Every finding on record at Nexus Pavilion at Belleville

Based on interview and record review, the facility failed to ensure residents are free from abuse for 4 (R1, R3, R4, R5) of 7 residents reviewed for abuse in the sample of 7.Findings include: 1. R4's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with no psychological diagnosis on admission. 7/8/2026 diagnoses including mood affective disorder and irritability and anger were added to his list of diagnoses. R4's admission Minimum Data Set (MDS), dated [DATE] documents R4 is cognitively intact and no behaviors exhibited. R4's Care Plan, dated 5/15/2026 addresses R4 is at risk for abuse. R4's Nurse's Note dated 6/16/2026 at 8:05 PM at about 2105 pm this nurse was on the phone with the hospital at the front desk when I heard a lot of yelling. This nurse witnessed a resident push the resident out of the wheelchair onto his side. The resident hit the side of his head, and I noticed a scratch to his right elbow. The resident is on blood thinners, so I called 911 and EMS to send to the hospital. I asked the resident what happened. The resident stated The MotherF***** knocked me out my wheelchair, I'm sick of these people, NWAs and I'm pressing charges. The resident started being combative and verbally abusive to staff. One of the staff members took the resident outside to possibly calm down. The resident came back into the building and to his room. The resident had c/o of an headache so I administered PRN Tylenol. This nurse assessed the resident. Made sure to keep the residents separate. This nurse called 911 at 2110 pm. The police or EMS did not arrive, so I called 911 again at 2150 pm. At 2210 pm the resident requested PRN Tylenol. This nurse administered PRN Tylenol. The police arrived at 2225 PM, and EMS arrived at 2230 pm. The resident left the facility at 2235 pm.R4's After Visit Hospital Summary dated 6/17/2026 documented diagnoses: fall, closed head injury, strain of neck muscle and rib pain. On 7/31/2026 at 2:43 PM V14, LPN (Licensed Practical Nurse) stated she was the night nurse assigned to both (R3) and (R4) on 6/16/2026. V14 recalled she heard yelling in the main dining room, and she was on the phone at the main entrance desk and then she observed (R4) self-propel in his wheelchair and (R3) came up behind him and tipped his wheelchair backwards and (R4) fell out of his wheelchair and laid on his right side. V14 stated she didn't know why the residents were in an altercation, but she recalled they were both yelling and cursing at that time. V14 stated she separated the residents and assessed them. V14 stated (R4) sustained a skin tear on his right elbow and he was sent to the local emergency room for further evaluation. V14 stated (R3) refused a skin assessment and refused to tell her what they were arguing about. V14 stated she recalled (R3) told her, I did what I had to do. V14 stated she reported the resident-to-resident altercation to administration when it occurred, and she wrote a statement and placed it under the Administrator's door the same night. V14 stated she called the police and they arrived to the facility but no police report number was provided. On 7/31/2026 at 9:55 AM (R4) sat up in a wheelchair in the day area and was alert and stated he has had three altercations with (R3) and he is sick of him hitting him. (R4) stated the first incident occurred in June 2026 (exact date unknown.) (R4) stated he was friends with (R3) and he tapped him on the shoulder in the dining room to ask if he wanted to play chess with him and (R3) turned around and hit him with a water pitcher on the side of his head. (R4) stated he left the dining room immediately and he self-propelled in his wheelchair to his room and (R3) chased him out of the dining room and tipped his wheelchair backwards and he fell to his right side hitting his head on the hard floor. (R4) stated he had no idea what (R3) was so mad at him for and he was very angry that (R3) treated him like that. (R4) stated he was assessed by a nurse who witnessed (R3) throw him out of his wheelchair and he was transferred to the local emergency room where he was diagnosed with a head injury, rib pain and neck strain. (R4) stated the second incident (exact date unknown) occurred right in front of V16, Former Administrative Assistant. (R4) stated (R3) was again mad at him and he was yelling and cursing at him and (R3) kicked him in his stump of his left leg. (R4) again stated he didn't know why (R3) was being so mean to him and at that point he wanted to hurt (R3) but he hasn't done so yet. (R4) stated the third incident really sent him over the edge. (R4) was told by staff that he was moving downstairs and he was ok with that. (R4) stated while he was in the process of moving V18, Social Service Director had to keep (R3) from entering (R4's) room by putting her body in his doorway. (R4) stated V18 instructed (R3) to go to his room, and he did at that time. (R4) stated he self-propelled down the hall and (R3) ran out of his room and punched him in his right ear. (R4) stated V18 came running down the hall because she heard the loud noise and them yelling. (R4) stated he doesn't know why (R3) is so mean to him and he just wants this abuse to stop. 2. R3's Undated Face Sheet, documents he was initially admitted to the facility on [DATE]. No psychological diagnosis. R3's Quarterly MDS, dated [DATE] documents cognitively intact and no behaviors. R3's Nurse's Note, dated 6/16/2026 at 21:05 PM this nurse was on the phone with the hospital at the front desk when I heard a lot of yelling. This nurse witnessed the resident push another resident out of the wheelchair onto his side. This nurse made sure to keep the residents separate. This nurse called 911 at 21:10 PM. The resident refused to go to the hospital. On 7/31/2026 at 9:20 PM R3 lay in bed, he was alert and stated he had to snap on another resident (R4) because that m*********** called him out of his name including a n***** so he hit him upside his head a few times, tipped him out of his wheelchair once and kicked him. R3 stated he doesn't have issues with (R4) anymore because he moved downstairs and they aren't friends anymore. R3 stated he didn't have exact dates of the fights. R3 stated staff including administration told him to keep his hands to himself. The Facility's Serious Final Injury Report, dated 6/16/2026 at 2:30 PM documents (R3) and (R4) had a resident-to-resident altercation. Detailed Incident Summary documents the investigation documents (R4) gently placed his hand on (R3's) shoulder to ask him if he wanted to play chess. (R3) was startled and began speaking loudly and they began an altercation. Residents were immediately separated and 1:1 support was given to both residents. A nursing assessment immediately performed showed no injuries. Residents and other staff were interviewed with no negative findings. The Facility's Serious Final Injury Report, dated 7/21/2026 at 2:30 PM documents (R3) and (R4) had a resident-to-resident altercation. Detailed Incident Summary documents the investigation included interviews with both residents and direct care staff. The residents' medical records were reviewed to evaluate diagnoses and any contributing cognitive or communication impairments. The investigation revealed that both residents have significant communication barriers and medical diagnoses that affect their ability to effectively communicate and interpret interactions with others. During the incident, the residents were passing one another in the hallway when incidental physical contact occurred. Interviews with staff and available witnesses indicated the contact appeared accidental and occurred as the residents attempted to pass each other, rather than as the result of an intentional physical altercation. Staff responded promptly, separated the residents, completed head-to-toe assessments, and monitored both residents. No injuries were identified. Social services to provide 1:1 support as needed and new interventions in place care plan reviewed and revised to meet resident's needs. 3. R1's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including anxiety and bipolar. R1's Quarterly MDS, dated [DATE] documents he has moderate cognitive impairment and no behaviors. R1's Progress Notes dated 7/12/2026 no documentation of a resident-to-resident altercation. On 7/31/2026 at 3:30 PM R1 lay in his bed and stated he recalled another resident hit him in the nose and he went to the hospital. R1 stated he couldn't recall exactly what occurred but that the other resident punched him on this nose. 4. R5's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including bipolar, dementia, psychosis and paranoid personality disorder. R5's Quarterly MDS dated [DATE] documents not cognitively intact and no behaviors. On 7/31/2026 at 3:45 PM R5 was observed sitting up in his wheelchair in the hallway. R5 stated he recalled he and (R1) were roommates at the time and (R1) always had the heater on blast and he was so hot so he threw all the clothes including (R1's) clothes out of the closet onto the floor and (R1) entered the room and he saw the clothes on the floor and attempted to pick them up and he got made and (R1) punched him twice on his head and he hit (R1) on the nose. R5 stated they are no longer roommates, and he is happy about that because he isn't so hot all the time. R5's Electronic Medical Record dated 7/11/2026 or 7/12/2026 no documentation a resident-to-resident altercation occurred. On 7/31/2026 V9 (LPN) stated at 11:52 AM a resident-to-resident altercation between (R1) and (R5.) V9 stated she worked day shift the day the altercation occurred. A CNA (Certified Nurse Aide) reported to her that she heard yelling and hitting in (R1's) and (R5's) room and (R1's) nose was bleeding. V9 stated she entered the resident's room and assessed both residents immediately and noted all the residents clothes were on the floor and both residents were yelling. V9 stated (R1's) nose was bleeding and he stated, He (R5) hit me! V9 stated she then asked (R5) what occurred and he stated (R1) hit him twice on the top of the head first. V9 stated (R1) was transferred to the local emergency room for evaluation. V9 stated V12 was the CNA that heard the altercation and reported it to her. V9 stated she reported the altercation to administration when it occurred, and no one asked her to write a statement. V9 stated she didn't know why there was no nurse progress note documented when the altercation occurred because she always documents where there is an altercation between residents. On 7/31/2026 at 12:04 PM, V12 CNA stated she was working the day (R1) and (R5) had an altercation. V12 recalled she was in the hall outside of their room and she heard hitting sounds and yelling and when she entered the room she observed (R1) was holding his nose. V12 stated she reported the altercation to V9 immediately and V9 assessed the residents. The Facility's Serious Injury Incident Initial Report, dated 7/12/2026 documents reporting an alleged physical interaction between two residents. Both residents assessed. Local Police, MD (physician) NP (nurse practitioner) and POA (power of attorney) notified. Final to follow. The Facility's Serious Injury Incident Final Report, dated 7/11/2026 documents an investigation determined that, at the time of the incident (R1) reported feeling warm and was removing belongings from his closet, throwing items onto the floor. (R5) observed the belongings on the floor and attempted to pick them up. As (R1) turned around, incidental contact occurred between the two residents, resulting in both residents making contact with one another. Interviews with staff and residents, along with a review of the circumstances, did not identify any evidence of intentional aggression, abuse or willful physical harm by either resident. The interaction was determined to be an unintended event influenced by both residents' underlying cognitive and behavioral impairments. On 8/4/2026 at 11:27 AM V1, Administrator stated she didn't have information about the resident-to-resident altercations prior to 7/19/2026 as her first day as the administrator was 7/20/2026. V1 stated it was her understanding that all altercations were verbal in nature, not physical. V1 stated when staff witness or a resident reports abuse to staff she expects staff to report it to her immediately so she could report it the allegation of abuse to IDPH and start an investigation. V1 stated she is not psychic and cannot report or investigation abuse allegations if staff or residents do not report it to her. V1 stated she feels there are too many hands in these abuse investigations and she doesn't know who's done what at this point. V1 stated there was never any proof of resident-to-resident altercations between (R3) and (R4) because there was no bruising or redness assessed after the residents skin was assessed by a nurse. On 8/7/2026 at 10:32 AM V1 stated the facility does not have an investigation policy that documents what should be included in an investigation but that all investigations, including resident to resident allegations are expected to include statements from residents that were involved in the altercations, staff and/or residents that witnessed the altercation and additional residents to ensure residents are safe. The Facility's Untitled Policy reviewed 9/2017 documents this policy affirms the right of our residents to be free from abuse or mistreatment. This facility therefore prohibits abuse and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse and mistreatment of residents. This will be done by immediately protecting residents involved in identified reports of possible abuse and mistreatment, implementing systems to promptly and aggressively investigate all reports and allegations of abuse and mistreatment and making necessary changes to prevent future occurrences and filling accurate and timely investigative reports. This facility is committed to protecting our residents from abuse land mistreatment by anyone including facility staff and other residents.

Based on observation, interview and record review, the facility failed to follow their abuse policy to ensure all residents are free from abuse for 4 (R4 R3, R1, R5) of 7 residents reviewed for abuse in a sample of 7.Findings include: 1. R4's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with no psychological diagnosis on admission. 7/8/2026 diagnoses including mood affective disorder and irritability and anger were added to his list of diagnoses. R4's admission Minimum Data Set (MDS), dated [DATE] documents R4 is cognitively intact and no behaviors exhibited. R4's Care Plan, dated 5/15/2026 addresses R4 is at risk for abuse. On 7/31/2026 at 9:55 AM (R4) sat up in a wheelchair in the day area and was alert and stated he has had three altercations with (R3) and he is sick of him hitting him. (R4) stated the first incident occurred in June 2026 (exact date unknown.) (R4) stated he was friends with (R3) and he tapped him on the shoulder in the dining room to ask if he wanted to play chess with him and (R3) turned around and hit him with a water pitcher on the side of his head. (R4) stated he left the dining room immediately and he self-propelled in his wheelchair to his room and (R3) chased him out of the dining room and tipped his wheelchair backwards and he fell to his right side hitting his head on the hard floor. (R4) stated he had no idea what (R3) was so mad at him for and he was very angry that (R3) treated him like that. (R4) stated he was assessed by a nurse who witnessed (R3) throw him out of his wheelchair and he was transferred to the local emergency room where he was diagnosed with a head injury, rib pain and a neck strain. (R4) stated the second incident (exact date unknown) occurred right in front of V16, Former Administrative Assistant. (R4) stated (R3) was again mad at him and he was yelling and cursing at him and (R3) kicked him in his stump of his left leg. (R4) again stated he didn't know why (R3) was being so mean to him and at that point he wanted to hurt (R3) but he hasn't done so yet. (R4) stated the third incident really sent him over the edge. (R4) was told by staff that he was moving downstairs and he was ok with that. (R4) stated while he was in the process of moving V18, Social Service Director had to keep (R3) from entering (R4's) room by putting her body in his doorway. (R4) stated V18 instructed (R3) to go to his room and he did at that time. (R4) stated he self-propelled down the hall and (R3) ran out of his room and punched him in his right ear. (R4) stated V18 came running down the hall because she heard the loud noise and them yelling. (R4) stated he doesn't know why (R3) is so mean to him and he just wants this abuse to stop. 2. R3's Undated Face Sheet, documents he was initially admitted to the facility on [DATE]. No psychological diagnosis. R3's Quarterly MDS, dated [DATE] documents cognitively intact and no behaviors. On 7/31/2026 at 9:20 PM R3 lay in bed, he was alert and stated he had to snap on another resident (R4) because that m*********** called him out of his name including a n***** so he hit him upside his head a few times, tipped him out of his wheelchair once and kicked him. R3 stated he doesn't have issues with (R4) anymore because he moved downstairs and they aren't friends anymore. R3 stated he didn't have exact dates of the fights. R3 stated staff including administration told him to keep his hands to himself. 3. R1's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including anxiety and bipolar. R1's Quarterly MDS, dated [DATE] documents he has moderate cognitive impairment and no behaviors. R1's Progress Notes dated 7/12/2026 no documentation of a resident-to-resident altercation. On 7/31/2026 at 3:30 PM R1 lay in his bed and stated he recalled another resident hit him in the nose and he went to the hospital. R1 stated he couldn't recall exactly what occurred but that the other resident punched him on this nose. 4. R5's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including bipolar, dementia, psychosis and paranoid personality disorder. R5's Quarterly MDS dated [DATE] documents not cognitively intact and no behaviors. On 7/31/2026 at 3:45 PM R5 was observed sitting up in his wheelchair in the hallway. R5 stated he recalled he and (R1) were roommates at the time and (R1) always had the heater on blast and he was so hot so he threw all the clothes including (R1's) clothes out of the closet onto the floor and (R1) entered the room and he saw the clothes on the floor and attempted to pick them up and he got made and (R1) punched him twice on his head and he hit (R1) on the nose. R5 stated they are no longer roommates, and he is happy about that because he isn't so hot all the time. The Facility's Untitled Policy reviewed 9/2017 documents this policy affirms the right of our residents to be free from abuse or mistreatment. This facility therefore prohibits abuse and mistreatment of residents.The Facility's Reporting of Unusual Occurrences Policy reviewed 9/2018 documents purpose: to provide a process for the reporting unusual occurrences. All unusual incidents/occurrences will be recorded in the Risk Management Portal of the EHR (Electronic Health Record). This includes incidents/occurrences to residents. Entries into the Risk Management Portal are completed for all resident-to-resident altercations and abuse allegations. The resident will be evaluated after the incident/occurrence and documented in the EHR. Once the staff nurse has evaluated the resident, a report is completed and entered into the risk management portal. The DON (Director of Nurses) and Administrator will review all incidents. If the incident report is serious, by which there is a serious harm or injury to the resident a final summary completed in 7 days.

Based on observation, interview and record review the facility failed to document a thorough investigation of allegations of abuse for 5 (R4, R3, R1, R5, R2) of 7 residents reviewed for abuse in a sample of 7. Findings include: 1. R4's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with no psychological diagnosis on admission. 7/8/2026 diagnoses including mood affective disorder and irritability and anger were added to his list of diagnoses. R4's admission Minimum Data Set (MDS), dated [DATE] documents R4 is cognitively intact and no behaviors exhibited. R4's Care Plan, dated 5/15/2026 addresses R4 is at risk for abuse. 2. R3's Undated Face Sheet, documents he was initially admitted to the facility on [DATE]. No psychological diagnosis. R3's Quarterly MDS, dated [DATE] documents cognitively intact and no behaviors. The Facility's Serious Final Injury Report, dated 6/23/2026 at 2:30 PM documents (R3) and (R4) had a resident to resident altercation. Detailed Incident Summary documents the investigation documents (R4) gently placed his hand on (R3's) shoulder to ask him if he wanted to play chess. (R3) was startled and began speaking loudly and they began an altercation. Residents were immediately separated and 1:1 support was given to both residents. A nursing assessment immediately performed showed no injuries. Residents and other staff were interviewed with no negative findings. Review of the abuse investigation no staff statements documented and no resident statements including (R3) and (R4) were documented. Did the investigation confirm question was documented N/A: (not applicable), no documentation if the facility substantiated abuse, neglect or misconduct. The Facility's Serious Final Injury Report, dated 7/21/2026 at 2:30 PM documents (R3) and (R4) had a resident to resident altercation. Detailed Incident Summary documents the investigation included interviews with both residents and direct care staff. The residents' medical records were reviewed to evaluate diagnoses and any contributing cognitive or communication impairments. The investigation revealed that both residents have significant communication barriers and medical diagnoses that affect their ability to effectively communicate and interpret interactions with others. During the incident, the residents were passing one another in the hallway when incidental physical contact occurred. Interviews with staff and available witnesses indicated the contact appeared accidental and occurred as the residents with attempted to pass each other, rather than as the result of an intentional physical altercation. Staff responded promptly, separated the residents, completed head to toe assessments, and monitored both residents. No injuries were identified. Social services to provide 1:1 support as needed and new interventions in place care plan reviewed and revised to meet residents needs. Review of the abuse investigation no staff statements documented and no resident statements including (R3) and (R4) were documented. On 7/31/2026 at 9:55 AM R4 stated V16, Former Administrative Assistant witnessed R3 kick him in his left leg/stump. R4 stated was told by staff that he was moving downstairs. R4 stated while he was in the process of moving V18, Social Service Director had to keep R3 from entering his room by putting her body in his doorway. R4 stated V18 instructed R3 to go to his room and he did at that time. R4 stated he self propelled down the hall and R3 ran out of his room and punched him in his right ear. R4 stated V18 came running down the hall because she heard the loud noise and them yelling. R4 stated he reported to V18 that R3 hit him on the right ear at that time. On 8/4/2026 at 9:48 AM V16, Former Administrator's Assistant stated sometime in July 2026 (exact date unknown) he witnessed (R4) and (R3) were in a verbal altercation. V16 stated he separated the residents at that time and he was standing between the two residents when (R3) stood up out of his wheelchair and kicked (R3's) left leg stump. V16 stated he reported the altercation to V1, Administrator and wrote a statement and left it on V1's desk. V16 stated V1 should have started an abuse investigation because it was a resident to resident altercation. On 7/31/2026 at 2:55 PM V18, Social Services Director stated the same day R4 was moving downstairs to ensure his safety from R3. V18 stated a few minutes later V18 was talking to staff on the same hall and she heard a loud smacking sound and heard R4 yelling. V18 stated she ran to see what occurred and R4 was holding his right ear and yelled that R3 just punched him on the right ear, V18 stated she reported the incident to V1 and thought it was taken care of. V18 stated she wasn't asked to write a statement of what occurred. R4's Electronic Medical Record, dated 7/22/2026 documents he moved rooms on this date. R4's Acute Care Note, dated 7/25/2026 at 9:33 AM V15, Nurse Practitioner documented chief complaint: right ear pain following an altercation. Resident evaluated following an incident involving another facility resident. Resident was hit on the right ear with a plastic water pitcher. Resident reports right ear pain.On 8/7/2026 11:15 AM V15, Nurse Practitioner stated she had discussed R3's and R4's multiple resident to resident altercations and V1, Administrator was aware that R4 alleged R3 hit him on the right ear sometime in July 2026 and she assumed it was investigated per the facility's abuse and investigation policiesReview of the facility abuse investigations no documentation of staff witnessing R3 kick R4 and no documentation of R4 alleging R3 hit him on the right ear. 3. R1's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including anxiety and bipolar. R1's Quarterly MDS, dated [DATE] documents he has moderate cognitive impairment and no behaviors. 4. R5's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including bipolar, dementia, psychosis and paranoid personality disorder. R5's Quarterly MDS dated [DATE] documents not cognitively intact and no behaviors. The Facility's Serious Injury Incident Final Report, dated 7/11/2026 documents an investigation determined that, at the time of the incident (R1) reported feeling warm and was removing belongings from his closet, throwing items onto the floor. (R5) observed the belongings on the floor and attempted to pick them up. As (R1) turned around, incidental contact occurred between the two residents, resulting in both residents making contact with one another. Interviews with staff and residents, along with a review of the circumstances, did not identify any evidence of intentional aggression, abuse or willful physical harm by either resident. The interaction was determined to be an unintended event influenced by both residents' underlying cognitive and behavioral impairments. The abuse investigation was reviewed and no staff statements were documented in the investigation. Did the investigation confirm question was left blank, no documentation if the facility substantiated abuse, neglect or misconduct. On 7/31/2026 at 1:35 PM V1, Administrator stated all abuse investigations were complete that were provided to the IDPH surveyor. 5. R2's Undated Face Sheet documents he was admitted to the facility on [DATE].R2's admission MDS, dated [DATE] documents R2 is cognitively intact and had verbal behaviors (threatening, screaming and cursing) directed towards others occurred 1 to 3 days. On 8/6/2026 at 8:55 AM R2 sat up in his wheelchair in his room. R2 was alert and stated a few weeks ago he called 911 because staff threw him out of his wheelchair near the front entrance and it was witnessed by all the staff there that day including V23, Psychiatric Rehabilitation Services Clerk (PSRC) but that was the only staff name he could recall. On 8/6/2026 at 1:02 PM V22, CNA stated she worked day shift on 7/18/2026 and she pulled R2 back away from the main entrance door and R2 yelled she treated him roughly at that time. V22 stated she knows she should have reported to the nurse that R2 stated she was rough with him but she didn't want to get in trouble and 2 staff witnessed the incident and they knew she didn't hurt R2. Review of the facility's abuse investigations no abuse investigation dated 7/18/2026 was documented regarding R2 reporting staff treated him roughly was documented. On 8/6/2026 at 10:43 AM V18, Social Services Director stated R2 reported to her on 8/5/2026 that staff whipped him away from the door really fast in his wheelchair and staff were rough with him and that was why he was discharged to the emergency room in July 2026. V18 stated she didn't report it to administration because she had a care plan meeting after she spoke to him and R2 told her that his health insurance was going to call a complaint in for it. On 8/4/2026 at 11:27 AM V1, Administrator stated she wasn't aware R2 alleged staff hurt him or that staff witnessed R3 kick R4 or that R4 alleged R3 hit him on the right ear. V1 stated when staff witness or a resident reports abuse to staff she expects staff to report it to her immediately so she can start an investigation and collect written statements from staff and residents. V1 stated she is not psychic and cannot investigate abuse allegations are not reported to her. V1 stated the facility does not have a investigation policy that documents what should be included in a abuse investigation but she expects staff and resident written statement and if the staff are interviewed over the phone staff can document the phone interview and if residents are not able to write out a statement she documents the statement for the resident to ensure the investigation is complete. The Facility's Reporting of Unusual Occurrences Policy reviewed 9/2018 documents purpose: to provide a process for the reporting unusual occurrences. All unusual incidents/occurrences will be recorded in the Risk Management Portal of the EHR (Electronic Health Record). This includes incidents/occurrences to residents. Entries into the Risk Management Portal are completed for all resident-to-resident altercations and abuse allegations. The resident will be evaluated after the incident/occurrence and documented in the EHR. Once the staff nurse has evaluated the resident, a report is completed and entered into the risk management portal. The DON (Director of Nurses) and Administrator will review all incidents. If the incident report is serious, by which there is a serious harm or injury to the resident a final summary completed in 7 days.

