Every finding on record at Midway Neurological / Rehab Center

Based on interview and record review, the facility failed to ensure the immediate availability of essential emergency resuscitation equipment for a resident designated as Full Code. Specifically, staff did not have an ambu bag (manual resuscitation device) readily available when a resident was identified as unresponsive and not breathing during a Code Blue event. This deficient practice affected one of three residents (R3) reviewed for cardiopulmonary resuscitation (CPR). As a result, staff were unable to immediately provide rescue ventilations while CPR was initiated.Findings include:On [DATE] at 3:44PM, V15 (nurse) said he responded to R3's code blue. V15 said he provided chest compression during the code. V15 said when he arrived to R3's room other staff were conducting compressions but unsure which staff. V15 said R3 had a non- rebreather mask on and observed that there was no ambu-bag in use. V15 said he asked for staff to get an ambu bag from another floor. V15 denied any delay in R3 receiving care. V15 was familiar and knowledgeable with code blue procedures. V15 said they sign off on the crash cart every shift.On [DATE] at 12:55PM, V18 (nurse) said she was working on another unit when she heard the code blue called. V18 said when she arrived to R3's room staff were providing chest compressions but unclear who was utilizing ambu-bag. V18 said she recalls staff looking for the ambu-bag and it was not readily available at start of R3's code but someone brought one in prior to emergency medical service (EMS) arrival.On [DATE] at 2:05 PM, V22 (Medical Doctor) stated an ambu bag is an important component of emergency resuscitation because it delivers positive-pressure ventilations to a person who is not breathing. V22 stated a non-rebreather mask requires spontaneous respirations and does not provide the same function as an ambu bag. V22 stated oxygenation and ventilation are essential components of effective life-saving measures during a resuscitation event.On [DATE] at 11:26AM, V23 (Director of Nursing - DON) said, he expects his staff to respond immediately in an organized manner with all necessary equipment to assist with the code blue. V23 said the equipment needed can consist of a board, ambu-bag, oxygen and IV starter kit. V23 said he was not aware supplies were not available during a code blue. V23 said the code cart is checked daily, we have supply staff that restocks the code cart, but it is the nurse's responsibility to ensure all the supplies are on the cart and available for use during an emergency. V23 said ambu-bag should be use with chest compression to provide oxygenation to the resident. V23 said a non-rebreather mask will not work in the place of an ambu-bag. Ambu-bags are the recommended device to use to assist a resident with resecure breaths. Nurses note dated [DATE] documents: The resident (R3) was noted in bed to be unresponsive to tactile stimuli he was last seen at 1:00PM. Vitals were undetectable, code blue protocol was immediately initiated, and CPR continues until 911 paramedics arrived and took over CPR.Facility Crash Cart Stock List no date documents: Top of Cart: 1 (one) Ambu-bags. Medical Emergency Policy dated [DATE] documents: To provide care and service to residents in accordance with Advance Directive that have been discussed with the resident's legal representative in advance of medical emergencies including medical interventions used to restore circulatory and respiratory function.Guidelines for Cardiopulmonary Resuscitation-CPR no date Intent: it is the intent of the facility to ensure that it is able to- and does-provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physician order, such as DNR (Do Not Resuscitate) as well as a resident's personal Advance Directives. Cardiopulmonary Resuscitation (CPR) -refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased.

Based on observation, interview, and record review, the facility failed to protect R2's right to remain free from physical abuse from another Resident (R3). This affects 2 of 3 residents (R2, R3) reviewed for abuse in the sample of 3. This failure resulted in R3 striking R2 with a wheelchair leg rest, causing multiple injuries including two fractures to the left hand, lacerations to the left arm, a mild brain bleed, a collection of blood in the lung, rib fractures, and a facial fracture.Findings Include:R3 is no longer lives in the facility.R2 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including encephalopathy, cerebral infarction, epilepsy, heart failure, osteoarthritis, dementia, anxiety, hypertension, major depressive disorder, and hemiplegia. R2's Brief Interview for Mental Status (BIMS) score was 6 (dated 3/9/2026).On 5/19/2026 at 11:32 AM, during the initial day of the investigation, observations and interviews were conducted on the facility's fourth-floor dementia unit. At the time of observation, activity and restorative programs were taking place in two separate rooms. Two Certified Nursing Assistants (CNAs) were observed positioned at opposite ends of the hallways monitoring resident activity. V5, (Certified Nursing Assistant/CNA), stated that the hallways require close monitoring to ensure resident safety because some residents frequently wander throughout the unit and in the residents' room.On 5/19/2026 at 11:40 AM, R2 was observed lying in bed with the left arm wrapped in an elastic bandage. Multiple facial lacerations and facial bruising were noted. The surveyor attempted to interview R2; however, R2 refused to engage.On 5/19/2026 at 11:46 AM, V18, Registered Nurse (RN), stated that residents on the fourth floor include individuals with dementia and psychiatric conditions. V18 stated that staff must closely monitor residents to ensure safety and prevent injuries, adding, we don't want any resident to be hurt. V18 added that the facility conducts two activities during the day on the fourth floor to help keep residents engaged and supervised because residents on that floor require close monitoring. V18 described R2 as quiet and not known to initiate physical altercations or fights.On 5/19/2026 at 12:00 PM, V19 (Licensed Practical Nurse/LPN), R2's nurse, stated that R3 was new to the floor and had been moved to the fourth floor due to multiple attempts to elope. V19 further stated that R3's room was located three rooms away from R2's room and would always be observed wandering around.On 5/20/2026 at 10:15 AM, V2 (Director of Nursing/DON) said that R3 was often confused, wandered throughout the facility, and frequently attempted to open doors. R3 experienced multiple room changes during his stay. V2 explained that the 4th floor was considered more secure because elevator access could be better monitored, allowing staff to observe R3 more closely. V2 described R3's behavior as delusional but non-violent. V2 stated that when staff responded to the incident, they found both residents, R2 and R3, together in R2's room and immediately separated them. R3 was placed on one-to-one observation immediately following the incident because it occurred during the night, and the facility's goal was to petition him out appropriately and prevent his return to the facility. R3 was petitioned the following morning and transferred to the hospital where he was admitted to the psychiatric unit.On 5/20/2026 at 11:48 AM V9 (Certified nursing assistant/CNA supervisor) stated that the night shift from 11:00 PM to 7:00 AM typically has three CNAs assigned, although occasionally there may be four. According to her, night shift CNAs are expected to complete rounds every two hours and as needed. The purpose of the rounds is to ensure and maintain that residents are safe, prevent falls, and check whether residents need assistance.On 5/20/2026 at 12:41 PM, V12 (Social Service Director) said that R3 was observed repeatedly attempting to open and exit through doors, appearing to move in a looping pattern. R3 was noted trying to look out of doors on the parking lot side and attempting to access the main entrance. V12 said that there was one time when he tried to hit a staff member while attempting to leave. V12 also added that it was the reason why R3 was placed on a locked dementia unit (4th floor) requiring a code for entry and exit. The night shift staff who were working at the time of the incident were contacted by telephone for interview. On 5/20/2026 at approximately 2:38 PM, V13 (CNA) stated that she was not assigned to the resident involved. V13 stated that a staff member informed her that there was something going on in R2's room. Upon responding, V13 observed R2 bleeding from the face. V13 stated that nurses called 911 and security, and R2 was transported to the hospital. V13 described R2 as quiet and stated that he always sleeps at night. Regarding R3, V13 stated that R3 was new to the floor and that she did not know much about R3. V13 further explained that staff conduct rounds and provide routine resident care to monitor residents and ensure their safety and well-being.On 5/20/2026 at 3:00 PM, V14 (LPN) who was the nurse on duty when the incident happened said that she checked on R3 around 1:00 AM and he was seen sleeping. Then later, V14 observed R3 walking in the hallway and was redirected back to his room. At approximately 2:15 AM, she heard noise coming from R2's room and heard R3 screaming inside the room. Upon entering, V14 observed R3 holding R2's hand while R2 was bleeding from his head and arm. V14 pulled R3 out of the room. She stated that there was blood on R2's bed and on the wheelchair leg rest on the floor. When V14 was asked why the incident occurred, V14 stated that she had no idea. V14 said that staff are responsible for ensuring residents are kept safe and free from harm. V14 explained that R3 had wandered into R2's room.On 5/20/2026 at approximately 3:02 PM, V20, (CNA), stated that at the beginning of her shift, around 11:00 PM, she observed R3 standing near his doorway while she was conducting rounds. V20 stated that she instructed R3 to return to bed because it was late. Then at approximately 1:00 AM, she observed R2 asleep in bed. According to V20, R2 typically goes to bed early as part of his normal routine and usually sleeps throughout the night. Then at approximately 2:15 AM, she heard the nurse calling for help. Upon arriving at R2's room, V20 observed R3 standing near the doorway and saw R2 covered in blood.On 5/21/2026 at 10:21 AM, V21 (CNA), stated that she regularly cares for R2. She described R2 as a resident who just smiles, is very quiet, sweet, and does not bother anyone. V21 stated that R3 was new to the unit and that she was not familiar with him. However, she reported observing R3 walking around the unit appearing confused and cursing. V21 stated that one of the responsibilities of nurse aides is to monitor residents and keep them safe. V21 further stated, No one deserved to be hurt. R2 was asleep in his bed and R3 should also be in his bed at that time. I felt bad and sorry for R2. V21 added that having security personnel assigned to the floor could help prevent incidents like this from occurring.On 5/21/2026 at 10:12 AM, interviews were attempted with R7 and R8, who were R2's roommates, regarding the incident; however, neither resident was able to provide details about the event. R7 stated, the guy next to me is now sick.According to the police report, R3 stated that R3 attacked R2 because he had gone to his room asking for a woman. None of the staff witnessed how the assault began. The nurse on duty learned of the assault because of R2's roommates approached her and told her that someone was fighting with his roommate (R2) in the room. Blood covered wheelchair leg was observed at the scene.Record reviews conducted on 5/22/2026 revealed the following:There were multiple Social Service notes indicate that R3 was observed wandering within the facility and had attempted to elope on multiple occasions, and they are as follows:4/28/2026 it was reported that R3 presented with verbal inappropriate language and attempted to hit at the staff while attempting to leave out the unit door.5/5/2026, R3 was observed by staff attempting to elope through the 2nd floor west exit. R3 presented with delusions that his family was waiting for him. Despite redirection, R3 remained non-receptive and continued to exhibit delusional behavior.5/7/2028, R3 attempted to elope through the back door. R3 was noted to be delusional, refused redirection, used profanity, and continued to display inappropriate behavior.5/8/2026 indicates that R3 attempted to elope again. Due to the resident's repeated elopement attempts, R3 was placed on a secured unit on the 4th floor.R3 was petitioned for involuntary discharge on [DATE]. According to the petition, R3 has a violent temper and was involved in a physical altercation with another male resident. R3 is uncontrollable, placed on 1:1 with staff and resident needs immediate hospitalization because is a danger to self and others.The primary care provider's note, dated 5/5/2026, states that R3 has diagnosis of delirium, alteration in mental status, and confusion.On 5/20/26 V12 (Social Service Director) acknowledged that although efforts were made to monitor and redirect R3, he could not definitively state that R2 was fully protected from R3 at all times. V12 further stated that R2 should not have experienced harm and acknowledged that additional measures potentially could have been implemented to better ensure R2's safety. V12 emphasized that residents have the right to feel safe and stated that no one should experience such an incident.Record Review of R2 and R3's care plan show they do not have an abuse care plan on their comprehensive care plans and no abuse assessments were completed.On 5/21/2026 at 2:02 P.M., V12 (Social Service Director) stated an abuse care plan should be included in a resident's comprehensive care plan. V12 stated an abuse care plan should be added for new residents, a significant change in status, revised and updated as necessary. V12 stated R2 and R3 did not have an abuse care plan implemented in their comprehensive care plan. V12 states it is expected that the residents have an abuse care plan. V12 states R2s care plan should have been in place after R2 sustained multiple injuries from R3.On 5/21/26 at 10:21 AM, V21 has agreed that a resident wandering can present a risk to other residents and entering other residents' rooms can cause fear or altercations, or physical aggression. All staff interviewed in relation to this investigation expressed that R2 should not have experienced the physical assault.The facility's abuse prevention program, (latest revision dated 1/2019), states that: As part of the social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect exploitation, mistreatment, 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 to these residents.

Based on interviews and record review, the facility failed to follow their Abuse Prevention Program by not implementing the care planning process, not identifying any problems, goals, and approaches which would reduce the chances of mistreatment for 4 residents (R1, R2, R3, R4) out of 4 residents reviewed for abuse.On 5/21/2026 at 2:02 P.M., V12 (Social Service Director) stated an abuse care plan should be included in a resident's comprehensive care plan. V12 stated an abuse care plan should be added for new residents, a significant change in status, revised and updated as necessary. V12 stated R1, R2, R3, and R4 did not have an abuse care plan implemented in their comprehensive care plan. V12 states it is expected that the residents have an abuse care plan. V12 states R2s care plan should have been in place after R2 sustained multiple injuries from R3.Record Review of Police Report documents on 5/12/2026 local police officer dispatched to facility regarding a battery that occurred between R3 to R2. R3 used a wheelchair leg to strike R2.Record Review of R3's social service notes 4/28/2026 at 3:51 P.M., reads it was reported that R3 presented with verbal inappropriate language and attempted to hit at the staff while attempting to leave out the unit door.Record Review of R1, R2, R3, and R4's care plans show no abuse care plan on their comprehensive care plans and no abuse assessments.Abuse Policy and Procedure Abuse Prevention Program:As part of the social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or who have needs 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.

Based on interview and record review, the facility failed to obtain a second witness signature for psychotropic medications consent prior to administration of psychotropic medications and failed to ensure resident signature was obtained prior to administration of psychotropic medication. These failures affected two (R1 and R2) residents reviewed for residents' rights to be informed in the total sample of five residents.Findings include:R1's admission Record documented, in part Diagnoses (include but are not limited to) COPD (Chronic Obstructive Pulmonary Disease), suicidal ideations, and psychosis. Responsible Party: Self.R1's (03/17/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R1's mental status as cognitively intact.R1's (Active Order as Of: 04/10/2026) Order Summary Report documented, in part Vistaril Oral Capsule (Hydroxyzine Pamoate) Give 100 mg by mouth three times a day for Anxiety. Active 03/17/2026. Mirtazapine Oral Tablet (Mirtazapine) Give 15 mg by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER. Active 03/25/2026. Seroquel Oral Tablet (Quetiapine Fumarate) Give 50 mg by mouth at bedtime related to PSYCHOSIS. Active: 03/25/2026.R1's (03/11/2026) Psychoactive Medication Therapy Informed Consent. 1. Psychoactive Medication. Vistaril Oral 50mg by mouth three times a day. Signed by: V8 (Psychotropic Nurse/LPN). Signed date: 03/11/2026. Of note, there was no second witness signature.R1's (03/18/2026) Psychoactive Medication Therapy Informed Consent documented, in part 1. Psychoactive Medication. Vistaril Oral 100mg by mouth three times a day. Signed by: V8 (Psychotropic Nurse/LPN). Of note, there was no second witness signature.R1's (03/25/2026) Psychoactive Medication Therapy Informed Consent documented, in part 1. Psychoactive Medication. Seroquel 50mg by mouth at bedtime. Signed by: V8 (Psychotropic Nurse/LPN. Signed Date: 03/25/2026. Signed by: R1. Role Resident. Signed Date: 04/10/2026. R1's (03/25/2026) Psychoactive Medication Therapy Informed Consent documented, in part 1. Psychoactive medication: Mirtazapine 15mg by mouth at bedtime. Signed by: V8. Of note, there was no second witness signature.R1's (03/2026 and 04/2026) medication administration record documented that R1 was administered Vistaril 50mg on 03/12/2026 and 100mg beginning 03/18/2026; Seroquel 50mg beginning 03/26/2026, and Mirtazapine 15mg beginning 03/25/2026.R2's admission Record documented, in part Diagnoses (include but are not limited) to bipolar disorder, psychosis, and insomnia. Responsible Party: Self.R2's (03/19/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 11. Indicating R2's mental status as moderately impaired.R2's (03/03/2026) Psychoactive Medication Therapy Informed consent for Lexapro was signed only by V8 (Psychotropic Nurse/LPN).R2's (12/30/2025) Psychotherapeutic Drug Evaluation documented, in part A. Antidepressant: 3a. Trazodone 100mg 2 tablets by mouth at bedtime. 3b. Escitalopram 10mg 1 tablet by mouth one time a day. B. Anti-anxiety. 3a. Lorazepam 2mg 1 tablet every 8hours as needed. C. Antipsychotic. 3a. Risperdal 4mg 1 tablet by mouth two times a day. H. Informed Consent. Signed by: V8 (Psychotropic Nurse/LPN). Of note, no second witness signature noted.R2's (03/2026 - 04/2026) Medication Administration Record documented that R2 was administered Lexapro 20mg one time a day beginning 03/04/2026; receiving Trazodone 100mg 2 tablets by mouth at bedtime with start date of 12/16/2025; and Risperdal 4mg 1tablet by mouth two times a day with start date of 12/15/2025.On 04/10/2026 at 4:11pm, V8 (Psychotropic Nurse/Licensed Practice Nurse) stated if the resident is responsible for self, she is expected to go over the psychotropic medications and get verbal consent from the resident and she (V8) signs the consent. This surveyor inquired what is her proof residents really consented to use of psychotropic medication if only her signature is shown in the consent. V8 stated I see what you are saying. V8 stated but there is no space for a resident to sign the consent in cloud-based Electronic Health Record (EHR) platform.On 04/10/2026 at 4:43pm, V8 stated the psychotropic medication consent should be signed by either the resident or POA or guardian. V8 stated they (R1 and R2) gave verbal consent, but the forms were not signed by them.On 04/11/2026 at 12:45pm, V2 (Director of Nursing) stated verbal consent should have a second witness signature and it should be obtained at the same time she (V8) electronically signed the psychotropic consent. The signatures for verbal consent should be obtained before administering the psychotropic medication. It is the regulation, and the facility has to follow the regulation. V2 stated the resident has the right to know the indication and side effects of psychotropic medication.The (undated) Psychotropic Drugs Usage documented, in part Policy: Psychotropic drug use is based upon the comprehensive assessment of the resident. Psychotropic medications are given as necessary to treat a specific condition that is diagnosed and documented. Residents receiving psychotropic medications will have gradual dose reductions and behavioral interventions implemented unless contraindicated. Procedure: 5. Any resident receiving psychotropic medications will have a signed informed consent for the use of the medication. Informed consents will be initiated upon the start of the medication usage and upon any additional increase in dosage. Informed consents may be signed by the resident, resident's guardian or other authorized resident representative.The (01/23/2026) Electronic signature UDA (User Defined Assessment) Completion/Consents/Contract Policy documented, in part Purpose: To establish standardized requirements and procedures for the use of electronic signatures within the cloud-based Electronic Health Record (EHR) platform eMAR (electronic medication administration record) and associated clinical documentation modules, ensuring compliance with regulatory, legal, and operational standards. Scope: This policy applies to all facility staff, contractors, and authorized users who utilize cloud-based Electronic Health Record (EHR) platform for medication administration, care planning, assessments, evaluations, and any documentation requiring electronic signatures. Policy Statement: Electronic signatures within cloud-based Electronic Health Record (EHR) platform are considered legally binding and equivalent to handwritten signatures. All electronic signing activities must be completed in accordance with system controls, user authentication requirements, and facility-defined workflows. Users are responsible for ensuring the accuracy, completeness, and timeliness of any documentation they electronically sign. Unauthorized use or misuse of electronic signatures is strictly prohibited. Definitions: Electronic Signature (e-Signature). A digital representation of a user's legally binding signature applied within cloud-based Electronic Health Record (EHR) platform. 5. Complete Electronic Signature. a. Select the assigned signer role (Resident, Nurse, Responsible Party, etc.). e. For all verbal consents obtain a second witness signature. 6. Finalize Signature. a. Ensure your signature status reflects as completed. c. If multiple signers are required, ensure handoff awareness for remaining signatures. 7. Post-Signature Responsibility. c. Ensure signatures are completed in a timely manner following assessment completion.

Based on interview and record review the facility failed to accurately assess a critical clinical sign (Battle sign) and implement their change in condition policy by failing to immediately activate EMS (emergency medical services) 911 to transport a resident with an acute change in mental status. This affected one of three residents R366 reviewed for change in condition and delay of treatment. This failure resulted in R366 being transported to the hospital and diagnosed with a large traumatic subdural bleed (collection of blood between the covering of the brain and the surface of the brain) with midline shift (displacement of the brain tissue across the midline) causing herniation. Findings include: On [DATE] at 10:10 AM, V17 LPN (Licensed Practical Nurse) stated that V17 worked day shift on the second-floor nursing unit on [DATE]. V17 stated that during initial rounds V17 saw R366 in room and talked to her. V17 stated that R366 was in bed with her face covered up with a sheet; V17 did not see R366's face. V17 stated that when R366 walked to the dining room for breakfast V17 called R366 to come get her medications. V17 stated that is when he observed R366's left eye and left posterior ear discolorations. V17 stated that V17 asked R366 what happened with the left side of her face; R366 rubbed face and informed V17 that she fell last night in her room. V17 stated that R366 stated she tripped and hit the left side of her face on her dresser. V17 stated that V17 asked if R366 told the nurse, R366 stated 'no, she just went back to sleep'. V17 stated that V17 assessed R366 for any other injuries, gave R366 an ice pack, initiated neurological checks, and paged V32 (physician). V17 stated that V32 called and was informed of the incident. V17 stated that V32 ordered a routine facial x-ray. V17 stated that R366 was still walking around during V17's shift. V17 stated that V17 informed staff that R366 cannot leave the nursing unit without a staff member. V17 stated that V17 informed on-coming nurse, V15 RN (Registered Nurse), to not let R366 leave the nursing unit alone. V17 stated that the skin surrounding R366's left eye was black. V17 stated that V17 also observed discoloration behind R366's left ear. On [DATE] at 10:50 AM, dietary mealtimes posted on the second-floor nursing unit notes breakfast is delivered 6:45-6:55 AM. On [DATE] at 10:52 AM, V17 stated that the meal trays are brought up between 6:45 and 6:55 AM and the trays are passed out in the dining room around 7:00 AM. V17 stated that is when V17 observed R366's facial bruising. R366's medical record, dated [DATE] at 9:35 AM, V17 LPN noted R366 was observed with discolorations around left eye and behind left ear. Upon interview with R366, R366 stated that she fell last night in the room and got herself up. R366 stated that she thought that she was fine and didn't report to anyone. V17 encouraged R366 to report incidents timely and to be mindful of her environment to prevent tripping, stated okay. R366 was assessed from head to toe and no other injury noted apart from the discolorations mentioned. R366 denied any pain or discomfort at this time. R366 was placed on observation with staff. Neurological checks were initiated and were normal. Active range of motion was completed with no issue. R366's neurological checks documentation notes it was initiated on [DATE] at 9:45 AM. R366's POS (physician order sheet), dated [DATE] at 9:50 AM, notes an order for facial x-ray due to fall. On [DATE] at 3:30 PM, V12 (smoke monitor) stated that he was working on [DATE] from 2:30 PM until 10:00 PM. V12 stated that R366 got a cigarette and sat down to smoke. V12 stated that R366 was on the patio until her smoke break was over at 5:20 PM. V12 stated that when R366 was finished smoking, R366 got up, walked over and placed cigarette butt in the discard container. V12 stated that R366 then walked around garbage can, staggered and fell to the ground hitting head. On [DATE] at 8:53 AM, V31 (Outside Program Employee) stated that V31 works for a program that assists residents to move back into the community. V31 stated that V31 was at the facility on [DATE] at 5:40 PM to visit with two residents. V31 stated that as V31 was signing the logbook at the reception desk, a security guard approached the receptionist and asked for a wheelchair and to have the nurse called because somebody fell on the patio. V31 stated that the receptionist said she would call nurse but did not know where to find a wheelchair. V31 stated that V31 informed them to get a wheelchair from the skilled therapy department. V31 stated that V31 observed R366 being pushed to the elevator; R366 had a dark red purple discoloration to left eye and was complaining her head hurt. V31 stated that V31 rode in the elevator with R366 and got off with R366 on the second-floor nursing unit. V31 stated that staff parked wheelchair with R366 at the nurses' station and the nurse was attempting to obtain R366's blood pressure. V31 stated that V31 visited one resident for 20 minutes. V31 stated that R366 was still in wheelchair at nurses' station with the nurse. V31 stated that V31 left the nursing unit to see another resident. V31 stated that about 6:15 PM V31 heard a code blue paged overhead. V31 stated that afterwards V31 approached the receptionist desk to sign out before leaving facility. V31 stated that V31 saw EMS (emergency medical services) crew arriving at facility. V31 stated that V31 asked the receptionist if the crew was here to get R366 and was informed 'yes'. On [DATE] at 12:35 PM, V16 CNA (Certified Nurse Aide) stated that he worked evening shift on [DATE]. V16 stated that R366 went down to the patio for smoke break. V16 stated that R366 can leave the nursing unit independently to smoke on the patio. V16 denied any staff member that accompanied R366 on that day. V16 stated that V16 does not recall what time it was when V15 RN (Registered Nurse) assessed R366 and screamed call EMS 911. V16 denied calling 911. V16 was unsure who did call 911. V16 denied any other staff coming to the nursing unit to assist V15. On [DATE] at 3:12 PM, V15 RN stated that V15 was coming out of the medication room and escorted R366 to R366's room and immediately assessed R366; R366 had a gash to the left side of her head. V15 stated that V15 obtained vital signs, R366 was lethargic. V15 stated that R366's vital signs were abnormal, oxygen saturation level was decreasing to 87% on room air. V15 stated that she placed R366 on oxygen 2 liters via nasal cannula and oxygen saturation level increased to 95%. V15 stated that EMS crew arrived 10 minutes later. R366's vital sign documentation, dated [DATE] at 5:55 PM, notes blood pressure 104/68, pulse 104 beats/minute, respirations 18 per minute, and oxygen saturation level 87% on room air. At 5:58 PM, oxygen saturation level 95% on oxygen. R366's EMS run sheet, dated [DATE] notes the facility contacted EMS at 6:12 PM for an unresponsive resident. EMS crew was en route to the facility at 6:14 PM, arrived at 6:18 PM, and were at R366's bedside at 6:21 PM. The narrative notes crew dispatched to patient unresponsive with CPR (cardiopulmonary resuscitation) in progress. Upon arrival, R366 laying supine in bed unresponsive with CPR being performed by nursing home staff. Crew advised staff to pause CPR and perform a pulse check on R366. Crew noted R366 had a pulse and was breathing. Crew placed defibrillator pads on R366 and cardiac monitor showed sinus rhythm. CPR discontinued. Staff reported R366 was downstairs outside of facility when she fell and hit her head. Staff reported they brought R366 back to her room in a wheelchair while she was alert and orientated x3 per her normal. Staff reported R366 became unresponsive when getting back to room. Staff reported they put R366 on the bed and initiated CPR because R366 was not breathing. Crew noted hematoma to back of R366's head. R366 presented with battle sign behind left ear. Crew noted R366 had swelling with black and blue discoloration to left eye. Staff reported R366 had a previous fall approximately one day prior to crew arrival. R366 transferred to ambulance. ALS (advanced life support) care initiated. Cardiac monitor showed sinus rhythm. Crew administered oxygen via nasal cannula at 6 liters/minute. Crew noted decreased lung sounds in lower fields bilaterally and some snoring respirations bilaterally in upper fields. R366 presented with dilated pupils. R366 arrived at closest hospital at 6:48 PM. R366's hospital record, dated [DATE] at 6:51 PM, R366 presented unresponsive to the hospital. R366 was noted to have bruising around left eye and around left mastoid. R366 noted to have a large scalp hematoma (swelling). R366 is minimally responsive. R366 is breathing on own but does not respond to pain or voice, does not open eyes. Pupils are fixed and dilated. Given exam, signs of trauma to the head, Battle sign, bruising over the mastoid, R366 was emergently taken for CT (computerized tomography) of head. R366 noted to have a large traumatic subdural with shift causing herniation. There was concern for catastrophic injury. At 7:00 PM, neurological checks noted corneal reflex absent to both eyes. R366 was seen by neurosurgeon who deemed that R366's prognosis was very poor without any chance for any significant functional outcome. The CT scan of R366's head showed a large right cerebral convexity acute subdural hematoma measuring up to 3 cm (centimeters) with severe 1.7cm leftward midline shift, subfalcine and uncal herniation and enlargement of the left lateral ventricle concerning for developing entrapment. R366 expired on [DATE] at 4:40 PM. R366's death certificate was not available for review during this survey. On [DATE] at 3:05 PM, V3 DON (director of nursing) stated that R366's facial Xray was not completed prior to R366 being transferred to the hospital. V3 stated that it was not ordered to be done urgently. V3 acknowledged that given the bruising to R366's left eye and posterior left ear, R366 should have been transferred to the hospital when staff first noted injury earlier in the day. The National Library of Medicine, dated [DATE], notes Battle sign is bruising over the mastoid process and typically requires significant head trauma and may indicate significant internal injury to the brain. It takes Battle sign 1-2 days for the sign to appear. Battle sign is a clinical sign. The facility's change in resident's condition or status policy, undated, notes except in medical emergencies, physician notification will be made within 24 hours of a change occurring in the resident's condition or status. During medical emergencies 911 will be notified for transport to the hospital.

