Every finding on record at Heather Health Care Center

Based on observation, interview, and record review, the facility failed to exercise reasonable care to protect a resident's personal property from loss by failing to ensure the resident's valuables were maintained in a safe and accessible location consistent with the resident's preferences. This failure affected one of three residents (R2) reviewed for protection of personal property. Findings include:On 8/4/2026 at 3:15 pm R2 said he has told staff about his missing items, including his car keys, his wallet, a vape, and some shoes. R2 does not recall who or when and no one has addressed his concern. R2 said when he arrived at the facility for admission, he had new work shoes, his car keys, his wallet, and a vape. He said the facility does not know where they are located and they have not addressed this concern. He has a cell phone, but it does not have any service. In his wallet he had his identification and his bank card. Review of R2 clothing and personal item list dated 9/4/2024 shows valuables deposited in the facility safe are car keys and vape. On 8/4/2026 at 3:40pm V3 (Behavioral Health Counselor) said she was not aware of R2 concerns, will look for his personal items in the social work office, and would go speak with him.On 8/5/2026 at 4:14pm V2 (Housekeeping Supervisor) said V2 located the clothing and personal item list. V2 said she was the manager on duty the day R2 was admitted and the valuables were given to the social worker on duty that day. The social worker that was on duty that day is no longer here. V2 said there are no resident person items stored in housekeeping or laundry. On 8/5/2026 at 4:22pm V3 (Behavioral Health Counselor) said they spoke with R2 and submitted a grievance form the V1 (Administrator). On 8/5/2026 at 4:48pm V1 (Administrator) said they do not have any items in the facility safe for R2. Reviewed facilities policy Resident Belongings dated 9/2020 shows are sent to the business office and placed in the facility safe. Reviewed Concern form dated August 5, 2026, completed by V3 (Behavioral Health Counselor) for R2 and signed by V1 (Administrator). Concern form shows the resident reported his keys and wallet missing. Documented follow-up by V1 (Administrator) details the wallet is being replaced, with an attached order summary for the wallet and the facility is searching for the keys. Reviewed facility concern forms and facility reported incidents from January 2026 to present, and resident council minutes for May, June, and July of 2026 with no concerns documented for R2. Other concerns of missing items observed, with follow-up action documented. On 8/6/2026 at 2:52pm observed the facility safe in the administrators office to be empty of resident belongings. V1 (Administrator) said the safe does not stay locked but the door to the office is secured when she is not present. On 8/6/2026 3:04pm observed the file cabinet drawer in the social services office with resident belongings present in addition to a resident cell phone with a charging cord plugged into an electrical receptacle on top of a cabinet. V4 (Social Work Director) said they keep items in their office as requested by the resident for safekeeping, the social services office is kept secure when they are not present and a member of the social services department works every day of the week.

Based on observation, interview, and record review, the facility failed to adequately supervise and develop an effective plan to prevent a resident from smoking in an unauthorized area. The facility also failed to implement an effective contraband practice/policy/program to prevent a resident from obtaining unauthorized items, including cigarettes, lighters, and failed to accurately complete a smoking evaluation. This affected one of one resident (R1) reviewed for safe smoking. Findings include: On 8/4/26 at 11:29a.m. during tour of the facility, when walking pass room XXX there was a strong cigarette smell coming from the room. R1 was resting on the bed, R1 was in the room alone. R1 gave permission for surveyor to enter, the room smelled of strong cigarettes had been smoked, there were ashes scattered on toilet. V4 (Social worker) was in hallway, V4 was asked to enter, and he said he smelled cigarette. V4 was asked to summon V1 (Administrator). At 11:33am V3 (Social Worker) arrived and stated she was planning to search the floor/unit. When she entered R1's room, she identified that she smelled an odor of someone smoking a cigarette. V20 (Assistant Director of Nursing/ADON) and V4 (Social Service Director/SSD) arrived to assist with room search. At 11:37am, after 3 to 4 minutes; V3, V4, and V20 all exit R1's room. Surveyor did not see any contraband in either of their hands. They were asked if R1 allowed them to observe his pockets for contraband. V3 said she checked the bathroom only. V20 (ADON) said she did not ask R1 to observe his pockets. V4 (SSD) returned to the room, asked to observe R1 pockets, R1 empty a red lighter from his pockets. There was an oxygen concentrator observed at R1's bedside. On 8/4/26 at 12:40pm V3 (Social Service) said R1 is a safe smoker. Review of R1's smoke assessment last completed 5/29/2025 denoted that R1 has problems with giving smoke material to others, smoking cigarettes butts, and smoking from others. V3 said R1 is considered safe based on score of 10. When asked how was R1 considered a safe smoker if he is demonstrating unsafe smoke behaviors of getting cigarettes from the ground and giving other residents cigarettes. V3 said R1 is a safe smoker because he does not drop ashes on his clothing and does not burn his fingers. V3 said the other behavior can be addressed with monitoring. V3 said staff monitors the smoke patio, the staff must light cigarettes, and the staff must keep the lighters. V3 was asked how is smoke monitoring effective: if R1 can pick up cigarette butts and smoke them? V3 did not respond. V3 said R1 should not have lighter in his possession because he uses oxygen. V3 said it could ignite a fire. V3 said the ashes in the bathroom could ignite a fire. V3 said R1's smoke behaviors should be in the care plan. V3 said the protocol for room searches is that the team come together and decide what area of the room is going to be searched, the staff that searches the room is responsible for asking the residents to empty their pockets. V3 said V20 should have asked R1 to empty his pockets during the room search. V3 said she will mention this when they meet about the matter. On 8/4/26 at 12:51pm V5 (Director of Nursing) said R1 can have cigarette lighter in his possession because is a safe smoker. V3 said it's in the policy. Facility policy was reviewed with V5. When asked what smoke material has R1 been assessed to have in his possession she referred surveyor to V3. V3 said the facility does not have a contraband policy, V3 said weapons, cigarette lighters and anything that can cause bodily harm to the staff or residents are considered contraband. V3 was asked how it is appropriate for R1 to have a lighter, he uses oxygen and has cognitive deficits with a BIMS score of 12, with documented behavior of picking up cigarette butts. V5 referred surveyor to speak with V3. V5 said smoking is an area that social services manage. On 8/5/26 at 10:44am R1 was observed lying in bed, permission granted to enter, R1 observed alert to person, place and date. R1 said he does not have money to buy cigarettes, he picks the cigarette butts up from the smoking patio, he rolls them up and smokes them. R1 said he got the lighter off the ground on the smoking patio. R1 said the facility told him he cannot smoke in his room because he uses oxygen and it can start a fire, and smoking in the room is not safe. R1 said the staff is there when he picks up the cigarette from the ground. R1 oxygen concentrator remains at the bedside for use. R1's care plan with initiated date of 5/29/2024 denotes in-part R1 is assessed to be a safe smoker. R1 will follow facility protocol for smoking and remain safe with smoking habits. Interventions are to monitor resident for adherence to smoking guidelines, and provide assistance with smoking cessation upon request, and staff will educate R1 on the smoking guidelines. Resident will follow the smoking agreement. R1's care plan does not address R1 having smoking material on his person or in his possession. There are no updates noted to R1 care plan for safe smoking. R1's MDS dated [DATE] section C for cognition pattern shows BIM score of 12 (cognitive impairment). R1's physician order sheet shows orders for respiratory: oxygen per nasal cannula at two liters per minute continuous every shift related to chronic obstruction pulmonary disease start date 2/2/2026. R1's last completed annual Smoke assessment dated [DATE] denotes in-part, R1 smokes cigarettes and cigars. R1 has severe problems with sanitary issues while smoking (smokes used cigarettes butts, smokes others cigarette while lit), and R1 has a severe problem with inappropriately provide smoking material to others. R1's quarterly behavior health assessment dated [DATE] denotes in-part resident has a habit of smoking in his room but can be redirected and is quick to apologize. Facility smoke policy with revision date of 8/2023 denotes the facility will assess hazards and risk factors associated with smoking, develop a plan of care to address hazards and risk, implement appropriate resident interventions, and revised the president's plan of care to minimize the risk of incident accident associated with smoking. Upon admission to the facility, residents and/or their representatives will be oriented to the facilities moved to smoking and to abide by facility rules (smoking agreement). The smoking agreement will be used to identify the residents as smoker or non-smoker. If a Residents are identified as smoker, a smoking risk assessment (SSD/MC/BH- smoking risk assessment) will be completed upon admission, annually, significant changes and upon any change in residence smoking behavior. Assessment is scored and used to categorize residents as a safe smoker or unsafe smoker. Safe smokers are those who score 0-10 on the smoking risk assessment. Safe smokers may be allowed to hold their own smoking materials and to smoke at their leisure in designated areas, at the discretion of the facility. Unsafe smokers are those who score between 11-21 on the smoking risk assessment. If resident is identified as a smoker, a care plan should be developed that defines risk level (safe or unsafe) and include goals and interventions that address the residents specific risk factors identified in the assessment. Review smoking risk on quarterly social service behavioral health/memory care assessment. If changes have been identified, complete a new SSD/ mc/bh- smoking risk assessment. If there have been no changes, a comprehensive smoking assessment is not required. Monitor for any changes in residents smoking behavior, including smoking- related incidents or cognitive or physical status affecting smoking behavior, and reassess risk and update care plan if warranted. Review and/or modify the resident's plan of care at least quarterly and as needed. Smoking area should be maintained in accordance with state and federal and local ordinance.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to transcribe physician's orders, failed to follow physician orders, failed to notify the wound care director of resident's skin integrity impairment, failed to ensure that staff were aware of required LALM (Low Air Loss Mattress) settings, failed to ensure that the LALM was on the right setting (while in use), failed to ensure that the LALM was on (while in use), failed to implement preventive interventions, and/or failed to ensure that treatments were administered for two of three residents (R1, R2) reviewed for pressure ulcers. These failures resulted in R2 developing the following (facility acquired) pressure ulcers: sacrum (stage 3), right heel (stage 3), left heel (stage 3), right buttock (stage 2), and left elbow (unstageable). R2's left elbow and left heel developed necrosis. Findings include: 1.) R2 was admitted to the facility on [DATE].R2's diagnoses which include dementia, transient ischemic attack, cerebral infarction, type II diabetes mellitus, (2/19/26) pressure ulcer of sacral region - stage 3, (3/2/26) pressure ulcer of right buttock - stage 2 and (3/12/26) pressure ulcer of left elbow - unstageable.R2's (3/3/26) functional assessment affirms the resident is dependent on staff for rolling left and right.R2's (3/3/26) risk assessment for skin integrity impairment determined a score of 10 (high risk).R2's care plan includes (9/29/25) Resident has an ADL (Activities of Daily Living) self-care performance deficit related to dementia, impaired cognition, incomplete performances, and history of stroke. Dependent on staff for care, interventions: assist with ADL tasks as needed. (3/3/26) Actual alteration in skin integrity due to sacral pressure ulcer, right heel, left heel pressure, interventions: low air loss mattress, turn and reposition every two hours and as needed. R2's (4/2/26) Physician Wound Assessment states preventive measures in place: no direct pressure on bony prominences. Heel protection with pillows or heel devices. Sacral (stage 3) reported 2/19/26 not resolved 1.3 x 1.2 x 0.3cm (centimeters), intact skin 90%, granulation 10%, exudate: serosanguineous, moderate. Clean with NS (NS) primary dressing: (brand name) paste, open to air. [Treatment has been changed on 4/2/26]. Right heel (stage 3) reported 2/19/26, 4 x 3.8 x 0, granulation 100% exudate: none. Left heel (stage 3) reported 2/19/26, 2.8 x 3 x 0, granulation 100%, exudate: none. Left elbow reported 3/12/26, 1.4 x 1.3 x 0cm, necrotic 100% black. Adverse factors affecting wound healing process: bed offloading, heels offloading, turning schedule, incontinence, muscle weakness. Team communication: dressings changed and discussed with the treatment nurse. Staff and nursing assistants educated about prevention, repositioning, and wound care. R2's POS (Physician Order Sheet) includes (2/17/26) Low Air Loss Mattress. (3/30/26) (brand name medicated) wound dressing paste apply to sacral topically every dayshift (and as needed) cleanse area with NS (Normal Saline), apply (brand name medication), cover with alginate then secure with island dressing. (3/30/26) (brand name medicated) wound dressing paste apply to right/left heel topically every dayshift Monday, Wednesday, Friday. Cleanse area with wound cleanser, apply adaptic and (brand name medication), cover with alginate then secure with foam dressing. (3/30/26) Betatine solution 10% apply to left elbow then apply protective dressing every Monday, Wednesday, Friday and PRN (as needed). [R2's 4/2/26 sacral treatment order per physician wound assessment - was excluded].R2's (April 2026) TAR (Treatment Administration Record) affirms (brand name medicated) wound dressing paste: apply to sacral topically every dayshift cleanse area with NS, apply (brand name medication), cover with alginate, secure with island dressing - was documented 4/3/26-4/5/26 and 4/7/26 therefore the incorrect treatment was applied for several days. [R2's 4/2/26 sacral treatment orders were excluded].R2's (3/3/26) BIMS (Brief Interview Mental Status) affirms resident was unable to complete the interview.On 4/6/26 at 1:50pm, surveyor attempted to interview R2, however a verbal response was not received. R2 was lying atop of a LALM which appeared to be firm and not fluctuating. The LALM control device was crammed between the mattress and foot of bed, placing additional pressure on the mattress. R2 was lying on her left side with wedge cushion behind her back, her feet were not elevated, and she was not wearing heel protectors/boots.On 4/6/26 at 2:05pm, V4 (Registered Nurse/RN) affirmed that she's (V4) assigned to R2. Surveyor inquired about R2's current LALM settings. V4 stated, I (V4) don't know because wound care came early and I'm (V4) not sure what they're (wound care) setting it. V4 removed R2's LALM control device from between the mattress and foot board (as requested) and placed it on the bed. The weight setting was 550 pounds. Surveyor inquired about R2's current weight. V4 responded, She (R2) would be less than 200. Surveyor inquired if R2's LALM was set on 550 pounds. V4 replied, Yes however failed to change the setting at this time. Surveyor inquired if R2 has any wounds. V4 stated, She (R2) has wounds on the feet. I think the heels and the sacrum is healed now. R2's sacrum was notably pink and appeared to be healing (scarring with granulation tissue). There was no treatment and/or cream on the sacral wound. V4 removed R2's heel dressings (kerlix and adaptic) which were not secured with foam dressing as ordered. R2's left heel was necrotic with red bleeding skin encircling the wound. R2's right heel skin appeared sheared off. On 4/6/26 at 2:09pm, surveyor inquired about R2's LALM settings. V6 (Wound Care Nurse) stated, It should be set to her (R2) weight, it's a little bit more than that. It's 550 and it's supposed to be according to her weight. Surveyor inquired if R2's mattress is set on 550, which is too high, what's the concern? V6 responded, It's too firm. Surveyor inquired about R2's heel wounds. V6 replied, She (R2) have 2 pressure wounds they were closed but last Thursday (4 days ago) they were open, so we (facility) changed the treatment to adaptic and calcium with honey. Surveyor inquired if R2's heels were recently debrided. V6 stated, I (V6) don't think he (Wound Physician) did it last Thursday, that was the last time seeing it. We (staff) cleaned it and applied the dressing. Surveyor inquired about R2's preventive measures to prevent further heel breakdown. V6 responded, She had booties, I'm (V6) not sure if they were moved. Surveyor inquired about the appearance of R2's left heel. V6 replied, I see some necrotic tissue.On 4/7/26 at 12:53pm (the following day), R2 was lying in bed while V4 (RN) was feeding her (R2). R2's LALM device was still crammed between the mattress and footboard. Surveyor inquired about the settings on R2's LALM. V4 removed the device from between the mattress and foot board, and it was noted to be off. Surveyor inquired why R2's LALM was off while the resident was in bed V4 stated Maybe the housekeeper messed with it, she (housekeeper) was just in here. Surveyor inquired if R2's LALM was currently on. V4 responded, It's not on right now. A note was observed on R2's LALM device with 105.2 handwritten. Surveyor inquired about the 105.2 note placed on R2's LALM device. V4 stated, That's her (R2) weight therefore R2's (4/6/26) LALM 550-pound setting - was incorrect.On 4/7/28 at 12:59pm, V11 (Restorative Nurse) entered R2's room and V4 advised that R2's LALM wasn't working. V11 inspected R2's LALM device and stated This if off, is it plugged up? and affirmed that it was unplugged.On 4/7/26 at 4:12pm, surveyor inquired about R2's wounds. V9 (Wound Care Director) stated, She (R2) had breakdown on her sacrum area and her feet as well (left elbow was excluded). They (staff) put in interventions for her supplements, like (protein supplemental drink). We (staff) ordered her (R2) an air mattress and she definitely has treatments. Surveyor inquired about preventive interventions for R2's feet wounds. V9 responded, We've been offloading she's been using pillows or heel lifts like booties [neither of which were in use for R2 on 4/6/26]. On 4/9/26 at 12:15pm, surveyor inquired about potential harm to a resident if a LALM is on the incorrect setting and/or off - while in use. V12 (Medical Director) stated, If it's the wrong setting it doesn't work as intended, and they (residents) have a potential to develop a wound if it is not working at all. Surveyor inquired about potential harm to a resident if wound care treatments are not followed. V12 responded, If the treatment is not implemented as recommended then the wound may not get better. Surveyor inquired about potential harm to a resident if treatments are not applied. V12 replied, If the treatment is something ordered and it's not done there is a problem with that, and the potential for the wound getting better may be reduced.2.) R1's diagnoses include altered mental status, malignant neoplasm of brain/breast/lung, adult failure to thrive, hemiplegia and hemiparesis.R1's (1/26/26) functional assessment affirms resident requires partial/moderate assistance with rolling left and right. R1's (4/2/26) risk for skin integrity impairment assessment determined a score of 10 (high risk).R1's (2/22/25) care plan states resident has alteration in skin integrity related to left elbow blister. Potential for further alteration in skin related to incontinence, weakness, right side hemiplegia, decreased mobility, non-ambulatory and weight loss. Interventions: barrier cream to areas exposed to moisture/incontinence. Inspect skin daily with care. Wound care consultation as ordered.R1's POS (Physician Order Sheets) include (3/27/26) Skin check completed every Tuesday and Saturday. (3/27/26) Wound consult. (4/4/26) Betadine solution 10% apply to left elbow every Monday, Wednesday, Friday and as needed. (3/27/26)(brand name) wound dressing external paste apply to buttocks topically every day and as needed for skin condition. On 4/6/26 at 1:40pm, V3 (Certified Nursing Assistant/CNA) affirmed that she's (V3) assigned to R1. Surveyor inquired if R1 has any skin integrity impairments. V3 stated, On her (R1) bottom it looks like it's healing; I (V3) just cleaned her up. Surveyor inquired about R1's skin integrity impairment. V3 responded, It's like a dot, I can't really explain. R1's (4/2/26) Physician Wound Assessment (4 days prior) includes left elbow 4 x 3 x 0.1cm (centimeters) 100% scabbing [buttock wound was excluded].On 4/6/26 at 1:43pm, R1 was lying in bed - on her back. V3 removed R1's incontinence brief (as requested) and a small circular open area (stage 2) was noted on the right buttock however wound treatments were not observed. On 4/7/26 at 4:07pm, surveyor inquired where resident skin assessments are documented. V9 (Wound Care Director) stated, When they (resident) first come in they will have it in a skin progress note or on the initial nursing assessment. We (staff) don't do the weekly skin assessment because the doctor comes in weekly and they would be in the miscellaneous notes. Surveyor inquired about R1's buttock wound. V9 responded, She (R1) doesn't have a buttock wound, she did when she first came in, but we (facility) healed it a while ago. The only wound she has is from an IV infiltrate in the left forearm. I only have her down for left forearm, they're (staff) supposed to notify me (V9), notify the family and notify the doctor if there's a wound and obtain a order. V9 subsequently reviewed R1's medical records and stated, She (R1) gets (brand name cream) that they ordered a couple days ago for her (R1) [NAME].The (3/2/24) prevention and treatment of pressure injury and other skin alterations policy states identify the presence of pressure injuries and/or other skin alterations. Implement preventive measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. The (03/2024) low air loss mattress policy states the Director of Nursing or designee is responsible for identifying residents who require the use of a low air loss mattress. Residents who have been assessed as in need of a low air loss mattress will have a mattress set up for their use. The Maintenance Supervisor, Housekeeping Supervisor of designee will be responsible for the set-up of the low air loss mattress for the residents. [staff responsible for LALM settings are excluded].

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to document meal intake, failed to provide meal within reach, and/or failed to provide required feeding assistance for two of three dependent residents (R1, R2) reviewed for nutrition. These failures resulted in R2's significant weight loss (-15.6% within 1 month) and R1's significant weight loss (-7.9% within 1 month).Findings include:1.) R2's diagnoses include obesity, dementia, transient ischemic attack and cerebral infarction.R2's (3/3/26) functional assessment affirms substantial/maximal assistance is required for eating.R2's (9/29/22) care plan states resident has an ADL (Activities of Daily Living) self-care performance deficit related to dementia, impaired cognition, incomplete performances, history of stroke, and poor oral intake. Dependent on staff for care, interventions: assist with ADL tasks as needed. The resident requires nutritional support secondary to weight loss, poor oral intake, and dementia. Total assistance is needed with meals, interventions: Set up resident's tray and provide assist or cueing for meals as needed. R2's POS (Physician Order Sheets) include (3/2/26) No added salt diet, pureed texture. (1/29/26) (brand name supplemental ice cream) twice a day for nutritional supplement give with lunch and dinner. (2/20/26) (brand name supplemental drink) 2.0 - 120ml (milliliters) with meals for nutritional supplement. R2's (1/29/26) Nutrition Assessment states total assistance is needed with meals. Significant weight change in the past 3 months? Yes. Significant weight change in the past 6 months? Yes. Variable intakes 0-100% per meal monitor documentation. R2's (March 2026) meal intake documentation affirms nothing was documented (entries were blank) on 3/7 (lunch), 3/9 (dinner), 3/10 (lunch), 3/15 (breakfast & lunch), 3/22 (breakfast & lunch), 3/28 (breakfast, lunch & dinner), and 3/29 (breakfast, lunch & dinner). 13 meals were not documented. 0 (indicating 0-25% intake) is documented 36 times.R2's (April 2026) meal intake documentation affirms nothing was documented 4/2 (dinner) and 4/6 (lunch), 0 was also documented for 9 of 19 entries therefore most of the meal intakes were 0-25%. On 4/9/26 at 2:18pm, surveyor inquired what blank entries indicate on the meal intake documentation. V2 (Director of Nursing) stated, They indicated that the CNA (Certified Nursing Assistant) did not chart on that shift. R2's (3/3/26) BIMS (Brief Interview Mental Status) affirms resident was unable to complete the interview. On 4/6/26 at 1:50pm, surveyor attempted to interview R2 however a verbal response was not received. On 4/6/26 at 2:05pm, surveyor inquired if R2 can feed herself. V4 (Registered Nurse/RN) responded, No, no, no, we (staff) assist her. On 4/7/26 at 12:53pm, V4 (RN) was observed feeding R2 the (brand name supplemental ice cream), however the plated meal was covered with the lid. Surveyor inquired if R2 ate the meal. V4 stated, She's (R2) taking juice and this (brand name supplemental ice cream), she also likes this applesauce too. V4 removed the lid from R2's plate (as requested) and the mashed potatoes and pureed vegetables were untouched. The pureed meat appeared as if only one (1) bite was removed. Surveyor inquired why R2 wasn't fed the plated meal. V4 responded, She just wants 2 spoons, and she said no more however made no attempt to offer R2 the mashed potatoes or vegetable at this time. R2's weights are as follows: (3/5/26) 124.8. (4/2/26) 105.3 (-19.5 pounds) therefore 15.6 % loss within 1 month. 2.) R1's diagnoses include altered mental status, malignant neoplasm of brain/breast/lung, adult failure to thrive, hemiplegia and hemiparesis.R1's (1/26/26) functional assessment affirms the resident requires supervision or touching assistance with eating. R1's care plan includes (2/8/25) resident has an ADL functional performance deficit related to right side hemiplegia, weakness, and brain cancer, interventions: offer assist at mealtimes. (2/28/25) Resident requires nutritional support secondary to weight loss, diagnosis of lung cancer with metastasis, failure to thrive, and major depressive disorder, interventions: assist with meals as needed. Monitor for changes in ability to feed self.R1's POS includes (1/11/26) general diet, mechanical soft texture. (12/19/25) (brand name supplemental ice cream) with dinner for nutritional supplement. (1/19/26) (brand name supplemental drink) 2.0 with meals (90ml) for nutritional supplement. (4/3/26) (brand name supplemental drink) with breakfast and lunch for nutritional supplement. R1's (4/2/26) Nutritional Assessment states significant weight change. Variable intakes 0-100% per meal monitor documentation. Able to feed self with limited to total assistance as needed. Current weight 115 pounds (4/1/26) Significant weight loss noted: -7.9% x 1 month, resident was 124.8 (3/5/26). R1's (March 2026) meal intake documentation affirms nothing was documented (entries are blank) on 3/1 (breakfast & lunch), 3/8 (dinner), 3/9 (dinner), 3/11 (breakfast & lunch), 3/18 (dinner), and 3/29 (dinner) therefore 8 meals were not documented.R1's (1/26/26) BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact). On 4/6/26 at 1:34pm, R1's lunch tray was on a table - near the foot of bed (out of reach). R1 was lying in bed. The right side of R1's bed was against the wall, and a thick floor mat was in front of the bed - impeding access to the tray. R1's tray was inspected and appeared to be untouched. The following items were on the tray: diced peaches (with the lid on), mighty shake (unopened), juice (cup full), bread (bagged), and the plate with mechanical soft potatoes, vegetables, meat (covered with the lid). Surveyor inquired if R1 received assistance with lunch today R1 stated No. On 4/6/26 at 1:40pm, V3 (CNA) was observed (seated) at the Nurse's station and affirmed that she's (V3) assigned to R1. Surveyor inquired if R1 requires feeding assistance V3 replied Yes. Surveyor inquired who's responsible for feeding R1, V3 stated Whoever passes trays on the floor. Surveyor inquired if V3 was responsible for feeding R1 today V3 responded I (V3) did dining room, I'm (V3) not sure who fed her (R1) for lunch. I didn't talk to the CNA that fed her yet. Surveyor inquired what time lunch is served on R1's unit V3 replied This unit is served around 12:30 (over 1 hour ago). R1's (4/6/26) meal intake documentation affirms the breakfast and lunch entries are marked 0.On 4/26/26 at 1:43pm, V3 inspected R1's lunch tray (as requested) and stated, I (V3) guess they (staff) didn't come around to feed her. Surveyor inquired where R1's lunch tray was placed. V3 responded It's away from the bed. On 4/7/26 at 12:37pm, surveyor inquired if R1 can feed herself V10 (CNA) stated Yes and no but the majority of the time, no. Surveyor inquired if R1 can use her right hand. V10 responded She can use the left, I (V10) don't know what happened with the other one. Surveyor inquired who's supposed to feed residents that require assistance? V10 replied If you're assigned to the floor, you're supposed to feed the resident.On 4/9/26 at 12:20pm, surveyor inquired about potential harm to a resident that requires feeding assistance - if feeding assistance is not provided V12 (Medical Director) stated The patient can lose weight and/or can get sick. Surveyor inquired about potential harm to a resident if intake is usually 0-25% at meals V12 responded Then the patient is going to be losing weight or becoming dehydrated.The (09/2020) feeding a resident policy states residents who need assistance will be fed a well-balanced meal, by a nurse, CNA, or in individual who has completed a state approved feeding course. Document on meal monitor sheet as applicable and/or report to the nurse if resident refused meal or had minimal intake or had difficulty swallowing or chewing meal.

