Every finding on record at Grove of Northbrook,The

Based on interview and record review, the facility failed to ensure residents received written notification of room changes; failed to ensure resident's family/resident representative or state guardian were notified of any room changes; and failed to have a policy in place address how residents and/or representative will receive written explanation of room changes. These failures applied to 15 (R1, R6, R7, R9, R10, R11, R12, R14, R15, R18 - R23) of 15 residents reviewed for room change and has the potential to affect all 134 residents currently residing in the facility. Findings include:Facility provided a current census upon entrance which showed 134 residents currently residing in the facility.1. R1 is an [AGE] year-old, male, admitted in the facility on 12/23/2025 with the following diagnoses: Parkinson's Disease without Dyskinesia, without Mention of Fluctuations and Other Genetic Related Intellectual Disability. MDS (Minimum Data Set), dated 06/17/26, documented a BIMS (Brief Interview for Mental Status) score of 3, which means severe cognitive impairment. Review of R1's census report showed R1's room was changed on the following dates: 06/10/26, 06/25/26, and 08/12/26. On 08/20/26 at 11:35 AM, during interview with residents in the facility, R3 stated R1 was transferred to his room in the middle of the night. This happened a couple of months ago; it was a 3-resident room, and 3 residents currently occupied the room.R3 is a [AGE] year-old, male, admitted in the facility on 12/09/2015 with diagnosis of Bipolar Disorder, Current Episode Depressed, Moderate and Anxiety Disorder, Unspecified. His BIMS score is 15 which means cognitively intact. R3 stated he had difficulty going to the bathroom and opening his closet because R1's bed was close to his bed and because of the limited space in the room. R3 mentioned he told V4 (Certified Nurse Assistant, CNA) about his problem, but she (V4) stated V1 (Administrator) is aware of the transfer.On 08/20/2026 3:06 PM, V4 was asked regarding room transfer of R1. V4 stated she cannot recall of a room transfer for R1. V4 verbalized when a hospital patient is admitted and requires isolation, an existing resident may be transferred to another room that has sufficient space to accommodate an additional bed. V4 stated a three-bed-capacity room may be temporarily converted to a four-bed-capacity room for overnight use only. She clarified this arrangement applies to the overnight shift, which is the only shift she works.On 08/24/26 at 1:21 PM, V6 (CNA Supervisor) was asked if she is aware of any room transfer of a resident to the room R3 shared with two other residents. V6 replied, One time, there were 4 residents there, the resident was placed there for an overnight because the roommate is on isolation and the resident has to be moved. The resident was moved to that room for an overnight. I remember I came that morning and Social Services asked for my assistance to do the room transfer again. I think it was (R1) who was transferred to that room.During interviews with V7 (Social Services Director) and V9 (Social Worker) on 08/24/26 at 2:08 PM, both stated they were not aware of any room transfer involving R1 to the shared room. V7 verbalized, (R1) has a lot of room transfers. One time his roommate was placed on isolation, so he had to move. When we do room transfer, we don't document the reason for transfer in the progress notes.On 08/25/26 at 10:22 AM, V1 (Administrator) stated, I was made aware, I received a call saying that there is a particular resident that needs to be out in the room, suggesting that we can put him to another room. I don't remember why he was moved; the roommate needs to be put on isolation. It was a temporary situation, for an overnight. I have no idea if it was documented. Technically it was not considered a room change, it was an emergency. At the time, it was a full house. I think it was 05/27/26 around 1 AM that I got the call for the transfer of (R1) to the new room.R1's room transfer to the shared room was not documented in his electronic medical record.2. R6 is an [AGE] year-old, female, admitted in the facility on 02/21/2019 with diagnoses of Dementia in other Diseases Classified Elsewhere, Unspecified Severity, with other Behavioral Disturbance; and Alzheimer's Disease with late Onset. MDS, dated [DATE], showed R6's BIMS score is 3, which means severe cognitive impairment.Census report showed R6 was had a room transfer on 08/06/26. On 08/20/26 at 12:30 PM, R6 was in her room, sitting in the wheelchair. R6 is alert and oriented to self and unable to hold a conversation.3. R7 is a [AGE] year-old, female admitted in the facility on 03/26/26 with diagnoses of Major Depressive /disorder, Single Episode, Severe Without Psychotic Features and Generalized Anxiety Disorder. MDS, dated [DATE], indicated R7 has BIMS score of 15, which means little to no impairment in cognition. Census report, dated 04/20/26, recorded she had a room transfer. 4. R9 is a [AGE] year-old male, admitted in the facility on 11/18/23 with diagnoses of Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Census report, dated 06/24/26, revealed a room change. MDS, dated [DATE], indicated a BIMS score of 14, which means little to no impairment in cognition. On 08/24/26 at 10:15 AM, R9 was asked regarding room change. R9 stated, I was moved to another room, but I don't recall the date. They did not tell me why I have to change room.5. R10 is a [AGE] year-old, female, admitted in the facility on 10/30/25 with diagnoses of Dementia in other Diseases Classified Elsewhere, Mild, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Paranoid Schizophrenia and Anxiety Disorder, Unspecified. MDS, dated [DATE], indicated a BIMS score of 12, which means moderate impairment in cognition.Census reports recorded room changes on the following dates for R10: 02/05/26, 05/14/26, and 07/13/26. On 08/24/26 at 10:32 AM, R10 was in the dining room attending activities. R10 was asked if she had room transfer. R10 stated, They move me from room to room and didn't tell me why.6. R11 is a [AGE] year-old male, admitted in the facility on 09/19/25 with diagnosis of Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. MDS dated [DATE] documented a BIMS score of 4, which means severe cognitive impairment. Census report, dated 03/19/26, showed R11 had a room change. Another room change was also documented on 05/17/26. Family members V15 and V16 (POA and Emergency Contact) were asked if they were notified of R11's room changes. Both V15 and V16 stated they were not notified of any room changes for R11. 7. R12 is a [AGE] year-old, female admitted in the facility on 04/24/2019 with diagnoses of Major Depressive Disorder, Recurrent, Unspecified; Schizoaffective Disorder, Unspecified; and Anxiety Disorder, Unspecified. A room change was recorded on 05/22/26.8. R14 is a [AGE] year-old, female, admitted in the facility on 03/24/25 with the following diagnoses: Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris; Paranoid Schizophrenia and Dissociative Identity Disorder. Census report recorded she had a move change on 06/24/26.9. R15 is a [AGE] year-old, male admitted in the facility on 10/21/25 with diagnosis of Unspecified Intracranial Injury with Loss of Consciousness Status Unknown, Subsequent Encounter. MDS, dated [DATE], indicated he has BIMS score of 3, which means severe cognitive impairment. The following are the recorded room changes for R15: 03/05/26, 03/11/26, 04/08/26, 04/24/26, 06/24/26, 08/05/26, and 08/23/26.10. R18 is a [AGE] year-old, female, admitted in the facility on 06/09/25 with diagnoses of Brief Psychotic Disorder; Bipolar Disorder, Current Episode Manic Severe with Psychotic Features; Delusional Disorders and Adjustment Disorder with Anxiety. Census reports recorded a room change on 03/06/26. On 08/24/26 at 1:32 PM, R18 was asked about any issues with room change. R18 stated she was moved to another room, but they did not tell her the reason why she was moved.11. R19 is an [AGE] year-old, female, admitted in the facility on 12/09/1997 with diagnoses of Dementia in other Diseases Classified Elsewhere, Mild, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Paranoid Personality Disorder and Major Depressive Disorder, Single Episode, Unspecified. Census reports recorded the following room changes: 03/06/26, 03/07/26, and 06/24/26.Review of R1, R6, R7, R9, R10, R11, R12, R14, R15, R18, R19 census reports and medical records showed no evidence that written notice prior to room change was provided, including the reason for the change. There was also no documentation that families/representatives or appointed state guardians were notified prior to room change.On 08/20/2026 at 3:15 PM, V5 (Registered Nurse, RN) stated the facility's policy is for Social Services to speak with the resident regarding room change, and the transfer is initiated by the Social Worker. The Social Worker is also responsible for notifying the resident's family of the transfer. V5 also mentioned the nurse's responsibility is to transfer the resident's medications to the nurse receiving the resident. The Social Worker notifies the nurse when a resident transfer is taking place.On 08/24/26 at 2:08 PM, V7 was asked regarding room transfer/room change. V7 stated, All staff are responsible for room changes or transfer. Social Services talked to the residents regarding room transfer if residents or families want room change, and we accommodate that. We help with the transfer of their belongings. If residents want their families to get notified, we notify them. If residents have guardians, we notify them via phone. We don't have to provide a written notice about room transfer to residents or to the POAs (Power of Attorney) or guardians or responsible party prior to room transfer. When we do room transfer, we don't document the reason for transfer in the progress notes.On 08/24/26 at 3:23 PM, V9 stated, I talk to residents regarding room transfer. If residents request room change, we see what is available and we contact POA or guardians prior to transfer. The process if we have to provide POA/guardians or representatives with written notice prior to transfer and reason for transfer. But I only call the family, written notice is given to residents. For demented residents, only verbal notification given to the nurse and call family to let them know their residents are moved to a different room.V9 further stated that the following room transfer notification forms were given to residents prior to room transfer:R20, on 08/12/26, with no reason for transfer.R21, on 08/05/26, per resident's request.R22, on 08/12/26, reason for transfer is to accommodate peer.R23, on 03/09/26, per resident's request.On 08/25/26 at 12:15 PM, R20, R21, R22 and R23 all stated they never get a copy of the transfer form. R20, R21, R22 and R23 are alert, oriented, without cognitive impairment. R21 mentioned he did not request a room change but was transferred to another room without a reason.On 08/24/26 at 11:50 AM, V10 (Guardian) was asked if she was notified and provided with written notice or reason prior to resident's room changes. V10, replied, No, facility don't notify me or the reason regarding room transfer. I usually learned it from my residents who got upset about that when they called me. It happens all the time. They move these residents' beds to accommodate new admissions.V10 is the State Guardian of R9, R10, R14, R18 and R19.On 08/25/26 at 10:22 AM, V1 stated there should be a reason for room change and proper notification to family members before room transfer. V1 also mentioned they don't have to provide written notice prior to room change.On 08/26/26 at 10:18 AM, V11 (Medical Director) was interviewed regarding residents' room transfer. V11 stated, They do room changes and transfers for necessity, for example if they need a room for isolation and or for safety. Sometimes we need to do room readjustments according to gender. The transfer should be done according to federal and state regulations.Facility's policy titled, Room Transfer, dated 7/19/26, documented:Policy Statement: The facility will transfer a resident to another room within the facility based on the needs of the resident.Procedures:1.The facility will notify the transferring resident or his/her responsible party of the transfer, the reason for the transfer, and the location of the new room.Facility's policy regarding room transfer did not address written notice that needs to be provided to resident or resident representatives.

Based on interview and record review, the facility failed to ensure residents' possessions were treated respectfully and safeguarded during the floor waxing process. This failure applied to two (R3 and R4) of three residents reviewed for residents' rights.Findings include:1. R3 is a [AGE] year-old male, with a diagnosis of Congestive Heart failure, but not limited to anxiety disorder and arthropathy, with a BIMS (Brief Interview of Mental Status) score of 15 (intact cognition).On 8/20/26 at 11:17 AM, R3 reported approximately two weeks ago, the floor in his room was being waxed and all the items and personal belongings in his room were moved into the hallway unprotected, and they were exposed. R3 stated he remained in the hallway for approximately six hours and did not have access to a bathroom during that time. According to R3, the facility did not arrange alternative accommodation for him. R3 stated he made arrangements with R16 to use his (R16's) bathroom if needed. R3 reported staff did not inform him of the availability of a common bathroom.2. R4 is a [AGE] year-old male with a diagnosis of delusional disorder, not limited to obstructive and reflux uropathy, and hyperglycemia, with a BIMS score of 15 (cognition intact).On 8/20/26 at 11:50 AM, R4 was observed lying in bed with a catheter bag hanging on the side of the bed and no privacy bag covering the catheter bag. R4 stated he remained in his bed in the hallway with his catheter bag on the bed while the floor was being waxed and all items from the room were also placed outside in the hallway. On 8/20/26 at 12:31 PM, R8 was interviewed. R8 is the President of the Resident Council. When asked about the floor waxing process and how residents' belongings are handled, R8 stated all belongings, including the bed and everything in the residents' room, are placed in the hallway and are publicly displayed. R8 stated this is an inconvenience for the residents throughout the day because the hallway is small and expressed concern that anyone walking by could potentially take the resident's belongings.On 8/25/26 at 12:04 PM, R16 was interviewed and stated R3 had asked to use his bathroom if necessary, and R16 agreed. R16 stated he observed R3's personal belongings in the hallway and noted the belongings were not placed in a box or otherwise covered, leaving them publicly exposed in the hallway. R16 also stated the floor waxing process may have taken at least six hours.On 8/26/26 at 2:10 PM, V13 (Registered Nurse) was interviewed and stated housekeeping notifies the nurses and CNAs (Certified Nursing Assistants) of the start and end times of the floor waxing process. The nurses and CNAs assist in moving residents out of their rooms, while housekeeping removes the furniture and belongings from the room and places them on the residents' beds in the hallway. V13 stated residents' personal belongings are not placed in a box during this process.The facility's Resident Rights policy did not mention any information related to residents' personal belongings.There are no policies presented by the facility related to the handling and management of personal belongings during housekeeping.