Based on observation, interview and record review the facility failed to ensure that the residents had a table to sit their food tray on to eat their meals. This affects eight of eight residents (R363, R303, R247, R22, R31, R466, R186, R245) reviewed for accommodations of needs. Findings include: On 6/10/25 at 12:03pm during lunch observation R363 was observed in the bed with her meal tray resting on the bed, R363 was eating her meal. R303 was observed with her lunch tray sitting on her lap, R303 was eating her lunch. R247 was observed eating his lunch, the lunch tray was resting on R247's legs while he was eating. R22 was observed with his lunch tray resting on his legs while he was eating his meal. On 6/11/25 at 12:01pm during lunch service R31 was observed sitting on a black tote, and his lunch tray was resting on the bed, R31 was eating his meal. R466 was observed eating his lunch, the lunch tray was resting on his legs while he was eating. R186 was observed with his lunch tray resting on the bed, while he was eating his meal. R245 was observed with her lunch tray sitting on the bed, R303 was eating her lunch. 6/11/25 at 10:45am during the hosted resident council meeting attended by R242 the residents stated that it would be nice to have something to eat on. 6/12/25 at 12:30pm V1 (Administrator) presents a purchase receipt for tables V1 stated that he is ordering bedside tables, he's working on getting tables for the residents. V1 was agreeable that the residents should have a table to eat their meals on.

Based on interview and record review, the facility failed to ensure resident's code status was readily accessible to staff by not having the code status documented on the face sheet or in the paper chart/ clinical record. This affected five of five residents (R616, R617, R618, R619 and R166) reviewed for advanced directives. Findings Include: R616 was admitted on [DATE]. R616's face sheet section titled advance directive did not document a code status, it was blank. R616's physician order sheet dated 5/30/25 documents: Full code On 6/11/25 at 4:25pm, R616's entire paper chart was reviewed. No advance directive paperwork was included to indicate R616's code status. The code binder on R616's unit documents: no residents on the do not resuscitate list (DNR) list. V17 (nurse) said, R616's code status was not in his paper chart. V17 said, a resident code status should be in their electronic record and paper chart. R617's was admitted on [DATE]. R617's face sheet section titled advance directive did not document a code status, it was blank. R617's physician order sheet dated 5/28/25 documents: Full code On 6/11/25 at 4:25pm, R617 entire paper chart was reviewed. No advance directive paperwork was included to indicate R617's code status. The code binder on R617's floor documents: no residents on the do not resuscitate list (DNR) list. V17 (nurse) said, R617's code status was not in his paper chart. V17 said, a resident code status should be in their electronic record and paper chart. R618's was admitted on [DATE]. R618's face sheet section titled advance directive did not document a code status, it was blank. Physician order sheet dated 6/5/25 documents: Full code On 6/11/25 at 5:15pm, R618's entire paper chart was reviewed. No advance directive paperwork was included to indicate R618's code status. V3 (don) said, R618's code status was not in his paper chart. V3 said, a resident's code status should be documented in the face sheet, in the resident's paper chart and in their unit binder. R619's was admitted on [DATE]. R619's face sheet section titled advance directive did not document a code status, it was blank. Physician order sheet dated 6/6/25 documents: Full code On 6/11/25 at 4:25pm, R619's entire paper chart did not have any advance directive paperwork to indicate R619's code status. V17 (nurse) said, R619's code status was not in his paper chart. V17 said, a resident code status should be in their electronic record and paper chart. R166's was admitted on [DATE]. R166's face sheet section titled advance directive did not document a code status, it was blank. Physician order sheet dated 5/02/24 documents: Full code. R166's paper chart was observed with an advance directive (POLST) form dated 3/14/14 which documents: attempt resuscitation. On 6/12/25 at 3:00pm, R166's entire paper chart was reviewed. No advance directive paperwork was included to indicate R166's code status. V3 (DON/Director of Nurses) said, R166's code status was not in his paper chart. On 6/12/25 at 3:00pm, V3 (DON) said, a resident's code status should be on the face sheet, in their chart and on the physician order sheet. Advance Directives Policy and Procedure not dated documents: Upon admission, the facility must determine if the resident executed an advance directive or has given other instruction to indicate what care is desired in case of subsequent incapacity. If the resident/resident legal representative has executed one or more advance directives (executes one upon admission), copies will be obtained and incorporated in the resident medical record.

Based on observation, interview and record review the facility failed to label all insulin pens and inhalers with open and expiration dates. This affects four of four residents (R154, R261, R60 and R191) reviewed for medication labeling and storage. Findings include: 1. On 6/11/25 at 2:51pm review of medication cart with assist from V33 (Registered Nurse), R154 albuterol inhaler was noted with an open date of 5/27/25, no expiration date noted, R154 Symbicort inhaler noted with open date 5/15/25, no expiration date noted. V33 said the inhaler expires 30 days after opening. V33 said the medication should be dated with an expiration date. 2. R60 Symbicort inhaler, open date 5/18/25, no expiration was date noted, V33 said the inhaler expires 30 days after opening. 3. R261 Albuterol (proair) inhaler was noted to be open, verified with V33, there was no open date or expiration date noted. R261 Trelegy inhaler noted with open date of 5/29/25, no expiration date noted there was no open date or expiration date noted. R261 Lantus insulin pen was noted to be open, verified with V33, there was no open date or expiration date documented on the yellow label on the pen. R261 Aspart insulin pen was noted with an open date of 5/28, no expiration date was documented on the label. V33 said the insulin pens expire 28 days after opening. V33 said the inhaler and insulin pens should be labeled with an open date and expiration date. 4. R191 Novolog insulin pen noted with open date of 6/1/25, no expiration date was documented on the label. V33 said the insulin pen expire 28 days after opening it. V33 said there should be an expiration date documented on the insulin pen. On 6/12/25 V3 (Director of Nursing) said insulin should be dated with an open date and expiration date, V3 said insulin expires 28 days after opening and inhalers expire 30 days after opening or according to manufactures recommendation , V3 said the inhalers should be label with and open date and expiration date.

Based on interviews and record reviews, the facility failed to notify the attending physician of an abnormal lab result for 3 days after recieving the result. This affected one of three residents (R239) reviwed for abnormal lab results notificaton. Findings include: On 6/12/25 at 1:06 PM, V22 (Infection Prevention Nurse) stated that V22 meets with infection prevention nurse practitioner weekly to review residents with abnormal laboratory results and/or receiving antibiotics. V22 stated that the nurse is responsible for notifying the physician of all abnormal laboratory results. V22 stated that staff will notify V22 when a resident is prescribed an antibiotic. V22 stated that V22 also gets a printout that identifies all residents on antibiotics. When questioned reason R239's urine culture was reported to this facility on 6/8/25 and physician was not notified until 6/11, V22 stated that she does not know the reason and will have to check with floor nurse. On 6/12/25 at 2:05 PM, V22 stated that V22 spoke with the V28 LPN (Licensed Practical Nurse) who informed physician of urine culture results and obtained an order for an antibiotic on 6/11. V22 stated that V28 informed her that R239 was not complaining of any pain with urination so V28 did not notify physician of culture results. R239 complained of pain on 6/11 so V28 called the physician and obtained an order for antibiotic. On 6/12/25 at 3:10 PM, V3 DON (Director of Nursing) stated that this facility has been having difficulty receiving transmission reports from the outside laboratory company. V3 acknowledged that the nurses are responsible for following up on all outstanding results and should have contacted the outside laboratory company for the urine culture results. R239's urine culture and sensitivity report, dated 6/8/25 at 7:02 AM, notes R239's urine with pseudomonas aeruginosa 50,000 - 100,000 colonies/milliliter. V29 LPN reviewed the urine culture results on 6/11/25 at 2:40 PM. V30 (attending physician) was notified of abnormal culture results by V28 LPN on 6/11/25 at 6:00 PM. R239's POS (physician order sheet), dated 6/11/25 at 6:00 PM, notes an order for ciprofloxacin (antibiotic) 500mg (milligrams) twice daily for UTI for seven days. R239's medical record notes R239 received first dose of ciprofloxacin on 6/12/25 at 3:45 PM. The CDC (Center for Disease Control and Prevention), dated 6/12/25, notes Pseudomonas aeruginosa (P. aeruginosa) infections typically occur in healthcare settings. Good hand hygiene and infection prevention and control can help reduce the risk of infection. P. aeruginosa can be resistant to antibiotics, making these infections difficult to treat.

Based on interviews and records reviewed the facility failed to provide effective interventions to prevent a resident-to-resident physical assault. This affected two of three residents (R568, R277) reviewed for physical abuse. This failure resulted in R277 being assaulted by R568 sustaining a discoloration to his left eye. Findings include: The facility reported incident report states the incident date is 4/4/25. Residents were engaged in a physical dispute. No injuries noted on R568. R277 did appear to have a slight discoloration to the left eye. R568 was transferred to the hospital for further evaluation. Conclusion: No witness were present. R277 alleges that R568 thought he was trying to take his food and he took an aggressive stance towards him. R568 remains in the hospital. R277 is [AGE] years old with diagnosis that include but are not limited to Bipolar Disorder, Schizophrenia, and Major Depressive Disorder. R277's cognition score on 1/13/25 is 15, cognitively intact. Progress note dated 4/3/25 at 12:49PM written by V19, LPN (Licensed Practical Nurse) states R277 was observed with discoloration to his left eye during medication administration this morning. Resident stated the incident happened in the middle of the night. Ordered X-ray. There is no social service note written for R277 related to incident on 4/3/25. R568 is [AGE] years old with diagnosis including but not limited to Major Depressive Disorder, Asthma, Unspecified Psychosis, Attention Deficit Hyperactivity Disorder, Auditory Hallucinations, Schizoaffective Disorder, Non-Compliance with Medical Treatment, and Cannabis Dependence. cognition score on 1/21/25 is 15, cognitively intact. R568 did not return to the facility after the incident for interview. Progress Notes dated 1/7/25 identifies writer received a report that R568 was being aggressive towards staff. Resident became increasingly agitated and attempted to charge at staff. Resident encouraged to attend anger management. Progress Notes 4/3/25 at 11:48AM completed by V19 states resident with agitation and aggression. Transfer to the hospital for psych evaluation. At 12:27PM progress notes states R568 had a physical altercation with another resident. Assessment initiated. At 1:03PM progress notes state R568 had physical altercation with another resident in his room. R568 stated he didn't know why he was physically aggressive. Complete body assessment initiated with no injury occurred. At 1:38PM R568 was transferred to the hospital. R568's care plan states he demonstrates behavioral distress related to poor verbal skills and inability to express self in more appropriate language. Symptoms include verbally aggressive behavior and physically aggressive behavior. This behavior occurs approximately 1 time per week. Interventions include talking to attempt to calm him down. If not successful try walking to a quiet area. Intervene by speaking calmly and professionally in a soft tone. Additionally, the care plan states R568 has auditory hallucinations. On 06/10/25 at 11:46 AM R277 said the other guy, my roommate he hit me. It happened in the middle of the night. He (R568) said something about the food, I didn't have any. He hit me in the eye. I was in bed sleeping and he came over. On 6/12/25 at 10:54AM V20, LPN, said R277 said his roommate went off on him. We called the administrator and director of nursing. V20 said R277 had an x-ray completed. V20 said R568 was sent out. On 6/12/25 at 11:16AM V21, LPN, said abuse can happen, but it should not happen. We should remove or separate them before an altercation occurs. I make rounds every 30 minutes to make sure the residents are safe. The staff is expected to look in the rooms and look at the residents when doing rounds. On 6/12/25 at 1:30PM V24, Social Service, said if residents are having a behavior we will separate them give them space, sit them down, ask them questions, how they feeling, what medications are they taking. Give them time to breathe. V24 said other staff, nurses, security, will let us know immediately of a resident having behaviors. V24 was asked how do you know who is at risk for abuse? V24 responded we talk to them ask them questions and talk to them on rounds. V24 said rounds are done daily. V24 at the time of the incident with R568 and R277 V23, Social Services, was covering them. V24 said I was not assigned on that floor at that time. On 6/12/25 at 1:55pm V23, Social Services, said neither R568 or R277 were my residents. V23 said in general, if an altercation occurs, I speak with the resident. I report the allegation to the administrator. V23 said if they have behaviors we document them in the progress notes. V23 said to prevent behaviors we look for signs of aggressive behaviors how they talk, if they don't talk, and how they move and intervene. On 6/12/25 at 2:57PM V7, Social Service Director, I was not aware of an incident between R277 and R568. V7 said after an incident occurs we document for 3 days. For an incident we would document on both of them for 3 days. On 6/12/25 at 3:06pm V3, DON (Director of Nursing) said R568 and R277 had a physcial altercation. V3 said they had an argument with them shoving each other. V3 said no one should wake up with an injury. V3 said I am not aware if R568 had behaviors before this one. V3 said rounds by nursing are every 2 hours or more and security staff is doing rounds ever 30 minutes. V3 was asked if the investigation for R277 was an investigation for injury of unknown origin? V3 replied no, it was not. On 6/12/25 at 2:04PM V1, Administrator, said the incident was reported to me by V3, DON. V1 said R277 wasn't forthcoming, and that V19, LPN, had said neither resident told us what happened. V1 said later V19 was told that R277 said R568 was trying to take his food. V1 said R277 did have a red mark under his left eye. V19 reported it happened in the middle of the night and R277 said in the middle of the night. V1 said we feel R568 possibly put his hands on R277. The surveyor requested records of R568's attendance in groups. R568 last group attendance is dated 2/18/25 for Anger management group. The facility reported incident report states the incident date is 4/4/25. Residents were engaged in a physical dispute. No injuries noted on R568. R277 did appear to have a slight discoloration to the left eye. R568 was transferred to the hospital for further evaluation. Conclusion: No witness were present. R277 alleges that R568 thought he was trying to take his food and he took an aggressive stance towards him. R568 remains in the hospital. The facility Abuse Prevention Program dated 11/21/20 states Prevention: the facility desires to prevent abuse, neglect, exploitation, and misappropriation by establishing a resident sensitive and resident secure environment. As part of the social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse .or who have needs and behaviors that might lead to conflict. Through care planning process staff will identify any problems, goals, and approaches which would reduce the chances of mistreatment for these residents.

Based on observation, interview and record review the facility failed to ensure one resident medication regimen was free from an unnecessary medication by administering one Quetiapine Fumarate 400MG (milligram) tablet without a physician order and failed to reevaluate the use of a psychotropic medications use at least every 14 days. This affected two of five residents (R7, R333) reviewed for unnecessary medications. Findings include: On 6/10/25 at 4:00pm during the medication observation with V25 (LPN/Licensed Practical Nurse), V25 administered R7 divalproex 500MG Extended Release/ 2 tablets, Benztropine 1MG/ 1 tablet, Famotidine 20MG/1 tablet, Olanzapine 20MG/ 1 tablet, Quetiapine Fumarate 400MG/1 tablet, Senna 8.6MG/ 1 tablet and Lorazepam 1MG/1 Tablet. V25 confirmed 8 pills administered to R7. Review of R7 physician order sheet Quetiapine Fumarate 400MG tablet, Olanzapine 20MG/ 1 tablet, is not listed as an active medication, both denoted on the discontinued medication list. R7 medication administration record reviewed, R7 did not have an order for Quetiapine Fumarate 400MG tablet, Olanzapine 20MG/ 1 tablet. On 6/13/25 at 10:00am V3 (Director of Nursing) stated Quetiapine Fumarate 400MG tablet was discontinued for R7, R7 should not have received Quetiapine Fumarate 400MG tablet, Olanzapine 20MG/ 1 tablet. Facility policy Titled Drug Administration, no date noted denotes in-part medication are administered as prescribed, in accordance with good nursing principles and practices and only be person legally authorized to do so. Medications are prepared, administered and recorded only by a licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations. Ten rights for administration of medications, 1 the right resident, the right drug: verify each drug against the medication record (MAR) before administering. Verify in at least 3 ways, such as by drug's size, shape, color, or label. The right dose, the right time, the right route, the right documentation, the right resident education, the right to refuse, the right assessment, and the right evaluation. R333 was admitted to the facility on [DATE] with a diagnosis of major depression disorder, depression, anxiety, vascular dementia and unspecified psychosis. R333's physician orders dated 3/14/25 documents: Haldol inject 2 mg intramuscularly every six hours as needed for behavioral disturbances related to anxiety. R333's physician orders dated 3/14/25 documents: Haldol 2 mg Give one tablet by mouth every six hours as needed for agitation. R333's progress note dated 4/29/25 documents: patient is not a current danger to herself or others under medication to increase Effexor and discontinue Remeron. Medication reduction indicated documents not attempted due to past reduction attempts resulted in psychiatric instability. Haldol is not listed as a medication in progress note. There is no documentation for the continued use of Haldol. There were no other psychiatric progress notes to review. On 6/12/25 at 1:45PM, V22 (Psychotropic Nurse) said residents with as needed antipsychotic medications are to have orders for 14 days. After 14 days, the doctor will reevaluate the medications and documents in the chart. Facility policy psychotropic drug usage dated 11/17 documents: Residents who receive as needed psychotropic medications will be evaluated and if the medication is extended longer than 14 days, the rationale for continuations will be documented in the residents' medical record.

Based on observation, interview, and record review the facility failed to follow professional standards of care to administer and obtain a physician order prior to administering medications. This affected two of two residents (R188 and R7) reviewed for professional standards of care, physician orders. Findings include: 1. On 6/10/25 at 4:00pm during the medication observation with V25 (LPN/Licensed Practical Nurse), V25 administered R7 divalproex 500MG (milligrams) ER(Extended Release)/ 2 tablets, Benztropine 1MG/ 1 tablet, Famotidine 20MG/1 tablet, Olanzapine 20MG/ 1 tablet, Quetiapine Fumarate 400MG/1 tablet, Senna 8.6MG/ 1 tablet and Lorazepam 1MG/1 Tablet. V25 confirmed 8 pills administered to R7. Review of R7's physician order sheet and medication administration record, R7 did not have an active order for Quetiapine Fumarate 400MG tablet and Olanzapine 20MG/ 1 tablet. 2. On 6/11/25 at 4:52pm during the continuation of medication observation with V15 (Registered Nurse), V15 was observed to administrator R188 Divalproex 500MG ER/ 2 tablets, Benztropine 2MG/1 tablets, Fenofibrate 120MG/ 1 tablet, Fenofibrate 48MG/ 1 tablet, Fluphenazine HCI 10MG/1 tablet, Fluphenazine 5MG/1 tablet, Metformin 1000MG/ 1 tablet, Lispro 18 UNITS subcutaneous (LEFT ARM). V15 confirmed 8 pills administered to R188. Review of R188 physician order sheet, R188 has an order for Clozaril tablet 100mg, give 1 tablet by mouth two times a day related to schizo-affective disorder bipolar type, give one tablet by mouth. Review of R188 medication administration record V15, initials are noted for administering Clozaril 100 mg tablets. During the medication observation with V15, V15 did not administrator Clozaril 100 mg tablet. On 6/12/25 at 4:31pm V15 said she made a mistake she signed out the Clozaril medication, but she did not administer the medication. On 6/12/25 at 3:30pm V3 (Director of Nursing) said his expectation is that the Nurse staff administer medications as order by the physician. Facility policy Titled Drug Administration, no date noted denotes in-part medication are administered as prescribed, in accordance with good nursing principles and practices and only be person legally authorized to do so. Medications are prepared, administered and recorded only by a licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations. Ten rights for administration of medications, 1 the right resident, the right drug: verify each drug against the medication record (MAR) before administering. Verify in at least 3 ways, such as by drug's size, shape, color, or label. The right dose, the right time, the right route, the right documentation, the right resident education, the right to refuse, the right assessment, and the right evaluation.

Based on observation, interview and record review, the facility failed to follow physician orders for hand splint and failed to ensure a fabricated right foot orthosis was ordered for a resident with a diagnosis of right drop foot, significant varus of the ankle, weakness of the knee extensor musculature and notable wrist drop, along with weakness of the wrist extensor muscles. This affected one of five resident (R215) reviewed for restorative services. Findings include: R215 was admitted to the facility on [DATE] with a diagnosis of transient cerebral ischemic attack and weakness. During the survey, on 6/10/25, 6/11/25 and 6/12/25 R215 was observed in common areas and room with no right hand splint in place. R215's right arm was flexed at the elbow with right hand fingers contracted. There was no device observed on R215's lower extremities. R215's right foot was observed turning inward. On 6/10/25 at 11:15AM, R215 who was alert and oriented at time of interview said he did not have his splint on today. On 6/11/25 at 1:34PM, R215 who was alert and oriented at time of interview said he did not have his splint on today. On 6/11/25 at 1:50PM, V8 (Restorative Aide) said she will put on residents splints in the morning after breakfast. V8 said she was assigned to R215 today and did not apply R215 splint today. V8 said she forgot and was not placed. V8 did not place splint on R215. On 6/12/25 at 1:16PM, V26 (Restorative Nurse) said splints are applied by staff in the morning after breakfast. V26 was unaware of any changes to R215's right foot and stated staff apply splint to right hand daily. On 6/12/25 at 1:45PM, R215 who was alert and oriented at time of interview said he did not have his splint on today. R215 was observed with no splint to right hand. V26 (Restorative Nurse) said she was unsure why R215's splint was not applied and called V8 (Restorative Aide). V26 said she did not place splint today and unsure reason why. V26 said R215 is alert and oriented and if splint was applied after breakfast it should still be on at this time. On 6/12/25 at 1:16PM, V26 (Restorative Nurse) said staff are expected to place splint after breakfast and leave for on for recommended time. V26 said R215 splint should be on for 6 hours. R215 physician order dated 4/2/25 hand resting splint wear four hours remove for skin check and redness. R215 physician order dated 6/12/25 hand resting splint wear 6 hours on after AM care remove for skin check and redness. R215's progress note dated 2/11/25: R215 is a pleasant [AGE] year old male, who is evaluated for a right AFO (Foot drop brace) & right Wrist Hand Orthosis. R215 has been diagnosed with right drop foot, significant varus of the ankle, and weakness of the knee extensor musculature. R215 also has notable wrist drop, along with weakness of the wrist extensor muscles. R215 is motivated to walk. To lessen the risk of falls, he would benefit from a custom fabricated right ankle foot orthosis. There is a need to control the ankle in the frontal and sagittal plane. R215 ankle and knee weakness should be addressed and stabilized to assist in ambulation and help to prevent falls. A pre-tibial component is also needed to provide a posterior directed force at the knee to prevent it from buckling. To address the wrist drop, a WHFO (Hand and Finger Splint) is indicated. R215 is motivated to reduce contractures and regain some of his prior function. There is a need to control the wrist, hand, and fingers in the sagittal plane. R215 is anticipated to use the devices for more than 6 months. Due to the above reasons, R215 ankle foot orthosis will require a custom fabrication to offer better control of his joints. Due to the above reasons, R215 wrist hand finger orthosis will require a custom fit to offer better control of his joints. The patient will coordinate the delivery and follow-up visits with the orthotic clinician. On 6/11/25 at 1:50PM, V8 (Restorative Aide) said R215 did not have a splint or brace for lower extremities. On 6/12/25 3:50PM, V3 (DON/Director of Nursing) said any recommendations for therapy devices are ordered by therapy department and unsure about brace for R215's foot. On 6/12/25 at 3:30pm, V26 (Restorative Nurse) was not aware of any previous order for right foot brace On 6/12/25 at 4:19PM, V27 (Therapy) said he recommended brace for R215's right foot in January and gave the information to the restorative nurse. V27 said he is unsure what happened to the order or if it was ordered. Facility was asked to provide documentation that order was place in January for brace but did not present information during the survey. R215's care plan dated 4/2/25 documents splint will be applied 4-6 hours as tolerated daily per the following schedule: apply following morning care. Facility policy dated 2/2015 Range of motion (ROM) and splint policy and procedure documents: once a resident has been evaluated by skilled therapist and the facility has recommendations for the splint; restorative nurse and the skilled therapist will select an appropriate splint and order per vendor.

