 showed that R16 was readmitted to the facility on [DATE]. The same assessment showed that R16 has moderately impaired cognitive skills for daily decision making. The assessment showed that R16 was independent in bed mobility and transfer. The assessment showed that R16's disease conditions include Diabetes Mellitus. R16 had no skin ulcers due to any cause, and had a history of [REDACTED]. The Rap Summary (RAP) for the above assessment dated [DATE] documented that R16 required assistance with ADLS's (Activities of Daily Living) due to impaired mobility. R16's Pressure Ulcer Rap documented " Will not address as a problem at this time but will continue to watch as he does have impaired mobility and uses a wheelchair. He frequently changes his position and is continent of both bowel and bladder at this time he is alert and oriented but has some poor decision making. (The RAP does not identify R16's hard plastic leg splint to his right lower leg as a risk factor for skin breakdown.) A Braden Scale for Predicting Pressure Sore Risk dated 9/3/10 documented a score of 19. (Not at risk) The Braden Scale tool showed the following score interpretation 15-18 = at risk, 13-14 Moderate risk, 10-12 High Risk, 9 or below Very High Risk. The Braden Scale was not reassessed after this date. The same assessment tool documents " If other major risk factors are present (advanced age, fever, poor dietary intake of protein, diastolic pressure below 60 mmHg advance to the next level. A hospital Operative Report dated 8/16/10 documented that R16 had hardware Removal from the lower extremity (right tibia) with irrigation and debridement. A hospital Orthopedic Note dated 9/7/10 showed that R16 would require soft tissue coverage of the surgical site of the right Tibia. R16's Nursing Notes for 9/8/10 documented that R16 had a Flap and Skin Graft on the right lower leg. The same note showed that R16 was receiving TPN (Total Parental Nutrition) to facilitate wound healing. R16 "not eating much." R16's Nursing Admission Body Sheet dated 9/10/10 documented that R16's right thigh had a skin graft site, and the right lower leg had a surgical site. The same diagram showed a note in the margin " unable to look at due to Doctor's orders." R16's heels were clear, with no documented skin breakdown. The same assessment did not identify any splint device to R16's right lower extremity. R16's October, 2010 Treatment Administration Record dated October 11, 2010 showed that an order for [REDACTED]. The Weekly Pressure Ulcer Surveillance Report dated 10/11/10 documented that R16 had a unstageable right heel ulcer acquired from a splint device found on 10/11/10. The same report showed that R16's pressure ulcer was 50% necrotic tissue (devitalized) and 25% slough (devitalized) 25% moist slough with serous exudate. The wound measured 2.0cm x 1.8 cm x 0.2 cm. On 10/19/10 at 1:55 PM, E7 Licensed Practical Nurse (LPN) said she had changed R16's dressing three times a week. E7 said that R16 was wearing a splint which went underneath his heel. E7 said the first time she found the heel wound was when she was changing the dressing on the leg and noticed drainage from the heel. E7 said this was on the 11th of October. E1 Administrator and E2 Director of Nursing confirmed on 10/20/10 at 10:45 AM that R16 did not have any daily skin check records. E1 said that R16 did not score on the Braden Scale so no daily skin checks were done. No documentation concerning R16's skin status was provided. (No daily skin checks, no skin attention forms) R16's Skin Risk Care Plan updated on 9/30/10 documented that R16 had open area on his leg that required hospitalization . The care plan does not identify where the open area is located, or that R16 had a hard splint on the right lower leg. The approaches included skin checks during showers. R16's ADL Functional/Rehab Potential care plan dated 9/30/10 documented the approach "encourage R16 to allow nurse or CNA ( Certified Nursing Assistant) to check his skin during showers, so any potential problems can be detected and treated early." According to the facility policy on Pressure Ulcer Prevention: Newly admitted or readmitted