Based on interview and record review the facility failed to provide a safe environment and adequate supervision to a resident (R1) who was at risk of self-harming or foreign-body (batteries) ingestion; failed to develop and update an individualized care plan addressing the behavioral problem; failed to ensure to provide continues/ongoing psychotherapy program; and failed to report the two (2) incidents of R1 ingesting batteries in the facility to IDPH (Illinois Department of Public Health). These failures resulted in R1 having repeated access to batteries from TV remote controls, resulting in two (2) separate episodes of battery ingestion within one week that required transfer to hospital for emergency battery removal. This deficiency affects one (R1) of three residents reviewed for Quality of care.Findings include:R1 was admitted on [DATE], with diagnosis listed in part but not limited to Acute and Chronic Respiratory failure, Chronic Obstructive Pulmonary Disease, Manic severe bipolar disorder with psychotic features, Schizoaffective disorder, Morbid Obesity, [NAME] in adults, Borderline personality, foreign body of alimentary tract encounter.R1's Physician order sheet indicated Amantadine HCl 100mg oral capsule for dyskinesia, Chlorpromazine HCl 50mg oral tablet for Bipolar disorder, Eliquis 5mg oral tablet for blood thinner, Seroquel 50mg and 200mg oral tablet for mood and sleep aid, Topiramate 100mg oral tablet for mood.R1's comprehensive care plan indicated: [NAME] eating disorder. R1 is an adult living with mental illness. She has diagnosis of [NAME] (eating disorder in which a person eats non-food items, some of which are dangerous, e.g. batteries). By ingesting nonfood items/objects she places herself at risk for potential intestinal blockages, dental issues such as severe damage to the teeth or abrasions to the gums and toxic side effects of the substance consumed initiated on 6/10/25. Behavioral issues on auditory hallucinations for ingesting batteries that led to petition for 3 involuntary hospital admission and 2 episodes actual ingestions of batteries requiring hospitalization for the removal of batteries were not reflected in care plan. Interventions were not revised/updated.R1's most recent psychotherapy notes, dated 12/29/25, indicated: LCSW (Licensed Clinical Social Worker) provided R1 with safe place to express self. LCSW praised R1 for the ability to get past impulses.R1's progress notes documented by V7, Registered Nurse/RN, dated 3/20/26 6:00PM, document change of condition (SBAR): ingestion of 2 AAA batteries. No documentation for details about how it happened. 3/20/26 at 10:00PM, V7 documented, R1 admitted to the hospital with diagnosis of swallowed batteries.3/21/26, documented by V8, RN, R1 returned to the facility. She had KUB and upper endoscopy and had two batteries removed from stomach. 3/23/26 documented by V9, Social service, R1 presented with an increase in hallucinations and suicidal ideation. R1 stated her voices are telling her to swallow batteries. An involuntary petition was completed for a psychiatric evaluation for her safety and the safety of others. 3/23/26 documented by V7, RN, R1 was admitted at the hospital with diagnosis of Suicidal Ideation. No documentation in the progress notes that R1 was re-admitted on [DATE]. Record review indicated it was documented in re-admission assessment form at 4:55PM. 3/27/26 at 9:03PM documented by V7, RN, change of condition (SBAR) R1 ingested 2 AA batteries. R1 was sent to hospital. No documentation for details about how it happened. 3/30/26, R1 was re-admitted to the facility. V10, Social worker, documented she initiated the petition of involuntary admission due to R1's acute psychiatric decompensation evidenced by escalating auditory hallucinations and suicidal ideation. R1 reported command hallucinations indicating a significant risk of self-harm and impaired judgement. Given the severity of symptoms and immediate safety concerns, R1 was determined to be a danger to herself. R1 was immediately placed at 1:1 and subsequently transferred to hospital for immediate psychiatric evaluation and further management to ensure safety and stabilization.R1's Petition for involuntary /judicial admission on the following dates: 11/12/23, 3/23/26 and 3/30/26 for psychiatric evaluation due to auditory hallucination, voices telling her to swallow batteries.R1's hospital records date of admission 3/20/26, discharge date [DATE] indicated: Presenting complaint: Swallow batteries. discharged Diagnosis: Battery Ingestion and Schizophrenia. Brief synopsis: (R1) is a [AGE] year-old female with primary medical history of Schizophrenia presenting after swallowing 2 AAA batteries. Has command hallucinations, voices telling her to swallow the batteries. (R1) denies suicidal ideations. Gastrointestinal consulted. Esophagogastroduodenoscopy is done in operating room with battery extraction.R1's hospital records date of admission 3/23/26, discharge date [DATE] indicated: Reason for admission- Suicidal Ideations. Principal diagnosis- schizoaffective disorder. Complaint- Bipolar.R1's hospital records date of admission 3/27/26, discharge date d 3/30/26 indicated: Diagnosis: Battery entering natural orifice, Ingestion of corrosive chemical intentional self-harm initial encounter.On 3/31/26 at 9:40AM, V3, ADON (Assistant Director of Nursing), denied the complaint presented by V20, Community Public Safety, that R1, who has schizophrenia disorder and history of swallowing batteries, was given by staff at the facility a remote control that contains batteries, which she took out and swallowed. V3 said R1 was sent to hospital this past weekend due to ingestion of a TV remote control battery. She said R1 has history of Pica, an eating disorder of ingesting items that are not food. R1 is a long-term care (LTC) resident in the facility and still in the hospital. V3 said she did not know the details of the incident. V2, DON (Director of Nursing), made the incident report.On 3/31/26 at 10:12AM, V2, DON, said R1 is an LTC resident in the facility, who has history of eating disorder of ingesting batteries of the TV remote control prior to admission. R1 was seen by psychiatrist. R1 did not present behavioral issues until 2 weeks ago. On 3/20/26, R1 reported to staff of ingesting 2 AAA batteries, which she removed from the TV remote control. V2 does not know where R1 got the batteries. R1 was sent to the hospital. R1 had KUB (Kidney Ureter and Bladder) x-ray and endoscopy, and batteries were removed. R1 returned to the facility on 3/21/26 with diagnosis of battery ingestion and Schizophrenia. On 3/23/26, R1 was sent out to hospital for psych evaluation due to the report from V9, Social Worker, that R1 was presenting with an increase in hallucination and suicidal ideation. R1 stated her voices are telling her to swallow batteries. An involuntary petition was completed for a psychiatric evaluation. On 3/27/26, R1 reported to staff that she swallowed 2 AAA batteries in response to the internal voice telling her to swallow batteries. Batteries were removed through endoscopy. On 3/30/26, R1 returned to the facility. R1 continues to hear voices telling her to swallow batteries. R1 was sent out to (name) Medical Center for continued care and treatment for low back pain. V2 said R1 is ambulatory and could go into other residents' rooms for batteries from the TV remote control. The facility monitored R1 but did not have documentation. V2 said they did not make incident reports and did not report to IDPH because it is a behavioral issue.On 3/31/26 at 10:40AM, V5, Care plan Coordinator, said when a resident is re-admitted , the individualized care plan is reviewed and revised. V5 said residents with behavioral issues are care planned by Social Services (SS). SS coordinates with nursing if a resident has psychotropic medications for medication adjustment. V5 said R1 is alert and oriented x 3. She can communicate her needs to staff. She is ambulatory and independent with her ADLs and transfer. V5 said she is aware that R1 has Pica, an eating disorder of non-food items. She is not aware it was specific to TV remote batteries until they had incident 2 weeks ago. She said any changes in resident behavior should be addressed in the care plan. She said SS is responsible for updating R1's behavioral care plan and interventions, not nursing. V5 was asked asked who's responsible for monitoring and removing access to the TV remote control in the room of R1. V5 said they are all responsible, but the SS is the one responsible for updating the care plan interventions. R1's medical records were reviewed, including progress notes and comprehensive care plan with V5, Care Plan Coordinator. The care plan was not updated when R1 had ingested remote control batteries in the facility on 3/20/26 and 3/27/26. The care plan was not updated when R1 was petitioned for involuntary hospitalization on 3/23 and 3/30/26 due to auditory hallucination telling her to swallow batteries. V5 said care plans should be updated when there is change in resident conditions or significant change in behavior, and formulation of new interventions to prevent re-occurrence of problems/issues such as removal of TV remote control access, monitoring of R1 activities/ where abouts, staff education, communication/coordination of care with IDT (Interdisciplinary team) involving R1.On 3/31/26 at 11:05AM, V4, SSD (Social Service Director)/Assistant Administrator, said for residents who have behavioral problems, Social Service will initiate/develop care plans and interventions. She is aware of R1's eating disorder of eating batteries from TV remote controls and R1 recently ingested batteries, but V4 was unaware of the details of how she got the batteries. She said R1 is ambulatory and can have access to TV remote control. She said care plans should be updated with current behavioral problems and updated interventions to prevent re-occurrence of the behavior. She said nursing should be involved in the care plan to remove access of remote control and monitor her daily activities.On 3/31/26 at 11:20AM, R2 said R1 was her roommate on 3/27/26 (Friday). R2 saw R1 with the TV remote control. R2 does not use her TV. R2 does not have a remote control, she is using her cell phone to watch news. R1 uses the TV remote/control from previous occupant of bed 1. R2 shares watching TV with R1's TV. R2 stated it was after dinner when R1 went to the bathroom and said loudly, O my God, I did it again. I ate the batteries again. R2 was surprised to hear it. R2 clarifies with R1, You're eating batteries? Then the nurse came and R1 reported it to the nurse.On 3/31/26 at 11:28AM, V15, Registered Nurse/RN said she has taken care of R1. R1 has diagnosis of Pica, an eating disorder of eating non-food items such as batteries. She said R1 will verbalize if she has urges to eat batteries. R1 has a history of auditory hallucinations of hearing voices telling her to eat batteries from TV remote control. She said R1's auditory hallucination happened last year. She said it could be prevented if they remove access to the TV remote control and monitor R1 closely.On 3/31/26 at 11:39AM, V6, Nursing Consultant, said they did not complete an incident report (for two episodes -3/20 and 3/27/26, that R1 ingested batteries in the facility and transferred to the hospital for emergency removal of batteries), nor report to IDPH because it is a behavior issue.On 3/31/26 at 12:00PM, V6, RN Consultant, said they don't have a resident safety policy. She said they have resident rights, which includes the resident has right to be safe/ safe environment.On 3/31/26 at 12:51PM, V7, RN (Registered Nurse), said she is one of the regular nurses who has taken care of R1. On 3/20/26, (R1) reported to me that she swallowed the batteries from her TV remote control. She has history of ingesting batteries prior to admission last June 2025. She did not present any behavioral symptoms nor verbalization of ingesting batteries until 2 weeks ago. She found a TV remote control in her room with empty batteries. I called (V12, PCP/Primary Care Physician) and sent (R1) to hospital via 911. (R1) was admitted but returned to the facility the following day after removal of batteries. I returned to work on 3/23/26. (R1) was sent to the hospital for psych evaluation due to auditory hallucination telling her to swallow batteries. (R1) returned to facility on 3/27/26. I assessed (R1) and attended to her needs. Around 9pm, she came to the nursing station crying and reported to me that she swallowed the batteries again from the TV remote control due to the voices commanding her to eat. (R1) has TV in her room, and it was on. She is ambulatory and can access the TV remote control from other residents' rooms. V7 stated V7 monitored R1, but there is no documentation. V7 said it could be preventable if they provided 1:1 supervision to R1. V7 said she completed an incident report in risk management in PCC (electronic medical record), similar when completing fall incident report. V7, RN, was informed that R2 said she was the roommate of R1 on 3/27/26 and saw her holding the TV remote control. R1 reported to R2 that she ate the batteries from TV remote control. V7 said R2 is alert and oriented x 3. R2 was the roommate of R1 on that day but she did not know about the TV remote control.On 3/31/26 at 1:12PM, requested copy of the incident report completed by V7, RN from V6, Nursing Consultant. V6 said they don't have incident report for R1.On 3/31/26 at 1:15PM, V8, RN, said she was assigned nurse to R1 when R1 was re-admitted from the hospital on 3/21/26 after removal of ingested batteries. R1 was apologetic of her behavior. R1 said she can't help but act from voices that she hears.On 3/31/26 at 1:50PM, V9, Social Worker, said she has taken care of R1. She is aware of R1's eating disorder of ingesting batteries for TV remote controls prior to admission last year in June 2025. R1 has had behavioral issues of ingesting batteries recently. On 3/23/26, R1 presented with an increase of hallucinations and suicidal ideation. R1 stated her voices are telling her to swallow batteries. An involuntary petition was completed for a psychiatric evaluation for her safety and the safety of others. V9 said R1 goes to a psychotherapy program for her behavioral management. V9 said care plans are updated and revised when there are occurrences of behavioral incidents or problems. V9 said V4, SSD, is the one responsible for updating and revising the behavioral care plan of R1.On 3/31/26 at 1:58PM, V10, Social Worker, said she initiated the petition of involuntary admission due to R1's acute psychiatric decompensation, evidenced by escalating auditory hallucinations and suicidal ideation. R1 reported command hallucinations indicating a significant risk of self-harm and impaired judgement. Given the severity of symptoms and immediate safety concerns, R1 was determined to be a danger to herself. R1 was immediately placed at 1:1 and subsequently transferred to hospital for immediate psychiatric evaluation and further management to ensure safety and stabilization. She said V4, SSD, is the one responsible for updating and revising R1 care plan.On 4/1/26 at 10:41AM, V12, PCP (Primary care Physician of R1), said she has taken care of R1 since her admission in June 2025. She said she is aware of behavioral incidents that happened 2 weeks ago in which R1 ingested batteries from a TV remote control twice in the facility, on 3/20 and 3/27, which required emergency removal of batteries at the hospital. R1 was also sent to hospital for psych evaluation on 3/23/23 due to auditory hallucinations, voices telling R1 to eat batteries. She said R1 is ambulatory, alert and oriented. V12 said per nursing report, R1 got the TV remote from somebody not from her room. They monitored her closely and updated the care plan. V12 was informed R1's care plan was not updated and there was no documentation in the progress notes of close monitoring of R1. V12 said R1's care plan should be updated. R1 needs to have 1:1 supervision and 24-hour monitoring to possibly prevent the behavioral re-occurrence of battery ingestion.On 4/1/26 at 11:02AM, V19, CNA (Certified Nurse Assistant), said he was assigned CNA for R1 on 3/20 and 3/27/26 3-11 shift, both days that R1 ingested batteries from the TV remote control. V19 is aware R1 has history of ingested batteries prior to admission. V19 did not know what happened. V19 did not see her eat the batteries. R1 does not have remote control in her room. V19 turned on and off the TV manually when R1 requested. V19 monitored R1 but did not document. V19 said it could be prevented if R1 is on 1:1 supervision so he can focus on her. V19 has 20-25 residents assigned to him, with 9 residents need total care with ADLs and transfers.On 4/1/26 at 11:28AM, V17, Psychiatrist, said he has taken care of R1 since her admission in June 2025. V17 was notified of her behavioral incidents that happened 2 weeks ago whenR1 ingested batteries from a TV remote control on 3/20 and 3/27/26 in the facility. V17 expected the facility to implement behavioral management interventions such as supervision, re-direction, education, and having the battery/TV remote control not readily available. It's a standard practice to update the care plan and develop new interventions with each re-occurrence of behavioral problems. 1:1 supervision could prevent the re-occurrence, but that's unrealistic.On 4/1/26 at 11:38AM, R1's care plan was reviewed with V2, DON. V2 said the care plan intervention for [NAME] (eating disorder of ingestion of battery) behavioral problem is generic and not individualized for R1. On 4/1/26 at 11:46Am, R1's medical records were reviewed with V4, SSD, regarding auditory hallucinations of R1 informing to eat batteries leading to petition of involuntary hospital admission on [DATE]. She was hospitalized and returned to the facility on [DATE] with diagnosis of Current manic severe bipolar disorder with Psychotic features. Same issues with petition of involuntary hospital admission issued on 3/23/26 and 3/30/26, in which R1 verbalized auditory command hallucinations telling her to eat the batteries from the TV remote control. V4 was informed R1's care plan was not updated since it was initiated on admission June 2025. The auditory hallucination of commanding R1 to eat batteries from the TV remote control was not included in the problem identified in care plan. V4 said she does not need to update the care plan because it was the same problem and the interventions were the same. V4 was informed R1 was not seen by psychotherapist since [DATE]. V4 said they changed psychotherapists and started at the end of January 2026. V4 said R1 refused the psychotherapy session but it was not documented.On 4/1/26 at 1:29PM, V18, Psychotherapist, said she is from outside vendor providing psychotherapy sessions to residents for behavioral symptoms management. She started coming to facility at the end of January, five times per week. She said R1 was referred to her end of January or early February 2025. She approached R1 and offered psychotherapy session but R1 refused. V18 does not have documentation of R1's refusal. V18 is not aware of R1's behavioral issues. V18 said psychotherapy programs will benefit residents with behavioral issues to control and manage their symptoms. The psychotherapy session will help residents manage challenging behavior and improve coping skills by 1:1 verbalization of feeling and thoughts.On 4/1/26 at 1:56PM, V6, Nursing Consultant, said they don't have policy on psychotherapy program, it's incorporated with Behavioral management policy. Facility's policy on Resident's right indicated:Residents' rights for people in LTC facilities: Rights to safety.Facility's policy on Incident reporting, revised 6/30/25, indicated: Procedures: 1. Any serious injury sustained by a resident that is not an expected outcome of the disease process will be reported to IDPH regional office. Physical harm includes fractures or blood flow not stopped by band aid or hospital treatment that involves more than diagnostic evaluation. 3. The facility shall, by fax, phone, email or directly through the IDPH portal notify the regional office within 24 hours after each reportable incident or accident.4. The facility shall send a narrative summary of each reportable accident or incident to the department within seven days after the occurrence.Facility's policy on Care Plan, revised 6/30/25, indicated: Policy statement: it is the policy on the facility to ensure that all care plans including baseline care plans are in conjunction with the federal regulations. Procedures: 4. After the comprehensive assessment is completed, the facility will put in place person-centered care plans outlining care for the residents within 7 days. 5. These periodically reviewed and revised by a team or qualified person after each assessment.Facility's policy on Behavioral management, revised 6/26/25, indicated: Policy statement: it is the facility's policy to ensure that resident's behavior is addressed properly. Procedures: 1. When a resident manifests a certain behavior, the facility will try to determine and address cause of behavior. 2. It the behavior puts the resident at risk of harming himself or herself, then the management is toward ensuring safety of the resident until properly assessed in a hostile setting. 5. The IDT, which consists of nurses, CNAs, activity staff and social service staff, will be involved in reporting and intervening when the behavior occurs. 6. The social service department will be involved in monitoring these residents with behavior and will address and intervene when the behavior occurs.