Based on interview and record review, the facility failed to provide adequate supervision and maintain a safe environment for one resident that had a diagnosis of schizophrenia, anxiety, and depression, with a documented history of self-harming behaviors and exit-seeking behavior. The facility failed to prevent the resident from accessing a fire extinguisher, which was used to break a second-floor window and exit the building without staff knowledge. This affected one of three residents (R162) reviewed for supervision. As a result, R162 exited through the second-floor window, landed face down outside the facility, and sustained a left leg [NAME] fracture, a severe fracture involving the distal tibia. Findings include:The Immediate Jeopardy began on 01/06/2026 when R162 broke a window in the dining room with a fire extinguisher and jumped out of a second story window (fifteen feet) without facility staff knowledge. R162 landed face down sustaining a [NAME] fracture. V1(Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 3/6/26 at 4:33PM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 3/7/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the interventions implemented.R162 was admitted on [DATE] with the diagnosed of Schizophrenia, Anxiety and Depression. Brief interview for mental status dated 12/18/25 documents a score of thirteen which indicates cognitively intact.Hospital Behavioral Health Integrated Assessment 12/16/25 documents: R162 reports that he has self-harm in the past. R162 was unable to recall the last time he self-harmed. Identified patient's perspective: R162 said, he was in the emergency department because it was cold outside, homeless and feeling depressed, R162 stated, he has never had thoughts of taking his own life, but he has had thoughts of harming himself. R162 stated that he has self-harmed in the past by hitting himself. R162 states the last time he self-harmed was a while ago, he was unable to provide any further information about when he last self-harmed.R162's baseline care plan dated 12/17/25 does not document anything about Anxiety, Depression, Schizophrenia or history of self-harming behavior. R162's care plan dated 12/17/25 documents the following: Receiving (name of medication) psychotropic medication. To manage behavior or mood issues of: Related to diagnosis of was blank. Interventions dated 12/17/25 include Document mood and behaviors as needed as they occur; Lab work per MD order; Monitor and report signs and symptoms of side effects to physician as needed.R162 is at risk for abuse related to diagnosis of Schizophrenia. Date Initiated: 12/18/2025 interventions: Encourage resident to process her feelings, fears, problems, etc. (Blank) times per week in 1:1 session with therapist or staff during periods of increased stress/depression/anxiety Date Initiated: 12/18/2025; Encourage/re-assure/re-direct/repeat as needed; Encourage resident to participate in activities.Elopement risk assessment dated [DATE] documents: R162 was NOT at risk for elopement.On 3/3/26 at 1:59PM, R162, who was assessed to be alert and oriented to person, place and time, was observed with a cast on his left lower leg. R162 was hesitant to report how the incident happened and how he ended up in a cast. R162 said he had a mental breakdown and a fall. R162 would not report exactly when the incident happened, or which staff were involved. R162 said the cast was put on since his admission to facility. On 3/4/26 at 2:36PM, R162 said he got the fire extinguisher off his unit, walked past the nursing station down to the dining room where the window by the vending machine was cracked open. R162 said he busted/hit the window with the fire extinguisher and jumped out. R162 said he landed on the ground face down. R162 said he was in extreme pain of hundred out of a one to ten pain scale with 10 being the worst pain. R162 said he was feeling frustrated and stressed. R162 said he had been feeling that way for a while. R162 said he informed staff members, but they did not help him. R162 said, when he jumped out of the window, he was mentally, physically and emotionally confused. On 3/4/26 at 3:07PM, tour of second floor dining room with V5 (Maintenance). The windows at the facility are a set of three windows with the two outer windows that can be opened, and the middle cannot. The windows have two glass panes, and the middle windows have blinds in between the panes. There is a latch to lock the window and a hand crank to open the windows. There should be a limiting chain on the window to prevent it from opening all the way. Observed the window that R162 jumped out. The outer windowpane had pieces of broken glass stuck inside the window frame and the inner windowpane had been replaced. The latch had three screws in place to prevent it from opening. The hand crank was removed. Another window in the same dining room was observed with no hand crank but was able to be opened when pushed. There was a limiting chain in place. The fire extinguisher case on R162's hallway, that was utilized had a piece of plastic plexiglass on the door with a small piece of glass within the case. The fire extinguisher was missing the pull pin tag. All the other fire extinguishers on R162's floor had glass windows and pull pin tags.On 3/5/26 at 10:10AM, V4 (Maintenance) said he recalls having to fix and clean up a broken window on second floor dining room in January. V4 said they replaced the one side of glass and placed screws around the lock to prevent it from opening. V4 said on the same day he also replaced the glass insert for the fire extinguisher case on the second floor. V4 said it was replaced with plexiglass because the glass was broken.On 3/5/26 at 4:00PM, V24 (Nurse) said he was R162's nurse for the day. V24 said R162 was an elopement risk. Observation of the facility elopement report binder did not include R162's picture, face sheet or elopement information. V24 said, R162's elopement information was not in the 1st floor unit elopement binder. V24 said, R162 resides on the 1st floor unit.On 3/6/26 at 10:46AM, V32 (Social Service) said, if a resident has a history or suicide or self-harm it should be care planned upon admission and quarterly. On 3/11/26 at 10:47AM, V22 (Behavior Health Counselor) said she does not recall who the Certified Nursing Assistant/CNA was that informed her of R162 pacing with his coat and bag in hand. V22 said the CNA informed her about R162 because she thought R162 was exit seeking. V22 said R162's pacing with his coat and bag in hand was exit seeking behaviors.Social services note dated 12/27/2025 documents: Writer (V22) was informed by CNA that resident (R162) was pacing with his coat and a bag in his hand. Writer approached resident to find out what he wanted to do. Resident stated that he feels like he is forty years old and not at a good point in his life. Writer advised resident to attend group and seek staff for assistance when needed. Staff will continue to monitor.R162's sign-in sheet for groups are as follows 2/12/26 (Basic Conversation), 2/25/26 (A Better Me), 2/26/26 (Basic Conversation) and 3/4/26 (Basic Conversation). There were no other group sign in sheet provided for R162 during this survey.On 3/13/26 at 12:04PM, V49 (Nurse) said R162 was calm and stated he wanted to leave. V49 said she questioned R162 as to why he wanted to leave. V49 said he did not know why he wanted to go. V49 said she asked R162 did he have something mental going on in his head. V49 said R162 replied he wanted to harm himself. V49 said she called the doctor who gave an order for R162 to go out to the hospital. V49 said R162 was at the nursing station and said he was just joking about harming himself. R162 refused to go to the hospital because he said he was just joking when he reported he wanted to harm himself. V49 said, she called the doctor back to update the doctor about R162's refusal. V49 said R162 was given snacks, juice and was allowed to call his daughter twice while V49 was waiting on the doctor's return call. V49 said the doctor called back at the end of her shift and was updated about R162's refusal. V49 said she was instructed if R162 was calm he did not have to be discharged to the hospital. V49 said she was instructed to monitor R162. V49 said R162 was monitored every fifteen minutes for three days. V49 said R162 was calm. V49's Progress note dated 12/28/2025 (12:49pm) documents: Resident (R162) saying he wants to leave, social service made aware, resident kept under 1:1 supervision.V49's Progress note dated 12/28/2025 (6:42pm) documents: Resident came to the nurse's station verbalized I want to leave, writer asked resident where he wants to leave, he said I just want to go I don't want to stay here. Where is the social worker? Writer informed resident that social worker had left for the day and he was encouraged to call his family and talk to them in order to calm him down, he call his seven year old daughter and was laughing on the phone, hang up the phone and went to his room.V49's Progress note dated 12/28/2025 (7:50pm) documents: Resident came back to the nurse's station again saying l want to go and verbalized desire to harm himself during the interaction with staff saying l want to leave or l will harm myself the statement was taken serious resident was assessed for safety appears so calm not agitated denied having a specific plan or means to harm himself, resident placed on close observation for safety, resident's room checked for any harmful object there was none found, resident encouraged to verbalized his feelings he keeps saying l just want to leave remains under supervision.V49's Progress note dated 12/28/2025 (8:02pm) documents: Resident's doctor called made aware, she gave order to transfer resident to Hospital for observation, resident is under supervision by the nurse's station heard what doctor said he verbalized I am not going to the hospital, I just want to leave here staff provides emotional support while still under supervision. Writer called the DON (Director of Nursing) made aware, resident at this time still sitting by the nursing station under supervision writer had another conversation with resident. He said l just want to go, l don't want to harm myself calm relaxed and communicating with staffs, ate his snack with a cup of juice, took his bedtime medication, resident said l don't have plan to harm myself. l don't want to go to the hospital with a smile on his face. Resident is still under supervision. Doctor notified twice to make aware of resident refusing to be transfer to hospital awaits call back.On 3/6/26 at 11:19AM, V19 (CNA) said, R162 looked sad. R162 was walking back and forth like he did not want to be at the facility. R162 said he wasn't feeling good. V19 said, she felt like R162 needed more monitor than she could provide because his sad look and pacing made her feel uneasy. V19 said R162 needed one to one (1:1) monitor. V19 said R162 verbalized he wanted to leave the facility prior to his jumping out of the window but not on the day of the actual incident.V19 witness statement date 1/6/26 documents: R162 got up and said, he wasn't feeling well, wanted to go to the hospital. R162 reported not feeling well. We went to the day room and we heard a sound. They (facility) already knew he had issues and R162 needed a 1:1.On 3/6/26 at 11:35AM, V20 (Nurse) said, she heard R162 had history of self-harming behavior prior to his incident but did not read R162's medical chart. V20 said, she normally works with R162. R162 paces at night. V20 said, the night of the incident, R162 had his coat on and a bag on his shoulder. V20 said, R162 did not wear a coat or have a bag on the other nights she worked with him when he was pacing. V20 said, residents with a history of self-harming behaviors without an active plan should be monitored every hour.Incident report dated 1/6/26 documents: R162 was pacing the unit throughout the night. When writer V20 (Nurse) notices he was walking back and forth, she asked the CNA to look in the dining room and she didn't see him. V20 then went to look in his room and he wasn't there. We checked all rooms on the units. V20 went to the dining room to look again and noticed the window in the dining room was broken. We looked down and R162 was lying on the ground trying to crawl away. 911 called. Predisposing Physiological Factors: Poor safety Awareness. Predisposing Situation Factor: ambulating without assist. Resident last observed - date time: pacing unit. Notes: Contributing factors include poor safety awareness related to the hospital preliminary evaluation suggests the resident behavior and memory lapse may be related to possible psychosis.On 3/6/26 2:09PM, V38 (Nurse Practitioner) said he felt R162 was trying to leave the building. V38 said he would expect staff to provide one on one monitoring for a resident when displaying behaviors like pacing and voicing wanting to leave the facility. V38 said he would expect staff monitoring until behaviors subsided or can give an (PRN) as needed medication. If they are exhibiting aggressive behaviors, they can try to give an (PRN) as needed medication or send them to the hospital.R162's ambulance run report dated 1/6/26 documents: Clinical Impression: Pain, acute due to trauma. Signs and Symptoms Leg pain, Altered mental status, Back pain, Neck Pain. Injury: Falls- Fall from, out of or through window- fifteen (15ft) - Nursing Home -1/6/26. Blunt Trauma. (Name of crew) dispatched to assist with nursing home patient who jumped out a window. Crew dispatched to assist for the nursing home patient (R162) who jumped out of a window. Hospital paperwork dated 1/6/26 documents: R162 brought in by the ambulance from nursing home for complaint of fall out of window. Per emergency medical service (EMS), R162 threw a small dresser out the window on the second (2nd) story of a building and dove out the window after it, EMS reported 162 landed on his left leg. Upon arrival R162 complained of neck pain, back pain, left leg pain, swelling noted on left ankle. Ortho at bedside splinting R162's ankle currently. Complaint: Trauma Fall.Nursing note 1/6/26 documents: R162 was admitted for diagnosis of closed displaced Pilon fracture of left tibia. (A severe, often comminuted (shattered) break at the bottom of the left tibia (shinbone) involving the ankle joint's weight-bearing surface).The Immediate Jeopardy that began on 1/6/26 was removed on 3/7/26 when the facility took the following actions to remove the immediacy.On 3/6/26, the Administrator initiated the interventions listed below. Education and quality assurance protocol will continue to be conducted and monitored on an ongoing basis until all staff scheduled to work have been educated and demonstrate understanding through return demonstrations and written competency/quiz validation. Education and audits will focus on all staff and direct care staff potentially impacted by the deficient practice, not limited to those involved in the incident.All residents were reassessed for self-harming behavior (Suicidal Screening) started on 3/6/26 and completed on: Completion date: 3/7/26All residents were reassessed for exit-seeking behaviors (Exit Seeking/Wandering/ Elopement Risk Assessment) started on 3/6/26 and completed on: Completion date: 3/7/26A sweep of all potential environmental hazards, including windows unlocked safety equipment, and other means of egress, were secured to prevent unsupervised access. Completion date: 3/7/26An In-service Education Session was initiated on 3/6/26 for all staff for the securing of the facility fire extinguishers. Completion date: 3/7/26An In-Service Education Session was initiated on 3/6/26 for all staff on the importance of recognizing, anticipating and responding to escalating or unsafe behaviors. Completion date: 3/7/26An In-Service Education Session was initiated on 3/6/26 for all staff, on exit seeking behaviors and reporting of any such behaviors. Completion date: 3/7/26An In-Service Education Session was initiated on 3/6/26 for all staff, on routine resident checks/supervision. Completion date: 3/7/26An In-Service Education Session was initiated on 3/6/26 for all staff for change in condition and reporting changes in condition. Completion date: 3/7/26A Quality Assurance Audit Tool for identifying residents with self-harm behaviors, exit-seeking behaviors, potential safety hazards, securing fire extinguishers, routine resident checks, and change in condition was initiated on 3/7/26. Daily audits will be conducted daily by facility department managers on 10 residents per day and all fire extinguishers x 5 days/week x 4 weeks, then weekly for 4 weeks. Audit results will be reviewed in weekly QA and monthly QAPI.Systems, Policies and Procedures:On 3/6/26, the facility Administrator reviewed and revised internal procedures regarding fire extinguishers and the securing of the extinguishers. While no policy changes were required at this time, the following systems were reinforced:Ensure all fire extinguishers are secured with audible alarm to alert staff if extinguishers are removed.Residents exhibiting signs of self-harming behavior are assessed and such behaviors are reported immediately to the nurse, and/or dept manager.Residents exhibiting signs of exit-seeking behaviors are assessed and such behaviors are reported immediately to the nurse and/or dept manager.Staff will be able to identify environmental hazards, including windows unlocked, safety equipment, and other means of egress, are secured to prevent unsupervised access.Monitoring, Audits, QAPI, and Facility Assessment:The Dept Managers will complete audits on self-harm behaviors, exit-seeking behaviors, potential safety hazards, securing fire extinguishers, routine resident checks, and change in condition on 10 residents and all facility fire extinguishers per day, 5 days a week for 4 weeks, then weekly for 4 weeks, using the newly implemented QA tool. Results will be submitted to the QA team and discussed in the weekly QA meeting and monthly QAPI to identify systemic gaps or retraining needsThe QA Committee will evaluate audit data and staff performance trends and adjust procedures as necessary. The Administrator, Medical Director, and Interdisciplinary Team will monitor compliance and policy adherence. An emergency QA review was held on 3/6/26 to address this event.

Based on observation, interview and record review, the facility failed to follow facility policy and infection prevention standards of practice by not conducting contact tracing, failing to immediately conduct testing, implement isolation orders and doffing Personal protective equipment prior to exiting an isolation room after two residents (R1 and R11) and one staff member (V8-Certified Nursing Assistant) tested positive for COVID-19 resulting in resident and staff exposure to COVID-19. This failure has the potential to affect a total of 155 residents at the facility. Findings Include:R11 was admitted to the facility on [DATE] with a diagnosis of ataxia, major depressive disorder, type II diabetes, and hypertension.R11's progress notes document on 3/2/26 that R11 sustained a fall and was sent to the hospital. R11 returned to the facility on 3/2/26 with a diagnosis of covid-19.R11's after visit summary dated 3/2/26 documents under diagnosis Covid-19.R11's census documents: 8/26/25 - 3/2/26 R11 room was on unit XYZ. 3/2/26 -3/3/26 R11 was moved to the second floor and 3/3/26 R11 was moved back to the unit XYZ.On 3/5/26 at 11:27AM, V3 (Infection Preventionist) said they were informed that R11 had tested positive for Covid 19 after a fall that resulted in hospital stay on 3/2/26. R11 returned to facility on 3/2/26. V3 said they reviewed any staff that came into close contact with R11. R11's roommate was tested but no other residents were tested as possible close contacts for R11. V3 said R11 was on unit XYZ, ambulatory in the unit, goes to outpatient group therapy and eats in the common dining room. V3 said no other residents were tested on R11's unit.Facility policy Acute Respiratory Illness Policy Review dated 2/2025 states: Contact tracing in response to a single new case of covid 19: complete contact tracing to identify residents who had close contacts and staff who had higher risk exposure to the newly identified case of covid19. Test all residents and staff identified as close contacts or who had higher risk exposure on day 1, day 3 and day 5. R1 was admitted to the facility on [DATE] with a diagnosis of bipolar, shortness of breath, and congestive heart failure.R1's census sheet documents: 2/28/26-3/4/26 R1 was on the XX floor.R1's progress notes dated 3/2/26 documents: R1 complaints of coughing for the past 2-3 days. R1 noted with wheezing back lower lungs. Positive phlegm with cough and stat chest x-ray ordered. Progress note dated 3/3/26 documents: R1 was out in day program when chest x-ray services came. They will come back in the evening upon R1's return from day program. Progress note dated 3/4/26 documents resident complaints of shortness of breath. Resident was sent to emergency room with chest x-ray results received with possible tuberculosis. Progress note dated 3/4/26 at 11:03PM documents: report received from hospital that R1 is Covid positive. Resident transported back into the facility. New orders received to initiate contact/droplet isolation.R1's physician order sheet dated 3/4/26 documents contact/droplet isolation. There were no other orders for isolation prior to 3/4/26.R1's hospital record dated 3/4/26 documents under diagnosis: Covid19. R1 presented to the emergency department at 5:28 AM on 3/4/26 with shortness of breath and cough and had a chest x-ray that apparently showed active tuberculosis though R1 has no history of tuberculosis. R1 stated that he has been having fevers, chills, shortness of breath and cough with brown-tinged sputum over the past week. SARS-CoV2 RNA testing was positive. R1 was discharged from the emergency department with a diagnosis of COVID-19 on 3/4/2026 at 10:52 PM. On 3/5/26 at 3:38PM, V3 (Infection Preventionist) said cough would be considered a symptom of respiratory disease and was unable to provide any acute respiratory testing prior to R1's hospitalization. V3 said we have not tested any residents on the XX floor. I will check with the consultant to see if we need to test the XX floor.R1's medical record did not document any testing for any acute respiratory viruses.Facility policy Acute Respiratory Illness Policy Review dated 2/2025 documents: Specimens for respiratory outbreaks should be collected immediately after the onset of the illness to identify the cause of the illness. When a resident shows signs of an acute respiratory illness, the following actions will be taken: initiate contact and droplet precautions, conduct a rapid antigen test for covid 19.3. On 3/5/26 at 11:27AM, V3 (Infection Preventionist) said she was notified on 3/2/26 that V8 (Certified Nursing Assistant/CNA) was positive for covid. V3 said they also were informed on 3/2/26 that R11 had tested positive after a fall that resulted in hospital stay. V3 said there were no other residents or staff with covid19. V3 said an outbreak would be 3 cases within 72 hours. On 3/5/26 3:38PM, V3 said there are now three cases of covid, and she was informed today that R1 tested positive. V3 said they still are not considered in an outbreak. V3 was unsure if R1 was back in the building.Facility policy Acute Respiratory Illness Policy Review dated 2/2025 documents: Outbreaks are now defined as and must be reported if three or more residents and/or staff in a facility, who within 72 hours of each other have: Acute Respiratory Illness (ARI) and/or Positive point of care test or laboratory-positive test for a single virus, and at least one of the cases is a resident. Outbreak closure still occurs after fourteen days have passed without additional cases. Testing Plan: Covid 19, influenza, RSV and other respiratory illnesses all have similar and overlapping symptoms. When an outbreak of acute respiratory illness is suspected, testing to determine the etiology of the disease is essential to determine the appropriate precautions needed to control the outbreak and if indicated to implement timely treatment.4. On 03/04/2026 at 3:15 PM V6 (Licensed Practical Nurse/LPN) and surveyor visited R11. R11 was in a two bed room and R11's bed was closest to the door (referred to as bed one). The bed by the window was empty (referred to as bed two). Signage on the door stated, Droplet Precautions and Contact Precautions. Personal Protective Equipment (PPE) was available and donned in the hallway. Upon room entry, the privacy curtain was pulled across the door entryway requiring V6 to move the privacy curtain to enter the room. Garbage receptacles were positioned between bed one and bed two in the middle of the room on the wall opposite the beds in the room. After visiting R11, V6 began to doff PPE in R11's room between bed one and bed two (then requiring V6 to walk past R11 and move the privacy curtain to exit the room). As V6 began to doff the isolation gown, surveyor stopped V6 and questioned V6 about the risk of infection spread if PPE is doffed in the room and V6 then walks past R11 and touches the privacy curtain before exiting the room. V6 stated You are right. It doesn't make sense. V6 moved the trash receptacle to just inside R11's entry/exit door and then doffed PPE. On 3/4/2026 at 3:25 PM V7 (LPN) was interviewed about the donning/doffing process in R11's room. V7 stated We take off PPE (personal protective equipment) in the room near the trash receptacle and then walk out. V7 stated All of the PPE comes off before we leave the room. V7 clarified that that means that the gown, gloves and mask all come off in the room before staff walk out. V7 stated that is the process that V7 and the Certified Nursing Assistants (CNAs) have been following today. V6 was present and asked if the trash receptacle has been between bed one and bed two all day. V7 stated yes. Surveyor asked to speak with the infection prevention nurse. V6 called V3 (Assistant Director of Nursing and Infection Prevention Nurse). V3 presented to the unit and observed R11's room. V3 stated I have told the staff that they should remove their PPE as close to the exit as possible. V3 confirmed that the trash receptacle should not be placed between bed one and bed two because it requires staff to walk past bed one and R11 before exiting the room. V3 stated Maintenance sets up these isolation rooms and nurses don't think that they can move anything. I have educated the nurses. I will reeducate them. 5. On 3/6/2026 at 9:50 AM V27 (Housekeeper) was observed in room ABC with the door open. A Droplet Isolation sign was on the door. The resident (R1) stood in the room and said to the surveyor I have COVID. V27 was observed wearing a surgical mask, gown and gloves. No N-95 or face shield was donned. V30 (Resident Care Coordinator/Nurse) was in the hallway and surveyor asked V30 to observe V27 in the room. V30 stated That is not correct. V27 was called to the entry of the room by V30. V27 stated that the resident is on droplet isolation. V27 stated That means there is something contagious in that room. I should have had an N-95 on. I don't have one on because I didn't look through the drawers (pointing to the personal protective equipment (PPE) three-drawer cart outside of the room). V30 pointed to a face shield on top of the PPE cart and V27 added And a face shield. I should have a face shield on. I wasn't paying close enough attention. Surveyor asked V27 why the PPE is important. V27 stated It's important that I don't catch what they have or spread it to anyone else. V27 doffed the gown and gloves in the doorway and then looked for hand sanitizer in the PPE cart. After opening and closing all three drawers in the PPE cart, V27 stated that there was no hand sanitizer available in the PPE cart. V30 was present throughout the interview and got hand sanitizer from the nurses' station for V27. V30 stated I agree that was inadequate. I will follow up with the Infection Control Nurse and the Administrator now. On 3/6/2026 at 1:56 PM R11 was observed sleeping in bed one of a two-bedroom room. Bed 2 was empty. Signage on the door stated, Droplet Precautions and Contact Precautions. Garbage receptacles were observed to be positioned between bed one and bed two in the middle of the room on the wall opposite the beds in the room. V37 (Licensed Practical Nurse) was interviewed. V37 stated that she has taken care of R11 today and has been in and out of R11's room three to four times today. V37 stated that (CNAs) have also been in the room providing care throughout the day. V37 explained that the signage on the door reminds staff that R11 has a diagnosis of COVID and requires isolation. That means that staff need to wear personal protective equipment (PPE) before going into the room. V37 stated that there is a trash can in the room and when staff finish providing care, they remove their PPE in the room and then exit the room and sanitize their hands. V37 stated All PPE comes off in the room. I stand in front of the trash can. The trash can is between bed one and bed two. V37 and surveyor then spoke with V3 (Infection Prevention Nurse) and asked about the process of PPE removal for residents on contact isolation. V3 stated Staff must remove their PPE as close to the door as possible. When V37 told V3 that the trash cans are between bed one and bed two and staff are removing PPE between bed one and bed 2, V3 stated That is not the correct process. V3 took paper out of V3's desk and stated I can be creative. I am going to cut and x and put it on the floor so nurses know where the trash can goes. V37 stated I wish I would have known that. I have been taking care of R11 all day. I have been in and out of that room at least four times today. I learned something today. It makes sense that we don't want to spread infection.On 3/5/26 at 3:38PM, V3 stated We will retest all of that staff on the XYZ unit on Friday especially since they were taking PPE off in the room. My concern is that they are exposing themselves because they weren't taking off PPE at the door. I told them that the garbage can should have been moved.Policy titled Infection Prevention and Control Program last revised 9/20/2024 stated in part that the mission of the program is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. It is the policy that this facility's Infection Prevention and Control Program (IPCP) is based upon information from the Facility Assessment and follows national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. Facility 671 documents 155 residents at the facility.

Based on observation, interview, and record review, the facility failed to follow its call light policy and ensure call light cords were within reach for 6 residents (R74, R78, R81, R121, R144, and R161) out of 10 residents reviewed for call light accessibility in a sample of 50.Findings include:On 3/3/26 at 10:15 AM, R161 was observed lying in bed. R161's call light cord was observed on the floor next to wall, not within reach.On 3/3/26 at 10:16 AM, 144 was observed lying in bed. R144's call light cord was observed to be twenty inches in length; not within reach.On 3/3/26 at 10:20 AM, R121 was observed lying in bed. R121's call light cord was observed dangling on floor, not within reach.On 3/3/26 at 10:25 AM, R78 was observed lying in bed. R78's call light cord was observed on the floor behind R78's nightstand, not within reach.On 3/3/26 at 10:35 AM, R81 was observed sitting in wheelchair on the left side of R81's bed. R81's call light cord was observed dangling through R81's bedframe at the head-of-bed on the right side of the bed, not within reach.On 3/3/26 at 10:38 AM, R74 was observed lying in bed. R74's call light cord was observed dangling on floor, not within reach.On 3/6/26 at 12:30 PM, V2 (Director of Nursing) stated that call lights should be placed within resident's reach at all times.The facility's call light, use of, policy, dated 09/2020, notes in part, be sure call lights are placed within resident reach at all times.

Based on observation, interview, and record review, the facility failed to provide assistance at least every two hours for four residents (R10, R98, R115, and R145) dependent or require maximum assistance of staff for incontinence care out of four residents reviewed for ADLs (Activities of Daily Living) in a sample of 50. Findings include: On 3/3/26 at 10:18 AM, R115 was observed ambulating in the halls. R115's sweatpants was observed to be wet in the buttocks, groin, and upper thighs.R115's MDS (Minimum Data Set), dated 12/8/25, notes R115 is dependent on staff for toileting. R115's BIMS (Brief Interview of Mental Status) score is 5 out of 15, severe cognitive impairment.On 3/5/26 continuous observations were made from 10:10 AM until 1:57 PM on the third unit for R10, R98, R115, and R145. R10 was observed sitting in reclining chair in the resident common area. R98 was observed sitting in wheelchair in dining room. R145 was observed sitting in wheelchair in the dining room.On 3/5/26 during continuous observations, R115 was observed ambulating in halls or sitting in resident common area. During this time, R115 was not checked by staff for incontinence care.On 3/5/2026 at 1:47 PM R145 was wheeled to the hallway by V10 (Activity Director). On 3/5/2025 at 1:54 PM, V11 (Certified Nursing Assistant/CNA) walked past R145 and V10 and stated Are you still waiting for me because I am not rushing and laughed as she reentered room XXX. On 3/5/2026 at 1:57 PM, V11 wheeled R145 into her room. V11 stood in front of R145 and lifted her from the wheelchair to the bed. V11 asked R145 to pee in the diaper before she took it off. V11 removed R145's pants which V11 stated were dry on the buttocks. Surveyor palpated the pants and confirmed that they were not wet. V11 then removed the diaper and described it as heavily wet from urine. V11 stated that R145 urinates a lot so her diaper is usually wet. An approximately 1 inch linear indentation of the skin was noted vertically along the proximal left leg. V11 was asked to describe the mark and stated I don't know how to describe it. It looks like a mark from sitting in the wheelchair.R145's MDS, dated [DATE], notes R145 is dependent on staff for toileting. R145's BIMS score is 2 out of 15, severe cognitive impairment.On 3/5/26 at 2:25 PM, R98 was transported to R98's room for incontinence care. R98 was transferred to bed via a mechanical lift device and two staff members. R98 was observed not assisting with care; two staff members were needed to provide care. R98's brief was saturated with urine.R98's MDS, dated [DATE], notes R98 requires maximum assistance of staff for toileting. R98's BIMS score is 7 out of 15, moderate cognitive impairment.On 3/5/26 at 2:40 PM, R10 was transported to R10's room for incontinence care. R10 was transferred to bed using a mechanical lift device and two staff members. R10's chair had a small puddle of urine and a deep indentation on the seat cushion. R10's sling and clothing were observed to be saturated with urine and dripping urine onto R10's bed during the transfer. Two staff members were needed to provide care.R10's MDS, dated [DATE], notes R10 is dependent on staff for toileting. On 3/5/26 at 5:10 PM, V2 (Director of Nursing) stated that staff should be checking and changing residents every two hours and as needed.

Based on interview and record review, the facility failed to follow its advance directives policy and ensure one resident's (R2) wishes for advance directives are documented in the physician orders of three reviewed for advance directives in a sample of 50.Findings include:On 3/6/26 at 10:45 AM, V32 (Social Services) stated that residents are asked upon admission regarding advance directives. V32 stated that if a resident was admitted with a POLST (physician orders for life sustaining treatment) it would be documented on social services initial assessment and uploaded into the resident's electronic medical record. V32 stated that social services would only notify nursing if there was a change to a resident's code status.On 3/6/26 at 12:30 PM, V2 (Director of Nursing) stated that the nurse is expected to ask the resident and/or resident's representative regarding advance directives. V2 stated that this is part of the admission checklist the nurse completes. V2 stated that the nurse is responsible for reviewing the resident's code status with the physician and obtaining an order and entering order into the physician orders section of the resident's electronic medical record.R2's face sheet notes R2 was admitted to the facility on [DATE]. There is no documentation noted regarding advance directives.R2's uniform do-not-resuscitate (DNR) advance directive is dated 1/25/26.R2's initial social services assessment, dated 2/5/26, notes R2 is DNR.There is no documentation in R2's medical record noting an advance directives care plan was initiated.R2's POS (Physician Order Sheet) does not note an order for R2's code status/advance directive.The facility's advance directives policy, dated 11/2022, notes in part, the resident will have a code status order entered in their physician orders in accordance with advance directives on file. Social service director and/or designee will assess if resident has pre-existing advance directives. If so, copies of any/all documents will be uploaded into electronic medical record and documented in the resident's care plan.

Based on interview and record review, the facility failed to notify the physician of diagnostic test results indicating the need for further evaluation for 1 of 3 residents (R159) reviewed for physician notification. The findings include:R159's face sheet shows diagnosis of type 2 diabetes, hypertension, anemia, acromegaly, personal history of transient ischemic attack and cerebral infraction without residual effects, unspecified osteoarthritis. R159's radiology results report dated 11/13/25 denotes in-part pt (patient) states he fell today on R159's head, pain in head, no bruising. Test procedures X-ray of skull, four views of skull with no prior studies. There is no definite displaced or depressed calvarial fracture by plain film. Nondisplaced fracture not excluded. Head trauma/injury not evaluated by plain film. Intracranial pathology not evaluated by plain film. CT is clearly and strongly recommended. Impressions CT is clearly and strongly recommended. R159's progress notes dated 11/13/25 completed by V17(Registered Nurse/RN) denotes in-part at 9:30pm views of the skull with no prior studies. There is no definite displaced or depressed calvarial fracture by plain film. Nondisplaced fracture not excluded. Head trauma/head injury not evaluated by plain film. Intracranial pathology not evaluated by plain film. CT is clearly and strongly recommended This report was relay to the NP (Nurse Practitioner) for review. R159's progress note dated 11/12/25 at 6:48pm denotes in-part the above resident was observed leaning over while, sitting in the wheelchair. The resident's forehead touched the floor due to his height, without him falling out of the wheelchair. The writer assessed the resident stat, the resident denies pain, no injury, no bruising, no swelling, nor redness to the forehead. The writer informed Nurse Practitioner, Director of Nursing, and Plenary Guardian. The resident is on Neuro checks and awaiting a stat X-Ray to the skull. Staff will continue to monitor the residents.Facility failed to present Neuro checks for R159 upon exit of this survey, request made on 3/6/26 at 3:15pm and 4:02pm.On 3/5/26 at 12:46 V18 (Nurse Practitioner/NP) stated the Nurse did not inform her of the X-ray results for R159, she would have given orders for R159 be sent to the hospital for further evaluation. On 3/5/26 at 3:15pm V17 (RN) said he was notified of R159 X-ray results on 11/13/25, V17 said he informed V18 (NP) of R159 Xray results of the skull. V17 said V18 (NP) told him to monitor the R159 for changes and if there's changes to send him to the hospital. V17 said he did not document the orders to monitor R159 for changes and to send R159 out if there are changes noted. V17 said R159 had a fall. V17 said R159 did not fall when he worked with R159. V17 said monitoring R159 for changes would include checking the vital signs and completing neuro checks. V17 said he checked R159 vital twice that shift, but he did not complete any neuro checks for R159. V17 continued to say R159 did not fall when he worked with R159. V17 clarified that V18 (NP) gave him orders to monitor R159. V17 said he did not contact V18 (NP) for clarification of frequency for monitoring nor did he contact V18 (NP) for clarification on what monitoring consist of. V17 continued to say R159 did not have a fall on his shift. V17 said he did not conduct neuro checks for R159. V17 agreeable that Nursing care is 24 hours a day, and that he would have to continue care of a resident that may not have fallen on his shift. 3/6/26 at 11:11am V2 (Director of Nursing) said V17 should have notified the physician of R159 X-ray results. V2 said V17 (RN) has been disciplined previously for failure to notify the physician. Facility policy titled Change of Condition dated 9/20 denotes in-part the purpose: to ensure that the resident physician/ physician on call / NP and responsible party is kept informed regarding the residents change in condition.

Based on interview and record review, the facility failed to follow their against medical advice policy by not notifying the physician and failing to provide medications for one (R128) resident who left the facility against medical advice for two of three residents reviewed for discharge.Findings include:R128 was admitted to the facility on [DATE] with a diagnosis of type II diabetes with foot ulcer, asthma, bipolar, hypertension and asthma. R128's brief interview for mental status score dated 12/11/25 documents 13/15 which indicates cognitively intact.R128's progress notes dated 3/3/26 at 6:30Pm with a created date of 3/4/2026 07:25:52 documents: Resident left against medical advice (AMA). He was educated on the risks and benefits of continued treatment, verbalized understanding, and elected to leave the facility despite medical advice.R128's progress notes does not document any notification to the physician or nurse practitioner related to R128's leave against medical advice.R128's physician order documents: sertraline, Depakote, Seroquel for bipolar; lisinopril- hydrochlorothiazide for hypertension; metformin for diabetes; gabapentin for frostbite/pain; daily wound treatments to toes related to frostbite.On 3/6/26 at 9:50AM, V26 (Nurse) said she was assigned to R128 on the day he left against medical advice. V26 said she did not call or notify the physician. V26 said she did not give R128 any medications upon discharge. V26 said R128 was wanting to leave prior to her shift and staff were aware.On 3/6/26 at 10:47AM, V32 (Social Service) said social service will have the resident sign against medical advice paperwork upon leaving. V32 said they did not notify any physicians. The nurses are responsible for notifying the physician and providing 2 weeks of medications.V32 said he was not present at the time but recalls R128 requesting to leave earlier in the day.On 3/11/26 at 10:44AM, V33 (Social Service) said she was present at the time of R128 left the facility. V33 said she assisted R128 to sign the against medical advice paperwork. V33 said she did not complete any other assessments at time of discharge. V33 said she did not notify any physician of R128's leaving. V33 was unsure if the R128 received any medications upon discharge.On 3/11/26 at 3:20PM, V2 (Director of Nursing) said when residents leave against advice, staff should provide a couple days of medications. V2 said staff should inform the doctor and document in the progress notes that they were notified. V2 was unsure of any other documents should be completed or given to resident upon leaving against medical advice.Facility AMA release leaving against medical advice policy dated 7/2025 documents: When a resident or the residents legal representative expresses the desire to leave the facility before the attending physician had discharged the resident. Notify the physician /nurse practitioner; notify administrator; notify director of nursing; notify case manager.

Based on observation, interview and record review, the facility failed to ensure Enoxaparin Solution Injection Solution Prefilled Syringe. Injection 0.4ml was available for administration as prescribed. This affected one of three residents (R86) reviewed for available medication.Findings Include:R86's brief interview for mental status dated 12/11/25 documents a score of fifteen which indicates cognitively intact. R86's physician order sheet dated 12/19/2024 documents: Enoxaparin Solution Injection Solution Prefilled Syringe. Inject 0.4ml subcutaneously two times a day related to chronic embolism and thrombosis of unspecified deep vein of lower extremity. Medication Administration Record dated 3/1/2026- 3/31/2026 documents: Enoxaparin Solution Injection Solution Prefilled Syringe; Wednesday 3/4/26 at 6am, 4pm and on 3/5/26 at 6am documents the number nine (9). Chart code/Follow up code nine (9) =other see progress notes. Electronic medication progress note dated 3/4/26 at 6:03am documents: medication not available, awaiting supply from the pharmacy as medication is being reordered, (4:57pm) medication not available and 3/5/2026 at 6:56am unavailable On 3/4/26 at 10:27am, R86 who was assessed to be alert and oriented to person, place and time, said, the facility runs out of R86's blood thinners at times. R86 said, he goes without his prescribed blood thinner for a day or two periodically. R86 said, the facility ran out of his blood thinners this morning. R86 said, he did not get my blood thinner this morning. On 3/4/26 at 12:22pm during observation of the medication cart. R86's Enoxaparin Solution Injection Solution Prefilled Syringe was not in stock/on hand/or available. V7(Licensed Practical Nurse/LPN) said, she did not administer R86's prescribed enoxaparin solution for the 6:00am morning dose. V7 said, she had to order it. Then V7 verified that she placed the order for the wrong medication, she ordered pantoprazole. Then V7 said, R86's medication did not arrive because there's an ongoing insurance issue. V7 denied informing V2 (Director of Nursing/DON) of the ongoing issue. On 3/11/26 at 1:26pm, V2 (DON) said, she was unaware R86 had any problems receiving his blood thinner. V2 said, she received prior authorization from the pharmacy, and the facility was going to pay for R86's medication. V2 said, then she was trying to determine why R86 was on blood thinner injection when he was mobile. V2 said, if there is an order for the medication to be administered she expects the nurse to ensure the medication is on hand to administer it as prescribed. Pharmacy Prior Authorization Request dated 3/5/26 documents: Is the patient (R86) currently treated with the requested medication. Yes. R86 resides in a long-term care facility, has been on this medication since 2024. Medication Storage/Labeling/Packing of Medication policy dated 5/2025 documents: resident-specific medications are placed in a locked cabinet or cart. Medication administration policy dated 9/2020 documents: Medication will be administered in accordance with the established policies and procedure. Drugs must be administered in accordance with the written orders of the attending physician.