residents will have a Pressure Ulcer Risk Assessment completed upon admission and 72 hours after admission. The resident's care plan will indicate the resident's risk factors and include individualized interventions as needed for a comprehensive pressure ulcer prevention program. All residents will have their skin checked and documented utilizing the CNA Skin Attention Form. This skin check will be performed a a minimum of weekly. According to Acute and Chronic Wounds, Bryant, pg. 225: Systematic skin assessments should be conducted and documented at least once per day on persons at risk. Skin inspections may be done when bathing, dressing, or assisting a patient. The WOCN (Wound, Ostomy, Continence Nursing Society) (2003) recommends removing special garments, shoes, heel and elbow protectors, orthotic devices, restraints, and protective wear during skin inspection. Special attention should be directed to specific, vulnerable pressure points for bed or chair-bound individual; supine position (occiput, sacrum, and heels. pg. 226; because heels have a small surface area and a large underlying bony surface, they are prime sites for pressure ulcer development. Persons with Diabetes need extra diligence in preventing heel ulcers. Pressure relief to the heels should be provided by pillow elevation or commercial product. Heel elevation with a pillow has been shown to be more effective than commercial products. 2. R4's Minimum Data Set of 9/18/10 shows that R4 has [DIAGNOSES REDACTED]. R4's Braden Scale for predicting pressure sore risk dated 8/23/10 shows that R4 scored a 16. (15-18= at risk). R4's Admission assessment dated [DATE] shows that R4 has no skin issues to his sacral area. The Nurse's Notes dated 8/28/10 state, "(Doctor) notified of wound (decub) on coccyx and new treatments ordered." The Wound Care assessment dated [DATE] states, "Upper Sacral Wound. Etiology: Pressure, Initial Stage: 3, Size: 3.5 x 2.0 x 0.2 cm, Exudate: Serous, Thick Adherent Yellow necrotic Tissue :80%, Granulation Tissue: 20 %. On 10/19/10 at 12:15 PM, R4 was observed in the dining room sitting in his wheelchair. R4 was sitting on a pillow. On 10/19/10 at 1:45 PM, E7 (Treatment Nurse) was asked why R4 was not sitting on a pressure redistributing cushion when in the wheelchair. E7 replied, "I don't have an answer for you." E7 was asked what R4's sacral wound looks like now. E7 stated, " It is a Stage I. It has a slight opening with no depth and no drainage." 3. R17's october, 2010 POS documented that R17's [DIAGNOSES REDACTED]. R17's MDS assessment of 9/9/10 showed that R17 had short and long term memory problems. R17 had moderately impaired cognitive skills. R17's primary mode of locomotion is the wheelchair. The same MDS documents that R17 had a pressure relieving device on her chair and bed. R17 was observed on 10/20/10 at 10:15 AM, in her room. R17 was seated in a wheel chair. R17's wheel chair cushion was flattened in the center and pushed out the back of the wheel chair. 4. On 10/20/10 at 12:25pm, R21 was observed sitting in her wheelchair in her room. R21's feet had a black and yellow vinyl covered foam pad in her chair that was flat and measured 1 inch thick. On 10/20/10 at 1:35pm, E2 Director of Nursing- DON) observed the cushion in R21's chair and confirmed the cushion was flat and 1 inch thick. R21's Nurse's Notes showed, "9/20/10 - No open skin; 9/23/10 at 9:00am - R21 receives total care with activities of daily living...; 9/23/10 at 8:10pm - Dressing intact to bilateral legs and left buttocks; 9/29/10 - Doctor here to check out bilateral leg wounds..." There were no wound sheets for R21's left buttock. The Monthly Summary for R21 for September 2010 showed, "Bladder: Frequent incontinent' Skin Integrity: receives wound care (see treatment record)." R21's Care Plan dated 4/26/10 showed, "the resident is at risk for skin breakdown related to the following factors which have a casual relationship to serve to complicate the condition: Lack of mobility. Dry skin condition. Advanced age. Excessive moisture. Altered level of consciousness/[MEDICAL CONDITION]; Approaches: Pressure reducing devices used - wheelchair cushion and pressure relieveing mattress." R21's physician's orders [REDACTED]. R21's Minimum data Set ((MDS) dated [DATE] showed extensive assistance required for bed mobility and transfers.