Based on observation, interviews, and record review, the facility failed to follow its Code Yellow (elopement) Policy regarding monitoring residents identified as at risk for elopement. This failure resulted in R1 eloping from the facility and being off grounds for an unknown amount of time before a search was started, and a Code Yellow was called. All 15 residents being monitored for risk of elopement can be affected by this failure. The Immediate Jeopardy began on 10/23/2024 when R1 eloped from the facility, and the door alarm was canceled by the staff without initiating the code yellow protocol. V1 (Administrator) and V2 (Director of Operations) were notified on 12/02/2024 at 3:45 PM of the Immediate Jeopardy. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 12/03/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1 is a [AGE] year old female admitted to the facility on [DATE]. Diagnosis includes: chronic multifocal osteomyelitis, multiple sites; mild cognitive impairment of uncertain or unknown etiology; gangrene, not elsewhere classified; adult failure to thrive; tachycardia, unspecified; hypotension, unspecified; hypothermia, not associated with low environmental temperature; osteomyelitis,unspecified; schizophrenia, unspecified; hypocalcemia; anemia, unspecified; unspecified severe protein-calorie malnutrition; unvaccinated for covid-19; personal history of covid-19; and patient'snoncompliance with other medical treatment and regimen for other reason. R1's MDS Section C Brief Interview for Mental Status (BIMS) score is 15 (intact cognition). R1's BIMS on 11/07/2024 is 99 (interview incomplete as R1 chose not to interview). R1's care plan states R1 is a DNR (Do Not Resuscitate) and has poor decision-making skills and poor judgment. She has been homeless for the past 2 years and was found to be unable to care for herself. She has a court appointed guardian that is in contact with R1 and facility. The facility sits in the parking lot of an outdoor mall, and is bordered on three sides by retail outlets and the main entrance faces a major expressway (which has a chain link fence barrier and road shoulder and landscaping before the expressway) making it inaccessible to anyone not physically fit to scale the fence and access the expressway. The facility is corralled on three sides by a privacy fence, so anyone leaving from the B doorway would be forced to walk around the fence in front of an external security camera before being able to make it to the bus stops on a busy street (which is about a 5-10 minute walk for an otherwise healthy person). The facility exit doors all have alarm monitors on them, and are all near a nursing station. There is a keypad on the wall next to the door to deactivate the alarm, or for the staff to disable the alarm prior to exiting and entering the door without setting off the alarm. Each nursing station and Reception desk was verified to have an elopement/Code yellow book in the nursing station. In addition to the protocol, there was a list of elopement risk residents that were posted in each nursing station. During the time of observation, the B nursing station was not occupied. Also, line-of-sight to the doors is not always available, so the alarm is the primary warning system. The door alarm did sound (when activated by staff activity) during survey, and was only audible within a few feet of the door. Many staff also reported they could not hear the door alarms from other areas of the building when they are not nearby. Record review and interviews revealed the Receptionist is the primary person to monitor the security cameras for the facility. The receptionist also controls the main door for visitors and answers phone calls. The monitoring of the alarm and camera is just one of the responsibilities of the Receptionist, and the desk is monitored by different people on a part-time basis during the week. On 11/29/24 at 12:40PM, V8, Wound Care Nurse, stated when R1 was first admitted to the facility, she had gangrene to her toes related to frostbite, and was in a lot of pain. R1's wounds were debrided and eventually she was able to move fast without pain, but she still received daily wound care. V8 stated R1 did not want to go to orthopedic appointments, and she was also recommended for surgery. R1 did have the necrotic skin removed, and she always slept in a chair. R1 would also wear the shoes of her choice instead of surgical shoes. R1 would also refuse treatment from time to time; this was reported to the guardian for R1 and R1's physician. R1 was seen by the Wound Care Nurse on the morning before she left. V8 could not remember the exact time he saw her on that day. On 11/30/2024 at 2:00PM, V15, Restorative aide, stated V15 was downstairs on the day R1 eloped and she was exercising downstairs with a group of residents. When she came upstairs to assist with lunch with the other residents, that is when V15 found out about the Code Yellow. She did not hear the alarm because of the television that was playing in her group. V15 stated she saw R1 earlier in the day before breakfast, and confirmed her (electronic monitoring) device was working, V15 stated when she is with a group, she cannot leave the group that she is working with to respond to the door alarms. V15 stated leaving her group could compromise the safety of the group. V15 verbalized she was able to join the group in the parking lot later and searched the retail stores for R1. On 11/29/24 at 2:30PM, V11, Certified Nursing Assistant/CNA, stated she saw R1 around 9:00AM on 11/23/24, and then about 5 minutes after that. R1 was on V11's case load that day. V11 remembers a Code Yellow was called around lunch time. V11 verbalized R1 did not need any assistance with her AM routine, so she only saw her briefly, and then would have checked on her again within the next two hours. When asked if two hours had passed since the last time she had seen R1, V11 could not remember. V11 stated she let the LPN (Licensed Practical Nurse) (V5) on the central unit know prior to her going on break, but did not recall hearing the door alarm. V11 could only remember R1 was noticed to be missing based on her lunch tray was untouched around lunchtime. V11 knew the Code yellow protocol and to do a head count during a Code Yellow. On 11/29/24 at 11:30AM, V5, LPN, stated V5 was the nurse on duty during the elopement. V5 said there were a lot of alarms going off that day. There were deliveries and staff entering and leaving that day. V5 also stated even though the nursing station is right in front of the exit that R1 left from, V5 was down the hall passing meds to the other residents that she was assigned to, so she did not hear the alarm sounding. V5 knew where the high risk for elopement log for residents on that side of the building. V5 also knew where the names of the high risk residents were posted. V5 knew the Code Yellow protocol, including conducting the head count. On 11/29/24 at 2:35PM, V5 added R1 does not have scheduled AM meds; her AM meds are only PRN, so she would not have a time on when she would have seen R1 without passing meds to her. On 11/29/2024 at 1:41PM, V9,CNA, stated he has been a CNA for about a year, and he normally works on the D station and was doing patient care on the day R1 eloped. V9 stated he was looking for a mechanical lift and there was one in the hall near the central exit. V9 apologetically said he heard the alarm when he got the mechanical lift from the hall, and he just turned off the alarm without checking to see if anyone left, or notifying anyone about the alarm. V9 stated he was in a rush to get back to his patient with the lift. V9 verbalized he just looked at the door and made a mistake, and feels really bad about it. V9 stated he did not open the door to check out what was going on the outside; he was going through the building looking for someone to assist with the transfer. V9 stated he cannot remember if there was anyone in the B nursing station at the time, but he found his supervisor, V10, to assist with the transfer, however, he still did not report to V10 the door alarm was sounding. V9 said V10, CNA, later discovered R1 was missing after lunch. V9 did not see R1 prior to her leaving the facility. V9 is familiar with the Code Yellow procedure and has since been in-serviced on what to do. On 11/29/2024 at 2:10PM, V10,CNA, stated she went to the bedroom of R1 on the day that she eloped and noticed her breakfast tray was not touched. V10 and her staff then started a search for R1. V10 was not sure about the time, she just knew it was about lunch time, as R1's breakfast tray was delivered to her room. R1 always eats in her room and the tray was untouched. After the search, it was determined she was not in the facility, V10 and some other staff started a search of the stores and buildings in the parking lot around the facility. V10 also got into her car and went to Chicago and started checking homeless areas. V10 verbalized she went to the city and started pulling back the blanket of homeless people sleeping on the streets to check for R1. She also asked people on the streets for information about R1. V10 stated she searched until the early hours of the morning, because she wanted R1 to be safe. V10 also verbalized she was in communication with her team of co-workers during the search, but cannot say that her colleagues searched as long as her. V10 said she searched the city based on hunches that she had. V10 stated she did not hear the door alarm prior to V9 disarming it, and V10 was familiar with the Code Yellow policy. On 11/29/2024 at 2:15PM, V16, CNA who was on duty at the time of the elopement. V16 stated she has worked at the facility for about 2 months as a CNA, on the day in question, V16 heard the door alarm, but was in a room providing care to a resident that is a total care. V16 verbalized she could not stop what she was doing and leave her resident alone. The next time she was alerted to the Code Yellow was from the overhead paging system, which was around lunchtime. V16 then began to search in the shower and around the facility. V16 stated she did go out to the lot and look around, but then came back inside to look in the bathrooms and in the facility. V16 stated she has been trained in the Code Yellow protocol. V16 did indicate she knew the procedure for Code Yellow. V16 was providing care in rooms (room numbers), which were right next to the point of exit for R1. On 11/30/2024 at 3:00PM, V18, Recptionist, stated V18 was the Receptionist on duty at the time of the elopement, and no longer works at the facility. V18 verbalized she didn't see R1 leave the facility (via the monitor), or what could have prevented her from seeing R1 leave the facility, as the equipment was functional on the day of the elopement. V18 said when the nurse silenced the alarm, she thought the situation was over. V18 verbalized she did call the Code Yellow when advised, but she was not trained on notifying of the all clear. She stated she has had in-service training, but did not have a clear understanding of the protocol. On 11/29/30 at 10:45AM, V1, Administrator, and V3, Director of Social Services, were interviewed. They discussed facility's efforts to coordinate with local and other municipal police departments, sister facilities, Chicago Transit Authority (CTA) and hospitals, in addition to facility staff members going into the communities to search for R1. V1 described the Code Yellow policy, and how the protocol should have worked. V1 and V3 also described how they started to in-service staff on proper execution of the policy. as well as revisions made to the Code Yellow policy. V1 also stated he was able to view the video of R1 leaving the facility through the door of station B. V1 was able to describe the clothing R1 was wearing, and that she had taken her belongings in two bags attached to her rolling walker. The video was not saved, and was erased by the camera system looping over the video. V3 was able to provide care plans and other documents related to facility policies. V3 also stated she is keeping a log of the efforts to return R1 to the facility. V3 did not share the log, and provided verbal information on progress towards R1's return to the facility. V1 also stated the door alarms are tested daily by the Maintenance Director. On 11/29/2024, V1, Administrator, V4, Activities Director, V6, Registered Nurse/RN, V7, CNA, V12, CNA, V13, RN, V14, Social Serivces, and V17, Part-time Receptionist, and all knew the protocol for Code Yellow and how to activate the head count. All workers also verbalized being recently in-serviced on the Code Yellow protocol. On 11/30/2024 at 12:05PM, V2 (VP of Operations) stated he was informed of the elopement around 1:30PM/2:00PM. V2 stated he was able to contact the CTA (Chicago Transit Authority) via the local police, and was able to determine R1 was near a sister facility and sent worker(s) to CTA facility to retrieve her, but was too late when they got there. It was determined by the CTA that R1 had gone into Chicago. V2 confirmed his team has searched known areas for R1 and homeless people to gather, and maintained contact with hospitals daily. On 12/01/2024 at 10:00AM, reviewed facility Code Yellow plan, dated 11/01/16 and revised 07/26/24, which reads: When the door alarm sounds, staff members shall immediately respond to determine the cause of the alarm; A) The staff member responding to the alarm shall check the outside/vicinity of the area to determine if a resident has exited the building. B) If upon investigation no reason can be found for the sounding of the alarm the Administrator/DON/designee must be notified. C) A head count will be completed on all units and completed accounting of all residents given to the administrator/DON The Immediate Jeopardy that began on 11/23/24, was removed on 12/03/24, when the facility took the following actions to remove the immediacy: 1.) Facility staff immediately called a Code Yellow on 11/23/24 at 1:00PM, when facility determined that resident was missing. Staff conducted a search inside the facility including outside of facility premises. 2.) A Police Report was immediately filed for a missing resident, R1, on 11/23/24 at 1:15PM to Officer (name, badge#) of the (city) Police Department. 3.) On 11/23/24, the CNA who responded to the alarm door was immediately educated not to turn off the alarm until a visual check/search is completed. This training was conducted by the Asst. Administrator. 11/23/24 at 3:15PM. 4.) The Receptionist assigned was educated on 11/23/24 to make sure to look at the monitor to make sure no resident had exited, and not to turn off the alarm until a visual check/search is completed. On 11/23/24at 3:00PM Training was conducted by Assistant Administrator. The in-service included proper Alarm Response and utilization of the zone panel & camera system. Discussed appropriate times to call Code Yellow and to not cancel the alarm until given the 'all clear' following a head count. Emphasized the scope of receptionist responsibilities as the 'security station' of the facility. 5.) All employees were in serviced to ensure an immediate response to an exit door alarm is done, educated not to turn off the alarm until a visual check/search is completed. A head count is also to be completed to ensure that all residents are accounted for. If a resident is noted missing, staff to follow the facility protocol on missing residents. This was initiated on 11/23/24 and completed on 11/26/24. This in service will also be provided for every newly hired staff moving forward. 11/23/24 at 4:30PM. The training was initially conducted by Social Services and Assistant Administrator on 11/23/24 for those present. The training continued both in person and over the phone for the remaining employees over the next 3 days and was conducted by Food Services Director, CNA Supervisor, Social Services, Assistant Administrator, and Administrator. HR Manager printed out a complete facility roster which was cross-referenced to ensure all employees were educated. 6.) The Maintenance Director conducted an immediate check of the facility exit alarmed doors. All exit doors are alarmed and functioning. This check was initiated on 11/23/24 and will continue checking daily. 7.) A facility wide audit to identify residents at risk for elopement, those at-risk for elopement must have photos in the elopement list posted on the bulletin board on each unit and at the reception desk for quick reference. Currently, there are 15 residents identified at risk for elopement. Audit was completed on 11/23/24 by Assistant Administrator/Social Services Director. Resident photos are taken upon admission to the facility and Elopement List is posted at each nursing station (both in a binder and on bulletin board for quick reference) and at the reception desk. Staff were in-serviced that bulletin boards will be used as the central location point in which to reference the elopement list at each nurse's station. 8.) The Social Service Department reassessed residents identified for elopement and elopement care plan was reviewed and updated. This was initiated and completed on 11/23/24 at 6:00PM by Social Services. 9.) On 11/23/24, a facility door alarm drill was conducted to ensure staff are appropriately responding to an exit alarmed door and not to turn off the alarm until a visual check /search is completed. A facility protocol was put in place to ensure a head count is conducted after the visual check/search is done to ensure all residents are accounted for. This in-service was initiated by Social Services at 5:00PM on 11/23/24. 10.) The facility has identified approximately 25 (city) & surrounding area hospitals which facility staff continue to call daily in search of R1. This began on 11/23/24 and is ongoing. 11.) On 11/30/24, (electric company) was called in to provide extra sound devices to project a more amplified sound to ensure staff can hear & respond to an alarm. (Electric company) will complete the work order on 12/1/24 to install necessary devices to address the concern. 12.) On 12/1/24, (electric company) arrived at 7:00AM and installed 7 new sound devices throughout the facility which project a more amplified sound to ensure staff better hear the door alarms. (Electric company) has also placed an order for dome lights to be installed at each exit door. This will hopefully be done by weeks end. 13.) All receptionists were in-serviced on Alarm Response and Utilization of Camera System to ensure camera is checked thoroughly before canceling the alarm system. This was completed on 12/1/2024. Receptionist separated from the facility on 11/27. Training was conducted by Assistant Administrator. The in-service included proper Alarm Response and utilization of the zone panel & camera system. Also discussed were appropriate times to call Code Yellow and to not cancel the alarm until given the 'all clear' following a head count. Lastly, we emphasized the scope of their responsibilities as representing the 'security station' of the facility. 14.) An additional in-service was conducted to all employees of the new amplified alarm devices to ensure staff are familiar with the amplified sound and respond immediately to the alarm. All staff were also in serviced on the purpose and locations of the zone panels should an exit alarm be sounded to determine location of alarm if uncertain. Staff were also in serviced on the location of the elopement risk residents' list that is posted on the bulletin board in every nurse's station for quick reference. This was initiated on 12/2/2024 and will be completed by end of day on 12/3/24. Training was initiated by our two Social Services Designees and our Social Services Director on 12/2/24 for those employees who were present. The training continued both in person and over the phone for the remaining employees through 12/3 and was conducted by the Food Services Director, CNA Supervisor, Social Services/Assistant Administrator, Administrator and Guest Relations. The HR Manager printed out a complete facility roster which was cross-referenced to ensure that all employees were educated. 15.) A QA (Quality Assurance) audit tool was initiated on 11/23/24 to ensure the main exit door alarm system and the (electronic monitoring) system are checked for functionality daily and documented by maintenance. This will be done daily x14 days and 3x/week x2 weeks and weekly x 8 weeks. 16.) A QA audit was initiated on 11/23/24 to ensure staff are following door alarm drill, and all residents are accounted for. This audit will be done daily x7 days and 3x/week x3 weeks and weekly x 8 weeks. 17.) The QA audit tool that was initiated on 11/23/24 was revised after the additional amplified alarms were installed by (electric company) on 12/1/24 to ensure the exit door alarm system remains amplified. This will be conducted daily x7days, 3x/weekly x 8 weeks. The QA tool revisions were made on 12/1/24 at 5:00PM 18.) A QA Audit was initiated on 12/1/24 to ensure receptionists are responding to an alarm system by initiating a 'Code Yellow' and checking the camera thoroughly before canceling the alarm system. This QA will be completed daily x 7 days and 3x/week x8 weeks. The QA audit was initiated at Approximately 11:00AM on 12/1/24. 19.) The elopement policy was reviewed and revised on 12/2/2024, which included specifying types of door alarms and defining them, as well as creating a centralized location at each nurse's station for quick reference of the elopement list. Policy was also revised to reflect the facility's specific protocols on Routine Procedure for Wandering Residents and Prevention of Missing Residents/Elopement. Training on the revised Elopement Policy was initiated by Social Services on 12/2/24 for those employees who were present. The training continued both in person and over the phone for the remaining employees through 12/3, and was conducted by the Food Services Director, CNA Supervisor, Social Services/Assistant Administrator, Administrator and Guest Relations. The HR Manager printed out a complete facility roster which was cross-referenced to ensure that all employees were educated. 20.) The QA trends will be discussed in QAPI scheduled on 12/9/24 and then monthly. 21.) The facility Medical Director was notified of the basis of abatement plan, and has approved on 12/2/24.

Based on interview and record review, the facility failed to monitor a resident during a change in mental condition. This resident was able to injure a resident by pushing a wheelchair aggressively, causing this resident to slide out of the wheelchair hurting her back. The failure affects one of three residents (R1) reviewed for resident-to-resident physical assault. Findings include: R1 is a [AGE] year-old female. R1's face sheet diagnoses are but not limited to high cholesterol, schizoaffective disorders, paranoid schizophrenia, and sciatica. R1's BIMS (Brief Interview for Mental Status), dated 07/18/2024, notes R1 is alert. R3 is a [AGE] year-old male. R3's face sheet diagnoses are but not limited to major depressive disorder, and bipolar disorder. R3's BIMS (Brief Interview for Mental Status), dated 06/06/2015, notes R3 is alert. On 09/14/2024, at 12:09 PM, V1 (Assistant Administrator) stated, (R3) is no longer in the facility. He went to a different nursing facility. He had never had any behavioral concerns. To my knowledge, he did not present with any changes in condition. I was in the building. I heard noises. I went into the hallway. I was told by my Social Services Department that (R3) was upset. I was told he had head butted staff. I was told that he may have gone into someone's room. 911 came. They took over from there. He was on a one to one. But the staff he head-butted was sent to the urgent care. No staff witnessed the incident between (R1) and (R3). On 09/14/2024, at 12:31 PM, R2 stated, (R3) pulled (R1) out of the wheelchair and put the wheelchair over her while she was down. (R3) had a tendency of yelling. (R1) was going to tell (R3) to keep it down. When (R1) went to tell (R3) to keep it down, (R3) yelled fu***** b****. Keep your mouth shut and stay out of my business. (R1) was sitting in the wheelchair, and she fell on the floor. She hit her back on the floor. I was scared because I thought I would be next. Staff was not too far, but it took them about five minutes to assess the situation. I was not hurt; it was just her. I heard him yelling before this occurred. It was like (R3) was not satisfied being in the facility, but he was very agitated. I do not feel safe here because there are other people that are here that must be watched and get agitated. On 09/14/2024, at 12:42 PM, R1 stated, (R3) was insulting to staff and tried to hit them. He was screaming. He was taking resident's lunches and throwing him. I went over to see what I could do. He got really enraged and he slammed my wheelchair into the bathroom door so hard that me and my wheelchair tipped over. I landed on my back and bottom. Social Services were in the hallway. The nurse came and put me in the chair. My back still hurts from the incident. On 09/14/2024, at 1:31 PM, V2 (Social Worker) stated, I was with (R3) for the one to one. The paramedics and my co-worker were there. Out of nowhere he became aggressive, and head butted me. I went straight to the office and stayed away from the situation. The purpose of a one to one to make sure they do not harm themselves or anyone else. On 09/15/2024, at 4:22 PM, V3 (Admissions Director) stated, I was monitoring (R3) after the staff member got hurt. I wanted to keep my distance, but also monitor him at the same time. I was trying to calm him down, and I spoke with him to keep tensions low. He was saying that he was very angry and going to residents' rooms and closing their doors. I cannot hold him down. I was unaware that any other resident was affected by this. I did not witness this incident. On 09/15/2024, at 4:30 PM, V4 (Social Worker) stated, I was at the front desk covering for the receptionist. (R3) had an independent pass. He was asking me to buy conditioner with my own debit card. I told him that I cannot do that. He got very agitated by that. He got angry and slammed open one of the doors. I contacted our Social Services Director. I was in the office with other staff. He came into the office where we were and said he wanted to leave. That is when (V1) stepped in and asked why he wanted to leave. Staff started (R3's) petition to a local hospital. When the ambulances came, he was in his room. Four of us went to go see what was happening with the paramedics. The paramedics stated that they needed help because he did not want to leave. (R3) went up to (V2) aggressively and he head butted her. I saw it happen. I stepped in and asked why he would do that. He ran into his room again and slammed the door. I grabbed (V2) and took her to the office. (R3) got out of his room and pinned (V3) to the wall. Everything happened so quickly. I had my eyes on (R3). When (R3) started getting aggressive, I could not see everything that was going on. The police ended up coming when he was in his room. Me and (V3) were there, but as soon as he flipped the stretcher and the housekeeping cart, I got startled. I did not see (R3) harm any residents. I have only been on a one to one, one other time. I have just been told to keep an eye on residents and make sure they do not get physical with others. On 09/15/2024, at 4:44 PM, V5 (Licensed Practical Nurse) stated, I did not witness the incident between (R1) and (R3). When I started my shift, (R3) was quiet. I did not notice any behavior. I witnessed him trying to shut residents' doors in the hallway and him hitting one of our staff. Not too long after that, I was informed by staff that (R1) was on the floor. I entered the room and (R1) was sitting on the floor. The wheelchair was behind or beside her. I asked her what happened. She claimed that (R3) pushed her wheelchair while trying to close her door. I asked her if he went inside her room. She said no. She was sitting near her door in her wheelchair. He was trying to close the door. According to her, he pushed her wheelchair. She sits towards the end of her wheelchair. She informed me that she lost her balance and fell out of the wheelchair. I did a head-to-toe assessment. She had a small size discoloration on her right arm and her low back. She denied hitting her head. She fell on her butt. She complained of generalized pain. She is alert and oriented and make her needs known. General progress note, dated 08/13/2024, R1 returned to facility around 7:15 PM via ambulance/cart. R1 is alert and approachable. Resident complained of pain to the lower back and buttocks. Skin assessment done with skin discoloration noted to the right upper arm. Right elbow has light purple discoloration.