Based on interviews and record reviews, the facility failed to ensure one resident who is incontinent of bladder receives appropriate treatment and services to prevent/ reduce the risk of urinary tract infections. This affects one of three (R239) residents reviewed for infections in a sample of 58. Findings include: On 6/12/25 at 1:06 PM, V22 (Infection Prevention Nurse) stated that V22 meets with infection prevention nurse practitioner weekly to review residents with abnormal laboratory results and/or receiving antibiotics. V22 stated that the nurse is responsible for notifying the physician of all abnormal laboratory results. V22 stated that staff will notify V22 when a resident is prescribed an antibiotic. V22 stated that V22 also gets a printout that identifies all residents on antibiotics. When questioned reason R239's urine culture was reported to this facility on 6/8/25 and physician was not notified until 6/11, V22 stated that she does not know the reason and will have to check with floor nurse. On 6/12/25 at 2:05 PM, V22 stated that V22 spoke with the V28 LPN (Licensed Practical Nurse) who informed physician of urine culture results and obtained an order for an antibiotic on 6/11. V22 stated that V28 informed her that R239 was not complaining of any pain with urination so V28 did not notify physician of culture results. R239 complained of pain on 6/11 so V28 called the physician and obtained an order for antibiotic. On 6/12/25 at 3:10 PM, V3 DON (Director of Nursing) stated that this facility has been having difficulty receiving transmission reports from the outside laboratory company. V3 acknowledged that the nurses are responsible for following up on all outstanding results and should have contacted the outside laboratory company for the urine culture results. R239's urine culture and sensitivity report, dated 6/8/25 at 7:02 AM, notes R239's urine with pseudomonas aeruginosa 50,000 - 100,000 colonies/milliliter. V29 LPN reviewed the urine culture results on 6/11/25 at 2:40 PM. V30 (Attending Physician) was notified of abnormal culture results by V28 LPN on 6/11/25 at 6:00 PM. R239's POS (physician order sheet), dated 6/11/25 at 6:00 PM, notes an order for ciprofloxacin (antibiotic) 500mg (milligrams) twice daily for UTI for seven days. R239's medical record notes R239 received first dose of ciprofloxacin on 6/12/25 at 3:45 PM. The CDC (Center for Disease Control and Prevention), dated 6/12/25, notes Pseudomonas aeruginosa (P. aeruginosa) infections typically occur in healthcare settings. Good hand hygiene and infection prevention and control can help reduce the risk of infection. P. aeruginosa can be resistant to antibiotics, making these infections difficult to treat.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate was less than 5%, by making 3 errors out of 30 attempts with an error rate of 10 %. This affects two of six residents (R7 and R188) reviewed for medication errors. Findings include: On 6/10/25 at 4:00pm during the medication observation with V25 (LPN/Licensed Practical Nurse), V25 administered R7 divalproex 500MG (milligrams)ER (Extended Release)/ 2 tablets, Benztropine 1MG/ 1 tablet, Famotidine 20MG/1 tablet, Olanzapine 20MG/ 1 tablet, Quetiapine Fumarate 400MG/1 tablet, Senna 8.6MG/ 1 tablet and Lorazepam 1MG/1 Tablet. V25 confirmed 8 pills administered to R7. Review of R7 physician order sheet and medication administration record, R7 did not have an active order for Quetiapine Fumarate 400MG tablet and Olanzapine 20MG/ 1 tablet. On 6/11/25 at 4:52pm during the continuation of medication observation with V15 (Registered Nurse), V15 was observed to administrator R188 Divalproex 500MG ER/ 2 tablets, Benztropine 2MG/1 tablets, Fenofibrate 120MG/ 1 tablet, Fenofibrate 48MG/ 1 tablet, Fluphenazine HCI 10MG/1 tablet, Fluphenazine 5MG/1 tablet, Metformin 1000MG/ 1 tablet, Lispro 18 UNITS subcutaneous (LEFT ARM). V15 confirmed 8 pills administered to R188. Review of R188 physician order sheet, R188 has an order for Clozaril tablet 100mg, give 1 tablet by mouth two times a day related to schizo-affective disorder bipolar type, give one tablet by mouth and medication administration. During the medication observation with V15, V15 did not administrator Clozaril 100 mg tablet. On 6/12/25 at 4:31pm V15 said she made a mistake, she signed out the Clozaril medication but she did not administer the medication. During this survey for mediation observation, there was 30 opportunities for errors and 3 medication errors identified, which equates to 10% medication error rate. Facility policy Titled Drug Administration, no date noted denotes in-part medication are administered as prescribed, in accordance with good nursing principles and practices and only be person legally authorized to do so. Medications are prepared, administered and recorded only by a licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations. Ten rights for administration of medications, 1 the right resident, the right drug: verify each drug against the medication record (MAR) before administering. Verify in at least 3 ways, such as by drug's size, shape, color, or label. The right dose, the right time, the right route, the right documentation, the right resident education, the right to refuse, the right assessment, and the right evaluation.

Based on interview and record review, the facility failed to follow their change in condition policy and did not notify a family member of a resident's (R2) change in condition and need to be sent out to the hospital for one (R2) out of four residents reviewed for change in condition in a total sample of seven. Findings Include: R2 is a [AGE] year old with the following diagnosis: psychosis, mood disorder, suicidal ideation, and anxiety disorder. A Social Service note dated 3/27/25 documents R2 became verbally and physically aggressive with staff. R2 attempted to go to the patio but the patio was currently closed. Staff redirected R2 back to R2's assigned unit, but R2 refused. R2 became increasingly agitated R2 then attacked staff by slapping them and kicking them in the stomach. A behavioral code was called, and CPI (Crisis Prevention and Intervention) methods were applied to stop R2 from attacking staff. R2 was escorted back to R2's unit once calm. Social services attempted to educate R2 on house rules and behavior expectations but R2 continued to display inappropriate verbal behavior. R2 was placed on 1:1 monitoring. A Nursing note dated 3/28/25 documents the nurse received in report that R2 was being sent to the hospital for a psych evaluation due to aggressive behavior and suicidal ideation. Transportation was called and R2 left the facility around 4:10PM. There is no documentation that family was notified of R2's behavior or that R2 left the facility that was documented before R2 left the facility. A Late Entry Nursing note dated 3/28/25 documents R1 remained on 1:1 monitoring for verbal threats to staff. The physician was notified and ordered to petition R2 to the hospital for a psych evaluation. All responsible parties were notified including family members. This note was entered into the charting system on 4/2/25 at 10:47PM. A Nursing note dated 3/29/25 documents R2 remained at the hospital for a psych evaluation. On 4/1/25 at 12:47PM, V1 (R2 Family Member) stated R2 called V1 on the evening on 3/28/25 to tell V1 that R2 was in the hospital. V1 reported R2 did not remember how or why R2 was sent to the hospital. V1 stated V1 tried calling the facility to confirm what R2 said but calls to the facility went unanswered. V1 reported V1 tried to call the facility eight to nine times but no call was answered. V1 stated V1 came to visit R2 at the facility on 3/29/25. V1 reported V1 was given badges to go up to the floor to visit R1 but R1 was not in the facility. V1 stated because it was a weekend no management was in the building to explain what happened to R2. V1 reported the nurse manager told V1 someone from the facility would call V1 on 3/31/25 with answers on what happened to R2 but V1 denied receiving a call yet. On 4/1/25 at 1:29PM, V4 (Nurse) stated the previous nurse (V9) coordinated the entire transfer for R2 except calling for transportation. V4 denied calling R2's family to notify them R2 was leaving the facility. V4 reported V4 thought V9 called the family. V4 stated family must always be called before a resident is sent out because the family needs to be made aware of what is going on. On 4/2/25 at 1:54PM, V9 (Nurse) stated R2 was aggressive and talked about self harming so R1 was sent out to the hospital for a psych evaluation. V9 reported V9 delegated to the next shift to arrange transportation for R2 that everything else was completed. V9 stated the DON (Director of Nursing), physician, and V1 were called to notify them of the situation. V9 reported V9 had a family emergency and needed to leave right when to the shift ended so V9 did not document that V9 spoke with V1. V9 reported family should be notified of a change in condition and transfer due to facility protocol and the family needing to be aware where a resident is located. V9 stated if there is no documentation then it means it wasn't done. V9 reported V9 was going to chart the conversation the next time V9 worked but V9 never got the chance to complete the note. On 4/3/25 at 10:15AM, V10 (DON) stated R2 began being aggressive and was put on 1:1 monitoring on 3/28/25. V10 reported the following day R2 was still aggressive and then began making comments about self harming. V10 stated R2 was sent to the hospital via petition for a psych evaluation. V10 stated the nurse's responsibility is to call the physician, call the family, and get the paperwork ready for transfer. V10 reported the conversation with the family needs to be documented. V10 stated V9 could not document the conversation with family due to V9 needing to leave early cause of a family emergency. V10 denied witnessing V9 speak to R2's family member. V10 reported telling V9 to enter in a late note about speaking to R2's family since V9 didn't get a chance to when R2 was sent out. The Petition for Involuntary Admission that is not dated documents R2 needed an emergency inpatient admission for being physically aggressive with staff and having suicidal ideation with a plan. The box for the guardians/family representative is blank indicating no family was notified of R2's transfer. There is no documentation that a Transfer form or Change in Condition form was completed for this transfer to the hospital. This again shows there is no documentation a family member was notified of R2 being sent to the hospital. The policy titled, Change in Condition Process, that is not dated documents, Intent: The purpose of this policy is to ensure the facility promptly informs resident, consults the resident's physician; and notify, consistent with his or her authority, resident's representative when there is a change requiring notification. Procedure: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Situation requiring notification include: .2. A significant change in the resident's physical, mental, or psychosocial status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications .4. A decision to transfer or discharge the resident from the facility .Situation to Consider: Competent individuals: The facility must still contact the resident's physician and notify the resident and/or resident's representative, if known and approved by the resident.

Based on interview and record review, the facility failed to follow their physician services policy and ensure the attending physician conducted face-to-face visits with residents within the first 30 days of admission/re-admission and/or at least once every 60 days. This affected four of four residents (R1, R4, R5, R6) reviewed for physician visits. Findings include: On 1/30/25 at 10:00AM, V2 DON (Director of Nursing) stated that physicians see residents monthly. V2 stated that some physicians still do paper charting, most document in the resident's electronic medical record. V2 stated that V5 (Attending Physician) documents in the resident's electronic medical record. V2 reviewed R1's medical record and stated that R1 was last seen by V5 in 2022. V2 reviewed R4's medical record. V2 stated that there are no notes by V5. V2 reviewed R5's medical record. V2 stated that R5 was seen in December 2024. V2 acknowledged that the previous visit by V5 was in 2022. R1 was admitted to this facility on 3/31/2022. V5 conducted face-to-face visits with R1 on 4/1/22, 5/9/22, 7/5/22, and 8/27/22. R4 was admitted to this facility on 8/17/2023. There is no documentation found in R4's medical record noting V5 has conducted any face-to-face visits with R4. R5 was admitted to this facility on 6/29/2022. V5 conducted face-to-face visits with R5 on 6/30/22, 7/5/22, 8/27/22, 12/31/22, and 12/31/24. R6 was admitted to this facility on 11/1/2023. There is no documentation found in R6's medical record noting V5 has conducted any face-to-face visits with R6. The facility's physician services policy, undated, notes the residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. All required physician visits will be made by the physician personally.

Based on interview and record review, the facility failed to schedule outside appointments and testing for one resident (R1) out of three residents reviewed for resident rights in a sample of 6. Findings include: R1's POS (physician order sheet) notes the following orders: 11/16/23, R1 to have CT (computed tomography) with contrast of lungs related to COPD (chronic obstructive pulmonary disease). 11/28/23, R1 to have CT with contrast of lungs related to COPD. 12/5/23, R1 to have CT with contrast of lungs related to COPD. 12/8/23, R1 to have CT with contrast of lungs related to COPD. 2/7/24, Schedule to see pulmonologist for evaluation and treatment, diagnoses COPD, chronic cough, and repeated upper respiratory infections. 3/27/24, Pulmonologist appointment 7/11/2024 at 2:45PM. On 1/30/25 at 9:55AM, R1 stated that R1 has not seen a pulmonologist yet or had the CT (computed tomography) scan done yet. R1 stated that R1 has asthma. R1 stated that R1 has waited a long time to see a pulmonologist. On 1/30/25 at 9:00AM, V4 (Appointment Scheduler) stated that the nurse has to notify V4 and give copy of order for outside appointments and diagnostic testing. V4 stated that R1's insurance denied CT scan because not enough information was provided to justify the need for CT scan. V4 stated that V4 does not have access to document in the resident's electronic medical record so she has to let nurses know when insurance approves or denies outside appointments and/or testing. V4 stated that the nurse is responsible for notifying the physician. V4 stated that the nurse is responsible for documenting in the resident's medical record if the resident refuses to go to appointment and informing V4 so it can be rescheduled. On 1/30/25 at 10:00AM, V2 Director of Nursing (DON) reviewed R1's medical record and stated that there is no documentation noting R1 refused to go to pulmonology appointment last July. V2 stated that V6 Nurse Practitioner (NP) noted on 8/14/24 that R1 missed pulmonology appointment and it needs to be rescheduled. V2 acknowledged that appointment was not rescheduled. V2 stated that he spoke with one pulmonology office and it would not accept R1's insurance. V2 stated that they have tried many times to schedule R1's appointments and CT scan. V2 stated that there should have been notes in R1's medical record noting this. V2 reviewed R1's medical record and stated that V2 does not see anything documented regarding appointments. V2 stated that all these orders are still active in R1's electronic medical record. V6 (NP) noted on 8/14/24, plan of care reviewed with nursing staff- nurse on duty aware R1 missed appointment with pulmonologist in July and needs to be rescheduled. There is no further documentation found in R1's medical record noting appointment rescheduled.

Based on interview and record review, the facility failed to follow its abuse policy by failing to report an alleged violation involving a resident-to-resident sexual abuse after being notified of the allegation. This failure affected one (R1) of one residents reviewed for abuse. Findings include: R1 is a [AGE] year-old female who has resided at the facility since 2022, past medical history of Iron deficiency anemia, schizoaffective disorder current episode mixed with psychotic features, other specified disorder of muscle, unsteadiness on feet, obesity, low back pain, delusional disorders, encounter for examination and observation following alleged adult rape, etc. 12/17/2024 at 10:00AM, R1 was observed in bed, awake, alert and oriented and stated that she was moved from the third floor to the fifth floor yesterday, she is not sure why. R1 was asked if anything happened between her and another resident (R2) and she said yes, that R2 came to her room and forced her to have sex with him. R1 said she told R2 to stop but he held her down, she asked him to use a condom, but he refused. R1 was asked what time of the day the incident happened, and she said that she cannot recall, she was not sure of the date, but added that her former roommate (R4) was in the room at the time of the incident. 12/17/2024 at 9:30AM, V8 (Health Insurance Casemanager) stated that she was at the facility yesterday and spoke to R1 in the presence of the administrator, DON (Director of Nurses), and social worker regarding the sexual abuse allegation made by R1 against R2. V8 added that R1 did not mention the sexual allegation at first but when V8 asked R1 if she called in a complaint to the health insurance company, R1 repeated the sexual abuse allegation and even mentioned the name of the accused resident. Per record review on 12/17/2024, there was no documentation of the meeting between R1, health insurance case manager, and management in medical record. A review of the facility reportable did not show any report of the sexual abuse allegation or any type of investigation. V1 (Administrator) later presented an initial report for the sexual abuse allegation dated 12/17/2024. 12/17/2024 at 10:58AM, V3 (DON) said that himself, the administrator, and someone from the health insurance company met with R1 yesterday (12/16/2024). R1 had a lot of allegations, the biggest one was sexual allegation. Initially R1 alleged that the abuser was unknown and then mentioned a resident's name when she was prompted by the lady from the health insurance company. The facility did not initiate an investigation or report the incident because R1 was all over the place, she was moved to another floor after the meeting because she wanted to move. 12/17/2024 at 11:22AM, V2 (Assistant Administrator) said that R1 made a complaint of sexual abuse to the health insurance company. On 12/16/2024, they met with R1, and she started talking about her roommate pooping on the floor and that she wants a room change. R1 admitted to the making a sexual abuse allegation when V8 asked her if she made such complaint., and she later said that nothing happened after V8 left. V2 added that R1 has not accused anyone of sexual abuse before as far as she knows. 12/17/2024 at 3:50PM, V1 (Administrator) said that a staff from health insurance company came to the facility yesterday (12/16/2024) and presented that she received a call from R1 stating that she was sexually abused. V1 met with R1 in the presence of V8 and that R1 did not mention the sexual abuse until V8 asked her about it. R1 admitted to making the sexual abuse allegation. V1 agreed that they were made aware of the allegation on 12/16/2024 and it should have been reported. Abuse policy revised 11/21/2020 stated in part that its the policy of the facility to prevent abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. The following procedures shall be implemented when an employee or agent becomes aware of .or an allegation of suspected abuse or neglect of a resident by a 3rd party. Under abuse reporting policy, the document states in part, when an alleged or suspected case of abuse, neglect or exploitation is reported to the facility, the administrator or DON in the absence of the administrator will notify the following persons or agencies of such incident immediately. 1. State licensing and certification agency (i.e., IDPH). 2. Resident representative. 3. Attending physician. Abuse allegation involving one resident upon another resident will be reported to IDPH.

Based on observations, interviews, and record reviews, the facility staff failed to 1. wear a hair restraint to cover a beard while in the kitchen, 2. failed to maintain sanitizing solution at 200 ppm (parts per million) of Quaternary Ammonium solution for dishes in the three-compartment sink, 3. failed to label and date food in the refrigerator. 4. failed to clean and sanitize the blender equipment and spatula after preparation of puree meal. This failure has the potential to affect all 357 residents who received oral meals from the facility's kitchen. Findings include: On 07/14/24 at 09:50 AM, V5 (Cook) oversaw the kitchen at this time. V4 (Dietary Manager) is not in the building. On 07/14/24 at 09:51 AM, Upon entrance to the kitchen observed two staff with beards in the food preparation area not wearing beard covers. V6 (Dietary Aide) was inquired of his beard. V6 said, I just didn't have it (beard covering) on. I know I'm supposed too. I have too much facial hair. On 07/14/24 at 09:52 AM, V7 (Certified Nursing Assistant/CNA) seen in the kitchen without wearing a beard cover while putting ice and water into the large water jugs. V7 was inquired of being in the kitchen without a beard cover. V7 said, I know I have to cover it, but I just started to get something. I know they were busy. On 07/14/24 at 10:04 AM, V6 (Dietary Aide) began washing dishes in the three-compartment sink. V5 (Cook) tested the sanitation level at 100 ppm (parts per million). V5 was inquired of the sanitation level. V5 didn't answer. V6 (Dietary Aide) said, It should be at 200, you have to put more (sanitizer) in. On 07/14/24 at 10:10 AM, there is a clear container with salad in the refrigerator with no label. V5 [NAME] was inquired of the container. V5 said, I don't know whose it is. On 07/14/24 at 2:46 PM, V4 said, The food that was in the refrigerator was for one of the staff. She puts her lunch in there. I told her she can't put it there; she knows now. On 07/15/24 at 9:36 AM, V17 (Cook) prepared the mechanical soft and pureed lunch of creamed chicken and noodles. On 07/15/24 at 9:43 AM, V17 (Cook) took the blender over to the food preparation sink, turned on the water, and wiped the blender out under the water with his gloved hand. V17 took the blender and lid over to the three-compartment sink and dipped the blender and lid into the sanitation water. V17 placed the blender and lid onto the drying rack. On 07/15/24 at 9:51 AM, V17 took the spatula used during the puree preparation to the food preparation sink and rinsed it off in the water while wiping it with his gloved hand. V17 placed the spatula onto the food preparation counter. There are utensils and equipment in the food preparation sink, a whisk, a four-ounce scoop, and a metal pitcher. On 07/15/24 at 9:53 AM, V17 was inquired of the food preparation sink and washing the equipment. V17 said, I clean the blender and spatula in the sink. I'm not to wash any dishes in the sink. It's only water for the food. There's no soap over here. I'm supposed to wash them in the three-part sink. I didn't use soap. The stuff in the sink is dirty and has to be washed. On 07/15/24 at 9:55 AM, V4 (Dietary Manager) was inquired of the food preparation sink. V4 said, It's the cook sink. They can rinse vegetables and fill pans with water. They're not supposed to be cleaning in this sink. V17 did not take the dirty blender, lid, and spatula to the three-compartment sink to be properly washed and sanitized. The food preparation sink is not to be used for washing any dishes or utensils. Dirty utensils and equipment should not be inside the food preparation sink. On 07/15/24 at 12:00 PM, V4 (Dietary Manager) was inquired of the three-compartment sink sanitation level. V4 said, I make sure the staff make fresh water throughout the day. They fill the water to the line and push the button one time for the Qaut (Quaternary Ammonium solution). There is a button on the wall above the sanitation sink with tubing that dispenses the quaternary ammonium solution into the water for sanitation. Observed a moderate amount of the solution remained in the tubing while dispensed. On 07/17/24 at 11:04 AM V4 (Dietary Manager) was inquired of sanitation of kitchen equipment and utensils. V4 said, All equipment has to be sanitized because it can have bacteria. Empty the food debris in the garbage. Then wash, rinse, sanitize, and air dry. It should be done in the three-compartment sink. The policy and procedure manual section: food safety & sanitation policy: three compartment sink use dated 4/2017 states in part: Policy: The facility will clean and sanitize food service equipment, utensils, dishes, and tableware using the proper procedure. Procedure: Food service employees are trained on the use of the 3-compartment sink according to the chemical manufacturer's specifications and instructions. A test kit will be available and used to accurately measure the sanitizer concentrations and water temperature per chemical manufacturer's specifications. A daily log of chemical concentration will be maintained. The policy and procedure manual section: food safety & sanitation policy: general preparation & cooking dated 4/2017 states in part: Policy: The facility will follow sanitary practices in food preparation and cooking to keep food safe. Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby prevent foodborne illness. Procedure: The food service employee will ensure workstations, cutting boards, and utensils are clean and sanitized. The policy and procedure manual section: food safety & sanitation policy: employee health & personal hygiene dated 4/2017 states in part: Policy: Food service employees shall maintain good personal hygiene and free from communicable illnesses and infections while working in the facility. Beards should be well trimmed and covered with an appropriate hair restraint. The policy and procedure manual section: food safety & sanitation policy: storage of refrigerated/frozen food dated 4/2017 states in part: Policy: The facility will follow safe handling and storage of refrigerated and frozen foods. Procedure: Foods in the refrigerator will be covered, labeled, and dated.