Based on interview and record review, the facility failed to report allegations of abuse within the regulatory timeframe reviewed for reporting abuse in a timely manner for 2 (R4, R3) of 7 residents reviewed for abuse in a sample of 7. Findings include: 1. R4's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with no psychological diagnosis on admission. 7/8/2026 diagnoses including mood affective disorder and irritability and anger were added to his list of diagnoses. R4's admission Minimum Data Set (MDS), dated [DATE] documents R4 is cognitively intact and no behaviors exhibited. R4's Care Plan, dated 5/15/2026 addresses R4 is at risk for abuse. On 7/31/2026 at 9:55 AM R4 stated one day (exact date unknown) (R3) was mad at him and he was yelling and cursing at him and (R3) kicked him in his stump of his left leg and it was witnessed by V16, Former Administrative Assistant. A few days later R4 stated staff let him know that he was moving downstairs. R4 stated while he was in the process of moving V18, Social Services Director had to keep (R3) from entering R4's room by putting her body in his doorway. R4 stated V18 instructed (R3) to go to his room and he did at that time. R4 stated he self propelled down the hall and (R3) ran out of his room and punched him in his right ear. R4 stated V18 came running down the hall because she heard the loud noise and them yelling. R4 stated he reported to V18 that (R3) just hit him on the right ear and he wanted to press charges. R4's Electronic Medical Record census report documents he moved to a downstairs room on 7/22/2026. R4's Electronic Medical Record no documentation of a resident to resident altercation that day and no documentation of a resident to resident altercation regarding R4 alleging (R3) kicked him on his left leg. 2. R3's Undated Face Sheet, documents he was initially admitted to the facility on [DATE]. No psychological diagnosis. R3's Quarterly MDS, dated [DATE] documents cognitively intact and no behaviors. R3's Electronic Medical Record no documentation of alleged resident to resident altercations between R3 and (R4) regarding R3 kicking (R4) on the left leg/stump or hitting (R3) on the right ear while (R3) was self propelling to move downstairs on 7/22/2026. On 7/31/2026 at 9:20 AM R3 lay in bed, he was alert and stated he had to snap on another resident (R4) because that m*********** called him out of his name including a n***** so he hit him upside his head a few times and kicked him. R3 stated he doesn't have issues with (R4) anymore because he moved downstairs and they aren't friends anymore. R3 stated he didn't have exact dates of the fights. R3 stated staff including administration told him to keep his hands to himself. On 7/31/2026 at 2:55 PM V18, Social Services Director stated the same day (R4) was moving downstairs to ensure his safety from (R3) (R4) was in his room packing his stuff and she was talking to him in his room and observed (R3) wheeled to (R4's) room and was cursing and yelling at (R4.) V18 stated she stood in the doorway of (R4's) room and (R3) stood up and was giving (R4) the middle finger and they were both yelling at one another. V18 stated she redirected (R3) to his room and she thought the residents were separated. V18 stated a few minutes later V18 was talking to staff on the same hall and she heard a loud smacking sound and heard (R4) yelling. V18 stated she ran to see what occurred and (R4) was holding his right ear and yelled that (R3) just punched him on the right ear, V18 stated she reported the incident to V1 and thought it was taken care of. V18 stated she wasn't asked to write a statement of what occurred. R4's Census dated 7/22/2026 documents he moved to the downstairs room on this date. On 8/4/2026 at 9:48 AM V16, Former Administrator's Assistant stated sometime in July 2026 he witnessed (R4) and (R3) were in a verbal altercation. V16 stated he separated the residents at that time and he was standing between the two residents when (R3) stood up out of his wheelchair and kicked (R3's) left leg stump. V16 stated he reported the altercation to V1, Administrator and wrote a statement and left it on V1's desk. V16 stated V1 should have reported the resident to resident altercation because it is abuse and it is required to be reported to IDPH (Illinois Department of Public Health.)Review of the facility's abuse investigations were reviewed, and no abuse investigation was documented regarding V16 witnessing (R3) kick (R4) left leg/stump or that R3 hit R4 on the right ear on 7/22/2026. R4's Acute Care Note, dated 7/25/2026 at 9:33 AM V15, Nurse Practitioner documented chief complaint: right ear pain following an altercation. Resident evaluated following an incident involving another facility resident. Resident was hit on the right ear with a plastic water pitcher. Resident reports right ear pain.On 8/7/2026 11:15 AM V15 , Nurse Practitioner stated she had discussed R3's and R4's multiple resident to resident altercations and V1, Administrator was aware that R4 alleged R3 hit him on the right ear sometime in July 2026 and she assumed it was reported to IDPH within the regulatory timeframe. On 8/4/2026 at 11:27 AM V1, Administrator stated she wasn't aware that staff witnessed R3 kick R4 or that R4 alleged R3 hit him on the right ear. V1 stated when staff witness or a resident reports abuse to staff she expects staff to report it to her immediately so she could report it the allegation of abuse to IDPH within the required timeframes. V1 stated she is not psychic and cannot report abuse allegations to IDPH if staff or residents do not report it to her. The Facility's Reporting of Unusual Occurrences Policy reviewed 9/2018 documents purpose: to provide a process for the reporting unusual occurrences. All unusual incidents/occurrences will be recorded in the Risk Management Portal of the EHR (Electronic Health Record). This includes incidents/occurrences to residents. Entries into the Risk Management Portal are completed for all resident-to-resident altercations and abuse allegations. The resident will be evaluated after the incident/occurrence and documented in the EHR. Once the staff nurse has evaluated the resident, a report is completed and entered into the risk management portal. The DON (Director of Nurses) and Administrator will review all incidents. If the incident report is serious, by which there is a serious harm or injury to the resident it will be reported to IDPH within 24 hours and a final summary completed in 7 days.

Based on interviews, and record reviews, the facility failed to ensure that medication was ordered and available in a timely manner for 6 of 6 (R5, R58, R84, R77, R101, R113), residents in a sample of 42. This failure resulted in R84 not receiving his pain medication and experiencing increased and excruciating pain, R5 not receiving a muscle relaxer and experiencing phantom cramps and pain in left lower extremity amputation. It also resulted in R58 not receiving is clonazepam and experiencing increased anxiety and chest pain resulting in transportation to hospital. Findings include:1 .R84's Care Plan, dated 7/29/2025, documents that PAIN: Resident has an alteration in comfort Advanced Disease process, Chronic physical. It also documents 7/29/2025 Administer pain meds and treatments as ordered. R84's Minimum Data Set, dated [DATE], documents that R84 is cognitively intact. R84's Physician Order, dated 7/25/2026, documents Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 1 tablet by mouth every 6 hours related to Unspecified Fracture of unspecified wrist and hand. R84's Medication Monitoring/Control Record, dated from 4/17/2026 to 5/30/2026 documents Tramadol not administered on 4/17 at 6p, 4/27 at 12AM, 5/12 at 6p, 5/20 to 5/26, 5/27 12AM, 6AM, and 12PM, 5/28, 5/29 12AM and 6AM, 5/30 12AM and 6AM On 6/9/2026 at 3:30 PM R84 stated that he has a lot of pain. R84 stated that he took Vicodin in the past and that helped his pain. R84 stated that he now takes Tramadol and that takes the edge off but doesn't take the pain away. R84 stated that when he doesn't get the pain medicine his pain is excruciating. R84 stated that he was out of the Tramadol recently for about a week. R84 stated that they gave him a pill here and there, but his pain level was so high it didn't really touch it. R84 stated that the last pill was given on a Tuesday and his medication didn't come in until Sunday. R84 stated that he was raised to be a man and not complain about pain. R84 stated that it doesn't change the fact that he was in excruciating pain. R84 stated that it was hard to get out of bed. On 6/10/2026 at 9:40 AM V22, Licensed Practical Nurse, stated that R84's medication had run out. V22 stated that it's an insurance issue. V22 stated that R84 takes the tramadol 4 times a day. V22 stated that when the medication is sent it is sent in 30 cards which run out within days of receipt, and the process must start all over which causes delays. V22 stated that R84 was originally admitted to a different hall and came with a brace to his wrist. V22 stated that R84 was on Norco but because of R84's cirrhosis of the liver the medication had to be discontinued. V22 stated that R84 is challenging to read. V22 stated that with psych patients the missing of 2 doses of medication can cause a problem. 2. R5's Physician Order sheet documents Cyclobenzaprine HCl Oral Tablet 5 MG (Cyclobenzaprine HCl) Give 5 mg by mouth every 8 hours as needed for muscle relaxer related to COMPLETE TRAUMATIC AMPUTATION AT KNEE LEVEL, LEFT LOWER LEG, Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 25 mg by mouth one time a day for Elevated Blood Pressure-Not given. Levothyroxine Sodium Oral Tablet 88 MCG (Levothyroxine Sodium) Give 88 mcg by mouth in the morning related to HYPOTHYROIDISM On 6/9/2026 at 8:47 AM observed R5's medication pass. R5's Levothyroxine Sodium Oral Tablet 88 MCG and Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG scheduled for 8AM was unavailable and not given. R5 requested Cyclobenzaprine HCl Oral Tablet 5 MG. The medication was not administered. When asked why R5's did not receive her medication V17, LPN, stated that she did not administer the medication. The medicine was not in the medication cart and needed to be reordered. On 6/10/2026 at 2:44 PM When asked if R5's medication came in V17 stated that if the Cyclobenzaprine HCl Oral Tablet 5 MG was in the cart she did not see it to administer it. On 6/11/2026 at 10:32 AM R5 stated that she has been doing good with her behaviors and anxiety. R5 stated that when she doesn't get her medication as ordered she starts to have increased anxiety and starts having behaviors that are hard to control. R5 stated that any medication that missing causes her anxiety to go crazy. R5 stated that they run out of her medication routinely or tell her it's not available. R5 stated that she is a bilateral amputee of her left leg. R5 stated that she has severe phantom pain. R5 stated that she requests her muscle relaxer twice a day because she has excruciating cramps in her left leg and toes. R5 stated that the pain can be unbearable. R5 stated that yesterday she had phantom cramps and spasms in her legs and toes. 3. R101's Care Plan, dated 3/4/2026, documents that Infection: Resident has active infection, osteomyelitis. It also documents Administer medications as ordered. R101's Progress Note- Follow Up note, dated 5/13/2026, documents [AGE] year-old male with PMHx of diabetes, plantar surface ulcerations, non-small cell lung cancer. Presents with 1 week of worsening redness and pain on the dorsal aspect of the left foot. Treated for a wound with infection on the ball of the left foot about 1 month ago. Diagnosed with acute hematogenous osteomyelitis (left ankle/foot) and cellulitis (left lower limb). No fever or chills reported. Physical exam: Erythema on dorsal left foot, callus/lesion on ball of left foot, no edema in lower extremities Assessment/Plan:M86.072 - ACUTE HEMATOGENOUS OSTEOMYELITIS, LEFT ANKLE AND FOOTMRI on 03/03/2026 showed a soft tissue wound extending to the joint space with increased marrow signal in the first metatarsal, sesamoids, and great toe phalanges, flexor hallucis tenosynovitis, and joint effusion with synovitis, suspicious for acute infection. X-ray on 03/02/2026 revealed osteolysis of the left great toe sesamoid, suggestive of bone involvement. CRP was elevated at 27.4 mg/L and ESR at 31 mm/hr on 03/02/2026, indicating ongoing inflammation. CBC on 04/30/2026 showed mild anemia (Hgb 9.8 g/dL) and albumin was low at 3.1 g/dL. Blood cultures drawn on 03/02/2026 showed no growth. Erythema on dorsal left foot and callus/lesion on ball of left foot, no edema in lower extremities observed on 05/06/2026. Wound care personnel reported wound to left foot increasing in diameter compared to measurements on admission. IV Cefepime dose and IV Daptomycin dose started on 05/10/2026 and 05/11/2026, respectively. R101's Physician Order Sheet documents 5/10/2026 Cefepime HCl Solution 2 GM/100ML Use 2 gram intravenously every 8 hours for Foot Infection for 5 Weeks. 5/10/2026 Daptomycin Intravenous Solution Reconstituted (Daptomycin) Use 540 mg intravenously one time a day for Foot infection for 5 Weeks Give 540mg. (8mg/kg) weight is 148. R101's Medication Administration Record (MAR) documents 5/10/2026 Cefepime HCl Solution 2 GM/100ML Use 2 gram intravenously every 8 hours for Foot Infection for 5 Weeks. Scheduled for 6AM, 2PM, 10PM. The MAR documents blanks for 6AM on 5/11, 5/12, 5/14, 5/16, 5/18, 5/20, 5/21, 5/22, 5/23, 5/25, 5/29, 5/30. It documents for 2PM- 5/13, 5/15, 5/16, 5/19, 5/26, 5/27. It documents for 10 PM 5/10, 5/11, 5/13, 5/15, 5/16, 5/17, 5/19, 5/20, 5/21, 5/24, 5/28 and 5/29. R101's Medication Administration Record documents 5/10/2026 Daptomycin Intravenous Solution Reconstituted (Daptomycin) Use 540 mg intravenously one time a day for Foot infection for 5 Weeks Give 540mg. (8mg/kg) weight is 148. Scheduled for 8:00 AM documents blank 5/13, 5/15, 5/16, 5/19, and 5/27. On 6/11/2026 at 11:27AM R101 stated that he does not receive his IVs as ordered. R101 stated that sometimes he gets them and sometimes he doesn't. R101 stated that his infection is in his bone and if he doesn't receive his treatment the infection will not go away. R101 stated that it scares him because they are supposed to make sure he gets it. R101 stated that he goes out on leave, but he can wait if they are going to do his IVs. R101 stated that the infection can kill him and cause him to lose more of his foot. R101 stated that this is what was explained to him at the hospital when his toe was amputated. On 6/11/2026 at 12:05 PM V4, Infection Preventionist, stated that she is over the antibiotic program. V4 stated that R101 is receiving 2 antibiotic therapy related to infection in wound. V4 stated that R101 is supposed to receive the medication as prescribed. V4 stated that she has become aware of the blanks in R101's MAR. V4 stated that the blanks indicate that the medication was not administered. V4 stated that the LPN's are assigned to the hall but the RN is responsible for the IV infusion. V4 stated that she is not sure if the medication was administered and not signed off or if it wasn't given. V4 stated that she can't verify if the medication was given. On 6/11/2026 at 12:12 PM V1, Administrator, stated that she was not aware of R101 not receiving his medication except when R101 came to V1 and told V1 that he had not received his IV medication. V1 stated that at that time she questioned her Director of Nursing. V1 stated that if the RN gave the medication, it would be signed off. On 6/11/2026 at 12:13 PM V3, Regional Nurse Consultant, stated that what should have happened is the medication was missed the physician should have been notified and new order received. V3 stated that if the RN administered the medication, it would be signed off. The facility's PHYSICIAN IV ORDERS Policy, dated May 2022, documents that the purpose of this policy is to provide guidelines for IV medication orders to be consistent with principles of safe and effective order writing so that all prescribed medications are administered safely and accurately. 4. R58's admission Record, not dated, documents that R58 was admitted to facility on 3/25/2026 with a diagnosis of Anxiety. R58's Care Plan does not address R58's anxiety. It does document 4/13/2026 R58 demonstrate a significant mood distress/ depression related to a diagnosis of depression. R58's Minimum data Set (MDS) dated [DATE] documents R58 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 15. R58's POS documents 5/29/2026 clonazepam Oral Tablet 0.5 MG (Clonazepam) *Controlled Drug* Give 0.5 mg by mouth every 12 hours as needed for anxiety for 14 Days. R58's Psychiatric Note, dated 6/4/2026 at 3:25 PM documents follow up for depression and anxiety. R58's note documents Clonazepam 0.5mg tab every 12 hours as need for 14 days. R58's Nurses Notes, dated 6/6/2026 at 11:51 AM, documents that Note Text: Resident requests Clonazepam for increased anxiety. Resident has order for 0.5mg q 12 hours but medication has not been delivered from pharmacy. Call placed to pharmacy and informed pharmacy is awaiting a new Rx (prescription) from the MD (doctor). Call placed to Provider on call and detailed message left. Resident given support and is stable at this time. Resting in bed with call light in reach. R58's Nurses Notes, dated 6/6/2026 at 6:00 PM, documents that Note Text: Resident called 911 and requested EMS (emergency medical service) transfer him to ER (emergency room) for evaluation of chest pain. EMS to facility and informed this nurse that resident called with request for transfer to ER. Bedside assessment performed with EMS, Vital signs stable 98.9 - 81 - 20 -143/76 - 100% room air. Resident reports chest pain, mid chest, feels like a rock is sitting on my chest. Call placed to Provider on call and detailed message left. R58's Medication Monitoring/Control Record, received date 5/8/2026, documents last dose administered 6/3/2026 at 10:42 PM. R58's Medication Monitoring/Control Record, received date 6/9/2026, documents first dose administered 6/9/2026. R58's after visit summary dated 6/8/2026 documents reason for visit: chest pain and abdominal pain. R58's after visit summary documents diagnosis; Benzodiazepine withdrawal, hypokalemia, chest wall pain. The after-visit summary documents pick up these mediations at Walgreens; Clonazepam On 06/08/2026 at 10:40AM R58 stated he is supposed to get clonazepam as needed every 12 hours for anxiety. R58 stated has not had any medication available since last Thursday. R58 stated he went out to the emergency room (ER) over weekend. R58 stated he was given medication and IV fluids for dehydration. R58 stated he has taken the medication for 20 years and he needs the medication. R58 stated the ER physician had called in a script to Walgreens and as of today still does not have the medication. R58 stated I am doing horrible. On 6/8/2026 at 10:31AM V7 Licensed Practical Nurse (LPN) stated they are out of medications over here. This is an MI facility, and the residents don't have their medications. V7, LPN stated R58 does not have any clonazepam. On 06/10/2026 at 1:03 PM V28, psychiatric nurse practitioner stated she was not aware that R58's clonazepam was not available. V28 stated R58 could experience withdrawals from not having the medication. V28 stated not having medication available could increase R58's anxiety. R58 stated sometimes residents have reported to her their medications are not available. V28 stated she would expect medications to be administered as ordered. 06/10/2026 at 3:10PM V1 administrator stated she was aware that R58 did not have his medication. V1 stated the script was sent to pharmacy. V1 stated the pharmacy that provides services usually has a 24 hour turn around or they can do an emergency run. V1 stated the nursing staff can also utilize the emergency medication dispenser at the facility. V1 stated would expect residents to have medications as ordered. The facility's SPECIFIC MEDICATION ADMINISTRATION PROCEDURES 11B15: INFUSION THERAPY MEDICATION ADMINISTRATION: MEDICATIONS ADDED TO INFUSION PREPARATIONS BY THE NURSE IN THE FACILITY. Purpose To provide for the safe, accurate, and effective administration of parenteral medications directly into the vascular system. Procedures: A. Obtain infusion therapy medication. E. Complete Infusion Therapy Solution/Additive label and place on IV bag or bottle. 5. On 6/9/26 at 9:25 AM, V11, LPN, was observed passing medications to R77. V11 opened the Vitamin D3 bottle, got a capsule out and put it on top of the dirty cart, then used her bare hands to pick it up and put it into the medicine cup. V11 then put the medicine cup on top of another cup of meds inside the top drawer of the medication cart, both seen unlabeled with no resident name. V11 left to get something to mix the medications in, came back and opened the drawer and picked up one of the medicine cups and crushed the pills, then mixed them with yogurt. V11 stated they are out of apple sauce and pudding, so she has to use yogurt to mix the medications in. V11 then administered R77's medications to him. On 6/11/26 at 1:15 PM, V1, Administrator, stated I would expect the nurses to maintain infection control and safe administration of medication practices while administering medications to residents. The facility's Oral Medication Administration Policy, dated 5/2022, documents in part Perform hand hygiene when beginning a med pass, or when contact with resident is expected or has occurred. For solid medications: I) Pour or push the correct number of tablets or capsules into the souffle or plastic cup, taking care to avoid touching the tablet or capsule, unless wearing gloves. 6.R113's Facesheet with a print date of /10/26, documented he was admitted to the facility on [DATE] with diagnosis of, in part, anxiety disorders and major depressive disorder. R113's MDS dated [DATE] documented he was cognitively intact. R113's Psychiatry/Med-Management Follow Up Evaluation Note dated 5/26/26 at 8:58 PM documented, . R113 reports passive suicidal ideation for three months. R113 denies plan or intent for suicide. R113 has safety planning and will tell staff if his symptoms worsen. R113 does not attend group activities. R113 states he prefers to be alone. R113 reports constant worrying. Will increase sertraline to 200mg (milligrams) daily and monitor symptoms . R113's MAR (medication administration record) for May 2026 documented he was administered 150 mg of sertraline on 5/26/26 through 5/31/26. R113's MAR for June 2026 documented he was administered 150 mg of sertraline 6/1/26 through 6/10/26. R113's Summary Report documented on 3/12/26 an order to start Sertraline HCl (hydrochloride) oral tablet 50 mg give 3 tablets by mouth one time a day related to other specified anxiety disorders. On 6/8/26 at 10:11 AM, R113 stated he is supposed to get 150 mg of Zoloft (sertraline) in three 50 mg tablets, but a lot of the agency nurses will come in and not realize this then give him just one tablet so he's only getting 50 mg then. R113 stated he sometimes doesn't get it at all and the next day he starts to feel more depressed and anxious. R113 stated Zoloft helps with his suicidal thoughts also but currently doesn't have any. R113 stated he sometimes will get negative thoughts also. On 6/10/26 at 8:31 AM, R113 stated they were supposed to increase his Zoloft and haven't done that yet and doesn't know why. R113 stated his depression, anxiety and passive suicidal ideations have not improved if anything they have remained the same. R113 stated if someone were to ask him if he cared that he would die the next day he would respond saying he couldn't care either way. R113 stated he's had those thoughts for 20 years now. R113 stated he feels like he has fallen through the cracks here and they've overlooked him because he is more independent but wishes he wouldn't have to be so on top of everything for them to make sure he is getting the care he needs. On 6/10/26 at 12:57 PM, V28 (Psych Nurse Practitioner/NP) stated she wanted to increase R113's Zoloft to 200 mg after seeing him on 5/26/26 with a goal to decrease or improve his symptoms of anxiety, depression, and passive suicidal thoughts. V28 stated she was not aware R113 had not had his increased dose of Zoloft yet. V28 stated she expects orders to be followed as recommended by her. V28 stated it is a concern he did not get his increased dose, and he risked staying at his baseline symptoms with no improvement. On 6/10/26 at 1:14 PM, V1 (administrator) and V3 (regional nurse consultant) both stated they expect orders to be followed as written for medications. The facility's Oral Medication Administration Record, revised on 2018, documented the procedure involved reviewing and confirming medication orders for each individual resident on the Medication Administration Record prior to administering medication to each resident.

Based on interview, observation, and record review, the facility failed to identify and treat pressure wounds for 2 of 3 residents (R4, R9) reviewed for proper wound care in the sample of 42. This failure resulted in R4 having new skin issues that were not identified nor treated. The findings include: 1. R4's admission Record, dated 6/9/26, documents R4 was admitted to the facility on [DATE] with medical diagnosis of Encephalopathy, Schizophrenia, Anxiety disorder, Delusional disorder, Major Depressive Disorder, Post-Traumatic Stress Disorder (PTSD), Paranoid Personality Disorder, Alzheimer's disease, Fibromyalgia, Cerebral Infarction without residual deficits, and Hypertension. R4's Care Plan, dated 5/27/22, documents R4 is at risk for skin issues related to the use of psychotropic medication, and Psoriasis. It continues 1/20/23: R4 is at risk for skin complications related to (r/t) Keratoconus and Psoriasis, Blister Left Heel. Blister Left Lower Leg Resolved. Eschar Right Heel. Stage 2 Pressure Left Buttock. Stage 2 Pressure Right Buttock. Interventions: Ensure adequate food and fluid intake, monitor weights and labs, notify MD (medical doctor) of abnormal findings, assess and document of progress of areas weekly, 12/4/23: Educate resident on MD orders for wound care, educate resident on the risks of infection and poor healing r/t non-compliance, 9/18/24: Prednisone TID (3 times a day) x 3 days, Eucerin cream r/t Psoriasis/ chronic rash, 4/16/26: Observe and assess regularly, protect elbows and heels if being exposed to friction, protect heels. R4's Minimum Data Set (MDS), dated [DATE], documents R4 has a moderate cognitive impairment and requires substantial/maximal assistance for activities of daily living (ADLs). R4's Weekly Skin Assessment, dated 5/4/26, documents R4 had pressure wound to right heel with measurements 5.0 CM (centimeters) length, 6.0 CM width, and 0.1 CM depth with a suspected Deep Tissue Injury (DTI). R4 had a stage II pressure wound to his right buttock with measurements 1.0 CM length, 1.0 CM width, and 0.1 CM depth. R4 also had a stage II wound to his left buttock with measurements 0.5 CM length, 1.0 CM width, and 0.1 CM depth. R4's Weekly Skin Assessment, dated 5/11/26, documents R4's skin is W/D/I (warm/dry/intact). There was no further skin assessment completed until 6/8/26. R4's Weekly Skin Assessment, dated 6/8/26, documents R4's skin is W/D/I with no new skin issues noticed or reported. R4's Physician Order (PO), dated 5/8/26, documents Triad Hydrophilic Wound Dress External Paste (Wound Dressings). Apply to Both Buttock topically every 8 hours as needed for skin redness. R4's PO, dated 4/14/26, documents Weekly Skin Screen (Complete skin screen form if new alteration is present). Every day shift every Thursday for Routine Screening. R4's PO, dated 4/14/26, documents Betadine External Solution (Povidone-Iodine). Apply to right heel topically every day shift for to promote wound healing and apply to right heel topically every 8 hours as needed for to promote wound healing. R4's PO, dated 4/14/26, documents Triad Hydrophilic wound dress external paste (wound dressings). Apply to both buttocks topically every 8 hours as needed for skin redness. R4's PO, dated 6/10/26, documents Skin Prep wipes miscellaneous (ostomy supplies). Apply to left heel topically every day shift for skin redness.On 6/8/26 at 11:25 AM, R4 stated he has sores to his heels. soft boots on both feet. R4 stated his butt also hurts. On 6/10/26 at 8:35 AM, R4 seen in bed, soft boots on wheelchair and not on R4. On 6/10/26 at 9:32 AM, V21, Wound Care Nurse, entered to do wound care on R4. V21 stated R4 has a DTI (deep tissue injury) Pressure Ulcer on his right heel. Supplies kept in the wound cart with V21 opening each drawer to get what he needs one at a time. V21 opened cart and got a 4x4 gauze, sprayed wound cleaner onto the 4x4, and wiped R4's heel wound. The old dressing was found in R4's bed, and not on R4 and appears dirty and was undated. Soft boots were not on R4. R4's right heel had large, blackened area covering entire heel. V21 opened his cart and got another 4x4 gauze, poured Betadine onto that gauze, then wiped R4's heel. V21 got a dressing out of the cart and applied occlusive dressing to the wound. When asked about R4's left heel, V21 removed the sock and R4's entire heel appeared reddened. V21 stated We do a skin assessment every week and I was not told of his heel being red. I will let the doctor know and get some orders for it. When asked about R4's butt because R4 was complaining of it being sore, V21 rolled R4 to his right and noticed his incontinence brief saturated with stool and soaking through to the pad under him. V21 advised Certified Nursing Assistant (CNA) to provide incontinent care. On 6/10/26 at 10:02 AM, During incontinent care, R4's coccyx area and bilateral buttocks was observed to have several red areas seen. V24, CNA, stated (R4) used to have open sores to his butt, and they have all heeled. There was no notification to V21 of R4's coccyx and buttocks being red and there was no application of cream on R4's coccyx area as ordered. On 6/11/26 at 1:15 PM, V1, Administrator, stated I would expect the CNAs to report any skin issues, redness or sores, to the nurse when doing showers/baths. All skin assessments should be completed and reported to the wound nurse if applicable so he can get physician orders to care for the skin issue. I would also expect staff to put barrier creams on residents when ordered by the physician. 2 On 06/11/2026 at 9:45Am V21, wound nurse sanitized hands donned gown and entered R9's room with treatment cart. V21 stated treatment for R9 for pressure sore to R ischium is 4x4 soaked with diluted sodium hypochlorite solution, calcium alginate and bordered dressing. With R9 on left sided V21 unfastens adult diaper and pulls back to expose wound. There is no dressing in place covering wound as verified by V12 or no dressing in adult diaper, no packing present in wound. V12 stated it must have come off when they changed R9. V12 then took 4x4 soaked with diluted sodium hypochlorite solution and packed inside wound with Q-tip then pulled out, this was done 3x then placed 4x4 soaked with dakin packed inside wound then skin prep wiped around diameter of wound. V12 then place 2x2 calcium alginate dressing over top of wound and covered with dressing. R9's current face sheet documents a diagnosis in part of paraplegic, unspecified ulcer of right buttock, unspecified stage. R9's physician orders dated 5/29/2026 documents diluted hypochlorite external solution external solution applied to right ischial tuberosity everyday shift and cover with dressing; calcium alginate apply to right ischial tuberosity and cover with silicone silver dressing. R9 does not have any order documenting to pack the wound. R9's care plan dated 4/9/2026 documents skin; at risk for skin complications related to pressure ulcer R buttocks; intervention dated 4/9/2026 documents treatment as ordered. R9's MDS dated [DATE] documents R9 is cognitively intact with a BIMS of 15. R9s' MDS documents R9 is at risk for pressure sores, has an unstageable pressure ulcer. On 06/11/2026 11:05 AM V1 administrator stated she would expect dressings to be in place as ordered. V1 stated treatment to R ischium makes no sense in regards to how V12 treated the wound. The facility policy Wound and pressure management, undated, documents all residents with wounds and pressure injuries will have treatments used to aid in the healing process. All residents with wounds and pressure injuries will have an individualized treatment plan that provides the appropriate treatment to facilitate healing and that assesses and addresses risk, comorbid conditions, and the wound itself in a systematic manner.Treatment recommendations are based on the assessment of risk, comorbid conditions, the wound itself, and resident choice. They may be used to formulate the treatment plan for the resident.