Based on observation, interview and record review, the facility failed to follow their medication storage policy by having opened, used, undated and unrefrigerated medication on the medication cart for two of three residents (R3 and R5) reviewed for medication storage. Findings Include:On [DATE] at 3:36pm, during medication cart audit with V26 (Nurse), R3's Insulin Glargine Subcutaneous Solution Pen-injector dispensed on [DATE] was opened, used and not dated. V26 said, R3's insulin should have been dated after opening to ensure expired medication is not given. V26 said, insulin is good for twenty-eight to thirty (28-30) days after opening. R5's Insulin Aspart (with Niacinamide) was observed on the medication cart, new and not used or opened. Refrigerate until opened was documented on the pharmacy bag that held R5's insulin. V26 said, all unopened, unused insulin pens should be refrigerated until they are opened/used. V26 said, R5's insulin should have been in the refrigerator.Medication Storage/Labeling/Packing of Medication policy dated 5/2025 documents: Medication requiring refrigeration are store in a refrigerator located in a locked room accessible only to licensed staff. Individual residents' medication are stored and labeled according to legal requirements, including requirement of acceptable manufacturing practices.

Based on observation and interview, the facility failed to maintain a clean and homelike environment on one of three 3 units reviewed. On the third locked unit, two lounge chairs located in the television room were observed with multiple old, dried stains on the seat cushions and armrests. Findings Include: On 3/4/26 at 10:09am, two filthy lounge chairs with multiple dried irregular shaped circles in the middle of the seat cushion, discoloration, dirt and other stains covering the chair and arm rest were observed in the resident television room on the third (3rd) unit. V6 (Nurse) said, residents sit in those chairs and watch television. V6 said, those chairs have been dirty for a long time. On 3/4/26 at 10:20m, V3 (Assistant Director of Nursing) said, the lounge chairs have stains on the cushion and arm rest. V3 said, some of the stains on the cushion are consistent with dried urine and the other stains are consistent with spills. V3 said, the red stain may be consistent with a red juice spill. V3 said, she would not sit in either lounge chair due to the multiple stains/spills. On 3/4/26 at 10:25am, V41(Housekeeping Director) said, she took pictures a week ago of the lounge chairs and how dirty they looked to see what could be done to clean them. V41 was unable to report where that current picture was, who she gave it to and what the resolution was. On 3/4/26 at 10:30am, R154 was observed sitting on the second lounge chair. R154 was asked how she felt about sitting in a stained chair. R154 refused to speak with surveyor.

Based on observations, interviews, and record reviews, this facility failed to follow its abuse policy and keep its residents free from abuse. This failure resulted in two residents (R2 and R3) having in a verbal altercation that escalated to a physical altercation before staff intervention out of three residents reviewed for abuse in a sample of 3. R3, with a history of physical aggression, hit R2 in the left eye with his fist. R2 sustained a laceration, bruising, and swelling to left eye. Findings include: On 4/16/25 at 2:30 PM, R2 was observed to have left eye swollen shut with ecchymosis (bruising), abrasions above and below left eye. On 4/16/25 at 2:30 PM, R2 stated that R3 has always given him problems. R2 stated that he was getting some more juice after lunch on 4/10, and R3 started yelling at him that he can't have more juice. R2 stated that he told R3 he wasn't the boss. R2 stated that he figured R3 wanted more juice so he threw his cupful of juice on R3 with his right hand. R2 stated that R3 then hit him in the left eye. On 4/16/25 at 1:00 PM, R3 stated that on 4/10 he was sitting outside dining room by the windows. R3 stated that he just finished eating lunch. R3 stated that staff had moved meal carts and drink cart out of dining room and placed them near where he was sitting. R3 stated that R2 had just finished his lunch and self-propelled in wheelchair to the drink cart. R3 stated that the CNA (certified nurse aide) informed R2 not to get drink by himself from cart. R3 stated that R2 started cussing at CNA. R3 stated that he observed R2 spilling drink onto floor while pouring it into his cup. R3 stated that he told R2 to be careful because he was spilling juice on floor. R3 stated that R2 started cussing at him. R3 stated that R2 then threw his cup of juice at his face and upper chest. R3 stated that he reacted by swinging left fist and hitting R2 in the face. R3 stated that staff separated them. On 4/17/25 at 10:50 AM, V5 LPN (licensed practical nurse) stated that V5 heard a commotion while in a resident's room. V5 stated that V5 exited the resident's room to see what was happening and heard R3 state why you threw that on me to R2. V5 stated that R3 had hit R2 prior to her exiting the resident's room. V5 stated that when she came out R2 was moving back in his wheelchair so she pulled him further away from the situation. V5 stated that both residents went to their rooms. V5 stated that R2 informed her that R3 hit him because he threw juice on R3. V5 observed R2's left eye swollen and with laceration below the eye. On 4/17/25 at 11:10 AM, V7 CNA stated that V7 was assigned to R3 on 4/10/25. V7 stated that V7 was providing care to another resident, did not hear anything. On 4/17/25 at 11:20 AM, V6 CNA stated that V6 was assigned to R2 on 4/10/25. V6 stated that V6 was providing care to another resident, did not hear anything. On 4/17/25 at 1:20 PM, V4 (housekeeping) stated that on 4/10/25 V4 was cleaning the residents' dining room. V4 stated that V4 heard R3 telling R2 not to mess with the food carts. V4 stated that V4 observed R2 getting juice off of the cart. V4 stated that V4 observed R2 throw cup of juice at R3. V4 stated that R3 hit R2 in the eye. V4 stated that afterwards R3 went his way. V4 stated that the nurse was passing medications to another resident at the time of the incident. R2: R2's BIMS (brief interview of mental status), dated 2/3/25, notes R2's score is 15 out of 15. R2 is cognitively intact and able to make needs known. R2's risk assessment, dated 11/9/24, notes R2 has a history of abuse towards someone. R2's medical record notes R2 with history of verbal and physical aggression as evidenced by: on 7/15/23, R2 was involved in a verbal altercation with peer. On 9/23/24, R2 was exhibiting socially inappropriate behavior. On 9/27/24, R2 threatened physical aggression and was verbally aggressive to staff member. R2's abuse care plan, initiated 3/28/2023, notes R2 is at risk for abuse related to a diagnosis of major depressive disorder and history of verbal aggression. On 4/10/25, R2 was involved in an altercation, conflict with a peer. On 9/27/24, R2 threatened physical aggression and was verbally aggressive with a staff member. R3: R3's BIMS (brief interview of mental status), dated 3/21/25, notes R3's score is 15 out of 15. R3 is cognitively intact and able to make needs known. R3's risk assessment, dated 3/9/25, notes R3 has a history of abuse towards someone. R3's medical record notes the following: On 9/30/24, R3 became argumentative when staff was redirecting him during smoke time. R3 began swearing and ranting about being in a facility, having to wait for a cigarette. R3 presented with anger and hostility. R3 proceeded down the hall and began arguing with a resident laying in bed in his room. R3 removed himself from the wheelchair and began walking toward the resident while displaying visibly aggressive behavior. On 12/9/24, R3 was displaying abnormal behavior yelling and making delusional statements, getting upset with peer who was on the line for cigarette break. On 12/17/24, R3 was on the smoking patio where he stated a peer was talking to him and he told the peer to stop talking to him, at which time the peer hit him in the jaw, and R3 hit him back. On 1/27/25, R3 was threatening physical aggression towards a peer. R3's behaviors care plan, dated 12/16/24, notes R3 may get angry easily. R3 has difficulties managing his anger/frustration as evidenced by aggressively walking towards others, threatening harm, and arguing with a peer. R3's behaviors care plan, initiated 1/27/25, notes R3 has the potential for physical aggression towards others. Poor impulse control. R3's identified offender care plan, initiated 2/20/25, notes R3 has been assessed as a potential risk towards other residents. This facility's abuse investigation involving R2 and R3 was reported to the State Surveying Agency on 4/10/25 at 3:22 PM. The initial reports notes no physical contact made between R2 and R3. Staff interviews: V4 stated that he was cleaning the dining room and R2 was trying to go to the food carts after everyone was through eating. R2 initiated a conversation with R3. R2 said something R3 didn't like, R2 threw cup of juice on R3, R3 jumped up and hit R2. Both residents were in wheelchairs, both were by small elevator across from R2's room. V4 stated that R3 left and went to his room. V4 stated that R2 went to his room. V4 stated that he was coming out of the dining room when all of this happened. V4 stated that they heard the commotion, none of the staff came over. The nurse came over to R2 to get his statement. V5 stated she came out of another resident's room and heard R2 and R3 arguing. V5 stated that she heard R3 say 'why you throw that on me'. V5 stated R2 and R3 were moving away from each other. R2 stated that he was getting juice and R3 came over and said 'you ain't supposed to do that' and R2 responded 'who made him the boss and he threw the juice on R3. R3 stated that R2 was pouring juice in his cup. R3 stated that he told R2 be careful, you shouldn't be doing that. R3 stated that it got to the point where R2 poured his juice on R3 and R3 ended up swinging at R2. R3 stated that is when staff intervened. This facility's abuse policy, dated 03/2025, notes this facility affirms the right of our residents to be free from abuse.

Based on observation, interview, and record review, the facility failed to follow their maintenance and housekeeping policy and procedures by not maintaining a clean, sanitary, and comfortable environment that is in good repair and by not providing a television for a resident who had been moved to a new room for three weeks. This failure applied to nine of nine residents (R17, R36, R100, R104, R108, R112, R119, R143, and R303) reviewed for environment. Findings include: On 4/6/2025 at 1:05PM, R303 said the facility is overall unsanitary and not in good condition. R303 said I admitted to the facility on [DATE] and many things in my room are broken or not in working condition. The sheets were stained, my television does not work, the bathroom looks as if there is water damage on the floor, and there is a hole in my wall next to my bed. At 1:15PM, R303 and R100 were interviewed in their room. Observed hole next to R303's head of bed, handles missing off of wardrobe, and large red stain on privacy curtain between beds. R303 and R100 said it gets so hot in here and the windows do not open. Observed windows knobs to be off and not in working order. Touched window curtain surface and noted to have dust and grime on curtains. Observed R303 television to be mounted on wall with chord hanging and not plugged in. R100 said this television has been broken since August of 2024. R303 said it is upsetting because I just admitted Friday and they placed me in this room with nothing in working order. Observed bathroom between residents room to have broken grab bar on one side of toilet. Also observed baseboard on wall to be missing and water damage noted to wall. It is to be noted that R100, R303, R112, and R119 all share a bathroom. R100 said this has been like this for a very long time. Sometimes when I go to the bathroom, water drips on my head from the ceiling. Observed ceiling tiles to be discolored and dark yellow in color. On 4/7/2025 at 12:30PM, V5 (Regional Maintenance Support) said rooms should be in working order before new residents are admitted . Maintenance logs dated January 2025-April 2025 show multiple maintenance requests that are outstanding and not resolved. 40718 R36 is a [AGE] year-old male with a diagnoses history of Paranoid Schizophrenia, Bipolar Disorder, Generalized Anxiety Disorder, Unspecified Mood Affective Disorder, Psychotic Disorder with Hallucinations, Restlessness and Agitation, Depression, and Violent Behavior who was admitted to the facility 07/26/2024. On 04/06/25 at 10:41 AM R36 stated they don't clean his room enough. Observed holes in R36's wall and he stated he would like them repaired. Observed chipped paint on the floor by R36's window, the pin board over R36's bed with multiple stains, his room sink with stains and residue around the faucet and on the back of the sink, his room radiator vents with buildup, his clothes cabinet with multiple stains and spills, and his room floors dirty. R104 is a [AGE] year-old female with a diagnoses history of Dementia, Schizophrenia, and Bipolar Disorder who was admitted to the facility 10/13/2022. On 04/06/25 at 10:46 AM Observed a urine odor in R104's room, observed the window next to R104's bed with splattered insulation foam and with multiple broken blinds. R104 stated she would like the blinds repaired and the foam in her window fixed if they can. Observed holes in the wall behind R104's bed. Observed the baseboard next to R104's bathroom peeled from wall. R108 is a [AGE] year-old male with a diagnoses history of Recurrent Major Depressive Disorder who was admitted to the facility 12/14/2022 On 04/07/25 at 08:25 AM R108 stated there are holes in the wall in his room and maintenance is aware of it. On 04/07/25 at 08:53 AM Observed R108's bathroom vent with heavy buildup of dust, observed holes and cracks in the wall underneath the window in R108's room. R17 is a [AGE] year old male with a diagnoses history of Schizophrenia, Schizoaffective Disorder, COPD, Spinal Stenosis, and Heart Failure who was admitted to the facility 09/18/2017. On 04/07/25 at 08:56 AM R17 pointed at the baseboard behind his bed. Observed the baseboard behind R17's ed was peeled away from the wall. R17 communicated that the maintenance man knows but hasn't done anything. On 04/07/25 at 08:59 AM Observed the floors underneath the sink in R36's room cracked and with buildup and with the baseboard peeling. Observed R36's clothes cabinet and sink with the same stains and spills present yesterday. Maintenance log reports from December 2024 - April 2025 documents on unknown dates R17's room has detached wall base board, missing window screen and window won't close, has a cracked sink and hole in the wall, and the light not working, R36's room has holes in the wall, R104's room has missing wall baseboard. On 04/08/25 at 03:09 PM V4 (Maintenance/Building Manager) stated he has been in the facility approximately 3 weeks. V4 stated V26 (Painter) typically patches holes, baseboards, and paints in residents rooms. V4 stated he uses the nurses logs to identify when these repairs are needed. V4 stated he walks around daily and performs preventive maintenance checks but doesn't observe all the residents rooms. V4 he mainly observes the halls, main doors, windows, exit doors, fire systems, and nurses station when performing these maintenance checks. V4 stated sometimes repairs are not listed in the logs and the nurses will call and report needed repairs. On 04/09/25 at 11:14 AM When asked by surveyor how often are resident's rooms cleaned? V1 (Administrator) responded, daily. When asked by surveyor should there be any visible spills, stains, or residue left on the residents room furniture, sink, or floors after housekeeping for more than one day? V1 responded, no. When asked by surveyor how often are bathroom vents cleaned? V1 responded, daily and as needed. When asked by surveyor should there be any visible signs of heavy buildup at any time on a residents bathroom vent? V1 responded, no. When asked by surveyor if the resident's room's show signs of disrepair such as exposed foam around their window seals, broken blinds, peeling or chipped paint, baseboards peeling from the wall, holes or cracks in the walls etc.; should staff be aware of this and should they report this to maintenance? V1 responded, yes. When asked by surveyor should maintenance monitor resident's room condition and identify these signs of disrepair? V1 responded, yes. On 04/09/25 at 12:36 PM When asked by surveyor if there should be any detectable unpleasant odors in residents rooms? V1 (Administrator) responded, not unless there is a recent happening like an incontinence episode and recent rounds. When asked by surveyor what should be done to remedy or prevent unpleasant odors? V1 responded, proper attention to the situation for example clean up the episode. 40920 R143 is [AGE] years and was admitted to the facility on [DATE], medical history includes, but not limited to hypertensive heart disease with heart failure, syncope and collapse, orthostatic hypotension, type 2 diabetes, insomnia, hyperlipidemia, other seizures, essential primary hypertension, etc. On 04/06/25 11:30AM, R143 was observed in his room, awake and alert and stated that he is doing okay but certain things are not going okay, he was moved to this new room about three weeks ago and has been asking for a television. Resident stated that all he does is stare at the blank walls, he have spoken to several staff but gets a run around, Resident said that last week a staff came and told him that all he needed was to find a mount for a television and he will come back, staff never returned, R143 said he is tired of asking and it is so frustrating. On 4/7/2025 at 9:40AM, V4 (Maintenance Manager) said that he is aware that R143 needs a television in his room, resident informed V4 last week and he informed his supervisor who completed a work order and ordered a new television. Currently they do not have any television in the facility. V5 (Regional Maintenance Director) who came to the room while surveyor was speaking to V5 said that V4 is new and still in training, V5 normally go to the facilities to train new staff and have not been to this facility to train V4, there is another maintenance staff that work with V4 but that one is new too. On 4/7/2025 at 12:25PM, V5 (Regional Maintenance Director) was observed in resident's room with a television mounted on the wall. Surveyor asked V5 when the television arrived, and he said that V4 is not really familiar with where to find some items. V5 said that he was cleaning the storage and found 2 televisions, there is no work order for the resident's room, but he will put in a work order today. The facility's Maintenance Policy and Description of Building Manager Responsibilities dated 03/2014 states in part but not limited to the following: Building Manager will assure that maintenance services are provided to all areas of the building, grounds, and equipment in a prompt and professional manner. The Building Manager is responsible for assuring that the following functions are performed as necessary for the safety and comfort of residents, staff, and visitors: Maintaining the building in good repair and free from hazards. Establishing priorities in providing repair service. Providing routinely scheduled maintenance services to all areas. The facility's Housekeeping Policy received 04/08/2025 states: The facility will follow an effective plan to maintain a clean, safe, and orderly environment. Unpleasant odors within the responsibility of Housekeeping and Maintenance will be controlled through proper cleaning of the environmental surfaces and proper ventilation. Floors will be maintained as clean and free of slipping and tripping hazards.

Based on observation, interview, and record review, the facility failed to ensure that staff administered scheduled medications on time for residents. This failure affected five (R65, R71, R79, R112 and R119) of five residents reviewed for medication administration and has the potential to affect all 31 residents in the west wing of unit 1 at the facility. Findings include: On 4/6/2025 at 10:30AM, observed medication administration for R71 with V25 (LPN). R71 received among other treatments, Keppra 500mg by mouth and Lamotrigine 100mg 1 tablet by mouth. Per physician order, both medications were scheduled to be given two times a day at 0900 and 1700. Medication administration record (MAR) showed both medications signed of at 0900, medication audit dated 4/6/2025 showed that both medications were given at 10:40AM. On 4/6/2025 at 10:40AM V25 was observed administering medication to R79. Resident received among other treatments: Metformin 100mg tablet, Metoprolol 100mg tablet, Gabapentin 300mg tablet, Hydralazine 25mg tablet, Enalapril 10mg tablet, Cyclobenzaprine 5mg tablet, Apixaban 5mg tablet and Magnesium Oxide 400mg tablet. Review of physicism order showed that these medications are scheduled or two or three times a day, all medications are documented as given at scheduled 0900 in MAR. Review of medication audit showed that these medications were charted between 11:01 and 13:50. On 4/06/2025 at 11:00 AM R71 said, I have received my medications late today, and I take medication for seizures. I am concerned about my health and want my medication on time. On 4/06/2025 at 11:10 AM R79, said, I received my medications late today, I take blood pressure medications and I want to keep my blood pressure down. Ob 4/6/2025 at 12:45PM, surveyor asked V25 how many residents she still must give medications and she said four residents, Surveyor asked V25 if she could ask for help when she is running behind with medication administration and she said yes. R65 received the following medications from V25, Lasix 20 mg tablet two times a day, Dicyclomine 10 mg tablet three times a day, Gabapentin 300mg three times a day, The above medications were signed off as given at 0900 per MAR, medication audit for 4/6/025 showed that they were administered at 12:54. R112 received the following medications as documented in MAR, Flonase allergy relief, 1 [NAME] in both nostrils twice a day, Metoprolol 25mg one time a day, Procardia XL extended-release tablet, by mouth one time a day. These medications were signed off as given at 0900, medication audit showed that they were given at 12:01. R119 received the following medications from V25, Clopidogrel 75 mg tablet one time a day, Carvedilol 25mg by mouth two times a day, Furosemide 40mg by mouth two times a day, metformin 500mg by mouth two times a day, Hydralazine 25mg by mouth three times a day, Ofloxacin ophthalmic solution, one drop in both eyes, four times a day, Ketorolac Tromethamine ophthalmic solution , on drop in both eyes four times a day, Prednisolone ophthalmic solution 1 drop in both eyes four times a day. These medications were signed off as given at 0900, medication audit review showed that they were charted at 13:00 to 13:18 by V25. On 4/8/2025 at 3:15PM V2 (DON) said that late medication administration is unacceptable and there should not be any reason for that, medications should be given an hour before or an hour after, giving medication ordered two or three times a day late will affect the next dose that will be administered too close together. V2 added that she constantly in-service the nurses about giving medication on time, if a nurse is running late, they can ask for assistance. V2 also said that when a medication is administered late, a prudent nurse should notify he physician and get an order to reschedule or skip the next dose. Medication administration policy dated 03/2021 states in part: to ensure that medications are administered safely as prescribed. Under procedure, the document states #8. Medications are administered within (1) hour of prescribed time. Unless otherwise specified by the physician, routine medications are administered according to established medication administration schedule.

Based on observation, interview, and record review, the facility failed to ensure that two residents (R88 and R115) were able to operate their call light by placing it was within reach. Findings include: R88 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R88 has multiple diagnoses including but not limited to the following: COPD, heart failure, hemiplegia, type II DM, HTN, depression, ESRD depending on renal dialysis, and history of falling. Per MDS (Minimum Data Set) dated 3/5/2025, R88 has a BIMS (Brief Interview of Mental Status) of 13 meaning resident is cognitively intact. On 4/6/2025 at 11:20AM, R88 said currently my call light chord is broken and I cannot use it when I am laying in bed. This surveyor observed call light chord to be disconnected from call light and hanging from bed. R88 said this has been like this for a week and the staff is aware. R88 care plan intervention dated 10/4/2024 shows placement of call light within reach. R115 is a [AGE] year-old male who originally admitted to the facility on [DATE]. R115 has multiple diagnoses including but not limited to the following: type II DM, peripheral vascular disease, CHF, CKD III, acquired absence of right and left leg below knee, and adult failure to thrive, osteoarthritis, and impingement syndrome of shoulders. On 4/7/2025 at 11:15AM, R115 was observed to be in bed with call light chord hanging from call light and not within reach. V21 (Certified Nursing Assistant) said the call light should be within reach and on the resident to make sure he is able to call for help when needed. R115 care plan intervention dated 7/10/2023 shows placement of call light within reach. Use of Call Light Policy dated 9/2020 states in part but not limited to the following: Procedure: Be sure call lights are placed within resident reach at all times.

Based on observation, interview, and record review, the facility failed to ensure that staff provided post-surgical wound care according to current physician's orders for 1 of 3 residents (R2) reviewed for wounds in the sample of 6; and failed to follow their facility policies on following physician orders for surgical wound care. Findings include: R2's face sheet indicated that resident admitted to the facility on [DATE] with a past medical history not limited to: chronic kidney disease, hypertension, convulsions, history of transient ischemic attack and cerebral infarction, major depressive disorder, and open wound to left foot. On 02/22/2025 at 11:37 AM, R2 was observed sitting in his wheelchair in his room wearing a slipper to his right foot, and a thick black sock to his left foot. R2 indicated that he had surgery last week and has a wound to his left foot that is painful at times. R2's Podiatrist Note by V7 (Wound Care Physician) dated 01/22/2025 at 11:42 documented that R2 underwent outpatient surgery today: excision of bone spur [left] first metatarsal. He tolerated the procedure and anesthesia well and will be discharged back to the facility today. Post op wound care orders have been entered into [electronic health record] and sent to (V6) wound nurse. Right foot should be elevated while the patient is at rest in bed. The patient may ambulate as tolerated in his post op surgical shoe and take [pain medication] as ordered for pain. Keep dressing clean dry and intact until first nurse dressing change on 01/27/2025. Call [V7] with any questions. Podiatrist Note by V7 (Wound Care Physician) dated 02/21/2025 at 16:03 documented that R2 was seen and chart reviewed .Upon removal of the silver alginate and bordered gauze dressing to the left foot there is a 2-1/2 cm (centimeter) x 4 cm stage II ulceration deep to subcutaneous tissue at the dorsal aspect of the first metatarsophalangeal joint .Following verbal informed consent I cleansed the wound thoroughly with [antiseptic povidone-iodine] solution. I then performed a thorough lavage with [antiseptic povidone-iodine] 10% solution. Next I applied collagen powder silver alginate wound pad gauze rolled gauze and [self-adherent wrap] with mild compression. I recommend this wound care be repeated every 24 hours until my next follow-up the patient in 5 days .I will also place an order with wound care nurses . On 02/22/2025 at 3:42 PM, V7 (Wound Care Physician) said that R2 has wound issues and delayed healing due to non-compliance with not wearing his surgical shoe, not elevating his leg, and continues to smoke. V7 indicated that R2 continues with antibiotic therapy, will have a doppler study done, and be seen by a vascular team next week. V7 added that R2's wound has slightly improved from 02/12/2025 to when he assessed the wound on 02/21/2025 and he ordered a new daily wound care treatment for R2. On 02/23/2025 at 09:20 AM, V6 (Wound Care Coordinator) performed wound care to R2's left foot. V10 (Wound Care Tech) was also present and removed the soiled dressing. V6 then cleansed the foot wound initially with an antiseptic povidone-iodine solution applied to a gauze pad, then cleansed the wound with normal saline applied to a gauze sponge. V6 then covered the wound with a sheet of silver alginate, applied a thin layer of 2x2 gauze pads over the alginate, then wrapped R2's wound and foot with a gauze bandage roll and secured the end of roll with medical tape. Review of R1's current physician's orders on 02/23/2025 at 10:00 AM showed the following wound care orders: clean left foot wound every 24 hours with [antiseptic povidone-iodine] solution, apply collagen powder, silver alginate, [prescription antibiotic] 2% ointment, gauze and self-adherent wrap or ace bandage for mild compression start date 02/23/2025 0900; apply mupirocin external ointment 2% to left foot wound topically one time a day with silver alginate and collagen powder daily, start date 02/23/2025 09:00; apply [alginate] to left medial foot topically every day shift for wound care, clean with [antiseptic povidone-iodine] solution, apply silver alginate, cover with abdominal pad, wrap with gauze bandage roll, then mild compression with self-adherent wrap or ace bandage and apply to left medial foot topically as needed for soiled/dislodged dressing, start date 2/21/2025 13:00; On 02/23/2025 at 12:00 PM, when asked about the observed wound care to R2's left foot and why it differed from the current physician's orders, V6 (Wound Care Coordinator) said V7 (Wound Care Physician) entered a new wound care order yesterday. After review of R2's active physician's orders with surveyor, V6 said that she followed the wound care order that popped up on the TAR (treatment administration record) and did not see the new order on the treatment record for collagen powder or antibiotic ointment but would have applied them if she would have seen it. At 12:04 PM, V6 (WCC) said that she misread the order, and will call V7 to inform him of what she did, and see if V7 wants her to provide wound care again for R2 to apply the missed medications. V6 (Wound Care Coordinator) added that she will have V7 (Wound Care Physician) clarify R2's wound order moving forward. Review of R2's treatment administration record for February 2025 showed on page 1 the following order: apply 2x2 silver alginate to left medial foot topically every day shift for wound care. Clean with [antiseptic povidone-iodine solution], apply silver alginate, abdominal pad, wrap with [rolled stretch gauze], then mild compression with self-adherent wrap or ace bandage wrap. Order Date-02/21/2025 1300. On 02/23/2025 at 12:10 PM, V6 (Wound Care Coordinator) said that she spoke with V7 (Wound Care Physician) who indicated the treatment did not have to be performed again but to continue with the previous treatment order tomorrow. On 02/23/2025 at 12:54 PM, V2 (Assistant Director of Nursing) said her expectation is for nurses to follow physician orders according to the physician order sheet (POS), orders should be carried out appropriately, and nurses should obtain a physician's order if changes were made to the current order. When asked if not following physician's wound care orders could contribute to a delay in wound healing, V2 (ADON) said yes, and that nurses should be following the direct physician order. The facility Wound Care (Surgical) policy dated 03/04/2021 reads in part: wound treatment will be performed as per MD (Medical Doctor) orders. Utilize clean/aseptic technique .Undress and expose only one area at a time .Change dressings in order from clean to dirty .Follow MD orders and apply new dressing . Physician's orders for medications and treatments policy dated 06/2022 reads in part: medications will be dispensed and subsequently administered to a resident only upon the clear, complete and signed order of a lawfully authorized prescriber. On 02/24/2025 at 09:45 AM, V1 (Administrator) provided education provided to staff regarding physician's orders for medications or treatments and counseling provided to V6 (Wound Care Coordinator) dated 02/23/2025 for not following physician's orders when providing wound care to resident.