Based on observation, interview, and record review, the facility failed to implement its abuse prevention policy by failure to complete abuse assessment and update abuse care plan after allegation of resident-to-resident physical altercation. This deficiency affects three (R25, R78 and R87) of three residents reviewed for Abuse prevention policy. Findings include: 1. Review Incident report of Resident-to-resident physical altercation involving R25 and R87 completed by V1, Administrator, indicated on 3/22/24 at 7:05AM, upon entering room, V28, RN (Registered Nurse), observed R25 on the floor. Upon initial interview of residents, it appeared that there was a disagreement over the volume of R87's TV. As R25 attempted to scurry away back to his bed with R87's remote, he lost his balance and fell . V1 interviewed R25 on 3/25/24. R25 admits to trying to take R87's remote control on the morning of 3/22/24, as he felt the volume of his TV was too loud. R25 also admitted to then taking his cell phone off the bed after R87 grabbed the remote back. R25 alleged R87 pushed him when R87 attempted to get his cell phone back from him, causing him to lose his balance and fall. R25 was immediately assessed and was able to move all his extremities with only slight discomfort to his back. R25 was sent to local hospital for precautionary evaluation and returned soon thereafter with no new orders or injury. V1 interviewed R87 on 3/22/24 and 3/25/24. In both instances, R87 alleged on 3/22/24, his roommate R25 walked over to his bed unprovoked and grabbed the remote control off his bed. R87 was able to immediately retrieve his remote at which time R25 grabbed for his cell phone. As R87 attempted to grab his phone back, R25 lost his balance and fell as he tried to scurry away R87. R87 strongly denied ever pushing R25 at any time. There were no witnesses to the alleged incident. R25 was readmitted on [DATE], with diagnoses listed in part but not limited to Psychotic disorder with delusion due to known physiological condition, bipolar disorder current episode depressed severe with psychotic features, Dementia with behavioral disturbance, Schizophreniform disorder, Alzheimer's disease, Cerebral infraction. Abuse/Neglect assessment done on 12/8/16 indicated he is at risk for abuse due to his history of abuse and substance abuse, as well as his mental health diagnosis and his history of abrasive/aggressive behavior. Abuse/neglect /trauma factors care plan for abuse neglect trauma assessment updated on 10/21/22. Both Abuse/neglect assessment and Abuse care plan intervention were not updated after the physical abuse resident to resident altercation on 3/22/24. R87 was admitted on [DATE], with diagnoses listed in part but not limited to Dementia with other behavioral disturbance, Paranoid personality disorder, Psychosis, Alzheimer's disease with late onset. Abuse/Neglect assessment done 2/10/22 indicated he at risk due to mental issues, presents with signs and symptoms of mood distress. Resident has history of exhibiting verbal outbursts when he becomes upset. Comprehensive care plan did not indicate abuse/neglect prevention care plan. After resident-to-resident physical altercation incident on 3/26/24, both abuse/neglect assessment and abuse care plan were not updated. On 6/4/24 at 8:24AM, R87 was lying in bed. He was alert and oriented, and could verbalize his needs to staff. R87 said he denied having resident to resident alteration with another resident, and denied incident happened last March 2024. On 6/4/24 at 8:38AM, R25 was lying in bed sleeping. Several attempts were made to interview R25, but he was sleeping, and nursing staff said that he becomes agitated when they wake him. On 6/4/24 at 8:53AM, V4, Social Service Director (SSD), said they do abuse/neglect assessment upon admission, quarterly, and as needed, such as when there is an allegation or incident of abuse. V4 said abuse/neglect prevention care plan is formulated after assessment, if indicated. V4 said after abuse/neglect/resident to resident altercation allegation or incident, the abuse/neglect assessment and abuse prevention care plan is updated. Reviewed R25's and R87's resident to resident physical altercation incident report with V4. Reviewed R25's and R87's abuse assessment and abuse prevention care plan with V4. Medical records of both residents indicated abuse/neglect assessment and abuse care plan was not updated after the resident-to-resident physical altercation incident on 3/22/24. 2. R78 was admitted on [DATE], with diagnoses listed in part but not limited to Epilepsy, Mild cognitive impairment, Dysarthria following cerebral infarction, Apraxia following cerebrovascular disease. Abuse/neglect admission assessment done on 10/3/19 indicated she is at risk for abuse. Resident triggered on numerous areas on depression assessment and per guardian, has hoarding tendencies. Guardian reports compulsive spending. Care plan indicated presence of abuse and neglect factors. She has history of serous trauma. Abuse assessment and abuse/neglect prevention care plan were not updated after resident-to-resident physical altercation incident on 6/7/23. R78's resident to resident physical altercation, dated 6/7/23 at 8:40AM, indicated R78 stated another resident hit her on her right shoulder as they passed each other in the hallway earlier in the morning. Both residents were immediately separated and monitored for safely. Upon initial assessment, R78 was noted with no redness, bruising or discomfort. Later in the day of 6/7/23, R78 complained of slight discomfort to her right shoulder. Tylenol was given with good result. Precautionary X-ray taken with negative results. R78 did not complaint of additional lingering discomfort. There were no witnesses to the incident or what led to the incident. On 6/7/24 at 9:30AM, reviewed R78's resident to resident physical altercation, dated 6/7/23, with V4, SSD. R78's abuse/neglect assessment and abuse prevention care plan were not updated after the incident of resident-to-resident altercation. V4 said resident 's abuse assessment and abuse prevention care plan should be updated after resident-to-resident altercation. Facility's policy on Abuse and Neglect, reviewed 7/14/23, indicates: Policy statement: it is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigation of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Prevention: *Identify, correct, and intervene in situations in which abuse, neglect, exploitation and or misappropriation of resident properly is more likely to occur. *Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property. *Identification, assessment, care planning for intervention and monitoring of resident with needs and behavior that might lead to conflicts or neglect. *The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents who toileting assistance to assistance to urinate or defecate in their beds.

Based on observation, interview, and record review, the facility failed to ensure the resident received medications, treatments, and care as ordered by physician. This deficiency affects one (R25) of three residents in the sample of 24 reviewed for Quality of care. Findings include: R25 was readmitted on [DATE] with admitting diagnoses but not limited to Type 2 Diabetes Mellitus (DM), Hypertension, Chronic Kidney disease, Cerebral infarction, Psychotic disorder with delusions due to known physiological condition, bipolar disorder current episode depressed severe with psychotic features, Dementia with other behavioral disturbance, Anxiety disorder, Alzheimer's disease, Gastroesophageal reflux (GERD). R25's physician order sheet indicates: Consistent carbohydrates diet. Regular texture. Thin liquids. Double portions. Metformin HCl oral tablet 500mg 1 tab twice a day for DM, Lamotrigine oral tablet 25mg 2 tabs for bipolar, Lorazepam tab 0.5mg 1 tab by mouth daily for anxiety, Risperdal 3mg 1 tab by mouth twice a day for schizophrenia, Sertraline HCl 100mg 1 tab by mouth daily for depression, Torsemide 20mg 1 tab by mouth daily for edema, Aldactone 25mg 1 tab by mouth daily for edema, Aspirin EC delayed release 81mg 1 tab by mouth daily for anti-platelet aggregation, Cholecalciferol 1000 unit 1 tab by mouth daily for Vit D deficiency, Claritin 10mg 1 tab by mouth daily for allergy, Folic acid 1mg 1 tab by mouth daily for supplement, Lidocaine external patch 4% apply to low back, bilateral knees in the morning for pain, Miralax oral powder 17 gm/scoop 1 scoop by mouth twice a day for constipation, Pantoprazole sodium oral tablet delayed release 20mg 1 tab by mouth daily before breakfast for GERD, Senna plus 8.6-50mg 1 tab by mouth twice a day for constipation, Thiamine HCl 50mg 1 tab by mouth daily for supplement, Vit B12 100mg 1 tab by mouth daily for supplement. On 6/4/24 at 8:38AM, R25 was lying in bed sleeping, with mouth open and eyes covered with wash cloth. Breakfast tray was left on bedside tray table. On 6/4/24 at 9:36AM, R25 was still sleeping in bed, with breakfast tray left on bedside tray table. V13, Licensed Practical Nurse (LPN), said R25 has behavioral issues. R25 does not want to be awakened. R25 can be agitated, aggressive, and will call 911. They will just wait for him to wake up. On 6/4/24 at 11:38 AM, R25 was still sleeping in bed. V21, Certified Nurse Assistant (CNA) Supervisor, said they took away the breakfast tray because R25 was still sleeping. V21 said R25 does not want to be awakened. R25 can be agitated, aggressive, and will call 911. They will just wait for him to wake up. On 6/4/24 at 12:16PM, R25 was still sleeping in bed, with lunch tray left on bedside table. On 6/4/24 at 12:57PM, R25 was still sleeping in bed, with lunch tray left on bedside table. On 6/4/24 at 1:42PM, R25 was still sleeping in bed, with lunch tray left on bedside table. V27, CNA, said she is the CNA assigned for R25. V27 said they don't wake up R25 for breakfast or lunch; they will just leave the tray at bedside for him to eat when he wakes up. On 6/4/24 at 2:30PM, R25 was still sleeping in bed, with lunch tray left on bedside table. V3, Assistant Director of Nursing (ADON), and V13, LPN, both said R25 has behavioral issues and can be agitated and aggressive when awakened for meals. R25 will wake up on his own time. Both said R25 has routine sleeping pattern of awake at nighttime and sleeping during daytime. V13 said she did not give R25's morning medications because he is sleeping. V13 said he has daily and twice a day scheduled medications. V13 said she did not call the doctor of R25's omission of 9am scheduled medications, and omission of breakfast and lunch meals because this is his baseline behavior. Reviewed R25's medical records with V13 and V3. R25 is diabetic and on metformin 500mg twice a day. Blood sugar test last done 6/1/24. V13 said R25 has order of blood sugar test before meal daily. The facility did not formulate individualized care plan interventions to address resident needs such as adjusting time of his medications, treatment, and care. There are discrepancies with documentation in MAR (Medication Administration Record) and Restorative program log for May and June 2024, indicating medications and treatment were given despite resident was sleeping. Nurse Practitioner's documentation on 5/29/24 had no documentation of R25's omitting medications, treatment, and care due to alteration in sleeping pattern. Dietary/Nutrition documentation on 5/20/24 had no indication of R25 missing breakfast and lunch due to sleeping. Daily blood sugar testing before breakfast reviewed from May 1 to June 4, 2024, indicates missing blood sugar test on the following days: June 2, 3 and 4. May 17, 19, 20, 21, 22, 23 and 24. Restorative log documentation on 6/4/24 indicated Dressing and grooming and transfers were provided for 15 mins, but R25 was observed sleeping. Restorative program for Active range of motion and ambulation daily as ordered was not done. R25's Medication administration Record (MAR) from May 1 to June 4 ,2024 indicates medications at 9am were given (marked checked), even R25 is sleeping. On 6/6/24 at 10:00AM, informed V2, Director of Nursing/DON of concerns identified that R25 has not been getting his scheduled 9am medications, treatment and care as ordered by physician. All interdisciplinary team is aware of R25 sleeping habit (awake at night and sleeps during the day) but no attempts to individualized care plan intervention to meet resident needs such as changing medications and treatment timing. The physician, Nurse Practitioner, dietitian, and pharmacist were not notified of resident not receiving is scheduled medications, treatment, and care at 9am because he was sleeping. There are no documentation in R25 progress notes that physician or nurse practitioner were notified of resident omission of medications, treatment, and care. No nursing monitoring documentation of resident's activities at night when he is awake. On 6/6/24 at 11:03AM, V22, Physician, said he is aware of R25 alteration in sleeping pattern, but he is not aware of each individual occurrence that R25 omitted his medications because he was sleeping. V22 said he is expecting the nurses to call him if the resident did not take his medications or treatment was not given so that he can make necessary changes in timing of medications or treatment. On 6/7/24 at 11:32AM, V32, Nurse Practitioner, said she comes weekly to the facility, but she is not aware the resident has been missing/omitting his medications and treatments because he is sleeping. She was only notified recently and addressed the concerns. Facility's policy on Missed Medication revised 7/28/23 indicates: Policy statement: It is the facility's policy to administer medications to the residents and promote resident's rights of refusal at the same time. The policy will address missed medications. Procedures: 3. If the resident refuses the medication, explain to the resident the importance of the medication and the risk associated with missing the dose 4. If the resident continues to refuse the medication, indicate in the eMAR the refused medication 6. If the medication that is missed is ordered more than once daily, call physician to determine if the physician would like to order anything related to the missed dose or would want to have missed dose administered to the resident when is become available. Facility's policy on Physician orders revised 7/28/23 indicates: Policy statement: It is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS (Physician order sheet). Procedures: 2. All medications administered to the resident/patient must be ordered in writing by the patient's attending physician. 6. Physician orders will be carried out at a reasonable time. 9. Provision of care, treatment and services administered by the facility to the patient must be approved by the attending physician unless these treatment and services are governed by the facility's clinical policy and procedures and approved by the medical director. .

Based on observation, interview, and record review, the facility failed to follow up with pharmacy recommendation review and document physician response in resident medical record. This deficiency affects one (R28) of three residents in the sample of 24 review for Pharmacy medication review. Findings include: R28 was admitted on [DATE], with diagnoses listed in part but not limited to Schizoaffective disorder, Bipolar disorder, Antisocial personality, Anxiety disorder, Pressure ulcer, Spina bifida. Active physician order sheet (POS) indicates Depakote ER oral tablet extended release 24-hour 500mg give 1 tablet by mouth two times a day for treatment. Valporic Acid oral capsule 250mg give 1 capsule by mouth two times a day for treatment. No clinical indication for usage of Depakote and Valporic acid. On 6/4/24 at 11:08AM, R28 was lying in bed. He was alert and oriented, could verbalize self to staff. V15, Wound Care Nurse, said R28 has behavioral issues. R28's Consultant pharmacist recommendation, dated 5/30/24, indicated: Resident has orders for Depakote ER 500mg BID (twice a day) and Valporic acid 250mg BID which may represent duplicate therapy as both have very similar therapeutic activities. Please clarify with prescriber if resident is to continue both of the above orders. On 6/6/24 at 1:32PM, V3, Assistant Director of Nursing (ADON), said they follow up with pharmacy recommendation review within 3 days. Informed V2, Director of Nursing (DON), V3, ADON, and V29, Nursing Consultant, of R28's Pharmacy recommendation, dated 5/30/24, was not followed up. R28's medical records including active physician orders and progress notes does not indicate documentation for clarification of physician orders for Depakote and Valporic acid as recommended by pharmacist. On 6//6/24 at 2:18PM, V26, Psychotropic Nurse, presented a copy of the pharmacy recommendation where she just wrote she notified the physician and continue as ordered. She said she did not write a physician order on R28's physician order sheet, or document notification with orders in progress notes. V26 said V3, ADON, received all the pharmacy recommendations for follow up. On 6/7/24 at 9:15AM, V3, ADON, said after the Pharmacist consultant completed the resident's medication review, the recommendations were emailed to V2, DON, and V3, ADON. V3 is responsible for following up with pharmacy recommendation within 3 days. V3 said V26, Psychotropic nurse, is responsible for following up with psychotropic medication recommendations. V3 said after the nurse call the physician or Nurse Practitioner regarding pharmacist recommendation, they should document it in the resident progress notes and write orders in there is new orders made. On 6/7/24 at 10:02AM, V26, Psychotropic nurse, was notified Depakote and Valporic acid written on POS did not have clinical indication for medication usage. Facility's policy on Medication regimen review, revised 7/28/23, indicates: Policy: The consultant pharmacist shall provide pharmaceutical care consultation including the medication regimen review at least once a month for each resident residing in certified areas of a skilled long term care facility. For residents residing in long term care facilities licensed for the developmentally disabled or assisted living, pharmaceutical care consultation including medication regimen review will be conducted in compliance with state regulation. Procedure: 6. The consultant pharmacist us available to consult with the prescribing physicians, the Medical Director or nursing staff regarding recommendations resulting from the medication regimen review. It is the responsibility of the facility to assure that each of the recommendations result in a written response by either a physician or nurse, as appropriate. The attending physician/Medical Director must document in the medical record that the identified irregularity has been reviewed and subsequent action taken, if required. In the event where no change will be made as a result of the identified irregularity, the physician/Medical Director will document rationale in the medical record.

Based on observation, interview, and record review, the facility failed to keep the medication cart locked during medication administration when cart was out of site. The facility also failed to keep the medications refrigerated as manufacturer recommendation. This deficiency affects all three residents (R49, R55 and R97) in the sample of 24 reviewed for Medication Safety Storage. Findings include: On 6/4/24 at 6:15AM, checked medication cart and count controlled substance/narcotic medications with V10 RN (Registered Nurse). Observed R49 's opened Lorazepam 2mg/ml bottle in the locked controlled drawer in the medication cart. V10, RN, said they kept all the controlled substance/narcotic meds in the locked drawer in the medication cart. Informed V10 lorazepam should be in the medication refrigerator as indicated on the medication bottle and manufacturer recommendation. On 6/4/24 at 6:33AM, checked medication cart and count controlled substance/narcotic medications with V11 RN. Observed R97's Lorazepam 2mg/ml bottle in the locked controlled drawer in the medication cart. V11 RN said they keep all the controlled substance/narcotic meds in the locked drawer in the medication cart. On 6/4/24 at 7:45AM, observed V13, RN, prepared medications for R55. After she prepared medications, the medication cart was left unlocked, and V13 went to R55's room to administer medications. V13 went back to unlocked medication cart at 7:57AM. V13 said she just forgot to lock it. She added it should be locked at all times when the medication cart is out of site during medication administration. On 6/4/24 at 11:38AM, V2, Director of Nursing, said the medication cart should be always locked when out of site during medication administration. V2 said they should follow manufacturer recommendation for medication storage. Facility's policy on Medication Storage, Labeling and Disposal revised 8/24/23. Policy statement: It is the facility's policy to comply with federal regulations in storage, labeling and disposal of medications. 3. Medications will be stored safely under appropriate environment controls. 4. Medications will be secured in locked storage area. Facility's policy on Medication Pass revised 7/28/23 indicates: Policy statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. Procedures: Controlled substances: 2. All meds are to be stored I room at temperature as recommended by manufacturer (example: meds needing refrigeration will be stored in the refrigerator)