Based on interview, observation, and record review, the facility failed to maintain resident safety by not following fall interventions put in place for 1 of 2 residents (R7) reviewed for resident safety in the sample of 42. This failure resulted in R7 being sent to the hospital and diagnosed with Subdural Hematoma, Temporal Fracture, and Nasal Bone Fracture. The findings include:R7's admission Record, dated 6/9/26, documents R7 was originally admitted to the facility on [DATE] with medical diagnosis of Schizophrenia, Bipolar II Disorder, Major Depressive Disorder, Type 2 Diabetes Mellitus (DM), Urinary Tract Infection (UTI), Hypertension (HTN), and an Artificial Hip Joint.R7's Care Plan, dated 9/17/18, documents R7 is at high risk for falls related to use of psychotropic medication and DX: DM II, Osteoarthritis and Hypertension, uses a walker for mobility, history of falls, and routine antihypertensive and diabetic medications. R7 often places his bed in high position. Resident has history of multiple brain bleeds r/t (related to) falling. Interventions: 9/17/18: Assess for fall risk quarterly and as needed, encourage resident to get up out of bed slowly to avoid dizziness, encourage resident to take rest breaks in between activities, monitor resident's safety during activities and anticipate needs, describe activities to resident, encourage resident to wear proper fitting shoes, evaluate for effectiveness and side effects of psychotropic medications for possible reduction in dosage or elimination of medications every 3 months and PRN (as needed), keep items frequently used by resident within easy reach to avoid overreaching, encourage resident to use call light and wait for assist, keep call light within easy reach, notify MD (medical doctor) and family of all falls or injuries, observe gait while ambulating for unsteadiness, SBA (stand by assist) as needed, provide a safe environment free from clutter or safety hazards, provide an environment with adequate lighting, free of glare. 11/16/25: Resident encouraged to use safety device to ensure safe transfers and ambulation. 12/19/25: Resident encouraged to use proper body alignment skills to avoid over reaching and falling. 2/4/26: Resident encouraged to wear proper fitting clothes. 2/16/26: Resident encouraged to keep frequently used items close on bed side table. 3/9/26: Resident encouraged to keep bed in low position to make it easier to get in and out of the bed. 3/11/26: Resident encouraged to use proper time management when needing to use the bathroom to avoid running to the bathroom. 3/21/26: Encouraged to use walker when ambulation. 4/1/26: Resident was assisted to wheelchair therapy to eval and treat for gait strengthening. 4/14/26: Resident encouraged to be seated on the edge of the bed with the back of the knees along the side of the bed. 4/18/26: Resident sent to the hospital upon return resident room moved to the top of the hall to increase supervision. 5/1/26: BCVQ (Brightly Colored Visual Que) placed in resident room to call for assistance. 5/2/26: Place resident's wheelchair out in the hallway. 6/1/26: (non-slip pad) added to residents wheelchair to assist with sliding out. R7's Minimum Data Set (MDS), dated [DATE], documents R7 has a moderate cognitive impairment and requires supervision/touching assistance for all activities of daily living (ADLs) and transfers. R7 is frequently incontinent of both bowel and bladder.The facility's fall log dated 1/8/26 through 6/8/26, documents R7 had falls on 2/4/26, 2/16/26, 3/9/26, 3/11/26, 3/21/26, 4/1/26, 4/14/26, 4/18/26, 6/1/26.R7's Fall Risk Assessment, dated 1/13/26, documents R7 was not a High Fall Risk.R7's Fall Risk Assessment, dated 2/5/26, documents R7 was a High Fall Risk.R7's Fall Risk Assessment, dated 6/1/26, documents R7 was a High Fall Risk.There were Fall Risk Assessments completed after each fall except for the 4/18/26 fall. R7's Telehealth Visit, dated 2/5/26 at 6:35 AM, documents Subjective: Chief Complaints: Resident had a fall at 10 PM last night, small skin tare to the right knee, denies pain at this time, ambulates without difficulty using a walker. No call back needed. Objective: Health Vitals: Blood Sugar: 94.0 MG (milligram)/DL (deciliter). Assessment: Diagnoses: Unspecified fall, initial encounter.R7's Nurse Practitioner (NP) Note, dated 2/11/26 at 9:38 AM, documents in part Initial Evaluation. Date of Service: 2/11/2026. Name: (R7). CC: Rehabilitation evaluation status post functional decline. HPI (history present illness): patient is a [AGE] year-old male start therapy post functional decline. Presenting with increased weakness. Last fall on 2/4. Patient sustained a skin tear to right knee. No other obvious injuries noted. On examination today patient is in his room in wheelchair. He is pleasant and alert. Breathing on room air. Denies any pain or discomfort. Abdomen soft and non-tender. To work with PT (Physical Therapy) and OT (Occupational Therapy) to increase strength, range of motion, and promote independence.R7's Nurses Note, dated 2/16/26 at 9:16 AM, documents Resident slid out of bed and onto floor reaching for his coffee. Helped into w/c (wheelchair) per therapy. This nurse witnessed resident sliding and was not in time to stop him. Resident did not hit head and did not receive any injuries. R7's NP Note, dated 3/9/26 at 5:01 PM, documents in part On today visit, staff report patient had an unwitnessed fall in room attempting to transfer himself from wheelchair to bed, no injuries noted.R7's Nurses Note, dated 3/11/26 at 3:05 PM, documents Pt (patient) had an unwitnessed fall in his bathroom due to bowel incontinence and rushing. Pt has two new abrasions one on L (left) scalp that's superficial and L shoulder abrasions that is also superficial. Both were cleaned, antibiotic ointment was applied, and a bordered foam dressing was applied to shoulder. VS (vital signs) were 123/71, 95 BPM (beats per minute), 98.1, and 18 RR (respiratory rate), 99%. Pt. denies pain or injury other than abrasions. Refuses to be sent to ED (emergency department) for evaluation despite extensive education r/t risks. Pt states he wants to go play bingo which he then did.R7's Nurses Note, dated 3/21/26 at 3:49 PM, documents This nurse was walking by resident's room when I heard a yell. As I was going into room he slid off the side of toilet to the floor. There was no walker or w/c by bathroom. Resident educated on the importance of his assistant devices. I'm sorry is all he said.R7's Nurses Note, dated 4/1/26 at 11:15 PM, documents The CNA (certified nursing assistant) was assisting the resident. The resident lost his balance and slid to the floor. The CNA told this nurse at 2315 (11:15) PM. I assessed the resident. No injuries noted. No c/o (complaint of) pain or discomfort noted. ROM (range of motion) WNL (within normal limits). VS 118/72, pulse 68, O2 (oxygen saturation) 95% RA (room air), respiration 18 and temperature 97.0. This nurse notified DON (Director of Nursing) at 2320 (11:20) PM. This nurse sent the NP a message at 00:45 AM. Will call the resident's emergency contact in the morning.R7's Nurses Note, dated 4/3/26 at 3:00 PM, documents Resident condition not improving, lethargic, malaise, no appetite, not taking in oral hydration, resident requesting to go to hospital, APRN (advanced practice registered nurse) notified, received order to send to ED for evaluation, 97.0, 86, 20, 136/70, 93%, blood sugar reading 118.R7's Nurses Note, dated 4/3/26 at 6:30 PM, documents This writer called ER (emergency room) at (Local Hospital) to get an update, per the doctor, they are keeping resident in the hospital. Resident noted with elevated WBCs (white blood cells), they are going to give him fluids and antibiotics.R7's Nurses Note, dated 4/4/26 at 4:57 PM, documents Nurse took call from (Regional Hospital) for admitting dx (diagnosis). Resident has brain bleed and UTI.R7's Nurses Note, dated 4/9/26 at 5:54 PM, documents Resident returned to facility via facility vehicle. placed in (room). resident A&O (alert and oriented) x3/4. Sustained Subdural Hematoma, Temporal Fracture, and Nasal Bone Fracture. No pain or discomfort reported. Order to continue routine meds. New order: stop Maxide, Dyazide 37.5-25 MG. Norvasc 5 MG paused until provider restarts order. Transfer- 1 assist with walker/w/c. Last BM (bowel movement) today. No new skin issues noted. NP notified at 553 PM. Plan of care continued.R7's Nurses Note, dated 4/14/26 at 6:03 PM, documents Resident was sitting on edge of bed and CNA was giving resident a straw for his juice and as she was walking out resident slid off the edge of bed onto (R) knee and bottom. Resident was then helped into w/c per three staff and area to right knee was cleaned and bandages applied.R7's Nurses Note, dated 4/18/26 at 6:27 PM, documents Summoned to room by CNA and made aware that resident had fallen. Upon assessment, resident states that he hit his head and has a bad headache. Resident neuros WNL. Able to voice concerns. Call placed to POA (power of attorney) to make aware with no answer. Call placed to DON and admin (administrator) to make aware with no answer. Spoke to on call MD. NO (new order) given to send pt out to hospital r/t fall.R7's Nurses Note, dated 4/20/26 at 3:34 PM, documents Resident admitted to (Local Hospital) Dx: Reoccurring Falls.R7's Nurses Note, dated 4/24/26 at 10:44 PM, documents Resident arrived back to facility via (Local Ambulance) and helped into bed per two EMT's (emergency medical technicians) in (resident's room).R7's Nurses Note, dated 5/2/26 at 9:45 AM, documents As writer was standing in hall passing AM medication pt yelled Please help me . Pt was lying on left side next wheelchair. PT was A/O (alert and oriented) X 1. Pt was confused and unable to arousal at all. Vital sign 80/70, 98% room air, HR 110, temp 97.6. Assessed pt had 3 hematomas noted to head. 2 was bleeding noted, and right arm was bleeding as well. Notified DON, awaiting response. Notified Admin as well, awaiting response. Notified EMS (emergency medical service) 10:02 AM. R7's Nurses Note, dated 5/2/26 at 4:00 PM, documents Pt arrived via EMS, assessed pt has 3 hematomas noted to skull area and right arm as well. Vital signs stable as well 104/68-89-18-97.5. A/OX 3-4. Educated pt he needs to call for assistance with all transfers as well. Notified DON of pt returning to facility.R7's Nurses Note, dated 6/1/26 at 9:56 PM, documents Resident slid off bed between wheelchair and bed transferring self-resident was sitting upright on his buttock, upon assessment no injury noted, moves all extremities WNL for him, staff helped resident up to his chair, resident propelled himself to the dining room, resident denies pain NP, Admin. notified will continue to monitor 98.0, 18, 125/76, 74.R7's Nurses Note, dated 6/1/26 at 10:15 PM, documents Resident slid off bed between wheelchair and bed transferring self, resident was sitting upright on his buttock upon assessment, no injury noted, moves all extremities WNL for him staff helped resident up to his chair resident propelled himself to the dining room resident denies pain NP, Admin. notified will continue to monitor 98.0, 18, 125/76, 74.R7's Hospital Record, dated 4/8/26, documents in part HPI (history present illness): Presents to the ED from facility following unwitnessed fall. Discharge Diagnosis: SDH (Subdural Hematoma). Secondary Discharge Diagnosis: Principal Problem: SDH. Active Problems: Renal Mass, Temporal bone fracture, Calvarial (skull) fracture, Nasal bone fracture, Malnutrition.On 6/8/26 at 3:20 PM, R7 was seen sitting on the side of his bed, with his wheelchair by the side of the bed. When asked about having any falls, R7 stated he has fallen too many times to count. R7 stated he fell and had a brain bleed and was sent to (regional hospital). Upon assessment of R7's room, there were no fall precaution signs posted, R7 had normal white cotton socks on, a soft cushion sitting on his wheelchair with no (non-slip pad) under or on top of the cushion, and R7's bed was in the mid-level position and not low to the floor.On 6/9/26 at 9:12 AM, R7 was seen lying in his bed, with regular white cotton socks on, his wheelchair next to his bed with no (non-slip pad) seen in the wheelchair. R7 stated he can't make it to the restroom due to no balance.On 6/10/26 at 8:43 AM, R7 was seen lying in bed, with his wheelchair on the side of his bed with no (non-slip pad) seen. On 6/11/26 at 9:26 AM, V32, CNA, stated fall risk residents typically have indicators on or around them, such as on their doors or wheelchairs. V32 stated to prevent falls, she needs to follow the fall interventions.On 6/11/26 at 1:15 PM, V1, Administrator, stated I would expect all staff to maintain resident safety and to follow all fall interventions that are put in place for residents that are a fall risk.The facility's Fall Prevention and Management Policy, dated 2/2026, documents in part This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. 1. A fall risk evaluation will be completed on admission, readmission, and quarterly, significant change and after each fall. 2. Residents at risk for falls will have fall risk identified on the interim plan of care and the ISP with interventions implemented to minimize fall risk.

Based on observation, interview and record review the facility failed to administer pain medications for 3 of 4 residents (R5, R84 and R101) reviewed for pain in the sample of 42. This failure resulted in R5 experiencing phantom pain, R84 experiencing excruciating pain in wrist and back, and R101's pain being elevated to a level 8 on a scale of 1-10 for 2 days. Findings include: 1 On 6/8/2026 at 10:27AM R101's wife stated her husband has not had his pain medication for 2 days and he needs it. R101 agreed he had not had his pain medication and needed it. R101's current face sheet documents a diagnosis in part of acute hematogenous osteomyelitis left ankle and foot, cellulitis of left lower limb, personal history of other malignant neoplasm of bronchus and lung. R101's medication administration record (MAR) dated June 2026 documents Hydrocodone-Acetaminophen oral tab 10-325mg (milligram); give one tablet every 6 hours as needed for pain with start date 6/4/2026. R101's MAR documents R101 did not receive Pain medication from 6/4/2026- 6/9/2026 at 9:30AM. R101's Minimum Data Set (MDS) dated [DATE] documents R101 cognitively intact with a Brief Interview of Mental Status (BIMS) of 15. R101's care plan dated 3/14/2026 documents pain, R101 has an alteration in comfort. R101's care plan documents intervention; administer pain meds and treatments as order, assess effectiveness of pain medication. On 6/8/2026 at 10:31AM V7 Licensed Practical Nurse (LPN) stated they are out of medications over here. V7 stated I don't understand it. On 6/10/2026 at 1:55PM R101 stated the days his pain medication was not available he was in pain in his back and would rated the pain level on a scale of 1-10 at a level 8. R101 stated the pain medication controls his pain. On 06/10/2026 at 1:03 PM V28, psychiatric nurse practitioner stated sometimes residents have reported to her their medications are not available. V28 stated she would expect medications to be administered as ordered. 2. R84's Care Plan, dated 7/29/2025, documents that PAIN: Resident has an alteration in comfort Advanced Disease process, Chronic physical. It also documents 7/29/2025 Administer pain meds and treatments as ordered. R84's Minimum Data Set, dated [DATE], documents that R84 is cognitively intact. R84's Physician Order, dated 7/25/2026, documents Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 1 tablet by mouth every 6 hours related to Unspecified Fracture of unspecified wrist and hand. R84's Medication Monitoring/Control Record, dated from 4/17/2026 to 5/30/2026 documents Tramadol not administered on 4/17 at 6p, 4/27 at 12AM, 5/12 at 6p, 5/20 to 5/26, 5/27 12AM, 6AM, and 12PM, 5/28, 5/29 12AM and 6AM, 5/30 12AM and 6AM On 6/9/2026 at 3:30 PM R84 stated that he has a lot of pain. R84 stated that he took Vicodin in the past and that helped his pain. R84 stated that he now takes Tramadol and that takes the edge off but doesn't take the pain away. R84 stated that when he doesn't get it his pain is excruciating. R84 stated that he was out of the Tramadol recently for about a week. R84 stated that they gave him a pill here and there, but his pain level was so high it didn't really touch it. R84 stated that the last pill was given on a Tuesday and his medication didn't come in until Sunday. R84 stated that he was raised to be a man and not complain about pain. R84 stated that it doesn't change the fact that he was in excruciating pain. R84 stated that it was hard to get out of bed. On 6/10/2026 at 9:40 AM V22, Licensed Practical Nurse, stated that R84's medication had run out. V22 stated that it's an insurance issue. V22 stated that R84 takes the tramadol 4 times a day. V22 stated that when the medication is sent it is sent in 30 cards which run out within days of receipt, and the process must start all over which causes delays. V22 stated that R84 was originally admitted to a different hall and came with a brace to his wrist. V22 stated that R84 was on Norco but because of R84's cirrhosis of the liver the medication had to be discontinued. V22 stated that R84 is challenging to read. V22 stated that with psych patients the missing of 2 doses of medication can cause a problem. 3. R5's Physician Order sheet documents Cyclobenzaprine HCl Oral Tablet 5 MG (Cyclobenzaprine HCl) Give 5 mg by mouth every 8 hours as needed for muscle relaxer related to COMPLETE TRAUMATIC AMPUTATION AT KNEE LEVEL, LEFT LOWER LEG, Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 25 mg by mouth one time a day for Elevated Blood Pressure-Not given. Levothyroxine Sodium Oral Tablet 88 MCG (Levothyroxine Sodium) Give 88 mcg by mouth in the morning related to HYPOTHYROIDISM On 6/9/2026 at 8:47 AM observed R5's medication pass. R5's Levothyroxine Sodium Oral Tablet 88 MCG and Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG scheduled for 8AM was unavailable and not given. R5 requested Cyclobenzaprine HCl Oral Tablet 5 MG. The medication was not administered. When asked why R5's did not receive her medication V17, LPN, stated that she did not administer the medication. The medicine was not in the medication cart and needed to be reordered. On 6/10/2026 at 2:44 PM when asked if R5's medication came in V17 stated that if the Cyclobenzaprine HCl Oral Tablet 5 MG was in the cart she did not see it to administer it. On 6/11/2026 at 10:32 AM R5 stated that she has been doing good with her behaviors and anxiety. R5 stated that when she doesn't get her medication as ordered she starts to have increased anxiety and starts having behaviors that are hard to control. R5 stated that any medication that missing causes her anxiety to go crazy. R5 stated that they run out of her medication routinely or tell her it's not available. R5 stated that she is a bilateral amputee of her left leg. R5 stated that she has severe phantom pain. R5 stated that she requests her muscle relaxer twice a day because she has excruciating cramps in her left leg and toes. R5 stated that the pain can be unbearable. R5 stated that yesterday she had phantom cramps and spasms in her legs and toes. On 06/10/2026 at 3:10PM V1 Administrator stated the pharmacy that provides services usually has a 24 hour turn around or they can do an emergency run. V1 stated the nursing staff can also utilize the emergency medication dispenser at the facility. V1 stated would expect residents to have medications as ordered. The facility policy pain management policy dated, reviewed 10/2025 document the purpose is to facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our resident's the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. The policy documents The pain management program is based on a facility-wide commitment to resident comfort. Pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following: Observing for the potential for pain Effectively recognizing the presence of pain Identifying the characteristics of pain Addressing the underlying causes of the resident's pain Developing and implementing approaches to pain management Identifying and using specific strategies for different levels and sources of pain Monitoring for the effectiveness of interventions; and modifying approaches as necessary.

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) was scheduled in the facility for at least 8 consecutive hours a day, 7 days a week. This had the potential to affect all 123 residents who reside in the facility.Findings include:On 6/10/2026 May and June 2026 staffing schedules were reviewed. The facility did not have at least 8 consecutive hours a day for the following dates: 5/4, 5/5, 5/6, 5/8, 5/13, 5/15, 5/16, 5/17, 5/18, 5/19, 5/25, 5/26, 5/28, 5/30 and 5/31.On 6/10/2026 at approximately 2:00 PM V38, Staffing Coordinator, stated that they don't always have RN coverage and are in the process of hiring nurses. V38 stated that they have an outside company that assists with obtaining staff for open shifts. The company is notified of the needs, and they assist as they can. V38 stated that they utilize the Director of Nurse's hours as well.On 6/11/2026 at 3:50 PM V1, Administrator, stated that on days that they did not have RN coverage they have nurses come in to run the IVs.V1 stated that they do not have a staffing policy and follow CMS guidelines.The Long-Term Care Facility Application for Medicare and Medicaid, dated 6/8/2026, documents 123 total residents.

Based on observation, interview, and record review, the facility failed to properly store, label, and discard expired medication. This has the potential to affect all 123 residents residing in the facility.Findings include:On 6/9/2026 at 8:28 AM the 100 Medication Cart was inspected. The medication contained:1. 1 open and partially used multidose Lantus Insulin Pen. No Name or open date on pen.2. 3 of R13's multidose Novolog Insulin Pens were open and partially used. 2 pens were open and in use without an open date. The 3rd multidose Novolog Insulin Pen was open and in use pen and had open date 4/8/2026 and exp date 5/6/26 handwritten on label of pen.On 6/9/2026 at 8:30 AM V16, Registered Nurse (RN), stated that the Lantus vial and R13's Novolog were open and in use. V16 stated that each medication should have an open date handwritten on the pens and bottles of medication. V16 stated that the medications have a shortened expiration date once open. V16 stated that the handwritten date is how they tell what the new shortened date is. V16 stated that she does not know who the Lantus belonged to. V16 stated that the medication should be in its original container, labeled with a person's name and date opened. V16 stated that expired medication or medication after the use by date should be removed from the cart and out of use.On 6/9/2026 at 8:33 AM the 100/200 hall Medication room was inspected. The medication room contained:3. 1 open bottle of Meclizine 12.5mg with expiration date of 1/26.4. Refrigerator Temperature Log dated May 2025. No other Temperature Logs observed.5. The medication room had multiple bags of open corn chips, sodas, used coffee and food containers. Dried spills on counter and floor. Floor sticky from dried spills. The refrigerator located in the 100/200 hall medication room contains the following:6. Thermometer with temperature readings of 66 degrees Fahrenheit.7. 1 open and partially used vial of Tubersol submerged in a clear fluid in a pink container. No open date and the paper labels were not legible.8. R28's open and partially used Levemir pen. No open date.On 6/9/2026 at 9:06 AM V17, Licensed Practical Nursed (LPN), stated that R28's medication is expired and should be removed from the cart and destroyed. The facility's Specific Medication Administration Procedures Injectable Medication Administration policy, dated May 2022, documents Procedures: Prepare medication - check refrigerator temp, assure label is attached, check expiration date, check vial for cracks, check that stopper is intact, check contents for discoloration, precipitation, or other unusual appearance. Write DATE OPENED and EXPIRATION DATE on container if new vial used. Refer to table of shortened expiration dates for expiration date to use.The facility's Storage of Medications policy, dated 3/2024, documents that Protocol: Storage of medications: 1. Medication and biologicals must be stored 1. Medication and biologicals must be stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. The medication supply should only be accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. 9 Medications requiring storage of room temperature are kept at temperatures ranging from 59*F to 86*F. Medications requiring refrigeration or temperature between 36*F and 46*F are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. 12. Outdated, contaminated, deteriorated medications will be moved from the Medication Carts and placed in pharmacy return bin within the Medication room. 15. Medication storage areas should be well lit, clean, and free of clutter and extreme temperatures. The Long-Term Care Facility Application for Medicare and Medicaid, dated 6/8/2026, documents 123 total residents.

Based on observation, interview and record review, the facility failed to distribute food under sanitary conditions to prevent food borne illness. This failure has the potential to affect all 123 residents in the facility.Findings include:1 On 6/10/2026 at 12:24 PM V30, Dietary Aide, ran a dishwashing cycle through the Eco Lab ES500 Dish Machine. V30 then took the Hydrion QT-40 test strips and placed them in the water in the dish machine. The strip did not change colors.On 6/10/2026 at 12:23 PM V30 stated that he performs the checks on the dishwasher. V30 stated that the Eco Lab ES500 Dish Machine Dishwasher was the only dishwasher and was used for cleaning the dishes in the kitchen. V30 stated that the dishwasher was a high heat dishwasher. V30 stated that he uses test strips to check the chemicals. V30 stated that he was not sure why the strips were not changing.On 6/10/2026 at 12:25 PM V9, Dietary Manager, stated that the strips V30 used were not the correct strips. V9 stated that the correct strips turn purple when chemical levels are correct. V9 stated that correct strips, Precision Chlorine Test Paper, were not available. V9 stated that the strips became wet and aren't useable. V9 stated that the eco lab tech did not have any extra strips for him. V9 stated that he was waiting for the correct strips. V9 stated that he does have some strips. V9 then showed strips rolled in aluminum foil. No label and not in a container.On 6/11/2026 at 8:00 AM V13, Regional Dietary Director, stated that the Dish machine was a low heat chemical dishwasher.On 6/11/2026 at 8:12 AM V9 stated that the dishwasher is tested at least daily.On 6/11/2026 at 9:19 AM V21, Licensed Practical Nurse, stated that all residents receive their food from the kitchen. The facility's Policy & Procedure Manual Policy Section: Sanitation and Food Safety TITLE: Dishwashing Machine Operation, not dated, documents Policy: Small wares may be washed and sanitized in the dishwashing machine or manually in the three-compartment sink. Procedure: Test kits with appropriate strips are used to determine the correct ppm's of the sanitizer in the final rinse. In the event that the test strip does not show the correct ppm' s, the dish aid notifies the person in charge who takes the following steps: No reusable small wares including plates, flatware, glasses, cups and trays will be used for meal service if the dishwashing machine does not meet ppm requirements as indicated by the test strip.The Long-Term Care Facility Application for Medicare and Medicaid, dated 6/8/2026, documents 123 total residents.