Based on observation, record review, and interview the facility failed to thoroughly assess a residents arm after two nursing assistants reported swelling and deformity of the resident's right arm. This failure resulted in R80's delay in treatment for [REDACTED]. This applies to 1 resident with a fractured right arm. (R80) The examples include: 1. R80's September, 2010 physician's orders [REDACTED]. R80's Minimum Data Set (MDS) Assessment, of 5/6/10 (Reference Assessment Date) documents that R80 had short and long term memory problem. R80 had severely impaired cognitive skills for daily decision making. The same MDS showed that R3 is dependent on one person for bed mobility, and two or more persons for transfer. R80 was dependent on one staff for dressing and personal hygiene. R80 had range of motion limitations on both sides with partial loss of voluntary movement, affecting R80's arm, hand, leg, and foot. R80 had a fall in the last 30 days. R80's Resident Assessment Protocol (RAP) dated 5/12/10 documents " R80 needs total staff assist with all ADL (Activities of Daily Living) care related to Severe Mental [MEDICAL CONDITION], Dementia, Anoxia at birth, and Severe Contractures. The RAP does not identify how R80 is transferred. Another RAP for Cognitive Loss/Dementia dated 5/6/2010 documented " R80 is bed ridden and has both legs amputated." R80's MDS of 8/3/10 (RAD) showed that R80 had no resistance to care. R80 was lifted manually. Incident reports for R80 showed that R80 had falls on 5/4/10 (rolled out of bed), 5/30/10, (fell out of bed), 5/25/10 fell out of bed found lying on the right side. R80's Nursing Notes dated 10/21/10 for 8:00 AM documented "R80's right arm is unusually swollen with a bruise in the inner elbow crease. Because this occurrence is of unknown origin at this time a call was placed to the Dr. An order was received for X-ray of the right shoulder/arm. No further assessment information was documented. E5 Licensed Practical Nurse (LPN) said on 10/26/10 at 1:00 PM that " someone mentioned some swelling a couple of days ago prior to the Xray." E5 said it may have been E10 Certified Nursing Assistant (CNA). E5 said that R80's arm was contracted "so I didn't think it was unusual, there was no bruising at that time." E5 said that bruising was seen a few days later, and that R80 arm was just reddened when she looked at it. E5 said that R80 would scream out whenever she was touched or cared for. E9 CNA said on 10/27/10 at 9:45 AM, that she had noticed something not right with R80's arm the morning of 10/19/10. E9 said that she got E10 CNA to come in to look at R80 arm. E9 said " It was not that way Monday, but you could tell she was in pain. Her elbow was turned slightly inward and it just looked funny. It looked like the top of the arm did not belong to the bottom." E9 said that R80 could move her arms about, and that they were down at her sides, and that she tended to hold the one arm near her elbow. E9 said on the morning of 10/19/10 R80 was holding her shoulder. E9 said that R80 transfers with a mechanical lift. E10 CNA said on 10/26/10 at 1:10 PM, that she went with E9 CNA to look at R80's arm Tuesday morning. (10/19) E10 said " E9 told me that R80's arm looked funny. I saw it and said it usually doesn't look like that. It looked like something wasn't connected at the elbow. We had the nurse (E5) come and look at it. I told the nurse it doesn't normally look like that. With R80 it is hard to tell, she cries a lot. She was protecting her arm, holding it near the shoulder. R80 required 2 people to turn her, she has contractures of her legs." An incident report dated 10/21/10 at 8:00 AM documented that " staff reported that R80's right arm was unusually swollen with a bruise in the inner elbow crease, cause unknown." An Xray report dated 10/21/10 of R80's Right Shoulder and Humerus showed the following: Examination reveals an oblique and slightly spiral [MEDICAL CONDITION] of the right humerus at the