Based on interview and record review, the facility failed to have effective interventions in place for the monitoring and supervision of residents assessed to be at risk for falls and requiring staff assistance with dressing and ambulation; and failed to follow the resident plan of care by not providing needed assistance with dressing and ambulation. This failure applied to two of two (R3, R4) residents reviewed for falls, and resulted in R3 sustaining a fall resulting in a left hip fracture requiring surgical intervention, and R4 sustaining a left wrist fracture after a fall while not being assisted during ambulation. Findings include: 1. R3 is an [AGE] year-old female admitted to the facility on [DATE], with medical diagnoses that include displaced fracture of base of neck of left femur, unspecified lack of coordination, Dementia, need for assistance with personal care, weakness, other lack of coordination, unsteadiness on feet, history of falling, and Schizoaffective disorder. Review of R3's MDS (Minimum Data Set) Assessment, dated 11/29/23 (Quarterly), documents R3 has a BIMS (Brief Interview for Mental Status) of 15 (cognitively intact), and (Section GG) requires supervision or touching assistance for upper and lower body dressing; requires partial/moderate assistance for sit to stand; requires supervision or touching assistance for walking 10 ft, 50 ft, and 150 ft. R3's current care plans include the following focus areas: Wandering/elopement risk with demonstrated signs and symptoms of cognitive loss/decline, poor judgement, and mood distress (Date Initiated: 6/8/23); abuse/neglect/trauma factors includes psychiatric illness (Date Initiated: 6/28/23); Mental health challenges including diagnoses with Schizophrenia, Schizoaffective d/o (disorder), Psychotic d/o, delusional d/o, major depressive d/o recurrent (Date Initiated: 6/30/23); PAS/MH Level II Notice of Determination: (R3) is in need of long-term care placement/services, has a diagnosis of severe persistent mental illness (Date Initiated: 7/20/23); Care Rejection - At times I present with anger, I may make decisions that are not in my best interests. This includes being resistive to care including refusing to take my medications. At times, I will be verbally aggressive towards my nurse when my nurse attempts to give me my medications or provide care. At times, resident is impatient and does not wait for staff's assistance despite education and encouragement (Date Initiated: 7/01/23); (R3) has an ADL Self Care Performance Deficit related to impaired ability with Dressing and Grooming such as: Put on or take off clothing, Unable to obtain or replace article of clothing, Unable to fasten clothing, Unable to groom self satisfactorily, Unable to complete task with personal hygiene, Unable to bathe and groom self independently (Date Initiated: 6/9/23); (R3) has an ADL Self Care Performance Deficit and Impaired Mobility r/t generalized weakness, limited ability to follow/retain direction, dx. of osteoarthritis disorder, major depression, HTN, anemia, general anxiety (Date Initiated: 6/9/23) - Interventions include: Dressing: I require staff participation to dress (Date Initiated: 6/9/23); (R3) at high risk for falls related to generalized weakness, limited balance in stance/endurance. On medications which may affect balance and judgement. Dx. of major depression, osteoarthritis, HTN (hypertension), bradycardia, general anxiety. Limited safety awareness. Does not use the call light for assistance/needs on consistent basis. History of fall. With diagnosis of dementia, schizoaffective disorder, osteoarthritis. Increased weakness, increased confusion, decline in urinary B&B (bowel and bladder) status (frequently incontinent of B&B), decline in gait, decrease endurance, require assistance of one/two with asl's task (Date Initiated: 6/9/23). New intervention added 2/2/24, Resident requires assistance of one staff with self-care task for completion and safety. (R3) is on Psychoactive medications (Date Initiated: 6/8/23). (R3) requires psychotropic medication [Olanzapine, Mirtazipine, Conazepam] to help manage and alleviate Agitation and aggressive behavior, Anxiety, neurosis, anxiety d/o, Depression, behavior with depressive features, Mood swings, mood lability, mood instability, Psychosis (i.e., delusions, hallucinations, altered thought process, loss of contact with reality) r/t other Schizoaffective Disorders (Date Initiated: 6/8/23). Per facility incident reportable, on 1/26/24, at around 7:15AM, R3 was found by the night nurse, sitting on the floor holding part of her pants in her hands and the other part was dangling on her left foot. Resident stated she was putting her pants on, lost her balance and fell over; resident said she hit her head. Nursing assessment done. MD (Medical Doctor) on call notified; new order to send resident to the hospital for further eval and treat. Resident is able to move all her extremities within her normal limitations, no external rotation noted. Resident was assisted back to bed by 2 CNA's (Certified Nursing Assistants), RN (Registered Nurse) and (mechanical) lift. Resident complaints of the groin pain on left side. Pain medication given. Noted left elbow scraped and left knee scrape no blood.Resident has a metal clamp in her head history of aneurysm. Report additionally includes on 1/26/24 at 2:15PM, facility received call from hospital with x-ray result of R3, revealing a left sub capital femoral neck fracture. R3 returned back to the facility on [DATE] status post L hip hemiarthroplasty, with follow up appointment with Bone Health and MD in two weeks, staples to be removed in two weeks. Review of R3's hospital record documents R3's admitted [DATE] and discharge date of [DATE], primary diagnosis of left femoral neck fracture, and summary of hospitalization and incident findings includes: Pt (patient) presents to (hospital) s/p (status post) fall where pt sustained a left hip fx (fracture). On 1/2,7 pt underwent a left hip hemi (hemiarthroplasty). Perioperative abx (antibiotic). Postoperative pain management, PT/OT (Physical Therapy/Occupational Therapy), and discharge planning. It is noted R3 is on anti-psychotic medication, Olanzapine 15mg (milligrams) daily at bedtime, and Rivastigmine 4.5mg daily at breakfast. Employee/Resident Statement form completed by V14 (CNA) documents R3 is able to transfer independently and R3 ambulates independently, but that a mechanical lift was used to transfer the resident after the fall. V14 also documents they were the assigned CNA for R3. Documentation also includes the last time V14 saw R3 prior to the fall was at 6:25AM, while in the room to check on R3's roommate. V14 documented R3 was getting dressed for the morning, but did not verbalize for any need for assistance. Statement continues to read R3 was trying to put on her pants, and while standing, she felt she was losing her balance and she grabbed the overbed table for support, but the overbed table moved causing her to fall. On 3/01/24 at 2:07PM, V14 (CNA) said, I have been working here since December. Prior to the fall, she was very independent. She could set up and do things independently. I always offered (to help). She walked slow but would get dressed on her own. She is alert, not forgetful, and communicates well. She's sleeping more now since the fall. The fall was a pure accident. There were no special interventions for her. Employee/Resident Statement form completed by V12 (Licensed Practical Nurse/LPN) documents R3 is able to transfer independently and R3 has Safety Risk Behavior of wants to exit. V12 also documented on the form R3 is independent for toileting. V12 also documented being the assigned nurse for R3 at this time, and had last seen R3 five minutes prior to fall, sitting on the bed. On 3/01/24 at 1:54PM, V12 (LPN) stated on 1/26/24, when R3 fell , she was doing rounds when she heard a sound. R3 had fallen and broken her hip. She was standing up, getting dressed. R3 was about 95% independent prior to falling. When asked what happened, R3 said that she was standing up and lost her balance, she grabbed on to the bedside table and it rolled. It was her normal routine to get dressed in the morning by herself. On 3/1/24 at 1:39PM, V11 (CNA) stated she has been working at the facility for over [AGE] years, and is familiar with R3. V11 said that prior to falling, R3 was able to do most things independently, but staff would help set her up, but she didn't want anyone to see her (when she was unclothed). She would get her clothes independently. R3 had no bed alarm before because she wasn't a fall risk but now, she has one. On 3/01/24 at 12:34PM, V8 (Restorative Nurse) stated, I do the restorative MDS (Minimum Data Set), section GG and H, monitoring resident functional abilities, if they need PT, falls, decline. I am in charge of falls and supplies like wheelchair and chair alarms. When the resident has a fall, the nurse on duty starts the process of 72-hour neurochecks, assessment, change of condition. That all gets documented in electronic medical record under Assessments - Post Incident 72 Hours Follow-up. The DON (Director of Nursing) and I will conduct the investigation, and if there is someone involved, they will also help with the investigation. Regarding (R3), prior to her fall, she could walk, with slow, steady gait. She is alert and quiet, but able to communicate her needs. She is able to do for herself, but she goes to the bathroom. She is incontinent. She is confused at times. There is no such thing as independent, she needs supervision and assistance - cueing, supervision, She is insistent on doing things independent, but she required assistance like helping put on pants and blouse over her head. We encourage residents to ask for help and provide reminders to staff to remind (R3) that she needs help. She is very slow in gait and walk and it's easy for her to lose her balance. She really needs assistance with ADL's. She would not normally ask for help. 2. R4 is a [AGE] year-old male admitted to the facility on [DATE], with medical diagnoses that include unspecified lack of oordination, cognitive communication deficit, need for assistance with personal care, unsteadiness on feet, other lack of coordination, extrapyramidal and movement disorder, unspecified, and adult failure to thrive. R4's MDS (Minimum Data Set) Assessment, dated 12/19/23 (Quarterly), documents R4 has a BIMS of 11 (moderate cognitive impairment) and (Section GG) uses walker; requires supervision or touching assistance for upper and lower body dressing, sit to stand, walking 10 ft, 50 ft, and 150 ft. R4's fall risk assessment, dated 1/2/24, documents R4's fall risk score is a 12 = high risk. Contributing factors include use of NSAIDS and anti-depressants, memory problem, inadequate vision, and history of falls. R3's current care plans include the following focus areas: Cognitive loss/disorientation (Date Initiated: 4/5/23). PASRR Level 2 screening indicates diagnosed with anxiety, schizoaffective disorder, bipolar type; I make decisions without thinking about the result; when I am sad or upset, I choose to come out of my room; I am often confused and have trouble with my memory (Date Initiated: 4/18/23). Care Rejection - At times I present with impatience. I may make decisions that are not in my best interests. This includes being resistive to care including refusing to allow staff to assist me walking to the dining room. I also do not put call light on or ask for assistance if I need it. (Date Initiated: 1/02/24); Intervention includes behavior = communication (R4) has an ADL Self Care Performance Deficit related to impaired ability with Dressing and Grooming such as: Put on or take off clothing, Unable to obtain or replace article of clothing, Unable to fasten clothing, Unable to groom self satisfactorily, Unable to complete task with personal hygiene, Unable to bathe and groom self independently (Date Initiated: 4/5/23); (R4) has Impaired Mobility r/t generalized weakness. Limited balance in stance. R4 is on a transferring program. (Date Initiated: 4/5/23); (R4) has an ADL Self Care Performance Deficit and Impaired Mobility r/t limited balance in stance, decrease endurance. Poor safety awareness. (Date Initiated: 4/5/23); Interventions include - requires staff participation with transfers (Date Initiated: 4/5/23). (R4) at high risk for falls related to generalized weakness, limited balance in stance, decrease endurance. On medications which may affect balance and judgement. Poor safety awareness. Slow respond in gait and directions. Easily gets tired during activity. Does not use call light for assistance/ needs on consistent basis. Requires assistance with adl's. Dx. of schizoaffective disorder, adult failure to thrive, anemia, major depression. 2/25/24 diagnoses of pneumonia. Decrease endurance, easily get tired upon exertion during activity. Increased weakness. (Date Initiated: 4/5/23) (R4) requires psychotropic medication [Olanzapine, Zoloft] to help manage and alleviate mood swings, mood lability, mood instability, Psychosis (i.e., delusions, hallucinations, altered thought process, loss of contact with reality) r/t other Schizoaffective Disorder, Bipolar type, Major Depressive Disorder, Recurrent, Mild. (Date Initiated: 4/5/23). Per facility incident reportable, on 2/28/24 at approximately 12:25PM, R4 was noted to be on the floor in the dining room. Resident stated he was trying to transfer himself from walker to chair to sit for lunch and lost his balance and fell , landing on his left hand first. R4 was able to move both upper and lower extremities, however, verbalized he was experiencing 7/10 pain on his wrist. Tylenol was administered and area kept immobilized. STAT Xray was ordered. Results showed acute Colles Fracture with Comminuted Intra-articular Fracture of the Distal Radius with slight dorsal impaction deformity, and nondisplaced fracture of the tip of the ulnar styloid process. Report also documents predisposing psychological factors for R4: lack of safety awareness, lower extremity weakness, and ambulating without assistance. During the course of this survey, R4 was noted in his room, sleeping, with a cast on the lower left arm. Medical Professional Progress Noted, dated 2/29/2024 at 12:09, reads: #. Left wrist fracture: - Xray of Left Wrist: 1. Acute/recent Colles fracture of the left wrist with comminuted intra-articular fracture of the distal radius with slight dorsal impaction deformity, and nondisplaced fracture of the tip of the ulnar styloid process. - s/p ER visit - cast in place - PRN Acetaminophen for pain - follow up with ortho - Monitor On 3/1/24 at 1:39PM, V11 (CNA) stated she has been working at the facility for over [AGE] years, and is familiar with R4. V11 said that prior to falling, R4 would do things independently, but now he uses a wheelchair. He required staff assistance with showers and changing, but he was not compliant with using the call light. At the time of the fall, I was in the dining room, but I didn't even notice when he came in. The dining room was full of staff, but everyone was passing trays. He was about to walk into the dining room for lunch, he usually sits at the first table when you come in. On 3/1/24 at 2:01PM, V13 (CNA) confirmed he has worked at the facility for almost six years, and is familiar with R4. V13 confirmed at the time of the fall, V13 was the assigned CNA for R4. Nurses, CNA's, and other staff monitor the dining room during mealtimes and activities. There's always someone supervising residents in the dining room. I did not witness the fall. He normally follows instructions. I don't know how he got to the dining room from his room. We got him up with the mechanical lift (after the fall). Prior to falling, I had seen him moving around. I've never seen him without assistance. I had gotten him dressed just minutes prior and told him to call me when he was ready to go to the dining room. On 3/01/24 at 3:35PM, V15 (LPN) said, I have worked here almost [AGE] years. I have been taking care of (R4) since he came here, I believe. He needs reminders, like when it's time for lunch and dinner. He needs a lot of encouragement. His sister is very involved in his care, and she is the POA (Power of Attorney) for him. I recently sent him to the hospital because his saturation is low. He walks by himself. He did therapy for many weeks with restorative. He is capable of doing things by himself. He walks independently with the walker. I would not say that he needs supervision when using the walker, he is steady. Even though he will sometimes say that he would like someone to be with him. But that's not possible, that's why he had therapy. He definitely doesn't need supervision. He is steady. He will constantly want someone to be with him 24/7 (24 hours a day, 7 days a week) to talk with him and be there with him but we can't do that level of attention. I had seen him about 15-20 minutes prior and he was fine in the room, laying down in his bed. I reminded him that lunch would be soon, so please get ready. I would disagree with the MDS/Care Plan when it comes to walking. They are always being supervised. I was called by the CNA to go in the dining room. I know there were a couple patients who are alert and oriented that witnessed it. There were a couple CNA's in there. V13 (CNA) came and helped me, and we used the mechanical lift. The Director of Nursing was there too. I don't think that anyone would think to help him because everyone knows that he has been doing this on his own. Even though I know him so well if I saw him walking, I wouldn't try to help him because I would think that he is just walking, he is fine. On 3/01/24 at 12:34PM, V8 (Restorative Nurse) stated, I do the restorative MDS, section GG and H, monitoring resident functional abilities, if they need PT, falls, decline. I am in charge of falls and supplies like wheelchair and chair alarms. When the resident has a fall, the nurse on duty starts the process of 72-hour neurochecks, assessment, change of condition. That all gets documented in electronic medical record under Assessments - Post Incident 72 Hours Follow-up. The DON and I will conduct the investigation, and if there is someone involved, they will also help with the investigation. Regarding (R4), prior to the incident (fall on 2/28/24) he was weak because of a recent diagnosis of pneumonia. He was in bed mostly because he was getting IV (intravenous) fluids and he needs help with getting up. The only thing with him is that he is not compliant with asking for help. Other than being in bed because of the pneumonia he was walking with a walker. From time to time he would need cueing when walking with the walker, but he wouldn't walk that far before going back to bed. Prior to the incident, I wouldn't say he was independent because of the recent increased weakness, and he gets tired easily, but he doesn't call anyone to help him. The nurses remind him and encourage him to make sure he asks for assistance. He is alert and able to communicate needs. (R4) is forgetful and very quiet. He doesn't remember right away and alert x2. I would say that he doesn't call for help as a combination of forgetting and also just not wanting to ask for help. On 3/1/24 at 2:47PM, V8 (Restorative Nurse) was again interviewed and asked about the discrepancy between R3's medical record documentation/MDS and staff interviews of R3 being independent. V8 responded, No, she is not independent. I disagree with the staff. I believe one of her diagnoses is Dementia, so at least because of her cognition she would be at least supervision with one limited assistance, but not independently. I will make sure to in-service the staff to make sure that they know this resident is not independent. Now since the fall, she is definitely not, but I will make sure that they know to follow the plan of care for the resident. They are expected to follow the plan of care for all residents. I will be sure to in-service the staff on making sure they follow the plan of care. On 03/01/24 at 3:48PM, V2 (Director of Nursing) was asked about the fall for R4, V2 said, I was in the room, but he wasn't in my view. When I turned over, he had just fallen, and I looked over and I saw him on the floor. I am not too familiar with him. I would expect staff to follow the care plan. The care plan is the one that's guiding the care. If the staff disagree with the MDS/Care Plan, then we would re-evaluate. If the nurse disagrees, then it's teamwork, they should get with restorative and the clinical team, Social Services to see how we can comply with the plan of care. No matter the interventions, if they don't follow then it's a different thing. It takes teamwork from the group. We involve all the departments. It would be an issue if the care plan isn't being followed because it's about safety.

Based on interview and record review, the facility failed to supervise residents to prevent them from drinking alcohol, becoming drunk and falling. This applies to 3 of 3 residents (R3, R4 and R5) reviewed for supervision in the sample of 7. The findings include: R3's MDS (Minimum Data Set Assessment), dated 12/26/23, shows she has no cognitive impairment. R3's Care Plan, last reviewed on 1/16/24, states, Alcohol addiction/dependency have negatively impacted my health and cognitive functioning. I acknowledge mixing a concoction of alcoholic beverages in my room while at (facility). Due to my addiction history and husband's reports of her begging to go to the bar while out on pass and general expectation that I will pursue alcohol, I am not appropriate for independent out on pass. The interventions include: Implement increasingly restrictive interventions in a effort to help the resident break the addictive cycle. Interventions may include: supervision while in the community, restricted independent pass privileges, implementation of money guidance and budget controls to reduce/prevent access to substances. R3's Fall report, dated 12/1723, states, At 11:30 PM (V11, Certified Nursing Assistant/CNA) calling NOD (Nurse on Duty) to check resident on the dining room floor. NOD checked resident immediately resident seen sitting down on the dining floor and claiming she lost her balance and slid to the floor. Assessed resident both upper and lower extremities able to move without any pain. Both legs are equal. No bones protruding on both sides. Able to stand up with assist. Resident assisted back to bed. Vital signs taken. Neuro check initiated. Denies hitting the head. MD informed and with order to send to the hospital for X-ray. R3's Hospital Documents, dated 12/18/23, state, Brief Synopsis: (R3) is a [AGE] year old female with a PMHx (Past Medical History) of alcoholic liver cirrhosis complicated by Hepatic Encephalopathy, Non-insulin Dependent diabetes Mellitus, essential hypertension, seizure disorder, major depression with psychosis who presented from the skilled nursing facility with unwitnessed fall. Patient reported consuming 3-4 drinks of vodka the night prior and she had a fall and was unable to get up. Her alcohol level was .233. She had mild abdominal pain and lipase was notable elevated to 565. CT (Computed Tomography) showed mild pancreatic ductal dilation, no inflammation or lesions seen. R3's Progress Notes, dated 12/18/23, states, At 1:55 AM resident was being sent to Hospital due to fall and per Hospital resident found out that she intoxicated with alcohol. Per Hospital x-ray of pelvis and chest x-ray done with negative of fractures. Resident still inER on IV fluids due to intoxication then they will run labs again. If result will be normal resident will come back to facility. Endorsed to A.M. nurse. R3's Progress Notes, dated 12/19/23, state, At 1:45 PM, resident returned from (local) Hospital ambulating with unsteady gait. Paramedic was walking with resident, stand by assist. Instructed and encourage resident to use walker during ambulation. Resident was evaluated post unwitnessed fall on 12/17/2023 with no fractures and negative CT scan per result records, and resident was treated for alcohol intoxication and mild acute alcoholic pancreatitis and lactic acidosis. R3's Progress Notes, dated 12/20/23, and written by V6 (Nurse Practitioner) state, Patient seen via video call regarding her recent ER encounter status post unwitnessed fall. Alcohol level was .233, she admits drinking vodka the night before the fall. She also complained of abdominal pain with lipase level of 565, CT abdomen with mild pancreatic ductal dilation. Patient was hydrated at the hospital with improvement symptoms wise and was sent back to (Facility). Currently patient reports having unsteady gait. She usually ambulates with walker independently. She denies pain or discomfort and is not in any acute distress. Promises not to drink alcohol ever again . On 1/19/24 at 9:30 AM R3 stated, The floors had just been waxed a few days before and I had my slippers on. I just slipped and fell . Me and (R5) had a little Christmas party in the dining room. We weren't supposed to but we had our own party. We had a bottle of Vodka-(R4) brought it in and (R5) paid for it. After I fell , I got up and I went to bed. Then they came in and and got me out of bed and put me in the ambulance. They were more concerned about my heart and my EKG than my fall. I know the rules are no alcohol. I went to the cafeteria to get a snack before bed and I slipped. I kind of caught myself with my hands. I wasn't hurt and I got myself up. I have a walker because therapy thinks I fell because my legs are weak, but I can walk without it. I didn't fall because I didn't have a walker. I fell because the floors were waxed and I had been drinking. On 1/19/24 at 1:30 PM, V11 (CNA) stated, I saw her on the floor as I was walking to my unit. She was saying help me, help me. I asked her what happened, and she told me the floor was slippery and she just wanted me to help her get up. I told her I had to get the nurse first, so I called for the nurse. (R3's) speech was slurred and she was walking funny. I kind of thought, did you drink? I just kept asking her if she was okay because she was walking sideways. She kept saying she was fine. We walked her to her room and got her in bed. She was very heavily perfumed, and that is all I could smell. She usually doesn't wear that much perfume. I went back to the dining room but I didn't see any alcohol. That is the only time I have heard of her doing that. The residents are not allowed to have alcohol in the facility. On 1/19/24 at 12:45 PM, V9 (Registered Nurse/RN) stated, It was right at the change of shift, and I was moving from one unit to the other. The CNA called to me and told me that (R3) fell . (R3) kept denying that she actually fell . We helped her up and she was very wobbly. She had been with a couple other residents (R4, R5) in the dining room for a while. She was just so wobbly. I called the doctor and I called my supervisor. (R3) smelled like alcohol and the doctor said to send her out. I had not ever seen her like this before. She seemed impaired. No one else was in the dining room with her when she fell , but (R4) and (R5) had been in there with her. They were having fun in there. We found out from the hospital that (R3's) blood alcohol level was really high. Residents are not allowed to have alcohol in the facility. On 1/19/24 at 9:50AM, R4 stated, I did not witness (R3) fall, I didn't see anything. She told me she was in bed and they came and got her out and took her by ambulance to the hospital. There was a bottle of alcohol brought in- ok, I brought it in. It was me, (R5) and (R3). It was a 750ml bottle and there wasn't any left when we were done, so I guess we drank it all. I had a pass to go out and (after that) they restricted it for like 3 weeks. I have it back now. When I was with (R3), she seemed fine. She was not stumbling or slurring her words or anything. No one wants to be treated like they are 12. They say this is not a jail, but there is really no freedom. It was never my intention to have anything happen to her. She seemed fine, and then she went to the hospital, and of course they drew blood and found the alcohol. I had gone back to my room and went to bed. R4's MDS, dated [DATE], shows she has no cognitive impairment. On 1/19/24 at 12:20 PM, R5 stated, The alcohol came from (Local Grocery Store). R5 did not want to say who brought it in, but when Surveyor asked if it was (R4) who got the alcohol, R5 agreed that it was. R5 continued, We sat in the dining room for a couple of hours. R5 was asked if R3 seemed impaired when they were done, and R5 smiled and stated, We all were. I went back to my room and went to bed. I did not see (R3) fall. I was diagnosed with Dementia a while back, and they took my pass away. I can't go out without someone going with me. I have never brought alcohol in before. We just wanted to have a little party. R5's MDS, dated [DATE], shows he has not cognitive impairment.