Based on interview, observation, and record review the facility failed to provide an accessible stairway to all residents, staff and the public; reviewed for Physical Environment. This failure has the potential to affect all 123 residents residing in the facility.Findings include:On 6/8/26 at 10:51 AM, after walking up the stairway from 500 hall to the main floor, the door did not have a handle on it, just a hole where it should be and could not be opened. No staff around to open door after knocking on it. The only way to get back up stairs was to take the elevator.On 6/8/26 at 10:52 AM, V8 licensed practical nurse (LPN) stated she doesn't know how to use the stairs, she just always uses the elevator. On 6/8/26 at 11:09 AM, V10 (Maintenance Director) stated the stairway door doesn't have a doorknob to get back on to the main floor. V10 stated they did that so residents can't use it because years ago there was a death. V10 stated that when the stairway needs to be used, staff are notified and stand at the door to open it. V10 stated the stairway door is supposed to be locked.On 6/9/26 at 9:19 AM, V1(Administrator) and V15 (Vice President of Clinical Operations) stated they were not aware the stairway door did not have a doorknob on it to get back in from downstairs.On 6/9/26 at 2:20 PM, V1 stated for emergency purposes all residents should have access to use of the stairs. V1 stated V20 (Regional Maintenance Director) came in today and looked at the door and said he was never notified of the door not having a knob on it and he was not aware until today. V1 stated V20 was going to order the new parts to fix the door today. On 6/10/26 at 8:16 AM, undated sign/plaque on elevator door documented, In case of fire do not use elevators use stairways.The facility's Resident Rights Policy revised on 11/2018 documented your facility must be safe, clean, comfortable and homelike.The Central Management Services (CMS) 671, Long Term care facility application for Medicare and Medicaid dated 6/8/26 documents a facility census of 123 residents.

Based on interview, observation, and record review, the facility failed to follow infection control practices, including wearing appropriate Personal Protective Equipment (PPE), donning gloves and performing hand hygiene when necessary for 4 of 25 residents (R4, R37, R77, R126) reviewed for infection control in the sample of 42. The findings include:1. On 6/9/26 at 9:25 AM, V11, Licensed Practical Nurse (LPN), was observed passing medications to R77. V11 opened the Vitamin D3 bottle, got a capsule out and put it on top of the dirty cart, then used her bare hands to pick it up and put it into the medicine cup. V11 then gave R77 his medications. 2. On 6/10/26 at 9:54 AM, V24, Certified Nursing Assistant (CNA), entered R4's room to provide incontinent care. R4 is on Enhanced Barrier Precautions (EBP). V24 did not do hand hygiene or don appropriate Personal Protective Equipment (PPE) prior to care. V24 failed to do hand hygiene before care, during glove changes, and after care was completed. On 6/10/26 at 10:02 AM, V25, CNA, entered to assist V24. V24 asked V25 to get him some more gloves from the box of gloves on the door, and when she opened the door to get the gloves, she brought in gloves and two isolation gowns. V25 stated Is it too late to put this on? When asked when they were supposed to put PPE on, both V24 and V25 stated Anyone on EBP, we should be putting the PPE on before we do the care. Neither CNA donned the PPE even after the discussion. 3. On 06/08/2026 at 12:08 PM V12, CNA took R126's hamburger placed her hand on the top bun and began to cut the hamburger in fourths. No hand hygiene was done prior to touching R126's hamburger. 4. On 06/11/2026 at 9:25 AM, V21 Wound Nurse put on gloves and gown, pushed the wound cart into R37's room, and got dressing supplies ready to do the wound change to R37's left gluteal fold. V21 went over and unfastened R37's incontinent brief, placed his hand on R37's left buttock, lifted the left buttock, looked at the wound (no dressing on the wound at this time), went over to the cart opened up the drawer got out a 4x4 and the wound cleanser, sprayed the wound cleanser on the 4x4 and then put the wound cleanser back in the cart, and cleansed the wound to R37's left gluteal fold with no hand hygiene or glove changes done. V21 changed his gloves, packed the wound then went to the cart, got out a clean dressing and placed the boarder gauze over the wound without changing gloves. On 06/11/2026 at 2:15 PM V1, Administrator said she would expect hand hygiene to be done appropriately during resident's care. The facility's Personal Protective Equipment (PPE), review date of 01/2020, documents Guideline: To prevent the spread of infections from residents' known to be infected or colonized with pathogens that can be transmitted by contact, droplet or airborne transmission. Procedure: 1. PPE is chosen based on the nature of the task to be completed and the type of precautions involved. 2. Preform Hand Hygiene thoroughly before beginning the procedure. 3. [NAME] PPE when entering the room as indicated and before contact with the resident in the following order: a. Gown, d. gloves. Enhanced Barrier Precautions Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing. The facility's Hand Hygiene policy, review date of 04/2026, documents General: Proper hand hygiene is necessary for the prevention and the transmission of infectious disease. Responsibility: All facility staff. Guideline: 1. Hand hygiene is done before and after resident contact, before and after any procedure, and after using a Kleenex or the rest room, before eating or handling food, when hands are obviously soiled and regardless of glove use. 2. Hand hygiene is to be done before putting on gloves and after removing gloves.

Based on interview, observation, and record review the facility failed to maintain resident dignity while eating in the dining room for 3 of 25 residents (R12, R77, R126) reviewed for resident dignity in the sample of 42. The findings include: 1. R77's admission Record, dated 6/10/26, documents R77 was originally admitted to the facility on [DATE] with medical diagnosis of Traumatic Brain Injury (TBI). R77's Care Plan, dated 11/29/22, documents R77 has potential for weight fluctuation related to good intake of meals, and he receives a snack at HS (hours sleep) daily, but he has diagnosis of Type 2 diabetes mellitus (DM), psychosis, cocaine abuse and unspecified focal TBI which may affect his intakes and/or weight. Interventions: Provide diet as ordered, he does use weighted utensils, staff assist with meal set up and feeding as needed, monitor and encourage diet compliance as needed. It continues 3/6/24: R77 at nutritional risk as disease progresses: type 2 DM and Hypertension (HTN). 11/16/25: Has had weight loss over last 3 months. 2/15/26: Has had weight loss x last 6 months, stable x 1 month. 4/12/26: Weight stable. Interventions: Provide diet as ordered, weighted utensils to be used with all meals. R77's weights have been stable each month for the past three months. R77's Minimum Data Set (MDS), dated [DATE], documents R77 has a severe cognitive impairment and requires setup/clean-up assistance for eating. R77's Physician Order, dated 1/20/26, documents Regular diet, Mechanical/Soft texture, Thin Liquids consistency. Weighted utensils for diet. R77's Physician Order, dated 10/7/24, documents Adaptive Equipment: Weight Utensils. On 6/8/26 at 12:05 PM, During the lunch observation, R77 was sitting at the dining room table in a dining room chair that was about 2-3 feet away from the table. R77's plate of food was on the table along with regular utensils with R77 unable to reach his food, and his left hand was contracted. V11, Licensed Practical Nurse (LPN), checked R77's blood sugar, pushed him close to the table, then got R77's fork and mixed all his food up together on the plate and while standing, began feeding R77. After V11 walked away, R77 was observed having difficulty using a normal utensil to pick up the food and feed himself. On 6/11/26 at 1:15 PM, V1, Administrator, stated I would expect all staff to sit while assisting residents with feeding and to provide the necessary utensils to the residents. 2. R12's Face Sheet, admission date of 03/26/26, documents R12 has diagnoses of but not limited to dementia, severe, with mood disturbance, disorientation, and Alzheimer's disease. R12's Minimum Data Set (MDS), dated [DATE], documents R12 is severely cognitively impaired, and she requires partial/moderate assistance with eating. R12's Care Plan, admission date of 03/26/26, documents Resident requires one assist with daily care related to recent falls. Resident has had a significant change in health, is unable to eat regular diet consistency, resident requires max assist with Activities of Daily Living (ADLs) and needs help eating and requires help and cuing from staff. On 06/08/2026 at 12:00 PM, V6, Restorative Aide was seen standing up and assisting R12 with her noon meal. She was seen wiping R12's face with the clothing protector. On 06/10/2026 at 12:08 PM, V29, CNA is currently standing while she is assisting R12 with her noon meal. 3. R126's Face sheet, admission date of 07/04/24, documents she has diagnoses of but not limited to need for assistance with personal care and chronic obstructive pulmonary disease (COPD). R126's MDS, dated [DATE] documents she is cognitively intact, and she requires supervision or touching assistance with eating. R126's Care Plan, admission date of 07/04/24, documents R126 has the potential for weight fluctuation related to (r/t) varied intake of meals and declining offers of alternatives offered and she has diagnoses of psychosis, bipolar disorder, schizophrenia, COPD, and emphysema which may affect her intakes and/or weight. Interventions include but are not limited to encourage intakes as needed. On 06/08/2026 at 12:08 PM, R126 was seen trying to eat her hamburger and having trouble eating it with no teeth. V12, Certified Nursing Assistant (CNA) was standing up and assisting her with her meal. On 06/11/2026 at 10:35 AM, V1, Administrator said when it comes to the staff assisting the residents with their meal, she would expect them to be sitting down when assisting them with their meal. The Illinois Long-Term Care Ombudsman Program Residents Rights, not dated, documents Your rights to dignity and respect. It also documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

Based on observation, interview, and record review, the facility failed to provide a clean homelike environment for 2 of 6 residents (R10 and R125) reviewed for environment in a sample of 42. Findings Include:1. R10's Face Sheet, print date of 06/11/26, documents R10 has diagnoses of but not limited to Parkinsonism, Type II Diabetes Mellitus, Schizophrenia, and Dementia. R10's Minimum Data Set (MDS), dated [DATE], documents R10 is severely cognitively impaired and requires some assistance with her ADLs. On 06/09/2026 at 9:05 AM, R10 said she has a lot of issues with bugs being in her room and that they are all over the place. R10 said the facility doesn't have enough towels and washcloths either. She said they don't have any toilet paper in the bathroom and no paper towels either. R10 said they don't ever put the toilet paper or the paper towel in the dispensers. On 06/09/2026 at 9:10 AM, R10's bathroom was inspected at this time. There was smeared bowel movement (BM) on the toilet seat, a smear of BM on the floor, a dirty towel lying on the floor in front of the toilet, and a large/heavy roll of toilet paper sitting on the back of the toilet. There was a roll of paper towels sitting beside the sink and the roll was almost empty. The soap dispenser was empty and a full bottle of soap that goes in the dispenser was sitting on the dresser by the sink. 2. R125's Face Sheet, print date of 06/11/26, documents R125 has diagnoses of but not limited to Chronic obstructive pulmonary disease with (acute) exacerbation, Acute Hepatitis C without hepatic coma, and depression. R125's MDS, dated [DATE], documents R125 is cognitively intact with a BIMS of 14 out of 15. On 06/08/2026 at 10:18 AM R125 said the bathroom is filthy and her floor in her room hasn't been swept up since she came to the facility. She said the toilet in her bathroom hasn't been cleaned and there is still a ring in the toilet, and she said there is also no toilet paper in there. On 06/08/2026 at 10:25 AM R125's bathroom was inspected, and the following was found; there is a ring in the toilet and dried bm in the toilet bowl. There was no toilet paper seen in the bathroom. There was a box of Kleenex on the back of the toilet. On 06/11/2026 at 10:35 AM, V1, Administrator said they are going through a change in the housekeeping management right now and they are unable to find the key for the toilet paper and paper towel dispensers, but they are working on getting that taken care of. She would expect them to be put in the dispensers. V1 said the housekeepers are to sweep, mop, empty trash, clean the bathroom daily and she would expect them to do that. The facility's policy Daily Cleaning Procedure, not dated, documents Purpose: To educate the housekeeping staff on how to properly clean/sanitize residents' room/restroom or any area in a healthcare facility. PLEASE FOLLOW THESE 6 STEPS ACCORDINGLY. 1. Check supplies A. Check hand soap B. Check paper towel C. Check toilet paper E. Check hand sanitizer 2. Empty Trash 4. Dust Mop 5. Disinfection Restroom B. Clean toilet: Clean the bowl with bowl cleaner and brush, also wipe down the toilet outside and flush toilet when done.

Based on interview, observation, and record review, the facility failed to provide a safe resident environment and protect residents from abuse for 1 of 10 residents (R2) reviewed for resident abuse in the sample of 10. The findings include: R2's admission Record, dated 6/2/26, documents R2 was originally admitted to the facility on [DATE] with diagnosis of Schizophrenia, Major depressive disorder, Anxiety disorder, Wernicke's Encephalopathy, Cocaine abuse, Hypertension (HTN), Hyperlipidemia, Falls, Anemia, and Sleep disorder. R2's Care Plan, dated 8/16/19, documents R2 has a diagnosis (DX): Schizophrenia. She is at risk for impaired social interaction, disturbed sensory perception, defensive coping and disturbed thought processes. Interventions: 1:1's with resident as needed and as resident requests, assist resident to an area that is calm, quiet and free of stimuli as much as possible if resident allows, resident is on enhanced supervision. R2's Care Plan, dated 9/1/19, documents R2 is at risk for abuse and/or neglect related to DX: Schizophrenia, Major Depression, and Cognitive impairment, psychotropic medication use, poor judgement skills. Interventions: 9/1/19: If resident becomes difficult during care, make sure resident is safe and walk away, allow resident time to calm down, then reapproach, keep resident safe from harm at all times, report any suspected abuse and/or neglect immediately to Administrator.R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a severe cognitive impairment and is dependent on staff for activities of daily living (ADLs), and supervision/touching assistance for transfers. R2's Nurses Note, dated 5/30/26 at 8:45 AM, documents Staff and resident approached this nurse and expressed that she was scratched across the face by peer. Residents separated immediately after incident occurred by staff. Resident was assessed 3 scratches notes with minor bleeding. Resident was escorted to room and face was cleaned. NP (Nurse Practitioner) and Abuse coordinator name aware of situation. Plan of care to continue. R1's admission Record, dated 6/2/26, documents R1 was admitted to the facility on [DATE] with diagnosis of Schizophrenia, Dementia, Asthma, Heart Disease, HTN, and Hyperlipidemia. R1's Care Plan, dated 1/30/26, documents R1 is at risk for abuse and neglect related currently in long term care facility and having schizophrenia, dementia, mood disturbance and anxiety. Interventions: Assess resident for abuse and neglect upon admission and quarterly, Assure resident that he/she is in a safe and secure environment with caring professionals. Explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse, CNA (certified nursing assistant), peer) and by verbalizing thoughts, needs and feelings, Assure the resident that staff members are available to help and department heads maintain an open door policy, Continue to in-service the staff about abuse and neglect, Continue to monitor medication, ADLs, status and behaviors. It continues R1 requires assist with daily care needs r/t (related to) decreased cognition, dementia and the absence of her right leg. Interventions: Assist resident with ADLs. It continues R1 is a smoker. She is at risk for smoking related injuries. She is supervised while smoking. Interventions: Educate resident on facility smoking policy and smoking safety practices, Staff will assess the resident's ability to smoke safely, Staff will supervise resident during all scheduled smoking times to ensure safe handling of cigarettes, lighters, and other smoking materials.R1's Care Plan, dated 4/29/26, documents R1 has diagnosis of Schizophrenia and may display symptoms that include but not limited to: being out of touch with reality (delusional or hallucinations), may have disorganized speech or erratic behavior, decrease in activities. Diagnosis of mental illness. Resident will stay in her room with her door closed and when staff goes in there, she will cuss you out. Interventions: Administer medications as prescribed the physician, Encourage participation in activities, Encourage participation in facility events and groups, Encourage the use of support system, Notify psychiatrist of any change in behavior. It continues R1 presents with moderate to extreme anxiety related to her mental diagnosis. Interventions: Encourage the resident to express feelings during supportive group and/or one-to one programs, Evaluate the potential factors contributing to feelings of anxiety. Work with the resident to use coping skills to eliminate anxiety, Teach the resident anxiety/stress management skills. It continues R1 presents with signs and symptoms of persistent anger towards self and others related to psych diagnosis. The resident will not let you in her room she will yell and cuss you out. Interventions: Encourage resident to utilize coping skills techniques, Encourage the resident to express feelings during supportive group and/or one to one programs, Encourage the resident to utilize anger management techniques and to seek out a staff member when anger persists. R1's MDS, dated [DATE], documents R1 has a severe cognitive impairment and requires supervision/touching assistance for most ADLs. R1's Nurses Note, dated 5/30/26 at 7:54 AM, documents Staff notified this nurse that resident was allegedly involved in an incident that occurred at the end of the 400 while waiting to smoke. Resident noted to be verbally aggressive upon arrival. Residents already separated at this time. De-escalation attempted with resident with no success. Abuse coordinator made aware, NP called and gave the order to send resident to (local hospital). Staff stayed with resident to monitor until transfer completed. (Local EMS) and (Local Police Department) arrived to transport resident. Resident left facility headed to (local hospital) at approx. (approximately) 8:30. R1's Nurses Note, dated 6/1/26 at 10:16 AM, documents Resident admitted to (local hospital) with diagnosis Schizophrenia. On 6/2/26 at 10:40 AM, R2 was seen in a tall back wheelchair with small scratches under her left eye and left chin. When asked what happened, R2 stated she had her back turned and was attacked from behind. R2 stated the resident hit her several times in the face and head and hurt her. When asked what she was doing, R2 stated she was just sitting there waiting to go smoke. When asked what happened after the incident, R2 stated the staff took her to her room and the nurse checked her out. On 6/2/26 at 12:00 PM, V1, Administrator, stated what she heard was that R1 and R2 were heading out to smoke and for some reason, R1 reached out and scratched R2 below her left eye. V1 stated R1 was sent to the hospital for her behaviors. V1 stated V11, Certified Nursing Assistant (CNA), witnessed the event and notified V5, MDS Nurse, who looked on the camera to see what happened, then he notified her. On 6/2/26 at 12:30 PM, V5, MDS Nurse, stated that V11, CNA, was with R1 and stated that R1 hit R2. V5 stated he reviewed the camera and R2 was by the vending machine and had her back to R1, they were yelling at each other, then R1 hit R2 across the face. V5 stated it really wasn't witnessed because R2 was off the camera, but you could see R1 charging towards R2, then R2 went up the hall yelling for a CNA to help her. V5 stated he questioned R1, and she denied hitting or even touching R2. V5 stated he called the NP and V1 to advise them what happened and the NP told them to send R1 to the hospital for her behaviors. On 6/2/26 at 12:45 PM, V2, Director of Nursing (DON) showed the video recording of the event that occurred on 5/30/26. This video showed R1 sitting in her wheelchair by the door that leads out to the smoking deck. R1 appears to be flailing her arms while yelling. Other residents began going down the hall to line up to smoke, along with multiple staff members, who eventually redirected the residents to head to the front door to smoke outside because they didn't have the door key to let them out. The video showed all residents and staff leaving that area except for R1 who remained sitting at the end of the hall. The video then showed R1 rolling herself across the hall and toward where R2 was sitting, then rolled herself back to her position at the end of the hall. The video then showed R2 rolling down the hall toward the nurse's desk and was met half way by V11. There were no staff seen at the end of the hall at the time when (R1) rolled herself to where (R2) was located, then rolled herself back to her original space. On 6/2/26 at 1:15 PM, V11 stated I was the only one working the hall and thought I would help everyone get outside to smoke. (R1) was already sitting at the end of the hall yelling and cursing at everyone and at no one. I didn't see (R2) get down the hall, but she usually sits around the vending machine and waits to smoke. I did hear (R1) and (R2) yelling and cursing at each other at the end of the hall, but I thought they had stopped. All the residents who came down the hall had to go back to the front to go out and smoke, but we couldn't get (R1) to go with us. (R1), (R2), and another resident (R6), were the only ones left down there. R6 always sits on the sofa by the vending machine and probably saw the whole thing. Since I was the only one on that hall, I left the area and was walking back down the hall towards the nurses desk, when I heard (R2) yelling and turned around to see (R2) coming at me and was bleeding on her face. There were no staff left at the end of the hall and if I could rethink it, I would have stayed with them. On 6/4/26 at 9:45 AM, V5 stated When that incident occurred at the end of the hall, (R1) was acting her normal expressive self by yelling out and flailing her arms around. (R1) was elevated in a loud almost different language while talking to herself. I talked to her and asked her to calm down and when I walked away from the end of the hall, I felt that (R1) was calmed down. (R2) was sitting in her wheelchair at the vending machine and I don't recall her yelling or talking because she is also loud and I would definitely know if she was. I was the one who told the staff to take all the residents to the front to smoke because of the incident, that is why they all went out front. I am not aware of (R1) and (R2) having issues with each other. I called EMS (emergency medical services) after talking with the NP (Nurse Practitioner) and they in turn called the police to respond as well. They both showed up and took (R1) to the hospital. On 6/4/26 at 9:53 AM, V13, Police Sergeant, stated I responded with another officer to the facility for a call for an aggressive resident. We always respond with the EMS for their safety. I was only told that the lady (R1) was waiting to smoke, got agitated and aggressive and needed to go to the hospital. She even got agitated with us and was pulling away from the officer almost like she was wanting to fight us. The staff didn't tell me anything about an assault, but they may have said something to the other officer (V14). Typically, the resident is usually very aggressive or physical with someone when they call us for assistance. There was no report done for the incident since it was an EMS assist. On 6/4/26 at V14, Police Officer, stated We got a call to assist EMS at the facility for an agitated female. The facility makes medical decisions for that person, and they needed her to go to the hospital. The staff told me that she was waiting to go smoke, but it was taking too long, and she didn't want to wait, so she got impatient and irritated and became aggressive. They said she was being aggressive with others, but I was not told she assaulted anyone. I was told she scratched someone but thought it was a staff member. We have been there before for aggressive residents, and we respond to keep EMS safe. There was no report made for this incident.On 6/4/26 at 11:15 AM, V1 provided her final report for the incident, dated 6/4/26, documents Administrator was notified of resident-to-resident altercation. Residents were immediately separated and 1:1 support was provided to both residents. Nursing assessment was completed on both residents. NP & responsible parties were notified of the incident. Investigation started and final report to follow. (R1), [AGE] year-old female, who has resided in the facility since 1/13/26. PMH (past medical history) Schizophrenia, hypertension, and hyperlipidemia. Unable to determine the BIMS (basic interview for mental status) score. (R1), [AGE] year-old female, who has resided in the facility since 7/31/19. PMH Major depression, HTN, and anxiety disorder. Unable to determine the BIMS score. On 5/30/26 at approximately 7:11 AM, (R1) and (R2) were at the end of the hall. (R1) was being her baseline, verbal and animated and (R2) was wheeling up and down the hall waiting for the smoke break. (V11, CNA) heard loud noises and went to inspect. Immediately separated and wheeled (R2) to (V5). (V5) directed staff to go sit with (R1) and he wheeled (R2) to her room. Performed a skin assessment. (R1) was sent to the hospital for evaluation. After review of statements and interviews, abuse cannot be substantiated. Care plans and medical record were reviewed and updated. Police did come on site, report #2026032470.On 6/4/26 at 11:50 AM, V15, Registered Nurse (RN), stated (R1) gets aggravated easily. I have seen her slap the EMS guys when they come to pick her up. She usually just wheels herself around the halls talking or yelling to herself. I have not seen her attack anyone other than the EMS guys. She does not like to be talked to. On 6/4/26 at 12:00 PM, V16, CNA, stated I see (R1) agitated a lot. She is usually talking to herself and waiving her arms around. I have seen her swing at the EMS guys when they show up for her. She has been agitated for the last couple of weeks because they moved her room and she doesn't like it. On 6/4/26 at 12:05 PM, R1 returned from the hospital and was seen rolling herself up and down the halls. When attempting to ask R1 questions, she got irritated and stated, Leave me alone and don't talk to me. then wheeled herself down the hall talking to herself. The facility's Abuse Prevention Policy, dated 9/2017, documents in part This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. This will be done by: orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse neglect, exploitation, and misappropriation of property; establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.

Based on observation, interview, and record review, the facility failed to dispose of expired medications on the medication cart when reviewed for pharmacy services in the sample of 9. This failure has the potential to affect all 29 residents residing on the 500 hall. Findings Include:On 5/13/26 at 10:20 AM, the 500-hall medications care was observed with the following expired medications noted: Oyster Shell Calcium with an expiration date of 12/11/23; Acetaminophen 325mg (milligrams) with an expiration date of 6/2025; Bisacodyl 5mg with an expiration date of 12/2024; Vitamin C 250mg with an expiration date of 3/2026; Vitamin B12 500mcg (micrograms) with an expiration date of 4/2026; Simethicone 125mg with an expiration date of 2/2026; Loperamide Hydrochloride Oral Solution 1mg/7.5ml (milliliter) with an expiration date of 10/2025; Aspirin 81mg with an expiration date of 3/2026. On 5/13/26 at 10:20 AM, V21, LPN (Licensed Practical Nurse), stated there probably are expired medications on the cart, the nurses don't always check them, and she has been off for three days and noticed some. When asked about the above expired medications, V21 looked at them and stated no one on that hallway takes those medications. On 5/13/26 at 2:25 PM, V2, DON (Director of Nurses), stated the nurse just checked the 500-hall medication cart last week and didn't find any expired medications. V2 stated the nurses check the medication carts regularly and she has just recently instructed the nurse managers to check them during rounds. V2 stated if a medication is found to be expired, they are to send it back to pharmacy, if it did not come from pharmacy or they are unable to send it back, the nurse is to dispose of it properly.The Storage of Medication Policy, dated 4/2017, documents, in part, the following: Over the counter medications will use the manufacturer expiration date, unless otherwise clinically indicated. Outdated, contaminated, or deteriorated medications should be immediately removed from stock and disposed of according to the medication disposal procedure. The 500-hall daily census report, dated 5/11/26, documents there are 29 residents residing on the 500-hall.