junction of the distal and middle third with some over-riding and slight displacement of the fracture fragments. There is also an old fracture deformity of the neck and proximal shaft of the humerus with no displacement. A hospital Orthopedic Consultation dated 10/21/10 documented that R80 was admitted today with pain and deformity of her right arm. The same report showed that R80 had bruising throughout her arm. She had tenderness to palpation, and crepitus (a grating sound heard on movement on ends of a broken bone) with motion. R80 had a Right Distal Humerus fracture with a previous healed [MEDICAL CONDITION] Humerus. Review of R80's care plan for Activities of Daily Living showed no approaches for how R80 should be transferred. On 10/27/10 at 12:58 PM, R80 was observed in the hospital. R80 had a full arm cast on her right arm. R80's left arm was at her side. R80 had flexion contractures of both lower legs. R80 did not respond to verbal stimuli. On 10/27/10 Z5 Registered Nurse was interviewed at 1:00 PM. Z5 said that R80 was fearful when touched, and would scream profanity to leave her alone. R80 was experiencing pain. Z5 confirmed that R80 had flexion contractures of both legs. Z5 said "she seems to understand when I explain what I am going to do." According to the Handbook of Diseases, third edition, 2004, pg. 66, Symptoms of fracture may include deformity, swelling, discoloration, crepitus, and loss of limb function, numbness and tingling, mottled cyanosis, cool skin at the end of the extremity, and loss of pulses distal to the injury. II. Based on interview and record review the facility failed to to ensure that staff were knowledgeable in emergency procedures regarding [MEDICAL TREATMENT] catheters. This applies to 1 resident with a [MEDICAL TREATMENT] catheter (R4). The example includes: The physician's orders [REDACTED]. On 10/21/10 at 9:00 AM, E4 stated, "I have one (shunt) in my left arm but they are not using it- they say it doesn't work. I have one (central line access port) up here (right chest) that they have been using." On 10/18/10 at 2:20PM , Z2 (Agency Nurse) stated, "He has a left arm [MEDICAL TREATMENT] shunt- I check for bruit and thrill." Z2 was asked what she would would do if R4 were to start bleeding from the [MEDICAL TREATMENT] catheter. Z2 replied, "I would apply pressure, stop the bleeding and call the doctor." On 10/20/10 at 8:55 AM, Z3 (Agency Nurse) was asked what she would do in case of an emergency regarding R4's [MEDICAL TREATMENT] catheter. Z3 replied, "I don't know. I'm from the agency, they just called me in this morning." R4's care plan dated 8/23/10 states, "AV fistula Left arm." The care plan does not address R4's central line access port that is currently being used for [MEDICAL TREATMENT] and does not list any interventions for emergency care of the central line." According to MedicalCenter.OSU.EDU accessed on 10/25/10 regarding care of a [MEDICAL TREATMENT] catheter it states: "If the catheter should come out: Lay down, Put pressure with your hand directly over where the catheter was and call 911 or an ambulance and get to the nearest hospital."

I. Based on observation, interview and record review the facility failed to prevent a resident with a known history of falls from having repeated falls with no new interventions. The facility failed to evaluate the effectiveness of a lap cushion restraint (R14). The facility failed to monitor a resident requiring supervision to eat in the dining room. These failures resulted in R14 choking on food on [DATE] and required emergency chest thrust and airway clearance. R14 was transferred to the emergency room where a foreign object was removed from R14's larynx. The facility failed to supervise a wheelchair bound, confused resident to prevent R29 from entering the stairwell and going down a flight of stairs in her wheelchair. R29 sustained a 3cm laceration to the left leg requring suctures on [DATE]. The facility failed to ensure that the floor was free of urine to avoid R27 from slipping and sustaining a fractured left ankle. The examples include: 1. The physician's orders [REDACTED]. The History & Physical of [DATE] showed