Based on interview and record review, the facility failed to utilize a gait belt during a transfer for a resident (R2) that requires substantial/maximum assistance for one out of three residents reviewed for falls in a total sample of three. This failure resulted in R2 suffering three fractured ribs after falling to the floor during the transfer. Findings Include: A Nursing note dated 11/13/24 at 1:11PM documents the nurse was notified by the wound care aide that R2 was complaining of exaggerated pain to the right side. R2 stated while being transferred to the wheelchair during the morning get up, balance was lost and subsequently R2 fell to the floor. The nurse was not aware of the incident prior to R2 reporting it. The nurse practitioner was notified and sent R2 out for further evaluation. A Nursing note dated 11/13/24 at 8:41PM documents R2 returned back from the hospital with a diagnosis of closed fracture of multiple ribs. The Hospital Records dated 11/13/24 document R2 came to the hospital with a chief complaint of fall. R2's emergency department diagnosis is listed as close fracture of multiple ribs, unspecified laterality. The x-ray of the ribs documents there are questionable fractures involving the interior aspect of ribs eight, nine, and ten on the right. On 12/3/24 at 1:58PM, R2 stated R2 had a fall last month while being transferred causing R2 to break ribs on the right side. R2 was not aware how many of the ribs were fractured. R2 reported a CNA (V8) tried to transfer R2 from the bed to the wheelchair but dropped R2 and R2 fell on the floor next to the bed. R2 reported R2 has the left arm and leg locked due to arthritis so R2 can stand and pivot to the wheelchair only. R2 stated R2 normally will talk the staff members through how to properly transfer R2 but V8 refused to listen to R2. R2 denied a gait belt was used during the transfer. R2 reported R2 sat on the side of the bed and V8 grabbed R2 under the left arm to stand R2 up. R2 said, It happened so fast. I don't really know what caused the fall, but I was up then I was down on the floor. R2 denied being slid down V8's leg and denied asking to be put on the floor. R2 stated when R2 began falling, V8 let go it R2. R2 denied having pain right away but told a staff member a couple hours later R2 began to feel pain in the side. R2 reported V8 and another staff member (V10 - CNA) got R2 back up in the wheelchair after the fall. R2 mental status was assessed and R2 reported the location, type of building, president, and R2's birth date correctly. R2 stated the date was 12/2/24. On 12/4/24 at 11:36AM, V8 (CNA) stated V8 was working the night shift and was getting R2 up around 5AM. V8 reported R2 needs a one person assist and is able to stand and pivot to the wheelchair. V8 stated V8 got R2 sitting up on the side of the bed and had R2 stand up and go to pivot to the wheelchair which was placed next to the bed. V8 reported while R2 was pivoting, R2 got leg spasms and could no longer move. V8 stated V8 asked R2 if R2 wanted to be set back down on the bed or on the floor, and R2 said R2 wanted to be set down onto the floor. V8 stated V8 slid R2 down V8's leg and laid R2 down on the floor. V8 reported going to get another CNA to help R2 up off the floor. V8 stated V8 then told V11 (Nurse) what happened. V8 reported R2 is alert and oriented times three. V8 stated both CNA's got R2 up off the floor by picking R2 up under R2's arms. V8 reported a gait belt should be used with every transfer. V8 stated a gait belt should be placed snuggly around the resident's lower chest area and the finger method should be used to test if it is on tight enough. V8 denied R2 reporting any pain after being lowered to the floor. The surveyor then asked how R2 ended up with fractured ribs if R2 was gently lowered to the floor, and V8 was unable to answer this question. When the surveyor asked V8 to describe a step-by-step process of how R2 was transferred that day the eight did not mention putting on a gait belt. The surveyor had to directly ask if a gait belt was placed on R2 to which V8 replied, yes. On 12/4/24 at 11:50AM, V9 (Nurse) stated a wound care aid reported to V9 that R2 was having pain on the side. V9 reported V9 went to assess R2 and R2 told V9 that R2 had a fall, but R2 did not want to report it earlier because R2 did not want to get anyone in trouble. V9 denied asking R2 what happened during the incident. V9 reported immediately telling V13 (DON) and V1 (Administrator) what R2 told V9. V9 stated V14 (Nurse Practitioner) was then called and R2 was sent out to the hospital for an x-ray. V9 reported R2 did have fractures per the hospital. V9 stated R2 first reported the pain around 12 PM. V9 reported R2 normally complaints of leg pain but pain on the side is new onset pain. V9 stated or two is alert and oriented times three and has the ability to verbalize what happened during the incident. V9 denied being notified by any staff from the previous shift that R2 fell . On 12/4/24 at 12:00PM, V8 then called the surveyor back on the phone and reported that R2 did not have a gait belt on during the fall. V8 stated R2's leg began giving out, and V8 tried to slide R2 down to the floor as best as V8 could. V8 reported staff are always supposed to use a gait belt when transferring residents. V8 was not able to answer why a gait belt was not used during this transfer. On 12/4/24 at 2:04PM, V10 (CNA) stated V10 did not witness the fall, but V8 came to ask V10 to assist with getting R2 back into the wheelchair. V10 reported R2 was lying on the floor when V10 entered the room. V10 stated both CNA's (V8 and V10) picked R2 up under the arms and got R2 back into the wheelchair. V10 denied R2 stating how the fall happened and V10 denied asking how the fall occurred. V10 reported V8 only told V10 that R2 asked to be laid on the floor during the transfer. V10 stated a gait belt should be used for any transfer for safety reasons. V10 reported R2 is a one person assist with transfers and is not able to walk. V10 stated when R2 returned from the hospital, R2 had fractured ribs. V10 denied R2 having a gait belt on when V10 first entered the room. On 12/4/24 at 2:18PM, V11 (Nurse) stated V8 reported to V11 that R2 almost had a fall. V11 reported going to check on R2 and R2 was sitting in the wheelchair when V11 entered the room. V11 stated R2 told V11 that R2 got weak in the legs and R2 told V8 to sit R2 on the floor. V11 reported R2 was given scheduled pain medication at that time but did not report any other pain. V11 denied V8 or R2 using the word fall when describing what happened. V11 stated anytime a resident is on the floor, it is to be considered a fall. V11 reported V13 educated V11 on this topic. V11 denied V8 or R2 telling V11 that a gait belt was not being used during the transfer. On 12/4/24 at 2:25PM, V12 (Wound Care Nurse) stated R2 did not report any pain during wound care treatments that morning. V12 reported the wound care aid was doing rounds in the afternoon when R2 reported pain on R2's side. V12 stated this information was reported to V9, and V9 handled it from there. On 12/5/24 at 9:49AM, V13 (DON) stated during the investigation, the wound aid told V9 that R2 was complaining of pain on R2's side. V13 reported interviewing R2 and R2 told V13 that R2's left leg started giving out so V8 slid R2 down V8's leg onto the floor. V13 stated V8 told V13 that R2 was having leg spasms and V8 slid R2 to the floor per R2's request. V13 stated V8 got another CNA to get R2 up off the floor and then told V11 what happened. V13 reported later R2 did complain of pain for the next shift. V13 stated within the past couple days V8 admitted to the administrator that a gait belt was not being used during the transfer. V13 reported gait belts are part of the CNA uniform and should be worn at all times during their shift. V13 stated staff should never transfer any resident without a gait belt because it is easier to control the resident if something happens if the gait belt is on. On 12/5/24 at 5:01PM, V14 (Nurse Practitioner) stated V14 was told that R2 was lowered to the floor as R2 was being transferred. V14 denied that facility staff notified V14 that a gait belt was not being used during the transfer. V14 reported the hospital x-ray report showed R2 had possible rib fractures so the actual imaging was requested but the hospital has not sent over that imaging yet. V14 stated all residents must have their gait belts on when being transferred for resident's safety. V14 said, That is like CNA 101, when asked when should a resident be wearing a gait belt during transfers. A Nursing note dated 11/18/24 documents R2 is alert and oriented to person, place, and situation with a BIMS score of 15. R2 requires partial to moderate assistance with the wheelchair. R2 reported that while being transferred to the wheelchair, R2 lost balance and fell to the floor on the previous shift. R2 reported pain to the right flank area it was given pain medication and an ice pack. The physician was notified and sent to the hospital. R2's fall is being investigated for increased weakness. A new intervention is to have therapy evaluate and ensure gait belt is used during transfers. The Final Incident Report dated 11/18/24 documents R2 reported being transferred to the wheelchair when R2 begin to have leg spasms and the leg started to give out. R2 stated that because of this the CNA (V8) attempted to lower R2 to the floor, which caused an unintentional change in plane resulting in a fall. Per V8, R2 was unable to assist with the transfer as typical and began having leg spasms. As a result of R2 not being able to continue to assist with the transfer, V8 had to lower R2 to the floor. It is coded that R2 require substantial/maximal assist, which was the type of assistance given at the time of the transfer. R2 has not had any previous falls involving a transfer. R2's fall is attributed to gait imbalance, and anticipated change in the ability to transfer and weakness. A head to toe assessment was completed after R2 complained of pain to the right link area. R2 was sent to the emergency department for x-rays and returned with a diagnosis of right intercostal rib fracture. The Fall Risk assessment dated [DATE] document score of a five indicating R2 is at risk for falls but not considered a high fall risk. A score of 12 or higher indicates a high fall risk. The Restorative Nursing assessment dated [DATE] documents R2's priority restorative programs are transfers and bed mobility/walking. The transfer program indicates the goal is R2 will tolerate staff assistance into getting in and out of the wheelchair. R2 has maintained the ability to perform ADLs. There is no documented decline in R2's mobility. The Care Plan dated 4/18/23 documents R2 has an ADL self-care performance deficit secondary to weakness, being a fall risk, pain due to leg wound, and history of falls. An intervention includes to provide the needed level of assistance and support to complete activities of daily living. This care plan also documents R2 is at risk for falls secondary to history of falls, weakness, bilateral lower extremity wounds, pain, and poor balance. R2 requires assistance from staff for transfers due to decrease muscle strength and weakness. Interventions include to explain the task prior to starting. Give simple step-by-step directions for transfer to assist R2. R2 will stand pivot and transfer with maximum assist from the bed to the wheelchair. The intervention documented after the fall on 11/13/24 is to place the gait belt under the fractured ribs. The Care Plan dated 11/13/24 documents R2 at risk for injury: a fall occurred. Interventions include to assess R2 to identify any injuries from the fall and to follow facility post fall policy regarding monitoring for signs and symptoms of injury. The Care Plan dated 11/14/24 documents R2 has limited transfer skills. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score as 15 (no cognitive impairment). Section GG of the MDS indicates R2 has upper and lower extremity impairments on both sides and uses a wheelchair. R2 needs substantial/maximal assistance for bed mobility and transfers. This means the helper does more than half the effort. The helper lifts or hold the trunk or limbs and provides more than half of the effort. The policy titled, Management of Falls, dated 08/2020 documents, .6. Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards. The policy titled, Gait Belt/Transfer Belt, documents, To assist with a transfer or ambulation. A gait belt will be used with weight bearing residents who require hands on assistance .2. The gait belt is securely clasped around the resident's waist unless contraindicated. The policy titled, Transfer Techniques, dated 02/2022 documents, Purpose: To safely transfer the resident from bed to chair or from one location to another. Transfer from bed to wheelchair .5. Have resident sit on the edge of the bed with feet crossed and resting on the floor. He/she may use this as an opportunity to practice sitting balance. Put on gait belt and shoes .7. Place gait belt around resident's waist unless contraindicated.

Based on observations, interviews, and record review the facility failed to protect a cognitively and visually impaired resident's (R1) right to be free from physical abuse from another resident (R2) with known history of aggressive behavior for 1 (R1) of 3 residents reviewed for abuse in a sample of 10. This failure resulted in R1 being physically assaulted by R2. The Immediate Jeopardy began on [DATE] at 04:10 AM when R2 physically assaulted R1 which resulted in R1's emergent hospitalization . V1 (Administrator) was notified on [DATE] at 11:14 AM of the Immediate Jeopardy. The facility presented an acceptable removal plan, and the immediacy was removed on [DATE]. The surveyor conducted onsite investigation on [DATE] to confirm the removal plan was implemented. Findings include: 1. R1 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Type 2 Diabetes Mellitus; Peripheral Vascular Disease; Schizophrenia; Hypertension; and Presbyopia. According to R1's MDS (Minimum Data Set) assessment dated [DATE] and [DATE] under section C, R1 has BIMS (Brief Interview of Mental Status) score of 7 indicating severely impaired cognition. According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section GG, shows that R1 required supervision/touching assistance or partial moderate assistance with all functional abilities. According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section GG, shows that R1 was dependent with all functional abilities. R1's Abuse assessment dated [DATE] shows that R1 is not at risk for abuse, despite Developmental/Intellectual Disability confirmed by R1's BIMS score of 7. R1's care plan dated [DATE] reads in part, Due to vision impairment resident may enter into the wrong room. The behavior may present as wandering. Assist as needed. Check and assure physical comfort. 2. R2 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Schizoaffective Disorder; Anxiety Disorder; Encephalopathy; and Hypertension. According to R2's MDS (Minimum Data Set) assessment dated [DATE] under section C, R2 has BIMS (Brief Interview of Mental Status) score of 13 indicating intact cognition. R2's Comprehensive Behavioral Health Initial assessment dated [DATE] shows that R2 has a history of aggression and violence; displays frequent Hallucinations/Illusions and almost constant Delusions; Attitude towards Admittance: angry, confused; Adjustment to Placement: Angry over facility placement; resents placement; Copes through display of anger and hostility. No care plan related to R2's need for monitoring due to aggressive behavior documented prior to [DATE], the day of the incident. R2's psychiatry progress note from previous facility dated [DATE] reads in part, Behavior: agitated, restless, combative, stealing from other residents. 3. On [DATE] at 10:42 AM Surveyor approached R2 on the 2nd floor hallway. Surveyor asked about the incident involving him and R1 on [DATE]; however, R2 stated something unintelligibly and walked away. R2 proceeded then to follow surveyor throughout the unit, staring, mumbling unintelligibly, and clinching fists in a threatening way. Surveyor did not observed staff redirecting R2 at any point. R2 is remaining in the facility displaying aggressive and intimidating behaviors as observed by a surveyor and shares a room with another resident at this time. On [DATE] at 10:49 AM Surveyor interviewed R7. R7 resided in the room directly adjacent to R1 and R2's room at the time of the incident. R7 stated, I was awake on the night of [DATE]. The incident happened around 2:00 AM. R1 was howling: Somebody help! while R2 was just beating on him. R1 came into my room, he was bleeding from all over his face. R2 beat R1 terribly. Staff didn't hear them. There was only one nurse that night, V17 (Licensed Practical Nurse), I don't know where all CNAs (Certified Nursing Assistants) were. R2 is still messing with other residents. Everybody knows what happened that day. Nobody talked to me about the incident, you're the first person who asked me about it. After R1 returned from the hospital, he didn't move anymore, didn't come out of his room like he did before. According to R7's MDS (Minimum Data Set) assessment dated [DATE] under section C, R7 has BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition. On [DATE] at 11:29 AM V1 Surveyor interviewed V1 (Administrator/Abuse Coordinator) who stated in summary: I found out about the incident early, around 4.00 am, on [DATE]. V17 (LPN) notified me that R1 had a fall and will be sent out to the hospital. Allegedly, R1 hit his head. While they were waiting for the ambulance, R1 said, My roommate pushed me. Based on that allegation, I initiated abuse investigation. All neighboring residents, in adjacent rooms and rooms across from R1 and R2 room, were interviewed; all of them said they were asleep and didn't hear or see anything. The door to R1 and R2 room was ajar throughout the night. Staff didn't hear or see anything, including V17 (LPN), V11 (CNA), and V15 (Social Worker). We called local police department as part of the abuse investigation procedure, they awoke R2 to interview him, and R2 denied knowing what happened to R1. When police came, R2's behavior changed, he was walking away from them. After that, R2 became agitated and was sent out for psychiatric evaluation. As an outcome of the investigation, we found that R1 had laceration above his right eye but no serious injuries from the incident. When R1 came back from the hospital, he remained in bed, so he wasn't ambulating like before. I spoke to R1's Power of Attorney and discussed moving R1 closer to the nursing station to keep him safe. After few days (on [DATE]), R1 was transferred out to the hospital for a medical reason, and he passed away (on [DATE]). On [DATE] at 12:43 Surveyor interviewed V12 (Licensed Practical Nurse) who stated in summary: R2 was admitted to the facility on [DATE] around 3:00 PM, close to the change of shift, I was one of the admitting nurses. R2 seemed agitated. When we tried to orient R2 to his room and point to his bed, R2 told us, I want to be where I want to be and said I'm leaving from here. R2 met R1 in the hallway that day but did not display any aggressive behavior towards him at that time. Couple of residents have brought to my attention later that day ([DATE]), that R2 walked up behind them, into their personal space, which made them uncomfortable. R1 was very active, talkative, and friendly, seemed very happy. R1's vision was very impaired. All residents liked R1 and looked out for him due to his vision impairment. I saw R1 after the incident (on [DATE]), the right side of R1's face was very swollen, he couldn't move, he wasn't able to walk or feed himself, or even sit up. R1 has never gone back to his baseline. On [DATE] at 12:59 PM Surveyor interviewed V13 (Housekeeper) who stated in summary: The way R2 talks and looks at me, I don't know, I'm trying not to acknowledge him. It feels like R2 is targeting me, and couple other residents as well. You know how he looked at you when you were in the unit today? R2 does the same to me. It seems like R2 is looking for trouble. It is hard to understood what he's mumbling under his breath too, but I make sure R2 is never behind my back. R2 also writes in his room and on the bathroom walls. I saw R1 after the incident (on [DATE]), and he looked really bad, swollen. Residents are asking me why they (facility staff) are not doing anything about R2, they feel very uncomfortable with him on the unit. Everyone is aware that R2 is aggressive. On [DATE] at 3:28 PM V1 (Administrator) stated that, per V15's (Social Worker) significant other, she is incapacitated and won't be available for an interview during this survey. On [DATE] at 10:02 AM Surveyor interviewed V14 (Resident Care Coordinator) who stated in summary: I performed R1's MDS assessment in section GG on [DATE]. R1 was ambulatory, required partial to moderate assistance with incontinence care, identifying objects, and positioning for safety due to his visual impairment. R1 was able to perform majority of ADLs but staff assistance was required due to his vision impairment and behavior, such as response to internal stimuli, and cognitive incapacity. On [DATE] at 10:38 AM Surveyor interviewed V11 (Certified Nursing Assistant) who stated in summary: On ,d+[DATE], I was working on the night shift (10:00 PM to 7:00 AM). I didn't hear or see anything that happened between R1 and R2 at the time of the incident. V17 (LPN) came to get me, between 3:00 AM and 4:00 AM, asking if I saw R1 recently. V17 (LPN) said R1 has a knot on his head. We both went to see R1. R1 had bloody face, swollen right eye, and swelling of the entire right side of his face. There was blood on R1's bed and the floor. R1 went to the bathroom to wash his face and hands, I assisted him. I didn't see any blood in the bathroom or on the bathroom floor. If I was going to judge where the incident happened, it would have been by R2's bed, that's where the blood was. In the conversation, R1 said he was punched twice in the face and kicked continuously by R2 while he fell to the floor. While I was awaiting an ambulance with R1, R2 kept coming around and asking how is R1 doing, if he's ok, and if his eye was ok. I told R2 to give us privacy, R2 got agitated but went back to his side of the room. I did not assess R2 or looked at his fists. Paramedics came 30 minutes later (around 4:00 AM - 4:30 AM). R2 was in the room the entire time. I usually round the unit every 2 hours. I came in at 10:00 PM, started rounding around 10.30 PM and went every two hours from then on. Last time I saw R1 that night was around 01:30 AM and he was asleep in the bed at that time. R2 was walking throughout the unit most of the night. No one mentioned that R2 required additional monitoring. When there is newly admitted resident in the unit, they should be monitored more frequently. I don't believe there is a specific policy for that, it is my personal experience. On [DATE] at 11:30 AM Surveyor interviewed V2 (Director of Nursing) who stated in summary: Myself and V5 (Clinical Director) are supposed to be part of the team who makes decision about resident placement in regard to appropriate room and roommate, but we are just told where to place residents. Surveyor clarified why are V2 (DON) and V5 (Clinical Director) excluded from roommate placement decision despite their clinical experience, V2 (DON) said, I have no answer to that. V2 (DON) continued: R2 has a psychiatric background, his referral packet showed past agitation but not violence. Placing R1 and R2 in the same room was not the decision we made. It would be V16 (Admissions Director). New residents should be monitored for the first 72 hours, nurses should be documenting the behavior, or anything abnormal. I was not a part of R1 and R2's incident investigation, I was off one day. I was told R1 had fallen. Upon hospital record review, I found out that something else happened. Medical record alerted me that there was physical assault that occurred. I presented it to V1 (Administrator) and she said that that the outcome of the investigation is that R1 fell . There were no further interventions for abuse because it was concluded it was a fall; therefore, we implemented additional fall precautions for R1. After R1 returned from the hospital (on [DATE]), he wasn't eating, dressing, or ambulating, so there was also referral that was placed for therapy. On [DATE], I was notified that R1 was not himself. When I went up to his room, staff had crash cart at the bedside. R1's oxygen saturation was 80%, he had nonrebreather mask, and his blood pressure was very low. R1's blood sugar read as high which means it was above 600. Nurse practitioner ordered 10 units of insulin before ambulance arrived. EMS took over from there. R1 was admitted with diagnosis of DKA (Diabetic Ketoacidosis). I didn't know he died (on [DATE]), I just found out today. On [DATE] at 11:40 AM Surveyor interviewed V5 (Clinical Director) who stated in summary: V1 (Administrator) has a social service background, so she is qualified to make decision in regard to resident placement. I feel like, when I looked at R2's admission packet, that showed agitation but not violence, I assumed it was safe to have R1 and R2 together, in the same room. We're not always familiar with entirety of residents' behavior. I was not part of R1 and R2 incident investigation, I was not here. After R2 returned from his psychiatric evaluation, he was placed back in the same room, R1 was moved to a private room, both were located on the same floor. R2 was placed on 72 hour checks and was referred to see a psychiatrist. I cannot answer why this resident was placed in the same room with a new roommate. On [DATE] at 12:00 PM Surveyor interviewed V16 (Admissions Director) who stated in summary: I am responsible for resident placement in regard to appropriateness of the room and a roommate. I did not think that R2 should not be placed back in the same room with a new roommate upon his readmission on [DATE]. Surveyor reiterated that R2 assaulted another resident (R1) recently, V16 continued: The focus was to remove R1 and place him in another room, but R2 was assessed as safe to return to the same room with a new roommate. I make my decision based on nurses and social service staff assessments when I make room assignments. On [DATE] at 12:40 PM Surveyor interviewed V17 (Licensed Practical Nurse) who stated in summary: I was doing rounds on [DATE], between 3:00 AM and 4:00 AM, when I found R1 sitting on the edge of his bed with some injuries. I asked him what happened, R1 said that he fell . I did my assessment then and notified the doctor. The doctor ordered to send R1 to the hospital. R1 had injury to his eye and had some bleeding. I assessed the rest of his body and there were no other injuries. R2 was agitated at that time, manic, restless, kept going back and forth all night, and talking to self. He was more agitated than usual. R2 was pacing in the hallway, going back to the room occasionally. I did not hear or see the incident and there were no witnesses at the time. I didn't see any blood on the room's floor, maybe a little on R1's sheet. I notified administrator and family in addition to the doctor. R2 was a new resident. I got a report upon beginning of my shift, but I was not endorsed anything special about R2. When we have a new resident, we should monitor every hour for about 3 days. The monitoring occurs between nurses and CNAs. Surveyor clarified if V17 (LPN) addressed R2's escalating behavior on [DATE] before the incident occurred, V17 said, R2 was sent out to the hospital for behavioral evaluation after the incident. Based on the record review, no documented interventions for R2's maladaptive behavior on [DATE] between 11:00 PM and 4:00 AM noticed. Based on the record review, no documentation of R2's new admission monitoring between [DATE] 2:30 PM and [DATE] 4:10 AM noticed. On [DATE] at 1:15 PM Surveyor interviewed V19 (Licensed Practical Nurse) who stated in summary: I performed R1's assessment on [DATE]. R1 was not responding and not talking, he was lethargic. I had to crush his medications that day. I checked his blood sugar, it was abnormal. I told another nurse, she put him on oxygen, and I went to call 911 and V2 (DON). I've known R1 for a very long time. R1 was almost blind, but he could walk around. R1 could also talk and was able to eat independently. R1 could even go to the bathroom with minimal assistance. All I know in regard to the incident that happened on [DATE], is that they sent R1 to the hospital but not sure why. I went to R1's unit the following day ([DATE]) and one of the resident's said that R1 was beat up by another resident. R1 said to me I was beat up because I was in wrong hand, I don't know what that meant. I've never met R2, but I spoke to one of the CNAs who took care of R2 in another facility, and she said, What is he doing here? (R2) is very dangerous, (R2) bit me up there. On [DATE] at 3:23 PM Surveyor interviewed V27 (Medical Director) who stated in summary: I am a medical director of this facility. I don't know specific details about the incident that occurred between R1 and R2 on [DATE], but I was notified that they had an altercation and R1 suffered laceration to the forehead. R1 was intact in regard to his functional ability before the incident on [DATE]. R1 was alert to self and had history of non-compliant behaviors. He had BIMS of 7, which means severe cognitive impairment. If R2 had BIMS of 13, that means he is not severely impaired and is able to understand and comprehend. Based on the BIMS score it does not seem these two residents are at the same level. If two residents like that are monitored and assisted, their cohorting may be acceptable; however, if there is lack of supervision and monitoring, it would not be appropriate. On [DATE] at 1:30 PM Surveyor interviewed V34 (Primary Metal Health Nurse Practitioner) who stated in summary: R2 was referred to psychiatry post the incident on [DATE]. I assessed R2 on [DATE]. R2 was very aggressive and irritable during my assessment that day. R2 was very guarded, not easy to talk to, and not very friendly. Facility should monitor residents like R2 closely and make sure their roommates are safe. Resident displaying agitation would not be appropriate to be placed in the same room with cognitively and visually impaired roommate. Especially, a resident who is visually impaired might invade others' space and appear as wandering into another's resident private space. That can cause a conflict. I would expect that a resident who displays aggressive behaviors, such as psycho motor agitation, in simple words, when someone is trying to hit, kick, bite, push, but also, call names, clench fists, mumble under their breath, or position in fight stand, should be initially admitted into a private room under close monitoring. Aggressive behavior may also take on indirect form, including walking up behind somebody, into their personal space, it's like bullying. R2 was definitely not appropriate to be placed with his roommate (R1). On [DATE] at 12:19 PM Surveyor interviewed V35 (Certified Registered Nurse Practitioner) who stated in summary: I get report from my company nurse who gets notified of any residents requiring assessment via record review. There is no face to face or phone report, it is exclusively based on record review. I came in and assessed R1 on [DATE], after his hospital readmission. R1 was weak, it was unlike him, usually R1 was able to get up and walk. R1 responded to his name only, unlike before, R1 was able to respond to questions not only to his name. R1 had steri strip and laceration to his right eyebrow. R1 also had some swelling to the right eyebrow. Based on his change in physical condition, I ordered physical therapy. I was told R1 fell , I did not inquire further. I reviewed R1's hospital records, hospital records said it was a physical assault. I asked the nurse on the floor for clarification, she said the incident was documented as a fall but R1 said he was assaulted. Based on R1's injury, it could have been either assault or a fall, but the hospital record read it was an assault; I don't know what was the source of R1's injuries. On [DATE] at 1:28 PM Surveyor interviewed V36 (Licensed Practical Nurse) who stated in summary: On [DATE], R1 was readmitted to the same room as before the incident. R1 complained of pain, so I notified NP, she ordered him pain medication and I gave it to him. R1 had laceration on the right side of his face, had steri strips on his forehead. He also had bruising around his right eye area. I didn't have a chance to assess the rest of his body because he refused due to pain. I didn't ask R1 what happened. He was not able to get up and feed himself. Before the incident he was able to walk and feed himself. I only worked with R2 on [DATE]. I was not told anything specific about him. We check on resident at least every 2 hours. If residents are yelling, have behaviors, or verbal altercation occurs, we notify social workers, check if they have PRN and notify the doctor. If they have physical aggression, we separate them and send them out to the hospital. If a resident is sent out to the hospital for behavioral evaluation, it is usually a behavior that we are not able to manage in the facility. On [DATE] at 11:07 AM, on [DATE] at 10:47 AM, and on [DATE] at 03:08 PM surveyor attempted to call V15 (Social Worker), no answer, voicemail left. Surveyor did not receive call back from V15 (SW) during the course on the investigation. On [DATE] at 12:38 PM Surveyor interviewed V40 (Emergency Department Clinical Lead) who stated in summary: We have certain criteria in the emergency department that we use to determine if trauma response needs to be initiated, some of those criteria are penetrating injury or exposed skull fracture. Team purple is trauma team who responds to patients with trauma triggered injuries. Trauma response is not triggered for falls from standing position, it can be triggered for falls from 10 feet and above. Surveyor clarified that team purple was triggered for R1 upon his admission into emergency department on [DATE], V40 said: If trauma response was initiated in the field, we know that patient's injury met trauma criteria and requires specialty team response, such as trauma team. 4. Progress noted dated [DATE] at 2:30 PM by V12 (Licensed Practical Nurse) reads in part, (R2) arrived on foot by admission staff. (R2) alert X3, confused, aggressive, and hard to redirect. (R2) doesn't want to be touched, don't allow for writer to complete assessment. Facility Reported Incident dated [DATE] reads in part, On [DATE] at approximately 4:00 AM while in his room, (R1), informed the unit nurse (V17 LPN) that he fell while attempting to go to the bathroom. (R2) later alleged to the CNA (V11), that he had an altercation with his roommate (R2). This allegation was unsubstantiated. Abuse is not found in this occurrence and was not substantiated as this allegation and fall appears to be a sign and symptom of his disease process. Progress note dated [DATE] at 4:10 AM written by V15 (Social Worker) reads in part, While doing rounds, (R1's) door was ajar and the writer noticed (R1) sitting on the bed in the middle of the night, the writer walked in (R1's) room and noticed an injury, the writer asked (R1) how did he get the injury but (R1) did not respond. (R1) just pointed to the injury. The nurse and the doctor were notified. Progress note dated [DATE] at 4:10 AM written by V15 (Social Worker) reads in part, The writer tried to speak to the (R2), and (R2) was very agitated, talking to himself, making delusional and very un-redirectable. (R2) was irritable every time anybody approached him. The nurse contacted the doctor, and the doctor ordered to send (R2) to local psychiatric hospital. R1's ambulance sheet dated [DATE] reads in part, Primary impression: Injury of Head; Chief Complaint: Head Trauma; Injury: Assault with bodily force. Initial Patient Acuity: Emergent; Final Patient Acuity: Emergent. (Ambulance) arrived on scene for (R1) A&Ox3 (alert and oriented to person, place, and time) per normal; now is A&O x1 (alert and oriented to person) head trauma. (R1) was assaulted by his roommate (R2). (R1) has swelling, deformity, and bruising. (R1) did state that he was hit 15 times by his roommate's (R2) fists and feet. R1's hospital record dated [DATE] reads in part, (R1) arrives via EMS s/p (status post) possible assault by roommate. Per EMS, (R2) hit (R1) approximately 15 times with hands and feet, (R1) unable to see out of right orbit. Exam: CT heads without intravenous contrasts; Findings: There is a hematoma along the right frontal scalp and right lateral orbital wall; Orbits: increased attenuation in the bilateral orbital globes suggesting vitreous hemorrhage. R2's hospital record dated [DATE] reads in part, Chief complaint: (R2) here via (local fire department) with involuntary petition from nursing home for aggressive undomiciled behavior per nursing home staff (R2) is unable to be redirected and does not follow commands very well, and hence render a threat to himself and others. All history was obtained from nursing home records as (R2) tends to remain agitated and noncooperative. Past medical history known of unspecified encephalopathy, psychoactive substance abuse, schizoaffective disorder, essential hypertension, CC: bizarre/Paranoid Behavior. R2's hospital record dated [DATE] reads in part, (R2), here for an evaluation of Altered Mental Status. History was obtained from nursing home records as (R2) remains agitated and uncooperative. (R2) is awake, restless, agitated, uncooperative, behavior unpredictable, incoherent speech. Police report dated [DATE] reads in part, Upon arrival, reporting officer, spoke with V15 (Social Worker) who stated that R2 had battered R1 in (their) room. The reporting officer spoke to V11 (CNA) who stated that (R1) told him that (R2) punched him in the face twice and knocked him down twice. The reporting officer spoke to V17 (LPN) who informed the reporting officer that R2 will be transported to (local psychiatric) hospital for mental health issues and R1 will be transported to (local) hospital for fractured face. 5. The facility Abuse Policy dated ,d+[DATE] reads in part, The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Serious Bodily Injury is an injury involving extreme physical pain, involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring [NAME] intervention such as surgery, hospitalization , or physical rehabilitation. As part of social service assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis. The Immediate Jeopardy that began on [DATE] was removed and the deficient practice corrected on [DATE] when the facility took the following actions to remove the Immediacy and correct the noncompliance. Corrective Action Taken: 1. A body check was performed on R1 on [DATE] (by V17 LPN) after the alleged abuse occurred and he was noted with injuries that were immediately treated. Family and physician notifications were made (by V17 LPN) on [DATE] - verified with no concerns. 2. A body assessment was performed on resident R2 on [DATE] by V17 LPN. There were no injuries noted - verified with no concerns. 3. The plans of care pertaining to the alleged abuse for R1 and R2 were reviewed and revised [DATE] by the Social Services Counselor. The interventions for R1 included 1:1 behavior monitoring until calm. Interventions for R2 included 1:1 behavior monitoring - verified with no concerns. 4. R1 and R2 were promptly sent to the hospital for evaluation on [DATE] - verified with no concerns. 5. R1 was readmitted to the facility [DATE] and was subsequently transferred to a private room. R2 was readmitted to the facility [DATE] - verified with no concerns. 6. On [DATE] R1 discharged from the facility and did not return. On [DATE] R2 was discharged to the hospital and remains hospitalized at this time - verified with no concerns. 7. All potential admissions that will have a roommate and room change considerations will be made upon review of their clinical record by Administrator, Clinical Director, Director of Nursing, Asst. Director of Nursing. Considerations to ensure appropriateness of roommates to avoid vulnerable residents being housed with aggressive resident include but not limited to clinical medical condition, cognition, functional ability, and past behavioral health symptoms - verified by staff interview with no concerns. 8. On [DATE] the DON, Administrator, ADON, Nurse Consultant and Medical Director reviewed the facility resources for stress management and policy related to the occurrence: Abuse. No changes were made - verified with no concerns. Identifying other residents having the potential to be affected by the same deficient practice: 1.On [DATE] all residents skin was assessed for any physical markings that could potentially be related to physical abuse. This was completed by the assigned nurses - verified with no concerns. 2. Interviewable residents were interviewed by the Activity Director [DATE] and completed [DATE]. To determine if there were any concerns related to abuse or mistreatment and there were none - verified with no concerns. 3. At Risk for Abuse Risk Assessments started on all residents on [DATE] (by the Social Services Counselors and Director) and completed on [DATE] with no concerns identified. The plans of care were revised as needed by Social Services Counselors and Director - verified with no concerns. Measures taken to ensure that the problem is corrected and will not recur. 1. All staff and managers are being reeducated on facility abuse policy and abuse prevention, stress management (by the Social Services Director and Activity Director). The reeducation was provided on [DATE] and completed on [DATE]. Educations will continue to be provided for those employees who have not received educations at the start of their shift. This will be ongoing - verified with no concerns. 2. The facility assigned department heads (Social Services Director, Activities Director) to provide pop quizzes to staff about abuse which began on [DATE] and completed [DATE]. Pop quizzes will continue to be provided for those employees who have not received educations at the start of their shift. This process will be ongoing - verified with no concerns. Measures or systems the facility will alter to ensure that the problem will be corrected and will not recur. 1. A review of compliance using Quality Assurance Audit tool for abuse started [DATE] (by the Administrator). Audits will be done weekly for four weeks, then monthly x 3 months, and then randomly by Administrator until goal is attained for 4 months - verified with no concerns. 2. A review of results of audit regarding abuse with the facility's interdisciplinary team started the week of [DATE]. Audits will be done weekly for four weeks, then monthly x 3 months, and then randomly by Administrator/designee until goal is attained for 4 months - verified with no concerns. 3. Abuse policy and prevention will be discussed with all new hires upon hire (by the HR Director/Business Office Manager) or Administrator - verified with no concerns. Quality Assurance Plans to monitor facility performance: 1. Audits on all resident's abuse assessment and abuse care plan was reviewed for accuracy. Audits will be done weekly for four weeks, then monthly x 3 months, and then randomly by Administrator/designee. All audits will be reviewed by the QA committee with evaluation of trends/patterns and corrective action implemented as indicated. Ongoing audit frequency will be based upon goal attainment to start [DATE] This will be monitored