Based on interview and record review, the Facility failed to provide adequate supervision for a resident with a history of substance abuse in 1 of 4 residents (R2) reviewed for accidents and hazards in the sample of 9.Findings include: 1-R2's Face Sheet documents R2 was admitted to the facility on [DATE]. R2's Minimum Data Set, dated [DATE] documented R2 was moderately cognitively impaired and dependent with mobility. R2's Initial Psychiatry Evaluation Progress Note dated 4/27/26 documents R2 has a history of opioid use disorder and stimulant use disorder. R2's Care Plan dated 5/12/26 does not address R2's history of substance abuse. R2's Progress Note dated 4/20/26 at 6:59 PM documents a pipe with white appearance was found in R2's bag and discarded. R2's family was not allowed to visit, per safety protocol. R2's Progress Note dated 5/3/25 at 8:35 AM documents alcohol was found at R2's bedside. R2's Progress Note dated 5/12/26 at 11:43 AM documents R2 was suspected of being under the influence. On 5/12/26 at 10:25 AM, R2 stated he had snuff and a drink in the Facility and did not realize that was not allowed. On 5/12/26 at 10:46 AM, V2, Director of Nursing (DON), stated R2 came from the hospital with a crack pipe on admission. She thinks R2's family brought in the alcohol that was found in his room. The Facility just placed him on 1:1 supervision today. On 5/12/26 at 2:15 PM, V10, Certified Nursing Assistant (CNA), stated she was going to get R2 ready for an appointment yesterday and noticed a pipe and lighter on his stomach. He was lying back in bed and also had a plate of food resting on his chest. R2 stated it was a meth pipe and had been in his bag since admission. On 5/13/26 at 7:55 AM, R2 stated he had 1:1 supervision because he made a mistake. He stated he had illicit drugs in his bag and on Monday morning (5/11/26) he saw it and made a mistake. On 5/13/26 at 1:20 PM, V11, Psychiatric Rehab Services Coordinator (PRSC), stated on 5/11/26 they found a pipe and a lighter in R2's room. They had already searched his bag on admission after finding the first pipe. V11 spoke with R5, R2's Roommate, and he thought R2's visitors were bringing it into the Facility. It was known that R2's visitors had brought in alcohol previously. On 5/13/26 at 1:39 PM, V2 stated the Facility does not have a policy regarding supervision. On 5/13/26 at 2:18 PM, V2 stated there was nothing else the Facility could have done to prevent R2 from getting drugs and alcohol in the Facility.

Based on observation, interview and record review the facility failed to maintain an effective pest control program related to bed bugs in the facility. This has the potential to affect all 123 residents residing in facility.Findings include:1. R8's Census, not dated, documents that R8 was admitted to room [ROOM NUMBER]C on 3/13/2026. R8 was then moved to room [ROOM NUMBER]A on 3/21/2026. R8 was moved to room [ROOM NUMBER]A on 3/23/2026. R8's Minimum Data Set (MDS), dated [DATE], documents that R8 moderately cognitively impaired.R8's psychiatry/med-management initial evaluation note, dated 3/16/2026 at 11:40 AM, documents that R8 is alert and oriented x3.R8's Braden Scale for Predicting Pressure Ulcer Risk Evaluation, dated 3/16/2026 at 10:47 PM, documents Braden Evaluation: Sensory Perception: No impairment. Moisture: Rarely moist. Activity: Walks frequently. Resident has No Limitation: Makes major and frequent changes in position. Nutrition: Excellent. Friction and shear: No apparent problem. SW - BRADEN Score: 23.0 R8's Acute Care Note, dated 3/23/2026 10:03 AM, documents that Date of Service: 3/21/20026. Visit Type: Acute Care. Interval History: On today visit, patient presents with pruritic erythematous papules and excoriation over trunk of body, bilateral arms and neck, no signs of secondary infection, presentation consistent with insect bites.R8's Physician order Sheet (POS), dated 3/22/2026, documents Hibiclens External Solution 4 % (Chlorhexidine Gluconate) Apply to entire body topically one time a day for skin excoriation Apply Hibiclens to a wet washcloth or directly to skin, using enough to cover the body from the neck down, leave solution on skin for 30 seconds or greater to maximize bacterial reduction, rinse thoroughly with warm water and pat dry.R8's Nurses Notes, dated 3/30/2026 2:24 PM, documents that R8 is alert and oriented x3.On 4/6/2026 at 10:19 AM R8 stated that he was a resident at the facility. R8 stated that during his stay he saw bed bugs in his room. R8 stated that he saw them on the bed, curtain and in the drawers of the room's dresser. R8 stated that he had several bites from the bed bugs on his arms, legs, and collar bone. R8 stated that the bites were painful. R8 stated that they itched so bad that he scratched sores on his skin. R8 stated that he was in 3 rooms during his stay. R8 stated that first 2 rooms had the bed bugs. R8 stated that he saw them in both rooms.On 4/6/2026 at approximately 1:25 PM V15, Licensed Practical Nurse (LPN), stated that R8 was on the hall for a short time and then moved. V15 stated that she observed bites and scratches on R8 skin. V15 stated that they were on his feet, arms, legs. V15 stated that she performed a skin check on R8 and this is when she found the areas.On 4/9/2026 at approximately 2:15 PM V2, Director of Nursing, stated that R8 moved on 3/21/2026 due to bed bugs.2. R12's MDS, dated [DATE], documents that R12 is cognitively intact.On 4/6/2026 at 9:45 AM R12 stated that he has saw a couple of bugs in his room a few days ago. R12 stated that 1 was small and the other was fat. R12 stated that when he squished it a lot of blood came out.3. R14's MDS, dated [DATE], documents that R14 is cognitively intact.On 4/6/2026 at 9:30 AM R14 stated that the facility has bedbugs. R14 stated that he has seen them in his room. R14 stated this is why there are no privacy curtains in his room.4. R16's MDS, dated [DATE], documents that R16 is cognitively intact.On 4/6/2026 at 2:45 PM R16 stated that she has bed bugs in her room. R16 stated Like those on the curtain. R16 stated that she squeezed the others.On 4/6/2026 at 2:45 PM observe 3 bugs crawling on R16's privacy curtain. 1 bug was small and flat whitish in color. 2 small reddish brown wingless balloon shaped bugs observed on curtain. R16 grabbed the 2 large bugs and squeezed them with a red liquid oozing from the bugs. V5 entered the room and verified the bugs were bed bugs.On 4/7/2026 at 10:38 AM observed 2 small reddish brown wingless balloon shaped bugs on R17's bed. Observed multiple small reddish brown wingless balloon shaped bugs crawling on the floor, and 3 small reddish brown wingless balloon shaped bugs on R16's bed and privacy curtain.On 4/7/026 at 11:30 AM V16, Certified Commercial Applicator, stated that he has performed treatments on several rooms in the facility. V16 stated that the chemical being used is not an immediate death for the bugs. V16 stated that it can take up to 90 days for the bugs to die. V16 stated that if an immediate response is wanted then heat treatment is required. V16 stated that when called in to the facility they assess and then recommend treatment. Heat chemicals were both recommended to the facility. Heat treatment is better and quicker, but it costs more. The facility determines which treatment they want. V16 stated that bedbugs are hitchhikers and attach to other things to carry them from place to place. V16 stated that bedbugs' source of food is blood. V16 stated that bed bugs are attracted to carbon dioxide (CO2). V16 stated that when you sleep you let off a lot of CO2s in one area. V16 said the bedbugs find that area and feed. V16 stated that bedbug's meal is blood. V16 stated that bedbugs will feed on whatever gives them blood and people are one of them.The facility's Bed Bug policy, dated 6/15, documents that 3. If bed bugs are found in a resident room the following will occur. 4. All resident clothing and cloth belongings will be bagged and sent to laundry and washed at a temperature greater than 115 degrees. 5. The Pest Control Company will be notified to treat the room, as well as adjoining rooms as necessary. 6. The room will be vacated for thorough cleaning. 9. The resident will receive a full body check and physician notified of any red patches and that bed bugs were found. Treatment will be ordered as determined by physician. 10. The Infection Control Preventionist/Nurse will be notified and determine the prevention of transmission. 11. Reporting will be done to IDPH after consultation to determine if it is a cluster of cases that may indicate public health hazard.

Based on observation interview and record review the facility failed to initiate Enhanced Barrier Precautions and provide personal protective equipment for 4 of 4 (R21, R23, R24, R25) residents reviewed for infection control in the sample list of 28.Findings include: 1 On 4/7/2026 at 3:15 PM V20, Infection Preventionist, provided a list of residents on Enhanced Barrier Precautions (EBP). R21 was not listed as requiring EBP.R21's Skin Issue note, dated 4/6/2026 at 2:58 PM, documents that R21 has Skin Issue: #001: New skin Issue. Location: Sacrum. Issue type: Pressure ulcer / injury. Progress: New: new wound. Wound was present on admission. Painful: No. Staged by: Wound care clinic. Length (cm): 4 Width (cm): 3 Depth (cm): 0.3 Undermining: No. Tunneling: No. Granulation: 80%. Slough: 20%. Exudate amount: Moderate. Exudate type: Purulent: indication of pus, typically thick, yellow, green, tan or brown. Odor after cleansing: Faint. Periwound: Attached. Surrounding tissue: Fragile. Surrounding tissue: Intact. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Saturated. Dressing appearance: Intact. Dressing saturation: Moderate 26-75%. Cleansing solution: Sodium hypochlorite. Primary dressing: Calcium alginate. Other primary dressing: Skin Prep Secondary dressing: Silicone. frequency of treatment: Daily and PRN 0Skin Issue: #002: New skin Issue. Location: Left Gluteal Fold. Issue type: Pressure ulcer / injury. Progress: New: new wound. Wound was present on admission. Painful: No. Staged by: Wound care clinic. Length (cm): 2 Width (cm): 1.5 Depth (cm): 0.4 Granulation: 100%. Exudate amount: Moderate. Exudate type: Serous: clear watery fluid, which is separated from solid elements. Odor after cleansing: Faint. Periwound: Attached. Surrounding tissue: Intact. Surrounding tissue: Fragile. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Intact. Dressing appearance: Saturated. Dressing saturation: Moderate 26-75%. Cleansing solution: Sodium hypochlorite. Other primary dressing: Dakins soaked 4x4 Secondary dressing: Silicone. frequency of treatment: Daily and PRNR21's Physician Orders (POS), dated 4/6/2026, documents Dakins (1/4 strength) External Solution (Sodium Hypochlorite) Apply to Right Ischial topically every day shift for To Promote Wound Healing Apply Dakins soaked 4x4 gauze to Right Ischial then cover with dry dressing and Apply to Right Ischial topically every 8 hours as needed for To Promote Wound Healing. Silicone dressing to Sacral daily and PRN every day shift for To Promote Wound Healing and every 8 hours as needed for To Promote Wound Healing. Silicone dressing to Right Ischial daily and PRN every day shift for To Promote Wound Healing every 8 hours as needed for To Promote Wound Healing. Calcium Alginate-Silver External Pad 4 (Calcium Alginate-Silver) Apply to Sacral topically every day shift for To Promote Wound Healing and Apply to Sacral topically every 8 hours as needed for To Promote Wound Healing.On 4/7/2026 at 2:50 PM R21 stated that he has wounds and a catheter. R21 stated that staff do not wear gowns, mask when providing care for him.On 4/7/2026 at 2:53 PM R21 does not have any signage on the door, doorframe or above the door. R21 does not have any PPE outside the door, on front of the door, on back of the door, in the room or in joining bathroom. Hand hygiene dispenser in R21's room is empty. R21 observed sitting wheelchair with catheter attached to wheelchair. 2. On 4/7/2026 at 3:15 PM V20, Infection Preventionist, provided a list of residents on Enhanced Barrier Precautions (EBP). R23 was listed as requiring EBP due to Chronic Wound.R23's Wound Noted, dated 3/30/2026 Generalized wound to buttocks. It also documents 4/1/2026 documents R23 has surgical wounds to left lateral thigh, Front left knee, and Front left trochanter.On 4/6/2026 at 9:15 AM R23 does not have any signage on the door, doorframe or above the door. R23 does not have any PPE outside the door, on front of the door, on back of the door, in the room or in joining bathroom.On 4/7/2026 at 2:45 PM R23 does not have any signage on the door, doorframe or above the door. R23 does not have any PPE outside the door, on front of the door, on back of the door, in the room or in joining bathroom.3. On 4/7/2026 at 3:15 PM V20, Infection Preventionist, provided a list of residents on Enhanced Barrier Precautions (EBP). R24 was listed as requiring EBP due to Dialysis Shunt.On 4/6/2026 at 9:14 AM R24 does not have any signage on the door, doorframe or above the door. R24 does not have any PPE outside the door, on front of the door, on back of the door, in the room or in joining bathroom.4. On 4/7/2026 at 3:15 PM V20, Infection Preventionist, provided a list of residents on Enhanced Barrier Precautions (EBP). R25 was listed as requiring EBP due to indwelling catheter.On 4/6/2026 at 10:14 AM R25 does not have any signage on the door, doorframe or above the door. R25 does not have any PPE outside the door, on front of the door, on back of the door, in the room or in joining bathroom.On 4/7/2026 at 1:15 PM V3, Assistant Director of Nursing, stated that she was not sure if the facility had any residents on isolation or EBP. V3 stated that she would find out.On 4/7/2026 at 1:21 PM V22, Licensed Practical Nurse, stated that they don't have anyone on isolation or EBP precautions.On 4/7/2026 at 3:15 PM V20 stated that R23, R24 and R25 were on EBP. V20 stated that each resident should have a sign on the door and PPE available. V20 stated that the PPE is located at the nurse's station for the staff. On 4/6/2026 during tour of facility from approximately 9:15 to 11:00 AM Nurses Stations observed. No PPE observed. No containers observed.On 4/7/2026 at approximately 6:00 AM V23, CNA, stated that she was not aware of where the PPE were located. On 4/7/2026 at approximately 6:15 AM V24, CNA, stated that when entering a room on precautions the PPE should be outside the room. V24 stated that he is from agency and did not get a good report and does not know where the PPE is and have not used it entering rooms. V24 stated that he believes the signs are on the door by mistake. The facility's Enhanced Barrier Precautions (EBP), dated 10/16/2023, documents that POLICY: Our facility employs the use of Enhanced Barrier Precautions (EBP) to reduce transmission of MDROs (Multi Resistant Drug Organisms) to staff hands and clothing that employs targeted gown and glove use during high-contact resident care activities. EBP are indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: open wounds that require a dressing regardless of MRDO status, OR an indwelling medical device regardless of [NAME] status, OR colonization with an targeted MDRO/XDRO ( Extensively Drug Resistant Organisms). PROCESS: Staff utilize gown and gloves for high-contact resident care activities when residents require EBP; high contact activities may include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and Wound care: any skin opening requiring a dressing. Post EBP signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) and listing high-contact resident care activities. Ensure PPE, including gowns and gloves, are available outside of the resident room. Position a trash can inside the resident room and near the exit for discarding PPE after removal.

Based on observation, interview, and record review the facility failed to ensure residents resided in a safe environment, free from actual and potential abuse. This failure resulted in R3 who has a diagnosis of Schizophrenia, Bipolar Disorder and Depression, experience physical abuse from a staff member, injury to left eye and feeling fear, anger, and ashamed. Findings include:R3's Care Plan, dated 7/31/2025, documents that R3 is at risk for abuse and/or neglect related to Self-Isolation, psychotropic medications, hallucination/delusions, history of compulsive behavior, history of verbal and physical aggression and DX: Schizophrenia, Bipolar Disorder and Depression. It also documents If resident becomes difficult during care, make sure resident is safe and walk away. Allow resident time to calm down, then reapproach. Keep resident safe from harm at all times. 10/5/25 CNA (Certified Nurse's Assistant) was sent home for allegation, investigation started, abuse coordinator made aware, BPD ([NAME] Police Department) called out to report incident. Resident sent to hospital for eval and treatment, psychosocial follow-up to continue upon return.R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact. It also documents that R3 has not had any behaviors affecting others. No hallucinations, delusions, verbal, or physical behaviors towards others.R3's Long-Term Care Facility & IID - Serious Injury Incident and Communicable Disease Report, dated 10/5/2025 at 8:07 PM, documents that on 10/5/2025 at 7:06 PM Resident (R3) accused an agency C.N.A. (V14) of abuse. investigation to follow MD/POA/(local) Police Notified C.N.A. suspended pending investigation.R3's Progress Note, dated 10/5/2025 at 7:22 PM, documents that Nurses Notes, Note Text: this nurse was notified by nursing assistant that resident throwing water and slipped and fell resident has a hematoma darkness under left eye. resident state she had a fight with nursing asst. on hall. administrator is notified as well as family. sending resident to [NAME] memorial for eval. resident v/s (vital signs) 135/95. P (pulse)-45. R (respirations) -21 98% room airR3's Progress Notes, dated 10/6/2025 at 4:44 AM, documents that Psychotropic Notes, Late Entry: Note Text: Follow-Up Evaluation Note, Chief Complaint: Follow-up History of Present Illness: 79 yo (year old) F (female) with Bipolar Disorder and Schizophrenia Disorder. Updated obtained from patient and staff. Patient was cooperative with the during today's visit. Patient reported to psych provider that she was involved in a physical altercation with a CNA. (R3) stated, in her words, that we were fighting like cats and dogs. She reported that she threw water on the CNA, who then struck her in the eye, after which the altercation escalated. (R3) did not provide specific times for the incident. Patients continue to deny anxiety, depression, sleep disturbances, appetite changes, suicidal or homicidal ideations, or auditory or visual hallucinations. Patient is non-compliant with current medication regimen. Patient is currently being treated for insomnia, depression, and anxiety. Patient has a documented diagnosis with Insomnia, anxiety disorder unspecified, and paranoid schizophrenia. Patient has a documented diagnosis of Insomnia, Schizophrenia unspecified, bipolar disorder unspecified, MDD recurrent unspecified, and Alzheimer's disease unspecified.On 10/6/2025 at 1:36 PM, observed R3's face. Observed scratches to R3's forehead. R3's left eye was swollen with scratches and abrasions, with dried blood, ranging from the inner top eye lid to the middle of the eyelid. R3 had various shades of purple and blue discolorations to the left eye covering the upper and lower lids of the eye. R3's sclera was red, and the surrounding tissue had purple and blue discolorations.On 10/6/2025 at 1:36 PM R3 stated that stated she was beaten by a staff member. R3 stated that she saw that a chair was in the hallway, took it in her room. R3 stated that V14 started to enter her room, R3 told V14 not to and pulled the privacy curtain in the room. R3 stated that she told V14 to not to come in her (R3) room but V14 came in anyway. R3 stated that she informed V14 to get out. R3 stated that they were fighting over the chair. R3 stated that V14 kept pulling the chair away from R3. R3 stated that she then she threw water on V14. R3 stated that V14 then punched R3 in the face causing R3 to fall to the floor on her back and roll onto her left side. R3 stated that she then began to swing at V14 as she was falling to the floor and continued once on the floor. R3 stated that she doesn't know if she hit V14, but she was trying to. R3 stated that she didn't hit her head on the floor. R3 stated that V5, CNA, came to the room to see what was going on. R3 stated that the CNA told them she fell but she didn't. R3 stated that V14 hit her in the eye. R3 stated that her eye hurts, she is having pain, and her vision is blurry. R3 stated that she is old and can get a little rough, but she didn't deserve to be hit. R3 stated that it scares her because she can't defend herself. R3 stated that she is embarrassed. R3 stated that she (R3) was beat up. R3 stated that they tried to send her to the hospital, but she refused. R3 stated they were trying to make it seem as though she was crazy, and she wasn't. R3 stated that she knows what happened. R3 stated that the police came. On 10/6/2025 at 1:55 PM V5, CNA, stated that around 7:30 PM she was sitting with another resident in the room next to R3's room. V5 stated that the rooms share a wall. V5 stated that she heard what sounded like a fight and people throwing furniture. V5 stated that she could hear R3 screaming but couldn't tell what was said. V5 stated she got up and went to R3's room right away. V5 stated that when she got there, she saw R3 lying on the floor and V14 standing over R3. V5 stated that R3 told her V14 hit R3 in the eye. V5 stated that she reported it to the nurse working at that time. V5 stated that after she reported it she went back into the room next door. On 10/6/25 at 2:15 PM, V6, Licensed Practical Nurse, (LPN) stated she wasn't at the facility when the incident happened, but she saw R3's injuries and didn't think she would have gotten those from a fall. V6 stated that R3 will have episodes of psychosis but periods of being alert and oriented completely and she has been that way today so far for her. V6 stated that the CNA working was with an agency group, and she was not familiar with her. V6 stated that she was told that R3 slipped and fell. V6 stated that she was informed by V5 that it sounded like grown men fighting in the room. V6 stated she has concerns about this CNA being able to work in the facility or any facility. V6 stated R3 has her typical behaviors and when she asks to be left alone, you leave her alone and she won't be bothered; she should have known to not bother her and left the room instead.On 10/6/25 at 2:57 PM, V18, LPN, stated that she was the nurse for R3's hall last night and has a good rapport with R3. V18 stated that R3 wanted to go outside for a bit so she took her out for about 40 minutes and R3 was in good spirits during that time. V18 stated that when she took R3 back inside, R3 headed to her room and V18 went to get her laptop. V18 stated hardly any time passed and she was being told by the other nurse that R3 was on the floor. V18 stated that she went to R3's room and R3 told her that the CNA hit her, and they were fighting. V18 stated she saw R3's eye and tried to calm her down, then assessed her and started notifying the proper people. V18 stated she went to the CNA and asked her to complete a statement of what happened, V14 was so calm and just sitting in the hallway. V18 stated she (V18) was shocked and confused. V18 stated that R3's story never changed no matter how many times V18 asked her and R3 seemed alert and oriented at the time. V18 stated that all the CNA told her was that she didn't touch R3, she just moved the chair, that she didn't do anything to her. V18 stated that R3 showed V18 a rubber bracelet R3 said was ripped off during the fight and it was ripped. V18 stated the police showed up. On 10/6/2025 at 2:49 PM V14 stated that R3 was upset that V14 had a chair in the hallway. V14 stated that R3 was yelling at V14. V14 stated that R3 informed V14 that R3 used to be a nurse and that 'Bitch you're not sitting down. Whore you're going to work.' V14 stated that she was sitting outside R3's room. V14 stated that she got up and answered a light. V14 stated that when she returned the chair was gone. V14 stated that she went into R3's room to get the chair. V14 stated that she grabbed a hold of the chair and started to remove the chair from the room. V14 stated that R3 was trying to get to V14. V14 stated that R3 threw water at her. V14 stated that she continued to pull the chair out of the room. V14 stated that R3 fell. V14 stated that she was not sure how R3 fell, she may have slipped in the water on the floor. V14 stated that R3 fell in slow motion. V14 stated that she didn't hit R3. If anything, she hit herself. V14 stated that she doesn't know how R3 got the black eye. V14 stated that R3 was agitated all day calling her bitches and whores. On 10/6/25 at 3:25 PM, V4, [NAME] President of Clinical Operations, stated that she showed up last night after being notified of the incident right away. V4 stated that R3 might have fallen on the chair to get the injury to her eye but hasn't finished up the investigation yet. V4 stated that R3 has been cycling lately and she came this weekend to see her room destroyed at one point. V4 stated she thinks the CNA might have argued when she shouldn't have with R3 but V4 still hasn't completed the investigation. V4 stated so far, she understands that the CNA went into R3's room to get the chair and R3 threw water at her. V4 stated when the CNA pulled the chair, R3 went after it and might have slipped on the water trying to grab the chair. V4 stated R3 told her the CNA punched her.On 10/8/2025 at 1:22 PM V10, LPN, stated that she was called to the room. V10 stated that R3 was lying on the floor. V10 stated that R3 stated that V14 hit her. V14 stated that R3 complained of pain to her left eye. V14 stated that R3 was alert. V14 stated that she works at the facility from time to time and V14 knew who she was and their last interaction. V14 stated that R3 has behaviors but R3 was alert and oriented. The facility's Abuse policy, dated 9/2017, documents that This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents.