Based on interviews and record reviews, the facility failed to use the proper equipment when providing incontinence care. This affected one of three residents (R11) reviewed for safety during care. This failure resulted in the use of a sit to stand device while providing incontinence care, contributing to R1 falling and sustaining a right shoulder fracture. Findings include: R11's MDS (Minimum Data Set), dated 7/7/23, notes R11's BIMS (Brief Interview for Mental Status) score is 15 out of 15. R11 is totally dependent on two persons physical assistance with transfers. R11 requires extensive assistance of two persons physical assistance with toileting. Functional limitation in range of motion notes impairment in both upper and lower extremities. R11's restorative assessment, dated 7/3/23, notes R11 with limitation in range of motion (flexion and extension) of both shoulders and both knees. R11's ADL (activities of daily living) care plan, initiated 4/26/2017, notes R11 has an ADL self-care performance deficit related to impaired balance. R11 has history of falls, limited balance and gait is unsteady, and limited mobility. On 4/22/2021, use mechanical lift (sit to stand) for transfers was added. The focus of this care plan was updated on 2/19/2022 to include discontinue sit to stand lift device now and use full mechanical lift device due to bilateral shoulder pain. R11's incontinence care plan, initiated 4/26/2017, notes R11 displays total bowel/bladder incontinence related to impaired mobility. R11 is unable to stand without staff interventions. R11 with obesity, weakness, and easily gets tired. The focus of this care plan was updated on 8/1/23 to discontinue use of mechanical lift (sit to stand) due to shoulder injury, limited range of motion especially of right shoulder. R11's falls care plan, initiated 4/26/2017, notes R11 is at high risk for falls related to incontinence, muscle weakness, lack of coordination, and unable to stand without staff interventions. On 12/1/23 at 1:10 PM, R11 who was assessed to be alert and oriented x 3, stated she is not able to bear weight on her legs. R11 stated V36, CNA (Certified Nursing Assistant) was using sit to stand lift device, and R11 fell hitting right upper arm and shoulder on floor. On 12/1/23 at 11:55 AM, V27 (Rehabilitation Director) stated R11 was seen by skilled therapy from February to March 2023. V27 stated at the time R11 was discharged from skilled therapy, it was recommended R11 use full mechanical lift device. On 12/1/23 at 1:20 PM, V8 (Restorative Nurse) stated R11 likes staff to use sit to stand lift device when providing incontinence care. V8 stated R11 was assessed and is appropriate for full mechanical lift device, not the sit to stand lift device. V8 stated residents have to be able to bear weight in order to use the sit to stand lift device. V8 stated R11 let go of the bar on the lift device with R11's right hand, and the CNAs lowered R11 to the floor. V8 stated V8 has educated R11 and staff regarding transferring R11 with full mechanical lift device for safety reasons. V8 stated the fall was due to a judgment error of staff to use sit to stand rather than full mechanical lift device. On 12/5/23, V36, CNA (Certified Nursing Assistant) stated V36 was providing incontinence care using the sit to stand lift device, R11 started to slide, and V36 and another CNA lowered R11 onto the floor. V36 stated when R11 is sitting in the wheelchair, the sit to stand lift device is used for incontinence care. R11's physical therapy discharge note, dated 3/21/23, notes R11's functional assessment for transfers with sit to stand - not applicable, chair/bed to chair transfer - dependent, toilet transfer - dependent. R11's mobility function score is 3 out of 12. R11's occupational therapy discharge note, dated 3/27/23, notes R11's functional assessment for toileting hygiene - dependent. R11's mobility function score is 0 out of 12. R11's hospital record, dated 7/27/23, notes, (R11) presented to the emergency room with complaints of right shoulder and elbow pain. (R11) has history of chronic right shoulder pain. (R11) reported last night she was being assisted in transfer with CNA using lift device and (R11) was standing with lift, then fell landing on her right shoulder. (R11) complained of increased right shoulder pain. X-rays done at facility reports possible humeral neck fracture. (R11) with bilateral lower leg lymphedema. Right shoulder x-ray shows comminuted fracture of the proximal humerus. Right elbow x-ray shows questionable impaction fracture of the right radial neck. The manufacturer's instructions for use of sit to stand lift device includes, but is not limited to, individuals must be able to support the majority of their own weight, otherwise injury can occur.

Based on interview and record review, the facility to follow their abuse policy and prevent incident of resident-to-resident physical assault, and resident to resident inappropriate touching. This affected three of four (R4, R5, and R10) residents reviewed for abuse prevention. Findings include: On 11-30-23 at 11:05 AM, R4 said she does not remember what happened. R4 said sometimes R5 is nice, and sometimes (R5) hates (R4's) guts. R4 said R5 will yell at her in-front of other people. R4 does not recall the altercation, but a physical altercation may have happened with R5. R4 said R5 has gotten so mad that she wanted to hit R5 before. R4 said she was sent out to the hospital for this incident. R4 said she tries to stay away from R5 as much as she can. R4 said there was no previous altercation before this incident. R4 said she threw an empty can of pop at another resident (name withheld) during another altercation with another resident. On 11-30-23 at 11:24 AM, R5 said R4 was mad at her going into another resident's room. R4 was hitting R5 with both arms, and R5 was using her unaffected arm to defend herself. R5 said R4 hit her right arm. R5 said there was no bruising or cut, however, she had pain. R5 described the arm pain at 5 out of 10. R5 said she had x-rays done and no findings of any fracture. R5 said this was the only altercation with R4. R5 said she is not aware of R4 having physical aggression towards other residents. R5 said R4 was her friend at one time, however, R5 tries to stay away from R4 with very little contact. R5 denies any concerns of resident-to-resident abuse. On 11-30-23 at 12:49 PM, V1 (Administrator) said R4 is alert, oriented, and able to make her needs known. V1 is not aware of any other history of aggressive behaviors. R4 admitted to V1 that she hit R5 in the arm. R5 complained of arm pain and x-rays taken with no findings of fractures. R4 and R5 were separated, and R4 was sent for petitioned for evaluation. R4 returned to facility, and both R4 and R5 remain separated. On 11-30-23 at 2:00 PM, V2 (Director of Nursing/DON) said she does not remember the incident between R4 and R5. V2 said after R4's return to facility, R4 and R5 had room changes, staff continue to monitor residents for behaviors, and psychiatrist is involved with R4. V2 said she is not aware of R4 having any aggressive behaviors, and is not aware of R4 and R5 having previous incidents. On 11-30-23 at 1:13 PM, V12 (Certified Nurse Aide Supervisor/CNA Supervisor) said R4 is alert oriented and able to make her needs known. V12 said she is not aware of aggressive behaviors with residents or staff. V12 said R4 is able to follow directions, and R4 is easy to redirect. V12 said she is not aware of R4 and R5 having history of altercations/incidents. V12 said she monitors all her residents and ensure R4 and R5 are separated. On 11-30-23 at 11:49 AM, V18 (Social Services Director/SSD) said R4 is alert, oriented x2-3, and able to make her needs known. R4 has bipolar disorder, dementia with behavior disturbance, dementia with agitation, major depression, low self-esteem, and generalized anxiety disorder. R4 has delusions, hallucinations, and hospitalized due to psychosis. R4 has frequent delusions and seeks reassurance from staff. V18 said she is not aware of any previous altercations between R4 and R5. V18 said she is not aware of R4 having aggression towards any other residents. R5 is alert, oriented x2-3, and able to make her needs known. V18 is not aware of R5 having aggressive behaviors. R5's Progress Note, dated 6-7-23, documents: Resident reported to this writer that she was hit on right upper arm by a peer this morning. ADON (Assistant Director of Nursing), social services, and administrator were notified. This writer performed head to toe assessment. No new skin concerns noted. Resident verbalized pain on right shoulder and radiating to right elbow. Resident has chronic pain on right shoulder and verbalized she received lidocaine cream this morning to area as ordered. This writer offered pain reliever medication and resident refused at first. This writer observed resident able to actively move right elbow and right shoulder with no restrictions but resident continues to verbalize pain. Cold pack was applied to right shoulder. No behavior observed at this time. At 10:45 AM, this writer offered Tylenol for pain management and resident agreeable. Tylenol 650 mg was administered by mouth and effective. This writer notified NP (Nurse Practitioner) with new order for STAT x-ray of right upper extremity (right shoulder, right humerus, right elbow, right forearm). This writer notified (company) of STAT order. Resident was seen by occupational therapy this shift. Vitals: 140/86BP 96.9T 72P 18R 96% oxygen saturation at room air. Will continue to monitor for any changes in condition. R5's Progress Note, dated 6-7-23, documents: Resident was involved in an incident this morning with another peer. Facility protocol was initiated. Resident agreeable to meet with psychotherapist today. Voicemail left for guardian. Awaiting call back. R5's Radiology Note, dated 6-8-23, documents: 1. Right forearm AP and lateral- Relatively good bone mineral density. No fracture, dislocation, bone destruction or periostitis. Small olecranon spur at the triceps tendon insertion. Otherwise, normal right forearm x-ray. No comparison exam. 2. Right Humerus, AP and Lateral - Good bone mineral density. No fracture, dislocation, or other bony abnormality. Normal right humerus x-ray 3. Sternum, oblique and lateral - Good bone mineral density. No fracture or retrosternal soft tissue swelling. No other skeletal abnormality. Normal sternum x-ray. No comparison exam. 4. Right elbow, three views -Good bone mineral density. No fracture, dislocation, or evidence of joint effusion. No degenerative arthrosis. Small olecranon spur at the triceps tendon insertion. Small Otherwise, normal right elbow x-ray. No comparison exam. 5. Right shoulder, three views Good bone mineral density. No fracture, dislocation, or significant degenerative change. No other skeletal abnormality. Normal right shoulder x-ray. No comparison exam. Relayed Results: Faxed results to De. [NAME] Follow up: Will endorse to morning nurse in AM. Initial State Reportable, dated 6-7-23, documents: Allegation Details: What was the reported allegation of abuse? On 6-7-23 at approximately 8:40 AM, resident (R5) stated that fell ow resident (R4) hit her on the shoulder as they passed each other in the hallway earlier in the morning. (R5) was assessed and noted with no redness or bruising. (R4) admitted to hitting (R5) claiming they were arguing over something, As a result, (R4) will be sent to hospital for an evaluation. Residents MD and guardian were made aware of the incident. (R4) is her own responsible party. Final State Reportable, dated 6-7-23, documents: Narrative of the Final Report Investigation: On 6-7-23 at approximately 8:40 AM, resident (R5) stated that fell ow resident (R4) hit her on the shoulder as they passed each other in the hallway earlier in the morning. Both residents were immediately separate and monitored for safety. Upon initial assessment, (R5) was noted with no redness, bruising, or discomfort. Later in the day on 6-7-23, R5 complained of slight discomfort to her right shoulder. Tylenol was given with good result. Precautionary x-ray was taken with negative results, (R5) did not complain of any additional lingering discomfort. (R4) admitted to hitting (R5) claiming they were arguing over something silly but couldn't exactly recall what it was. (R4) does not have a history of physical aggression towards staff or peers and regrets the way she acted. Due to her behavior, (R4) was admitted to local hospital. As both ladies are often seen hanging around each other, both were strongly encouraged to stay away from one another upon (R4's)return from the hospital. Residents MD (Medical Doctor) and guardian were made aware of the incident. (R4) is her own responsible party. Petition for Involuntary/Judicial Admission, dated 6-7-23, documents: (R4) is a 62 y/o Caucasian female with dx (diagnosis) of Bipolar D/O (disorder), Major Depressive D/O. Generalized Anxiety D/O, & suicidal ideations. Resident is presenting with verbal and physical aggression towards peer. Resident placed on 1:1. Resident is need of immediate hospitalization and evaluation to prevent harm to self and/or others. On 12-1-23 at 11:39 AM, R4 said she was not romantically involved with R10. R4 said R10 gave her an unwanted kiss on the cheek. R4 said she did not ask or was prepared for a kiss. R4 said she did not attempt to stop R10 because she was afraid him. R4 said she heard rumors of R10 coming out of prison, and R4 was scared of and intimidated by R10. R4 said R10 kissed R4, went away, and R4 reported R10 to Social Services. R4 said R10 was sent to hospital for delusional behaviors. R4 said she is satisfied with facility handling the incident. R4 said she has seen R10 talk to other residents about religion prior to this incident. On 12-1-23 at 11:18 AM, R10 said he kissed R4 on the forehead. R10 said R4 was not expecting this kiss from R10. R10 said R4 was not protesting or telling R10 to stop. After the kiss, R10 went away. Later the staff questioned R10 about why he kissed R4. R10 said he was told that he was going to the hospital because he kissed a girl on the forehead without permission. On 12-1-23 at 12:11 PM, V18 (Social Services Director/SSD) said R10 is alert, oriented, and able to make his needs known. R10 has a lot of delusional behaviors and hallucinations centering around religion. V18 said R10 had delusions prior to SSD employment at facility. R10 is seen by psychiatrist and psychotherapist. V18 said R10 would receive standard rounding by staff. Religious delusions were not a threat to himself or others, however an unwanted kiss was a behavior escalation and R10 was petitioned for psychiatric evaluation. On 12-1-23 at 10:46 AM, V23 (Licensed Practical Nurse/ LPN) said R4 is alert, oriented, and able to make her needs known. R4 is attention seeking. V23 said she was made aware of a R10 did something to R4. V23 said this was not witnessed by V23, but it was reported R10 kissed or touched R4 on the forehead. V23 said R10 was talking about religion and having delusional moments. V23 found R10 on the floor and asked what he was doing and R10 said why are you disturbing me? V10 said he was praying to Jesus and Jesus was sitting next to him. V23 said she notified psychiatrist who gave order to petition due to delusional behaviors. V23 thinks R10 was admitted at that time. V23 said R4 said R10 did something she did not like and R4 didn't give any detail. V23 called social services who met with R4. R10's Social Service Progress notes, dated 7-10-23, 7-11-23, 7-17-23, and 7-19-23, documents R10 having delusional episodes. Initial State Reportable, dated 7-19-23, documents: On 7-19-23 at approximately 9:15 AM, (R4) alleged to social worker that earlier in the morning resident (R10) pecked her on the forehead as he said Good Morning to her. She claimed to never have any prior issues with (R10). Both residents were immediately separated and placed on 1:1 observation. (R10) will be sent for psychiatric evaluation due to an increase in delusional thought process. Residents MD made aware of the allegation. Both residents are their own responsible parties. Final Reportable, dated 7-24-23, documents: Narrative of the Final Report Investigation: On 7-19-23 at approximately 9:15 AM, (R4) alleged to social worker that earlier in the morning resident (R10) pecked her on the forehead as he said Good Morning to her. She claimed to never have any prior issues with (R10), nor has (R10) ever displayed such behavior in the past. Writer spoke to (R10) soon thereafter. (R10) admitted to lightly pecking (R4) on her forehead while saying 'good morning' to her that day. (R10) claimed to be good friends with (R4), and did not mean to make her feel uncomfortable in any way. (R10) admitted to this write that he regretted what he did and apologized to (R4). Both residents were immediately separated and placed on 1:1 observation. (R10) was educated /counseled on displaying appropriate behavior towards peers. (R10) was sent to local hospital for psychiatric evaluation due to an increase in delusional thought process. Upon return, both residents were encouraged to stay away from one another. Residents MD made aware of the allegation. Both residents are their own responsible parties. Care Plans updated. Petition For Involuntary/Judicial Admission documents: (R10) is a 60 y/o Caucasian male with dx of Schizoaffective D/O, Bipolar D/O, Major Depressive D/O, & Anxiety D/O. Resident is presenting with an increase in delusional though content and hallucinations centering around religion. Resident is intrusive towards staff and peers, pushing his religious beliefs onto others. Resident is in need of immediate hospitalization and evaluation to prevent harm to self and/or others. Abuse and Neglect Policy, dated 7-14-23, documents: Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment.