Based on observation, interview, and record review, the facility failed to ensure that staff provide timely assessment and adequate intervention for a resident who was experiencing complications with an indwelling urinary catheter. This failure affected one (R2) of two residents reviewed for urinary catheter care. This failure resulted in R2 experiencing a delay in assessment and treatment while experiencing a leaking urinary catheter, abdominal fullness, and pain before being transferred to hospital and being treated for urinary retention secondary to malfunctioning urinary catheter and (UTI) urinary tract infection. Findings include: R2 is a [AGE] year-old male admitted to the facility on [DATE], medical diagnosis includes, but not limited to Multiple Sclerosis, quadriplegia, cardiomyopathy, bipolar disorder, other specified myopathies, abnormal posture, vitamin D deficiency, major depressive disorder, essential primary hypertension, acute cholecystitis, epilepsy, hyperlipidemia etc. Minimum Data Set (MDS) assessment dated [DATE] section C (cognitive) documented that resident is cognitively intact with a BIMs score of 15; Section H (bowel and bladder) stated that resident is always incontinent of bowel; Section GG (functional status) documented that R2 requires substantial/maximal assistance to total dependence on staff for all activities of daily living (ADL) care. Care plan initiated 2/9/2024 stated that R2 is at risk for complications related to catheter use, interventions include monitor indwelling catheter and change urinary bag as needed, observe intake and output, monitor urine for increase sediment, cloudy urine, odor, etc. 6/24/2024 at 11:45AM, R2 was observed in his room, awake and alert sitting in his motorized wheelchair. R2 stated that he has been at the facility since February 2024. The day he went to the hospital, his urinary bag was leaking, bladder was very full, urine was backing up to his bladder and causing him a lot of pain. R2 went to the nurse at the nursing station and told the nurse that he would like his bag to be changed and she told him to go back to his room. R2 said he went to the nurse again because he was in a lot of pain and asked the nurse to call 911 and she told him to call 911 himself after all he has a phone. R2 called 911 and was taken to a local hospital where they drained a large amount of urine from him and he felt better immediately, the hospital told him that he had a bladder infection, and he was started on antibiotics. Hospital record dated 6/23/2024 to 6/24/2024 states in part: patient's presentation seems most consistent with acute urinary tract infection and urinary retention secondary to malfunctioning urinary catheter, urinalysis seems consistent with infection. Patient's urinary catheter was replaced, and he had decompression of his bladder with resolution of his lower abdominal discomfort. Patient received an IV dose of ceftriaxone in the emergency room and to be discharged with 10-day course of Keflex. emergency room physical assessment of the abdomen documents the following: there is tenderness, palpable suprapubic fullness, tenderness to palpation. Bladder scan on 5/23/2024 at 23:44 showed 1358 ml of urine. Medication administration record (MAR) documented that R2 was receiving Keflex 500mg, 1 tablet by mouth three times a day for UTI starting 5/24/2024 and completed on June 2, 2024. On 6/24/2024 at 10:16AM, V5 (Registered Nurse/RN) said that she was the nurse that took care of the resident at the hospital, resident was crying and stated that he asked numerous nurses at the nursing home to change his urinary catheter, he was in so much pain and felt like his bladder is full. V5 said that it took them 5 minutes to change the resident's urinary catheter and he felt immediate release. V5 added that R2 was also treated with oral antibiotics for urinary tract infection, she stated that all these could have been avoided if the facility just changed the resident's urinary catheter. 6/24/24 at 3:50PM, V2 (Director of Nurses/DON) said that the day R2 went to the hospital, he called 911 because he said that his urinary catheter was leaking and needed to be changed, the nurse told him to wait until after medication pass because it is not an emergency. V2 stated that resident's urinary catheter was changed in the emergency room , and he was treated for urinary tract infection (UTI). V2 added that UTI can be caused by lack of proper urinary catheter care, not being changed on time or urine output not being emptied, poor hygiene etc. 6/24/2024 at 12:45P, V3 (RN) said that she was off for two days, came back to work the day R2 went to the hospital and worked double shift that day. Resident came to her and stated that he has been asking nurses to change his urinary catheter for the past three days, his catheter was leaking. V3 checked the catheter, and it was not leaking, resident still wanted his catheter changed and V3 told the resident to wait until after medication pass. V3 stated that this happened around 4 to 5PM, resident never told her to call 911, the next thing she saw was the paramedics that came to take resident to the hospital around 10:00pm. 6/25/2024 at 1:50PM, V7 (Certified Nursing Assistant/CNA), said that she was assigned to R2 the day he had an issue with his urinary catheter. R2 stated that his urinary catheter was pulling and leaking, that was before lunch and the nurse was aware. V7 added that she did not empty any urine from resident's bag on her shift (7am to 3pm) because his bag was leaking and all the urine was in the incontinence brief, resident was also complaining of pain. V7 added that the CNAs are supposed to tell the nurse how much urine they emptied from the urinary catheter bag, the nurses document them in medical record. 6/26/2024 at 11:46AM, V6 (Attending Physician) said that that nurses are supposed to change resident's catheter every month and as needed and this should be documented. V6 added that some factors that could contribute to the development of UTI in residents with urinary catheter include lack of routine care with aseptic technique, making sure the catheter is in place, monitoring intake and output, etc. Physician order dated 2/9/2024 reads as follows: Change urinary catheter bag monthly and as needed every night shift starting on the 10th and ending on the 10th every month for infection control. Urinary catheters care every shift and as needed for soilage, Monitor and record amount/character of urine every shift for urinary catheter, Monitor and Record Color of urine. A document presented by V2 (DON) (undated), titled, Urinary Catheter Care states in its purpose: a resident with an indwelling catheter is susceptible to urinary tract infection. Under standards, the document states in part: catheter care should be provided every shift and any time incontinent episode occurs .urinary bags will be changed monthly and PRN (as needed). Intake and output will be monitored via physician orders.

Based on interview and record review the facility failed to develop an individualized plan of care for a resident identified to be at risk for aspirations and assessed to have impairments while eating. The facility also discharged resident from speech therapy before reaching the short-term goals identified in evaluation. This affected one of one resident (R13) reviewed for safe oral intake. This failure resulted in R13 becoming unconscious, CPR (cardiopulmonary resuscitation) being initiated, excessive amount of food found in R13's airway, and resident being admitted to hospital. Findings include: R13's face sheet shows diagnosis of alcohol dependence with alcohol induced persisting dementia, induced by alcohol dependence, heart failure, atherosclerotic heart disease of native coronary artery. R13's MDS (Minimum Data Set) dated [DATE] section C for cognition denotes a score of 9 (cognitive impairments). Section G for functional status denote in part eating, self-performance is extensive assist (resident involved staff provide weight bearing support), support denotes 2 (one-person physical assist). Police report dated [DATE] denotes in-part ambulance call, to nursing home name listed, victim is R13, date of birth noted, other individual denotes V40 name and date of birth, call in at 12:34pm, In brief on [DATE] at 12:34 pm, r/o (responding officer) was dispatched to (facility address noted) 4th floor (facility name noted) in regard to an ambulance call. Upon arrival r/o spoke with V40 Nurse (name is noted in police report) advise that patient identified as R13 was observed on the ground in the hallway in the middle of the hallway unresponsive and not breathing. Staff immediately began CPR (cardiopulmonary resuscitation) on R13 and called paramedics. R13 was seen eating lunch prior to this incident and believed that may have been choking. FD (fire department) arrived on scene and began working on patient. Patient was transported to (hospital name) for further treatment. R13's emergency room records denote in-part, prior to seeing patient review of triage note, vitals. This is a [AGE] year-old male presenting as a cardiac arrest, patient was at the nursing home today was eating lunch walked out of the dining room, had jerky movements was lowered to the to the ground, turned blue, arrested. Patient often walked around all day long, staff did CPR for 10 minutes. EMS (emergency medical services) arrived and did additional 20 minutes of CPR. Patient initially pulseless, had 2 defibrillations for ventricle tachycardia. He receives epinephrine 4 times prior to arrival and his second shock was just prior to arrival. On arrival his first pulse check he had a pulse. Patient had a LMA (laryngeal mask airway) placed. They noted in route that there was some foreign material in his airway, but they were able to bag with that with slight difficulty. Resuscitation cardiac arrest. I spoke with patient's sister and nursing home. Per the family patient was at the nursing home, he has dementia in the setting of alcohol abuse. He was eating in the dining hall, got up and walked out to the hallway. Began to have choking, staff came to assist, they lowered him to the ground where he continued to choke and went unresponsive and turned blue. He started CPR. Suspected hypoxic arrest. Here with occlusion of airway, able to bag with removal of significant foreign body. Impression and plan; cardiac arrest. Chief complaint; cardiac arrest. R13 is a [AGE] year-old at (nursing home name) presenting for cardiac arrest. History per EMS (emergency medical services), NH (nursing home) staff, chart review based on clinical condition. Per EMS, they were called for cardiac arrest to NH. Witnessed, bystanders EMS chest compressions. There were concerns about a choking episode. EMS removed a significant amount of food from his airway upon arrival. They placed a supraglottic device. They were able to use BVM (bag valve mask) without resistance. Downtime prior to EMS arrival at the nursing home was 12 minutes. EMS remained on scene for 19 minutes. They administered a total of 3 rounds of epinephrine. Initially patient was PEA, asystole. V-fib, PEA, V-fib, PEA. A total of 3 rounds of epinephrine. Two defibrillations. Antiarrhythmics not given. Normal accu-check. Patient arrives to us with I-gel in place. Repeated accu-check in the 200s. Definitive airway established, see MDM. Additional history obtained from nursing home staff. Patient has resided at nursing home x 4 years. He is admitted for severe alcohol induced dementia. The patient was in the dining room, ate lunch. Walked out of the dining room into the hallway and started making chocking noises. They immediately went to attend to him and then the patient collapsed, was cyanotic. CPR was initiated. Full code. ED course, based on history and airway findings, concerns for aspiration event, hypoxia, cardiac arrest. ED diagnosis; cardiac arrest. R13 fire department report dated [DATE] denotes in part in summary: was dispatched to the nursing home to assist fire department for [AGE] year-old male for the reported cardiac arrest, U/A (upon arrival) to the scene pt (patient) was found lying supine on the ground unresponsive, pulseless, and apneic with (fire department) crew actively performing CPR with BVM (bag valve mask) ventilation. Healthcare staff on scene stated the patient was eating when he walked into the hallway gasping for air and was witnessed collapsing to the ground inro cardiac arrest. Nursing home staff originally began CPR and applied AED, patient had been down approximately ten minutes when crew arrived. When visualized the vocal cords via laryngoscope crew noted an excessive amount of food in the patient's airway. Crew began to remove the debris, via forceps from patient airway intermittently between ventilations. Number 4 I-gel inserted after vocal cords were still unable to be visualized due to aspiration, confirmed by other crew members. Continues CPR began. On [DATE] at 10:56am V40 (Licensed Practical Nurse/LPN) said she was in the dining room when she observed R13 with jerky movements. V40 said she went over to R13 and R13 became unconscious. V40 said a code blue was called and R13 was lowered to the floor. V40 said R13 did not have a pulse nor did R13 have any respirations. V40 said she don't know why she was in the dining room; she just knows she was there. V40 said she don't know how long she was in the dining room. V40 said she did not see R13 eat his lunch. V40 said R13 was finished with lunch when she observed him. V40 said she don't remember if R13 needed assist with meals. V40 said she don't know who she told to call a code blue; she doesn't know who she told to call 911. V40 said she don't know if R13 had issues with chewing or swallowing, she doesn't know if R13 had all his teeth. V40 said she started chest compression on R13 when R13 was observed unconscious. V40 said she may have talked to the paramedics when they arrived on the scene. V40 said she did not tell the medics that R13 was found in the hallway unconscious. R13 Fire department report reviewed with V40. V40 said she don't know why the paramedics stated that in their report. V40 denied telling the paramedics that R13 was in the hallway collapsed. V40 said sometimes the hospital do call the facility when they want more information on the resident. V40 said she don't remember if she talked to the emergency room regarding R13. V40 denied knowing if R13 was at risk for choking, V40 denied that R13 was at risk for aspiration. On [DATE] at 1:38pm V43 (Certified Nursing Assistant/CNA) said she was R13's aide on [DATE]. V43 said R13 spoke Spanish but was able to understand English when she communicated with him. V43 said she passed R13 his tray lunch tray on [DATE], but she did not assist R13 with his meal. V43 said she only cut R13's food up. V43 said she was in the dining room doing a one-to-one observation with a resident that was experiencing a behavior episode. V43 said lunch was over, trays had been picked up. V43 said she looked over and saw R13 shrugging his shoulders. V43 said she did not hear R13 making any coughing sounds. V43 said she thought R13 was exercising. V43 said V40 was in the dining room, and she got V40 attention and told her to check on R13. V43 said V40 was in the dining room covering for another aide that was completing patient care at that time. V43 said V40 went to R13 and placed him on the floor from the chair. V43 said V40 told her to call code blue. V43 said she don't know who called 911. V43 said all the staff came to assist V40. V43 said she don't know who came, she doesn't recall. V43 said she don't know what happened after that because she was removing the resident from the dining room. V43 said she often worked with R13 and R13 did not need any assistance with meals. V43 said she has never assisted R13 with any meals. V43 said she only cut up R13's food (set up tray). V43 said she cut the food up because that's what they do for all the residents on the 4th floor because they have dementia. V43 said R13 does have dementia. V43 said some residents on the 4th floor be gobbling their food down, V43 said the residents eat fast. V43 omitted reporting her observations of residents gobbling there food down to the nurse or the Director of Nursing. V43 denied knowing if the resident that was gobbling their food down were at risk for aspiration. V43 said she only observed R43 being assisted with meals once. V43 said the residents were served pork on [DATE]. V43 denied that R13 was at risk for choking/ aspiration. During a follow up interview on [DATE] at 3:56pm V43 said she documented 3, 2 for eating for R13 on [DATE] for breakfast and lunch. Review of the documentation denotes 3 is for extensive assist, and 2 is for one-person physical assist. V43 said she thought she was documenting for set up only. V43 said she received training on documentation in the system. V43 said she knows the difference in extensive assist and set up because she helps R3 get dressed and R13 needs extensive assist with dressing. Review of V43 documentation for R13, denotes V43 documented 3, 2 for eating for R13 on multiple days that week for multiple meals. V43 then said R13 does need a lot of cueing when eating, V43 said R13 was constantly reminded to eat his food. V43 said she puts R13's hand on the spoon and guide R13 to put the food in his mouth also when she had to cue him. V43 described R13 would stop eating and began to stare, that's why he needs constant reminders to eat. V43 said she cuts R13's food up because he has dementia. V43 said V40 was responsible for monitoring the dining room on [DATE] and V40 was responsible to monitor the residents for safety. V43 said V40 was to monitor to make sure the residents were eating, monitor the residents for choking, and assist and cue the residents as needed. V43 said usually there are 3 to 4 staff (activity aides and social worker) monitoring the big dining room, and all CNAs would monitor the small dining room during meals times. V43 restated that she did not assist R13 with lunch on [DATE]. V43 denied that she spoke to the paramedics when the arrived at the facility on [DATE]. Review of the facility 4th floor dining room time for [DATE] denotes V40 name listed for the 12:30pm time. There is no name or time listed for the 12:00pm time. V43 name is listed for the 11:30am time. On [DATE] at 2:28pm V51 (Rehab Director) said R13 was referred to speech therapy on [DATE] for a swallow assessment due to weight loss and increased need for assistance/ cues required to complete meals for adequate and safe oral intake. V51 said she did not conduct the evaluation, V51 said she was not sure of some of the language in the evaluation and discharge summary. V51 agreeable to have a speech pathologist assist with review of R13's speech evaluation and discharge summary. On [DATE] V51 said R13 did not have dysphagia, and the diagnosis dysphagia is a treatment diagnosis to allow for the speech evaluation. V51 said R13's last speech treatment date was [DATE], and that [DATE] was not correct. On [DATE] at 12:25pm am V56 (Speech Pathologist) said she did not complete the assessment for R13 in [DATE] however was agreeable to review the evaluation and discharge summary. V51 was present. V56 said R13 was referred per MD orders and facility dietary tech for evaluation for swallow assessment due to recent decline in weight and increase need for assistance/ cues required to complete meals for adequate and safe oral intake. V56 said R13's evaluation denotes labial closure for solids, mild (difficulties). V56 described R13 had difficulties with bring the lips to a closure, R13 ate with his mouth open. V56 said R13 noted with rapid mastication (R13 ate fast). Bolus formation - moderate (difficulty). V56 said R13's evaluation denotes R13 was found to have swallow disorder involving the oral phase. Patient presents with mild oral dysfunction, evidenced by difficulty initiating oral stage, anterior spillage of solids, incomplete bolus formation, inadequate mastication/ rotary chew pattern, effortful mastication, oral residue, and poor attention to task. V56 said R13 had behaviors, the therapist documented R13 would get up walk away, R13 would eat fast. V56 explained that difficulty initiating oral phase could be getting R13 started with the meal, anterior spillage is food falling out the mouth, R13 had difficulty chewing the food and forming a bolus of the food (that's when chew the food and mixing it with saliva making it a bolus, inadequate mastication is inadequate chewing of the food, oral residue is when some food remains in the mouth after swallowing, and poor attention to task.) V56 said the recommendations was for dysphagia treatment. Supervision was distant supervision. Strategies to facilitate safety and efficiency, it is recommended the patient use the following strategies and or maneuvers during oral intake, general swallow techniques/precautions, alterations of liquids/solids and bolus size modifications, upright posture during meals and upright posture for greater than 30 minutes after meals, environmental modifications via reduction of distraction, setup and food cutting up assistance, supervision. V56 said general swallow techniques and precautions as listed. V56 described alternating between solids and liquids would be taking a sip of water/liquids after swallow food. V56 described cutting the food into small sizes would be bolus size modifications, sitting upright during meals and sitting up after meals for greater than 30 minutes would aide in digestion of food. During the evaluation short term goals are developed based on the identified issues. Review of R13's goals, patient will improve oral clearance during meals in response to cues/strategies provided by ST (speech therapist) and trained caregivers at 80% of opportunities. Patient will improve bolus control and labial seal to reduce bolus loss in response to cues/strategies provided by ST and trained caregivers at 80% of opportunities. Patient will improve attention to meals in response to cues/strategies and environmental modification provided by ST and trained caregivers. V56 said R13's discharge recommendations were that prognosis was good with consistent staff follow through. R13's recommended diet was regular texture, thin liquids, swallow strategies/position: to facilitate a safety and efficiency, it is recommended patient use the following strategies and maneuvers during oral intake; general swallow techniques/ precautions, alterations of liquids/solids, rate modification and bolus size modifications, upright posture during meals and upright posture for greater than 30 minutes after meals, meal intake in dining room. Supervision for oral intake; distance supervision. V56 said she don't know how the facility planned to ensure swallow techniques/precautions, alternating between liquids and solids, rate modifications and bolus size if the recommendation is distance supervision. V56 said the discharge report denotes R13 was discharged prior to meeting his goal for oral clearance at 80% of opportunities. V56 said R13 was discharged meeting goal at ,d+[DATE]% of opportunities. R13 did not meet his goal for improving bolus control and labial seal to reduce oral bolus loss in response to cues/strategies, and R13 continued to need for redirection and attention to meal. V56 said R13 was at risk for aspiration due to the swallowing difficulties identified, eating with mouth open, incomplete bolus formation, inadequate bolus control, inattention, fast eating, and difficulty with oral clearing. V56 said upon review of the evaluation and discharge, she would have questions as to why was R13 discharged before meeting his short-term goal. On [DATE], V13 (Director of Nursing) said he was not at the facility during the code blue for R13. V13 said the nurse documented what happened. V13 was asked if R13 choked on food. V13 said the nurse documented what happened. V13 said the facility did not complete an incident report for R13. V13 said he is aware that R13 was admitted to the hospital for aspiration. V13 said he is aware that R13 expired. On [DATE] at 2:00pm V50 (Restorative Nurse) said she was the restorative nurse, she was not employed in 2023, review of R13's care with V50, V50 said R13 required extensive assist of one-person physical assist with meals. Review of R13's annual restorative review with V50, V50 said R13 required extensive assist with eating, support of one-person physical assist with eating. [DATE] at 1:57pm V10 (Prior Restorative Nurse) said she is familiar with R13. V10 said she was the restorative Nurse in 2023. V10 said R13 required extensive assist of one-person physical assist with meals. V10 said the staff should be assisting with feeding by sitting with R13, cutting up R13's food, cueing R13 as needed, assisting R13 with eating. V10 said the aides are aware of the level of care the resident need because it's listed on the (electronic) charting. V10 said the aides also document the level of assist that's provided during ADLs and eating in the (electronic) charting. On [DATE] at 2:20pm V52 (Assistant Administrator) said she completed R13's restorative assessment on [DATE] for R13. V52 said R13 needed extensive assist of one-person physical assist with eating. V13 explained that she was helping the Director of Nursing when she completed R13's assessment. V52 said she completed a physical assessment and she also review the 7-day look back for R13 and it was documented that R13 needed extensive assist of one-person physical assist greater than 3 times. V52 said the staff did not inform her of any issues, concerns with R13's eating abilities. R13's progress note dated [DATE] completed by V40 at 1:05pm denotes in-part resident was noted at approximately 12:30pm in the dining room and had finished eating (per staff), he started to have some jerky movements and was lowered by staff to the floor. Resident loss consciousness and code blue was called. CPR was initiated and 911 was called. Resident was taken to hospital via stretcher, resident sister was notified, MD (Medical doctor) was also called, and supervisor made aware. At 1:55pm hospital called back, and stated resident was admitted to hospital with diagnosis of aspiration. All parties made aware and resident belongings remain in his room, at this time meds placed in proper storage. R13's physician order sheet dated [DATE] denotes in-part ST (speech therapy) to evaluate and treat 5 times a week for 4 weeks for dysphagia management s/p (status post) weight loss and increased need for assistance at meals. R13's care plan dated [DATE] denotes in-part R13 requires assist with ADL's (activities of daily living) to maintain highest possible level of functioning as evidence by the following limitations and potential contributing diagnosis, schizophrenia, heart failure, dementia, weakness, abnormalities of gait and mobility, hyperlipidemia, chronic kidney disease, anemia, anxiety disorder, unsteadiness on feet abnormal posture. Bed mobility up to EXT-X1 (extensive assist x1), transfer up to EXT-X1 (extensive assist x1), toileting up to EXT-X1 (extensive assist x1), eating up to EXT-X1 (extensive assist x1), transfer. R13 will maintain present level of function without decline by next review. Assist with meals as needed, bathing dressing transfers as needed, explain all tasks prior to starting, ensure proper positioning while in bed/chair, encourage resident to participate in all areas of care we are involved in exercise program as tolerated, rest periods as needed, involve social services as needed, turn and reposition every 2 hours, all meal trays to be set up with milk and other container open. R13's care plan for alteration in nutrition denotes in part receives therapeutic diets or mechanically altered diet, receives double portion with all meals, staff supervision with all meals. R13's care plan dated [DATE] denotes in part R13 has some or all-natural tooth loss, R13 will tolerate diet as ordered through next review. Monitor for chewing difficulty, monitor for mouth, or tooth pain, refer to dentist as needed encourage good oral care and/or assist with oral care as needed, encourage resident to wear dentures and/or bridges if applicable and that food serves as appropriate. R13's death certificate denotes date of death [DATE], cause of death complications of choking, how injury occurred choked on food bolus. Facility policy titled Care Plan Policy and Procedures, no effective or review date noted, denotes in-part each resident will have a comprehensive assessment completed that will assist in the development of an individualized plan of care that will include goals and interventions and to improve or maintain the residents highest level of function prevent decrease the complications of medical conditions medications and diagnosis decrease risk of injury or to promote comfort at end of life. Each resident will have a comprehensive assessment completed by the interdisciplinary team upon admission quarterly and with significant changes and an individualized care plan will be developed and updated as needed with readmissions and changes in condition. Weather care plans will be reviewed and updated as needed with readmissions quickly and with any significant changes in condition. The MDS nurse will be the primary lead of the care conference but in the absence of MDS the nurse, Social Services or other designee may conduct the meeting. The care plan will also be updated with any additional identified problems or approaches. Review of R13 care plan there is not documentation denoting the identified issues observed during the speech evaluation had resolved, there is no documentation of reevaluation of identified issues for safe oral intake for R13. Upon exit of this survey the facility failed to present the plan to ensure safe oral intake for R13, and or plan to reduce risk for aspiration for R13. Facility failed to present documentation denoting R13 was discharged from speech therapy before he met his short-term goals. Facility failed to present documentation for plan for aspiration for R13.

Based on observation, interview, and record review the facility failed to develop, implement, evaluate, and reevaluate a plan to prevent a continued insidious unplanned weight loss for one of three residents (R14) reviewed for unplanned weight loss. This failure resulted in R14 having a continued weight loss resulting in a significant weight loss of 18.55% in 90 days. Findings include: On 4/11/25 at 4:30pm V25 (R14's family) said R14 has lost a lot of weight. V25 said R14 lost about 30 pounds. V25 said she knows this because R14 would visit her home from time to time and she could recognize the difference in R14's weight. V25 said R14 has told her that the facility doesn't feed him. On 4/9/24 at 12:08pm R14 observed awake, alert, unable to be interviewed. R14 observed with non-sensical speech, very low tone. R14 cannot be interviewed. R14's physician order sheet dated 11/07/23 denotes orders for no added salt and concentrated sweets diet, regular texture, thin liquids consistency, add double portions at breakfast and sandwich at HS (nighttime). R14 weight record dated 4/8/24 denotes R14 weighed 179.2 pounds. R14 weighed 220 pounds on 1/5/2024. On 4/23/24 at 2:12pm with assist from V42 (Restorative Aide) and V50 (Restorative Nurse), R14 observed to weigh 175.3 pounds. On 4/9/24 at 12:58pm V26 (Dietary Assistant) said the resident's meal is served based on the information on the meal ticket. V26 said the dietary staff do not inform nursing staff if a resident does not come down for meals. Request was made to review R14's meal ticket. On 4/9/24 at 2:24pm V26 (Dietary Assistant) presents R14's diet slip. V26 reviewed the diet slip and stated she do not see any orders for double portion for breakfast and sandwich at night-time. R14's diet slip presented by V26 does not denote double portions and sandwich at HS as noted in the physician order sheet. On 4/11/24 at 8:46am V47 (Certified Nursing Assistant) said he was R14's CNA. V47 said he works with R14 often. V47 said he is familiar with R14. V47 said R14 was finished with breakfast, request was made to observed R14 breakfast tray. V47went to the food cart, retrieved R14's tray, R14's meal ticket observed on tray. R14's meal ticket did not denote double portions for breakfast and sandwich at HS. V14 said R14 ate 50% of meal. There was a half of a biscuit and sausage gravy observed on R14 tray. V47 said R14 did not have double portions for breakfast. V47 was asked if R14 should have double portions for breakfast. V47 said he does not know. V47 said he do not know if R14 had a significant weight loss. V47 said he is not aware of R14 having a weight loss. V47 said he does not know if R14 is currently on a calorie count. On 4/9/2024 at 3:12pm V49 (Psych Physician) said he did not have much time to speak with surveyor as he had to pick his children up from day care. V49 said he does not deal with weight loss. V49 said psych medications do not cause weight loss but in-fact will result in weight gain. V49 was made aware that one of R14's recommendations for weight loss was to consult the psych provider. V49 said he will assess R14 in front of surveyor, surveyor made V49 aware that, that was not necessary. V49 said he will speak to the Director of Nursing regarding the recommendations for him to see R14 due to weight loss. On 4/24/2024 V48 (Dietitian) said R14 is reviewed during the NARS (Nutrition at Risk) meeting in February 2024, V48 said R14 is reviewed for unplanned weight loss. V48 said R14 has had a significant weight loss in 6 months. V48 said initially in 2023, R14 had a desirable weight loss. V48 said the plan was to implement double portions at breakfast and a sandwich at HS, consult with the psych physician, and weekly weights. V48 did not respond when asked when did the planned weight loss become unplanned weight loss. V48 said usually the facility serve the resident meal based on the information on the diet slip. R14's diet slip from 4/11/24 (retrieved from meal tray) and 4/9/24 (presented by dietary assistant) reviewed with V48. V48 confirmed that there is not documentation denoting that R14 should have double portions for breakfast and a sandwich at HS. V48 said she believes she knows why but she does not want to discuss that with the surveyor. V48 made aware that surveyor retrieved the tickets on different days and surveyor cannot conclude that the physician orders and dietitian recommendations was followed for R14 for weight loss interventions. V48 was made aware that the psych physician said he does not see residents for weight loss, and that psych medications do not cause weight loss but in fact will result in weight gain. V48 said the double portion and sandwich is to increase calorie intake to stop weight loss. R14's dietary progress note dated 4/8/2024 denotes in-part weight warning, 7.5%, 10%, diet NCS/NAS (no concentrated sweets, no added salt) regular thin liquids, double at B (breakfast), sandwich at HS, plan recommendations continue current nutritional management. R14's care plan for weight loss denotes in part, resident has experienced weight loss, resident will not have any sig (significant) wt. (weight) until next review. Intervention refers to MD/RD if there is a 5% wt. loss x 1 mo. (month) or 10%, wt. loss over 6 months. Weight resident monthly per facility protocol, weekly weights/ NARs review. Provide diet as ordered. Notify MD of weight change greater than 5% x 1 month. Double portions at breakfast, sandwich at HS, refer to SS(social services)/psych, weight monitoring/NARS review refer to RD (Registered Dietitian). Facility policy titled care plan and procedures, no effective, review or revised date noted denotes in-part each resident will have a comprehensive assessment completed and will assist in the development of an individualized plan of care that will include goals and interventions aimed to improve or maintain the resident highest level of function prevent decline decrease risk of complications of medical conditions medications and diagnosis, decrease risk of injury or to promote comfort and end of life. Each resident will have a comprehensive assessment completed by the interdisciplinary team upon a mission quarterly and with significant changes and in individualized care plan will be developed and updated as needed with quarterly assessment, readmissions, and changes in condition. Resident care plans will be reviewed and updated as needed with readmissions quarterly reassessment annually and with significant changes in condition.