Based on interview, observation, and record review, the facility failed to provide supervision to prevent elopement for 1 (R7) of 3 reviewed for elopement in the sample of 13. This failure resulted in R7, a resident with known desire and attempts to leave the facility, eloping from the facility and found 12 miles away approximately 8 hours later by police.This failure resulted in an Immediate Jeopardy, which was identified to have begun on 7/25/25 when the R7 eloped from the facility. V1, Administrator, V2, Director of Nursing (DON), V3, Regional Nurse Consultant (RNC), and V19, Regional Director of Clinical and Operations, were notified of the Immediate Jeopardy on 7/30/25 at 4:08 PM. The surveyor confirmed by interviews, observations, and record review, the Immediate Jeopardy was removed on 8/1/25, but the noncompliance remails at Level Two due to additional time needed to evaluate implementation and effectiveness of training.The Findings Include:R7's admission Record, dated 7/28/25, documents R7 was admitted to the facility on [DATE] with diagnosis of Schizophrenia, Alcohol Abuse, Cocaine Abuse, Chronic Obstructive Pulmonary Disease (COPD), Seizures, Hypertension (HTN), and Hyperkalemia.R7's Care Plan, dated 5/20/25, documents R7 has diagnosis of Schizophrenia and may display symptoms that include but not limited to being out of touch with reality (delusional or hallucinations), may have disorganized speech or erratic behavior, decrease in activities. R7 is at risk for seizure activity related to diagnosis of seizures. R7 requires assist with daily care needs. R7 is at risk for falls related to Seizure disorder. R7's Care Plan did not address that R7 was an elopement risk. R7's Minimum Data Set (MDS), dated [DATE], documents R7 is cognitively intact and required supervision/touching assistance for Activities of Daily Living (ADLs).R7's current and active physician orders included the use of the following medication regimen: Aricept (dementia) Benztropine (involuntary movements), Losartan (HTN), Mirtazapine (depression), Naproxen, Nifedipine (HTN), Phenytoin (seizures), Risperidone (anxiety), Trazodone (sleep).R7's Nurses Note, dated 7/25/25 at 2:46 PM, documents EMS (Emergency Medical Service) showed up because resident called 911. Resident met EMS at the front door and advised she wanted to be taken to The Center due to her medication not agreeing with her and wanting to visit her son and daughter. Resident educated that if she wants to speak with her son or daughter to let the staff know and we will get in touch with them for her if she is unable to. Resident verbalized understanding. This RN (registered nurse) attempted to contact daughter with no answer, left message.R7's Nurses Note, dated 7/25/25 at 12:00 AM, documents This writer discovered resident missing from her room at approx. 11:30p during routine beginning of shift rounding. This writer immediately searches her bedroom/ bathroom, surround hallways as well as a common seating area for residents. No signs of resident. At 11:36p Nurse manager on duty (Xxxxxxx) was notified of the missing patient, as well as a call placed to DON (V2) at 11:38p. An elopement procedure was initiated. 11:40p conducted a thorough search of 100/200 hall, including all patients, rooms, bathrooms, common areas, and exits. Other staff members were notified and assisted with the search. Facility-wide search and outside building perimeter search. Resident emergency contact (daughter) informed of the situation. MD (medical doctor) (V21, Physician) notified of patient absence; no new orders given. 12:20a search of the hall and facility continuing. 12:19a Writer placed a call to 911 and officer gave the writer a non-emergency number to contact for (local) PD (police department). 12:20a the writer spoke with badge #54 officer and gave information about the missing resident and connected me to officer that was on duty patrolling. 12:35a officer arrived to the facility to get more information on resident. Face sheet with photo of resident given to officer. 2:23a (local) PD called and notified residents had been entered in missing person data. 2:30a managers are still out driving around the neighborhood in attempts to locate resident. Will cont. to follow up. [SIC]On 7/28/25 at 2:46 PM, V7, Licensed Practical Nurse (LPN), stated she was the night nurse who found R7 missing. V7 stated she came on duty at 11:00 PM and when she was doing her rounds checking on the residents, R7 was missing. V7 stated she did the proper elopement protocol and notified everyone. V7 stated she is unsure what time R7 left because she was gone by the time she got on duty, there were no alarms going off when she got to work. V7 stated R7 was not exit seeking and she does not recall her walking out the front door. V7 stated just about every resident who leaves the facility must have someone sign them out of the building. V7 stated for days and evenings, there is someone who mans the front desk, but for nights there is no one there but the alarms do go off. R7's Nurses Note, dated 7/26/25 at 6:50 AM, documents At approx. 6:50a this Nurse received a call from (local) county jail requesting the resident med list. This writer verbally provided Nurse with all current medications. Nurse states the resident is being held due to a warrant for [NAME]. (Nurse) states (local town) has 5 days to pick up the resident and cannot be released back to the facility until she sees a judge on Monday. Manager on duty (V20) notified. Called the place to daughter to update her. [SIC]R7's Police Report, dated 7/26/25 at 00:21 AM, documents in part that On 07/26/2025 at approximately 00:21 hours, I, Ofc. (officer) 154, responded to (facility address) (this facility) for a report of a missing person. The caller advised dispatch that as employees were doing rounds, they noticed that a female resident was missing, and the last time she was seen was around 1900-2000 (7:00 PM to 8:00 PM) hours. I filled out a missing person form and later turned it into dispatch. (R7) was entered into LEADS (Law Enforcement Agencies Data System) as a missing person. I have attached a photograph of (R7's) face sheet from the facility, which includes her medical diagnosis and a photograph of her to reference. At approximately 0550 (5:50 AM) hours, (Local County) Deputies located (R7) at the Metrolink (5th/Missouri). (R7) had an active warrant out of (area town) and was taken into custody for the warrant, and she was removed as missing from LEADS.On 7/28/25 at 11:15 AM, V1, Administrator, stated We had a resident (R7) who had orders that she can leave whenever she wants. (R7) left the faciity on her own, was seen by Police walking down the sidewalk and when they checked on her, she had a warrant for her arrest and was taken to the (local town jail) where she had her warrant. Early this morning, the judge released her, and she is walking around (the local town). We have someone driving there now to talk to her and hopefully bring her back to the facility. (R7) is her own responsibility and has the right to leave when she wants.On 7/29/25 at 11:53 AM, V11, Nurse Practitioner (NP), stated (R7) was alert and oriented but did have Schizophrenia, Alcohol Abuse, and Cocaine Abuse. I believe there were a couple of issues going on with her. I was told that on Friday afternoon (7/25/25) (R7) called 911 herself, not because she wanted to go to the hospital, she wanted to leave the facility and go into town. When she found out that the ambulance was not going to take her to town, she refused to go with the ambulance, so they did not transport her. Then on Saturday (7/26/25) I got a text message from the DON (Director of Nurses) that stated (R7) eloped from the facility and the police found her and put her in jail. Then it said further review showed that (R7) left AMA (Against Medical Advice). I believe it was around 10:00 PM that she left, and the facility didn't realize she was gone until the night staff came in around 11:00 PM and made their rounds. On the Monday morning meeting at the facility, I was told that the Social Service Director and the Administrator watched the cameras and seen another family member, who knew the code, open the front doors, walk out the door and leave, with R7 exiting right behind that person. From my standpoint, R7 was alert and oriented but had a psychiatric history. She was able to make her own decisions, and she definitely wanted to leave the facility. When asked if R7 had an order to leave the facility whenever she wanted to, V11 stated There would never be an order for any resident to go outside or leave the facility on their own. There may be a LOA (Leave of Absence) order for a resident to go with a family member, but they must be signed out first. That facility is not that type of facility where a resident would be able to come and go whenever they wanted. So, in my opinion, yes, (R7) eloped from the facility against providers wishes. When asked if R7 was able to take care of herself or was she putting herself in danger by eloping, V11 stated I don't believe (R7) was at a point where she would be able to care for herself. By eloping, I would consider her a great risk to harm herself. The managers all had a group message going around about (R7) leaving the facility, you may want to try and get that group message, it started with (R7) eloped from the facility.On 7/29/25 at 12:37 PM, V11, NP, called back and stated, I talked to my Physician, and he told me he believes that incident was an elopement at the time, but then he was told that after further investigation by the facility, they had the resident sign an AMA form.On 7/29/25 at 2:00 PM, V3, RNC, showed this surveyor the security video of when R7 walked out of the facility. The video shows a family member of another resident, walk out the door at 9:55 PM and within a second or two, R7 was right behind him, and she walked down the sidewalk and away from the facility. On 7/29/25 at 2:19 PM, V12, Human Resource, stated that she got a call on Friday (7/25/25) night from V1, Administrator, stating that she needed to go to the facility and help look for R7 and to look at the camera to see if she left. V12 stated when she looked at the camera, she saw a resident's family member leaving and shortly after, R7 walked out the door. V12 stated apparently the family member had the code to get out the door and they shouldn't have had it.On 7/29/25 at 2:47 PM, V2, DON, stated as far as she knows, only the employees of the facility should have the code to the doors. V2 stated the night R7 left, she was not able to come in to help but all the managers and corporate came in to look for R7. V2 stated she was not aware of R7 exit seeking, however, R7 was put on every 15-minute checks because she was wandering around and they wanted to keep an eye on her. V2 stated the front door is manned up until around 8:00 PM. On 7/29/25 at 3:10 PM, V1, Administrator, stated that they changed the code to the front doors Monday after R7 left. V1 stated only the employees are supposed to have the code to the door and she is unaware of how R11's father got the code. V1 stated they have smart residents living there and most of them will watch people leave and put the code in and will learn the code. On 7/29/25 at 3:30 PM, V13, Receptionist, stated she works the front desk from 8:00 AM until 4:00 PM on Monday through Wednesday, then works 8:00 AM until 8:00 PM on Thursday and Fridays. V13 stated someone else works the desk from 4:00 PM until 8:00 PM on Monday through Wednesday, then 8:00 AM to 8:00 PM on Saturday and Sunday. V13 stated she never gives out the door code and has no idea how family members are getting the code. V13 stated after 8:00 PM, there is no one that mans the door.On 7/29/25 at 3:35 PM, While speaking with V13, a new sign was seen posted on the front doors. This sign documents Attention Visitors and Staff: For our resident safety, please be aware of our resident's when you enter or leave the building and immediately report any residents observed exiting the building to management or charge nurse at the nursing stations.On 7/30/25 at 3:25 PM, V18, Certified Nursing Assistant (CNA), stated that R7 was always carrying her purse around, telling people she was going home, and would call her mother frequently telling her she wanted to go home.On 7/29/25 at 9:15 AM, V4, LPN, stated that she worked with R7 and that R7 always had a bag packed and stating she was going home. V4 stated that she never saw R7 go out the doors but would always walk around the facility telling people she was going home. R7's Elopement Evaluation, dated 6/20/25, documents R7 was a Low Risk for Elopement.R7's Enhanced Supervision Monitoring Tool, dated 7/25/25, documents R7 was last seen in the dining room at 9:45 PM. At 10:00 PM, it documents Looking for Resident.Per Google Maps the distance from the facility to the Metrolink 5th/Missouri station is 12 miles. R7's Social Service Update, dated 7/23/25, documents in part that R7 is alert and oriented to person, place, and time, but is not oriented to situation and mental function varies throughout the day. It continues R7 has clinical issues that interferes with her thought process, R7 is prescribed psychotropic medication to address her symptoms and conditions related to mental illness, is required to attend psychosocial support groups, and R7 has made attempts to walk away from this LTC since the last review. It continues the Risk Screen for Elopement 0-9 is a Low Risk =/> 10 is At Risk with R7's score of 21 indicating R7 was at risk for Elopement.An untitled, undated, document provided by V3, documents a timeline for the incident involving R7's elopement. This in part, documents Per the Nurses Notes: This writer discovered resident missing from her room at approx. 11:30 PM during routine beginning of shift rounding. This writer immediately searched her bedroom/bathroom, surround hallways as well as a common seating area for residents. No signs of resident. At 11:36 PM, Nurse manager on duty (V20, LPN) was notified of the missing patient, as well as a call placed to DON (V2) at 11:38 PM. An Elopement procedure was initiated. At 2:30 AM, managers are still out driving around the neighborhood in attempts to locate the resident. Will continue to follow up.On 7/31/25 at 12:48 PM, V1 stated Only the high-risk elopement residents will go into the elopement binder. On 7/31/25 at 2:20 PM, V1 stated You are not seeing the clarification on At Risk for Elopement because you don't have the correct policy, we updated the policy on 7/28/25 to reflect only the High Risk for Elopement residents. Per investigation, R7 eloped prior to the change in policy.The Facility's Elopement Policy, dated 9/2022, documents in part Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. All residents will be assessed for elopement risk upon admission, with significant change in condition, and quarterly. Any resident identified at risk to elope will be reviewed every 90 days or with significant change in condition. Elopement Risk: Residents who are at risk to elope are closely supervised to keep them safe in their environment, while allowing them to move freely about the safe environment. 1. Any resident identified as an elopement risk will have pictures available, one kept at the reception desk and the others in a facility-designated area. 2. Any resident identified at risk to elope upon admission will have the Elopement Risk identified and included in the Interim Plan of Care. A comprehensive elopement prevention plan of care will be developed at the first care plan meeting. The plan will be reviewed at least every 90 days or more often if necessary. 3. There will be a Master List of all residents at risk to elope. The Social Service Department or designated staff will update the list as additional residents are determined to be at risk to elope and it will be reviewed weekly. The list will be available at the nurses' stations and reception area. 4. Residents at risk to elope will be closely monitored. This policy which was in use at the time of R7's elopement did not identify Low or High risk, just At Risk residents. The Immediate Jeopardy that began on 7/25/25 was removed on 8/1/25, when the facility took the following actions to remove the immediacy. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. Completion Date: 7/31/25. RNC in-serviced DON and Administrator on elopement policy start date 7/30/25 end date 7/30/25. R7 no longer resides in the facility. DON/Designees to provide in-servicing on elopement policy to all staff prior to the start of their next shift. Start Date 7/26/25 End date- ongoing All residents were reassessed by the clinical leadership team, using the Elopement Risk Assessment Tool. Started on 7/26/25 completed on 7/26/25. All residents identified as at high risk for elopements have had their care plans reviewed by the nurse managers for resident specific interventions. Start date 7/26/25 Completed 7/26/25. Yes, Nurse managers and MDS nurses revised the care plans. The elopement binder was reviewed by the Regional Nurse Consultant, to ensure those residents identified as at high-risk for elopement, have a face sheet and picture in the binder. Started 7/26/25 Completed 7/31/25. DON/Designee will in-service CNA's on reviewing of care plan of residents prior to their next shift. Started 7/26/25 Completion date- ongoing. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 7/26/25) The DON/designee will in-service staff on facility elopement policy once a month for the next 3 months. Started on 7/26/25. The DON/designee will audit new admissions daily to ensure the Elopement Assessment Tool has been completed and that risk factors, safety measures, and resident specific interventions are reflected on the care plan as well as updated on the individualized service plan. It was initiated on 7/26/25 but there have been no admits. A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. 7/31/25 The elopement binder has been updated on 7/31/25 by DON, facility staff, and the Regional Nurse and provided to all nursing units and front reception. The elopement binder will be updated with new admissions, at least quarterly and as needed. The door exit code to the main entrance was changed and will be changed monthly. Completed by Maintenance Assistant. Date Code was changed on July 28, 2025 A receptionist is posted at the front desk 24 hours a day. Date Started July 31,2025 The elopement prevention poster for the staff and visitors are currently posted at the main entrance for entering and exiting the facility. Administrator Responsible. Completed 7/26/25 Letters with a copy of the Elopement prevention poster was sent out as part of the education to family members about not to assist any resident out of the facility without staff assistance. Sent 8/1/25. Completed by: Business Office Manager. Policy on Elopement has been reviewed and revised on 7/28/25. Completed by Chief Nursing Officer. Inservice included not to share door codes to families and visitors. Start date 7/26/25 completed 7/26/25. All new staff and staff who will be returning to work will be trained prior to start of the shift. Completed by: Director of Nursing and unit managers. The Interdisciplinary Team (IDT) have addressed and will continue to address any identified high-risk residents as part of the regular leadership meeting. The teams consist of the Administrator, Director of Nursing, Social Services, MDS nurse, Business Office, Therapy. Start dated of July 29, 2025, ongoing. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. QAPI will be held this Thursday, August 7, 2025.

Based on interview, observation, and record review, the facility failed to provide pain medication to 1 of 3 residents (R3) reviewed for pain control in the sample of 8. This failure resulted in R3 having excruciating pain and having trouble functioning during that time in pain. The Findings Include:R3's admission Record, dated 7/21/25, documents R3 was admitted to the facility on [DATE] with diagnosis of Diabetes Mellitus (DM), Pneumonia, Bacteremia, and a Lung Abscess with Methicillin Resistant Staphylococcus Aureus (MRSA) infection.R3's Care Plan, dated 7/9/25, documents R3 Is Independent with Activities of Daily Living (ADLs). R3 has an alteration in comfort with interventions including administer pain meds and treatments as ordered, assess pain characteristics: duration, location, quality, encourage to report any pain, monitor for nonverbal indicators of pain (moaning, crying, grimacing, wincing), report any acute changes to Physician. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact, is independent on all ADLs. R3 is always continent of both bowel and bladder. On 7/21/25 at 1:25 PM, R3 stated They cut my pain meds in half to 5 MG twice a day, then added a muscle relaxer, and right now my pain is an 8.On 7/22/25 at 9:00 AM, R3 stated They ran out of my pain medication, and I had to wait around 6 days for my pain medication. The nurses kept telling me that they were waiting on pharmacy to send the medication. They may have given me Tylenol once or twice, but that did not help. I was in excruciating pain and had trouble functioning day to day during that time while I was in pain. My pain right now is between a 6 or an 8. On 7/22/25 at 9:15 AM, V7, Registered Nurse (RN)/Nurse Practitioner (NP), stated If a resident has an order for a pain medication and runs out, we have to print out the actual hard script/order and then either fax it to the physician or NP to sign it, or catch them while they are here. We do carry Oxycodone in the medication machine; however, we cannot just get one out. We have to have pharmacy on the phone, with the signed hard script, then they have to send a code to the nurse in order to get the medication out of the machine. V7 stated that is probably why R3 was waiting so long to get his meds.On 7/22/25 at 10:20 AM, V2, Director of Nursing (DON), stated If a resident has an active order for Oxycodone, such as (R3), all the nurse has to do is call the pharmacy and they will release a dose from the E-Kit (machine) to be dispensed. If it is a refill, then it has to have a hard script with the physician's signature. There are instructions on the entire process at the nurse's desk, but a lot of our nurses are agency, and they don't seem to understand the process.On 7/23/25 at 8:55 AM, V10, NP, stated I was not notified that (R3) was not receiving his Oxycodone for pain. I did meet with (R3) and the DON about (R3's) pain and I was not sure if it was lung pain or muscular pain and the way the Oxycodone was ordered, I wasn't sure if he was getting 5 MG or 10 MG, so I just made it 5 MG every 6 hours and added the muscle relaxer Cyclobenzaprine to help. I would expect the nurses to give (R3) his pain medication to keep up with his pain control. Any foreign substance in our lungs causes pain and with (R3) having a lesion with MRSA in his lung, it definitely has the potential to be painful.On 7/23/25 at 9:20 AM, R3 stated he did get his morning pain pill but stated they never ask him what his pain level is, they just hand him his pills. R3 stated right now, his pain is an 8 and it typically is between 6 to 8 depending on if he is lying down or up moving around.On 7/23/25 at 9:30 AM, V2 stated I would expect the nurses to provide pain medications as ordered to maintain the resident's level of pain to a minimum and if they run out of the medication, I would expect the nurses to order the medications when they run out in a timely manner, so the resident does not go without getting them. I would expect the nurses to administer antibiotics as ordered for any resident.R3's Physician Order (PO), dated 6/28/25, documents Oxycodone HCl (Hydrochloride) Oral Tablet 5 MG (milligram), give 1 tablet by mouth every 6 hours as needed for pain take 1-2-tab 5-10 MG by mouth every 6 hours as needed. Max daily amount 40 MG. This order was discontinued on 7/1/25. R3's PO, dated 7/1/25, documents Oxycodone HCl Oral Tablet 5 MG, give 1 tablet by mouth every 6 hours as needed for pain take 1 tab (5 MG) for pain scale 1-4 and 2 tabs (10 MG) for pain scale 5-10 by mouth every 6 hours as needed. Max daily amount 40 MG. This order was discontinued on 7/16/25.R3's PO, dated 7/16/25, documents Oxycodone HCl Oral Tablet 5 MG, give 1 tablet by mouth every 6 hours as needed for pain. This order was discontinued on 7/18/25. R3's PO, dated 7/18/25, documents Oxycodone HCl Oral Tablet 5 MG, give 1 tablet by mouth every 6 hours related to Methicillin Resistant Staphylococcus Aureus Infection.V2 provided the Controlled Substance Receipt/Record/Disposition Form for R3's Oxycodone, dated 6/29/25. This form documents R3 did receive Oxycodone from 6/29/25 up to 7/6/25 with nothing documented past 7/6/25. V2 stated this is what they have for documentation of R3 getting his Oxycodone.R3's Electronic Health Record (EHR), Weights/Vitals, Pain Level, documents R3 was experiencing pain on 7/7/25 at a 6 with no Oxycodone given, on 7/8/25 at 00:21 AM at a 5 with no Oxycodone given, on 7/8/25 at 6:19 AM at a 3 with no Oxycodone given, on 7/8/25 at 9:08 AM at a 5 with no Oxycodone given, on 7/8/25 at 9:09 AM at a 5 with no Oxycodone given, and on 7/9/25 at 7:36 AM at a 3 with no Oxycodone given. R3's Medication Administration Record (MAR), dated July 2025, documents R3's Pain Level on 7/7/25 during evening was a 5, on 7/8/25 during days was a 5, on 7/9/25 during days was a 3 and during evenings was also a 3. There was no Oxycodone given to R3 during the time frame from 7/5/25 at 5:30 PM through 7/12/25 at 7:58 AM. The Facility's Pain Management Policy, dated 10/2024, documents General: To facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our resident's the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. Guideline: The pain management program is based on a facility-wide commitment to resident comfort. pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Policy: 1. Pain is assessed using the Comprehensive Pain Assessment form: Upon admission, quarterly, with significant change, following a fall, when new pain is identified, when existing pain worsens. 2. Pain will be assessed at least once every shift and documented in the EMAR using the pain scale appropriate for the patient.3. Development of the Care Plan. 4. If nursing recognizes pain, the staff may attempt non-pharmacological interventions, physical modalities, body alignment, rehabilitation therapy, exercises, and/or cognitive/behavioral interventions. 5. Licensed Nursing may notify the Health Care Provider of any new development of pain, change in pain, change in condition that could potentially cause pain, for pharmacological interventions based on the individual's pain factors.

Based on interview, observations, and record review, the facility failed to provide an antibiotic for 1 of 1 resident (R3) reviewed for medication administration in the sample of 6. This failure resulted in R3 not receiving his antibiotic as ordered, his Vancomycin Trough levels subtherapeutic therefore not sufficient in treating R3's Methicillin Resistant Staphylococcus Aureus (MRSA) infection in his lungs. The Findings Include:R3's admission Record, dated 7/21/25, documents R3 was admitted to the facility on [DATE] with diagnosis of Diabetes Mellitus Type 2 (DM2), Pneumonia, Bacteremia, and a Lung Abscess with Methicillin Resistant Staphylococcus Aureus (MRSA) infection.R3's Care Plan, dated 7/9/25, documents R3 Is Independent with Activities of Daily Living (ADLs). R3 has an alteration in comfort with interventions including administer pain meds and treatments as ordered, assess pain characteristics: duration, location, quality, encourage to report any pain, monitor for nonverbal indicators of pain (moaning, crying, grimacing, wincing), report any acute changes to Physician. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact, is independent on all ADLs. R3 is always continent of both bowel and bladder. On 7/21/25 at 1:25 PM, R3 stated I have a PICC (Peripherally Inserted Central Catheter) line in my right arm and I am supposed to get antibiotics in it twice a day. I have not received my antibiotic yet today that I was supposed to get this am. I think the IV pump is broke and that is why I am not receiving it.On 7/21/25 at 1:37 PM, V7, Registered Nurse/Nurse Practitioner (NP), stated I did not give (R3) his antibiotic this morning because he had a trough drawn and I have to wait until that result comes back in order to give this dose, in case I have to hold the dose.On 7/22/25 at 9:00 AM, R3 stated That bag is still hanging from yesterday because the nurse could not give it to me because the pump was broke. A bag of Vancomycin 1750 MG (milligram)/500 ML (milliliter) was seen hanging and attached to the IV pump which was turned off. On 7/22/25 at 9:15 AM, V7 stated The bag of antibiotics hanging in (R3's) room is the one from yesterday. I got the trough level back yesterday and went to hang it and the IV pump would not work. I even had another nurse try and the same thing. I called the pharmacy this morning and spoke with them, and they stated they would bring us a new pump today. The pharmacy showed up this morning and only delivered bags of antibiotics and no pump, so we still can't give (R3) his antibiotic. I told the DON of the situation.On 7/23/25 at 8:55 AM, V10, NP, stated I was not notified that (R3) was not receiving his antibiotic. I would expect the nurses to give the antibiotics as ordered. There is definitely a potential that (R3's) condition could get worse, or not get any better, by not getting his antibiotic. I also was not notified that (R3) was not receiving his Oxycodone for pain. I did meet with (R3) and the DON about (R3's) pain and I was not sure if it was lung pain or muscular pain and the way the Oxycodone was ordered, I wasn't sure if he was getting 5 MG or 10 MG, so I just made it 5 MG every 6 hours and added the Cyclobenzaprine to help with his muscles. I would expect the nurses to give (R3) his pain medication to keep up with his pain control. Any foreign substance in our lungs causes pain and with (R3) having a lesion with MRSA in his lung, it definitely has the potential to be painful, especially if it is not getting any better.On 7/23/25 at 9:30 AM, V2 stated I would expect the nurses to order the medications when they run out in a timely manner, so the resident does not go without getting them. I would also expect the nurses to administer antibiotics as ordered for any resident.R3's Physician Order (PO), dated 6/28/25, documents Micafungin Sodium Intravenous Solution Reconstituted 100 MG, use 100 MG intravenously (IV) one time a day for Antifungal for 12 Days inject 1 dose by IV every 24hrs. This was discontinued on 7/8/25.R3's PO, dated 7/8/25, documents Micafungin Sodium Intravenous Solution Reconstituted 100 MG, use 100 mg intravenously one time a day for Antifungal for 12 Days inject 1 dose by IV every 24hrs.R3's PO, dated 6/28/25, documents Vancomycin HCl Intravenous Solution 1500 MG/300ML, use 1 dose intravenously every 12 hours for Anti- infection for 41 Days. This was discontinued on 7/18/25.R3's PO, dated 7/18/25, documents Vancomycin HCl Intravenous Solution 1750 MG/350ML, use 1 dose intravenously every 12 hours related to Methicillin Resistant Staphylococcus Aureus Infection. This was discontinued 7/18/25.R3's PO, dated 7/18/25, documents Vancomycin HCl Intravenous Solution 1500 MG/300ML, use 1 dose intravenously every 12 hours for Anti- infection until 07/18/2025 23:59. This was discontinued 7/18/25.R3's PO, dated 7/18/25, documents Vancomycin HCl Intravenous Solution 1750 MG/350ML, use 1 dose intravenously every 12 hours related to Methicillin Resistant Staphylococcus Aureus Infection. This is the current order. R3's Medication Administration Record (MAR), dated July 2025, does not show that R3 received Vancomycin IV as ordered on 7/6/25 AM dose, 7/9/25 AM dose, 7/13/25 AM dose, 7/20/25 AM dose, and 7/21/25 both AM and PM doses. R3's MAR, dated July 2025, does not show that R3 received Micafungin IV as ordered on 7/7/25, 7/8/25, 7/15/25, and on 7/20/25. R3's Nursing Note, dated 7/21/25 at 3:56 PM, documents Resident missed AM dose of IV Vancomycin yesterday. NP notified. No signs/symptoms of infection noted.R3's Nurses Note, dated 7/21/25 at 4:11 PM, documents Nurse informed (facility pharmacy) about the malfunction of the IV pump. The IV pump will be sent out today along with the medication run. Dr. (doctor) ordered that the PICC line dressing be changed weekly.R3's Nurses Note, dated 7/22/25 at 8:28 AM, documents the nurse contacted (facility pharmacy) to discuss the delivery issue with the IV pump. (Pharmacy) explained that the courier had left the pump, and another pump would be delivered promptly. The courier and DON were notified about the missing dose of medication. The corporate nurse delivered the pump from an affiliate facility. The IV medication was administered to the patient without any difficulties. The PICC line was flushed and found to be patent, with no signs of redness or warmth at the site. Monitoring will continue.R3's Nurses Note, dated 7/22/25 at 3:24 PM, documents NP on call notified of missed Vancomycin doses and verbal order received to extend medication x 2 doses. Resident is afebrile, no s/s (signs/symptoms) of infection noted at this time.R3's Acute Care (NP) Note, dated 7/23/25 at 00:35 AM, documents in part Nurse reports pt (patient) missed 2 doses of Vancomycin. (R3) is a [AGE] year-old male with PMH (primary medical history) of DM2, and acute on chronic pancreatitis. He was admitted to the hospital on [DATE]rd after previously leaving AMA (against medical advice). He was found to have MRSA bacteremia with a right upper lobe abscess versus infarct and perirenal abscess. Bronchoscopy on June 18th showed MRSA, Group B-Strep, and Serratia. He received a PICC line, and he was on vancomycin and Ceftazidime, with Fluconazole added due to thrush. He was admitted to (this facility) on 6/28 for LTC (long term care) and continuation of IV abx (antibiotics).R3's Lab Result, Vancomycin Trough Level, dated 7/11/25, documents R3's Vancomycin level was 8.5 (Low) with a reference range of 10.0 to 20.0. R3's Lab Result, Vancomycin Trough Level, dated 7/17/25, documents R3's Vancomycin level was 9.0 (Low) with a reference range of 10.0 to 20.0. R3's Lab Result, Vancomycin Trough Level, dated 7/21/25, documents R3's Vancomycin level was 8.6 (Low) with a reference range of 10.0 to 20.0. The Facility's Medication Administration Policy, dated 4/2024, documents in part General: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Licensed staff will administer medications as ordered by the physician. Guideline: 22. If a medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required. 26. If medication is ordered, but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication. If available, obtain it from the contingency or convenience box. 27. If the physician's order cannot be followed for any reason, the physician should be notified in a timely manner (depending on the situation), and a note should reflect the situation in the resident's medical record.