R14 had a history of [REDACTED]. The nurse's notes dated [DATE] showed, R14 was admitted to the facility. R14 received a Regular diet and was able to feed himself. The Dietary Communiucation sheet dated [DATE] showed R14's diet was changed to mechanical soft. R14's Medication Administration Record of [DATE] showed, "Mechanical diet, orginal date [DATE]. Nutritional Progress Notes written by Z6 (Registered Dietitian) dated [DATE] documented R14 receives a Regular diet. The Minimum Data Set (MDS) assessment reference date of [DATE] showed R14 as being moderately impaired in cognitive skills for decision-making with long and short term memory problems. R14 was assessed as requiring supervision with set-up for meals. R14 needed extensive assistance of 1 staff for locomotion in the wheelchair. The MDS does not show R14 is on a mechanically altered diet. Nurse's note dated [DATE] at 6:30pm documented, R14 was in the dining room eating his mechanical soft dessert when resident began choking. Staff performed three abdominal thrust with no success. R14 was placed on the floor and staff attemped to open R14's airway. R14 was noted to have his mouth open trying to gasp for air but there was no intake or sound. R14 could not speak. CPR given and abdominal thrust continued. Staff able to get a "small amount of cake" out by doing finger sweeps. R14 was able to breathe at this time. R14 was taken to the hospital for evaluation. R14's Social Work Services Progress Note dated [DATE] documented, "Informed that this resident was choking while eating dinner. I was told he wasn't breathing. They gave him CPR and was able to revive him. They called the ambulance and (R14) was sent to the hospital." Hospital emergency room Note dated [DATE] for R14 documented the admitting [DIAGNOSES REDACTED]." R14's POS of [DATE] documented, "change to mechanical soft." The incident report dated [DATE] showed R14 fell out of the chair while eating lunch in his room (unsupervised). R14's Nutritional care plan showed no evidence of a choking episode or new approaches to prevent R14 from choking on food. Z6 (Registered Dietitian) was interviewed on [DATE] at 10:30am, Z6 said she was not made aware that R14 had choked on food. "If I would haver known I would have referred and made recommendations." 2. The physician's orders [REDACTED]. The Psychiatric Exam dated [DATE] documented, R14 was living in a group home but was transferred to a long term care facility "after frequent falls and depression. Cognitive impairment was considered and the patient has known Parkinson's Disease. The patient had ECT (Electroconvulsive Therapy) in a psychiatric unit. He had been throwing himself off of the chair, blowing his nose to the point of blood coming out and refusing to do his ADL's." The nurse's notes dated ,[DATE] and [DATE] document R14 fell out of bed. The nurse's notes of ,[DATE] showed R14 fell out of the wheelchair twice that day. The notes showed that an order for [REDACTED]. The nurse's notes showed R14 fell out of the wheelchair on ,[DATE], ,[DATE] and had 2 falls on ,[DATE]. The nurse's notes dated ,[DATE], ,[DATE], ,[DATE], ,[DATE] resident refused to wear lap cushion restraint and would remove it. The nurse's notes documented falls occurring on ,[DATE], ,[DATE] (2 times), ,[DATE] (3 times), ,[DATE], ,[DATE], and ,[DATE]. The 72-hour documentation sheet documented a fall on [DATE]. The nurse's notes dated ,[DATE], ,[DATE], ,[DATE] and ,[DATE] showed R14 standing up or leaning foward and falling out of the wheelchair. The 72-hour documentation sheets of ,[DATE], ,[DATE], ,[DATE], ,[DATE] documented falls for R14. The documentation showed the use of the lap cushion still in place as a fall intervention. The incident report dated [DATE] showed R14 fell out of the chair while eating lunch in his room. The lap cushion was noted as a fall intervention for R14. The incident report of [DATE] documented, "R14 lightly bumped head on the wall while being repositioned. Staff advised to use caution when turning/repositioning resident in bed." The incident report dated ,[DATE] showed R14 fell out of a rolling reclining chair. The report showed that staff