Based on interview and record review, the facility failed to keep a resident free from involuntary seclusion by not allowing a resident to discharge from the facility against medical advice immediately after the resident expressed the desire to discharge from the facility. This failure applied to one (R569) of one resident reviewed for discharge and resulted in R569 being kept in the facility against her will for two days and experiencing anxiety and psychosocial harm as a result of not being allowed to leave the facility. Findings include: R569 was admitted to the facility on [DATE] with primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Other diagnoses include essential hypertension, [CONDITION(S)], and long term (current) use of anticoagulants. On 8/16/22 at 9:01 AM R569 was asked about her experience surrounding her admission and discharge to the facility and stated the following: I have my own apartment. I have CHF (congestive heart failure) and I don't have a vent (in my apartment) and only have fans. My neighbors smoke and everything comes in here. I was feeling sick and called 911, and the ambulance took me to (local hospital). Thinking that the hospital social worker would help me find a better place, I agreed to go to the facility. When I went into the room, I saw all these men running around, God knows what was going on. I asked what kind of place is this? I'm not mentally ill, why did they bring me here? I'm supposed to be at an independent living place. The hospital social worker told me that I am free to leave whenever I want. When I tried to leave, the security guard came and then called the med team and said they were going to give me a shot. I told them they weren't going to give me anything and they better not touch me. They wouldn't let me leave so I called the police; they came, and the ambulance came. The police came and said I couldn't leave because the medical record said I was drunk and using drugs, I never used drugs in my life. The facility must have given them false information from my medical record, so they told me I couldn't go anywhere. After the police left, I went back into my room. They had such a nasty attitude and said no, I have to talk to the social worker tomorrow. My mind was in shock, I stayed up half the night and waited until the morning. I told the lady I was on my monthly and they still didn't give me anything to take a shower or nothing. Social work director or something like that came into my room in the morning and asked me why I was in this facility. I told him that I didn't know why I was here. He looked at the computer and said my record said I had meth and something in my system, I don't know what that is, I don't use drugs. They said I had alcohol in my system and slobbering at the mouth; I told him I never did any of those things. Then he looked and said that is not me, that's a man. I offered to show him my driver's license so he could see that it wasn't me. They treated me like a dog. They didn't feed me. I couldn't take a shower and I was on my cycle. The same way they are treating me, they are treating all of those people in there. The staff talk to people like they are dogs. I have no mental illness. I have lupus and heart problems. My niece had to sign me out of that place. It felt like a dream, or a movie, something that is not real. It's so sad. I cried and cried and cried. I have video and you can hear how they are talking to me, and you can hear me just crying. R569 became very emotional and crying during interview; she stated that she always cries when she talks about this experience because she can't believe it actually happened. Local Police Department - Event Report dated 8/8/22 20:26:40 documents the following information: Nature: Assist Citizen Caller: (Resident Name) R569 Notes: Caller is in (room#), would like to leave and is hysterical [8/8/22 20:28:10] SAYS HER FRIEND IS ENRT TO GET HER, AND THEY ARE TELLING HER SHE CAN'T LEAVE [8/8/22 20:28:52] Subject is calm and was advised by staff that she cannot leave until she is evaluated by social worker tomorrow morning [8/8/22 20:46:30] Call Received: 8/8/22 20:26:40 Call Routed: 8/8/22 20:28:35 1st Dispatch: 8/8/22 20:31:20 1st En-Route: 8/8/22 20:31:20 1st Arrive: 8/8/22 20:41:36 On 8/18/22 at 4:39 PM, V19 (Social Service Coordinator) was asked about interaction with R569 since he had written a note in the medical record, documenting that resident had behaviors when redirected off the elevator. V19 stated that the resident was not on his caseload. V19 continued to explain that the resident was not allowed to leave as she requested because she needed to have someone sign her out and would not provide them with her address or the name of her landlord or phone number. It's part of the policy and procedure for residents to provide this information if they are leaving. She did not have a guardian or POA that I'm aware of. When asked why R569 had to provide the name and phone number of her landlord to discharge if she is her own decision maker. V19 said, we just want to make sure that residents have a safe discharge. We needed to make sure that someone is here to pick her up for her safety and her health. Surveyor asked V19 why a resident who is their own decision maker, has no guardian or POA, no diagnoses of mental illness or developmental disability, and no apparent skilled care needs was not allowed to leave AMA as requested? Further, why does someone need to sign this individual out? V19 stated that the situation was brought to the attention of his supervisor, V17 (Social Service Director). On 8/18/22 at 4:51 PM, V17 (Social Service Director) was asked the same questions as were asked to V19. V17 said, R569 came in the day before and so I saw her the next day - we basically tried to see what she was here for and what we could do to help her. When I found out that she wanted to be discharged we called the doctor and informed him that she wanted to be discharged . I wanted to make sure that she had a safe ride and could make it to her destination. We tried to know where she was going to make sure that she had a legitimate ride for a safe discharge. From my understanding her ride didn't show up to pick her up. When her ride didn't show up, she needed a dial-a-ride to come and get her so the next day she left. There wasn't really a delay - her transportation didn't come to get her. Our number one concern was her safety. She was her own decision maker that I know of and did not have a POA. She just did not have transportation. When asked why transportation was a requirement for discharge? V17 stated that it was to ensure the resident's safety. On 8/18/22 at 5:07 PM V1 (Administrator) said, I spoke to the social services team on the 9th when they were trying to assist her, when they told me that a family member was going to pick her up. Social service wanted someone to be aware that she would be leaving. We gave her $5 and allowed her to go. She waited patiently for her family to come but they never arrived. There was conflicting information with the paperwork that we received from the hospital versus the packet that the patient arrived with, in social services trying to dissect that, they discovered the discrepancy. V1 was asked what the admissions process is in determining that a resident is appropriate for skilled nursing care and their facility. V1 responded that the resident was appropriate because the PASRR showed that the resident was eligible for skilled care. When asked again what specific, skilled care needs the resident had, V1 stated that she had congestive heart failure. When asked if a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 confirmed that R569 had no psychiatric diagnoses but was in the facility for medical care. V1 was asked what were the medical needs of the resident that caused her to be admitted and V1 did not answer the question and referred to V2 (Assistant Administrator), who is part of the clinical team that makes admission decisions. On 8/18/22 at 10:56 AM, R569 continued with interview and stated, that the facility wanted her to be signed out by someone when she told them she wanted to leave. I told them I have no family members in Chicago, and I have only been here for two years. If I had no one to sign me out, I would have had to stay there. They weren't going to let me leave without anyone. My niece in Louisiana had to email them back the form with a copy of her driver's license so that I could get signed out. Then (dial-a-ride) service came to pick me up. I had to pay (dial-a-ride) service $3.25 to come and pick me up (when I finally was allowed to leave). The first night a friend of mine paid someone she knows $40 to come and pick me up. My friend was there when the police came, and they told her too that I couldn't leave. The second night I called (dial-a-ride) service and the supervisor opened a case because it wasn't a 24-hour notice, and you are supposed to call 24 hours in advance, but when they came to pick me up, the facility still wouldn't let me leave with them. I have no care needs. I am fully independent and need no assistance with anything. I have no problem taking my medication or accessing care or other needs. I have no pain management issues. I only have pain when my lupus flairs up and my skin gets irritated, but I just keep it clean and wash it. I just try to rest as much as I can. I never saw a doctor or nurse practitioner while I was in the facility. When they (facility staff) came toward me, I told them don't put your hands on me and they didn't touch me, but it felt like it came close. It's like a movie, I never seen such a thing in my life. I didn't even think anything like this ever existed. I told them they are holding me against my will, and they were just telling me that I wasn't going anywhere. I thought my life was gone. I'm in the medical field, I'm a lupus advocate and I know that they really give people shots to knock them out. They wouldn't take me to the hospital because they said, they will just bring me right back. On 8/21/22 at 1:19 PM, (post survey exit) surveyor received a return call from V44 (Hospital Social Worker). Surveyor asked V44 if she was familiar with (R569) and V44 recalled the resident well. When asked why R569 was admitted to a skilled nursing facility if her hospital discharge paperwork documents that resident was waiting for placement at an assisted living facility (ALF). V44 responded that the resident was ready to be discharged and it was taking long for any ALF facilities to get back to her and it was much faster to discharge the patient to a nursing home. She had gotten a response back from one other nursing home in the city. Also, they were waiting for the resident's toxicology screen to come back (which came back negative). When asked what care needs the resident had that needed to be provided by a nursing home, V44 responded that R569 did not have any care needs as she was very independent. R569 seemed to just want to get out of the basement apartment that she was living in at the time. V44 also confirmed that R569 is her own decision maker and has no impairment in regard to making decisions on her own. On 8/18/22 at 3:46 PM V45 (Admissions Director) stated that she mostly works outside of the facility, meeting with residents and working on screening for admissions. When asked if she had met with R569 prior to admission, V45 stated that since COVID, she can't always go to the hospital to see the patient before admitted them. In that case, she will just go off the paperwork received from the hospital and will do an initial assessment and then forward it to the clinical team to decide about whether they can meet the residents care needs and if they are appropriate for the facility. V45 confirmed that she did not meet with R569 or provide her with any information about the type of facility this was. On 8/18/22 at 5:18 PM V2 (Assistant Administrator) was asked why R569 was admitted to the facility. V2 stated that the hospital paperwork said that she was admitted for smoke inhalation, she has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I think the hospital gave her the idea that she was going to an assisted living facility. The record says that she was cleared by cardiology for discharge and was awaiting placement at an assisted living facility. Asked how the determination is made to accept a resident. V2 said, we review the packet sent over from the hospital and if they have the PASRR. When asked what medical care needs or activities of daily living the resident needed assistance with, which required skilled nursing care. V2 responded that (R569) had pain and did not provide any further details as to why the resident was admitted or what skilled care needs the resident had. Review of care plans and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility provided the following care plans (including but not limited to): - Discharge Potential / Discharge Planning Care Plan dated 8/8/22 includes: My discharge potential is: Fair My tentative plan is for me to move to: Not applicable Approaches/Interventions: As necessary, meet with me/my representative on a regular basis to help me with the mental preparation for discharge. Provide me with an opportunity to express my thoughts or feelings. Address my concerns prior to discharge. -R569 has a care plan for Specialized Psychiatric Programming dated 8/8/22 includes: I have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The symptoms that I have are manifested by: Need for on-going psychoactive medication. Approaches/Interventions: Utilize assessment data (i.e., MDS, CAA's, Psychiatric Evaluation, Level of Functioning and Psychosocial History) to help determine my present needs, deficits, abilities and strengths. -Care plan for History of Suspected Abuse/Neglect/Trauma dated 8/8/22 and includes: I have the following Strengths and Abilities: Able to make needs and wants known. Hospital records document an admitted [DATE] and admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . - Assessment: Atypical chest pain, Lupus, [CONDITION(S)], and Cardiology consult: 2D ECHO normal; non-coronary ischemia - Plan: Cleared by cardiology for discharge, [CONDITION(S)] workup as outpatient - Social worker paid a visit and will be reverting to the patient regarding an assisted living facility. Awaiting placement in an assisted living facility. - UDS (urine drug screen): Negative 8/5/22 - Discussed with ER MD - Apparently patient is waiting for placement History of present illness: 49yo F with PMH SLE and CHF presented to the ED with non-radiating left chest pain that woke her up from sleep this morning after smelling smoke coming from the units above her basement. She also reports having some palpitations and mild dyspnea earlier, but they are now subsided. No fever, chills, cough/URI symptoms, N/V, leg swelling/pain, back pain, or other acute physical complaints. No recent travel or sick contact. Denies tobacco or illicit drug use. Pt denies any chest pain now. Review of New Admission packet for R569 includes (but not limited to) the following information: Approved by V2 (Assistant Administrator). Admission packet also includes copy of PASRR Screen Outcome which documents PASRR Level I Determination: No Level II Required - No SMI/ID/RC .Your Level I screen does not show that you have a serious mental illness or an intellectual/developmental disability (IDD). You do not need more screenings unless you have or may have a serious mental illness or an IDD and experience a significant change in treatments needs. Please note admission to a nursing facility is a choice made by you or the legal entities that have the authority to make decisions for you. This nursing facility screening notice does not require you to admit to a nursing facility. Typical Living Situation: Home alone Mental Health Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] Substance Related Diagnoses - Does the individual have a substance related disorder (abuse or dependency)? Yes, Opioids, When was the last known use - Less than 7 days Is the request for nursing facility in any way associated with or resulting from the substance related disorder? No Dementia/Neurocognitive Disorders - Does the individual have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ? No Behaviors & Symptoms - Interpersonal Behaviors There are no known mental health behaviors which affect interpersonal interactions There are no known mental health symptoms affecting the individual's ability to think through or complete tasks which she/he should be physically capable of completing. There are no known recent or current mental health symptoms Behavioral Health Services - Has the individual received any of the following mental health services now or in the past? NO Behavioral Health Impact - Has there been legal intervention due to mental health symptoms/behaviors? NO Has the individual had to move to another setting because of mental health symptoms? NO Has the individual even been homeless? NO Are there other examples where the individual's life has been seriously affected because of mental health symptoms? NO Does the individual have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ? NO Is the individual suspected to have an intellectual disability that has not been diagnosed ? NO Recommended Services - No recommendations at this time Recommended Supports - No recommendations at this time On 8/18/22 at 12:44 PM V3 (Director of Nursing) was asked about the procedure for residents wanting to discharge AMA (against medical advice). V3 stated that if they are their own responsible party, they call the physician and get orders. As long as the resident is stable, we provide education and have them sign AMA paperwork. On 8/19/22 at 2:39 PM, V43 (Medical Director) was asked if he was made aware that R569 requested to be discharged against medical advice. V43 confirmed that he was made aware. V43 said, I advise them that you have to consider the resident's mental condition but there is consideration for the patient's medical and psychiatric condition; but we investigate every allegation of abuse. Whenever the allegations come thru, they take it extremely serious no matter what time of day; they call me at my cell phone at any time of day. A lot of the patients' say that they are being abused so that they get attention. There is no shot except for COVID testing and shot for vaccination; that's not a threat. This is a free country and people can leave; there is free will. The resident could not be held at the hospital any longer, so we found the fastest way to get her out of there. We asked her to bring a family member to sign her out for her safety. I told them to give her a day or two, sometimes the resident's say they want to leave but need time to adjust. Review of AMA (Against Medical Advice) Form - Release of Responsibility for Discharge (completed for R569) Dated 8/10/22, Time: 1pm Form is signed by R569 and witnessed by V17 (Social Services Director) Form reads: Authorization must be signed by the resident, or by the nearest relative when the resident is physically or mentally incompetent. Facility AMA - Against Medical Advice Policy (undated) reads: It is the policy of the facility to administer care and treatment to the residents according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident decided to leave the facility for whatever reason while at a time in the course of their stay where their physician and other disciplines in the facility feel that it is not recommend as being in the best interest or welfare of the resident, this is considered leaving AMA or Against Medical Advice. Should this desire on the part of the resident be expressed, the following should happen: Procedure: 1) As soon as the resident expresses a desire to leave AMA, appropriate leadership staff to include the Administrator/DON/SSD and the physician or Nurse Practitioner as available should meet with the resident in an effort to discover the reason why the resident is wanting to leave. Note: Examples of reasons residents might choose to leave AMA include, but are not limited to .b) they change their mind about being a nursing home resident . 2) When possible to discern the reason they desire to leave, the appropriate facility staff will help them formulate a plan that can address and lessen or even possibly solve their issue of concern. 3) If they are adamant on leaving, be sure that the risks of their leaving against medical advice are clearly explained to include possible negative outcomes when the services, care, treatments and whatever they will not be receiving if they leave - are no longer available to them. This must be clearly documented. 4) If they are not their own representative, their representative should be involved in a care plan meeting prior to the resident leaving . 5) The resident has the right to leave the facility. The facility will ensure that leaving is an informed decision as much as possible. The facility will be respectful of the resident's decisions. 6) All discharge paperwork will be completed to include the discharge summary information. The related doctor's orders will be followed. This will include assisting in making any follow up appointments arranging for any ordered Home Health and disposition of meds/prescriptions per policy . Note: Detailed timely and accurate documentation must be done on any resident who chooses to leave AMA. The AMA form must be completed and copies of all documents given to the resident must be kept on file at the facility.

Based on observation, interview, and record review, the facility failed to follow their abuse policy by not ensuring 5 of 5 (R9, R11 R14, R24 and R27) were free from abuse. This failure resulted in R9 sustaining a left third distal phalanx (finger) comminuted tuft (tip) fracture and laceration requiring seven sutures. In addition, R11 sustained a nasal fracture. Findings Include: Facility abuse prevention program policy revised 01/2019 documents: It is the policy of the facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and crime against a resident in the facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker of goods and services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, means the individual must have intended to inflict injury or harm. Physical abuse: hitting, slapping, pinching, kicking, etc. R9 was admitted to the facility in 4/18/2014 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's brief interview for mental status dated 1/1/22 documents a score of 15/15 which indicates cognitively intact. On 4/13/22 at 12:35 pm, R9, who was alert and oriented at time of interview, said he was attacked by roommate identified as R10. R9 denies any negative interactions with R10 prior to the incident. R9 said R10 hit him with a metal rod from the closet and R9 was using his arm and hands to protect his head. R9 said he sustained a laceration on his hand and had to go to the emergency room . At 1:44 pm, R9 said he felt scared of R10 at the time and unsure why R10 hit him. On 4/13/22 at 12:50 pm, R22 (roommate of R9 and R10 at time of incident) who was alert and oriented at time of interview, said he saw R10 hit R9 multiple times with a metal rod from the closet. R22 said R10 had the rod within his wheelchair and there were no negative interactions with R9 or R10 prior to the incident. R9 was near his bed at time of incident and was unprovoked incident. On 4/13/22 at 4:41pm, R10 who was alert and oriented at time of interview, said he hit R9 with a metal rod because he was trying to touch his penis. R10 said he got metal rod from closet. On 4/19/22 at 4:39 pm, V6 (security) said he was on the unit when he heard R9 and R10. R10 admitted to hitting R9 with a metal rod. R9 was in the hallway saying he got hit in the hand with a pole. V20 (Nurse) said R10 was unable to say why he hit R9, and the metal pole was removed from his possession. V20 said he threw the pole in to the dumpster outside. R9's hospital record dated 2/23/22 documents: R9 presenting today for evaluation from nursing home after being attacked by another person at the nursing home. R9 states today was his birthday, and he was having a great day, after dinner he wanted to go into his room and one of the other patients at the nursing home came in and attacked him. He states that he was hit in the shoulder, he fell , he did not hit his head, but the other person took a metal rod and began to beat him with it. He tried to cover himself with his hands and he was screaming for help. He states he did not provoke attack. Under exam: patient has dried blood on the left side of his face with no abrasions, tenderness present in bilateral lower arms, wrist, and hands. Left hand: laceration (base of thumb-minimal bleeding, third digit actively bleeding. Seven sutures were placed to left palm wound measuring 4 cm in length. Under radiology results documents a left third distal phalanx (finger) comminuted tuft (tip) fracture. R11 R11 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's brief interview for mental status score dated 12/10/21 documents a score of 3/15 which indicates severely cognitively impaired. R11's hospital record dated 3/6/22 documents: On discussing with nursing home staff, patient was wandering into the room of another resident. He got into an altercation with another resident, the resident pushed him, and he fell and struck his face. CT of facial bones documents a naso-orbital-ethmoid fracture. Under physical exam: left parietal scalp abrasion, posterior occiput abrasion, punctate laceration inferior to left orbit, bilateral periorbital ecchymosis, oozing from bilateral nares, 0.5cm lower lip laceration. R12 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R12 has a brief interview for mental status score dated 2/11/22 documents a score of 15/15 which indicate cognitively intact. On 4/27/22 at 2:10 pm, R12 who was alert and oriented at time of interview, said R11 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On day of the incident, R12 said he observed R11 in his bathroom urinating on the floor. R11 would not leave his room and was mumbling something in Spanish. R12 said he hit R11 in the back of head and punched him the stomach. R12 said R11 began lifting his leg and it got caught between the footboard and frame causing him to fall. R12 said he dragged R11 out into the hallway by his legs. R12's incident report dated 3/6/22 documents: R12 had no injury sustained. R12 hospital record dared 3/7/22 documents: Resident admitted due to verbal and physical aggression towards other residents at the nursing home. R14/R15 R14 has the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimal Data Set (MDS) section C (cognitive patterns) documents a score of fifteen which indicates cognitively intact. Nursing note dated 2/24/22 documents: R14 was observed presented with agitation due to a peer being disrespectful towards R14's boundary. R15 has the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS section C (cognitive patterns) documents a score of fifteen which indicates cognitively intact. Psychiatric progress note dated 2/24/22 documents: the nurse reports that R15 hit another resident (R14). The other resident (R14) was near or taking to his girlfriend (R21) of seven months. On 4/13/22 at 1:00 pm, R15 who was assessed to be alert to person, place and time said, we were standing in line for a smoking break. R14 was standing very close to R21. I asked R14 to move over a little bit to the right. R14 replied by hitting me in the face, knocking my mask off. I hit R14 back in the face. I stopped myself from fighting R14. Staff didn't see what happen because they were at the nursing station, we were at the end of the hallway around the corner. On 4/14/22 at 12:48 pm, V3 (Director of Nursing) said, R15 thought R14 was trying to talk to his girlfriend (R21).There wasn't a physical altercation between R15/R14. On 4/14/22 at 1:48 pm, R14 who was assessed to be alert to person, place, and time, said, R15 asked me to move away from (R21) his female friend. I didn't want to move. I didn't feel like I had to move. R15 started hitting me in the face with his fist. I just stood there, let R15 hit me. I was hit five times in the face. My eyes were blacked and my nose was bleeding. No staff intervene. It took me weeks to heal. On 4/19/22 at 4:18pm, R21 who was assessed to be alert to person, place and time said, R14 was standing behind me very close. I felt like R14 was trying to touch my buttock. R15 asked R14, to move back away from me twice. R14 hit R15 in the face knocking off R15's face mask. R15 in returned punch R14 in the face multiple times. Staff was not present. R15 stop hitting R14 by himself. R14 had two purple eyes and a bloody nose. On 4/19/22 at 4:48 pm, V6 (security aide) said, a code gray was call. I went to the code gray. R15 and R14 was having a verbal altercation. It happened around 6pm which was smoke time. I'm not sure what happen to R15 that night, but he is not usually aggressive. R15 swung at me and made contact with my arm. Hospital records dated 2/25/22 documents: R15 was admitted because he was increasingly aggressive involving in a physical altercation with another peer at the nursing home. R15 state he had an argument with him (R14) and R15 punched his (R14) face then eventually pulled back. R24/R23 R24 has the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimal Data Set (MDS) section C (cognitive pattern) dated 4/11/22 documents a score of six which indicates serve impairment. Nursing note dated 4/15/22 documents: R24 was involved in a verbal argument with her roommate that quickly escalated into a physical altercation in the room. R24 was noted with a left eye discoloration. R24 as discharge to the hospital for medical evaluation. Incident report dated 4/15/22 documents: R24 was confused/disoriented, unable to give a description. R23 stated, R24 tried to take her blanket and pillow. R23 has the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS section C dated 4/1/22 document a score of 12 which indicates moderate impairment. Incident report dated 4/15/22 documents: R23 was agitated/anxious. R24 told me that R23 hit her. On 4/21/22 at 12:41 pm, R24 was observed with the sclera (white layer of the eye) bright red in color. R24, who was alert to self, said it hurts (unable to rate pain). A girl hit me. I was angry. I didn't hit her back. I got up and put my clothes on and left. On 4/21/22 at 1:03 pm, R23 who was assessed to be alert to person, place and time said, R24 let me see an empty bottle, then pull back, I went forward. R24 thought I was taking the bottle from her. R24 attempted to punch me with a closed fist. I blocked R24's punch twice. Then staff came in and said, R24 had a black eye. I did not hit R24. On 4/21/22 at 1:26pm, V17 (Nurse) said, R24 said R23 slapped her. R24 had a redness in the bottom right corner of her eye. R24 was very agitated. R24 eye look like it was hit with a fist. On 4/22/22 at 1:52pm, V33 (Certified Nurse Assistant) said, I was at the nursing station when I heard, R24 say that [NAME], [NAME]. I ran to R24's room, saw R23/R24 tussling/pulling a pillow. I separated both resident. I did not see any injuries on R24 until Saturday. R24 had a redden area in the eye. R24 will take items from other residents without provocation. Final Reportable dated 4/21/22 documents: Interview view with R26 who witnessed the incident said, R24 took R23's pillow and they started to fight. R23 was lying in bed. R24 attempted to take R23's pillow which led to a physical altercation. R23 refused to give up her pillow. R24 was sent to the hospital for evaluation due to discoloration to the left eye. R27/R23 R27 had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimal data set section C (cognitive status) dated 4/5/22 documents a score of fifteen which indicates cognitively intact. Incident report dated 5/3/22 documents: R27 said, I came out my room. R23 struck me in the face. I hit R23 but not sure if I made contact, but I pushed R23. R23 said, I didn't punch anyone and declined further interview. On 4/29/22 at 10:11am, R27 was observed with dark circles under both eyes. R27 had a darker bruised area that was semi-crescent in shape under the left eye slightly off to the side consistent with a black eye. R27 who was assessed to be alert to person, place and time said, I was in the hallway with a bottle of tea. R23 asked me to give her my raspberry tea. I told her no. R23 hit me in the eye with a closed fist. R23 was so fast. I was stung for a minute. R23 kept coming after me. I had to out push R23 down to the floor keep her from hitting me again. R23 thought I stole her tea. I had left eye discoloration. I don't feel safe or comfortable on this floor. On 4/29/22 at 1:41pm, R23 who was assessed to be alert to person, place and time said, I asked R27 to let to me see an empty tea bottle. I was interested the bottle because I've purchased one three months ago. R27 swung at me, I fell down. I got myself off the floor. R27 thought, I was taking the bottle from her. R27 attempted to punch me with a closed fist. I blocked R27's punch twice. Then staff said, R27 had a black eye. I did not hit R27. On this floor we get into arguments and fights every day. On 5/4/22 at 2:02pm, R30 said, I heard R23 and R27 arguing in the hallway while in my room. I walked into the hallway and saw R23 getting up off the floor. R27 had a black eye. R27's eye was black the day of the incident and multiple days afterwards. Incident report dated 5/3/22 documents: R27 said, I came out my room. R23 struck me in the face. I hit R23 but not sure if I made contact. I pushed R23. R23 said, I didn't punch anyone and declined further interview. R23 ' s census does not document discharge/stop billing.