Based on observation, interviews and record reviews, the facility failed to provide adequate supervision and monitoring on a resident assessed to be at risk for elopement due to history of elopement from previous nursing home; failed to ensure the resident did not leave facility without staff knowledge or supervision; and failed to follow elopement policy on procedures and reporting. These failures affected one (R5) of three residents in a sample of 10 reviewed for elopement risk and supervision. These failures resulted in R5 able to eloped from facility. R5 experienced harm by walking to emergency room without shoes on and having to cross a high-volume traffic intersection at night, while allegedly experiencing chest pain. The Immediate Jeopardy began on 04/06/24 when R5 left facility unnoticed and unsupervised, walked without shoes on to local hospital while crossing a high volume traffic intersection at night while allegedly experiencing chest pain. V1 (Administrator) was notified of the Immediate Jeopardy on 04/15/24 at 11:59 AM. The survey team confirmed by observation, interviews and record reviews that the Immediate Jeopardy was removed on 04/07/24 and the deficient practice was corrected on 04/08/24, and completed on 04/10/24. Findings include: R5 is a [AGE] year-old, female, admitted in the facility on 10/20/23 with diagnoses of Schizophrenia, Unspecified; Schizoaffective Disorder, Unspecified; Dementia in other Diseases Classified Elsewhere, Moderate, with Other Behavioral Disturbance; and Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. Exit Seeking/Wandering/Elopement Risk assessment dated [DATE] documented that R5 is cognitively impaired with deficits in orientation, decision making related to Dementia, Severe Mental Illness, and was assessed at risk for elopement. Community Survival Skills assessment dated [DATE] recorded that R5 is not able to navigate safely on community streets. MDS (Minimum Data Set) dated 04/01/24 documented R5's BIMS (Brief Interview for Mental Status) score of 9 which means moderate impairment in cognition. Hospital referral packet dated 10/20/23 recorded that R5 has history of elopement from previous nursing home; and will need placement in a memory care unit. According to progress notes dated 04/06/24, at around 9:30 PM, V4 (Licensed Practical Nurse, LPN) observed the alarm on the back door gone off and sounding. Code Green for elopement was called and headcount on the unit was initiated. One staff went outside to look for a resident who left unattended but reported did not see anybody. Another staff helped with the head count. As staff conducting head count, a staff from another unit received a call that R5 was in the hospital. On 04/08/24 at 2:12 PM, V3 (Certified Nurse Aide, CNA) was asked regarding incident on 04/06/24 with R5. V3 stated, On 04/06/24, I was the CNA on the floor, and she (R5) was my resident at the time. Like around 8:00 to 9:00 PM, I started putting residents on bed. She came to me and asked if I was her CNA. I said yes and asked if she needs something. She said she needed a brief and a blanket. I gave it to her, and she went back to her room. She is not incontinent. Then, I continued to put other residents on bed. Suddenly, the door alarmed. V4 (Licensed Practical Nurse, LPN) called me to check the alarm. He (V4), I and V30 (CNA) checked residents in their rooms and did a head count. V30 went outside and looked for the resident who opened the door. While we were doing the head count, V28 (LPN) came down and said that R5 was in the hospital. We were doing the head count for like less than half an hour. V28 turned off the alarm and we continued to check on everybody. I am not aware that she (R5) has history of elopement. She (R5) was always sitting in her bed during my shift. She is alert, oriented, able to move around without assistance. She has a walker. V4 was also interviewed on 04/08/24 at 2:45 PM, stated, On 04/06/24, I was the nurse assigned on R5. Around 9:30 PM, I heard an alarm went off from the unit exit door. I asked myself, maybe somebody must have used the door. So, I called Code Green right away. Code Green is for elopement. My staff, V3 and V30 went to the door and went outside. While I do the head count, I found out R5 was missing. That would be like 9:40 PM already. As we were doing the head count, V28 came down and said hospital called, said R5 was in the hospital. I called hospital, was told that she (R5) was with them, in the emergency room . I called V1 (Administrator) and reported the incident. To be honest, R5 is not one of those residents that need to be monitored. She does not have a behavior and very compliant. I was unaware that she has history of elopement. She walked with the use of walker, he walked slowly. That time, she was able to leave facility unnoticed. V28 also stated during interview on 04/08/24 at 3:19 PM that she was working on the second unit when the phone rang. V28 continued, That was 10:00 PM, I received a call from the hospital stating that they have a lady in the lobby and wants to know if the lady is from our facility. I asked the name and she gave me R5's name. I went to third unit; the code green was on. I told V4 that she (R5) was in the hospital, and I gave him the hospital phone number. R5 was able to leave facility on 04/06/24 unnoticed, unsupervised. R5 is a resident in the Memory Care Unit in the facility, which is a secured and locked unit on the first floor. Observation on 04/09/24 at 10:25 AM showed that the exit door where R5 exited on 04/06/24 has an alarm. The door will alarm when push bar is pressed and when door is fully opened, a secondary continuous loud alarm will be heard in the entire unit. The hospital is located two blocks east from the exit door. The hospital is situated at the intersection of a busy street. On 04/09/24 at 9:58 AM, V5 (Social Services Director) was interviewed regarding R5. V5 verbalized, She is alert and oriented, sometimes she gets confused. She uses a walker to ambulate. Prior to her coming here, she is already on the list for elopement risk. However, since she'd been here, she never attempted to elope. Basically, it is more on supervision. The staff are made aware of these elopement risk residents. Regarding incident on 04/06/24, I was made aware on Sunday, 04/07/24 that she (R5) eloped and was in the hospital. She (R5) cannot go out by herself, she needs staff or family assistance. She has Dementia, has Schizophrenia and Schizo affective disorders. The exit doors have alarms. When staff heard an alarm, they have to attend to the door and redirect resident who wants to go out. She (R5) came back last night; she was placed on a 72-hour well-being check; I am sure her physician was notified and she remains in the elopement risk and we will be monitoring her - one on one counseling; every 15 minute check; she needs to be supervised all the time. On 04/09/24 at 10:40 AM, R5 was observed sitting in her rollator walker by the nurses' station. She was alert, oriented, wearing yellow nonskid socks. R5 was asked regarding incident on 04/06/24. R5 replied, I came back from hospital last night. I was in the hospital down there. I had chest pain and I had pain in the stomach and tooth. That time, I told the nurse that I was having chest pain, don't know his name, and he was not paying attention or anything so I walked down there to the hospital. I was scared that I might be having a heart attack, it frightens me. I was gone for a day. Progress notes dated 04/08/24 time stamped 8:59 PM recorded R5 came back to facility. On 04/09/24 at 11:40 AM, V1 was asked regarding elopement incident on R5. V1 replied, I am the one investigating her elopement. She is alert, oriented to place, able to ambulate using a rollator. She was placed on the elopement risk upon admission. Her referral paperwork stated that she had history of elopement. All the staff were made aware that she is an elopement risk. For her, she had not displayed any exit seeking behaviors since admission, she was placed in the Memory care unit, Unit 3, which is one of our secured units. She is monitored and supervised - CNAs and nurses do rounds every hour. We also have ambassador rounds which we check residents if they have behaviors, concerns and for needs. These are the basic interventions that we implement and should be in the care plan. I was notified last 04/06/24, like little after 10:00 PM by V4, the nurse, that she (R5) had left the building and was in the hospital. I asked him about the details. He told me that CNA provided her with care around 9:30-9:35 PM and continued with her rounds. The door alarm was activated roughly around 9:45 PM. He said he went down to door where the alarm was and asked other CNAs to come. One went outside to search around but did not see her. They started the headcount, initiated the code green. And that's when she discovered R5 was missing. He was headed to the phone when he was given information that she (R5) was in the hospital. He made his notification to me, to V2 (Director of Nursing) and V32 (Assistant Director of Nursing). We did the debriefing and started the investigation to find out how it happened. We started to do in-services on staff regarding elopement. We did not do any reporting to local state agency because she was found in less than an hour, probably like 20 minutes and sustained no injuries. I still have no definitive answer as to how she (R5) was able to get out that night. Nobody said that they saw her out the door and was never seen when they looked outside. She exited from the exit door at the end of the hallway. That was the only one activated at the time she was missing. And that was the conclusion that it was the main exit point. On 04/09/24 at 1:32 PM, V30 was asked regarding R5's incident on 04/06/24. V30 verbalized, On 04/06/24 about 10:00 PM, I started my shift, I will be working night shift. The moment I was coming in the unit, I headed to the break room. As I enter the break room, V4 came into the breakroom and asked me if I heard an alarm. I didn't hear any sounding alarm, but something sounded like a call light. He (V4) said door alarm was going off, and we need to do a head count. It was me and him (V4) doing the head count, while V3 was doing the head count on the other side of the unit. As I do the head count, I immediately noticed that R5 was not in her room. I told V4. I started to look where the alarm was. I went out of the back door and back of facility, but I did not see her (R5). I searched into the back alley but did not see her (R5). It was only me who went and looked outside. I went back and as I was about to enter the unit again, V28 said R5 was in the hospital. When I came in that time around 10:00 PM, I did not hear any alarm but as I entered Unit 3, the alarm already went off. We did head count first, then I went outside to look. We were told during in services that if we hear an alarm, do a head count first, then search from the door where alarm was going off. R5's Hospital Records dated 04/07/24 recorded in part but not limited to the following: Chief complaint - chest pain History of Present Illness - presents to emergency department via emergency medical services for evaluation after found wandering in traffic with a walker and without shoes. Patient (R5) resides at a nursing home. Patient (R5) states she has been experiencing left sided chest pain for three days. She describes a fullness at her chest. She has new onset tooth pain, shortness of breath, and left upper extremity pain. She reports alerting nursing home staff of her symptoms. Patient (R5) became concerned due to having history of a heart attack and decided to leave the facility due to not getting proper care. Review of systems: HENT (Head/eye/nose throat): tooth pain; Cardiovascular: Positive for chest pain and leg swelling (chronic); Respiratory: Positive for shortness of breath; Musculoskeletal: Positive for left upper extremity pain Clinical Impression: Chest pain, Unspecified type V29 (Physician/Hospital) stated during phone interview on 04/09/24 at 1:27 PM that R5 was found wandering and came to the hospital for chest pain. V29 added, She is alert, oriented to time, place and person. I was told by resident (R5) that she left on her own and she was having chest pain, and she was admitted in the hospital. V10 (Hospital Staff) also stated, I was the nurse assigned to R5. That was last Saturday, 04/06/24, she was found in the middle of the road by a bystander. The bystander called paramedics and she was sent here. She had no shoes at the time, said she was having chest pain. She told me that facility told her to leave and helped her out the door. I called facility, spoke to V4. V4 said he saw her leaving the facility but then he changed his story that he did not see her leaving, then changed his story that he just heard the door alarm. On 04/10/24 at 9:30 AM, R5 was observed in her room, sitting in her rollator walker. Surveyor made a follow up interview on the night she eloped from facility. R5 stated, When I went to the hospital, I was on my feet, no socks. I walked on the rocks. A lady passed by, and she said if I needed help. She helped me and brought me to the hospital. No one saw me when I left that night, I passed by the nurses' station though. A follow up interview with V4 was conducted on 04/10/24 at 9:51 AM stating that he did not see R5 leaving the facility and did not speak to the hospital staff about seeing her (R5) leaving the unit. V4 also stated that he has no knowledge and awareness that R5 was complaining of chest pain on 04/06/24. R5's care plan dated 03/30/24 documented: R5 is at risk for elopement related to physical ability to leave unit/facility, exit seeking behavior at former placement per hospital referral packet. Interventions: Consider potential variables, boredom, thirst, hunger, need for toileting, pain, exercise, companionship, exhaustion and over stimulation. On 04/10/24 at 11:24 AM, V2 stated during interview, I believe R5 is on the elopement risk list. The list needs to be updated as needed. The expectation from staff is they do rounds frequently; observe for signs of behavior like exit seeking and residents should be directed. When door alarms, they should get up and see where it is coming from. If it is a door alarm, they need to go to the door, look outside and around the area. The rest of the staff are already doing the head count. If there is a missing resident, they should call Code Green. V32 just told me today that she (R5) had an incident of elopement last 04/06/24. I was off during the weekend and just came back today. On 04/10/24 at 3:22 PM, V27 (Medical Director) was asked regarding R5 and elopement precautions in the facility. V27 stated, R5 was the one who eloped. I was notified that she just eloped, did not find her, tried to look for her everywhere and found that she was in the hospital. She has no history of elopement from what I have known, not sure if she had one. She was placed in a locked unit. If it is a locked unit, staff wants to make sure it is locked all the time, which means it is secured making sure everybody is safe and secured inside. Keep the place locked, secured. Monitor the flow on who is going and coming. I don't know why it happened because it is a locked unit. We need to do an investigation how it happened. Staff needs in-services regarding elopement prevention protocol and see if they follow the protocol, and implement the protocol. Somebody did not follow the process. I am sure there is an elopement protocol that I need to review. She (R5) came back, from what I remember on the same day and there were no injuries, nothing significant based from the nurses' notes from the hospital. I was not aware that she had chest pain. I did not know about it. Typically, if a resident complained of chest pain, take vital signs, make them stable and call paramedics to hospital as I ordered. Facility's policy titled, Elopement and Management of Missing Resident dated 03/28/2023 documented in part but not limited to the following: Policy: It is the policy of this facility to report and investigate all reports of missing residents and to minimize risks of elopement. Procedure: 1. Responding to a Door Alarm: a. It is the responsibility of all staff to respond to activated door alarms to determine the reason for the alarm sounding. b. If able to determine the reason for the alarm sounding, reset the door alarm and no further action is needed. c. If unable to determine the reason for alarm sounding, CODE GREEN and the location of the CODE GREEN should be announced 3 times over the intercom. 3. Suspected Missing Resident: p. Upon return of the resident to the facility, the Director of Nursing or designee should: vii. If resident sustained injury, a report will be made to local state agency. On 04/11/24 at 10:51 AM, V1 was asked regarding R5's elopement incident notification to local state agency. V1 replied, On 04/06/24, I was notified by V4 that she (R5) was missing. We did not do any reporting to local health agency because she was located within an hour of missing with no injuries. When she came back, we did not do any reporting as well because she has no injuries. I spoke to R5 when she came back and did not mention that she went to the hospital because of chest pain. I called hospital and was told that she went there because of bunch of reasons but not chest pain. R5's Hospital Discharge Summary dated 04/08/24 recorded diagnosis: Atypical Chest Pain. R5's care plan dated 04/04/24 documented: Potential for altered cardiac function - Intervention: Monitor for changes in status and report to MD (Medical Doctor) as needed. Facility's policy titled Incident/Accident Reports dated 09/2020 stated in part but not limited to the following: Procedure: 12. The Director of Nursing, Assistant Director of Nursing or Nursing Supervisor must notify: a. (Name of local state agency) of any serious incident or accident. Serious means any incident or accident that causes physical harm or injury to a resident. Note: Physical harm or injury does not include skin tear or bruise or something covered with a band-aid. Physical harm would include a broken bone, or blood flow not stopped by a band-aid or hospital or emergency room treatment that involves more than diagnostic evaluation. The Immediate Jeopardy that began on 04/06/24 was removed on 04/07/24 when the facility took the following actions to remove the immediacy and correct the noncompliance. Corrective Action Taken: 1. Upon readmission R5 was reassessed for elopement risk by social services on 04/08/2024 and deemed an elopement risk. This was completed on 04/08/24, and verified with no concerns. 2. R5 returned to the facility, was readmitted from hospital on 04/08/24. Per discharge records from hospital no injuries were noted and no change in orders. Upon return, R5 was placed on the second floor unit - observed and verified with no concerns. 3. R5 care plan was updated by Social Services pertaining to elopement on 04/08/2024. This was reviewed and verified with no concerns. 4. On 04/08/2024 the DON, Administrator, ADON, Nurse Consultant and Medical Director reviewed the facility policies related to the occurrence: Elopement, Routine Resident Checks, Exit Seeking, Abuse, and Incidents/Accidents. No changes were made. This was reviewed, verified with no concerns noted. - The Social Services Director and counselors are responsible for the assessments and updating care plans. This was verified with V5 and reviewed with no concerns noted. - The Administrator/designee is responsible for monitoring and reeducation of staff to ensure safety, verified with V1, with no concerns noted. - Resident in question R5 has been assessed every shift for pain. Nurse will immediately address any identified pain. This was initiated on 04/08/24 and ongoing. This was verified with V36, and confirmed via electronic health records with no concerns noted. - Nurse will monitor all residents for change of condition including new acute onset of pain. If change of condition is identified, primary physician will be notified immediately. This was initiated on 04/08/24 and ongoing. This was verified with no concerns noted. - Resident was provided with appropriately fitting shoes on 04/11/24. This was verified with R5 with no concerns noted. Identifying other residents having the potential to be affected by the same deficient practice: 1. This failure has the potential to affect all residents who experience a change of condition resulting from pain. No other residents were identified to have a change of condition as a result of pain. This was verified with no concerns noted. 2. Resident elopement assessment and careplan updated upon re-admission initiated 04/08/24 and completed on 04/08/24, verified with no concerns noted. 3. All residents were reassessed by the social services staff for elopement risk by social services on 04/08/2024 and completed on 04/10/24. Careplans were updated as needed. These were verified with no concerns noted. 4. All new admissions will have an elopement risk assessment that will be completed within 24 hours by Social Services staff upon admission and interim care plan will be initiated based off the assessment, and will be reassessed every three months, and PRN (as needed) based on behaviors resulting in risk. These were verified with no concerns noted. 5. All residents that are identified as at risk for elopement during admission had a review of their care plan by social services staff and updates were made where applicable, completed on 04/10/24 and ongoing. This was initiated on 04/08/24, and were verified with no concerns noted. 6. On 04/08/24 facility initiated the process of ensuring pictures of at-risk residents were placed in a binder on all nursing stations (1st,2nd,3rd unit) and the receptionist desk which was completed on 04/10/24. This is updated by Clinical Director as needed. Pictures are only privy to staff and placed in a manner that promotes privacy and dignity. These were verified through observation; and interviews with V6 (LPN), V12 (LPN), V36 (LPN), V43 (CNA) and V44 (CNA), with no concerns noted. 7. On 04/08/24 facility initiated the process to ensure the list of residents at risk for elopement is placed at the front desk. Pictures are posted on the bulletin at the front desk. Pictures are only privy to staff and placed in a manner that promotes privacy and dignity. This was completed on 04/10/24 and will be updated as needed by the Clinical Director. This was verified with V24 (Receptionist) with no concerns noted. 8. On 04/09/24 Special Resident Council Meetings were held by the Activity Director educating the residents on the seriousness of safety, informed of the requirement to leave facility out on pass process. Some of the residents are cognitive enough to be educated regarding facility rules/protocols and follow the facility's rules they are not at risk for elopement. This was completed on 04/09/24 and will be ongoing for newly admitted residents. This was verified with no concerns noted. Measures taken to ensure that the problem is corrected and will not recur. 9. The staff members on duty at the time of the occurrence on 3rd unit included 1 LPN, 2 CNA's received a formal disciplinary action as well as re-education. This was reviewed, and verified with no concerns noted. 10. On 04/08/24 facility initiated the process of ensuring pictures of at-risk residents were placed in a binder on all nursing stations (1st,2nd,3rd unit) and the receptionist desk which was completed on 04/10/24. This is updated by Clinical Director as needed. Pictures are only privy to staff and placed in a manner that promotes privacy and dignity. This was verified through observation and interviews, with no concerns noted. 11. Staff and managers are being reeducated by Administrator, DON, ADON, Clinical Director, Activity Director, Scheduler, Nurse Consultant, Business Office Manager on routine resident checks, exit seeking, incidents/accidents, change of condition, notifications for change of conditions, elopement policy and procedure and where to locate the at risk of elopement binders. The reeducation was provided on 04/07/24 with a completion date of 04/08/24. Educations will continue to be provided for those employees who have not received educations at the start of their shift. Routine checks allow the staff the opportunity to address any identified resident needs, change of condition or medical concerns. These were verified with staff interviews, with no concerns noted. 12. Reeducation provided by Administrator, Psychosocial Coordinator, Clinical Director regarding assessing for elopement risk which was initiated 04/07/24 and completed on 04/08/24. This was verified with no concerns noted. 13. Staff and managers are being reeducated by Administrator, DON, ADON, Clinical Director, Activity Director, Scheduler, Nurse Consultant, Business Office Manager on elopement risk and reporting behaviors or changes in factors related to elopement risk to appropriate discipline. This was started on 04/07/24 and completed on 04/09/24. The reeducation was provided on 04/07/24 by the Administrator and her designees. Educations will continue to be provided for those employees who have not received educations at the start of their shift. These were verified with no concerns noted. 14. Staff and managers are being reeducated by Administrator, DON, ADON, Clinical Director, Activity Director, Scheduler, Nurse Consultant, Business Office Manager regarding door alarms, checking to ensure doors are opening and closing properly, responding to door alarms to ensure it was not triggered by a resident, which started on 04/07/24 with a completion date of 04/09/24. This was verified with no concerns noted. 15. The alarm at the north exit door on third unit was checked to ensure that it was functioning properly on 04/07/24 this was completed on 04/07/24. The facility building manager is assigned to monitor the alarm on all units and lower level on day shift. Manager on duty and charge nurse will monitor the alarms on all units and lower level on all shifts, weekends, nights and overnights. This is ongoing. This was verified upon observation and interviews with no concerns noted. 16. The receptionist will monitor the front entrance door 8am-8pm. All other exit doors will be alarmed. The door leading to the lobby area will remain alarmed. This was verified with no concerns noted. 17. Exterior door alarms will be checked by Maintenance Director, Manager on Duty, Unit Charge Nurse to ensure they are in working order on each shift. QA (Quality Assurance) initiated on 04/07/24 and completed 04/07/24 and is ongoing. This was verified with no concerns noted. Measures or systems the facility will alter to ensure that the problem will be corrected and will not recur. 18. A review of compliance using Quality Assurance Audit tool for elopement was completed by the Clinical Director and completed by her designee and Door Alarm working condition started 04/07/24 by Clinical Director and completed by her designee. The Elopement Audit started on 04/07/24 by the Clinical Director. The Audits will be done weekly for four weeks, then monthly for 3 months, and then randomly by Administrator, DON, until goal is attained in 4 months. This was verified and reviewed with no concerns noted. 19. On 04/08/2024, the facility DON, Administrator and Nurse Consultant reviewed policies and procedures listed below with the Medical Director. This review included but is not limited to staffing, environment, addressing risk factors, and assessing changes in condition related to pain. The following policies were reviewed with no changes made. Changes in Condition - DON/ADON - Elopement - Clinical Director/Activity Director/Business Office Manager - Door Alarm - Maintenance Director/Scheduler/Business Office Manager/Housekeeping Supervisor - Routine Checks - Scheduler/DON/ADON/Business Office Manager - Incident/Accidents - DON/ADON - A review of results of audit regarding elopement and door alarm working condition with the facility's interdisciplinary team started on 04/07/24. Audits will be done weekly for four weeks, then monthly for 3 months, and then randomly by Administrator/designee until goal is attained in. - During orientation of new hires, the new door alarm enhancements and functionality will be discussed and the safety of it. These were verified with no concerns noted. Quality Assurance Plans to monitor facility performance: - The facility Quality Assurance Team/ IDT (including Medical Director, Administrator, Social Services, DON, ADON and facility consultant) shall meet monthly or as PRN. This was verified with no concerns noted. - The QA meeting is held as needed and quarterly. An emergency QA meeting was held on 04/08/24 at 10am by the Administrator with the Interdisciplinary Care Team and Medical Director. The Elopement from facility on 04/06/24 by the Administrator, DON, ADON, and Social Services. This was verified with no concerns noted.

Based on interviews and record reviews, the facility failed to provide necessary care and treatment during change in condition on a resident complaining of chest pain; and failed to monitor escalation of maladaptive behavior for two (R2 and R5) of five residents in the sample of 10 reviewed for quality of care. This deficiency resulted in R2 exhibiting increased wandering and pacing, resulted R2 to commit an assault behavior. This deficiency also resulted in R5 experiencing severe chest pain, eloped from the facility to go to the nearest emergency room for further evaluation and treatment. Findings include: R5 is a [AGE] year-old, female, admitted in the facility on 10/20/23 with diagnoses of Schizophrenia, Unspecified; Schizoaffective Disorder, Unspecified; Dementia in other Diseases Classified Elsewhere, Moderate, with Other Behavioral Disturbance; and Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. Exit Seeking/Wandering/Elopement Risk assessment dated [DATE] documented that R5 is cognitively impaired with deficits in orientation, decision making related to Dementia, severe mental illness, and was assessed at risk for elopement. Community Survival Skills assessment dated [DATE] recorded that R5 is not able to navigate safely on community streets. MDS (Minimum Data Set) dated 04/01/24 documented R5's BIMS (Brief Interview for Mental Status) score of 9 which means moderate impairment in cognition. Hospital referral packet dated 10/20/23 recorded that R5 has history of elopement from previous nursing home; and will need placement in a memory care unit. According to progress notes dated 04/06/24, at around 9:30 PM, V4 (Licensed Practical Nurse, LPN) observed the alarm on the back door gone off and sounding. Code Green for elopement was called and headcount on the unit was initiated. One staff went outside to look for a resident who left unattended but reported did not see anybody. Another staff helped with the head count. As staff conducting head count, a staff from another unit received a call that R5 was in the hospital. On 04/08/24 at 2:12 PM, V3 (Certified Nurse Aide, CNA) was asked regarding incident on 04/06/24 with R5. V3 stated, On 04/06/24, I was the CNA on the floor, and she (R5) was my resident at the time. Like around 8:00 to 9:00 PM, I started putting residents on bed. She came to me and asked if I was her CNA. I said yes and asked if she needs something. She said she needed a brief and a blanket. I gave it to her, and she went back to her room. She is not incontinent. Then, I continued to put other residents on bed. Suddenly, the door alarmed. V4 (Licensed Practical Nurse, LPN) called me to check the alarm. He (V4), I and V30 (CNA) checked residents in their rooms and did a head count. While we were doing the head count, V28 (LPN) came down and said that R5 was in the hospital. V4 was also interviewed on 04/08/24 at 2:45 PM, stated, On 04/06/24, I was the nurse assigned on R5. Around 9:30 PM, I heard an alarm went off from the unit exit door. I asked myself, maybe somebody must have used the door. So, I called Code Green right away. Code Green is for elopement. My staff, V3 and V30 went to the door and went outside. While I do the head count, I found out R5 was missing. That would be like 9:40 PM already. As we were doing the head count, V28 came down and said hospital called, said R5 was in the hospital. I called hospital, was told that she (R5) was with them, in the emergency room . I called V1 (Administrator) and reported the incident. To be honest, R5 is not one of those residents that need to be monitored. She does not have a behavior and very compliant. I was unaware that she has history of elopement. She walked with the use of walker, he walked slowly. That time. she was able to leave facility unnoticed. Unit 3 is on the ground floor. R5 was able to leave facility on 04/06/24 unnoticed, unsupervised. R5 is a resident in the Memory Care Unit, a secured and locked unit in the facility. Observation on 04/09/24 at 10:25 AM showed that the hospital is located two blocks east from the exit door where R5 exited on 04/06/24. The hospital is situated at the intersection of a busy street. Hospital records dated 04/07/24 recorded that R5's chief complaint was chest pain. According to history of present illness, R5 resented to the emergency department after found wandering in traffic with a walker and without shoes. R5 stated she has been experiencing left sided chest pain for 3 days. She describes a fullness at her chest. She has new onset tooth pain, SOB (shortness of breath and left upper extremity pain. She reports alerting nursing home staff of her symptoms. She became concerned due to having history of a heart attack and decided to leave the facility due to not getting proper care. Hospital records also documented the following: Past Medical History: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris Review of systems: HENT (Head/eye/nose throat): tooth pain Cardiovascular: Positive for chest pain and leg swelling (chronic). Respiratory: Positive for shortness of breath Musculoskeletal: Positive for left upper extremity pain Clinical Impression: Chest pain, unspecified type R5's hospital discharge summary dated 04/08/24 indicated: Diagnosis: Atypical Chest Pain On 04/09/24 at 9:33 PM, V10 (Hospital Staff) was interviewed regarding R5. I was the nurse assigned to her (R5). That was last Saturday, 04/06/24, she was found in the middle of the road by a bystander. The bystander called paramedics and she was sent here. She had no shoes at the time, said she was having chest pain. V29 (Physician/Hospital) also mentioned during interview, On 04/06/24, she was found wandering and came for chest pain. She is alert, oriented to time, place and person. I was told by her (R5) that she left on her own and she was having chest pain, and she was admitted . Progress notes dated 04/08/24 time stamped 8:59 PM recorded R5 came back to facility. On 04/09/24 at 10:40 AM, R5 was observed sitting in her rollator walker by the nurses' station. Alert and oriented, R5 was asked regarding incident on 04/06/24 when she eloped from the facility and went to the hospital. R5 stated, I was in the hospital down there. I had chest pain and I had pain in the stomach and tooth pain. That time, I told the nurse (don't know his name) that I was having chest pain and he was not paying attention or anything, so I walked down there to the hospital. I was gone for a day. I was scared that I might be having a heart attack, it frightens me. R5 also mentioned during follow interview, When I went to the hospital, I was on my feet, no socks. I walked on the rocks. A lady passed by, and she said if I needed help. She helped me and brought me to the hospital. I was having extreme pain on my chest, 8 out of 10, (8 meaning severe pain). I had tooth ache as well and pain in my left armpit. I was thinking I was having a heart attack at the time because I had one before and I know how it feels. I was actually short of breath when I get into the hospital. V1 (Administrator) was also asked regarding R5 chest pain on 04/06/24. V1 verbalized, On 04/06/24, I was notified by V4 that she (R5) was missing. When she (R5) came back, I spoke to her, did not mention that she went to the hospital because of chest pain. I called hospital and was told that she went there because of bunch of reasons but not chest pain. On 04/10/24 at 3:13 PM, V4 was asked if R5 complained of chest pain on 04/06/24. V4 stated, On 04/06/24, I was the nurse assigned on R5. No, she did not complain of any chest pain. I was not aware of her having chest pain. On 04/10/24 at 3:22 PM, V27 (Medical Director) was interviewed regarding R5. V27 replied, I was notified that she just eloped, did not find her, tried to look for her everywhere and found that she was in the hospital. She has no history of elopement from what I have known, not sure if she had one. She was placed in a locked unit. If it is a locked unit, want to make sure it is locked all the time which means it is secured making sure everybody is safe and secured inside. I was not aware that she had chest pain. Typically, if a resident complained of chest pain, take vital signs, make them stable and call paramedics to hospital as ordered. R5's Care Plans (CP) documented the following: At risk for elopement related to physical ability to leave unit/facility, exit seeking behavior at former placement per hospital referral packet (CP dated 03/30/24) - Intervention: Consider potential variables, boredom, thirst, hunger, need for toileting, pain, exercise, companionship, exhaustion and over stimulation. ADL (activities of daily living) functional performance deficit (CP dated 04/04/24) - Intervention: Monitor for presence of pain, intolerance during ambulation. Potential for altered cardiac function (CP dated 04/04/24) - Intervention: Monitor for changes in status and report to MD (Medical Doctor) as needed. Potential for alteration in health condition (CP dated 04/04/24) - Intervention: Notify MD and family with any changes in condition. On 04/16/24 at 10:14 AM, V32 was asked regarding R5. V32 verbalized, I was notified on 04/06/24 at 10:15 PM regarding her elopement. I was just notified that she got out of the facility, and I notified V1. When a resident is complaining of pain, staff has to do the vital signs, notify physician and sent resident out as ordered. Pain is subjective, we cannot say they are not having it. Whatever resident say if it is pain, it is pain. Facility's policy titled Change of Condition (Resident) dated 09/20 documented in part but not limited to the following: Purpose: To ensure that the resident's physician/physician on call/NP (Nurse Practitioner) and responsible party is kept informed regarding the resident's change in condition. Policy: The attending physician or physician on call/NP and responsible party will be notified with changes in a resident's condition. Facility's policy titled, Pain Management Evaluation dated 09/2020 stated in part but not limited to the following: Purpose: Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. Procedure: 2. Acute pain is generally pain of abrupt onset and limited duration, often associated with an adverse chemical, thermal or mechanical stimulus such as surgery, trauma and acute illness. 4. During the pain evaluation, determine the most workable pain rating scale for the resident. The following scales are available: a. The numeric rating scale (NRS): 1-3 (mild), 4-6 (mod), 7-10 (severe); b. PAINAD scale 1-3 (mild), 4-6 (mod), 7-10 (severe); 5. Pain will be evaluated each shift 46066 Findings include: 2. R2 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Schizoaffective Disorder; Anxiety Disorder; Encephalopathy; and Hypertension. According to R2's MDS (Minimum Data Set) assessment dated [DATE] under section C, R2 has BIMS (Brief Interview of Mental Status) score of 13 indicating intact cognition. R2's Comprehensive Behavioral Health Initial assessment dated [DATE] shows that R2 has a history of aggression and violence; displays frequent Hallucinations/Illusions and almost constant Delusions; Attitude towards Admittance: angry, confused; Adjustment to Placement: Angry over facility placement; resents placement; Copes through display of anger and hostility. No care plan related to R2's need for monitoring due to aggressive behavior documented prior to 03/17/2024, the day of the incident. R2's psychiatry progress note from previous facility dated 02/23/2024 reads in part, Behavior: agitated, restless, combative, stealing from other residents. On 04/09/2024 at 10:42 AM Surveyor approached R2 on the 2nd floor hallway. Surveyor asked about the incident involving him and R1 on 03/17/2024; however, R2 stated something unintelligibly and walked away. R2 proceeded then to follow surveyor throughout the unit, staring, mumbling unintelligibly, and clinching fists in a threatening way. Surveyor did not observed staff redirecting R2 at any point. R2 is remaining in the facility displaying aggressive and intimidating behaviors as observed by a surveyor and shares a room with another resident at this time. On 04/09/2024 at 12:59 PM Surveyor interviewed V13 (Housekeeper) who stated in summary: The way R2 talks and looks at me, I don't know, I'm trying not to acknowledge him. It feels like R2 is targeting me, and couple other residents as well. You know how he looked at you when you were in the unit today? R2 does the same to me. It seems like R2 is looking for trouble. It is hard to understood what he's mumbling under his breath too, but I make sure R2 is never behind my back. R2 also writes in his room and on the bathroom walls. I saw R1 after the incident (on 03/17/2024), and he looked really bed, swollen. Residents are asking me why they (facility staff) are not doing anything about R2, they feel very uncomfortable with him on the unit. Everyone is aware that R2 is aggressive. On 04/10/2024 at 10:38 AM Surveyor interviewed V11 (Certified Nursing Assistant) who stated in summary: On 03/17/2024, I was working on the night shift (10:00 PM to 7:00 AM). R2 was walking through out the unit most of the night. No one mentioned that R2 required additional monitoring. R2 was a new resident at that time, I was not familiar with him. When there is newly admitted resident in the unit, they should be monitored more frequently. I don't believe there is a specific policy for that, it is my personal experience. On 04/10/2024 at 12:40 PM Surveyor interviewed V17 (Licensed Practical Nurse) who stated in summary: R2 was a new resident. I got a report upon beginning of my shift, but I was not endorsed anything special about R2. When we have a new resident, we should monitor every hour for about 3 days. The monitoring occurs between nurses and CNAs. Surveyor clarified if V17 (LPN) addressed R2's manic behavior on 03/17/2024 before the incident occurred, V17 said, R2 was sent out to the hospital for behavioral evaluation after the incident; however, V17 (LPN) did not directly answer surveyor's question. Based on the record review, there is no documented interventions for R2's escalation in maladaptive behavior on 03/17/2024 between 11:00 PM and 4:00 AM. On 04/11/2024 at 11:09 AM PM Surveyor interviewed V2 (Director of Nursing) who stated in summary: Resident's change in condition is any abnormality in resident's condition, ex. decline in functional ability, change in labs, vital signs, or behavior. The expectation is for the nurse to call the doctor and family to notify of resident's change in condition, monitor, and carry out physician's orders in regard to change in resident's condition. Also, document of any change in condition for 72 hrs or until change if condition has resolved. On 04/10/2024 at 3:23 PM Surveyor interviewed V27 (Medical Director) who stated in summary: I am a medical director of this facility. I don't know specific details about the incident that occurred between R2 and his roommate on 03/17/2024 but I was notified that they had an altercation. R2's roommate was alert to self and had history non-compliant behaviors. He had BIMS of 7 which means severe cognitive impairment. If R2 had BIMS of 13, that means he is not severely impaired and is able to understand and comprehend. Based on the BIMS score, it does not seem these two residents are at the same level. If two residents like that are monitored and assisted, their cohorting may be acceptable; however, if there is lack of supervision and monitoring, it would not be appropriate. On 04/11/2024 at 1:30 PM Surveyor interviewed V34 (Primary Metal Health Nurse Practitioner) who stated in summary: R2 was referred to psychiatry post the incident on 03/17/2024. I assessed R2 on 04/01/2024. R2 was very aggressive and irritable during my assessment that day. R2 was very guarded, not easy, and not very friendly. Facility should monitor residents like R2 closely and make sure their roommates are safe. Resident displaying agitation would not be appropriate to be placed in the same room with cognitively and visually impaired roommate. Especially, a resident who is visually impaired might invade others' space and appear as wandering into another's resident private space. That can cause a conflict. I would expect that a resident who displays aggressive behaviors, such as psycho motor agitation, in simple words, when some trying to hit, kick, bite, push, but also, call names, clench fists, mumble under their breath, or position in fight stand, should be initially admitted into a private room under close monitoring. Aggressive behavior may also take on indirect form, including walking up behind somebody, into their personal space, it's like bullying. R2 was definitely not appropriate to be placed with his roommate. The facility Behavior Symptom Tracking, Assessment, and the Behavior Management Program police dated 04/2014 reads in part, Staff will document residents' maladaptive moods and/or behaviors in order to track and utilize data to determine patterns and trends of resident conduct and lead to improved care planning and treatment. Upon witnessing any maladaptive moods and/or behaviors, staff's first priority is to maintain safety of residents, staff, and visitors. Any necessary interventions, as trained, to maintain safety will be performed.