Based on observation, interview and record review the Facility failed to ensure residents were being monitored and supervised to prevent elopement for 1 of 3 residents (R2) reviewed for supervision to prevent elopement in the sample of 11. This failure resulted in R2 attempting to exit the facility around 2 AM on 6/10/2025. R2 was redirected but no other interventions were implemented and R2 then later eloped from the Facility on 6/10/2025 at 5:49 AM and was sent out to the hospital for six days with a diagnosis of Paranoid Schizophrenia and behaviors. The Immediate Jeopardy began on 6/10/25 when the facility failed to implement resident-centered interventions after R2 previously displayed exit seeking behaviors to prevent R2 from eloping the facility again the same day. V10, Regional Nurse Consultant, and V2, Director of Nursing (DON), were notified of the Immediate Jeopardy on 6/20/25 at :4:05 PM. On 6/25/25, the surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy was removed on 6/23/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training and current policy and procedure regarding elopement. Findings include: R2's Physician Order Sheet (POS) dated June 2025 documents diagnoses of Paranoid schizophrenia, muscle weakness, cognitive communication deficit, hypertension, drug induced subacute dyskinesia, anemia, allergic rhinitis, and primary generalized osteoarthritis. R2's Minimum Data Set (MDS) dated [DATE] document R2 was cognitively intact for decision making of activities of daily living. R2 has no impairment and walks independently with minimal assist for most activities. R2 does not have or wear a (resident wandering/monitoring device) management system. R2's Care Plan date initiated 1/19/2023, (R2) is at risk for elopement. He has a history of leaving facilities by climbing out his window. Provide one on one should resident attempt exit seeking behaviors. Date initial 7/30/2020. Redirect resident when he is exit seeking (Revision date 7/30/2020). R2's Care Plan does document ROM (Range of Motion): is at risk for developing an impairment in functional joint mobility. (R2) has impaired functional mobility to both upper and lower extremities r/t (related to weakness and inactivity). (R2) has a DX (diagnosis) Paranoid schizophrenia. He is at risk for impaired social interaction, disturbed sensory perception, defensive coping and disturbed thought process (revision date of 3/21/2025). On 6/12/2025 at 4:49 AM, R2's photo was at the nurse's station in a binder book labeled Elopement. R2's Nurse's Notes dated 6/10/2025 at 6:43 AM, Resident left out of facility back door. Writer was notified at 6:23 AM. Resident was found in shed on property yard at 6:30 AM. Brought resident back to facility via walking with staff. Resident has a history of elopement and is being sent to hospital for evaluation. (Author V9, Licensed Practical Nurse, LPN). On 6/25/2025 at 2:21 PM, V9, stated I am agency nurse and had only worked in that facility a few times. I started my shift around 10:30 PM, and I did not see (R2) go out of the building. I really do not remember much except (R2) got out during shift change. Again, this was only my second time working in that building. Nobody from the facility took a statement from me. On 6/12/2025 at 4:49 AM, V6, LPN stated, (R2) is exit seeking at times. (R2) had gotten out of the building off the 400-smoke door. I was working when (R2) got out. No staff actually saw him leave, but when he opened the door, it set off the alarm. They found him later in a shed. This all happened during shift change. He was gone for about 10-15 minutes. I know the nurse supervisor (V8) received a call telling her (R2) had gotten out of the building. The Facility did not provide any statement from V6 regarding R2 eloping and/or attempting to elope on 6/10/2025. No statement was provided, and all statements were requested. On 6/12/2025 at 6:03 AM, V7, Certified Nursing Assistant (CNA) stated, I was on the 400-hall earlier doing a one on one with another resident. About 2 AM, I saw (R2) pacing and attempting to exit, and I went and redirected him, and he did not say anything but easily took my suggestion and went back into his room. I then went and notified the nurse on that hall that we needed to put the lights on so we could see better in case (R2) attempted to exit again. A few hours later, I know it was in the middle of shift change, I heard the alarm go off and looked up saw the door on the 400-hall smoker door closing and I went chasing after (R2) yelling for staff to watch my resident. By the time I got there, I lost sight of (R2). He was fast. He was also dressed and wearing an orange jacket. He was gone, I would say he got out about 5:50 AM. Staff came running and they were all outside looking for (R2). I did not call the police, and I am not aware of anyone calling the police. They found him later in a shed. He said he wanted to be with his brother. His brother used to be a resident here. I am not sure when his brother was moved to a different facility. I asked him where he was going and he just said, 'I had to go, I had to go'. I called the CNA supervisor earlier to let her know (R2) was exit seeking and I physically went to the nurse's station and told them (R2) was trying to get out of the building. Then a few hours later he did just that and got out of the building. The Facility did not provide any statement from V7 regarding R2 eloping and/or attempting to elope on 6/10/2025. No statement was provided, and all statements were requested. On 6/12/2025 at 5:19 AM, V8, Certified Nursing Assistant (CNA) Supervisor stated, (R2) got out the 400-hall smoke door. I found him in the shed when we were looking for him and brought him back. (V7) had notified me earlier that he was pacing back and forth and was wanting to go out towards the door. (V7) saw him leave and she followed him the whole time. He was hiding in the shed. I went and got him and brought him back in. This happened during shift change. Once we brought him back into the building then we put him R2 on a one on one. I asked where he was going, and he said he missed his brother. His brother used to be a resident here too. I did not call or notify the police when he went missing. He was missing for about 15 minutes, but staff had eyes on him at all times. A statement by V8 dated 6/10/2025 documents, To whom it may concern, I arrive at work about 5:40 AM, same in the AM on June 10, 2025, about 6:20 AM, CNA let me know (R2) ran out back doors, staff went after him when he came out the front door running towards the parking lot, came around the building and I saw something by the shed, so I told the CNA's to come assist me and (R2) was in the shed building hiding behind mattress. Brung [sic] resident back to the facility put him on 1:1 till EMT (emergency medical team) arrived. An additional statement by V8 dated 6/19/2025 at 8:08 AM, document, She (V7, CNA) did text me and told me he (R2) was trying to get out. Arrived at building at 5:40 AM. Did rounds, Posted staffing. I was almost at 300 nurse's station when I heard he had got out. (V7) did not contact me at 2:00 AM. On 6/18/2025 at 1:42 PM, V19, CNA stated, (R2) has a history of trying to leave the facility and is exit seeking. (R2) used to be on the bottom floor and would try and crawl out the window, that is why they moved him to the upper floor. He is in the elopement book. On 6/18/2025 at 1:43 PM, R2 stated he did leave the facility, but he was looking for deer, he likes to deer hunt. When asked if he was deer hunting that day R2 replied yes, he was deer hunting and had his gun. On 6/20/2025 at 4:14 PM, V10, Regional Nurse Consultant stated, (V7) did not notify management (V8) that (R2) was exit seeking but (V8) did not get a call until after 4:00 AM. V10 also stated she would expect staff to follow policy and if a resident was exit seeking, she would expect management including the Administrator to be notified right away if they were exit seeking. On 6/12/2025 at 5:52 AM, review of the video footage shows the following, R2 came out of his room at 5:49 AM, sat in a chair next to door, (smoking door) exited the door at 5:51 AM, two staff ran after him and then at 6:05 AM, staff brought him back inside the facility. The camera only shows him leaving the facility and returning. No video footage was available to review once R2 was outside of the facility. The video shows R2 returning to the facility surrounded by multiple staff at 6:05 AM. Per the video footage R2 was gone for 15 minutes. On 6/12/2025 at 5:54 AM, the shed is really a metal cargo container which was located on the facility property. The metal cargo container has a door on the side of it, inside are stacked used mattresses, about five of them, old luggage, doors (around 10 wooden doors standing upright), spiders, mouse droppings, and lots of boxes crammed into a small space. The door was locked and had to be opened with the Maintenance Director. On 6/12/2025 at 5:58 AM, V10, Regional Nurse Consultant (RNC) stated (R2) was found in the metal cargo container that staff are referring to as the shed. I am not sure why the door was not locked or how he got in it. On 6/18/2025 at 10:24 AM, V35, Psychiatrist stated he did not have his records/chart in front of him for (R2). V35 stated from what he could remember R2 was admitted to the psych hospital because he was agitated and paranoid. He remembers he did try to elope from the nursing home. V35 stated he does not remember R2 being guarded, and he was alert x 3. V35 stated R2 knew he was at the hospital and R2 was redirectable. V35 stated he does not feel he had any issues with safety awareness and could navigate safely, but he was paranoid. On 6/25/2025 at 3:54 PM, V40, CNA stated I was at the nurse's station the day (R2) eloped. I had just done a round, and I went to nurses' station and saw (R2) sitting next to the door, next thing I know (R2) bolted out the door, the alarm was going off and I remember running after him. (R2) was running and he was running fast. I did lose sight of him, but other staff were searching the area and they did find him in the red shed. Statement from V40 dated 6/10/2025 documents, Today, I was at the nurse's station getting a drink when a CNA yelled, 'He's running out'. Myself and other CNA tried to chase him but couldn't catch him. We later found him in a shed. On 6/12/2025 at 4:39 AM, V41, CNA stated she was not aware of any resident eloping from the facility in the last 30 days. Statement from V41, Certified Nursing Aid dated 6/10/2025 documents, I saw a resident run out (R2) of the door. I proceeded to chase him along with several others. I looked around for him, found him hiding in the shed. Statement from V27 dietary undated documents, When I got to work, I heard a lot of yelling I came out the back door and saw (R2) by the shed, but I didn't walk up on him cause (V8) was already there. Statement not legible and undated documents, I was charting when I heard the door alarm go off, I heard the aids say (R2) was running out the back door. I ran out the front door to see if I could see him. We looked around and found him. R2's EMS (Emergency Medical Services) report dated 6/10/2025 at 8:04 AM, EMS dispatched to (facility) for a [AGE] year-old male with behavioral and elopement issues. Upon arrival nurse gave a brief report stating the patient is alert x 4. The patient has a history of paranoid schizophrenia, HTN (High blood pressure) and anemia. Upon arrival patient was found standing in the hallway and initial assessment was done and patient was found to be alert and orientated x 4. Patient self-walked to the cot where he was then secured to the cot with the safety belt and side rails. Once in the ambulance a second set of vitals were obtained as well as a signature from the patient. R2's Hospital Record dated 6/10/2025 at 8:37 AM, document, [AGE] year-old male history of dementia, schizophrenia, who was brought to the emergency room from a psychiatric facility for psychiatric evaluation. Patient is poor historian; all information was obtained from EMS per facility report. Patient, per report, has been agitated, had multiple attempts this week to elope, patient denies any suicidal or homicidal ideation, being compliant with his medications. Patient is alert and orientated x 2, his judgement and insight are limited. He is paranoid and guarded. He is irritable and labile. Certified Medical Emergency, Patient's condition represents a Certified Medical Emergency. Hospitalization required. Diagnosis dementia in other diseases classified elsewhere with behavioral disturbances. R2's Hospital Psych Discharge Notes dated 6/16/2025 documents, Reason for admission and hospital course. Patient was a resident at the nursing home. He was sent to the hospital because of increased paranoia and agitated behavior. Patient was admitted to the closed psych unit. He was started on medication. His medications were adjusted. He was provided educations, supportive therapy. The Facility Elopement Policy with a review date of 9/2022 documents, Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. This does not include alert and oriented residents who handle themselves outside the facility and choose to leave the facility, even if against medical advice. While presenting different care challenges, these alert residents are not in the same category of potential danger as the residents with impaired cognition trying to leave the facility, and their absences from the facility are not considered to be an elopement. The Immediate Jeopardy that began on 6/10/25 was removed on 6/23/25 when the facility took the following actions to remove the immediacy: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. Completion Date: 6/23/25 -V10, Regional Nurse Consultant, RNC, in-serviced V2, DON, and V1, Administrator on elopement policy 6/20/25. -V2, DON/Designees to provide in-serving on elopement policy to all staff prior to the start of their next shift. Ongoing. -All residents were reassessed by the clinical leadership team, using the Elopement Risk Assessment Tool completed 6/20/25. -All residents identified as at risk for elopements have had their care plans reviewed by the MDS nurses, V28, LPN, and V29, LPN, for resident specific interventions. Completed 6/23/25. -The elopement binder was reviewed by the V10, Regional Nurse Consultant, to ensure those residents at risk for elopement, have a face sheet and picture in the binder. Completed 6/23/25. -V2, DON/Designee will in-service CNAs on reviewing of individual service plans of residents prior to their next shift. Ongoing. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. Completion Date: 6/23/25 -The DON/designee, V2, will in-service staff on facility elopement policy once a month for the next 3 months. Started on 6/20/25. -The DON/designee, V2, will audit new admissions daily to ensure the Elopement Assessment Tool has been completed and that risk factors, safety measures, and resident specific interventions are reflected on the care plan as well as updated on the individualized service plan. It was initiated on 6/20/25 but there have been no admits. -The Corporate Nurse/Consultant Nurse will review all elopements within one working day for three months to ensure an RCA has been conducted and that resident specific interventions are reflected in the care plan as well as updated on the individualized service plan. Initiate 6/20/25, there have been no elopement since initiation. -The DON/designee, V2, will review all elopements at the daily stand-up meeting with the IDT for three months to ensure appropriate elopement interventions are implemented, the resident's care plan has been reviewed and revised, and the individualized service plan has been updated. Initiated 6/20/25. -A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. QAPI will be held this Thursday, June 26, 2025.

Based on observation, interview, and record review, the facility failed to provide timely incontinent/colostomy care in 1 of 1 resident (R2) reviewed for ADL (Activities of Daily Living) care in the sample of 6. This failure resulted in R2 developing painful, red excoriation around his colostomy site extending down to the abdomen, perineal area and buttocks. Findings include: On 4/23/25 at 8:45 AM, R2 was observed in bed with V8, R2's family member at bedside. R2's colostomy site and abdomen were observed with V8. There was a towel covering R2's abdomen, V8 removed the towel and R2's colostomy bag was about 3/4 full and was leaking moderate amounts of liquid stool onto R2's abdomen, down into R2's abdominal folds, perineal area and under R2's bottom. R2's abdomen was red and excoriated. R2 was stating don't touch it, it hurts, burns and was shaking, appearing to be apprehensive and in pain. On 4/23/25 at 8:55 AM, R2 turned his call light on, V9, CNA (Certified Nurse's Assistant) came into the room, asked what was needed and then left the room to gather supplies. Upon V9's return, V9 explained to R2 that she was going to clean him up, R2 was shaking his head no and stating it hurts, it burns, don't use the cleaner in the white bottle pointing to a bottle of wound cleanser. V9 was able to calm R2 and R2 agreed to allow V9 to clean him up. V9 attempted to clean R2, but liquid feces continued to leak from the bottom of the colostomy wafer that attaches to the bag. During this time R2 continued to shake and appeared to be in pain. V9 stated the nurse would need to change the colostomy bag because it kept leaking. V9 then left the room and notified V10, RN (Registered Nurse). On 4/23/25 at 9:20 AM, V10, RN, came into R2's room to change R2's colostomy wafer and bag. The wafer and bag was removed with red excoriation noted around the colostomy site extending down to R2's abdomen, abdominal folds and perineal area. V10 cleaned around R2's colostomy site and abdomen with incontinence wipes, then applied a new wafer and bag. V10 told R2 and V8 that she would need to get a CNA to finish cleaning R2 up because she still had a lot of medications to give. The liquid feces remained on R2's lower pubic area, buttocks on the incontinence pad underneath R2. On 4/23/25 at 10:30 AM, R2 was observed still soiled with liquid feces on his lower pubic area, buttocks and incontinence pad. An aide from Hospice, came in R2's room to see him, V8 told her that he had been waiting over an hour to get cleaned up. The aide then cleaned R2 up. R2's perineal area and buttocks were red. V8 was in R2's room and stated she has been at R2's bedside and no one from the facility came in to change R2, so the hospice aide did it, the facility CNAs never came to R2's room after V10 left the room. On 4/26/2025 at 9:42 PM, V18, family member, came to the nurse's station and put a container on the counter and stated, R2 just threw up and nobody has been checking on him. I told you two hours ago he said he was not feeling well. His call light in his room does not work and if I had not been here, he would have thrown up all over himself because nobody is checking on him. This is not right. On 4/26/2025 at 9:46 PM, R2's call light was tested and did not work. On 4/26/2025 at 9:52 PM, V18, R2's family member, stated I told them at 8:00 PM, that he was not feeling well, and nobody has been down here to check on him. He is like a kid; his call light does not work. I told them he needed checked on, but they don't care. What would have happened if I was not here? On 4/26/2025 at 9:58 PM, V23, CNA stated I am not sure what is happening with (R2). R2's Face Sheet, undated, documents R2 has the following diagnoses: Unspecified Kidney Injury, Pituitary Dependent Cushing's Disease, Hypertension, Autism, Congenital Renal Failure, Acquired Absence of Parts of the Digestive Tract, Presence of Functional Implants, Acute Infarction of the Large Intestine, Chronic Kidney Disease and Critical Illness Polyneuropathy. R2's (MDS) Minimum Data Set, dated dated [DATE], documents R2 has a BIMS (Brief Interview of Mental Status) score of 8, indicating R2 has moderate cognitive impairment, is dependent with toileting and has no skin issues. R2's Care Plan, dated 4/21/25, documents R2 requires assist with daily care needs, is incontinent of bowel and bladder, has a potential risk for complications related to altered elimination for bowel elimination, as evidenced by a colostomy and is at risk for skin complications related to Stoma Incontinence Associated Dermatitis with an intervention to provide skin care after each incontinence episode. R2's Wound Care Note, dated 4/8/25, documents R2 has incontinence associated dermatitis. Treatment: cleanse wound with soap and water, pat dry and apply triad and miconazole cream BID (Twice Daily) and PRN (As Needed). Leave open to air. R2's Grievance, dated 4/16/25, filed by V8, documents R2 was put in diapers and not attended to throughout the night. Findings: CNA educated on the needs of the resident and customer service. On 4/23/25 at 8:45 AM, V8, R2's family member, stated R2 is Autistic and doesn't always know or understand what is going on. V8 stated about a year ago, he had his gallbladder removed at a local hospital, he developed an infection in his blood and surgical wound resulting in the colostomy. V8 stated R2 was transferred to a higher acuity hospital, then to 2 different rehab hospitals and before coming to this facility. V8 stated R2 has been at the facility for a short time and the staff isn't changing his colostomy bag, so feces is coming out and sitting on his skin for long periods of time resulting in a painful red rash all over his belly. V8 stated when R2's bag is full, that is when it leaks onto his belly and into his folds. On 4/23/25 at 11:00 AM, V1, Administrator, stated he spoke with V8, R2's family member, regarding her concerns with R2's care. V1 stated they had placed a diaper on R2, so he put a sign on R2's wall, not to use diapers and educated the staff. V1 stated he isn't familiar with colostomies, so he spoke with V5, Wound Nurse, who explained to him that when the feces sits on the skin it can make it excoriated and he recommended to place a towel under and below the colostomy in case it starts leaking. V1 has instructed the nursing staff to make sure it is checked frequently, and care provided as needed. V1 stated the problem occurred (referring to the grievance) during the night with an agency nurse that wasn't familiar with R2's care or how he is because they don't have any other residents like him, so that agency nurse was also educated. V1 stated he checks on R2 and speaks with V8 everyday to make sure R2 is being cared for. On 4/24/25 at 10:50 AM, V5, Wound Nurse, stated feces shouldn't be left on the skin because it causes excoriation. V5 stated he would expect the nursing staff to keep R2 clean, change his bag and apply the creams as ordered. The Incontinence Care Policy, dated 1/2025, documents incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown.

Based on observation, interview, and record review, the facility failed to provide colostomy care to 1 of 1 resident (R2) reviewed for ostomy care in the sample of 6. This failure resulted in R2 developing painful, red excoriation around the colostomy site extending down to the abdomen and perineal area. Findings include: On 4/23/25 at 8:45 AM, R2 was observed in bed with V8, R2's family member at bedside. R2's colostomy site and abdomen were observed with V8. There was a towel covering R2's abdomen, no abdominal binder present, V8 removed the towel and R2's colostomy bag was about 3/4 full and was leaking moderate amounts of liquid stool onto R2's abdomen, down into R2's abdominal folds, perineal area and under R2's bottom. R2's abdomen was red and excoriated. R2 was stating don't touch it, it hurts, burns and was shaking, appearing to be apprehensive and in pain. On 4/23/25 at 8:55 AM, R2 turned his call light on, V9, CNA (Certified Nurse's Assistant) came into the room, asked what was needed and then left the room to gather supplies. Upon V9's return, V9 explained to R2 that she was going to clean him up, R2 was shaking his head no and stating it hurts, it burns, don't use the cleaner in the white bottle pointing to a bottle of wound cleanser. V9 was able to calm R2 and R2 agreed to allow V9 to clean him up. V9 attempted to clean R2, but liquid feces continued to leak from the bottom of the colostomy wafer that attaches to the bag. During this time R2 continued to shake and appeared to be in pain. V9 stated the nurse would need to change the colostomy bag because it kept leaking. V9 then left the room and notified V10, RN (Registered Nurse). On 4/23/25 at 9:20 AM, V10, RN, came into R2's room to change R2's colostomy wafer and bag. The wafer and bag was removed with red excoriation noted around the colostomy site extending down to R2's abdomen, abdominal folds and perineal area. V10 cleaned around R2's colostomy site and abdomen with incontinence wipes, then applied a new wafer and bag. V10 told R2 and V8 that she would need to get a CNA to finish cleaning R2 up because she still had a lot of medications to give. The liquid feces remained on R2's lower pubic area, buttocks on on the incontinence pad underneath R2. On 4/23/25 at 10:30 AM, R2 was observed still soiled with liquid feces on his lower pubic area, buttocks and incontinence pad. An aide from Hospice, came in R2's room to see him, V8 told her that he had been waiting over an hour to get cleaned up. The aide then cleaned R2 up. R2's perineal area and buttocks were red. V8 was in R2's room and stated she has been at R2's bedside and no one from the facility came in to change R2, so the hospice aide did it, the facility CNAs never came to R2's room after V10 left the room. On 4/23/25 and 4/24/25, R2 was observed without the abdominal binder in place. R2's Face Sheet, undated, documents R2 has the following diagnoses: Unspecified Kidney Injury, Pituitary Dependent Cushing's Disease, Hypertension, Autism, Congenital Renal Failure, Acquired Absence of Parts of the Digestive Tract, Presence of Functional Implants, Acute Infarction of the Large Intestine, Chronic Kidney Disease and Critical Illness Polyneuropathy. R2's (MDS) Minimum Data Set, dated dated [DATE], documents R2 has a BIMS (Brief Interview of Mental Status) score of 8, indicating R2 has moderate cognitive impairment, is dependent with toileting and has no skin issues. R2's Care Plan, dated 4/21/25, documents R2 requires assist with daily care needs, is incontinent of bowel and bladder, has a potential risk for complications related to altered elimination for bowel elimination, as evidenced by a colostomy and is at risk for skin complications related to Stoma Incontinence Associated Dermatitis with an intervention to provide skin care after each incontinence episode. R2's Progress Note, dated 3/25/25 at 11:44 AM, documents the following: Patient arrived at nursing facility via EMS (Emergency Medical Services. Patient transferred from gurney into bed. Patient oriented to room and call light system. Patient was able to give return demonstration on using the call light. Patient alert and oriented times 3. The patient reports feeling nervous and afraid. Patient reassured that he was safe, and the nursing staff will attend to his needs. Patient mother at bed side. The patient denied pain at time of assessment. Patient respiration even and not-labored. Patient lungs clear throughout. Patient noted to have a g-tube (gastrostomy tube) at left mid abdomen- patent and intact, colostomy at right mid abdomen- no stoma noted. Patient has an opening to the right mid abdomen, but stoma is submerged in abdominal cavity. Abdominal area surrounding opening red and excoriated. Patient abdomen soft and non-distended. Patient bowel sound present. The patient is noted to have redness to pannus and groin and perineal area. Patient to bed sent to ER (emergency room ) for evaluation for stoma evaluation. R2's Progress Note, dated 3/25/25 at 5:32 PM, documents the following: Patient back from hospital at 1733 (5:33 PM) via 2 EMT (Emergency Medical Technician). Resident's stoma looks normal. Resident is resting in bed with his family around. No c/o (complaints) pain and distress. Will continue to monitor. R2's Progress Note, dated 4/8/25 at 9:21 PM, documents the following: Patient continues on hospice care, g-tube patent/intact, remains afebrile. Colostomy intact, patient keeps messing with it, so it keeps leaking. Skin on abdomen has redness. Patient cleaned as needed. Plan of care ongoing. R2's Progress Note, dated 4/9/25 at 10:39 AM, This Care Plan nurse met with resident and residents' mother regarding resident pulling and tampering with colostomy device after being placed on resident. Residents mother expressed that resident has no understanding due to his diagnosis of why he shouldn't mess with the colostomy device and the risk of further damaging the skin integrity by doing so. Resident was encouraged to notify staff if his colostomy was bothering him which he agreed. Resident colostomy bag is currently in place and intake. Staff will be encouraged to check resident for any signs of colostomy bag being compromised. R2's Wound Care Note, dated 4/8/25, documents R2 has incontinence associated dermatitis. Treatment: cleanse wound with soap and water, pat dry and apply triad and miconazole cream BID (twice daily) and PRN (as needed). Leave open to air. R2's Wound Care Note, dated 4/15/25, documents R2's incontinence associated dermatitis is resolved and triad and miconazole cream was changed to PRN. R2's (POS) Physician Order Sheets were reviewed with the following orders noted: 3/28/25, Comfort focused treatment; 3/28/25 - Abdominal Binder/Elastic Large Miscellaneous (Elastic Bandages & Supports). Apply to Abdomen topically one time a day for skin redness; Excoriation; 4/15/25 - Triad Hydrophilic Wound Dress External Paste. Apply to Abdomen and Groin topically as needed for skin redness; 4/15/25 - Micatin Cream 2 % (Miconazole Nitrate). Apply to Abdomen and Groin topically as needed for skin redness. There were no orders for colostomy care or how often to change the colostomy bag on the POS. R2's (TAR) Treatment Administration Record, documents the following: Micatin (Miconazole) and Triad cream was not applied as ordered on 4/8/25, 4/9, 4/12/25, or 4/15/25. The new orders on 4/15/25, changing them to PRN has not been applied since the new order was received. There was no documentation of colostomy care or when the colostomy bag was changed on the TAR. R2's Grievance, dated 4/16/25, filed by V8, documents R2 was put in diapers and not attended to throughout the night. Findings: CNA educated on the needs of the resident and customer service. On 4/23/25 at 8:45 AM, V8, R2's, family member, stated R2 is Autistic and doesn't always know or understand what is going on. V8 stated about a year ago, he had his gallbladder removed at a local hospital, he developed an infection in his blood and surgical wound resulting in the colostomy and he has a feeding tube that they use for his medications because he won't take them by mouth. V8 stated R2 was transferred to a higher acuity hospital, then to 2 different rehab hospitals and then to this facility. V8 stated he has been at the facility for a short time and the staff isn't changing his colostomy bag, so feces is coming out and sitting on his skin for long periods of time resulting in a painful red rash all over his belly. V8 stated when R2's bag get's full, that is when it leaks onto his belly and into his folds. V8 stated some of the nurses told her that he messes with it, but that isn't true, he doesn't like it to be changed because it hurts, but he does allow them to do it, he just moves around. V8 stated sometimes he'll remove the towel to look and see what it looks like when it's leaking and then covers it back up. V8 stated the problem was mainly on the night shift. V8 stated R2 is on hospice because his kidneys are failing, and they decided not to put him on hemodialysis. V8 stated hospice provides all of R2's colostomy, incontinent supplies and medications/creams/powders. On 4/24/25 at 8:30 AM, V8, family member at bedside and stated no one has come into R2's room to check on him this morning. On 4/23/25 at 9:20 AM, V10, RN, stated the nurses change the colostomy bags as needed. V10 stated, R2 is picky with his changes, because he knows what makes him hurt and what doesn't, so he only likes certain products used. V10 stated hospice provides R2's colostomy supplies, wound care medications/powders/creams, incontinent wipes and incontinent pads. On 4/23/25 at 9:30 AM, V4, MDS/Care Plan Coordinator, stated R2 picks at the colostomy bag so it becomes loose and leaks. On 4/23/25 at 11:00 AM, V1, Administrator, stated he spoke with V8, regarding her concerns with R2's care. V1 stated they had placed a diaper on R2, so he put a sign on R2's wall, not to use diapers and educated the staff. V1 stated he isn't familiar with colostomies, so he spoke with V5, Wound Nurse, who explained to him that when the feces sits on the skin it can make it excoriated and he recommended to place a towel under and below the colostomy in case it starts leaking. V1 has instructed the nursing staff to make sure it is checked frequently, and care provided as needed. V1 stated the problem occurred (referring to the grievance) during the night with an agency nurse that wasn't familiar with R2's care or how he is because they don't have any other residents like him, so that agency nurse was also educated. V1 stated he checks on R2 and speaks with V8 everyday to make sure R2 is being cared for. On 4/24/25 at 10:50 AM, V5, Wound Nurse, stated they are using Miconazole and Triad creams for R2's excoriation to his abdomen. V5 stated it helps with the excoriation and the burning sensation/pain caused by the excoriation. V5 stated the excoriation is chronic, comes and goes. V5 stated R2's reaction to the excoriation is 50/50 pain and anxiety, R2 has Autism, so it causes him anxiety and he guards that area. V5 stated R2 does pick/mess with the bag, and it leaks constantly. V5 stated feces shouldn't be left on the skin because it causes excoriation. V5 stated he would expect the nursing staff to keep R2 clean, change his bag and apply the creams as ordered. The Colostomy/Ileostomy Care Policy, dated 6/2015, documents the purpose is to provide guidelines that will promote cleanliness, protect peritoneal skin from irritation and infection and exposure to fecal matter. Colostomy/Ileostomy bags will be changed at a minimum once every 5 days and as needed. Apply barrier cream as indicated, document in the nursing notes any skin issues and the condition of the stoma, report these issues to the physician, and document the changing of the colostomy bag on the TAR.