Based on interview and record review, the facility failed to follow physicians order to obtain a stat x-ray post fall for one of one resident (R18) reviewed for physician orders. This failure resulted in R18 having a delay of over 13 hours before being sent to the hospital, where it was determined R18 had a left humerus fracture. This failure resulted in harm that a reasonable person would have pain with a fracture. Findings include: R18 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's brief interview for mental status score dated 11/12/21 documents a score of 3/15 which indicates severely cognitively impaired. R18's incident report dated 1/29/22 at 7:23 pm documents: R18 stated left arm pain 5/10 and Tylenol 325 mg was given. R18's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the R18's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's medical record did not document any follow up or notification to the doctor of x-ray not being completed within 4-hour timeframe or any follow up to local x-ray company on update of estimated time of arrival. R18's progress note dated 1/30/22 at 9:35 am documents: Resident left shoulder noted this morning swelling, small discoloration on the lateral side. Resident complains of pain. X-RAY ordered is not yet done. MD contacted to send to local emergency room . Resident left the facility at 9:20 am with two (company name) attendants. R18's local hospital record dated 1/30/22 documents: patient was not moving his left arm secondary to pain. X-ray of shoulder documents: mildly comminuted, mildly displaced and angulated transverse fracture of the left proximal humerus metaphysis. On 4/26/22 at 11:59 am, V42(Nurse Practitioner) said if the stat x-ray was not able to be performed he would expect the facility to notify them of delay and would have requested for the resident to go hospital for evaluation. V42 does not recall being notified by the facility of any delay or x-ray not being done.

Based observation, interview, and record review, the facility failed to follow their fall prevention and management program, ensure interventions were implemented, and failed to supervise and monitor a resident with known wandering behaviors. This affected 2 of 5 (R11, R20) residents reviewed for avoidable accidents and supervision. These failures resulted R20 falling and sustaining a laceration to the back of the head requiring treatment/staples at the local hospital. These failures also resulted in R11 wandering into another resident's room and being physically assaulted sustaining a nasal fracture. Findings include: R20 R20 has the diagnosis of [CONDITION(S)], Unsteadiness of feet, Weakness, Convulsions, Sarcopenia (muscle loss/atrophy). Minimal data set (MDS) section C (cognitive pattern) date 4/1/22 documents a score of twelve which indicates moderate impairment. Nursing note dated 2/15/22 documents: R20 fell in his room while attempting to climb his closet. R20 had a skin tear and swelling noted to posterior side of the head and a swelling to the left upper arm. On 4/14/22 at 12:41 pm, V3 (Director of Nurses) said, R20 was trying to get something on top of his wardrobe cabinet/closet. R20 fell from the cabinet. On 4/14/22 at 2:13 pm, R20 who was assessed to be alert to person and place, said, I was looking for my laundry. I usually throw it on top of the cabinet. I opened the door, step inside on the bottom of the cabinet. The cabinet started to move, I fell backwards, hitting my head on the floor. R20 was observed with a medium size dried scab area on the back of the head. Two small clear bags of clothed with names written on white paper was observed on the top of R20's wardrobe closet/cabinet. On 4/19/22 at 1:05 pm, V17 (Nurse) said, R20 had a fall with injury to the back of his head. R20 was trying to get something off the top of his cabinet. On 4/22/22 at 10:34 am, V28 (Nurse) said, I was called to check R20. R20 was confused. R20 tried to climb on the wardrobe closet/cabinet. R20 had a laceration to back head. On 4/27/22 at 3:59 pm, V3 said, nothing should be on the top of the wardrobe cabinets. Everything should be with reach for the resident. Nursing note dated 2/15/22 documents: R20 fell in his room while attempting to climb his closet. A skin tear and swelling were noted to the posterior side of the head and a swelling to the left upper arm. R20 returned from the hospital with four staples to the back of the head. Incident report dated 2/15/22 documents: R20 was observed lying on the floor beside bed. R20 said, he fell while trying to climb the closet. R20 had a laceration to the back of head and swelling to the top scalp. Interventions dated 2/18/22 documents: Reacher provided. Hospital paperwork dated 2/15/22 documents: R20 had the diagnosis of closed head injury, laceration of scalp and contusion to left lower extremity. R20 had a mechanical fall climbing on some furniture to get clothes from dresser, slipped backwards striking his head on the ground with loss of consciousness. R20 said, my whole body hurts especially my head and leg. R20 had a hematoma to the left occipital scalp, laceration that measured two centimeter in length and five millimeter in depth requiring wound closure with seven staples. Fall Prevention and Management Program undated documents: Provide appropriate intervention to prevent falls. Falls in nursing home resident are usually the consequence of a combination of intrinsic and extrinsic risk factors. Common extrinsic risk factor: Personal items - Inaccessible personal items. R11 R11 was admitted to the facility on [DATE] with a diagnosis of dementia with behavioral disturbance, [CONDITION(S)] disorder, anxiety and weakness. R11's brief interview for mental status score dated 12/10/21 documents a score of 3/15 which indicates severely cognitively impaired. On 4/27/22 at 2:10 pm, R12 who was alert and oriented at time of interview, said R11 had a history of taking items from his room at night and urinating within his room. On day of the incident, R12 said he observed R11 in his bathroom urinating on the floor. R11 would not leave his room and was mumbling something in Spanish. R12 said he hit R11 in the back of head and punched him the stomach. R12 said R11 began lifting his leg and it got caught between the footboard and frame causing him to fall. R12 said he dragged R11 out into the hallway by his legs. On 4/29/22 at 12:43 pm, R11 was observed leaving common dining room and walking the hallways without staff. R11 entered R28 and R34's room and then exited 12:45 pm. Staff then redirected R11 to common dining room. On 4/29/22 at 10:00 am, R27 who was alert and oriented at time of interview, said she has observed R11 in her bed and wandering the unit on varies days. On 4/29/22 at 12:13 pm, R34 who was alert and oriented at time of interview, said she has observed R11 in her room and wandering the unit. On 5/4/22 at 2:09 pm, R30 who was alert and oriented at time of interview, said R11 has urinated in his room on the floor near the door. On 5/4/22 at 3:59 pm, V3 (DON) said R11's interventions for wandering include redirection. V3 said R11 has history of wandering behavior and they only way to stop would be to medicate him, physically restrain him, or close all the doors on the units which are not options the facility would do. The only way to prevent R11 from wandering is for R11 to move out of the facility. V3 said he would expect staff to allow R11 to walk around unit but within vision of staff, and if R11 enters another room to promptly redirect him. V3 said R11 is not violent or observed with aggressive behavior towards others. R11's hospital record dated 3/6/22 documents: On discussing with nursing home staff, patient was wandering into the room of another resident. He got into an altercation with another resident, the resident pushed him, and he fell and struck his face. CT of facial bones documents a naso-orbital-ethmoid fracture. Under physical exam: left parietal scalp abrasion, posterior occiput abrasion, punctate laceration inferior to left orbit, bilateral periorbital ecchymosis, oozing from bilateral nares, 0.5cm lower lip laceration. R11's care plan dated 3/16/22 documents: Resident wanders, rummages and hoards. Urinates in the hallways with the following interventions: Review behavioral symptoms that I display to determine strengths or abilities and needs are communicated via the behavior. Use with me interventions that address ability and needs reflected in the specific symptoms that I display; Intervene when I am observed to display any inappropriate behavior. communicate that I am responsible for exercising control over my impulses and behaviors. Use creative refocusing to alter my behavioral patterns especially if I have dementia and am observed to be rummaging provide me drawers or laundry basket for rummaging; assess me for potential elopement; post a picture of me at/near front desk/nursing station; use electronic monitoring device; encourage me to participate in exercise programs and movement activities to help dissipate the excess energy that I may have; try to develop environment with a combination of soothing sensory props for independent activity and to help satisfy my ongoing needs for curiosity.

Based on interviews and records reviewed the facility failed to prevent intimidation and resident to resident physical assault. This failure resulted in R7 being intimated and physically assaulted by R8. R7 now verbalizes fear towards R8. This effects 1 of 3 residents reviewed for abuse. Findings include: R7 is a [AGE] year-old male. R7's Cognitive Assessment indicates he is cognitively intact. R7's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 is a [AGE] year-old male. R8's care plan dated 11/10/21, states he is alert and oriented. R8's care plan diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/30/21 at 12:20PM R7 said around 10/1/21 he was in his room in bed on the 2nd floor after breakfast was served. R7 said a large man came into his room and hit him on the outer leg. R7 said he did not know the man at the time. R7 said he found out later the man who hit him was R8. R7 said there was no witness to this. R7 said after that happened I feared for my life. R7 said he requested to be moved to another floor away from R8. During an interview on 12/1/21 at 12:55PM, R7 said he reported the incident to V27, Nurse. On 11/30/21 at 1:57PM V6, Psychiatric Rehabilitation Services Coordinator, said R7 accused another resident of bullying him and then we moved him to the 5th floor. V6 stated that R7 said that a resident came in and bullied him. V6 stated R7 said it was R8 who bullied him. V6 said as a result, R8 was placed on monitoring. On 12/1/21 at 10:00AM V3, Director of Nursing, said there were no reports or investigations related to R8 prior to 11/30/21. On 12/1/21 at 1:06PM V27, Nurse, said when R7 told him R8 was intimidating him he took R7 to a social worker. V27 was unable to name the social worker. V27 said the purpose of taking R7 to the social worker was to have them take care of the issue. On 12/1/21 at 11:25AM V23, Psychiatric Rehabilitation Services Coordinator (PRSC) said R7 is alert and oriented, can be impulsive at times, is rational, and is easily redirected. V23 said he has not known R7 to be delusional or hallucinate. On 12/1/21 at 12:07PM, R8 who was alert and oriented x3 said he attends groups at least weekly including anger management. R8 said there was a resident he approached in the hallway to introduce himself and the resident blew him off. R8 said he got mad and punched the other resident in the leg. R8 stated, it happened about a month ago and he cannot remember residents name, but the resident moved to the 5th floor. On 12/1/21 at 1:40PM V1, Administrator, said allegations of abuse should be reported immediately. V1 said intimation from resident to resident is abuse and would be investigated. Surveyor read portions of R8's progress notes dated 10/10/21, which state R8 was verbally inappropriate by bullying another resident. V1 stated, I should have been made aware, should have reported, and it should have been investigated. Abuse training occurs with staff and orientation at least annually and with any new incident. Review of R7's Progress Notes does not include any documentation from 9/30/21 thru 11/1/21 of a resident hitting him or bullying him. Review of R8's Progress Notes dated 10/10/21, states R8 was verbally inappropriate by bullying another resident. The facility policy and procedure Abuse Prevention Program revised 11/21/20, states: This facility will not tolerate resident abuse or mistreatment by anyone. All personnel, residents, visitors, etc. are encouraged to report incidents of resident abuse, mistreatment or neglect or suspected abuse, mistreatment or neglect; any alleged violations involving mistreatment, abuse, neglect, exploitation, misappropriation of resident property and any injuries of an unknown origin MUST be reported to the Administrator or Director of Nursing. The Administrator is the Abuse Coordinator of the facility. The charge nurse must complete an incident report and endeavor to obtain a written, signed and dated statement from the person reporting the incident.

Based on interviews and records review the facility failed administer [MEDICATION(S)] tablet 5-325 MG ([MEDICATION(S)]-Acetaminophen) by for complaints of pain scores of 7 out of 10 for 1 of 4 residents reviewed for pain management. This failure resulted in a delay in pain medication administration for approximately 5 days post hospitalization . Findings include: Record review of R4's face sheet documents R4 as a [AGE] year-old female with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress note dated 11/21/2021, documents R4 sent to the hospital for pus draining from right breast surgical incision cite. Progress note dated 11/25/2021, documents R4 returned from hospital. Discharge instructions dated 11/25/21, document [MEDICATION(S)] PRN (as needed) is continued. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 11/25/2021 [MEDICATION(S)] tablet 5-325 MG ([MEDICATION(S)]-Acetaminophen) give 1 tablet by mouth every 6 hours as needed for pain related to Malignant Neoplasm of Unspecified Site of Right Female Breast. On 11/30/2021 at 1:40 PM, R4 states she is not getting her [MEDICATION(S)] pain medication that she was prescribed after getting out of the hospital. R4 states she has been asking for the [MEDICATION(S)] medication since she got out of the hospital. R4 states she has pain in her right breast is 7/10. R4 states, the charge nurse [V40], I think she likes to see me in pain. On 11/30/2021 at 1:49 PM, V10 (RN) states R4 requested [MEDICATION(S)] and V10 told R4 that she couldn't take [MEDICATION(S)] with [MEDICATION(S)] this morning. V10 states she told R4 that V10 would give [MEDICATION(S)] to her around 4 hours from now. V10 states she told R4 that around 9:00 or 9:30 AM. V10 states R4 can have the [MEDICATION(S)] now. V10 states, she has given R4 [MEDICATION(S)] once when I she had her before. V10 states R4 can have [MEDICATION(S)] every 6 hours. On 11/30/2021 at 3:26 PM, R4 states she still has not gotten any [MEDICATION(S)] and her pain is 7/10. 11/30/2021 at 3:29 PM at the nurse's station, V10 (RN) states she had not given R4 [MEDICATION(S)] yet, it just got here, I told her (pointing to V17 RN) and she will give it to her. V10 states R4 doesn't have any other [MEDICATION(S)] cards and she didn't know R4 didn't have any [MEDICATION(S)] earlier when R4 asked for it this morning. On 11/30/2021 at 3:34 PM V41 (RN) states, the pharmacy just delivered the medication today, just now. On 11/30/2021 at 3:36 PM observed V17 (RN) take [MEDICATION(S)] for R4 out of white bag. V17 (RN) states R4 has been asking for the [MEDICATION(S)]. V17 states R4 asked about it before today. I don't remember what day. I told her I would order it. V17 states they order [MEDICATION(S)] in the computer. Review of facility's Controlled Drug record documents the following: Form 1) [MEDICATION(S)] received 10/26/2021 and completed on 11/20/2021. Form 2) [MEDICATION(S)] received on 11/30/2021 On 11/30/2021 at 11:47 PM V24 (Pharmacy Tech) states [MEDICATION(S)] was filled on 11/30/2021 and delivered to the facility at 3:32 PM the same day. On 12/2/21 at 11:25 PM R4 states, it made me mad that they didn't give me my medication because I was in pain. I told them the doctor ordered it. They told me there was no prescription in there. I felt like they were playing favoritism. [V40] is mean, she told me 'you ain't hurting girl.' V40 said they just gave it to me after the procedure. I told [V40] that's not what the doctor said. It made me sad. It made me feel like I wasn't anything. On 12/2/2021 at 12:28 PM V40 states she is R4's regular nurse and R4 was looking for [MEDICATION(S)] prescription on 11/29/2021. V40 states she did not look to see if R4 had [MEDICATION(S)] already ordered. She did not know that R4 already had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 states she ordered the [MEDICATION(S)] on 11/29/2021 from the pharmacy. Review of R4's pain review dated 11/25/2021 documents: Lists [MEDICATION(S)]-acetaminophen 5-325mg as a prn medication.

Based on interviews and record reviews, the facility failed to follow their Fall Prevention and Management Program Policy by not identifying risk for falls with effective intervention for assistance to the bathroom to decrease the risk of falling for one of three residents reviewed for fall incident. This failure resulted in R2's having a fall incident while attempting to go to the bathroom unassisted and was found on the floor. R2 was transferred to local hospital. R2 was assessed and treated for subdural hematoma and subarachnoid hemorrhage and minimally displaced right femoral neck fracture. Findings Include: R2's facility record reviewed. R2 with initial admission on 2/22/2013. R2 had two fall incidents during R2 stay in the facility. First incident dated on 4/12/2020 when R2 observed sitting on her bathroom floor attempting to use the restroom. Resident description: R2 states I slipped and fell on my butt while attempting to use the restroom. Second fall incident documented on 5/10/21 when nurse observed R2 on the floor. Nurse noted bump on forehead and received an order to send R2 to local hospital for evaluation. R2 returned on 5/17/21. Hospital record reviewed and read in part: 5/10/21 Hospital Chief of Complaint was fall. Right hip with questionable femoral neck fracture that will be followed-up with MRI, ortho is on consult and following. No hip fracture on dedicated x-ray of hips. Neurosurgery on consult after findings of subdural hematoma on initial CT (Computed Tomography). Repeat CT of head prior to MICU (Medical Intensive Care Unit) admission demonstrates stable appearance of acute subdural and subarachnoid hemorrhage overlying left frontal convexity. R2 care plan reviewed dated 4/10/21, documented that R2 is at risk for falls related to: Requires ADLs assistance for transfers and mobility. Impaired range of motion and/or loss of functional movement of joints. Incontinence. Decrease strength and endurance. Use of Antipsychotic medications. Heart failure, [CONDITION(S)] (Chronic Obstructive Pulmonary Disease) and Dementia. On 5/10/21 facility added intervention status post fall, 5/10 21 interventions reads in part: Voiding Diary, Call light at easy reach, neurological check, Physical Therapy to screen upon return, send resident out for evaluation. Fall Risk Review (prior to fall incident on 5/10/21) dated 4/3/21 conclusion shows a total score of 10. A score of 10 or above represents HIGH RISK. Interviewed V2 (DON) on 6/23/21 at 10 am, stated We added voiding diary, frequent voiding activity encouragement. Because there was a history of fall about a year ago that R2 tried to use the washroom. R2 needs assistance for safe transfer. R2 still can move in bed, wiggle herself out of bed if she wanted to move. R2 because of [CONDITION(S)] diagnosis in the hospital, she was confused prior to the fall, IDT (Interdisciplinary Team) believed that the root cause was probably R2 woke up in the middle of the night wanting to use the toilet and thought she was able to use the toilet independently and tried to get up and fell . Floor mat is not appropriate for R2 because it could trip R2 and fall. Side rails is a restraint, but I am considering it when R2 returns. I will talk to the family about side rails. Interviewed V17 (ADON) on 6/23/21 at 10:30 am, stated I am the one that investigate the fall incidents in the facility. R2 is confused and has dementia. R2 reside on the 4th floor. R2 not able to give any description of what R2 was attempting to do. IDT members discuss fall incidents in the facility to know what intervention to put in place. For R2, we made sure that PT saw her upon return. We placed voiding diary. The team feels like the fall was because she was trying to attempt to use the washroom. R2 is not bed ridden, R2 still able to move in bed but not safe to physically get up on her own. Prior to the fall, R2 functional ability was still able to assist in turning herself to bed. I observed R2 moving in bed by herself at times. There is no other intervention we can put to prevent a fall, because if we put a preventative such floor mat it could be a trigger for her to fall. R2 has a history of getting up off her bed, but R2 is not able to stand on her own, and because R2 has not fallen in a long time, there were no added intervention. The mat might trip R2 if we put it in place. If the bedridden resident is fall risk the mat would work and be effective because it would not trip them and cause them to fall. But during R2 fall incident, the nurse reported that the bed was in lowest position and call light within reach. We cannot put side rail because this could be a form of restraint for this resident. Interviewed V18 (Restorative Nurse) on 6/23/21 at 10:45 am, stated I am familiar with this resident. R2 was declining with walking ability, wheelchair was provided but R2 refused to use the wheelchair and still wants to use her walker, however the wheelchair is still available in her room when needed. I assessed R2 and R2 needs to use wheelchair and not walker because R2 has an unsteady gait, in which R2 is not safe to be walking with a walker. Interviewed V19 (Certified Nurse Assistant/CNA) on 6/23/21 at 11:50 am, stated I have been R2's CNA lately. R2 started declining and started using a wheelchair and place in dining room for monitoring. R2 stays in bed and able to move her body, but not off the bed. Facility's Fall Prevention and Management Policy reviewed and reads in part: The Fall Prevention and Management Program uses clinically accepted guidelines to guide the prevention and management of falls. The Program will: Identify risk for falls, decrease the incidence of falls, and decrease the incidence of fall with injuries. Fall related injuries decrease the resident's quality of life and ability to function. Resident who fall without injury may develop a fear of falling that leads to self-imposed limitation of activity. Falls can lead to fractures, traumatic brain injury, decreased mobility, fear of falling, and increase isolation. This facility uses SAFETY FIRST approach for falling prevention.