Based on interview and record reviews, the facility failed to conduct pain assessment and provide necessary care and treatment on a resident complaining of chest pain. This deficiency affect one (R5) of one resident reviewed for pain. This deficiency resulted in R5 experiencing severe chest pain, eloped from the facility without shoes on, to go to the nearest emergency room for further evaluation and treatment. Findings include: R5 is a [AGE] year-old, female, admitted in the facility on 10/20/23 with diagnoses of Schizophrenia, Unspecified; Schizoaffective Disorder, Unspecified; Dementia in other Diseases Classified Elsewhere, Moderate, with Other Behavioral Disturbance; and Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. MDS (Minimum Data Set) dated 04/01/24 documented R5's BIMS (Brief Interview for Mental Status) score of 9 which means moderate impairment in cognition. According to progress notes dated 04/06/24, at around 9:30 PM, V4 (Licensed Practical Nurse, LPN) observed the alarm on the back door gone off and sounding. Code Green for elopement was called and headcount on the unit was initiated. One staff went outside to look for a resident who left unattended but reported did not see anybody. Another staff helped with the head count. As staff conducting head count, a staff from another unit received a call that R5 was in the hospital. On 04/08/24 at 2:12 PM, V3 (Certified Nurse Aide, CNA) was asked regarding incident on 04/06/24 with R5. V3 stated, On 04/06/24, I was the CNA on the floor, and she (R5) was my resident at the time. Like around 8:00 to 9:00 PM, I started putting residents on bed. She came to me and asked if I was her CNA. I said yes and asked if she needs something. She said she needed a brief and a blanket. I gave it to her, and she went back to her room. She is not incontinent. Then, I continued to put other residents on bed. Suddenly, the door alarmed. V4 (Licensed Practical Nurse, LPN) called me to check the alarm. He (V4), I and V30 (CNA) checked residents in their rooms and did a head count. While we were doing the head count, V28 (LPN) came down and said that R5 was in the hospital. V4 was also interviewed on 04/08/24 at 2:45 PM, stated, On 04/06/24, I was the nurse assigned on R5. Around 9:30 PM, I heard an alarm went off from the unit exit door. I asked myself, maybe somebody must have used the door. So, I called Code Green right away. Code Green is for elopement. My staff, V3 and V30 went to the door and went outside. While I do the head count, I found out R5 was missing. That would be like 9:40 PM already. As we were doing the head count, V28 came down and said hospital called, said R5 was in the hospital. I called hospital, was told that she (R5) was with them, in the emergency room . R5 was able to leave facility on 04/06/24 unnoticed, unsupervised. R5 is a resident in the Memory Care Unit, a secured and locked unit in the facility. Observation on 04/09/24 at 10:25 AM showed that the hospital is located two blocks east from the exit door where R5 exited on 04/06/24. The hospital is situated at the intersection of a busy street. On 04/09/24 at 10:40 AM, R5 was observed sitting in her rollator walker by the nurses' station. Alert and oriented, R5 was asked regarding incident on 04/06/24 when she eloped from the facility and went to the hospital. R5 stated, I was in the hospital down there. I had chest pain and I had pain in the stomach and tooth pain. That time, I told the nurse (don't know his name) that I was having chest pain and he was not paying attention or anything, so I walked down there to the hospital. I was gone for a day. I was scared that I might be having a heart attack, it frightens me. R5 also mentioned during follow up interview, When I went to the hospital, I was on my feet, no socks. I walked on the rocks. A lady passed by and she said if I needed help. She helped me and brought me to the hospital. I was having extreme pain on my chest, 8 out of 10, (8 meaning severe pain). I had tooth ache as well and pain in my left armpit. I was thinking I was having a heart attack at the time because I had one before and I know how it feels. I was actually short of breath when I get into the hospital. On 04/09/24 at 9:33 PM, V10 (Hospital Staff) was interviewed regarding R5. I was the nurse assigned to her (R5). That was last Saturday, 04/06/24, she was found in the middle of the road by a bystander. The bystander called paramedics and she was sent here. She had no shoes at the time, said she was having chest pain. V29 (Physician/Hospital) also mentioned during interview, On 04/06/24, she was found wandering and came for chest pain. She was admitted for chest pain. She is alert, oriented to time, place and person. I was told by her (R5) that she left on her own and she was having chest pain, and she was admitted . Hospital records dated 04/07/24 recorded that R5's chief complaint was chest pain. According to history of present illness, R5 resented to the emergency department after found wandering in traffic with a walker and without shoes. R5 stated she has been experiencing left sided chest pain for 3 days. She describes a fullness at her chest. She has new onset tooth pain, SOB (shortness of breath and left upper extremity pain. She reports alerting nursing home staff of her symptoms. She became concerned due to having history of a heart attack and decided to leave the facility due to not getting proper care. Hospital records also documented the following: Past Medical History: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris Review of systems: HENT (Head/eye/nose throat): tooth pain Cardiovascular: Positive for chest pain and leg swelling (chronic). Respiratory: Positive for shortness of breath Musculoskeletal: Positive for left upper extremity pain Clinical Impression: Chest pain, unspecified type R5's hospital discharge summary dated 04/08/24 indicated: Diagnosis: Atypical Chest Pain Progress notes dated 04/08/24 time stamped 8:59 PM recorded R5 came back to facility. On 04/10/24 at 3:13 PM, V4 (Licensed Practical Nurse, LPN) was asked if R5 complained of chest pain on 04/06/24. V4 stated, On 04/06/24, I was the nurse assigned on R5. No, she did not complain of any chest pain. I was not aware of her having chest pain. V1 (Administrator) was also asked regarding R5 chest pain on 04/06/24. V1 verbalized, On 04/06/24, I was notified by V4 that she (R5) was missing. When she (R5) came back, I spoke to her, did not mention that she went to the hospital because of chest pain. I called hospital and was told that she went there because of bunch of reasons but not chest pain. On 04/10/24 at 3:22 PM, V27 (Medical Director) stated during interview, I was not aware that she had chest pain. I was notified that she just eloped. Typically, if a resident complained of chest pain, take vital signs, make them stable and call paramedics to hospital as ordered. V36 (LPN) was interviewed on 04/15/24 at 1:43 PM regarding R5. V36 mentioned, I have taken care of R5. I am not aware of any chest pain complaint, just body pain. If a resident complained of chest pain, if they have an order for Nitro, we give it to them. If no order, I will call physician for order; monitor resident, take vital signs and follow physician's order. On 04/16/24 at 10:14 AM, V32 (Assistant Director of Nursing) was asked regarding chest pain. V32 verbalized, When a resident is complaining of pain, staff must do the vital signs, notify physician and send resident out as ordered. Pain is subjective, we cannot say they are not having it. Whatever residents say if it is pain, it is pain. R5's care plans (CP) documented the following: ADL (activities of daily living) functional performance deficit (CP dated 04/04/24) - Intervention: Monitor for presence of pain, intolerance during ambulation. Potential for altered cardiac function (CP dated 04/04/24) - Intervention: Monitor for changes in status and report to MD (Medical Doctor) as needed. Potential for alteration in health condition (CP dated 04/04/24) - Intervention: Notify MD and family with any changes in condition. Facility's policy titled, Pain Management Evaluation dated 09/2020 stated in part but not limited to the following: Purpose: Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. Procedure: 2. Acute pain is generally pain of abrupt onset and limited duration, often associated with an adverse chemical, thermal or mechanical stimulus such as surgery, trauma and acute illness. 4. During the pain evaluation, determine the most workable pain rating scale for the resident. The following scales are available: a. The numeric rating scale (NRS): 1-3 (mild), 4-6 (mod), 7-10 (severe); b. PAINAD scale 1-3 (mild), 4-6 (mod), 7-10 (severe); 5. Pain will be evaluated each shift Facility's policy titled Change of Condition (Resident) dated 09/20 documented in part but not limited to the following: Purpose: To ensure that the resident's physician/physician on call/NP (Nurse Practitioner) and responsible party is kept informed regarding the resident's change in condition. Policy: The attending physician or physician on call/NP and responsible party will be notified with changes in a resident's condition.

Based on interview and record review, the facility failed to follow their Abuse Prevention Policy by not keeping residents free from physical and verbal/mental abused by staff. These failures applied to two (R15, R19) of seven residents reviewed for abuse and resulted in R15 experiencing mental abuse by feeling retaliated against by a staff member and R19 was physically abused by staff hitting R19 with a hanger to the right buttock, leaving a red discoloration. Findings include: R19 is a [AGE] year old male admitted to the facility 7/17/2020 with diagnoses of Alcohol abuse with alcohol-induced anxiety disorder, Unspecified Dementia, Hypertension and dysphagia. According to R19's health record, he is dependent on staff for activities of daily living. On 9/16/23 R19 made an allegation of physical abuse against V4 CNA. Progress note dated 9/16/23 stated, The writer was at the nurse's station and heard a loud popping sound and I traced the sound in the hallway. I then saw the above resident frantically stumbling toward his bed and I asked him if he is ok and then he stated The CNA hit me I stat pulled the cna off the floor and approached her at the nursing station in regard to the accusation. The assistant administrator/MOD [Manager on Duty] at that time was notified immediately. Administrator, POA (Power of Attorney), Don [Director of Nursing], Np [Nurse Practitioner], and [Medical Doctor] made aware. I immediately did a full body assessment on the resident, and I observed a red discoloration on the Rt buttock. The resident denies pain and refuses pain medication at this time. This incident was reviewed and investigated by V1 Administrator shortly after the incident occurred. On 10/31/23 at 11:44AM V1 said when the event occurred, the assistant administrator was on duty and in the building. V39 Assistant Administrator removed V4 from the building immediately and called me. He said, there was an allegation which V4 admitted to. I came to the facility shortly after and began my investigation. I interviewed V4 a few days later and she admitted to hitting R19 with the hanger as well. I told her that she was terminated for not adhering to the abuse policy. She did not return to the facility since the incident occurred. Facility Abuse Policy revised 9/2020 states in part; This facility affirms the right of our resident to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: 3. Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. This facility is committed to protecting our resident from abuse by anyone including, but not limited [NAME] facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends or any other individuals. This facility will not knowingly employ individuals who have been convicted of abusing, neglecting or mistreating individual. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Willful mean the individual acted deliberately, not that the individual must have intended the injury or harm. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and /or maintain physical, mental and psychosocial well-being. This includes suspicion of a crime. Assuring that physical restraints re used sparingly and properly and that chemical restraints are not used. This assumes that all instances of abuse of resident, even those in a coma cause physical harm or pain or mental anguish. 40718 R15 is a [AGE] year-old male with a diagnoses history of Recurrent Major Depressive Disorder, Unspecified Convulsions, End Stage Renal Disease, Type II Diabetes Mellitus with Complications, Diaper Dermatitis (August 2023), Legal Blindness, and Amputations of Fingers and Lower Limbs who was admitted to the facility 07/31/2017. R15's current care plan initiated 07/20/2022 has a history of physical aggression towards others due to poor impulse control with interventions including validated his feelings and ensured his safety; remove resident form any potential situation which could precipitate aggressive behavior. Final Facility Reported Investigation Report dated 05/13/2023 documents on 05/03/2023 a staff member reported that R15 made an allegation of abuse toward a staff member with the specific allegation against staff being unclear in the report; documents his allegations were inconsistent and range from verbal abuse to denying all allegations; R15 reported that he thought a staff member was speaking about him in the hallway about him not needing any help with his care; The CNA (Certified Nursing Assistant) in question (name not included in report) was interviewed by the charge nurses regarding R15's claims that he requires no assistance and when the CNA asked R15 if he had any concerns about his care he became verbally abusive, used profanity against the staff and requested she leave his room stating he does not want her to provide him with care; R15 has a history of false allegations and verbal aggression toward staff; Staff denied witnessing any form of abuse against R15; R15 did not have any roommates at the time of the alleged incident; R15's provided inconsistent accounts of the alleged incident; The allegation was not substantiated. Investigation statement dated 05/03/2023 documents R15 reported that V31 (Certified Nursing Assistant) was negligent in her care towards him, she never brought him his food and he heard her in the hallway stating R16 was bitching about his food, to another CNA and when he confronted her she stated she was just playing with him; R15 then reported another incident in which he asked her to go to his closet and give him a shirt out of his bag and she told him that she wasn't going to do it because these were too many clothes to go through so first shift staff can do it. R15's investigation statement dated 05/03/2023 documents V31 (Certified Nursing Assistant) went off on him because he reported to V33 (Certified Nursing Assistant) that she won't change him or give him his food and the CNA stated she didn't appreciate him informing V33; R15 felt it was retaliation from reporting her to V33. Investigation statement dated 05/04/2023 documents V27 (Licensed Practical Nurse) reported V33 CNA (Certified Nursing Assistant) came to report how rude and unruly the CNA was with herself, the nurse on duty and the resident and V27 advised she write a statement and leave it with the Director of Nursing. Resident Post Occurrence Follow Up report dated 05/12/2023 documents R15 reported his CNA approached him asking if everything is ok and asked if he told people that she's not doing her job, he didn't appreciate her questioning him, so he went off on her. Investigation statement dated 05/03/2023 from V33 (Certified Nursing Assistant) documents Attn V34 (Former Director of Nursing): Today R15 asked me to report V31 (Certified Nursing Assistant) negligent behavior towards him, he stated that she never brought him his food and he heard her in the hallway stating R16 was bitching about his food, to another CNA and when he confronted her she stated she was just playing with him; R15 then reported another incident in which he asked her to go to his closet and hive him a shirt out of his bag and she told him that she wasn't going to do it because these were too many clothes to go through so first shift staff can do it. R15 states that he doesn't want her to come in his room or care for him, upon notifying V32 (Registered Nurse) of what R15 stated V31 walks up and asks if R15 was talking about her and what was said, I asked V32 if it was ok to repeat what R15 stated and he said it was ok, upon hearing what R15 had to say V31 went in the room and confronted him and made him furious, I went in the room and calmed him down, moments later she walked in to another 1st floor room and stated she is gonna spaz out on everybody report people to the state and anybody can get it just loud unprofessional and rude, I spoke to V27 (Licensed Practical Nurse) about this and she advised to inform you (V32). On 11/01/2023 from 12:16 PM - 2:10 PM V1 (Administrator) stated V33 (Certified Nursing Assistant) initially reported R15's allegation regarding V31 (Certified Nursing Assistant). V1 stated the investigation report documents V31 stated to R15 regarding his allegation, did you tell people that I wasn't doing my job, but V31 was not hostile or confrontational when using those words and asking that question. V1 stated she could see it being offensive for a resident to be asked that question by staff. V1 stated V31 wasn't privy to R15's history of being aggressive and hostile towards staff because that wasn't her experience with him. V1 stated staff are responsible to familiarize themselves with residents based on their care plans. V1 stated it's not appropriate for staff to ask residents about allegations made against them and it could trigger R15. V1 stated she would train staff on resident rights and behavior management to address these issues. On 11/01/2023 at 2:45 PM V1 (Administrator) stated it is subjective as to whether a resident would feel intimidated by staff when being asked about an allegation the resident reported against them. The facility's Abuse Policy reviewed 11/02/2023 states: This facility affirms the right of our residents to be free from abuse. This facility prohibits mistreatment or abuse of it's residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment or abuse of our residents. This will be done by: Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. This facility is committed to protecting our residents from abuse by anyone including but not limited to facility staff. Abuse means any mental injury inflicted upon a resident other than by accidental means in a facility. Abuse is intimidation with resulting mental anguish. Willful means the individual acted deliberately, not that the individual must have intended the harm. Mental Abuse may occur through verbal contact which has the potential to cause the resident to experience intimidation, fear, agitation or degradation. Mistreatment is inappropriate treatment or exploitation of a resident.

Based on observation, interview and record review, the facility failed to re-evaluate fall care plan interventions for effectiveness after resident falls for residents assessed to be at risk of falling, and failed to have individualized interventions, taking resident cognitive function into account, included in the plan of care to meet specific resident needs to address re-current falls. This failure applied to three (R4, R5, R26) of three residents reviewed for falls and resulted in R4 having multiple falls and sustaining a laceration to the forehead, which required sutures; R5 had a fall which resulted in hospitalization for acute intracranial hemorrhage; and R26 having multiple falls and being observed to wander into other resident rooms unsupervised.The facility failed to keep a resident (R16) free from injury while being provided care by staff and by not implementing effective and personalized fall interventions for a resident (R17) with a history of falls. These failures applied to two (R16, R17) of two residents reviewed for accidents. Findings include: R5 is a [AGE] year-old man who resided at the facility from [DATE] to [DATE], with past medical history of Type 2 diabetes, Heart failure, Hyperlipidemia, Essential Primary Hypertension, Dysphagia, Gastro-Esophageal Reflux disease without Esophagitis, etc. Per record review, R25 (RN) documented the following on [DATE], resident fell , speech slurred able to lift right and left arm as well as stick tongue out with no deviation, however no improvement in speech. Resident sent out 911. Hospital record dated [DATE] states in part, [AGE] year-old male with past medical history of .presented from a nursing home after an unwitnessed fall. On arrival, CT head showed large acute intracranial hemorrhage with extension to right basal ganglia and 2mm midline shift. Neurosurgery consulted by emergency room physician, their evaluation pending. On my evaluation patient is obtunded, not following any command, occasionally moans to painful stimuli, systolic blood pressure is above 200. Review of death certificate showed that R5 expired on [DATE], cause of death was listed as non-traumatic intracranial hemorrhage. Care plan initiated [DATE] stated that R5 is at risk for falls related to the use of anti-hypertensive medication, unsteady gait, uses walker, requires assistance with toileting. Interventions include assist resident at night when he needs to go to the bathroom, orient resident to surroundings frequently, including location of bathroom, dining room, bedroom, etc., provide proper well-maintained footwear, etc. The additional intervention after the fall on [DATE] was for resident to request assistance with transfer from staff. Care plan initiated [DATE] stated that resident has limited ability to manage and complete functional tasks due to balance deficit musculoskeletal. Interventions include to assist and instruct resident with all prescribed physician precautions, fall risk education and therapeutic exercises to improve balance ability. Minimum Date Set (MDS) assessment dated [DATE] section G (functional) coded R5 as requiring staff supervision with set up or one-person physical assistance for all ADLs. Section GG (functional abilities) of the same assessment coded resident as requiring supervision or touching assistance to partial to moderate assistance for ADLs. On [DATE] at 4:17PM V45 (LPN) said that she recalls R5 and recalls the last time he fell . R5 needed assistance with ADLs, he is incontinent sometimes but other times he goes to the bathroom. The day R5 fell , V45 said that she was working on the other side of the floor, another resident notified her that R5 was on the floor, resident stated that he was going to the bathroom when he fell . R45 added that she does not know the last time resident was seen by a staff before the fall. On [DATE] at 12:55PM, V25 (RN) said that he recalls R5, he was on break the day resident fell , according to the nurse that was covering for him, resident was grabbing something on his dresser and fell , he did not witness the fall.V25 added that R5 has fallen before and he is a fall risk, V25 said that he did not follow up with the hospital after resident was sent out, he did not complete the incident report either because he did not witness the fall, not sure if resident had any injuries. Fall incident dated [DATE] documented by V26 (LPN) stated that she was made aware resident needed assistance, resident noted sitting next to wall in bedroom with his walker on the floor next to him. Resident stated that he was going to the washroom and lost his balance. R5 also had a fall on [DATE] as documented by V26 (LPN) at 00:32, resident sustained an injury to the back of his head and was also sent to the hospital for further evaluation. On [DATE] at 12:24PM, V26 (LPN) said that she recalls R5, he can walk, he gets around on his own but requires staff supervision, she does not recall what resident was doing before the fall, she was notified by another resident. V26 cannot recall the last time herself or the CNA saw the resident before he fell . R26 is a [AGE] year-old female who was admitted to the facility on [DATE] with past medical history of essential primary hypertension, unspecified dementia, iron deficiency anemia, schizophrenia, generalized muscle weakness, etc. On [DATE] from 1:25PM to 1:30PM, observed about five residents sitting in one area in the dementia unit eating lunch and there was no staff in sight monitoring or supervising them. At 1:32PM, a resident came down from the hallway and stated that another resident came to her room while she was eating and did something in the garbage can on her roommate's side of the bed, she stated that she does not know who the resident is or what room she came from. Surveyor followed resident to her room and observed R26 lying down in the first bed, awake but confused and could not answer any questions, Surveyor also observed some yellowish liquid in the garbage can and on the floor in room. On [DATE] at 1:34PM, V6 (ADON) was spotted in the hallway, surveyor presented this observation to her, and she said that R26 is from (another) room, resident wanders. V6 walked resident back to her room, Surveyor notified V6 that there was some yellowish liquid in the garbage can in room (number provided) and the other resident complained that R26 did something in the garbage can, V6 looked in the garbage can and stated, that is urine, I will get housekeeping to take care of that, I bet you the other resident did that and is trying to pin it on R26 I don't think she will do something like that. On [DATE] at 1:37PM, V7 (CNA) was observed guiding resident to her room and told surveyor that this resident does that all the time, she wanders into other residents' rooms, pull her pants down and urinates anywhere, she has taken care of the resident for a while, and she does that all the time. Per facility fall log, R26 has had multiple unwitnessed falls since admission ([DATE] found on the floor in the dining room; [DATE], another resident informed staff that resident was on the floor in the nursing station; [DATE], resident was found on the floor in the hallway and sustained swelling to the right side of her face). MDS assessment dated [DATE] section G coded resident as requiring supervision with set up to one-person physical assistance for ADLs. Fall care plan initiated [DATE] stated that resident is at risk for falls due to poor safety awareness. Interventions include but not limited to encourage resident to keep room free of obstacles, encourage resident to report falls, resident was placed in a unit where she could be more closely monitored and constantly redirected, resident was sent to the hospital for further evaluation, provider was consulted for further evaluation, etc. R4 is a [AGE] year-old female who has resided at the facility since 2022 with past medical history of unspecified dementia, essential primary hypertension, underweight, muscle wasting, restlessness, and agitation, etc. MDS dated [DATE] section G coded R4 as requiring extensive assistance with one-person physical assist for ADLS, section H stated that resident is always incontinent of bowel and bladder. Fall care plan initiated [DATE] stated that R4 is at risk for falls related to having cognitive deficit, incontinence, muscle weakness, poor balance, poor safety awareness, etc. Interventions include assist resident to get up and out of bed when resident is not feeling sleepy, rounding of every two hours and prompt or assist for change in position, toileting, promote placement of call light within reach etc. R4 had an unwitnessed fall on [DATE], sustained a laceration to her forehead, was sent to the hospital and returned to the facility with sutures to her forehead. R4 also had unwitnessed falls on [DATE], [DATE], and [DATE]. On [DATE] at 2:04PM, V44 said that residents who are assessed as needing supervision could be more of cueing, not hands on, and depends on residents. Those who are assessed with weakness or lack of coordination should be monitored frequently, those in the memory care unit should be always monitored all day long. 40718 R16 is a [AGE] year-old female with a diagnoses history of Partial Paralysis, Cerebrovascular Disease, Contracture of Muscle Right Upper Arm, COPD, and Schizophrenia who was admitted to the facility [DATE]. On [DATE] at 12:46 PM R16 stated V35 (Certified Nursing Assistant) pushed her right hand into the left bed rail when turning her over and injured her hand. R16's Minimum Data Set assessment dated [DATE] documents she requires extensive one person assistance with bed mobility and totally dependent on two-person assistance for transfers. R16's current care plan initiated [DATE] documents she is noted to resist care with interventions including Accept residents right to refuse and show respect for residents decision. R16's progress notes dated [DATE] at 12:21 PM documents she reported to nursing staff that she was abused by a CNA (Certified Nursing Assistant); at 12:50 PM V28 (Licensed Practical Nurse) documented she was made aware that R16 was bleeding from her right hand, her right hand fifth finger area was bleeding, pressure was applied to stop the bleeding and area cleaned and wrapped with gauze. Final Incident Investigation Report submitted to the state agency [DATE] documents R16 made an allegation against V35 (Certified Nursing Assistant) concerning delivery of care; The incident occurred in R16's room and V35 was immediately sent home; Her roommates are alert and oriented and did not witness any abuse against R16, other residents interviewed expressed no concerns regarding the care rendered; R16 has given various reports in the past of her hand being broken years ago by her husband and her hand being broken from her bed when she was younger: R16 denies feeling intimidated by staff and has a history of hallucinations, delusions, erratic behavior, and bizarre thoughts. Resident Services Screening Tool dated [DATE] documents R16 reported her husband broke her hand and it had been broken for years, she broke her hand when she was a little girl, and she told them her CNA broke her hand too. Undated statement included in Final Incident Investigation Report submitted to the state agency [DATE] from V28 (Licensed Practical Nurse) documents a CNA (Certified Nursing Assistant) came to her and reported R16 was upset with her while performing activities of daily living care and she hit her, V28 went to R16's room and R16 stated she pushed me so hard, she hit me and broke my finger, she threw my pop away, right finger observed bleeding, area cleaned and bandage applied. Investigation statement from V29 (Scheduler) dated [DATE] documents V28 (Licensed Practical Nurse) notified me that R16 informed her that a CNA broke her finger and pushed her. Investigation statement included in Final Incident Investigation Report submitted to the state agency [DATE] from R33 (Resident) documents she reported she saw a CNA shove R16. Investigation statement dated [DATE] from V35 (Certified Nursing Assistant) documents when providing activities of daily living care to R16 she became upset and became physical with staff, during this incident R16 tore her skin in between her fingers with her long nails; V35 informed the nurse and was advised by the nurse that whenever R16 denies care to leave her. R16's undated investigation statement on allegation included of abuse included in Final Incident Investigation Report submitted to the state agency [DATE] documents a Certified Nursing Assistant jumped on her while she was taking care of her; her jaws and fingers are hurting; the person's name is V35 (Certified Nursing Assistant) pronounced in a different manner. On [DATE] from 12:16 PM - 2:10 PM V1 (Administrator) stated she believes she received two allegations involving resident care for V35 (Certified Nursing Assistant). V1 stated one resident reported he didn't like the way V35 was providing feeding assistance and she received another report from R16 with an allegation that V35 broke her hand. V1 stated CNA's (Certified Nursing Assistants) are informed if a resident becomes combative or resists care you should back off and request assistance because that's how reportable incidents occur. V1 stated it is plausible if R16 has long fingernails that her hands were caught down in the railings and possibly became wedged during the alleged incident and could have injured her finger that way. V1 stated R16's injury during the incident was a fresh wound on her hand. V6 (Assistant Director of Nursing) stated in the process of being repositioned or turned over it's possible for R16's hand to become wedged in between the mattress and bed rail. V6 agreed it can't be determined if this did or did not occur during the alleged incident. V6 stated the fact that V35 reported that R16's hand was injured while activities of daily living care was being provided is why she came to the conclusion that it's possible that R16's hand became injured in the process of receiving care in the manner in which it was described. R17 is an [AGE] year-old female with a diagnoses history of Stage 3 Chronic Kidney Disease, Dementia, and Other Specified Depression Episodes who was admitted to the facility [DATE]. R17's Quarterly Minimum Data Set, dated dated dated [DATE] documents she requires one-person physical assistance and supervision for walking in room, corridor, and ambulating on and off the unit. R17's current care plan documents she is at risk for falls due to Cognitive Deficits, Diagnoses and/or Disorders, Incontinence, Dementia, use of anti-hypertensive and psychotropic medication with interventions including assure resident is wearing eyeglasses; ensure that R17 takes brakes with ambulating and has somewhere to sit near the nurses station when she is there; Monitor for changes in ability to navigate the environment. R17's current fall care plan does not include supervision while ambulating. R17's incident report dated [DATE] documents he was observed sitting in her room on the floor, when asked why she stated she just wanted to sit down, upon assessment it was noted she had swelling on right side of her forehead. R17 was assessed, bed remained in lowest position. Injury included swelling of forehead. R17's progress notes dated [DATE] 07:10AM Post Occurrence Documentation states she was noted setting in her room on the floor, when asked why she was sitting on the floor she stated that she just wanted to sit down, upon assessment it was noted that she had swelling noted on the right side of her forehead. R17's progress notes dated [DATE] at 08:30 AM documents writer called PPHP (Provider Partner's Health Plan) hotline to report new findings from the follow-up on the resident whose right eye is now black and swollen; at 10:36PM writer assessed the resident and observed swollen on the right orbital region (right eye), vitals are stable nurse practitioner notified, ice packed was placed on the affected part, Resident complained of slight pain during shift writer continue to placed ice pack on patient affected part. On [DATE] from 12:16 PM - 2:10 PM V1 (Administrator) stated R17's black eye was due to a fall. V1 stated there was no root cause analysis completed for her fall in March, and she doesn't want to guess as to how she fell . V6 (Assistant Director of Nursing) stated R17 has an unsteady gate but isn't sure if this was her status in March. V6 stated R17 ambulates on her own, is very combative at times and walks all day on the unit. V1 stated R17 had a fall in [DATE] and [DATE]. V1 stated a root cause analysis should be done when a resident has a fall which would be documented under a risk management report and it there isn't one for her fall in March. V1 stated whatever is determined from a root cause analysis would be added to the care plan. V6 stated in January R17 fell in front of a nurses station after standing for a long period of time. V6 stated the results of the root cause analysis from that was impaired cognition and balance. V6 stated R17's incident report from March does not document where she was located but the black eye she sustained could have been from hitting her bedside table or dresser during the fall. V6 stated R17 doesn't need consistent supervision however, she refuses care daily and needs consistent redirection throughout the day. V6 stated one person staff supervision means having a staff member present with a resident to observe them directly when they are moving. V6 stated this means staff should have their eyes directly on R17 when she is self-ambulating. V6 stated R17's status of requiring one person staff assistance and supervision according to her quarterly minimum data set assessment from January means someone being present to observe her may have prevented her from falling in March. V1 stated R17 has a BIMS (Basic Interview for Mental Status) of 15 means she was able to pull her call light and if she pulled the call light when she had her fall in March someone could have assisted her. V6 stated R17 does not use her call light. V1 and V6 stated they are not sure if R17 was using her call light to request assistance in March. V1 stated she believes R17's fall was unavoidable because she has the cognition to be able to pull her call light. V1 agreed they would not be expecting her to use her call light for assistance based on her current behavior of not using it. The facility's Fall Management Policy reviewed [DATE] states: The facility is committed to minimizing resident falls or injury so as to maximize each resident's physical, mental and psychosocial well-being. While preventing all resident falls is not possible, it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment. Plan of care reviewed and updated at time of occurrence, quarterly, and as needed in order to minimize risk for fall incidents.