had the chair in the upright position and not reclined. The Minimum Data Set assessment reference date of [DATE] showed R14 as being moderately impaired in cognitive skills for decision-making with long and short term memory problems. R14 was assessed as being totally dependent on 1 staff for hygiene, bathing and toilet use. R14 required the assistance of 1 staff for bed mobility, transfers and locomotion in the wheelchair. The assessment showed R14 was not able to stand without physical help. R14 fell in the past 30 days and fell in the past ,[DATE] days. The assessment showed R14 had no behaviors. R14's fall risk assessment of [DATE] showed a score of 13 with a score of 10 or more being high risk. The Physical Restraint care plan dated [DATE] and [DATE] showed, R14 has problem of frequent falls due to impaired mobility, strength and having severe neuropathy in the lower extremities- tries to transfer self- new order for lap buddy but is not cooperative with its use. The documentation showed R14 had a total of 29 falls between the time he was admitted on [DATE] and [DATE]. The care plan had no new interventions in place to provide for R14's safety and does not evaluate the effectiveness of the lap cushion restraint as a safety device. On [DATE] at 10am, E2 (Director of Nursing-DON) commented that the lap cushion restraint was being used for R14 to prevent falls. 3. The physician's orders [REDACTED]. The Minimum (MDS) data set [DATE] assessed R29 as being moderately impaired in cognitive skills for decision making and having no memory problems. R29 did not walk during the assessment period and used the wheelchair as the primary mode of locomotion. The assessment showed R29 had behaviors of wandering and being socially inappropriate ,[DATE] days in the last 7 days and was not easily redirected. The assessment showed R29 fell in the past 30 days and fell in the past ,[DATE] days. Nurse's notes documented on [DATE] and [DATE] (sustained injury), R29 fell out of the wheelchair while reaching for objects. R29's Fall's Resident Assessment Protocol (RAP) dated [DATE] showed, "Has had recent falls, takes psych meds, needs supervision with transfers. Mentally unstable at this time. Uses wheelchair as her main mode of transportation." The Cognitive Loss RAP dated [DATE] documented, "R29 has a [DIAGNOSES REDACTED]. Makes poor decisions regarding her health and will refuse medications. At times, can be hard to redirect her." R29's nurse's note dated [DATE] showed resident was confused, quiet and withdrawn. R29's nurse's note dated [DATE] at 9pm documented, "Sent to hospital due to altered mental status." R29's Elopement Risk assessment dated [DATE] showed: resident had a history of [REDACTED]. Social Work Services Progress Notes for [DATE] entry documented, R29 saying she is ready to give up and have intentions of suicide. Entry documented on [DATE] showed, "R29's symptoms appear to be increasing. She continues to believe she is going on vacation, leaving the facility to go out to dinner, etc. She then becomes highly agitated when she is told she is not leaving the facility because she does not have a pass. She has also been observed yelling at residents for no reason (delusional), then laughing the next minute." Nurse's note entry on [DATE] at 6:50pm showed, R29 was readmitted from the hospital. She was withdrawn, depressed and wanted to be left alone. R29's nurse's notes dated ,[DATE] and [DATE] documented, 'R29 up in wheelchair. Resident confused.' R29's Physical Therapy Note dated [DATE] and [DATE] documented, "Patient demonstrates delusions and depression; she states, she "is going home and a taxi will pick her up." R29's Occupational Therapy Notes dated [DATE] and [DATE] showed, Pt. was increasingly confused and disoriented. R29's Physical Therapy note dated [DATE] documented, "Pt. was very confused today. Pt was found getting off the elevator in the nude with all of her clothes laying in the elevator. PTA (Physical Therapy Assistant) took pt back upstairs to room to get dressed. After getting dressed, pt. was informed by PTA to go to dining room to eat lunch. Pt. was later found in stairway where she had