Based on interview and record review, the facility failed to follow their abuse policy by not protecting a resident from resident to resident assaults in 1 of 4 residents (R1) reviewed for physical abuse. This failure resulted in R1 being punched in the head by a peer resident and attacked by another peer resident. This attack resulted in R1 sustaining a subdural hematoma, skull fracture and right orbital fracture. Findings include: 1. R6 admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's baseline care plan dated 8/13/19 documents under behavioral concerns: Resident stated when he gets frustrated, he will get violent towards other. R6's Preadmission screening dated 8/12/19 documents under poor judgement placing self or others at risk documents high level and under description documents history of noncompliance with treatment. Patient endorsed auditory hallucinations and multiple hospitalization s. R6's screening for indicators of aggressive and/or harmful behaviors documents a score of 5. A score of 5-10 documents potentially able to integrate with structure, direction, and supportive counseling. Additional SMI interventions may include limited/supervised community access, group intervention and one to one intervention. Under comments documents, R6 appears to be at minimal risk for aggressive/harmful behavior at this time. Staff to continue to monitor resident as needed. R6's incident report dated 12/25/20 documents R6 was involved in physical altercation with co-peer. Under resident description documents R6 pulled R1 by his leg from bed. Facility abuse report dated 12/25/20 documents under brief description: R6 returned to his room to find R1 asleep in his bed. R6 grabbed R1's feet and pulled him from the bed causing R1 to fall to the floor. Under conclusion documents the facility conducted a comprehensive investigation and the evidence does not indicate that there was any intent by either resident to engage in a physical altercation. Therefore, the situation cannot be classified as abuse. R6's interview statement documents he pulled R1 out of his bed because he did not want to get COVID. R12's (R6 roommate) interview statement documents R6 pulled R1 by his legs out of bed and R1 fell to the ground. On 4/30/21 at 11:00 am, R12 (R6 roommate) who was alert and oriented at time of interview said he heard R6 tell R1 to get out of their room and heard R6 punch R1 and then kick him in the head. Staff came in but unable to recall what staff. R6's progress notes dated 12/25/20 document: Nurse was summoned to resident room. Staff observed resident being agitated. Staff stated he was immediately redirected. Resident was seen pulling peer out of his bed. Resident became slightly agitated when he was approached by staff. Resident stated you don't know if he has COVID. Why is he on my bed? Staff immediately placed resident on 1:1 monitoring, PRN was administered as directed by the psychiatrics. Resident was later calm and was educated to report such incident to a staff instead of intervening. Will continue to monitor. R6's progress notes dated 12/25/20 document: Resident returned to his room and found a Peer asleep in his bed. Resident grabbed Peer's feet and pulled him from the bed causing the Peer to fall to the floor. Upon conversation, resident who appeared calm stated to staff he might have COVID. Staff immediately redirected resident by assuring resident that all residents are frequently tested and that any resident diagnosed with the COVID virus are separated from residents who do not test positive for the virus. Resident became slightly agitated and stated y'all don't know who's got it. Resident was exhibiting paranoia and continued to voice non-factual beliefs about COVID-19. Resident is not receptive to redirection and reality orientation at this time. Resident is currently on monitoring till he can present as stable. Staff will continue to monitor and educate Resident as needed. On 4/30/21 at 10:50 am, R6 who was alert and oriented at time of interview said he came back from getting a pop and saw R1 in his bed. R6 told him to get out of his bed and R1 didn't listen so he grabbed his arms and pulled him out of bed. R6 does not recall anything else about incident. R6's care plan dated 11/18/20 documents R6 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Explain facility rules, resident behavioral expectations and resident rights. Provide psychiatric management to monitor psycho-active medications, provide support and enhance structure. Staff will encourage resident to be in compliance with mental health treatment as well as attend therapeutic groups and activities of interest. Under concern dated 11/18/20 documents R6 requires [CONDITION(S)] medication to help manage and alleviate [CONDITION(S)], agitation, depression, [CONDITION(S)], paranoid personality. The interventions documented include assure residents diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Teach resident coping strategies to enable him/her to compensate for delusions; if behaviors symptoms are observed record, document untoward effects and abnormalities to MD; psyche evaluation s needed, social service visits to increase socialization, give positive reinforcements. R6's progress notes dated 10/21/20 document R6 attacked security then jumped the fence. On 5/4/21 at 11:17 am, V5 (Psychiatric Rehab Services Director/PRSD) said he did not observe any documentation after incident 10/21/20 until 11/18/20 which was a quarterly review of R6 behaviors. R6 would have been provided one to one counseling since groups were suspended due to COVID. One to one may be documented in progress notes or behavior tracking. Review of R6's behavior monitoring tool dated 10/22/20 through 1/4/21 documents under behavior observed R6 appears calm. No other documentation of counseling provided. R1 was admitted to facility in 5/14/2015 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's progress note document on 12/25/20 that he wandered into peer's room. R1's incident report dated 12/25/20 documents R1 was observed on the floor in co-peers' room. Under immediate action documents discoloration noted to right side of face and abrasions to right elbow, right eye above eyebrow and bilateral legs. New orders to schedule CT scan at local hospital. R1's progress note dated 12/27/20 R1 had appointment for CT scan at hospital. R1's hospital record dated 12/28/20 documents R1 was allegedly in an altercation with another peer over the weekend. R1 CT scan documents acute subdural hematomas measuring up to 4mm on left and 5mm on right, right parietal scalp hematoma, acute nondisplaced fracture of the right side of skull and acute fracture of right orbital wall. R1's progress note dated 12/29/20 document R1 admitted to local hospital with subdural hematoma. On 5/4/21 at 12:21 pm, V1 (Administrator) said physical abuse would include hitting or striking another resident causing harm. The incident with R1 and R6 was not substantiated because they did not intend to fight or cause harm to each other. The Surveyor asked V1 if pulling someone from the bed would cause harm and he responded not all the time. V1 was asked if R1 sustained harm from this incident and responded yes. Abuse prevention program revised 6/21/20 documents it is the policy of this facility to prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm or pain or mental anguish or deprivation by an individual, including caretaker of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Physical abuse is hitting, slapping, pinching kicking etc. It also included controlling behavior through corporal punishment. 2. R13 was admitted to facility on 3/20/20 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R13 Minimum Data Set, dated dated dated [DATE] document brief interview for mental status score 15/15 which means cognitively intact. On 4/22/21 at 4:05 pm, R13 who was alert and oriented at time of interview said he hit R1 in the head. R13 said R1 fell on his bed on 4/21/21. R13 was upset because R1 incontinence product was dirty, and he was unable to get off R13' bed. R13 said he hit R1 in back of the head and R1 fell off bed near window. R13 said V9 (Certified Nurse Assistant/CNA) came and assisted R1 back to bed. On 4/22/21 at 4:08 pm, R1 who is alert and oriented x1 said R13 hit him in the back of head but no other details provided. R14 was admitting to facility in 6/5/2018 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R14 Minimum Data Set, dated dated dated [DATE] document brief interview for mental status score 15/15 which means cognitively intact. On 4/22/21 5:02 pm, R14 who was alert and oriented at time of interview said yesterday (4/21/21) he observed R1 fall onto R13's bed. He saw R13 hit R1 in the head and then R1 fell off the bed. Staff came in and helped R1 back to bed. Abuse prevention program revised 6/21/20 documents it is the policy of this facility to prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm or pain or mental anguish or deprivation by an individual, including caretaker of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Physical abuse is hitting, slapping, pinching kicking etc. It also included controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to develop an effective plan to provide safety interventions to prevent or reduce the risk of falling and failed to ensure the safety intervention of wearing a helmet were implemented to reduce the risk of serious injury during a fall incident for 1 of 3 residents (R1) reviewed for fall risk and prevention. This failure resulted in R1 having multiple falls, sustaining closed head injury, and right humeral head and neck fracture. Findings include: 1. R1 was admitted to facility in 5/14/2015 with diagnosis of [CONDITION(S)], [CONDITION(S)], abnormal posture, unsteadiness on feet, extrapyramidal and movement disorder. R1's progress note dated 1/16/21 states Writer responded to a sound heard from resident's room. Upon entering the room, resident was observed on the floor but quickly got himself up before writer could get to him. A head to toe body assessment was conducted on resident. A mild swelling to the right shoulder and a skin tear to left upper eyelid area were noted, first aid treatment was immediately provided. Resident was observed bear footed, resident had removed his shoes before attempting to walk. R1's fall care plan under problem dated 1/6/21 documents R1 is at risk for falls related to history of falls, visual acuity impairment, [CONDITION(S)] disorder, decreased strength and endurance. Interventions include the following: ensure call light is within reach and encourage to use it for assistance; gather information on past falls and attempt to determine cause of falls. Anticipate and intervene to prevent future occurrence. R1's Minimum Data Set, dated dated dated [DATE] documents under toilet use extensive assistance and two-person assist. Under locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor) documents extensive assistance and two-person assist. Under balance during transitions and walking documents not steady, only able to stabilize with staff assistance. R1's fall risk assessment dated [DATE] and 4/2/21 document a score of 5. A score of 10 or above represents high risk. On 4/30/21 at 11:44 am, V4 (ADON) said R1 wanders and is impulsive. R1 has had these behaviors upon admission. R1 is at high risk for falls and unsure why fall risk assessments do not reflect that. R1 needs monitoring at least every 2 hours. On 4/27/21 at 3:15 pm, V7 (nurse) said R1 is a fall risk because he has unsteady gait and wanders. V7 said on 1/16/21 she heard a noise in the R1's bathroom. V7 entered bathroom and observed R1 getting up from the floor. There was no staff present with R1 in the room. Upon assessment V7 observed changes in R1 Range of motion to right arm and orders for x-ray received. R1 did not have socks or shoes at time of fall. R1's x-ray report dated 1/17/21 document acute humeral head and neck fracture. Facility reportable dated 1/18/21 documents under conclusion that R1 sustained right humeral head and neck fracture as result of a fall. R1 was attempting to use the bathroom unassisted and failed to put on appropriate footwear. 2. During the survey on 4/22/21 at 12:30 pm and 4/28/21 at 11:35 am, R1 was observed in his bed without helmet. R1's care plan dated 1/6/21 documents R1 is high risk for falls/safety issues and wears a safety helmet. Intervention listed include: Educate resident and staff on use of helmet; monitor intervals for proper placement any discomfort; keep environment free of clutter; provide glare-free lighting; remove helmet if complaints of pain, signs of redness or improper fitting; anticipate and intervene to prevent recurrences. Educate on safety reminders. R1's progress note dated 4/27/21 documents: Staff member heard resident yell help from room and noted him lying on floor. Writer was called immediately, and observed resident lying on floor near left of second bed. When asked resident stated he was trying to get in bed. Writer had just left resident room about 35-40 minutes ago giving his medication and was in his own bed. Range of motion done. No skin break noted. Resident has raised area over right eyelid. R1's incident report dated 4/27/21 documents resident is known to be impulsive and restless. Under notes documents swelling to forehead. On 4/28/21 at 11:52 am, V12 (nurse) said R1 was observed on the floor near window. R1 had discoloration to right upper eye lid. V12 said R1 did not have helmet on at time of fall. On 5/4/21 at 10:33 am, V21 (NP) said he was unclear when R1 received helmet, but he should be wearing it to prevent head injuries due to falls and seizures. R1's hospital record dated 4/27/21 documents under diagnosis: Fall, closed head injury and traumatic hematoma of forehead. Facility policy titled fall prevention and management program version 7 documents the program will identify risk for falls, decrease incidence of falls, and decrease the incidence of falls with injuries. The facility will provide fall prevention assessment, implement interventions to prevent falls as much as possible and manage post fall treatment by: individualized fall risk assessment; interventions that are implemented based upon the identified risk factors, reassessment of risk after fall with modification and additional interventions as appropriate.

Based on interview and record review the facility failed to implement their policy for abuse prevention and have a system in place to prevent resident to resident abuse. This failure applies to 1 of 12 residents (R12) reviewed for abuse in a sample of 14. This failure resulted in R12 sustaining a nasal fracture, black eye, contusions and head Injury when R10 attacked and physically assaulted R12. Findings include: According to an incident report dated 11/19/18, R10 is a [AGE] year old resident with [DIAGNOSES REDACTED]. R10's MDS assessment dated [DATE] indicated R10 mental status is intact (BIMS =15). R10's nursing progress note dated 10/14/2018 at 9:52pm documents: Resident had physical altercation with peer in the elevator. Both residents were immediately separated and placed on 1:1 monitoring. no apparent injury noted. PRN (as needed medication) given as order tolerated Well. Denies any pain at this time. MD (medical doctor) made aware, family member notify, Police department Notify. R10's social service note dated 10/16/2018 12:13pm documented: Writer spoke with resident to know how he's doing following incident with peer on the 2nd floor elevator on 10/14/18 Resident stated that he's fine and in good spirits . Resident was encouraged to seek staff if he has any issues and/or concerns and verbalize any feelings that he may have. Resident agreed to seek staff if needed . The incident final report sent to the state agency on 10/20/2018 for the incident documented on 10/14/18 involving R10 and R15 read as follows: Incident date 10/15/2018 (no time given): Staff received report that R10 was physically aggressive towards R15. The conclusion include: The facility conducted a comprehensive investigation and the evidence does not indicate that there was any intent to harm, therefore there is no abuse or neglect. R10's social service note dated 11/19/2018 at 9:28 pm documents: Resident was observed with bruising on hand. When resident was asked about the bruising resident became aggressive toward staff. Resident was immediately placed on 1: 1 monitoring with male staff until paramedics arrived for resident to be sent out. R10's nursing progress note dated 11/19/2018 at 10:24pm documents: Resident was involved in physical altercation with his room mate (R12). Both residents were immediately separated and placed on 1: 1 monitoring. PRN given as order tolerated well. Police notified. MD made aware order resident to be transfer to hospital for evaluation. Paramedics redirected to another hospital due to increase heart rate. The facility had another final incident report dated 11/24/2018 regarding a resident to resident altercation between R10 and R12 on 11/19/2019. The reports had the following information: Incident date 11/19/2018 time 3:45pm, Resident (R12) was observed exiting his room with multiple bruises and swelling to facial area. Upon entering room, roommate (R10) was observed with bruises to hand. The conclusion of the investigation included but not limited to the following information. The facility conducted a comprehensive investigation and concluded the evidence does not indicate that there was any intent to harm, therefore there is no abuse or neglect. Also staff interviewed R12 who stated: I was hit by a truck. R10 stated he went over to check on R12 because because he sometimes bothers me. I made him (R12) hit himself with his own hands. R16 was in the room during the altercation and was able to confirm that R10 hit R12. R16 stated he was asleep and awakened by the sound of scuffling coming from R12's sleeping area. R16 further reported the privacy curtain was closed, therefore he was unable to view how the incident began. R10 was re-assigned to another room. R12 had a [DIAGNOSES REDACTED]. R10 has been counseled on the need to maintain appropriate verbal and physical boundaries with peers. R12's hospital records dated 11/19/18 reads Patient states another resident struck him for no reason. Hospital discharge summary for R12 dated 11/19/18 reads 1. Nasal Fracture 2. Black Eye 3. Contusion in Adults 4. Head Injury R10's hospital records dated 11/20/18 reads Reason for Assessment: There was an argument or something. I got mad, confrontation, violence. On 12/28/18 during interview at 2:14pm, R10 said he controls what his hands do. No additional information was offered regarding the incident of 11/19/2018 involving R12. The surveyor attempted to interviewed R16, the roommate of R10 and R12, and was not successful in obtaining any additional information beyond the incident report. On 1/2/19 at 12:20PM , R12 said R10 punched me in the face and he said he is still sore and pointed to under his left eye. R10 indicated ,with closed fist, that R10 had hit him in the upper right rib area and lower left rib area. R12 said if he saw R10, he would feel afraid. On 1/3/18 at 10:25AM during interview, in the presence of V2, Director of Nursing, R10 said I got mad and I think I hit him. On 1/3/18 V1, Administrator, and V12, Psychosocial Rehabilitation Services Director, said neither R10 or R12 told them what exactly happened. V1 said the investigation is based on what R10 and R12 told them. V1 said exactly what the resident said is what is written in the investigation and conclusion. During phone interview on 1/3/18 V12 said It was implied that R10 hit R12's face. R10's care plan with an original initial date of 4/25/2018 and target of 1//25/2019 had no indication of changes or revision for agitation and aggressive behavior that could lead to abuse after the incidents involving altercations with peers on 10/14/2018 and 11/19/2018. This included but not limited to how staff would monitor the resident for possible abusive behaviors. Facility Policy for Abuse reads: It is the policy of this facility to prevent resident abuse, neglect , mistreatment and misappropriation of resident property. The facility's definition of abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a care taker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. The prevention of abuse the policy includes but not limited to the following: -As part of the social history assessment and MDS assessment, staff will identify residents with increased vulnerability for abuse, neglect, mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify and problems, goals and approaches which would reduce the chances of mistreatment for [REDACTED]. -On a regular basis, supervisors will monitor the ability of staff to meet needs of residents; staff understanding of individual resident care needs, and situations such as inappropriate language, insensitive handling or impersonal care will corrected as they occur. Incidents short of willful abuse (willful infliction of injury according to the facility's definition) will be handled through counseling, training and if necessary or repeated , the facility's progressive discipline policy.

Based on interview and record review, the facility failed to ensure that a resident is free from physical abuse by a staff member for one of seven residents (R8), reviewed for abuse in the sample of 16. V14's actions during a resident to resident altercation provoked R8, resulting in increased agitation and a forcible takedown by multiple staff. While the resident was on the floor, staff inflicted additional physical abuse by kicking the resident in the face. This failure resulted in R8 experiencing agitation and restlessness and verbalizing homicidal ideation's requiring inpatient hospitalization . Findings include: Review of R8's ambulance run sheet narrative (11.26.2018, written by V4, EMT-Emergency Medical Technician) documents: In summary (BLS-Basic Life Support Ambulance) was dispatched for a (R8) to be taken from (facility) to (hospital) for a psych (psychiatric) evaluation for getting into a fight with residents and staff. UA (upon arrival) on scene EMS (Emergency Medical Services) crew makes contact with nursing home nursing staff. While trying to gain report from nurse, physical fight breaks out between residents and staff members with one nurse grabbing who wound up to be our pt (patient) but we didn't know at the time grabbing by the throat and staff taking pt to the ground and separating everyone. Once fight is broken up report given to EMS crew (?) who pt was at that time. He was being sent for getting into fights with pt (patient's) girlfriend and fighting with staff. Staff also states that pt has snuck in alcohol and was drunk. Pt continues to be verbally loud and threatening to anyone who (?) and speaks to pt. Nursing home calls PD (Police Department) for assistance. EMS crew waits for PD to arrive on scene and assist with trying to talk pt into getting onto stretcher. Once PD arrives they try and help talk pt onto stretcher and are unable to talk onto stretcher. They do get pt to say that he wants to bring all of pt's (patient's) with if he does leave. At this point (PD) says that they can not force pt to leave and this isn't a law enforcement issue and PD leaves. Pt is back in pt('s) room. Pt is talking with members of staff. Pt was still screaming and being loud with staff but not physical. At this point a nurse called (V14) by staff and residents gets into pt('s) face and then proceeds to punch pt in face and throat. Pt then wrestled (to) the ground by 3 staff members. Then same nurse who punched pt also kicks pt in the face while pt laying on the ground restrained by staff. EMS crew call dispatch and medical control to keep them informed of situation and decision made (?) point that if pt is taken he will be taken to nearest hospital which would be (local hospital). After approximately 20 minutes pt able to be talked into getting on stretcher and pt is secured x 8 . Review of the facility's final incident report (12.04.2018) documents: Facility received a call from (hospital RN-Registered Nurse) reporting that (hospital) received report that staff member, (V14, LPN-Licensed Practical Nurse) was physically aggressive towards resident (R8) during crisis prevention intervention. Review of R8's hospital record (emergency room Record Progress Notes, 11.27.2018) documents R8 (Under Chief Complaint) HPI (History of Present Illness) patient transferred from nursing home for psychiatric evaluation. Patient presumably got into argument with the staff and patient got upset and subsequently states that he wants to kill everyone at the nursing home .Patient states he was struck in face . R8's final [DIAGNOSES REDACTED]. Per Social Service Notes: Discharge to inpt (inpatient) psych unit. V4 (EMT, 12.04.2018 at 5:09 PM) stated when he arrived at the facility (11.26.2018) he observed a fight going on between residents (including R8) and staff at the Nurses Station. V4 said he saw V14 grabbing R8 by the throat and additional unidentified staff grabbing R8. V4 said he later saw V14 square off and punch R8. V4 said three additional staff members (unnamed/unidentified) got R8 on the floor and, while restrained on the floor, V14 kicked R8 in the face. V4 said he never saw or heard staff intervene to stop the abuse nor did he see R8 become physical with V14. V5 (EMT, 12.04.2018 at 6:03 PM) stated when he got off the elevator on the second floor (11.26.2018), he observed a fight between residents and staff. He said a staff member (later identified as V14) had a resident (later identified as R8) by the throat. V5 said R8 was heard yelling at V14 and, V14 punched R8 twice. V5 said three staff members tackled R8 and V14 kicked R8 in the face while he (R8) was on the floor. V5 said he never heard or saw staff intervene when V14 punched or kicked R8. V5 stated R8 was verbally abusive toward staff but was never physically abusive. R8's written statement, obtained by V1 (Administrator) on 11.28.2018 documents: I recognize that I had been drinking and I wanted to take my meds. I asked (V9, LPN-Licensed Practical Nurse) for my meds and he said no. I got angry and we sort of argued and we was arguing for a minute then I seen the ambulance come and that's when I got mad. Then, the police came but they left. I told them I wasn't going to the hospital. I told them to let me go AMA (Against Medical Advice). They told me they where (were) going to call you (V1) and we kept arguing, then they all grabbed (me) and (V14) hit me while I was down on the ground. R5 (12.05.2018 at 12:58 PM) said that he saw staff grabbing R8, (staff) were trying to bring him down, they were grabbing at him, his head, his neck, everyone was grabbing a part of him. R16 (12.05.2018 at 11:57 AM) said: (V14) punched (R8) and kicked him in the face. V1 (Administrator, 11.30.2018 at 11:30 AM and 2:02 PM) said that the facility does have security cameras, however, it's taped over every 24 hours. V1 also said that it's never appropriate for staff to react in a physical way towards a resident. My staff, any staff at any facility, should never put hands on a resident in an inappropriate manner nor retaliate against a resident.

Based on observation, interview and record review, the facility failed to provide adequate supervision for two residents (R9, R10) out of three reviewed for monitoring in a total sample of 17. R10 is assessed as an elopement risk with no community survival skills. As a result of the inadequate supervision, R10 eloped from the facility on 8/20/17 and was hosptalized on [DATE] with a [DIAGNOSES REDACTED]. R10 required 3 liters of intravenous fluid in the emergency room . Findings include: R10 face sheet documents [DIAGNOSES REDACTED]. Original admitted is listed as 1/29/14 with a date of birth of 2/6/1956, making R10, [AGE] years old. On 12/22/17 at 1:05 pm V11(Police Officer/Desk Sergeant, Star 116) stated, Took a missing person report on 8/20/17 at 21:51(9:51 pm). Report # 92 for (R10). V12, (Licensed Practical Nurse) called from facility to file report. Told resident was [MEDICAL CONDITION] and [MEDICAL CONDITION]. Facility accident/incident, concern and grievance reports were requested on entrance from V1(Administrator) and V2(Director of Nursing) for past 6 months. There was no accident/incident report documenting an elopement by R10 from the facility in August. Facility was advised on December 29th at 11:00 am, there was no incident report for R10 related to event of elopement. As of 4:30 pm, no incident report was presented. On January 2nd at 10:35 am, V1(Administrator) and V2 (Director of Nursing) reported just finding a binder with the information on R10's elopement. An incident report with Illinois Department of Public Health notification was not part of the information presented in the binder related to R10's elopement. Summary email report included in the binder and sent from V13(former facility Administrator) and forwarded to V2 on 8/27/17, concludes, After a through investigation, record reviews, interviews and observations - (R10), an alert and ambulatory resident, exited the facility via the front door while there was a guard present. She has apparently carefully thought of the plan to leave. She appeared to have been dressed as Certified Nurse Assistant (smock top, and beige smock bottoms with a purse) when she left the facility. With no hesitation, she walked towards the lobby from first floor hallway going straight to the glass double doors, waved her hands(as in aiming for a red-eye sensor) and the doors opened. R10 walked towards vestibule and waved her hand again(as in aiming for a red-eye sensor) doors opened and left the facility. R10 did not score an elopement risk. R10 was determined to exercise her right not to be confined and can go anywhere she wishes to Additional information in email from V13 to V2 documents outside agency is used to guard front desk and the guard on duty was asked to not return to facility. On 1/2/18 at 3:00 pm ,call was placed to (Outside security agency personnel) V19. V19 reported their staff go through training on how to handle visiting and pass privileges. V19 noted up until 8:00 pm there is always a facility staff person on duty, with the outside agency guard at the lobby door. The 2nd staff person on duty at the lobby door on 8/20/17 before 4:00 pm cannot be identified. None of the staff writeups include disciplinary action for a staff member at the lobby entrance on 8/20/17. V19, after answering a few questions, would not answer any additional questions. According to handwritten timeline for date of 8/21/17 at 3:30 pm which is included in binder with facility's investigation and corrective actions, after R10 eloped the Front Desk to ID(identify) all persons upon entrance and leaving. Initial review of computerized progress notes for R10 on 12/21/17 include a nursing note on 8/10/17 at 4:00 pm describing R10 as arriving via ambulance from the hospital. The next note is on 8/21/17 which documents report received as admitted at (hospital) for [DIAGNOSES REDACTED]. on 8/20/17. V2 (DON) logged in and showed additional progress notes titled, draft which included documentation of R10's elopement from the facility. Without V2's computer authorization, these notes were not available for review. The draft note documents that at 4:00 pm on 8/20/17 R10 was noticed missing and a search was begun to locate. emergency room records with date of arrival of 8/21/17 and time of arrival of 07:18 am with notes by V15, (emergency room Physician) describes R10 as oriented x 1, with moments of confusion and uncooperation, arriving by ambulance after being found in parking lot of local business. Clothing disleveled and dirty. Vital signs are blood pressure of 189/95, temperature of 36.9, Pulse 77, Respiratory Rate 18 and pulse oximetry of 98%. V16(Registered Nurse in emergency room of hospital for R10) on 8/21/17 at 7:40 am described R10 as confused with thought pattern rambling. R10 reports to the emergency room staff she is in the hospital because neighbor kidnapped her. R10's Laboratory results on admission to the emergency roiagnom on [DATE] were as follows: Glucose at 8 am = 676(normal 70 - 105) Blood, Urea, Nitrogen = 64(normal 8 - 21) Creatinine = 2.34 CK = 1144 3 liters of .9 saline solution are administered to R10 on arrival to the emergency room with primary impression documented as acute kidney injury. Added to the problem list are: abrasion, altered mental status, dehydration, elevated troponin, [MEDICAL CONDITION], rhabdomyolysis, and Evidence of Rhabdomyolysis with CK of greater then 10,000. Given fluid resuscitation with decreased troponin and CK. Discharge summary was requested from the hospital but not forwarded. Note from Hospital Attending physician states R10 had prerenal azotemia, electrolyte imbalance, abnormal troponin with Diabetes out of control. R10 has an elopement risk review dated 7/18/17 and a community survival skills assessment dated [DATE]. These are the last 2 assessments of this type prior to R10's elopement. Both V2(DON) and V14(Social Worker) were shown the results of these assessments on the computer and verified the assessment results on 12/29/17 at 11:10 am and 1:00 pm respectively, as showing R10 was an elopement risk and not able to navigate safely on streets. Oriented x 1. Not able to make decisions. V14(Social Worker) completed both of these assessments. On 12/29/17 at 1:00 pm V14(Social Worker/psychosocial rehabilitation counselor) explained need for elopement risk and supervision stating, In talking to her would sort of think has husband since 5 and said would go move with husband, When symptoms flair she would say husband needs her. It's part of her delusion. Oh you're trying to hold me from my husband. I need to be with him. That's why she is concidered an elopement risk. When moved to 3, she joined my caseload. I put picture down at front desk I would ask explain to me how to cross street. R10 would say just cross street. R10 would not explain a person would need to look both ways. V14 statesI wouldn't give a pass unsupervised. On 12/29/17 at 11:10 am V2 (DON) confirmed R10 had exited the building via the front desk according to camera footage. V2 reported the camera footage was no longer available and could not remember who the staff member at the front desk was. Given R10's elopement risk, V2 noted this resident needed to be monitored. After returning to the facility V2 stated R10 was moved to a different floor and staff received training. Elopement, according to V2, is considered an incident. On 1/2/18 at 2:15 pm V2(DON) reported it was an outside agency person who was by himself on the evening shift covering the front door when R10 eloped. V12(Licensed Practical Nurse) works with R10 regularly in the evening and was on duty when R10 was noted missing. On 1/2/17 at 2:00 pm V12 described R10 as someone who takes her medications, needs supervision because she's not safe and not supposed to let outside. V12 reports she would have been checking a blood sugar on R10 for the evening shift. Medication Administration Record [REDACTED]. R10 also refused her [MEDICATION NAME] Tablet Delayed Release of 500 mg which is ordered two times a day for treatment of [REDACTED]. Insulin injection of [MEDICATION NAME] 16 units subcutaneously was also not given at 8:00 pm on 8/20/17 as R10 had eloped at that point. On 1/2/18 at 1:45 pm V20(Medical Director) stated the reason R10 developed dehydration was because not drinking enough fluid, walking, coupled with Diabetes. At the time of R10's elopement R10 had a wandering/elopement care plan active through 10/18/17. R10's goal was to respond to staff direction to re-direct attention from a potentially problematic situation(such as elopement or entering a peers' room) when any difficult behavior occurs. Approaches/interventions include: implementing preventive interventions strategies: Assess for potential elopement/unauthorized departure risk. Post a picture of the resident at/near the front desk and/or mursing station im a discrete place identifying possible elopement risk. Notify staff of risk potential. Make rounds/room checks per facility protocol to minimize chance of unauthorized leave After the elopement facility moved R10 from the 3rd floor to an alarmed 4th floor. Follow up wandering/risk of elopement) care plan which is dated with goal date of 12/28/17 and 3/19/18 has no approaches or interventions documented. On 12/29/17 at 1:45 pm V14(Social Work) stated the current elopement care plan was not complete. Symptoms, Goal/Objectives, Approaches/Interventions are missing. Elopement care plan lets someone who doesn't know resident gives them synopsis of what to watch out for. On 12/20/17 from 10:45 am until 11:30 am continuous, uninterrupted observations were completed on the 3rd floor. At 11:14 am, while seated at the nursing station , loud screaming of someone help me, could be heard from about 10 feet away. R9 was identified as screaming from his room and during continuous, uninterrupted observations, R9 was heard screaming again someone help me at 11:15 am, and 11:18 am. At 11:18 am while R9 is screaming V6(Housekeeper) is in the hallway outside R9's room within approximately 3 feet. While R9 is screaming, V6(Housekeeping) is in the hallway. In addition to V6, V7(Certified Nursing Assistant) who is on the phone and V8(Staffing Office) are in the staffing office almost directly across from R9. While standing within a few feet from V7 and V8's office the screaming from R9 could be heard. The screaming continued at 11:19 am with no response from V6, V7 and V8. By 11:20 am with R9 still screaming, V9 (Certified Nursing Assistant) rounds the corner from the nursing station and goes directly to R9's room. On 12/20/17 at 11:30 am V9(CNA) identified R9 as the resident who was screaming. V9 reports, If something is heard, someone should respond. Someone can be hurt. Housekeeping should at least come investigate. On 12/20/17 at 11:20 am, V6(Housekeeper) when asked what she did when R9 was screaming responded, Always screaming like that. Sometimes I ask what I do for him. V7 denied hearing the screaming as she was on the phone. On 12/20/17 at 3:30 pm V1(Administrator) stated, When there is a behavior, staff should immediately intervene .Any employee of facility should respond. Housekeeping should check immediately. Could be resident hitting another resident. Nursing inservice of 4/19/17 directs all staff need to monitor behaviors and intervene when noted or redirect.