Based on observation, interview, and record reviews, the facility failed to provide adequate supervision to a cognitively impaired and vulnerable resident to prevent an injury that resulted in one resident (R2) sustaining a hematoma with a laceration of unknown origin to his right brow line; failed to provide medical treatment by not sending resident (R2) to the hospital for further evaluation of his injury after staff reported resident bumped his head into the wall multiple times. This failure affected one of five residents reviewed for improper nursing care related to supervision but has the potential to affect all 149 residents residing at the facility. Findings include: R2's face sheet indicates resident has a past medical history not limited to: Peripheral Vascular Disease, Unspecified Convulsions, Schizophrenia, Type 2 Diabetes with Unspecified Diabetic Retinopathy, Thrombocytopenia, and Presbyopia (age-related farsightedness). R2's care plan with last completion date of 05/16/2023 reads in part: has impaired cognitive functioning related to his mental diagnosis (Date Initiated: 06/18/2019); requires assistance with ambulation. Balance problems. Diagnosis: Type 2 DiabetesMellitus, Schizophrenia, Convulsions. History: Amputation of one right toe, and right second toe. Date Initiated: 06/20/2019; receiving anti-psychotic, psychotropic, and anti-depressant medications to manage symptoms related to his mental diagnosis (Date Initiated: 06/18/2019); has potential for injury related to seizure disorder (Date Initiated: 06/18/2019); at risk for abuse related to his diagnosis of severe mental illness. R2's Brief Interview for Mental Status dated 5/10/2023 showed score of 11 which indicates moderate cognitive impairment. R2's Resident Safety/Abuse Screening assessment dated [DATE] 20:05 (8:05 PM) indicates that resident has no history of unexplained injuries or self-injurious behaviors, is easily redirected, has no history of or current repetitive verbalizations or behaviors, and has no history of or current socially inappropriate behavior. R2's assessment dated [DATE] 16:54 (4:54 PM) indicates that R2 is not easily redirected and has a history of socially inappropriate behavior. On 06/26/2023 at 12:48 PM, observed R2 standing in the hallway on the second floor in front of his room door. At 12:50 PM, R2 pointed to the right side of his forehead then said he had a knot on my head from a female aide who threw me into the door then into my bed. Resident added that his head was dripping blood. R2 said the incident happened five and a half days ago and there was three female aides present but only one pushed me into the door then onto the bed. Observed a raised area to resident's right brow line with a small laceration to the center of the raised area with no visible drainage noted at this time. On 06/26/2023 at 1:02 PM, V5 (Certified Nursing Assistant/CNA) said last week, R2 thought he was moving downstairs and took an armful of his personal belongings with him down the elevator. V5 pointed to the elevator across from the second-floor nurses' station where this surveyor observed a keypad on the wall next to the elevator doors. V5 (CNA) then said staff had redirected the resident (R2) back to the second floor when he slipped on something while coming off the elevator. V5 said it started as a skin tear then the area swelled up later. When asked if she observed R2 exit from the elevator on day in question, V5 (CNA) said no. On 06/26/2023 at 1:05 PM, V4 (Licensed Practical Nurse) said R2 was not sent out after the incident but was most likely seen in-house by the nurse practitioner. Upon leaving second floor unit, V5 said a code is needed to use the elevator and proceeded to enter a code onto the keypad next to elevator doors for surveyor. At 3:00 PM, surveyor informed V1 (Administrator), who is also the abuse coordinator, of the allegation made by R2. No documentation found indicating R2 was assessed by a physician post injury. R2's nurses note dated 6/26/2023 17:32 (5:32 PM) reads in part, resident reported to staff that he was allegedly pushed into a wall and hit his head. Complete head to toe assessment was performed at that time. Resident was not observed with any swelling, lacerations or signs of injury at that time. Staff will continue to monitor. Nurses note dated 6/20/2023 17:40 (5:40 PM) reads in part, skin tear with bleeding was observed on resident [right] eyebrow upon coming out of the elevator, findings revealed that resident kept bumping into walls during activities and prior to returning to the unit. Resident was assessed, pressure was applied on the tear, ice pack was applied, [as needed acetaminophen] 650 milligrams administered. Resident is in stable condition, will continue to monitor him. No documentation found indicating R2 was sent to local hospital for evaluation or assessed by a physician post injury. On 06/27/2023, V1 (Administrator) provided initial incident investigation report regarding R2's allegation that reads in part, date of incident 06/21/2023 then continues with on 06/26/2023 resident alleged to surveyor that 5 days ago, three women pushed him into a wall and onto his bed causing his head to bleed. Response for any obvious or complaints of injury reads none. R2's social services note dated 6/27/2023 16:48 (4:48 PM) reads in part, it was reported that the resident made allegations against three unknown women. He reported they pulled or pushed him up against the wall. While interviewed it was reported he said, I didn't deserve to be raped like that! Resident added to the 72hr wellbeing checks. An investigation has been initiated. Staff will continue to monitor resident and the doctor was notified as well as nursing notified the family. No documentation found indicating R2 was previously placed on wellbeing checks or being routinely monitored by staff to avoid any accident and/or injuries. On 06/28/2023 at 12:18 PM, V1 (Administrator) said there was no abuse or staff identified in the investigation of R2's allegation. Reviewed routine resident checks policy dated 09/20 that reads in part: To ensure the safety and wellbeing of our residents, a resident check will be made at least every two hours throughout each 24-hour shift by nursing service personnel. Resident checks involve entering resident's room to determine if resident needs are being met, if there is a change in condition, if resident has any complaints, etc.

Based on observation, interview and record review, the facility failed to ensure residents receive care consistent with professional standards of practice to prevent avoidable pressure ulcers from developing; failed to follow their policy for wound prevention by failing to provide the necessary treatment and services to prevent and promote healing of a facility developed pressure ulcer for 1 of 3 (R109) residents reviewed for pressure ulcers in the sample of 32. These failures resulted in R109 sustaining a clinical stage 3, facility-acquired pressure ulcer to the right hip. Findings include: R109 is a [AGE] year-old male admitted to the facility on [DATE]. R109 was hospitalized on [DATE] and is not currently in the facility. R109 is a cognitively impaired resident with diagnosis including but not limited to: Unilateral Primary Osteoarthritis to Right Knee; Fusion of Spine to Thoracic Region; History of Falling; Spondylosis of lumbar Region; and Cognitive Communication Deficit. MDS (Minimum Data Set) assessment dated [DATE] completed upon admission, shows R109 does not present with any pressure ulcers. R109 requires extensive assistance of two+ person physical assist with bed mobility. R109's Braden scale assessment dated [DATE] reads that R109 is at moderate risk for developing pressure ulcer. Facility records showed no care plans to prevent the development of any pressure ulcers nor was any care plan developed after the formation of the facility-acquired pressure ulcer. Per record review, R109 has facility acquired stage 3 pressure ulcer to the right hip measuring 5.5cmx4.5cmx0.1cm. On 04/26/2023, general observations conducted on the unit 3, showed R94 with multiple linens on the special mattress and another resident R127 was observed with multiple linens with no specialized mattress. Per record review, R94 has facility acquired re-opened sacral stage 2 pressure ulcer measuring 0.2cmx0.2cmx0.1cm. Per record review, R127 has facility acquired healed sacral stage 2 pressure ulcer. On 4/26/2023 at 2:51 PM Surveyor interviewed V13 (Registered Nurse/ Wound Care Coordinator), V13 stated, R109 has facility acquired wound, it was noticed on 4/12/2023. Upon initial assessment on 04/12/2023, the pressure ulcer measured 5.5cmx4.5cmx0.1cm. The family was made aware, we explained the treatment and protocol. Recommended treatment was Santyl ointment and Opti foam. R109 was able to move, so he was not enrolled in turning program. V13 further indicated that one of R109's interventions to prevent pressure ulcer was air mattress; however, it was ordered after his pressure ulcer was discovered. Staff also used skin barrier ointment as a standard protocol. On 4/26/2022 at 03:53 PM Surveyor interviewed V16 (Wound Care Nurse Practitioner), V16 stated, R109 developed stage 3 pressure ulcer to right hip. It was reported to me on 04/12/2023. I measured it at 5.5cmx4.5cmx0.1cm, it was 70% necrotic at the time. I debride it and it was staged at 3. Santyl and foam dressing were prescribed to be applied daily. When I saw R109, he was laying on his right side. R109 needed assistance with repositioning and couldn't turn himself. V16 further clarified that he didn't see R109's pressure ulcer again because R109 was transferred to the hospital on 04/18/2023. Prevention and Treatment of Pressure Injury and Other Skin Alterations dated 04/2021 reads in part, Identify residents at risk for developing pressure injuries. Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through the individual program plan. Based on individual Braden Scale Assessment, implement measures according to the Pressure Injury/Prevention Algorithm.

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidental falls and injuries for two of four (R11, R109) cognitively impaired residents reviewed for accident hazards in a sample of 32. This failure resulted in R11 sustaining a left humerus (arm) fracture that required emergent transfer to the hospital for medical treatment; and R109 sustaining a head laceration that required emergent transfer to the hospital for medical treatment. Findings include: 1. R11's medical records showed he is a [AGE] year-old and cognitively impaired resident with a past medical history not limited to falls, gait and mobility abnormalities, difficulty in walking, lack of coordination, and weakness. R11's fall report dated 01/09/2023 showed R11 was found sitting on the floor by V18 (Licensed Practical Nurse) and he was holding his left arm yelling out it hurt. R11 was sent emergently to the hospital and admitted on [DATE]. New intervention showed to round on resident at a minimum of 2 hours. R11's orthopedic initial consult dated 01/10/2023 showed R11 was diagnosed with a left humerus (arm) fracture. R11's Nurses Note dated 1/10/2023 15:05 showed R11 remained in the hospital status post fall on 01/9/22 which resulted in the resident being admitted . R11 sustained a displaced fracture of the distal humerus of his left arm, but no operation is needed according to the Surgical physician. On 04/25/2023 at 10:54 AM, observed R11 lying in bed, partially on his left side wearing a hospital gown. Bed position was knee high level and not low to the floor. R11 was positioned near the edge of the bed with both feet hanging off the side of bed. No fall mats were observed on the floor or within R11's room. On 04/26/23, observation period made by surveyor on 1 West and 1 East units from 09:20 AM to 11:35 AM with the following noted. At 09:25 AM, observed R11 lying in bed on his back near the edge of the bed wearing a hospital gown with both legs hanging off the side of bed from his knees down. Bed position was knee high level and not low to the floor. No fall mats were observed on the floor or within R11's room. Observed call light clipped to the bottom sheet at the head of R11's bed and not within resident's reach. At 11:30 AM, observed R11 lying in bed on his back near the edge of the bed with both legs hanging off the side of bed from the knees down. Bed position was at waist high level and not low to the floor. Observed call light clipped to the bottom sheet at the head of R11's bed and not within resident's reach. On 04/26/2023 at 1:40 PM V9 (Restorative Nurse) said R11 is a fall risk due to history of falls and behaviors. V9 said R11 was placed on 2-hour rounding after the fall in January. She added that R11 was placed in a high low bed to the ground when in bed, or as low as it will go. V9 then said, as a team, we double check staff are checking on all residents, especially high fall residents every two hours and R11 does not have fall mats due to how his room is, and res has been okay without them. On 04/26/2023 at 3:58 PM, V18 (Licensed Practical Nurse) said she was working the day of R11's fall incident. V18 said when she entered R11's room, he was sitting on the floor holding his arm and complained of left arm pain. V18 then said upon assessment, R11's left arm was deformed looking so she called the physician who ordered a stat (immediately) x-ray of his arm. V18 added that the x-ray results showed a fracture and R11 was sent 911 (emergent) to the hospital. On 04/26/2023 at 04:20 PM, V25 (Certified Nursing Assistant) said on the day of R11's fall, she went to his room and saw him sitting in a chair. V25 said that she told R11 she needed to weigh him but needed to get someone to help stand him up. V25 said when she returned to the room with V18 (Licensed Practical Nurse), R11 was sitting on the floor and holding his left arm and said he fell . V25 was unable to identify any fall preventions for R11. R11's quarterly fall risk assessment dated [DATE] showed R11 to be at risk for falls. R11'S fall care plan dated 02/22/2023 reads in part: R11 is at risk for falls related to history of falls with interventions to assure he is in view of staff when out of bed (12/22/2020), promote placement of call light within reach (11/21/2017), round on resident at a minimum of 2 hours, toileting and offering him snacks and water (01/10/2023). No staff were observed entering R11's room or rounding on him during surveyor's observation period on 04/26/2023 from 09:20 AM to 11:35 AM on 1 West. 2. R109 is an [AGE] year-old male admitted to the facility on [DATE]. R109 was hospitalized on [DATE] and is not currently in the facility. R109 is a cognitively impaired resident with a history of falls and diagnosis listed in part with: Unilateral Primary Osteoarthritis to Right Knee; Fusion of Spine to Thoracic Region; History of Falling; Spondylosis of lumbar Region; and Cognitive Communication Deficit. R109's fall risk assessment dated [DATE] showed R109 to be at risk for falls. On 04/18/2023 R109 was found on the floor by the staff with bleeding to the face. V109 was sent to the hospital on 04/18/2023 and diagnosed with a laceration to the forehead that required stitches. Hospital records dated 04/18/2023 read in part, R109 seen on 04/18/2023, Upon emergency department arrival noted laceration to the forehead and previous lacerations from other falls. Assessment and plan: History of fall; forehead laceration, stitched. On 04/24/2023 at 11:00 AM Surveyor interviewed V23 (R109's family member), V23 said that whenever he came to visit R109 the bed was 2.5 - 3 feet off the ground and no fall matts were present on the floor. On 04/26/23 at 12:23 PM Surveyor interviewed V9 (Registered Nurse/Fall Coordinator). V9 said that R109 had two most recent falls. V9 stated, I investigated both of R109's falls on 04/16/2023 and 04/18/2023, both were unwitnessed. On 4/16/2023 he was trying to transfer from the wheelchair into the bed and ended up falling. R109 was sent out to the hospital for further evaluation; he suffered abrasion to the face. The second fall was on 4/18/2023. R109 attempted to reposition himself in the bed and had fallen out of bed. R109 suffered laceration on the forehead. Staff provided wound care and sent R109 out to the hospital. On 04/27/2023 at 01:46 PM Surveyor interviewed V24 (Licensed Practical Nurse), V24 stated, R109 fell in the evening on April 16th, 2023. He just used a washroom and we put him back in the wheelchair. Shortly after, I was passing evening medications and I found him on the floor. I assessed R109 and put him back in the wheelchair. R109's right eyebrow had some bleeding, I put pressure onto the wound and 911 was called. R109 went to the hospital, where he received 4 sutures and was brought back to the facility on the same day. I immediately called V22 (R109's family member) and told him what happened. I called V22 again when I got an update from the hospital. On April 18th, 2023, R109 was sleeping during my morning rounds. As I was passing morning medications, the CNA came to me and told me that R109 fell again. I went to the room and saw R109 laying on the floor. His face was laying on the nightstand. R109's right eyebrow reopened, and he had additional cut on the right cheek. I called 911 again and R109 was send to the hospital. I called the V22 again to notify him of the incident. R109'S fall care plan dated 07/05/2022 reads in part, Monitor for changes in gait or ability to ambulate; Monitor resident for tolerance and endurance; Use proper fitting, non-skid footwear. Care plan did not include any additional interventions previous to the falls that R109 suffered on 04/16/2023 and 04/18/2023 even though R109 was cognitively impaired and assessed as a fall risk resident. Management of Falls policy dated 08/2020 reads in part the following: Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Procedure: 3. Develop a plan of care to include goals and interventions which address resident's risk factors. 4. Provide assistive devices for mobility, hearing and vision as appropriate for resident. 6. Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards. Routine Resident Checks policy dated 09/2020 reads in part the following: Policy Interpretation and Implementation: 1. To ensure the safety and well being of our residents, a resident check will be made at least every two (2) hours throughout each 24-hour shift by nursing service personnel. 2. Routine resident checks involve entering the resident's room to determine if the resident's needs are being met. On 04/26/2023, facility presented a two page in-service attendance record dated 04/25/2023 for Falls and Fall Interventions. 46066 On 04/26/23 12:23 PM V9 (RN/Fall Coordinator), I investigated both falls on 04/16/2023 and 04/18/2023, both were unwitnessed falls. The resident had to be redirected multiple times, on 4/16/2023 he was trying to transfer form his wheelchair into the bed and ended up falling. He was evaluated, vitals were done. He did not call for help. His wheelchair was locked. When resident was in bed, they were fall matts. DON, guardian and MD was notified. He was sent out to the hospital for further evaluation. He suffered abrasion to the face. The second fall was on 4/18/2023. The resident attempted to reposition himself in the bed and had fallen out of bed. He did not call for help. Staff assessed him and assisted him back to bed. Resident suffered laceration on the forehead. Staff provided wound care and sent out to the hospital. Fall mats were paced on the floor, bed was in the lowest position and call light was within resident's reach.

Based on observation, interview and record review the facility failed to ensure quality care and treatment for one resident and failed to implement physician ordered wound treatments. These failures affected one of three residents (R1) reviewed for quality of care. Findings include: 1. R1 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's brief interview for mental status dated 5/30/22 documents a score of 15/15 which indicates cognitively intact. R1's medical record documents resident was hospitalized on [DATE] and returned to facility on 6/7/22. R1 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's treatment administration record for June 2022 documents an order dated 6/7/22 for [MEDICATION(S)] solution. Apply to both feet topically every night paint with [MEDICATION(S)] and wrap with kerlix. The treatment record on 6/7/22, 6/8/22, 6/9/22, 6/11/22, 6/12/22, 6/14/22, 6/16/22 and 6/18/22 do not document any treatment given or refused. On 6/10/22, 6/13/22, 6/15/22, and 6/17/22 it documents a 2 which indicates refusal. R1's progress note dated 6/18/22 documents: When offered wound care this morning resident refused. White worm like bugs present on dressing and around left foot. Nurse practitioner called regarding refusal of care and gave orders to send resident to hospital. On 7/22/22 at 12:47PM V4(Nurse) said she did not see R1's wound or resident. V4 reported she went to resident's doorway on 6/18/22 and privacy curtain was pulled. V5 said she asked R1 if she could do wound care and he refused. V4 said she observed pieces of the dressing on the floor with small white worms on it. Worms were the size of macaroni noodle about 5 in total. On 7/26/22 at 2:18PM, V24(wound NP) said maggots can be found in wounds if a fly lays eggs within the wound. V24 unable to give time frame of how long it would take for maggots to form but said maggots can lead to potential wound infection and would need to be cleaned out of the wound. R1's local hospital record dated 6/18/22 documents under wound check: Both feet swollen, oozing and draining with skin peeling. Patient has underlying [CONDITION(S)] and unable to care for himself. Sent here from nursing home for wound getting worse, requiring new dressing. Frost bite injury last winter and now area worse with necrosis. Maggots coming out of the left heel. Concerns for bilateral heels due to depth and noncompliance. During the survey on 7/26/22 at 12:40PM, tour of second floor with V17 (maintenance) who confirmed screens were missing in R1 (room while at facility), R6 and R4's room. On 7/26/22 and 8/2/22, R6's window was observed open with no screen. On 8/2/22 at 1:39PM, Fly observed in R7's room. According to orkin, Life cycles of house flies' documents: A female fly is capable of laying up to 150 eggs in a batch. Female flies favor damp, dark surfaces such as compost and other decomposing organic material for egg laying. Within a day, house fly eggs hatch into larvae, also known as maggots. Maggots are legless, white insects that feed from the egg-laying site three to five days. On 7/26/22 at 1240PM, V17(maintenance) said he was not aware of screens missing in rooms identified. He said they did do a count and ordered screens which was awaiting approval due to concerns related to materials. V17 (maintenance) said he was unsure if they had screens ready to install in windows that were missing. V17 said there is no procedure for checking or ensuring screens are in the windows. Facility screen work order estimate dated 5/11/2021 documents: accepted date 5/18/22. On 8/9/22 at 1:27PM, V37(owner glass company) said the estimate for screens was done over a year ago in May 2021. V37 said the facility never approved order and finally approved it 2-3 weeks ago.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent pressure ulcer development for residents who were admitted without pressure ulcers and were assessed to be at risk for skin breakdown as indicated in their care plans; the facility also failed to provide ongoing skin assessments to observe skin conditions as ordered by the physician. This failure affected two (R20 and R104) and led to R20 developing unstageable pressure ulcers of three residents reviewed for pressure ulcers. Findings include: R20 is a [AGE] year-old female who was admitted to the facility on [DATE], with past medical history including, but not limited to [CONDITION(S)] with right sided [CONDITION(S)], Dementia, [CONDITION(S)], CAD, [CONDITION(S)], [CONDITION(S)], DVT, GERD, [CONDITION(S)] with psychotic features, new G-tube placement, etc. Nursing admission progress note dated 3/7/2022 states: head to toe assessment completed, no open areas or pressure ulcers noted at this time. Skin warm and dry, No pitting [CONDITION(S)] or swollen extremities. She keeps her arms in a flexed position. Incontinent of Bowel and bladder. Needs total care and ADL assistance. R20 developed an unstageable pressure ulcer to her right heel measuring 4.5 in length and 3 as documented in wound assessment note dated 5/26/2022, and an unstageable pressure ulcer to her left heel measuring 3.0x2.0x0.5 with an onset date of 5/26/2022. Nurse's progress note dated 5/26/2022 reads; resident has wound to both big toes. Wound care NP was called and notified. Ordered [MEDICATION(S)] ointment once daily to affected areas cover with 4x4. Facility minimum data set (MDS) assessment dated [DATE] section G (Functional) coded R20 as 4/3 indicating total dependence with two persons physical assist for bed mobility, transfer, toilet use, dressing and personal hygiene. R20's care plan dated 3/07/2022 states, resident has Potential for alteration in skin integrity: [CONDITION(S)], incontinent of B/B, G-Tube, PVD, CAD, NPO. Interventions include Inspect skin daily with care, Pressure reduction foam mattress or pressure redistribution support (low air or alternating air) in bed, Turn and reposition every two hours and as needed, etc. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/06/22 11:45AM, R20 was observed in her room, awake but non-verbal, just nods yes and no to questions. G-Tube pole noted by the bed side, no feeding infusing, resident on oxygen via nasal canula. Resident was lying in bed on a regular mattress that was leaning to the left side, no heel protection was observed. 6/06/2022 at 11:46AM, V5 (Housekeeping) came in the room and said that resident's bed does not work, they ordered a new one about two weeks ago, but it will be installed today. At 1:15PM V5 (LPN) stated that resident's mattress was uncomfortable, and she was starting to get bed sores, that is why the old one is being switched. At 12:21PM, V4 (LPN) said that resident's low air loss mattress was ordered to prevent pressure wounds, she does not have any breakdown on her bottom at this time, just on her big toes. 06/07/22 9:25AM, observed wound care with V9 (LPN) and noted blisters on the side and bottom of resident's right heel, at the bottom of the right heel was a large area of skin break down with a scab. The resident's feet were very dry, the toenails were overgrown and looked brownish on both feet. On the resident's left heel was a big area on her big toe that looks beefy red with active bleeding, also noted a large area of excoriation at the bottom of the left heel. At 10:30AM, V9 (LPN) said that resident was on antibiotic for wound infection because the wound had a foul smell at the beginning, the doctor just ordered a culture to determine if resident will be placed back on antibiotic. V9 added that they do not have strip for the wound and is waiting on pharmacy to bring one. V9 said that when a resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .N.A) are supposed to do the skin assessment as ordered and report any observations to the doctor. 6/8/2022 at 12:55PM, V3 (DON) said that Braden score assessment is done upon admission for 4 weeks and quarterly, it is used to assess the risk for skin breakdown, the score determines if a resident is at high risk or not and what type of interventions they will need. V3 added that the facility does not provide air loss mattress unless a resident has a stage three or four pressure ulcer or multiple stage two, and they do have a policy for that. At 2:27PM, V1 (Administrator) said that they do not have any policy on low air loss mattress. 6/09/2022 at 11:40AM, V26 (Medical Director) said for residents at risk for pressure ulcers, the first thing is to make sure that resident is clean and dry, turned, and repositioned, placed on low air loss mattress, etc. If the preventive measures are not in place, wounds will develop and that will not be considered unavoidable. A document presented by V3 (DON) titled prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Under procedures, the document states to identify residents at risk for developing pressure injuries utilizing Braden scale. R104 is a [AGE] year old male that was admitted to the facility 5/9/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 6/08/22 at 04:15 PM Observed with V4 LPN and V3 Director of Nursing who said, I see R104 has a break in skin. It is an opening in the skin that is positioned under the stopper of the g-tube. It could have caused a pressure ulcer if it was against the skin with the abdominal binder. V4 LPN said, R104 likes to pull at the gtube a lot because he gets confused and is usually not oriented which is why the binder is in place. 06/09/22 at 11:46 AM V27 Medical Director said, Calcium alginate is usually used for stage 3 and 4 wounds not for superficial wounds. It is part of the nursing staff's routine every day to check the skin for issues of breakdown. If a resident has an abdominal binder, it could cause an additional point of providing pressure to the abdomen. The staff should also be checking to make sure that it is not too tight. R104 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/08/22 an order was placed for calcium alginate with silver and foam dressing. On 4/24/2022 Progress notes for admission did not identify any skin breakdown. No further assessments for skin were able to be presented at the time of this survey since recent admission.

Based on observation, interview, and record review, the facility failed to implement fall risk interventions for a resident assessed to be at risk for falls, by not maintaining the resident's bed in the lowest position to minimize the risk of injury. This failure applied to one (R2) of four residents reviewed for accidents and resulted in R2 being hospitalized after a fall, for obtaining a cervical spine injury and brain concussion. Findings include: R2 is a 98- year- old male who was admitted to the facility on [DATE], with the following past medical history; [CONDITION(S)], dementia in other diseases classified elsewhere with behavioral disturbance, undeferential [CONDITION(S)], essential primary hypertension, peripheral vascular disease, unspecified injury of right wrist, abnormal weight loss, [CONDITION(S)], personal history of pulmonary embolism, etc. R2 had an unwitnessed fall on 3/11/2022 and was sent to the hospital for evaluation. Hospital record dated 3/12/2022 states; This is a [AGE] year-old gentleman who was admitted to the hospital with unwitnessed fall sustaining traumatic type 11 atlantoaxial rotatory fixation along with facial contusion, now with acute [CONDITION(S)] due to brain concussion. Fall risk assessment dated [DATE] scored R2 as an 8 (at risk for fall). Care plan initiated 5/15/2017 states that R2 is noted to be at high risk for falls related to muscle weakness, dementia, use of medication, etc. Fall interventions include always have bed in lowest position while resident is in bed, floor mats while in bed, rounding at a minimum of every 2 hours and prompt, or assist for change in position, reposition away from side rails, etc. Minimum Data Set (MDS assessment dated [DATE] section C (Cognitive) coded R2 with a BIMs score of 00, section G (Functional status) coded R2 as extensive assist with one staff physical assist for all ADL care, and total dependence for bed mobility and bathing. Progress note dated 3/11/2022 documented by V6 (LPN) state the following: Resident was discovered on the floor during rounds assessment revealed swollen face. Further documentation the same day states, Writer called hospital regards to resident admission, The ER Nurse confirmed that resident was admitted With Diagnosis of Contusion. 4/19/2022 At 1:38PM, V6 (LPN) said that he recalls R2, he had many falls, but he was the assigned nurse for the last one that resulted in him being sent out to the hospital. V6 said that R2 fell around 5:00AM on that day while he was doing medication pass, the C.N.A informed him that R2 was on the floor. Upon assessment, R2 had a swelling to the left side of his face and could not open his left eye, V6 called the Nurse Practitioner (NP) and got an order to send resident to the hospital. V6 added that R2 is a fall risk, is bed bound and his bed is supposed to be on the lowest position, he cannot recall if he had a floor mat, he might have been on a manual bed because the bed was not super low, was probably up to the knee. V6 said that he saw R2 probably three hours before the fall, he followed up with the hospital and was told that R2 was still under evaluation but would be admitted . 4/19/2022 at 12:59PM, V5 (Maintenance Director) said that the facility has two types of beds, the manually operated and the electric ones, the manual ones stay about 1 foot 25 inches from the ground and that is as low as they can get. V5 was asked what happens to residents that are fall risk and he said that all residents at risk for fall are not supposed to be on the manual bed, they usually put them on the low/electric beds, those ones can go all the way to the ground. 4/20/2022 at 11:42AM, V13 (C.N.A) said that she remembers R2, the day he fell , she did her round 3:30AM, R2 was in the middle of his bed. When she started her final round around 4:00 to 4:30AM, she found R2 on the floor, his bed was not all the way down, it was about the height of her knee. She called the nurse and they helped the resident back to his bed. V13 changed R2 and noted swelling to right side of his face. V13 said that she saw R2 at about 1:30AM and his bed was not down to the floor at that time either. V13 stated that maybe someone from second shift left it like that, she did not lower the bed, she thought it must have been left like that for a reason. V13 continued to state that R2 might have been a fall risk but she was not too sure; the nurse was supposed to be rounding too, so he could have lowered the bed if he thought it was too high. 4/19/2022 at 2:41PM, V9 (Restorative Nurse) said that a bed can be as low as knee high, but for a fall risk resident, it should not be that high, bed is expected to be in the lowest position and residents are supposed to be checked on every 2 hours and repositioned as needed. 4/20/2020 at 11:00AM, V2 (DON) said that residents that are fall risks have electric beds and they should be down to the floor. R2 was a fall risk, he had a low/electric bed and one of his fall interventions was for the bed to be on the lowest position and floor mat when in bed. Document presented by V2 (DON) titled, Management of Falls (dated 08/2020) states: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care to minimize the risks for fall incidents and/or injuries to the resident. Under procedure, the document states: assess and monitor resident's immediate environment to ensure appropriate management of potential hazards.

Based on observation, interview and record review, the facility failed to safely supervise a resident who fell in his room and was left unsupervised and fell a second time. This failure resulted in R2 found on the floor in his room lying on his right side and sustained a right [CONDITION(S)] requiring surgical intervention. This applies to 1 of 5 residents (R2) reviewed for safety in the sample of 5. The findings include: On July 9, 2021 at 10:15 AM, R2 was lying in his bed and complained of right hip pain. R2 said he had a fall on my right hip. R2's Physician Order Sheets dated through July 2021 shows he has diagnoses including fracture of the right femur, contusion of the right shoulder, contusion of the scalp, weakness and dementia. The Minimum Data Set assessment dated [DATE] shows R2's cognition is moderatly impaired and R2 requires assistance with transfers and walking. The Fall Risk assessment dated [DATE] shows he is at risk for falls related to decreased mobility, post fall, impaired memory/judgement, and history of falls within the past 3 months. R2's current care plan shows he is at risk for falls related to dementia and use of [CONDITION(S)] medications with interventions including to monitor for safety and ensure resident has a wheelchair. R2's Fall report dated June 10, 2021 documents V4 (LPN) was called to R2's room by staff. R2 was observed on the floor next to his bed. R2 was alert and responsive, denies pain and range of motion to his upper and lower extremities. R2 was assisted to the wheelchair by staff. Injuries observed at time of incident include a hematoma to the top of the scalp and abrasion to the right arm. Mental status disoriented. The same report documents no injuries. R2's Final Incident report dated June 18, 2021 documents per interviews with staff on June 10, 2021 around 11:00 AM, R2 was observed laying on his left side in his room after an unwitnessed fall. A complete body assessment was done and R2 was noted to have a hematoma to the left side of his forehead Range of motion to all extremities with no complaints of pain. R2 was sent to the local hospital for further evaluation due to his hematoma .Facility later received a call from the hospital stating he required emergency orthopedic surgery due to a right [CONDITION(S)]. R2's Nursing Home to Hospital Transfer form dated June 10, 2021 documents R2's reason for transfer states, Fall. On July 9, 2021 at 11:47 AM, V5 (CNA) said on June 10, 2021 she was in R2's room sitting with his roommate (R4) when R2 got up out his bed unassisted and fell on the floor. V5 said R2 was lying on the floor on his left side. V5 said she called for help and V6 (CNA) came. V5 said V6 helped her transfer him into the chair. V5 said she left the room to get bed sheets for R2 because his bed sheets were soiled with urine. V5 said V6 remained in the room with R2 and R4. V5 said when she came back into the room R2 was on the floor again. He was lying on his right side on the floor. V5 said he was bleeding from his right elbow and had a bump to the right side of his head. V5 said they transferred him into the chair and R2 could not stand up straight. On July 9, 2021 at 12:45 PM, V6 (CNA) said on June 10, 2021, V5 called for help because R2 had a fall and was on the floor. V6 said she helped V5 transfer R2 into the chair. V6 said V5 left the room to get new bed sheets for R2. V6 said R2 was trying to get up from the chair and she was holding down the chair to keep him from getting up. V6 said I thought (R2) was okay and she left R2 in the chair to change R4's (R2's roommate) incontinent brief. V6 said she heard a noise and pulled the privacy curtain and saw R2 rocking in the chair side to side. V6 said then R2 fell over in the chair and landed on his right side. V6 said R2's right side of the head hit the dresser. On July 9, 2021 at 12:00 PM, V4 (LPN) said on June 10, 2021 the CNA called me down to the R2's room because he fell . V4 said when she entered the room and R2 was on the floor lying towards his right side. V4 said R2 had a hematoma to the right side of his forehead. V4 said she notified the nurse practitioner and he was transferred to the local hospital. V4 said it was reported to her R2 had a fall the previous day and is a fall risk. On July 9, 2021 at 8:26 AM, V7 (RN) said residents who are a fall risk should be monitored closely. If a resident has a fall staff should remain with the resident for safety until the nurse comes to assess the resident. On July 9, 2021 at 10:48 AM, V2 (DON) said R2 was sent to the hospital on June 10, 2021 for a fall. V2 said he was admitted with a hematoma and [CONDITION(S)]. V2 said the hospital called and said R2 had a fall at the hospital and sustained a [CONDITION(S)]. V2 said she did not have any evidence R2's fall was at the hospital. V2 said residents at risk for falls should be monitored for safety. R2's hospital records dated June 10, 2021 shows he was admitted to the hospital with diagnoses including fall at nursing home, scalp hematoma, [CONDITION(S)] and pneumonia. R2's CT Head report dated June 10, 2021 shows right frontal tissue swelling. R2's hospital consultation note dated June 11, 2021 documents R2 presented to the hospital following an unwitnessed fall at the nursing home. R2 reports pain to the right hip and shoulder since the fall. R2 has significant pain to right hip and points to the distal femur as well. Right shoulder with bruising and pain with range of motion to the right lower extremity . unwitnessed fall at nursing home associated with a right femoral neck fracture and required surgical intervention. R2's X-ray report dated June 11, 2021 shows a right femoral neck fracture with overlap and varus angulation. The facility's Management of Falls Policy dated August 2020, states, The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions and revise the residents plan of care in order to minimize the risks for all fall incidents and/or injuries to resident.