Based on interview and record review, the facility failed to follow hospital discharge instructions and neurosurgeon's recommendation for a repeat CT (Computed Tomography) scan of head prior to restarting anticoagulant therapy. This affected one of three residents (R1) reviewed for physician orders and discharge instructions. Findings Include: R1 was admitted in the facility on 10/12/23. R1 had right temporal parietal intraparenchymal hemorrhage and was taken emergently for right craniotomy for hematoma evacuation on 10/3/23. Hospital record on 10/17/23 hospitalization reads: Per Neurosurgery recommendation, R1 needs repeat CT in approximately one week with follow up prior to determining whether to restart formal AC (Anticoagulant). Physician order sheet Warfarin 2.5 mg by mouth in the evening for 3 days, start date 11/3/23, with order date on 11/2/23, and Enoxaparin 60mg/0.6ML two times a day, start date 11/8/23, with order date of 11/7/23. On 11/21/23 at 1:30PM, V4 (Registered Nurse/RN) stated V4 received a call from neurosurgery nurse and instructed to have the INR in therapeutic level before the CT scan can be done. V4 stated V4 relayed this call to V5 (Nurse Practitioner/NP), and V5 ordered to start R1 on warfarin 2.5mg. On 11/21/23 at 2:20PM, V5 (Nurse Practitioner) stated, (R1) has an aortic valve replacement, goal is to have INR of 2.5 to 3.5 and we have to play with the dose because INR was low. November 7, INR was 1.1 and (V14, Physician) ordered to give warfarin and start in enoxaparin injection until INR is in therapeutic level. On 11/28/23 at 1:45PM, V14 (Physician) stated V14 was the covering physician, and the INR result was relayed to V1,4 and the result was not in therapeutic level, and V14 added enoxaparin injection order. When asked if V14 was aware during hospitalization R1 was placed in warfarin with Enoxaparin Bridge and on 10/3/23 developed large right temporal parietal intraparanchymal hemorrhage, V14 stated V14 was not aware about the bleeding, and he based his order on the stroke diagnosis and heart valve replacement. V14 stated INR was in the low level, and would like it in the therapeutic level fast. On 11/29/23 at 11:00 AM, V5 (Nurse Practitioner) stated V5 was aware about the brain bleed upon initial admission in the facility, and V5 documented it in history and physical on 10/13/23. When V4 (RN) called and relayed neurosurgery wants R1 to be in the therapeutic level of INR, V5 started warfarin and not enoxaparin. V5 was on vacation when enoxaparin was started, and V5 knew the enoxaparin was added. V5 spoke to R1's attending physician, and agreed to keep the enoxaparin injection order along with warfarin, because INR was not in therapeutic level. V5 denied communicating with neurosurgeon about anticoagulant medication prior and while on warfarin and enoxaparin, while R1's was in the facility. On 11/20/23, R1 sent out to hospital due to abdominal bleeding at the injection site. Was found to be having acute subdural hemorrhage, without much compression of the brain and or midline shift. Hospital Record, dated 11/20/23, reads: 10/17/23, R1 was evaluated for chest pain with new T wave inversion and elevated troponin. In lights of R1's recent neurosurgical intervention and held anticoagulation, we were contacted for further support in R1's management. Repeat CT head was reviewed with our team with improving heme, no acute hemorrhage. If anticoagulation was indicated from a cardiac standpoint, it was advised that heparin could be started preferably without boluses. Recommended repeat CT head when patient reached therapeutic levels and close neurologic monitoring. Bridging was not recommended given bleed risk per discussion with cardiology.

Based on interview and record review, the facility failed to follow their medical records request and access policy and furnish records upon request with 2-day advance notice for 4 of 5 (R1, R2, R4, R6) residents reviewed for medical records request. Findings include: On 3/13/23 at 8:40am, V1 (Department of Health/ Mental Health) said the facility has not been sending the requested records for the residents when requested to the [NAME] Young Center, and this has been an issue since October 2022. V1 said wait is sometime more than 30 days. On 3/13/23 at 11:38am, V3 ([NAME] Young Center representative) said the facility has not been sending the requested medical records for the residents; V3 said she had to send multiple requests for the records. V3 said she has received records greater than 30 days after initial request. V3 said she has called the facility and spoke to V2 (Administrator) regarding the matter, with no resolution and sometimes no response to the email. V3 said she requested R1's records on 10/6/22 and received on 11/1/22; R2's record on 11/16/22 and received them on 1/30/23; R4's records were requested on 11/14/22 and received on 2/1/23; and R6's records were requested on 2/21/23 and received on 3/13/23. On 3/12/23 at 10:21am, V5 (Medical Records personnel) said he is responsible for processing the facility medical records. V5 said he was working remotely from 10/18/22 until 11/1/22. V5 said he continued with his duties for processing medical records at that time. V5 said the facility gets medical record request via fax and email. V5 said he was not getting any medical records requested via fax when he worked remotely. V5 said he doesn't know who was getting the faxed medical request at that time. V5 said he doesn't know who was responsible for getting the medical record request off the fax machine at that time to send to him, so he coud process the request. V5 said when he's in the facility, he checks the fax machine 4 to 5 times a day for requests, and he checks his email constantly for requests. V5 said when he gets a request, he then sends the request to the corporate office for approval and directives for processing. V5 said corporate processes the very large records, and corporate delegates him to process any records less than 1000 pages. V5 said the turnaround time for processing medical records is 2 weeks. Request was made to review all medical record requests from 10/1/22 to 3/12/23. V5 presented 9 medical record requests including request for R1, R5, R6. V5 did not present a medical record request for R2 or R4. On 3/13/23 at 10:40am, V2 (Administrator) said he does not know what the turnaround time is for a medical record request, and he would have to review the policy. V2 said he spoke to someone from the [NAME] Young Center. V2 said it was a while back, but he does not remember who it was. V2 presented an email from the [NAME] Young Center. V2 said V5 was out for medical leave for a while, and V5 was working remotely for a while also. V5 said he does not know was responsible for checking the fax machine and sending the medical request to V5 when he was working remotely. R1's medical record request form to The Grove of Northbrook, dated 11/01/22, was reviewed. R2's medical record request form to The Grove of Northbrook, dated 11/14/22, was reviewed. R4's medical record request form to The Grove of Northbrook, dated 11/16/22, was reviewed. R6's medical record request form to The Grove of Northbrook, dated 02/21/23, was reviewed. On 3/13/23 at 11:05am, R4 said she was working with the [NAME] Young Center, and the facility should send the records if they ask for them. On 3/13/23 at 11:12am, R1 said she was working with the [NAME] Young Center, and the facility should send the records if they ask for them. Facility policy titled Medical record request and access, dated 7/28/2,2 denotes in-part: the facility will follow federal regulation in regard to medical records access and request for copies of a resident or responsible family member. In the event federal regulation does not have specific guidance on medical records access and request, the facility will follow the state requirement on this particular area. The resident or legal representative of the resident will be allowed access to inspect residents' medical records within 24 hours of a valid oral or written request to the administrator excluding weekends or holidays. If the resident or the legal representative makes a valid request to make copies of the medical record, the facility will furnish the records upon request and 2 days advance notice to the facility.

Based on observation, interview, and record review, the facility failed to ensure a resident was free of a significant medication error for 1 of 4 residents (R10) reviewed for medications in the sample of 10. The findings include: R10's face sheet showed he was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's facility assessment, dated 9/10/22, showed he has no cognitive impairment. On 9/17/22 at 12:15 PM, R10 said, One or two of my medications make me extremely groggy. The timing of certain medications enhances their affects and I need to find out what medications those are. Some of them need to be a certain number of hours apart. I believe they are all necessary but the timing is off. R10's September 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's September 2022 eMAR (electronic Medication Administration Record) showed the medication was scheduled to be given daily at 9:00 AM, 12:00 PM, 5:00 PM, and 9:00 PM. R10's Medication Administration Audit Report for 9/17/22 showed R10 received his 9:00 AM dose of [MEDICATION(S)] at 10:42 AM and received his 12:00 PM dose at 11:52 AM (1 hour and 10 minutes apart). According to Drugs.com (https://www.drugs.com/search.php?searchterm=[MEDICATION(S)]&a=1), . [MEDICATION(S)] is used to treat symptoms of [CONDITION(S)] . Follow all directions on your prescription label and read all medication guides or instruction sheets. Use the medicine exactly as directed. Measure liquid carefully . What happens if I miss a dose? Take the medicine as soon as you can, but skip the missed dose if it is almost time for your next dose. Do not take two doses at one time . This same website showed a side effect of this medication is dizziness, drowsiness and weakness and if this medication is taken along with other drugs such as medications for anxiety that make you drowsy, this can worsen the effect. On 9/17/22 at 9:17 AM, V4 (Licensed Practical Nurse - LPN) said she was behind on her medication pass today because a resident on her hall was going out with his family and needed his medications prepared to go with him and that took some time. On 9/17/22 at 11:40 AM, V2 said, Medications can be passed one hour before the scheduled time and one hour after the scheduled time. At 1:33 PM, V2 provided a copy of the Medication Administration Audit report for R10's 9:00 AM medication administration was delayed today. The facility's policy and procedure for medication pass was reviewed and showed, . Policy Statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures . The policy did not include anything specific to medication pass timing.

Based on observation and interview, the facility failed to repair leaking water from the air-conditioning unit in the resident's room. This deficiency affects 4 (R14, R20, R34 and R54) residents in the sample of 25 reviewed for Safe environment. Findings include: On 7/27/22 at 9:37AM, water was leaking from the air conditioning unit in R54's room, which caused a puddle of water on the floor going under the bed. Surveyor observed towel soaked with water placed at the base of the air conditioner. V10, Licensed Practical Nurse/LPN was showed problem in R54's room. V10 said she did not notice the puddle of water, and did not place the towel to absorb the water. V10 said no one reported to her there was leaking water from the air conditioner. V10 said, (R14) always carries a towel, she probably placed the towel to absorb the water. On 7/27/22 at 9:40 AM, R20, who resides in the same room, said V7, Maintenance Director, has been working with that air conditioner. R20 said V10, LPN, placed the towel there earlier. R34 ,who also resides in the same room, said she did not place that towel at the base of the air-conditioner. On 7/27/22 at 9:42 AM, V14, Certified Nursing Assistant/CNA said he is the assigned CNA for R54. V14 said he came in at 6:30 AM, and he already observed the towels were placed at the base of the air conditioner to absorb the leaking water. He did not report it to maintenance because it was too early. On 7/27/22 at 9:45 AM, V7, Maintenance Director, said the air conditioning unit has problems with the condenser. He said the drainage pipe was clogged, so the water instead of draining outside, it drains back to the inside, causing a puddle of water on the floor. He said it has had the same problem since last week. He said nobody told him of the water leaking problem again. He said staff should call him if there is problem so he could repair it immediately. On 7/27/22 at 10:01 AM, V6, Environmental Services, said they are short of housekeeping aides today. She said there is no assigned housekeeping aide in the unit until this afternoon at 3pm, but a housekeeping aide from other unit is available if needed. She said no one reported to her leaking water from the air conditioning unit in R54's room. On 7/27/22 at 3:02 PM , Requested facility's policy on Safe environment from V2, DON ( Director of Nursing) On 7/28/22 at 10:33 AM, Follow up requested policy from V2, DON. V2 said they don't have a policy.

Based on observation, interview, and record review, the facility failed to conduct a fall investigation to determine the cause of a fall, failed to update a resident's fall care plan after each fall incident, and failed to ensure a functional alarm was attached a resident who is at risk for falls. This deficiency affects 4 (R38, R72, R77 and R85) residents in the sample of 25 reviewed for Fall prevention management. Findings include: 1. R72 was admitted on [DATE], with diagnoses to include Disorder of the brain, Unsteadiness on feet, Gait and mobility abnormality. Lack of coordination, need for assistance with personal care, history of falling, and ataxic gait. R72's care plan indicates he is at high risk for falls. Admission fall assessment, dated 4/1/19, Re-admission fall assessment, dated 7/8/19, and Re-admission fall assessment, dated 8/15/20, all indicated R72 is at high risk for fall. On 7/26/22 at 10:49 AM, V10, Licensed Practical Nurse/LPN said R72 had an unwitnessed fall in his bathroom on 7/11/22. R72's unwitnessed fall incident, dated 7/11/22 at 1:30 PM indicates: V10, LPN called by CNA (Certified Nursing Assistant) to R72's room and found him sitting on the bathroom floor next to the toilet. R72 stated, I tried to stand up after using the bathroom and I lost my balance and landed my butt on the floor. Head to toe assessment was done and staff transferred him back to his wheelchair by mechanical lift. No injuries observed at the time of the incident. On 7/27/22 at 9:47 AM, R72 said that he put on the call light, but only one came, so he went to the bathroom and transferred himself. On 7/27/22 at 10:05 AM, V10 LPN said she is the nurse who worked with him when he fell . She said she came to answer his call light, but he was already on the floor. On 7/27/22 at 10:10 AM, V5 MDS(Minimum Data Set)/Care Plan Coordinator said the Restorative Nurse is the one who does the root cause analysis and updates the fall care plan interventions. R72's fall incident report, dated 7/11/22, indicated no root cause analysis done and the fall care plan was not updated. On 7/27/22 at 10:22 AM, V9, Restorative Nurse, said after each resident fall, a fall investigation and root cause analysis of the fall is conducted. After investigation, the fall care plan should be updated based on root cause analysis, and the individualized care plan is updated to prevent future falls. V9 said a fall assessment is done upon admission, re-admission, quarterly, and after each fall incident. V9 said the fall assessment after each incident report is done by the floor nurse. Informed V9 that no fall assessment done after fall incident on 7/11/22. V9 said she did not do the root cause analysis and did not update the fall care plan interventions after the fall incident. She said it was not done. She added she works on the unit most of the time and overlooked it. On 7/28/22 at 11:03 AM, V2, Director or Nursing/DON, said, Fall assessment is done upon admission, re-admission, quarterly, and after each fall incident. The fall care plan is updated based on root cause analysis after each incident to prevent future fall. 2. R38 was admitted on [DATE], with diagnoses not limited to: Diabetes, Hypertension, Dementia, symptomatic [CONDITION(S)]. Fall risk assessment, dated 9/05/2020, indicated R38 is high risk for falls. R38 had a fall incident on 1/11/2021. Alarm list updated on 7/29/2022 indicates R38 has a bed alarm started on 5/13/2018. R38 is on the fall monitoring list, updated on 7/26/2022. R38 was not care planned as high risk for falls, and the care plan did not indicate use of a bed alarm. On 7/26/2022 at 10:50 AM, R38 was observed lying in bed with bed alarm. On 7/26/2022 at 11:55 AM, V16 (Nurse) checked the bed alarm, and said that it was off. V16 turned it back on, and said it should be turned on. On 7/28/2022 at 12:15 PM, V9 said bed alarms should be checked for functioning every morning, mainly by Restorative Aide, but all staff are expected to check and inform V9 or Restorative department if it is not working. 3. R77 was admitted on [DATE], with diagnoses not limited to: Diabetes, unsteadiness of feet, lack of coordination, spinal stenosis, and polyosteoarthritis. Admission fall risk assessment, dated 2/18/2020, indicated R77 is high risk for fall. R77 had a falls on 3/16/2021 and 4/16/2022. Care plan indicated high risk for falls, with intervention that includes bed sensor alarm to staff when R77 is trying to rise up without assistance to prevent fall. Alarm list updated 7/29/22 indicates R77 has a bed alarm started 4/06/2020. R77 is on the fall monitoring list updated on 7/26/2022. On 7/26/2022 at 10:45 AM, R77 was observed sitting in her wheelchair; no bed alarm was observed on her bed. On 7/26/2022 at 11:58 AM, V16 checked R77, and said R77 does not have any bed alarm. On 7/28/2022 at 12:15 PM, V9 said bed alarms should be checked for functioning every morning, mainly by Restorative Aide, but all staff are expected to check, and inform V9 or Restorative department if it is not working. 4. R85 was admitted on [DATE], with diagnoses not limited to: [CONDITION(S)], unsteadiness on feet, unspecified abnormalities of gait and mobility, unspecified lack of coordination, and history of falling. R85 fall risk assessment upon admission, dated 6/22/2021, indicates high risk for fall. R85 had a fall incidents on 7/6/2021, 7/24/2021, 8/10/2021, 8/19/2021, 9/8/2021 twice, 9/11/2021, 10/5/2021 and 3/16/2022. Care plan indicated high risk for falls, with intervention that includes provide use of bed alarm for safety and reminder to ask help or any assistance to prevent fall. Alarm list updated on 7/29/2022 indicated R85 had a bed and chair alarm started 7/6/2021. R85 is on the fall monitoring list updated on 7/26/2022. On 7/26/2022 at 11:18 AM, R85 was observed lying on her bed with bed alarm, but no wheelchair and chair alarm at bedside observed. On 7/26/22 at 11:18 AM, V16 checked the bed alarm, and said that it was off, and V16 turned the bed alarm on. V16 said she was not sure where R85's wheelchair alarm was. On 7/28/2022 at 12:15 PM, V9 said bed alarms should be checked for functioning every morning, mainly by Restorative Aide, but all staff are expected to check, and inform V9 or Restorative department if it is not working. Care plan reviewed with V9 for R85 fall on 10/5/2021, and V9 admitted she updated the care plan on 7/28/2022. Incident report for R85 fall on 3/16/22 was reviewed with V9. V9 said the root cause analysis for 3/16/22 fall was not done. Facility's policy on Fall occurrence indicates it is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place and interventions are re-evaluated and revised as necessary. Procedures: 5. The fall coordinator will review the incident report and may conduct his/her own fall investigation to determine the reasonable cause of fall. 6. The nurse may immediately start interventions to address falls in the unit, even prior to the Falls Coordinator's investigation. 7. Ultimately, the Fall coordinator may change the interventions provided by the nurse if the Falls Coordinator's investigation identifies a more appropriate intervention for the individual fall. 8. The Falls Coordinator will add the intervention in the resident's care plan. 10. The interventions will be re-evaluated and revised as necessary. Facility's fall prevention program guidelines indicates: The fall prevention program guidelines shall be implemented to promote safety of all residents in the facility. This program shall include measures to determine the individual needs each residents by assessing the risk for fall and the implementation of evidence- based prevention interventions. Procedures: 5. All fall incidents shall be monitored, analyzed, root causes identified by the DON or designee. 8. An individualized evidence-based plan of care shall be created to reflect fall prevention interventions which could be but not limited to: K. May utilize personal alarms when appropriate such as bed alarms, chair and motion sensor alarm and floor mat alarms.