tried to go down the stairs in her w/c (wheelchair)." R29's incident report dated [DATE] at 12:15pm documented,"This alert and oriented resident wheeled herself to the 2400 hall exit and opened the door. Staff immediately responded to security door alarm sounding. Resident was observed laying on the first landing with wheelchair resting on top of her. She apparently sustained a fall from the second floor to the landing between the first and second floors. Nurse assessed resident and noted a 10cm x 3cm laceration to the left lower leg. The resident was sent to the emergency room and received staples. The resident was re-educated on safety." On [DATE] at 9am E4 (Psych Social Director) stated, "It happened around lunch time. The staff heard the alarm and got to her (R29) just as she was falling down the stairs in her wheelchair. She was really confused. She had behaviors of wanting to take everyone to Hawaii and would call a cab (to come to the facility to pick up everyone). She would also get it in her mind that her daughter was coming. She was a fall risk but very agile in her wheelchair." 4. The Minimum Data Set of [DATE] shows that R27 has no memory problems and modified independence in cognitive skills for daily decision making. This same document shows that R27 is independent with ambulation. On [DATE] at 12:30, R27 was observed standing in the dining room. R27 had a black orthotic boot on his left foot. The Nurse's Notes dated [DATE] at 8:00 PM state, "Resident slipped on urine in the lobby and turned ankle. I put ice on it. Then 45 min-1 hour later ankle started swelling. Called MD for order to send resident to the ER for eval. At 11:30 PM the NN state, "Resident returned at 11:30 PM with a [DIAGNOSES REDACTED]. On [DATE] at 3:20 PM, R27 stated, "There was urine on the floor by the nurse's station. They only have 1 housekeeper in the building on 2nd shift. I stepped in it and I did the splits. The nurse put ice on it for about 1 hour. Then called the MD. I was sent to the ER. I broke my Left ankle. This is the third fall I have had from a puddle on the floor either by the nurse's station or in the dining room." On [DATE] at 3:10 PM, E2 (DON) stated, "Yes, he slipped on urine." The facility Incident/Accident Report dated [DATE] states, "Resident was walking in the lobby and slipped on a yellow substance that looked like urine. Resident twisted his ankle. " E2 added to the back of this same form, "Resident confirmed this and now calls this area of the nurse's station, "Devil's Corner." R27's falls care plan dated [DATE] states, "Use cone for wet floors, wipe up all spills, and encourage (R27) to observe floors for spills, avoid and alert staff." II. Based on observation, interview, and record review the facility failed to ensure residents do not have unsupervised access to potentially hazardous materials. This applies to all residents on the 500-hall and 2400-hall. (R12, R19, R25, R27, and R32-R77) The example includes: On [DATE] 3:00 to 4:00 PM during the facility environmental tour there were two shower room doors which were open to resident access. The 500-wing shower room contained the following potentially hazardous materials: (4) safety razor blades, (2) cans of shaving cream (with warning label " keep out of the reach of children " ), and (5) bottles of peri-cleanser. The 2400-wing shower room contained the following materials: (4) bottles of total bath cleanser. The facility incident report dated [DATE] on the 1st shift states, " R13 drank whole bottle of Peri-fresh (body cleanser). " On [DATE] 9:15 AM, E4 (Psych/Social Rehabilitation Director) stated " When I spoke with R13, he stated he wanted to get high. " On [DATE] at 3:40 PM, E6 (Maintenance Director) stated, " The shower rooms are to stay locked at all times. " The non-dated facility policy titled, Shower Room Doors, states, " It is the policy of this facility that shower room doors should be locked to assist in maintaining resident privacy and secure equipment and supplies that are stored. PROCEDURES: 3. Staff members should view shower rooms when unlocking doors to ensure equipment and supplies are safe for individual residents. "