Based on observation, interview and record review, the facility failed to correctly identify whether or not a resident had a do not resuscitate (DNR) status and failed to have a system in place that allows nursing staff to identify if a resident has a DNR status during a medical emergency. These failures affected one resident (R4) and has the potential to affect all 138 residents residing at the facility. As a result, (R4) cardiopulmonary resuscitation (CPR) was delayed when he was found unresponsive in the bathroom. This situation was identified as an immediate jeopardy. The immediate jeopardy began on [DATE]. The immediate jeopardy was identified on [DATE]. The Administrator was notified on [DATE]. The surveyor confirmed by observation, interview and record review the immediate jeopardy was removed on [DATE] but noncompliance remains at the level two because additional time is needed to evaluate the implementation and effectiveness of the facility's inventions (including staff in-services). Findings include: 1. R4 was a [AGE] year-old male that resided at the facility since [DATE]. His medical record did not include a Code Status. R4's death certificate lists date of death on [DATE] at 2:34am with cause of death as Ischemic [MEDICAL CONDITION]. [DATE] ambulance sheet and V34's (paramedic) narrative states Emergency Medical Personnel (EMS) dispatched to facility and V34 arrived on unit at 1:34am. R4 was nonresponsive. Staff was seen doing compressions. Crew asked staff to discontinue CPR for the moment. Patient is very warm to the touch, crew then asked facility nurse if patient was a full code or DNR. Crew was originally told he was an active DNR. Nursing home staff could not find the DNR, therefore patient resuscitation was delayed. Crew was then told patient does not have a DNR. Patient has been down for 15 minutes but nurse states it was unwitnessed and found on the floor. Crew then initiated CPR at 1:43am and was discontinued at 1:57am with no results. R4 was pronounced dead. 2. The following interviews were conducted with staff members present [DATE] right before R4's death. On [DATE] at 11:50am, V19 (Evening Nurse) stated that R4 was stable and all vitals within normal range for him on [DATE]. On [DATE] at 10:45am, V17, (Certified Nursing Assistant) CNA originally stated that I arrived at work about 10:30pm on [DATE]. R4 asked right when I arrived if he could take a bath. I gave him a towel and body wash. He went into the bathroom and 15 minutes later, I knocked on the door and told R4 that he needs to come out. He didn't answer so I went in and saw him in the tub that was filled with water. His head and his feet were above the water and his mouth was open. I called his name and he didn't respond. I called V23 (social service) on the phone and he was in his office on the 2nd floor. I also called V18 (nurse) on the third unit since there was not a nurse on the 2nd floor. When V18 (3rd floor nurse) came up to me, V18 and V30 (CNA) got R4 out of tub and put him on the floor. I was told to call code blue and call 911. I overhead paged a code blue and stayed in the hallway until the paramedics came. Later, on [DATE] at 5:10 pm, V17 went on to state that R4 asked me for towels to take a bath after 12:30am (not 10:30pm). I gave him the towels; he went back to his room to get his clothes then I saw him go into the shower room about 12:40am. I went to check on him about 1:00am. On [DATE] at 6:39 pm, V23 (Social Worker) stated on [DATE], I went to the 2nd floor around 11pm and went straight to my office to do some paperwork. I was in my office until around 1:00 am when V17 (CNA) called me and told me that R4 was in the bathroom that would not come out. I went in and saw the resident lying face up on the floor (not in the bathtub) and immediately came out and told the CNA to call a code blue. V17 and I were the only staff on the unit at this time. On [DATE] at 4:45 pm, V18 (Nurse) stated at 1:13am, V17 (CNA) called me and told me that R4 was refusing to come out of the bathroom. I told her that is a behavior and to call V23 (social services). A minute later, V23 (social service) called and said he needed me up on the 2nd floor right away. I arrived on the 2nd floor at 1:15am. V17 and V23 ushered me to the bathroom and when I opened the door, I saw R4 on the floor. His body was wet, and he was unresponsive. I told V17 to call a code blue. On [DATE] at 3:20pm, V18 went on to say that I could see R4's full code status in the computer. I tried two different computers to print it but could not because I knew the paramedics would want it. When the paramedics arrived, they wanted to see the face sheet and code status. It was not on paper but in the computer. On [DATE] at 2:14 pm, V30 (CNA) stated that I was called up to R4's floor by V18 and when I heard the overhead page for code blue. I ran upstairs and V18 (nurse) and V17 (CNA) were in the bathroom. V18 asked me to help get R4 out of the bathtub. He was not underwater but was unresponsive, so we put him on the floor. When the other staff came up, V18 asked them to look for the DNR papers. Even when the paramedics came, they were looking for the papers on the computer and everything. When they couldn't find the DNR papers, the paramedics started the CPR again. I went back down to my floor after the paramedics started the CPR again and I am not sure if they ever found the papers. On [DATE] at 4:24pm, V25 (Registered Nurse, RN) stated that I was working on the 1st floor on [DATE], night shift. I heard a code blue then ran upstairs to the 2nd floor. When I got to the bathroom, R4 was laying on the floor and his skin was dry. V17 (CNA), V18 (Nurse) and V23 (Social Worker) were standing around. I did not know the resident, so I started CPR . V17 then stated that R4 was already gone. V18 stated that R4 was a DNR (Do not Resuscitate). Nobody else was doing CPR. I did CPR until the paramedics came. V18 told the paramedics that R4 was a DNR so they did not start CPR. They told me to stop CPR so they could put the pads on him, and he did not have a shockable heart rhythm. The staff were looking for the papers. After they put the pads on him, I went back downstairs. On [DATE] at 2:55pm, V34 (Paramedic) stated that (V25) was the only one doing CPR when we arrived on the unit on [DATE]. V18 (Nurse) gave me a rundown of what he saw. He said they found R4 unresponsive in the bathroom floor and said he was down for 15 minutes although he reported that it was unwitnessed, so I do not know how he got that timeline. I asked what R4's code status was he stated that he was a DNR and that I have the papers. He sent 2 other people to find the DNR papers. I told V25 to stop CPR and put him on the monitor. He had no rhythm or pulse and was not breathing. After about 5 minutes, I realized they could not find the papers, my partner and I started CPR. V18 had still not gotten back to me with the DNR paperwork. V18 ended up giving me the face sheet and he stated that R4 did not have a DNR. There was no water on the ground and the tub was full. R4's skin was dry, but his fingers were wrinkled like he was in the water for a while. We were not able to revive him, so we called the emergency room and he was pronounced dead at the facility. On [DATE] at 4:16pm, V18 (Nurse) stated that again, I saw the code status on the face sheet. Surveyor explained to V18, the surveyor and V3 (DON) looked in computer and there was not a code status on the face sheet or a current status in the computer. V18 stated then maybe there was an order. V8 (ADON) looked at record with surveyor and V18. She (V8) stated the code status order was discontinued in June and there was not an active code status order in the computer for R4 at the time he coded. On [DATE] at 3:15pm, V3 (DON) stated that when a resident has an arrest, the nurses will look at the code statues in the computer, it should be on the face sheet. All residents should have a code status even if they are a full code. If they are a DNR, we keep the DNR form in a binder at the nurses' station. V3 confirmed there was not a code status on R4's face sheet in the computer and stated, there should have been one there. 3. The surveyor did a random search in resident's record to determine what system was in place for a resident's code status. R3, R11 and R20 did not have code status noted on the face sheet or orders in the computer. On [DATE] at 3:55pm, R20's face sheet and orders did not mention code status. V29 (Nurse) stated that when there is an emergency, we look in the computer on the face sheet to determine the code status. V29 confirmed that R20 did not have this stated in computer. V29 called V3 (DON) and stated I was told there is a DNR book and if she is a DNR, it would be in there. V29 looked at all the binders on the 1st floor and there was not a DNR binder. V29 stated that if a resident was having an emergency and I did not see a Code status on the face sheet, then I may look at the last hospital paperwork, or call the family. I would not take their word for it alone though; I would also call the Doctor. V29 then stated the DNR book is in the front office and produced it. It contained a DNR for one resident. On [DATE] at 3:58pm, V36 (Licensed Practical Nurse, LPN) stated that the Code status is usually always in the computer on the face sheet. If it is not, then we can look at the hospital records if they were recently readmitted . On [DATE] at 4:05pm, V37 (Nurse) stated that there should be a binder with DNR forms for residents who are DNR's. V37 found a binder that is labeled DNR but it was empty. V37 then stated that I find out the code status of my residents during report and it should be on the face sheet in the computer. We need to know the code status in case there is an emergency. On [DATE] at 4:30pm, surveyor informed V3 (Director of Nursing, DON) that the process she stated on [DATE], of having a binder on the unit with DNR forms was not in practice on 1st, 2nd or 3rd unit. She stated that she was going to put the active DNR's at the nurses' station but has not done it yet. On [DATE] at 5:00pm, V1 (Administrator) stated that I spoke to V25 the morning after the incident on [DATE] when R4 was unresponsive. I know that she responded to the code blue on the 2nd floor and was the only one who initiated and performed CPR. I also know that R4 was found in the bathtub, with his head back against the tub, out of the water and his hand over his chest and was non-responsive. I am not aware of the process at the facility regarding code status, how it is communicated to staff or who is responsible for reviewing that. On [DATE] at 5:00pm, the facility is unable to produce policy that addresses resident Code Status while at the facility. On [DATE] at 12:53pm, V3 stated that we did a chart audit and there were 20 residents that did not have a code status in the computer or an order for [REDACTED]. They should enter it on the face sheet. There are several new staff. Facility CPR policy states that the American Heart Association guidelines will be followed, and CPR will be initiated on all residents as indicated. Facility Code Blue/Medical Emergencies guidelines notes the purpose is to ensure that residents with medical emergencies will be assessed and appropriately handled. Basic Life Support will be administered. Facility DNR policy notes that staff are permitted to withhold or withdraw medical care pursuant to a valid DNR order. If there is any doubt as to the validity of the DNR order, treat the resident as soon as possible. Facility personnel will be oriented to the provisions of this policy upon hire and at least annually. Facility census on [DATE] is 138 residents. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: On [DATE], the facility updated their Code Status Identification (,[DATE]) policy to include how a staff member will identify if a resident has a DNR status in a medical emergency. Completed by facility Administrator. On [DATE], the facility reviewed, verified, and obtained physician's orders [REDACTED]. A resident's code status was placed in the electronic medical record or in the DNR (Do Not Resuscitate) status place in a binder. This was completed by the Assistant Director of Nursing. On [DATE], the facility initiated in-services for the nursing to ensure staff members could find the names of residents with DNR status in a binder placed at each nursing station and residents with DNR status are reviewed during daily stand up meetings. Nursing staff in-services were completed on [DATE] and [DATE] and will be ongoing for any staff members who were unable to attend. This will be carried out by the facility Director of Nursing.

Based on observation, interviews and record reviews the facility failed to follow their policy and protocol for respiratory assessment. This failure affects (R1) one of 3 residents reviewed for difficulty breathing. R1 was observed unresponsive by staff after receiving a breathing treatment and later died . Findings include: MDS(Minimum Data Sheet) dated April, 2020, shows R1 has [DIAGNOSES REDACTED]. POS (Physician order [REDACTED]. V3 Nurses progress note dated [DATE] at 4:43a.m, documents, At 1:30am R1 asked for a breathing treatment. Treatment given for fifteen minutes, lungs auscultated and clear. Resident conversed with writer and aide. Resident (R1) allowed to rest. Upon doing 4:00 a.m. rounds resident observed in bed with no signs of life. No palpable pulse. No respirations. 911 called code blue initiated by all staff. Emergency services arrived and noted resident was unable to be coded. 4:25a.m. emergency services exited the facility. On [DATE] at 4:07p.m V7(CNA/Certified Nursing Aide) said on [DATE] at approximately 1:30 a.m., R1 complained of difficulty breathing. However, at this time, V7 changed his story and said it was 2:00a.m when R1 was complaining of difficulty breathing. V7 said he informed the nurse (V3) right away and V3 came and gave R1 a nebulizer breathing treatment and once the treatment finished the nurse came back to the resident room and removed the mask. On [DATE] at 4:50p.m, V5(Nurse) said, At approximately 1:00 a.m.,V7 came to the first floor nurses station and stated that R1 complained of difficulty breathing. V5 said she stood up, asked V3 if R1 had anything for difficulty breathing. She went to the medicine cart and retrieved the medication ([MEDICATION NAME]), took the medication to the room, asked R1 if he needed a treatment, put the medication in the in apparatus and placed the mask on R1's face. V5(Nurse) said she administered the breathing treatment for [REDACTED]. When asked about R1's condition prior to V5 giving R1 the breathing treatment V5 continued to say she did not complete the respiratory assessment she thinks that V3 completed the assessment. Nurse's progress notes dated [DATE]th, 2020 did not show documented assessment of R1's vitals(blood pressure, temperature, respiration, pulse), oxygen levels or lung sounds completed prior to R1 receiving the breathing treatment. There was no documented assessment completed of R1 vital signs (blood pressure, respiration, pulse, temperature) or oxygen levels for R1 post the breathing treatment. MAR(Medication Administration Record) dated [DATE] indicates there was no documentation showing [MEDICATION NAME] treatment for [REDACTED]. A review of R1's plan of care does not show a plan of care of management of shortness of breath. On [DATE] at 9:27a.m, V2 (Director of Nursing) said the nurse should assess the blood pressure, temp, pulse, respirations, oxygen levels and complete an assessment of lung sounds prior to administering breathing treatment. V2 said the nurse should stay with the resident during a breathing treatment. V2 said CPR should be initiated by the first person to observe the resident with no pulse, and no respiration. V2 said the aide(V7) should not have left R1 whom was unresponsive. He should have called out for help, continue to stay with the resident and initiate CPR. On [DATE] at 12:51p.m, V4(NP-Nurse Practitioner) said he visited R1 on [DATE] and R1 did not have any concerns related to shortness of breath or difficulty breathing. The cause of death cannot be determined without having an autopsy. R1's death was sudden. A [MEDICAL CONDITIONS] embolism and Covid 19 can cause sudden death without warning but he cannot make that determination. V4 said he was not notified of R1 having difficulty breathing on [DATE], he was not on call. He said the [MEDICATION NAME] treatment was appropriate for a resident experiencing shortness of breath. The breathing treatment did not cause R1's death. V4 said when a resident is having difficulty breathing the provider should be notified to try and determine the cause of the difficulty breathing especially since covid 19 is causing a pandemic right now. There could have been many reason any person experience difficulty breathing, and further testing may have been warranted. It's just a difficult circumstance because R1's death was sudden. V4 said he would expect the nurse to complete an assessment if the resident is complaining of difficulty breathing. On [DATE] at 11:08a.m., V6 (Nurse) observed administering breathing treatment to R2. V6 assessed R2 lungs sounds. She took R2's vitals prior to administrating the breathing treatment. V6 said the rational for assessing the lungs and vitals pre and post treatment is to determine if the medication was effective, also explained the rationale for staying with the resident while the treating is going, to encourage the resident to take deep breaths and also to ensure the resident gets all the medication. V6 observed documenting the vital signs and oxygen level post treatment. There were no concerns with V6. Administering Med Via Nebulizer Policy dated ,[DATE] shows in part: Administering medications via nebulizer for medications to be dispensed into the respiratory tract. Equipment stethoscope, medication, nebulizer tubing and chamber and air compressor or oxygen hook up. Procedure shows to gather equipment check order against MAR, perform hand hygiene, knock before entering the room and identify yourself, explain the procedure to the resident, complete necessary assessment before administering medication, open nebulizer cup and place premeasured unit dose inside and close cup, turn on air compressor or oxygen, instruct resident to inhale slowly and deeply through the mouth, continue inhalation until all mediation in the nebulizer cup has been aerosolized, stay with the resident while receiving medication. Reassess lung sounds and document medication administration. On [DATE] at 4:07p.m during an interview with V7(CNA), he stated rounds are done every 2 hours or as needed. He said at about 3:30a.m he was doing rounds. R1 was laying in the bed. V7 called R1's name and shook R1 but he did not respond. V7 said he checked for a pulse on R1's neck and R1 did not have a pulse. V7 said he did not initiate CPR, he left the room to go get the nurse. V7 said he felt that the nurse could take care of R1 better than he could. V7 has active CPR certification dated [DATE]. On [DATE] at 4:50p.m during an interview, V5(Nurse) stated that at approximately 4:00a.m she announced Code Blue for R1 because R1 was not breathing. V5 said she was doing chest compressions for R1. V5 said she called 911. When asked who assisted her with the code, V5 didn't give an initial response. However, a few minutes later, V5 said, We all(V5 and V3) were doing CPR. V5 said when the paramedics arrived, they did not administer CPR because R1 had expired. Cardiopulmonary Resuscitation Policy dated ,[DATE] shows in-part: The American Heart Association guidelines will be followed. Cardiopulmonary resuscitation (CPR) will be initiated on all residents, employees or visitors whom this intervention is indicated. CPR will be initiated by any staff member certified in CPR. See guidelines from American heart association. BLS (basic life support) consist of these main parts: chest compressions airway, breathing, defibrillation. Step 4 shows begin cycles of 30 chest compressions and 2 breaths cycles. Figure 12 shows two rescuer CPR. The first rescuer performs chest compressions the second rescuers performs bag mask ventilation using a mask with supplemental oxygen (when available). The second rescuer ensures that the chest rises with each breath. Rescuers should switch roles after cycles of CPR (about every 2 minutes).

Based on interviews and record reviews, the facility failed to ensure physician orders [REDACTED]. in a sample of 6. This failure resulted in a 6 month delay in the identification/treatment of [REDACTED]. Findings include: On 11/13/19 at 10:30am, V12, LPN (Licensed Practical Nurse), stated that in February, R1 went to an appointment at an outside gynecology medical office, but was noncompliant at this visit. V12 stated that V12 is unsure if this office sent any documentation from R1's appointments. V12 stated that R1 was seen at a different outside gynecological medical office recently; no documentation was sent with R1 upon returning from this appointment regarding any recommendations. On 11/13/19 at 11:00am, V11, LPN, stated that V11 received verbal orders from V10, NP, (Nurse Practitioner) for a gynecology consult and a pelvic ultrasound. V11 stated that V11 filled out the outside diagnostic imaging company's request form for the pelvic ultrasound, but forgot to enter the consult and ultrasound orders into R1's EMR (electronic medical record). V11 stated that verbal orders from the physician or nurse practitioner should be entered into the resident's EMR immediately after the orders are given to the nurse. On 11/13/19 at 1:15pm, V13, PA (Oncology Physician Assistant), stated that V14 (Gynecology Oncologist) was consulted during R1's hospital stay in (MONTH) for suspected [MEDICAL CONDITION]. V13 stated that this type [MEDICAL CONDITION] is not rapid, it takes months for the mass to grow to its current size. V13 stated that a gynecological exam in (MONTH) when R1 was exhibiting vaginal bleeding and malodor, would have identified concern for [MEDICAL CONDITION]. V13 stated that a gynecologist would have recognized R1's vulvar mass during a visual exam of R1's pelvic area. V13 stated that R1'[MEDICAL CONDITION] is locally advanced, the mass is very large. It is clinically a stage 3B, which has spread to the pelvic lymph nodes; testing showed 2 or more lymph nodes are involved. V13 stated [MEDICAL CONDITION] treatment has a curative goal. The plan was for R1 to receive 5 hour [MEDICAL CONDITION] treatment starting on 10/25, but R1 refused it. Yesterday, it was determined that [MEDICAL CONDITION] would be stopped and [MEDICAL CONDITION] treatment started. After R1 receives 5 weeks of [MEDICAL CONDITION] treatments, she will be re-assessed for response to treatment. If [MEDICAL CONDITION] does not respond to the [MEDICAL CONDITION] treatments, R1's prognosis is poor. Review of R1's hospital medical record, dated 8/29/19, notes R1 was seen in emergency room for complaints of vaginal pain. Noted to have painless genital ulcers and significant vulvar [MEDICAL CONDITION] on the right with some surrounding redness with a 9cm (centimeter) ulcerated cauliflower like mass on the right vulva and a palpable inguinal lymph node on the right greater than 4cm that was fixed and matted. CT scan (computed tomography) of R1's abdomen and pelvis demonstrated a diffuse soft tissue density in the perineum and enlarged necrotic bilateral inguinal lymph nodes. Review of R1's medical record notes the following: On 1/16/19 at 3:54pm, V12, LPN, noted R1 went to gynecologic clinic and did not cooperate to be seen by doctor. R1's family was asked to go with R1 to the next rescheduled appointment. On 2/8 at 1:45pm, V11, LPN, noted R1 seen by V10, NP (Nurse Practitioner), who gave orders for gynecological consult and pelvic ultrasound. Orders will be entered by V11. On 2/26 at 2:45pm, V4, LPN, noted R1 out to gynecological appointment, alert and oriented. No complaints of any pain. R1 returned at 1:30pm. Gynecologist stated that R1 would need to see a specialist to do exam. Nursing to follow-up. On 8/22 at 2:42pm, V12, LPN, noted R1 returned from appointment with gynecologist. During appointment, V12 received a call from the gynecologist with recommendations to send to hospital for further evaluation based on findings during exam. On 8/29 at 2:37pm, V12, LPN, called V9 (attending physician) and made V9 aware of R1's gynecologist's concerns, and received orders to send R1 to the hospital for medical evaluation by gynecology. On 9/1, R1 was readmitted to this facility with orders for follow-up appointment with V14 (gynecology oncologist) on 9/17/19. On 10/25, R1 went out for testing and to receive [MEDICAL CONDITION] for 5 hours. R1 had testing done but refused [MEDICAL CONDITION]. On 11/12, the facility was notified by the Oncology department at hospital that R1's [MEDICAL CONDITION] will be stopped and R1 will begin [MEDICAL CONDITION] treatment. Treatment dates to be determined. There is no documentation found noting R1 was seen by a gynecologist between 2/26 and 8/22. Neither V1 (Administrator) nor V3, DON (Director Of Nursing), were able to provide this surveyor with any documentation of any gynecological appointments scheduled or transportation arranged for R1 between 2/26 and 8/22. Review of R1's gynecology appointment, dated 2/26/19, notes unable to place R1 for proper evaluation of pelvis, referred to hospital. Review of R1's gynecological appointment, dated 8/22/19, notes R1 presented for evaluation of vaginal odor. Physical examination: gynecology: total breakdown of perineal skin. Area pink and tender. Unable to perform pelvic exam as R1 expressed pain when area was touched. Review of this facility's telephone/verbal order processing policy, dated 06/2019, notes the nurse receiving the verbal order must record the date and time order was received. Sign the order with the first and last name and title of the prescriber, and the nurse's first and last name and title. Write order on the physician's orders [REDACTED].

Based on observation, interview and record review the facility failed to ensure that 2 of 24 sampled residents (R2, and R10) were free from verbal and physical abuse. The facility failed to protect residents by allowing E10 (nurse aide) to continue to provide direct care to residents after allegations of mistreatment/abuse had been made and while the facility conducted an investigation. The facility failed to follow the abuse protocol for protect of residents from potential mistreatment/abuse during the course of the investigation. This deficient practice has the potential to affect all 127 residents in the facility. This failure resulted in an Immediate Jeopardy. E1(administrator ) was notified of the Immediate Jeopardy on 2/24/2011 at 4:40 PM. The Immediate Jeopardy was determined to have begun on 2/24/11 at 12:21 PM. While the immediacy was removed on 2/25/11, the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the abuse policies and procedures and their system of communication. Findings include: 1. On 2-23-2011 at 1:05 PM, R10 was observed propelling self in a wheelchair very slowly down the hallway from the dining room very slowly. R10 stated to the surveyor that she needed some help from the staff to get to her room. E10 (nurse aide), when asked if someone could assist R10 to her room stated in response "I'm busy with someone else". At 1:30 PM on 2/23/11, R10 requested to have assistance to go to the bathroom. E10 was observed to enter the room and assist R10 to the bathroom. E10 stated to the surveyor that R10 had recently returned from the hospital and was a little weak but that R10 could do things for herself. R10 dropped her head. R10 stated when interviewed at this time "They take a long time to answer the call light, and this is a long hallway to push back and forth from, I need help. They don't listen and tell me that I can do things by myself." R10 stated to the surveyor that what E10 stated was upsetting to R10. During an abuse interview with E10 (nurse aide), on 2/23/11 at 3:00 PM, "Verbal abuse was when you yell and scream at a resident, mental abuse is when you hurt someone mentally, like punishing them." 2. On 2/23/11 at 1:35 PM, E11 (CNA) was observed providing direct care for R2. R2 had wasted urine from the urinal in the bed. E11 was observed to enter R2's room, and pushed R2 on his right side. E11 was observed failing to explain to R2 what E11 was about to do, failed to draw the privacy curtains or close the door prior to removing R2's top bed covers and exposing R2's buttocks. E11 was further observed to roughly roll the incontinent pad from under R2. E11 obtained a wash basin and towel from the bathroom and began to vigorously scrub R2's buttocks area. R2 screamed out in a loud voice "Oh, that's hurting me" during the course of the care. E11 stated "Well, I have to clean you up." R2 began moaning and making facial grimaces. Then E11 was observed to pull the soiled linens from under R2 very roughly. R2 continued to scream out as he jerked from side to side "Have mercy on me." E11 gave no further explanations to R2 as she exited the room with the soiled linens. During observations of R2's care given by E11, R2 was observed to have a [MEDICAL CONDITIONS] feeding tube, and two large gauze dressings on the mid- right side of the abdomen. A review of R2's clinical record documents that R2 was recently readmitted to the facility from the hospital on 2-14-2011 with [DIAGNOSES REDACTED]. R2 has a history of a Left Below Knee Amputation, Diabetes Mellitus, Acute [MEDICAL CONDITION], and a Right [MEDICAL CONDITION]. R2 stated when interviewed after receiving care that "They throw me around in here. When I complaint they don't listen. I want to get out of here, I was in a nursing home years ago but was never treated so roughly like I'm treated here." R2 stated that he was in pain and the nurse call light was pulled. E11 stated in an interview following providing care. E11 was interviewed concerning the verbal responses and rough handling of R2. E11 responded "Oh well". During an interview on 2/23/11 with E9 (nurse) stated that R2 had recently returned from the hospital where he had surgery and still had abdominal staples in place. During daily status report on 2-23-2011 at 4:30 PM, E1 (administrator) was informed of possible verbal, mental and physical mistreatment of [REDACTED]. E1 stated that she would investigate the allegations. On 2-24-2011 at 9:40 AM, E10 was observed on the unit providing direct resident care. On 2-24-2011 at 12:20 PM E10 was observed assisting E13 (nurse aide) to provide care for R2. E1 (administrator) stated when interviewed on 2/24/11 at 10:00 AM, that it is the facility's policy that when a staff member has an allegation of mistreatment/abuse leveled against them, the staff member is sent home until an investigation into the allegation has been completed. E1 was made aware by the survey team that E10 had been observed on the unit providing resident care. E1 stated that an investigation into the mistreatment/abuse of R10 and R2 had been conducted that morning (2/24/11), and faxed to the department of public health, there had been no findings. At 11:30 AM, E1 presented the survey team with the following incident/accident reports that documented: description of occurrence: R10, "reported abuse against staff member, investigation conducted". R2, "abuse/neglect alleged, investigation conducted." E1 further stated that the investigations had been completed and that is why E11 was allowed to work and provide resident care. There was no documented evidence that indicated that the resident, E10 or E11, other staff member or other residents had been interviewed concerning the allegations of mistreatment/abuse. At 12:30 PM on 2/24/11 E1 informed the survey team that the investigation into the allegations of abuse had not been completed and that E10 was being sent home until the investigation was completed. E10 was observed by the survey team leaving the facility at 12:58 PM. It was observed that E10 had been allowed to provide direct resident care from 6:00 AM until 12:58 PM. At 12:58 PM Administrator , E1 stated" I just sent E10 home for investigation. and E11 has been placed on leave for investigation of abuse." At 4:40 PM on 2-24-2011 Immediate jeopardy was announced to the facility during daily status meeting. The Immediate Jeopardy was removed February 25, 2011 at 3:35 PM. E1 was notified per telephone conversation. Facility policy titled "Abuse Prevention Program" documents that....physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Mental abuse includes, but is not limit to humiliation, harassment, and threats of punishment or deprivation....5. Protection of Residents: The facility will take steps to prevent mistreatment while the investigation is underway....c. Employees of the facility who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation has been reviewed by the administrator or designee. Employees accused of possible abuse shall not complete the shift as a direct care provider to residents....6. Investigation: a. Once the administrator or designee determines that there is a reasonable cause for mistreatment, the administrator or designee will investigate an allegation and obtain a copy of any documentation relative to the incident. c. The final investigation report will be completed within five working days of the reported incident. The final report shall include facts determined during the process of the investigation, review of medical records, personnel files and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts....7. Reporting: Initial Reporting of Allegations Within twenty four hours after the occurrence, a written report shall be sent to the Department of Public Health. ...a The administrator or designee will also inform the residents representative of the report of an occurrence of potential mistreatment and that an investigation is being conducted....b. It there is a finding of abuse by a certified nurses aide or licensed staff, the Department of Public Health will notify the Nurse Aide Registry or the Department of Professional Regulations....c. ...Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation will be sent to the Illinois Department of Public Health....d. Informing the residents representative. d. The administrator or designee will inform the resident or representative of the conclusion of the investigation. The facility submitted the following plan: On 2/24/11 key facility staff, including Administrator was immediately in-served on the importance of conducting thoroughly investigating and thoroughly documenting the results of the investigation for all allegations of abuse. The facility Abuse prevention Policy was reviewed for any necessary revisions. This in-service was conducted by external resource consultants. On 2/24/11 the facility promptly initiated additional in-service education with staff regarding the facility Abuse Prevention Policy. This in-servicing had previously been initiated on 2/22/11 by the Administrator and the Psychiatric Rehabilitation Services Director. On 2/24/11 facility residents were immediately interviewed to ascertain if there were any concerns related to staff treatment. Families/Responsible Parties were contacted and interviewed for residents that are not interviewable. These interviews were conducted by the Director of Clinical Services (Psychiatric Rehabilitation Services Director, Psychiatric Rehabilitation Coordinators and the Administrator. On 2/24/11 the facility conducted a full house body check (sweep) to identify injuries of unknown origin. This was conducted by the Director of Nursing and nursing staff. There were no injuries of unknown origin. Based on the results of the review, the facility has implemented additional necessary follow up which was completed on 2/25/11. A QA Tool has been developed and implemented to ensure ongoing monitoring. The administrator and Director of Nursing are responsible for daily ongoing monitoring and completion of the tool. Immediate actions shall be taken as necessary based on the completing of the tool. If the Abuse coordinator determines that an allegation of abuse exists, then the administrator and Director of Nursing are responsible for immediately ensuring that the resident is removed from any threat and that his/her safety is maintained. This shall include (but is not limited to) the immediate removal of the alleged perpetrator. The tool shall be reviewed and analyzed more in depth for trends and patterns at least monthly during the facility Quality Assessment and Assurance Meeting. The Medical Director shall participate in the analysis and action planning.