Based on observation, interview, and record review, the facility failed to follow their Medication Storage Policy by not returning to the pharmacy expired medications belonging to R3, R4, R6, R19, and R112; the facility also failed to return, destroy or store seperately expired stock medications. This affects 5 residents (R3, R4, R6, R19, and R112) in the sample reviewed for medication storage. Findings: D - WING MEDICATION CART On 7/27/2022 at 10:23 AM, surveyor observed: 1. [MEDICATION(S)] 0.005% ophthalmic solution, belonging to R4, opened on 4/23/22. Label indicates Refrigerate unopened. Store opened at room temperature. Discard after 6 weeks. 2. [MEDICATION(S)]/[MEDICATION(S)] for R19 was not in a foil wrapper, and there was no indication of the date the medication was opened. Label indicates Discard 3 months after removal from the foil pouch. On 7/27/22 at 10:41 AM, V13, Licensed Practical Nurse (LPN), verified there is no open date for R19's Glycopyrolate/[MEDICATION(S)], and R4's [MEDICATION(S)] ophthalmic solution was opened on 4/23/22. V13 said no open date is needed for the inhaler, but the [MEDICATION(S)] should have been discarded. A - WING MEDICATION CART On 7/27/2022, at 11:35 AM, the following medications were observed in the cart: 1. [MEDICATION(S)] sodium 100mg tablet with 75 tablets remaining in the bottle, with expiration date of 6/2022. 2. Vitamin D3 10mcg (400 IU) with 55 soft gel capsules left in the bottle, and an expiration date of 10/2021. 3. [MEDICATION(S)] 10 mg for R6 with 2 pills left, with expiration date of 5/4/2022. 4. [MEDICATION(S)] 10 mg for R112, with use by date of 5/30/22, and with 30 pills left. 5. [MEDICATION(S)] 200 mg, with use by date 5/30/2022, with 7 pills left. 6. [MEDICATION(S)] 5 mg for R3, with use by date of 2/28/22. 7. Microdot glucose gel, with use by date of 6/2022, with 2 tubes left. On 7/27/2022, V10, LPN, verified [MEDICATION(S)], Vitamin D3, R6's [MEDICATION(S)], R112's [MEDICATION(S)] and [MEDICATION(S)], R3's [MEDICATION(S)] and Microdot glucose gel were all expired. V10 added R112's [MEDICATION(S)] was discontinued. On 7/28/2022 at 2:00 PM, V10 said they removed expired medications, and put them in a bag to return to the pharmacy. On 7/28/2022 at 2:30 PM, V2 Director of Nursing (DON), said she expects her staff to remove expired medication, put them in the return to pharmacy bag, and hand it over to her (V2) or V2's assistant. On 7/28/2022 at 2:45 PM, V2 said the facility does not have a policy on Expired Medication, and they don't need to date [MEDICATION(S)]/[MEDICATION(S)] when opened. On 7/28/2022 at 3:00 PM, V2 confirmed with the facility pharmacist [MEDICATION(S)]/[MEDICATION(S)] should be dated once opened. V2 further said the pharmacy told her (V2) the medication is no longer effective after being opened for 3 months. Policy Title: Discontinued medications: [MEDICAL RECORD OR PHYSICIAN ORDER] Policy When medications are discontinued by the prescriber or the resident is discharged and medications are not sent with the resident, the medications are stored in a secure and separate area from the active medications. Residents whose medications are sent home on discharge are provided medications in accordance with state laws and regulations, and according to discharge medication policies. Procedures 2. Medications are removed from the medication cart or active supply immediately upon receipt of an order to discontinue (to avoid inadvertent administration).

Based on observation, interview, and record review, the facility failed to provide privacy for one resident (R84) of eight residents reviewed for privacy in the sample of 25. Findings include: On 7/26/22 at 11:40 AM, V15 (Certified Nursing Assistant) was preparing to provide incontinence care to R16. V15 entered the bathroom that was shared with the room next door without knocking. R84 was in the bathroom on the toilet. V15 did not excuse herself, and proceeded to wet the washcloths she used for R16. V15 was asked if she should have knocked on the door. V15 said, Yes, I should have knocked. On 7/28/22 at 2:47 PM, V2 (Director of Nursing) said, all staff should knock on the door before entering. A Policy titled, Privacy and Dignity indicates, 2. Knocking prior to entering resident's will be done by all staff.

Based on observation, interview and record review the facility failed to implement aspects of their infection control program for 3 of 7 sampled residents (R3, R5 and R6) and 5 residents (R8, R9, R10, R11, R12) in the supplemental sample on contact isolation. The facility failed to place these residents in private rooms or cohort residents with the same infection in the same room. The facility failed to clean and disinfect environmental surfaces and resident equipment per disinfectant manufacturer's instructions. Facility staff failed to wash hands and wear protective equipment during direct care (R5,R6). Failed to educate a resident on contact precautions (R12). Failed to analyze infection control data. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 4/13/2012, the Facility remains out of compliance at a Severity Level 2 until policies and procedures are revised, implemented and evaluated for effectiveness. Findings Include: 1. On 4-10-2012 at 11:30AM during tour with E2 (Director of Nursing), three (3) residents were observed in a four bed room. E2 stated, "...This is one of our infection control rooms...R5 has ESBL (Extended-Spectrum Beta Lactamase) of urine...R8 has MRSA (Methicillin Resistant Staphylococcus Aureus) of wound...R9 has MRSA of urine and VRE([MEDICATION NAME] Resistant [MEDICATION NAME]) in the rectum...and R10 has MRSA of wound..." R5 was in bed with a Gastrotomy tube feeding and a urinary drainage system in place. R9 was in bed and did not verbalize. R10 was sitting in a wheelchair next to R9's bed but did not verbalize anything. R5 has [DIAGNOSES REDACTED]. The Physician order [REDACTED].." The current POS for R5 dated 3-28-2012 states, ...'Contact Isolation for ESBL urine...". A lab report for R5 dated 3-26-2012 documents, "...Positive for Acinetobacter Baumannii in the urine...". R8 has [DIAGNOSES REDACTED]. A lab report for R8 dated 11-15-2011 documents, "...Positive for Proteus Mirabilis and positive for MRSA in the wound..." A lab report dated 3-19-2012 documents, "... positive ESBL in the urine..." R9 has [DIAGNOSES REDACTED]. Lab reports for R9 collected 2-7-2012 and 3-18-2012 document being positive for VRE in the stool. R10 has [DIAGNOSES REDACTED]. A Lab report for R10 collected 10-23-2011 documents Morganella Morganii and MRSA in the wound. A POS dated 4-1-2012 through 4-20-2012 documents, "...Contact Isolation for MRSA of wound...." R10 had one negative culture for MRSA dated 1-28-2012. On 4-13-2012 at 10:24AM, E 2 stated, "...There are no further lab reports...that is all we have..." E2 had no response to the reason why only one culture for MRSA was drawn. R5, R8 , R9 and R10 are cohorts in the same room for contact isolation. 2. On 4-10-2012 at 11:33AM in the next isolation room, R12 was sitting in a wheelchair. R6 was sitting covered in a shower chair in the hallway. E2 stated, "...This is the other isolation room...R3 is in the hospital...R6 has MRSA in the wound...R11 has ESBL in the urine... and E12 has MRSA of nares..." R11 was not in the room at the time. R3 was admitted [DATE]. Lab Reports for R3 are as follows: Reports for 8-17-2011 and 9-2-2011 were positive for ESBL of urine. Report for 12-14-2011 was positive for VRE in the urine. R3 was hospitalized from 3-11-2012 until 3-26-2012 and was diagnosed with [REDACTED]. As a result of this hospitalization , R3 was treated with intravenous antibiotics and had a spleen drain placed. On 4-10-2012 at 1:50PM, E6 (Nurse) stated R3 had a stage two sacral sore prior to hospital admission on 3-11-2012 and when R3 returned from the hospital no longer had a sacral sore. On the morning of 4-10-2012, R3 went out via emergency due to breathing difficulty. . On 4-11-2012 at 2:52PM, E2 stated,"...I do not know how R3 could have developed sepsis...I did not analyze that trend..I will call the doctor today and speak with him about it..." The current Surveillance Program does not analyze trends or possible reasons for attaining infections. On 4-12-2012 at 11:16 AM Z1(Attending Physician) stated, "...The most likely source of Sepsis for R3...was urine and the organism is [MEDICATION NAME] is functionally immobile..... even with the best incontinent care it could have developed..." R6 has [DIAGNOSES REDACTED]. A Consultation Report for R6 dated 3-13-2012 documents, "...MRSA in wound..." A Physician order [REDACTED]." R11 has [DIAGNOSES REDACTED]. The April, 2012, POS for R11 documents, "...Contact Isolation ESBL in urine...." A lab report dated 4-3-2012 documents Escherichia Coli and [DIAGNOSES REDACTED] Pneumoniae in the urine. R12 has [DIAGNOSES REDACTED]. R3, R6, R11 and R12 are cohorts in the same room on contact isolation. 3. On 4-11-2012 at 2:52PM, E2 stated, "...We do not have too many rooms so if someone is on isolation precautions we put them all-together...I am aware of our policy on isolation...what can we do...we do not have the space..." On 4-11-2012 at 2:52PM, E2, "...I do not know how R3 developed sepsis. I did not analyze that trend. I will call the doctor to day and speak with him about it." The current Surveillance Program does not analyze trends or possible reasons for attaining infections. 4. After being informed of observations of cohort residents R5 and R6 treatment procedures which took place on 4-11-2012, Z1 stated, "...We need to follow isolation precautions, infectious disease protocol and standard precautions...that needs to be investigated... that could cause the sepsis from the [MEDICATION NAME] growth..." 5. On 4-12-2012 at 2:20PM, Z2 (Medical Director) stated , "...The effects of cohorting residents depends on the organism...on colonization and on the site...I can not answer what would be some of the effects that is has on residents...None of the residents on isolation are my patients.." After being informed of observations made during resident treatment procedures for co-horted residents R5 and R6 on 4-11-2012, Z2 stated," ...I am not there everyday...you were there you made the observations...it is your judgement on what effects of co-horting multiple residents with different MDRO's can have on those residents..." 6. The facility's policy "Fundamentals of Isolation Precautions" (updated 11-5-2009) states, " ...A variety of infection control measures are used for decreasing the risk of transmission of microorganism. These measures make up the fundamentals of isolation precautions. Appropriate placement is a significant component of isolation precautions. A private room is important to prevent direct or indirect contact transmission when the source resident has poor hygiene habits, contaminates the environment or cannot be expected to assist in maintaining infection control precautions. When possible a resident with a highly transmissible or epidemiologically important microorganism is placed in a private room. When a private room is not available, an infected resident is placed with an appropriate roommate. Residents infected with the same microorganism usually can share a room, provided they are not infected with other potentially transmissible microorganisms. Such sharing of rooms, also referred to as co-horting is useful during an outbreak..." 7. On 4-11-2012 at 10:00 AM, E8 (Treatment Nurse) began pressure sore treatment for [REDACTED]. E8 did not clean the tray before placing the clean material on it. At 10:18AM, E8 went into an isolation room. R6 was lying in bed without dressings on any of R6's four (4) wounds. E9(Certified Nursing Assistant, CNA) was inside the room to help E8. E8 placed the tray on R11's cluttered, soiled bedside table; R11 is roommate to R6. On the bedside table was a flower pot, books and other personal items that E9 said belonged to R11. R6's bedside table was soiled and cluttered with a purse with contents falling out of it,a computer and cups containing a clear fluid. E8 placed the gauze and wound cleanser on the bedside table. On several occasions during R6's treatment, E8 removed gloves, did not wash hands and opened the door using the door knob to get supplies from a treatment cart in the hallway. Then E8 would come back in room, closed the door using the door knob and placed the supplies on the bedside table. After cleaning the wounds, E8 measured each of R6's four (4) wounds with the tape measures from the soiled tray. E8 applied Santyl (R) to the right shin and the right heel pressure area. The Santyl (R) was taken from the medicine cup with contaminated cotton tip applicators which were on the soiled tray. Before E8 treated R6's largest wound, R6 was incontinent of stool. E8 cleaned stool from R6, removed gloves, donned a new pair of gloves without washing hands, then cleaned R6's large wound with full thickness skin loss with green and yellow slough. E8 stated, " ...This is the infected site MRSA in the wound..." E8 measured the wound using a contaminated tape.(11.3 cm by 12 cm). On 4-11-2012 at 10:40AM E10(Nurse) donned a Personal Protective Equipment (PPE)gown in the hallway. E10 came into the isolation room (without washing hands or wearing gloves), leaned over the bedrail with gown touching the railing, raised the head of R6's bed with bare hands, R6 medicine in a cup, lowered the head of the bed, then left the room without washing hands. E10 removed the PPE gown in the hallway. E8, already inside the room, closed the door. During R6's treatment time, on 4-11-2012 at 10:59AM, R12 was in the room. R12 with (MRSA) of nares, while sitting in a wheelchair, began coughing into R12's hands, then without washing hands, rolled self over to the bedside table and touched all of the supplies on the bedside table that were being used for dressing changes for R6. E8 told R12 to "stop" but did not change any of the supplies. R12 stated later in the day that R12 touches everything in this room. R12 had positive lab work for MRSA of nares dated 3-21-2012. Later that day at 2:20pm, R12, (alert and oriented) stated, "...oh I touch everything in this room...I do not know why I am in this room...I do not wash my hands...why do I need to?..." E8 cleaned R6's ischial wound last. E8 measured the area with a contaminated tape measure that was on the soiled tray, applied Santyl (R) with a contaminated cotton tip applicator from the soiled tray ( 2 cm in length by 4 cm in width partial thickness skin loss). Treatment to R6's pressure sores ended at 11:17AM on 4-11-2012. E8 removed the PPE, washed hands, went outside of the room and wiped the soiled tray with Micro-Kill (TM) for 10 seconds, then proceeded to do R5's treatment in the other isolation room. 8. On 4/11/12, in the hallway E8 placed treatment supplies([MEDICATION NAME] (R), cotton tip applicators, [MEDICATION NAME] (R) , plastic tape measure , and Santyl (R) in a medicine cup) on the same tray used for R6. Then E8 and E3(Certified Nursing Assistant) donned PPE and entered R5's room. E8 placed the tray on R5's night stand. The night stand was cluttered with personal items including soiled socks. E8 did not clean the night stand. The supplies were falling off the tray onto the night stand. E8 cleaned R5's sacral wound, measured the would, then applied Santyl (R) with a contaminated cotton tip applicator from the tray. 9. On 4-11-2012 at 11:50AM, after completion of treatments for R5 and R6, E8 was able to scrub/clean all of the black substance from the tray used for the residents treatments. E8 stated, "...I did not clean the tray... Micro-Kill (R) instruction for MDRO kill time 2 minutes according to the package... I did not do that...the tray was dirty...I thought it was ink but I was able to remove the dirty black pieces...I should have washed my hands after removing the gloves and cleaning R6's stool...I did not provide a sanitized surface (bedside table and night stand) to do the treatments on... I should have cleaned the tables prior to placing the supplies on it...that can cause cross-contamination..." Micro-Kill trademark document states, "...Contact time for a disinfectant is the amount of time a surface must remain wet with the product to achieve disinfection. Overall Kill time needed is 2 minutes...." 10. On 4-13-2012 at 9:17AM, E10 stated, "...I did not have to wash my hands...I did not think I would touch anything...I only came in the room to give R6 pain medicine...I do not remember raising or lowering the head of the bed or taking off PPE in the hallway..." 11. The facility's policy titled, " Fundamentals of Isolation Precautions" (updated 11-5-2009) states, "...Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves were removed, between contacts and when otherwise indicated. It may be necessary to wash hands between tasks on the same resident to prevent cross-contamination of different body sites..." This same policy states, "... MRSA(Methicillin Resistant Staphylococcus Aureus Prevention: 1. Practice Good Hygiene. Handwashing or use alcohol based hand sanitizer. 2. Compromised skin integrity. Keep cuts scrapes clean and covered with bandage. 3. Contact Isolation. 4. Avoid sharing personal items and 5. Maintaining a clean environment..." 12. On 4-11-2012 at 3:30PM during a meeting with E1(Administrator) and E2, observations of R5 and R6 treatment procedures were discussed. E2 had no response for how the facility monitors staff and residents for compliance with infection control. The Infection Control Policy, updated 11-2-2009, and the last six months of surveillance for infection control does not address monitoring for compliance. On 4/12/12, an Immediate Jeopardy was identified. The Immediate Jeopardy situation began on 4/11/12 after speaking to Z1, Physician for R3 and R5, regarding facility infection control practices. E1, Administrator, and E2, Director of Nursing, were notified of the Immediate Jeopardy on 4/13/12 at 10:26AM. The facility took the following steps to remove the immediacy. The facility's current policy and procedures on infection control is to be modified immediately and will include the following: 1). All residents with the same microorganism will be in the same room. All Current isolation rooms will be thoroughly stripped, disinfected and cleaned. All eight of the following residents(R3, R5, R6 and R8-R12) listed that were on isolation were assessed using their current lab work and based on their microorganism were separated into appropriate isolation rooms on Friday, April 13, 2012. 2). Residents will be re-evaluated based on lab results to ensure they are in a proper isolation room. The lab results will be reviewed by the Director of Nursing, post antibiotic treatment or every two weeks until the culture becomes negative. All new residents with isolation needs will be places in an isolation room with the same infectious agent only. Director of Nursing in conjunction with the Medical Director will monitor for compliance. 3). All residents with isolation needs will be re-educated on their specific type of isolation needs and what precautions they need to follow. This re-education for each resident was added to their care plan on April 13, 2012. And any new resident with new isolation needs will be educated and documented in their care plan. Also family and visitors will be educated on the resident's needs and equipment for isolation. Based on the resident's cognitive level, those resident who are cognitively impaired will be placed in a private room if possible or may co-habitate with a non-medically compromised resident who is alert and oriented. This resident must be educated on isolation procedures and such counseling documented in their care plan. The Director of Nursing or designee will educate residents and all staff nurses will educate family an visitors. 4). The Director of Nursing will monitor all laboratory results and be in constant communication with the physician os each resident on isolation to monitor proper treatment. Completed by April 13, 2012 and done weekly thereafter. The administrator will monitor for compliance. 5). The director of Nursing and the Medical Director will review (i) any resident currently on isolation, (ii) any new resident with isolation, and/or(iii)any new residents with the isolation and/or(iii)if any new changes in isolation needs occur. The Medical Director was informed with the policy changes in isolation on April 13, 2012 by phone and chart review on 4-16-2012. 6). The monthly infection control meeting, as a part of quarterly Q. A. Committee, will now focus on isolation and prevention of transmission. A surveillance form has been developed to monitor compliance. All staff will be randomly selected for observation on handwashing, equipment use, techniques, cleaning procedures and sanitizing procedures. This will be done weekly by the Director of Nursing. Housekeeping supervisor and Director of Nursing will report findings with any needed solutions to the QA Committee. 7). We will identify and address any infection control issues as a part of our quality assurance. All data, findings, and further actions will be presented by the Director of Nursing and the Administrator. Medical Director will monitor for overall compliance. 8). The nurses were inserviced on proper use of sanitizing agents during treatments. New disposable trays for dressing changes have been obtained and used by April 13, 2012. 9). All residents on isolation will also be assessed for the proper incontinence program. Based on that assessment, the proper incontinence products/supplies and toileting schedule will be given. The Program Coordinator will assess and the CNA(Certified Nursing Assistant) supervisor will monitor through the use of Q. A. form. Treatment Nurse E8 was re-educated on proper sterile techniques and isolation techniques with return demonstration by both the Director of Nursing and the wound care physician. All nurses were in-serviced on infection control procedures by both the Assistant Director of Nursing and Housekeeping Supervisor. The Director of Nursing will monitor for overall compliance. All staff will be-inserviced on hand washing techniques and isolation procedures. This change in procedure will be effective April 13, 2012. By April 13, 2012(or next work day for staff members not at work on that day), all staff will be-inserviced on the changes. Any staff members on vacation or leave of absence will be in-serviced immediately on return to work. Additionally, these policies and procedures that are being implemented will also be a part of the orientation process for new employees, as well as a part of the employee in-service program. Overall compliance with this policy and procedures will be the responsibility of the Director of Nursing and on a daily basis his/her designee will monitor and QA the process. Total compliance will be completed by April 13, 2012 and monitored by the Administrator.