Based on observation, record review and interview, the facility failed to prevent a resident from entering a restricted room containing a linen chute to the facility laundry area. As a result, R1 entered the room and fell down the linen chute five stories into a laundry bin in the facility's laundry room. R1 sustained fractured bones in both legs and spine and required hospitalization and surgery. This applied to one out four resident (R1) reviewed for falls and supervision. The findings include: An incident report dated February 22, 2017 showed that at 2:15PM showed that R1 fell and sustained laceration to bilateral elbow and swelling to bilateral ankles. The report showed that R1 was unable to give any information. The report showed the resident was confused and disoriented. The report does not give a location of the residents fall. A final report sent to IDPH (Illinois Department of Public Health) dated February 26, 2017 showed that R1 was found on the floor with a laceration to bilateral elbow and bilateral ankle swelling. The outcome of the report showed that R1 was observed in the first floor laundry room. The report showed that after R1 was sent to the hospital, R1 was admitted to the hospital with [REDACTED]. The history and physical from the community hospital emergency room dated February 22, 2017 at 3:15pm showed that R1 had multiple abrasions to multiple areas on the back and elbow. R1 had one laceration to the right elbow, gross deformity of both ankles, left lower extremity shorter that the right lower extremity. The diagnostic report showed that R1 had left intertrochanter fracture of the left femur, closed right proximal and distal tibial fracture closed fracture of the left calcaneous, mild compression deformity of the superior endplate of Thoracic vertebrae 12 and lumbar 1, chronic fracture to cervical vertebrae 7, lumbar 5 burst fracture and fracture of lumbar 1 through 4 The facility investigation for this incident showed that based on findings in the investigation it was determined that R1 fell down the laundry chute from the fifth floor. The investigation showed that E1 (administrator) was asked by the community police department to review videotapes from the incident. The videotapes showed R1 going into the fifth floor laundry chute room. The investigation showed the door did not latch at that moment. The investigation showed that based on the facility findings of the investigation eight staff were suspended without pay for two days. On March 8, 2017 at 9:25AM, the fifth floor linen room was observed. The exterior door contains a self locking door with a linen chute located inside. The chute opening measures 18 inches by 18 inches and is approximately 5 feet above the floor, an opening that was large enough to accommodate an ambulatory resident. On March 7, 2017 at 11:35 in the conference room E1 administrator said that R1 had entered the laundry chute room and that the door was did not latch properly. Later, on March 8, 2017 at 12:15pm in the conference room E1 Administrator confirmed that a security video tape was viewed by the community police to rule out foul play. E1 stated that R1 was seen on the video tape entering the fifth floor room that houses the linen chute. E1 stated, that is how we knew he fell from the fifth floor. E1 said that the hospital call the police to investigate. E1 said that the police did not identify foul play. E1 stated, R1 may have seen the door propped open. R1 could be seen entering the laundry chute room. E1 confirmed during the interview that the door to the linen chute area needs to be locked and closed at all times. R1 was admitted to the facility November 26, 2001 per the admission face sheet. The current physician order [REDACTED]. The current care plans for R1 showed that R1 has problems with auditory hallucinations, poor contact with reality and poor judgment. Interventions to prevent complications from these problems in the care plan included assessment, supervision, observation and structured environment. The MDS (Minimum Data Set) dated September 1, 2016 showed that behaviors exhibited by R1 included hallucinations, poor contact with reality and poor judgment. The MDS for this date showed that R1 had some cognitive deficit particularly with recall and disorganized thinking. The nursing notes in R1's clinical showed that on February 22, 2017 at 1:30pm R1 ate 100 percent of his lunch and voiced no concerns and had no behaviors. The next entry made in the nursing notes was at 7:49pm. E2 DON documented that an attempt was made to obtain the status of R1. The note showed that R1 was still being evaluated in the emergency room at a local hospital. The next nursing note written on February 22, 2017 was at 11:12pm and showed that R1 was being admitted with the [DIAGNOSES REDACTED]. Notes written by Z2 (NP -Nurse Practitioner) on February 22, 2017 showed that R1 had a complaint of anxiety. Psychiatric review of systems showed R1 was positive for anxiety, hyperactivity, irritability, agitation, combativeness, impulsiveness and paranoia. The mental exam done by E NP showed that R1 had impaired judgment, insight and impulse control. The exam showed that R1 was disoriented to person, disorganized thought process, moderate flight of ideas, perceptual disturbances and delusional material was expressed. On March 7, 2017 at 2:45pm in the conference room E3 DON (Director of Nursing) said that the incident happened somewhere between 12:00pm and 1:00pm. E3 said a code was called for all nurses to go to the laundry room. E3 said R1 was found in a bucket that receives the laundry. E3 said that a wound could be seen by the right elbow. E3 stated, Someone had already called 911. There was a pillow to immobilize feet. I could not see where the blood was coming from. E3 also confirmed that the linen chute room door should be closed and locked at all times. On March 7, 2017 at 3:25pn in the conference room E5 LPN (Licensed Practical Nurse) said that he was assigned to work on the second floor. E5 said the last he saw R1 was around 12:30pm for having lunch. E5 said the last he saw him was around 12:45pm. The next time he saw him was after the fall. E5 reported that he did the transfer papers to go with R1 to the hospital. E5 stated, I could see blood coming from the back area and a laceration by the elbow, I don't remember which one. Somebody stabilized and neck and we were able to remove R1 from the bin. E5 also stated that the linen chute room should be locked at all times. On March 8, 2017 at 9:05am in the conference room E8 CNA said that the laundry chute/linen room doors are to be locked. E8 stated, It's only since the incident that the chute itself is also padlocked. E8 went on to add that if R1 was able to get into the room, the door would have been propped open. On March 8, 2017 at 9:10am in the conference room E14 LPN wound nurse said that on February 22, 2017 he was working and heard an announcement. E14 was not sure what was said but saw all of the nurses running so he followed. E14 said they went to the first floor laundry area and they found R1 in a laundry bin. E14 said that R1 was not talking but was trying to move. E14 stated, I saw spattered blood coming from the bottom of the bin. I couldn't tell where it was coming from. R1 was trying to move his arms. We told him to hold still. R1's ankles looked deformed. R1 had a deep laceration to the right elbow and superficial lacerations to both wrists. E14 said that after R1 was taken away by the ambulance the staff received an in-services on keeping the doors locked. On March 8, 2017 at 10:23am E9 said that if she saw R1 on the fifth floor she would direct back to his own unit. E9 stated, The door to the linen room where we put the soiled linen should be locked. We put linens in a bag and put it down the chute. Only nurses and CNA's have keys to the room. On March 8, 2017 at 10:37am in the conference room E10 LPN said that the linen chute room door was to be locked at all times. E10 stated, Only the nurses and CNA's have the keys. The residents do not have keys for those areas. March 8, 2017 at 11:14am in the conference room E13 LPN (Licensed Practical Nurse) said that R1 lived on the second floor. E13 said that on the day of the incident she was working on the fifth floor. E 13 did not remember seeing R1 as she was providing patient care in another resident's room. E13 said that a few days after the incident the entire firth floor staff was suspended. E13 stated, The administrator said we were suspended as the doors were not locked properly. We were suspended for two days.

Based on observation, interview, and record review the facility failed to provide supervision to 2 of 5 residents ( R2 and R3) who are demented and aggressive and are wanderers in the sample of 15. This failure resulted to R3 wandering into the room of R2, who has a history of pushing other residents and staff, regardless if he was provoked or not. This failure resulted to an Immediate Jeopardy which started on 6/6/11 at 2:00 PM, when R3 wandered inside R2's room unsupervised, and was pushed on her back, causing her to fall on the floor face first, causing a laceration and bleeding on the lip, hematoma on the left eye and left eye injury. The Administrator ( E1 ) was notified of the Immediate Jeopardy on 8/25/11 at 1:04 PM While the Immediate Jeopardy was removed on 6/8/11, the facility remains out of compliance at severity level 2, because the facility has yet to inservice the new hires on all shifts, has yet to assess if new interventions and policies are effective on the possible affected residents, and evaluate the new plan of care that has yet to be done. Findings include : Per facility's incident report dated 6/6/11, at 2:00 PM, R3 was found on the hallway floor with injuries. R3 stated she was accosted and knocked down by another resident. In a separate incident investigation sheet dated 6/6/11 (without a time), R3 wandered into R2's room and was pushed to the ground by R2. R3 sustained a hematoma to the left eye and sustained a laceration on the lip. Per E10 (CNA - Certified Nursing Assistant) 8/23/11 at 2 PM, on 6/6/11, she was walking from the supply room after lunch when a housekeeper flagged her and said R2 pushed R3. E5 ( housekeeper ) on 8/23/11 at 2:20 PM,said that she interpreted E6's ( housekeeper ) statement as E6 was the only staff who saw what happened. E5 said that E6 said that she was in the isolation room next to R2's room when she heard a noise coming from R2's room. E6 peeked at the door and saw R2 push R3 on the back causing R3 to fall on the floor. E6 stated on 8/24/11 at 2:05 PM (thru an interpreter) that she was cleaning the isolation room 43 when she heard a noise coming from R2's room next door. E6 said that when she looked outside she saw R2's hands pushing R3 who fell on the floor. E6 said that there were no staff members with R3 or with R2 during this time. According to E15 ( nurse ) on 8/24/11 at 2:35 PM, she last saw R3 in the corridor prior to the incident on 6/6/11. E15 added that R2 might have been in his room that time. On 8/25/11 at 10:10 AM, E15 stated she was in a meeting prior to the incident and by the time she got to the unit, a CNA told her that R3 was lying on the floor already. According to E17 (CNA) on 8/26/11 at 1:43 PM, the last time she saw R3 was during lunch time while R3 was eating lunch in the dining room. Z1 at 10:16 AM said that their investigation showed that there is only 1 witness in the 6/6/11 incident between R2 and R3. The hospital's History and Physical dated 6/7/11 states R3 sustained a left eye injury secondary to fall. This fall resulted from R2 pushing R3 to the floor after R3 wandered to R2's room unsupervised. R3's care plan dated 5/25/11 indicated that R3 has dementia and her behaviors are manifested by wandering, pacing, roaming in and out of peer's rooms, motor agitation, verbal and physical aggression, restlessness, rummaging, and repetitive movement. During 8/23/11 interview at 3:25 PM, E2 ( Dementia Unit Coordinator ) said that R3 has long term and short term memory deficit, poor safety awareness, wanders in and out of other resident's room and rummages through their belongings, and would swing at staff when being redirected at times. On 8/23/11 between 1:33pm and 2:55pm, E8 ( nurse ), E9 ( Certified Nurse Aide / CNA ), E4 ( CNA ) and E14 ( activity staff ) all confirmed that R3 is a wanderer and has the behaviors mentioned by E2. ( CNA ) stated 8/23/11 at 2 PM, she heard that R2 can be aggressive to staff if asked to change his clothes or shower. E10 also added that R2 doesn't like to be touched. E3 ( CNA ), E4 (CNA), E10 (CNA), E17(CNA), said on 8/23/11 and 8/26/11 at 2:30 PM and 2:40pm that although R2 never says a word, R2 can be physically aggressive if being redirected by staff, has pushed staff and residents without provocation, does not like to be touched, resists care (showers and changing clothes). E3 added that she is sure that R3 had been in R2's room before because R2's room is close to R3's room. On 8/23/11 at 3:25 PM, E2 ( Dementia Unit Coordinator ) stated the she was not even aware that R2 had pushed staff and residents alike in the past with and without provocation and was physically aggressive. No one has reported these behaviors to her since she started working in the facility. Despite staff knowledge of R2's physically aggressive behaviors towards staff and other residents, there was no indication of any facility assessment, care plan or monitoring plan to ensure that wanderers like R3 do not go into rooms of aggressive residents like R2. There was no plan to supervise R2's behaviors. Per facility's policies and procedures on Aggressive Residents states: "If an episode of Resident to Staff aggression occurs, the staff should report the situation immediately to the head nurse manager or designee, whose responsibility will be to advise the Administrator. If this incident occurs, the facility is going to evaluate precipitating / triggering circumstances regarding the incident, institute a 24 hr monitoring of the residents, complete an incident report, and document the incident and resident's response to immediate interventions in the clinical notes. The aggressive resident's existing care plan will be modified to reflect the resident's potential for future aggressions. The facility should reassess the resident, the interventions, and any other potentially triggering situations on a regular basis". Per the facility's policy and procedure on Resident to Resident Aggression states: "The above procedure will be implemented in case a resident to resident aggression occurs". None of these procedures were done when E4, E3, E10 and E17 experienced, heard, and witnessed physical aggression from R2. E17 also did not report witnessed pushing of other residents in the past by R2. This resulted in R2's physical aggression not being assessed and addressed. All of these failures were prior to 6/6/11 altercation between R2 and R3 which resulted to R3's facial and eye injury. The facility took the following steps to correct the Immediate Jeopardy : 1) R2 was sent out to the hospital immediately on 6/6/11 for evaluation. Upon his return to facility, R2 was placed on 1:1 supervision. During this readmission, he declined physically and is unable to be physically capable of physically pushing other residents. R3 was sent out to the hospital immediately and did not return to the facility. 2) The Administrator, Assistant Director of Nursing ( ADON ), and Dementia Unit Coordinator immediately inserviced staff starting 6/7/11, reporting aggressive and wandering behaviors to the nurse, Dementia Coordinator, or to he Dementia Activity Director immediately. Any resident identified with wandering and aggressive behaviors will be placed on 1:1 monitoring, stop signs will be placed on the aggressive residents' doors, and they will be separated to prevent altercation. Their care plans will be updated immediately. This inservice was completed on 6/8/11. Part of this inservice was to redirect wanderers away from aggressive residents at all times. 3) The Dementia Unit Coordinator and her staff reassessed all aggressive and wandering residents on 6/7/11 and completed the assessment on 6/8/11. Beginning 6/8/11, screening for residents with aggressive and wandering behaviors upon admission was implemented. The list of these identified residents was given to staff on 6/8/11 and will be kept in a binder at the nurses station, and will be updated as needed. The list will be discussed during morning meeting and will be monitored on a daily basis. 4) New staff were trained on supervision policy beginning 6/8/11 by the Administrator, DON, ADON, and Dementia Unit Coordinator. 5) As part of the QA process, inservicing by the Administrator, DON, ADON, and Dementia Unit Coordinator was started for the month of June on 6/7/11 and will be done monthly. The nurse consultant will monitor that this is done on a monthly basis. 6) The nurse consultant will also review all allegations of altercations on file on a quarterly basis, to see if facility is compliant with plan of correction put in place.

A. Based on observation, closed record review, interview and fall policy/procedures. the facility failed to reassess, analyze the circumstances of falls, develop interventions, re-evaluate for the effectiveness of interventions, attempt alternative interventions and supervise residents to minimize the risks for fall and serious injuries for 4 of 30 residents (R12, R13, R29 and R30) in the sample. R29 was found on the floor unresponsive. Z1 was called and R29 was transported to Z2 hospital, upon arrival Z1 reported that R29 was unresponsive and in cardiac arrest. Finding Includes: 1. R29 is a [AGE] year old female with a [DIAGNOSES REDACTED]. The minimum data sets dated [DATE] denoted section C1000 score 1 ( moderate independent - some difficulty in new situations only). The Nurses notes dated: [DATE]- Late entry - Resident stated that while sitting on the chair feeling sleepy and slid down on the floor. [DATE] - 7:30 pm - Resident observed on the floor in the second floor dining room stated that she was trying to sit on the chair her feet went to sleep then she missed the chair. [DATE] 12:30 pm - Received call from program stated the resident fell on a sitting position. [DATE] - Resident observed on the floor in hallway area near a resident's room hit her head at the door. Stated that her legs gave up on her and lost her balance. Resident sent out to hospital. [DATE]- 3:30am readmitted resident from Z3 hospital via Z4 ambulance on a stretcher with [DIAGNOSES REDACTED]. Follow up with Z5. Non-weight bearing up per wheelchair. [DATE] - 11:20 am Resident noted on the floor face down and unresponsive. Vital Signs not able to be obtained. Cardiac Pulmonary Resuscitation started and 911 called. 11:25 am 911 in facility. Resident remains unresponsive at this time. CPR in progress. 11:35am - Resident left the facility to the hospital. The Incident/Accident report dated [DATE] at 6:30 pm stated," Resident observed on the floor in the hallway area near a resident patient room hit head at the door." There were no incident/accident report for the following dates [DATE], [DATE], [DATE] and [DATE]. The Z1 hospital history and physical dated [DATE] stated," Patient presents to emergency department per ambulance services from nursing home as full arrest. Patient down 25 minutes. Patient arrived unresponsive. CPR in progress. R29 on [DATE] at 11:20am in the large dining room on second floor stated," Her wheelchair got caught between the bed. She slip and fell . I got up and called E3 (Assistance Director of Nursing). She was unresponsive and died . She was face down. She was not responsive. They were suppose to help with dressing, put into wheelchair and bathroom. They help put her bras and clothing on." Surveyor ask R29 did any one come back to help her. R33 stated," No, they did not come back to assisted her. She was alert. She was not sick. When I saw her fall out of wheelchair. I went to her . She was not breathing." Surveyor ask R33 did the chair alarm go off. R33 stated," No, I did not hear any alarm." E3 on [DATE] at 10:45 am in the conference room stated," I was on the floor returning a chart. Her roommate which was R33, she approach me at the nurse station. She said that R29 was on the floor. So, I went into the room. Observed R29 on the floor by bed. I called her name. She was unresponsive. I attempted to rolled her over. She was to heavy for me. I went to door scream for help. E21 came into the room and called code. E21 grasp the crash cart with other staff. We call 911. She had a soft mole cast with ace wrap. She was ambulatory before the fall. She was found on the floor by bed face down." E25 (Nurse) on [DATE] at 3:30 pm in conference room stated," Her leg was in a soft cast. She tried to get bathroom. She had a previous fall moving around without wheelchair. Resident observed on the floor in hall area near a resident room. She hit her on the door." E23 (Nurse) on [DATE] at 3:45am in conference room stated," She fell on [DATE]. We send her to the hospital. When she came back with a brace on the leg." Surveyor attempted to interview direct care staff that were working those days that R29 was falling. All stated did not remember what happen. Surveyor attempted to interview the direct care staff that were on the schedule to work. The assessment or care plan was not revised or updated to prevent from further injury. 2. R30 is a [AGE] year old female with [DIAGNOSES REDACTED]. The Minimum Data Sets dated [DATE] denoted Section B/4 Cognitive and Decision Making score 2 ( Moderately impaired - decision poor, cues/supervision required. The Nurse Notes for R30 dated [DATE] 6:00pm - Per patio monitor, R30 was walking on ice and snow outside, lost her balance and fell backward to the ground landing on her bottom. Per monitor resident did not bump her head. [DATE] at 6:30 am received patient laying on the floor. Patient stated she fell while walking. Patient was unsteady gait , lethargic and diaophetic. Send to Z6 hospital emergency. [DATE] 6:30 am Received patient laying on the floor. Patient stated she fell while walking. Hitting back of the head. Patient was unsteady gait, lethargic and diaophestic. Send to Z7 hospital emergency. [DATE] at 4:00 pm Per Social services at Z7 hospital. R30 bring admitted to hospital with [DIAGNOSES REDACTED]. Interview with family member on [DATE] at 1:30pm stated the resident expired. Surveyor attempted to interview direct care staff that were working on [DATE] that R29 fell . All stated did not remember what happen. Surveyor attempted to interview the direct care staff that were on the schedule to work. The facility did not present any reassessment or revised/updated care plan. 3. R12 was observed on [DATE] at 11:30am, standing at the entrance of her room. R12 [DIAGNOSES REDACTED]. She was alert and oriented X 2. The Minimum Data Sets dated [DATE] denoted C1000 Cognitive Skills for Decision Making score was 3 (Severely impaired - never/rarely made decision). The incident dated: [DATE] at 1:45 pm Observed resident on floor on buttock in dining room. Stated she leaned over and she fell out of chair. [DATE] 11:45 pm Resident was observed sitting on floor beside bed by the certified Nurse Aide. The care plan was not updated or revised to prevent further incidents. 4. R13 was observed in his bed watching television on [DATE] at 11:45 am. R13 was oriented x2. R13 [DIAGNOSES REDACTED]. The Minimum Data Sheet dated [DATE] for C-1000 indicates a score of 2(Modified independence-some difficulties with new situations). The incident dated: [DATE] at 9:30 pm received patient with large purple/ yellowish lump to right side of head. [DATE] at 8:10 pm observed lying on the floor . Asked what happened he just looked to the staff. Put back to bed. Body assessment done. No injury nor bruise noted at this time. [DATE] at 3:30 pm attempted to slide out of wheelchair unto floor. Activity aide eased resident to the floor to prevent fall. Skin tear noted to left posterior arm. [DATE] at 7:00 pm resident noted lying on floor with chair alarm attached. Abrasion / Hematoma noted to the occipital lobe. Received order to send to Z8 hospital. [DATE] at 7:30 am staff observed resident on floor pads by bed with hearing bed alarm. Resident complained of right leg and knee pain. Resident sent out to Z2 hospital. The Facility did not revise or update the care plan to prevent further falls. The Fall Program Guidelines stated," (6). Resident's identified as a fall risk will have an individualized care plan to address the contributing factors that place them at risk, goals to prevent falls/injury, and interventions/approaches to promote safety of the resident. (8). The care plan will be reviewed and revised as necessary by the interdisciplinary team quarterly, with a change of status, and when there is an incident involving a fall with the resident. The facility also failed to maintain a safe environment by storing cardboard boxes next to hot dryers and not providing a crash cart to the first floor that was accessible to staff 24 hours a day 7 days a week. The findings include: During tour of the facility on [DATE] from 10:30 AM to 11:30 AM with E1 Administrator and E50 Maintenance Director observation was made of 3 large cardboard boxes being stored between two hot dryers that were in operation at the time. E1 instructed laundry staff to remove the boxes right away. Observation of the therapy room noted that the crash cart was stored inside the room. The crash cart had a wheelchair foot pedal laying on top of it. Interview with E51 Therapy Director, stated that the door is locked at all times when therapy is not in session. Interview with E1 stated that the facility will find an alternative place for the crash cart to be stored so that staff can access it at any time. The second floor crash cart was noted behind the nursing station with 2 paper hole punchers on top. Based on observation and interview, the facility failed to provide a hazard free environment for one resident (R8) in the sample. R8 had a "no lye" hair relaxer stored in refrigerator. Findings Include: 1. [DATE], during the initial tour of the 3rd floor, that started at approximately 7am with E22 (CNA), a box of "no lye" hair relaxer was observed in R8's room refrigerator. R8 is legally blind. The resident was asked who applies the relaxer to her hair? "Either the Beautician that works here or I have someone else do it."