Based on observation, interview, and record review, the facility failed to identify pain and provide pain relief to 1 of 1 resident (R2) reviewed for pain management in the sample of 6. This failure resulted in R2 having pain and discomfort related to excoriation around his colostomy site extending down to the abdomen and perineal area and that is not being treated or recognized. Findings include: On 4/23/25 at 8:45 AM, R2 was observed in bed with V8, family member, at bedside. R2's colostomy site and abdomen were observed with V8. There was a towel covering R2's abdomen, no abdominal binder present, V8 removed the towel and R2's colostomy bag was about 3/4 full and was leaking moderate amounts of liquid stool onto R2's abdomen, down into R2's abdominal folds, perineal area and under R2's bottom. R2's abdomen was red and excoriated. R2 was stating don't touch it, it hurts, burns and was shaking, appearing to be apprehensive and in pain. On 4/23/25 at 8:55 AM, R2 turned his call light on, V9, CNA (Certified Nurse's Assistant) came into the room, asked what was needed and then left the room to gather supplies. Upon V9's return, V9 explained to R2 that she was going to clean him up, R2 was shaking his head no and stating it hurts, it burns, don't use the cleaner in the white bottle pointing to a bottle of wound cleanser. V9 was able to calm R2 and R2 agreed to allow V9 to clean him up. V9 attempted to clean R2, but liquid feces continued to leak from the bottom of the colostomy wafer that attaches to the bag. During this time R2 continued to shake and appeared to be in pain. On 4/23/25 at 9:20 AM, V10, RN, came into R2's room to change the colostomy bag. The bag was removed and there was red excoriation noted around the colostomy site extending down to R2's pubic area. V10 cleaned around the colostomy site, R2's abdomen and pubic area with incontinent wipes, this is what R2 prefers to be used. V10 then placed a new colostomy bag and told R2 and V8 that she would need to get the CNA to finish cleaning him up because she still had a lot of medications to give. No creams were applied, and the feces remained on R2's lower pubic area, buttocks and on the disposable incontinence pad under R2. On 4/23/25 at 10:30 AM, R2 was still soiled and hadn't been cleaned up, hospice aid arrived and cleaned R2 up. R2's perineal area and buttocks were red. V8, R2's Mom, in room and stated she has been at R2's bedside and no one from the facility has changed R2 until now, the CNA never came back to the room after V10 left. R2's Face Sheet, undated, documents R2 has the following diagnoses: Unspecified Kidney Injury, Pituitary Dependent Cushing's Disease, Hypertension, Autism, Congenital Renal Failure, Acquired Absence of Parts of the Digestive Tract, Presence of Functional Implants, Acute Infarction of the Large Intestine, Chronic Kidney Disease and Critical Illness Polyneuropathy. R2's (MDS) Minimum Data Set, dated dated [DATE], documents R2 has a BIMS (Brief Interview of Mental Status) score of 8, indicating R2 has moderate cognitive impairment. R2's Care Plan, dated 4/21/25, documents R2 has an alteration in comfort due to advanced disease process with the following interventions: assess effectiveness of pain medication, assess pain characteristics: duration, location, quality, encourage to report any pain, and to report any acute changes to Physician. There are not any interventions for R2's pain from the excoriation or how to effectively assess and act on R2's pain in relationship to his diagnosis of Autism and cognitive disabilities. R2's Progress Note, dated 4/8/25 at 9:21 PM, documents the following: Patient continues on hospice care, g-tube patent/intact, remains afebrile. Colostomy intact, patient keeps messing with it, so it keeps leaking. Skin on abdomen has redness. Patient cleaned as needed. Plan of care ongoing. There was no documentation in R2's records of him being assessed for pain since 3/30/25. R2's Wound Care Note, dated 4/8/25, documents R2 has incontinence associated dermatitis. Treatment: cleanse wound with soap and water, pat dry and apply triad and miconazole cream BID (twice daily) and PRN (as needed). Leave open to air. R2's Wound Care Note, dated 4/15/25, documents R2's incontinence associated dermatitis is resolved and triad and miconazole cream was changed to PRN. R2's (POS) Physician Order Sheets were reviewed with the following orders noted: 3/28/25, Comfort focused treatment; 4/15/25 - Triad Hydrophilic Wound Dress External Paste. Apply to Abdomen and Groin topically as needed for skin redness; 4/15/25 - Micatin Cream 2 % (Miconazole Nitrate). Apply to Abdomen and Groin topically as needed for skin redness. R2's (TAR) Treatment Administration Record, documents the following: Micatin (Miconazole) and Triad cream has not been applied since 4/14/25. R2's Pain Assessment, dated 3/25/25, documents the following: pain scale for cognitively impaired: displays vocal c/o (complaints) pain, facial grimacing, bracing and restlessness, characteristics - aching, burning, Faces scale - hurts a little bit. On 4/23/25 at 8:45 AM, V8, family member, stated R2 is Autistic and doesn't always know or understand what is going on. V8 stated about a year ago, he had his gallbladder removed at a local hospital, he developed an infection in his blood and surgical wound resulting in the colostomy. V8 stated R2 was transferred to a higher acuity hospital, then to 2 different rehab hospitals and then to this facility. V8 stated he has been at the facility for a short time and the staff isn't changing his colostomy bag, so feces is coming out and sitting on his skin for long periods of time resulting in a horrible painful red rash all over his belly. V8 stated when R2's bag is full, that is when it leaks onto his belly and into his folds. V8 stated some of the nurses told her that he messes with it, but that isn't true, he doesn't like it to be changed because it hurts, but he does allow them to do it, he just moves around. On 4/24/25 at 8:30 AM, V8, R2's Mom at bedside and stated no one has come into R2's room to check on him this morning. On 4/24/25 at 10:50 AM, V5, Wound Nurse, stated they are using Miconazole and Triad creams for R2's excoriation to his abdomen. V5 stated it helps with the excoriation and the burning sensation/pain caused by the excoriation. V5 stated the excoriation is chronic, comes and goes. V5 stated R2's reaction to the excoriation is 50/50 pain and anxiety, R2 has Autism, so it causes him anxiety and he guards that area. V5 stated feces shouldn't be left on the skin because it causes excoriation and pain. V5 stated he would expect the nursing staff to keep R2 clean, change his bag and apply the creams as ordered. The Pain Management Policy, dated 1/20/20, documents the following: The purpose is to facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. The pain management is based on a facility-wide commitment to resident comfort. Pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical need. Pain management is a multidisciplinary care process that includes the following: effectively recognizing the presence of pain, identifying the characteristics of pain, addressing the underlying causes of the resident's pain, identifying and using specific strategies for different levels and sources of pain, monitoring for the effectiveness of interventions and modifying approaches as necessary. Pain will be assessed at least once every shift and documented in the EMAR (Electronic Medication Record) using the pain scale appropriate for the patient. Based on the documentation, a pain management care plan will be developed, maintained, and/or updated. If nursing staff recognizes pain, the staff may attempt non-pharmacological interventions, physical modalities, body alignment, rehabilitation therapy, exercises, and/or cognitive behavioral interventions.

Based on observation, interview, and record review, the facility failed to prevent physical abuse for 3 of 4 residents (R5, R6, R10) reviewed for Freedom from Abuse and Neglect in a sample of 16. This failure resulted in R6 acquiring a subarachnoid hemorrhage and left orbital wall fracture. Findings include: 1. R6's Face Sheet documented R6 was admitted to the facility on [DATE] with diagnosis of, in part, bipolar disorder, chronic obstructive pulmonary disease and dementia. R6's Minimum Data Set (MDS) dated [DATE] documented she was cognitively intact. R7's Face Sheet documented R7 was admitted to the facility on [DATE] with diagnosis of, in part, schizophrenia, bipolar disorder and dementia. R7's MDS dated [DATE] documented he was cognitively intact. Facility's Serious Injury Incident and Communicable Disease Report dated 3/21/25 documented, It was alleged that there was a resident to resident altercation between (R6) and (R7). Upon investigation, (R7) was in the bathroom when (R6) entered and stood in the doorway as he was using it with her back to him. When he was done, he exited the bathroom pushing her with one hand saying move out my way. (R6) stumbled forward and fell face first to the floor. She was immediately assessed and sent to hospital. I (V1, Administrator) was notified of her being transferred and admitted to another hospital and as a result from this incident she has a fracture of left orbital floor and subarachnoid hemorrhage. The report continued to document, Upon investigation, (R6) was standing in front of the resident restroom door by the nurse's station when a resident was coming out of the restroom. He tried to move her out of the way so he could get by, and she fell face first sustaining a head laceration. She was sent on 3/16/25 to the hospital for evaluation. I (V1) was notified on 3/21/25 when we received and reviewed documentation from the hospital. It was noted she was diagnosed with a subarachnoid hemorrhage with left orbital fracture. Hospital Progress Note dated 3/19/25, documented R6 was diagnosed with SAH (subarachnoid hemorrhage and a L(left) interior orbital wall fracture. Police report dated 3/18/25, documented On March 18, 2025, the office manager of the facility contacted detective from the number. The manager stated that the incident occurred around approximately 1400 - 1430 hours (2:00 PM-2:30 PM) but it was not captured on video due to the angle of the camera in relation to where the incident occurred. On 3/26/25 at 3:00 PM, R15 stated he saw R7 push R6 down and R6 was lying face down on the floor with blood around her. R15 stated R6 hit her head. R15 stated he did not hear any yelling. R15 stated he thinks R6 made R7 mad by walking in on him while he was using the restroom. On 3/25/25 at 12:35 PM, V1 stated R7 was on the toilet when R6 opened the door on him. R6 yelled and preceded to stand in the doorway with her back toward R7. R7 got up and told R6 to move out of the way while pushing her over. V1 stated he did not witness the incident, but V14 CNA did and R15 did. V1 stated R6 suffered a subarachnoid hemorrhage and was sent to the emergency room immediately. V1 stated he reported the incident. On 3/25/25 at 1:06 PM, V17, R6's daughter/guardian, stated R6's injuries don't seem to match with what the facility says happened. V17 stated R6 suffered life threatening injuries including a brain bleed and broken orbital socket and is still in the hospital now. V17 stated R6 could only remember she was with a staff member then blacked out and was in the ambulance. V17 stated she did talk to the police. On 3/26/25 at 12:30 PM V16, Licensed Practical Nurse, LPN stated R6 gets into a lot of issues and roams a lot, she never liked staying on the female side, would sleep over by the vending machines at the end of the hall down the men's side all the time. V16 stated R6 would get upset easily if someone said or did something she didn't like. V16 stated R6 was just really psychotic, she might be hearing different things not there. V16 stated she's not aware of anything the staff is/was supposed to be doing to try to prevent R6 and R7 from getting into an incident of abuse. On 3/26/25 at 1:15 PM, V15 LPN, stated R6 was noncompliant and very verbally abusive to staff, she was a lady with a lot of behaviors, and it put her in bad situations with other residents. V15 stated R6 was set in her own ways and dismissive to those around her. V15 stated R6 was just a time bomb waiting for something bad to occur, this place was not appropriate for her. V15 stated she's seen R7 hit and punch staff in the past, he doesn't care about others and doesn't understand others enough to prevent an altercation. V15 stated when physical abuse occurs between residents, she separates them first, tends to injuries, notifies the proper people and the administrator. V15 stated 1 on 1 observation interventions seem to really help improve prevention from abuse reoccurring. On 3/26/25 at 1:20 PM V5, Certified Nursing Assistant (CNA) stated R6 was aggressive and confrontational with verbal outbursts, also stubborn with how she wanted things, would curse a lot. V5 stated if R6 could have been strictly separated from the male's side we might not have failed to prevent the incident. On 3/26/25 at 1:43 PM V7, LPN stated V7 stated R6 used to use the restroom on the male's side and her behaviors put her at risk of abuse and she would try to relocate her as much as she could because the men on this side are easily agitated. On 3/26/25 at 4:00 PM, V14 CNA stated she saw the altercation between R6 and R7 take place. V14 stated she heard commotion from R7 yelling which got her attention. V14 stated she saw R6 hit the floor and then R7 came out of the restroom behind her and walked away. V14 stated R6 hit her head, was bleeding and loss consciousness. V14 stated R6 really liked to be over on the male's side but some of the male residents did not like her being over there. V14 stated R7 was probably upset R6 walked in on him using the restroom. 2. R11's face sheet documented R11 was admitted to the facility on [DATE] with diagnosis of, in part, encephalopathy, type two diabetes mellitus, and hemiplegia and hemiparesis. R5's Face Sheet documented R5 was admitted to the facility on [DATE] with diagnosis of, in part, paranoid schizophrenia, mild cognitive impairment and hypertension. The Facility's Serious Injury Incident and Communicable Disease Report dated 3/5/25 documented that R5 was the alleged victim of R11. The report further documented, It was reported that (R11) allegedly stuck (R5) in the dining room. Resident assessment no injuries noted. Local police notified. Investigation initiated. Final to follow. Upon investigation, (R5) took (R11's) food off his plate and ate it. (R11) was upset and made contact with (R5's) chest staff immediately intervened separating both residents removing them from the dining room. (R5) was assessed and no injuries noted. After interviewing him, an order was placed for double portions due to him saying he was still hungry. Staff explained to him that he could have asked for another helping of food. He said he understood. (R11) was educated on informing staff of any issues he may have so that staff can assist him, but it is not ok to put his hands on anyone. Also, both residents had psychosocial follow up interviews, updated care plans and all staff inserviced on abuse and neglect reporting. 3. R10's face sheet documented R10 was admitted to the facility on [DATE] with diagnosis of, in part, unspecified injury of head, traumatic subdural hemorrhage with loss of consciousness, and bipolar disorder. R14's face sheet documented R14 was admitted to the facility on [DATE] with diagnosis of, in part, bipolar disorder, type two diabetes mellitus, and major depressive disorder. The facility's incident report dated 12/19/24, documented, This nurse was alerted by nursing staff that help was needed. On assessment (R10) was in room (XXX) on the floor. Nursing staff stated another resident had pushed (R10) down after he was in their room touching their belongings. (R10) unable to give description. The report continued to document, Nursing staff alerted to (R14's) room. At that time another resident was found on the floor. Nursing staff states (R14) pushed another resident down when the resident entered his room without his knowledge. (R14) states I'm tired of him coming to my room taking my things! You cannot tell me physical abuse and mental abuse are not the same! On 3/27/25 at 1:05 PM, V2, Assistant Director of Nursing, stated all residents have the right to be free of abuse. On 3/27/25 at 9:13 AM, V1, Administrator, stated he agreed that the residents have a right to be free of abuse/neglect/misappropriation. The facility's Abuse Policy and Prevention Program dated 2022, documented, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, or mistreatment of residents.

Based on interviews, observations, and record reviews the facility failed to prevent development of additional pressure injuries for 1 of 3 residents, (R1) reviewed for treatment/services to prevent/heal pressure ulcers in a sample of 16. This failure resulted in R1 developing two new Stage 2 pressure injuries. Findings include: R1's Face Sheet, documented R1 was admitted to the facility on [DATE] with diagnosis of, in part, paranoid schizophrenia, pressure ulcer stage 3, and atherosclerotic heart disease. R1's Minimum Data Set (MDS) dated [DATE], documented he is moderately cognitively impaired and required partial/moderate assistance with toileting hygiene; substantial/maximal assistance with showering/bathing and all transfers; and partial/moderate assistance with rolling left to right in bed. R1's Care Plan dated 1/24/25 documented he is at risk for skin complications r/t (related to) psychotropic medications and impaired independence with activities of daily living functions. Stage 3 Pressure ulcer to Coccyx on 6/18/25 interventions to assess and document of progress of areas weekly. On 1/10/25 intervention to assist and encourage resident to turn and reposition every one to two hours and as needed. R1's care plan also documented he has a self-care deficit in bed mobility related to decreased ability to position or reposition self in bed/ turn from side to side; on 11/29/23 a halo bar was placed above the resident's bed for turning and repositioning and to assist with transfers; on 11/29/23 position and reposition resident in bed for comfort, joint support, and skin integrity. On 3/25/25 this surveyor observed R1 to be on his left side at 8:25 AM, 8:35 AM, 8:49 AM, 8:55 AM, 9:10 AM, 9:11 AM, 9:23 AM, 9:35 AM, 9:50 AM, 10:01 AM, 10:16 AM, 10:28 AM. R1's door was left closed from 10:32 AM until 11:22 AM. On 3/25/25 this surveyor observed R1 still on left side at 11:22 AM and 11:33 AM. On 3/24/25 at 9:50 AM, R1 had a sign above his bed stating, turn schedule. On 3/24/25 at 1:50 PM V7, Licensed Practical Nurse (LPN) stated she was not sure how long R1 has had his pressure ulcer but thinks it should be improving with the wound vac, he is typically compliant with that. On 3/24/25 at 2:00 PM, V8, Wound Nurse, stated R1's pressure ulcer was in house acquired and R1 has had it for about 6 months, it started out as moisture associated because he likes to pour liquids on himself leaving him wet. V8 stated the ulcer had slough around it at first and was small but then went to the hospital and came back with it debrided and a lot larger. V8 stated he emphasizes implementing care plans and following interventions to improve patient care. On 3/25/25 at 1:17 PM, V8, provided R1 wound care to his stage 4 pressure injury while he was on his left side. After pressure ulcer care was completed, V8 got V11, Certified Nursing Assistant (CNA) to come assist him with peri care on R1. While V11 turned R1 on to his right side, two pressure ulcers with no dressings on them were noticed. V8 stated these were new, facility acquired pressure ulcers. The pressure ulcer to R1's left ischial had approximately 5-6 centimeters of erythema surrounding a darken red wound bed of granulation tissue that was approximately 2 centimeters in diameter with a skin flap peeled open, this part of the wound did not blanch when V8 applied pressure to it. V8 stated he would call this an open blister. R1's new pressure ulcer to his left hip had erythema covering approximately 4 centimeters in width by 1.5 centimeters in length with a patch of open excoriated skin in the center approximately 0.5 centimeter in diameter. V8 stated that the hip pressure ulcer was from R1's catheter tubing being underneath him while on his left side, it has the exact indentation of it. V8 stated it could have been caused by excessive time being on top of the tubing without being repositioned. V8 preceded to take pictures of both the wounds, applied skin prep to them and a bordered foam dressing to the left ischial and an island dressing to the left hip. V8 stated he would notify the wound nurse practitioner and get new orders for care. At 2:23 PM, V11 and V8 turned R1 back on to his left side. V11 and V8 stated they turned R1 on his left side again because he won't stay on his right side. V11 and V8 stated we can turn R1 on his right side and show that he won't stay there. R1 was turned to his right side by V11 and V8 cooperatively without complaints or refusal. R1's Skin and Wound assessment dated [DATE] documented an in-house acquired blister to his left ischial tuberosity involving 100% granulation to the wound bed and to have erythema surrounding it. On 3/25/25, a second Skin and Wound Assessment documented a new in-house acquired skin tear to R1's rear left trochanter (hip) with 100% granulation to the wound bed and erythema surrounding. On 3/26/25 at 8:41, AM, R1 stated he doesn't mind being turned and doesn't refuse unless the staff reposition him roughly because his butt hurts. R1 stated the staff will sometimes drag my butt when they turn me and it hurts a lot but if they are gentle, I don't care what side I'm on. R1 stated no one asked or offered to turn me yesterday. R1 stated he was on his left side for most of the day 3/25/25. On 3/26/25 at 3:53 PM, R16, R1's roommate, stated he doesn't see staff come in and turn him frequently. On 3/26/25 at 12:30 PM, V16, LPN, stated residents are on turn schedules to prevent break down of the skin, if a resident is non-compliant V16 stated she would try to at least offer a wedge under one side to turn even slightly. On 3/26/25 at 1:20 PM, V5 CNA stated turning schedules prevent skin break down and wounds from worsening, typically occurring every 1-2 hours. V5 stated if a resident is noncompliant with turning, a wedge can be used to turn them slightly and offer encouragement. V5 stated if a resident is not turned it is likely to cause a sore. On 3/27/25 at 1:05 PM, V2, Assistant Director of Nursing, stated she expects the nursing staff to be turning residents that require it at least every two hours, if they do not turn a resident within that timeframe, they are at risk for causing skin break down. V2 stated she does not expect a resident to be lying on top of a catheter tube, this could cause skin sores. The facility's Turning and Reposition Policy dated 8/2024 documented all residents at risk of, or with existing pressure injuries, will be turned and repositions, unless it is contraindicated due to a medical condition. In this case, small shifts in repositions with be employed. Repositioning techniques in bed includes avoiding positioning the resident onto medical devices or other foreign objects and avoid positioning residents on surfaces with existing pressure injuries, including persistent redness. Repositioning techniques in chair include if the resident is unable to make position changes, reposition every hour. The facility's Skin Management: Pressure Injury Treatment/General Wound Treatment Policy dated 10/2024 documented for management of tissue loads, pressure redistribution devices offer an effective means of reducing interface pressure but because they cannot provide pressures consistently less than 25 to 32 mm/HG (millimeters of mercury), a turning schedule should be implemented as well.

Based on interview and record review the facility failed to prevent abuse for 3 of 7 (R20, R30, R62) residents investigated for resident-to-resident abuse in a sample of 39. Findings include: 1. R20's EMR (Electronic Medical Records) undated documents that the resident was admitted to the facility on [DATE]. R20's EMR dated 07/28/16 documents a diagnosis of Schizophrenia. R20's MDS (Minimum Data Set) dated 02/04/25 documents a BIMS (Brief Interview for Mental Status) score of 6 out of 15. The MDS documents that the resident has not exhibited physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, or other behavioral symptoms not directed towards others. R20's Care Plan dated 9/27/23 documents (R20) has a history of aggressive, inappropriate, attentions-seeking and/or maladaptive behavior. The resident has a diagnosis of paranoid schizophrenia. 06/14/22 (R20) was verbally and physically aggressive towards a peer. 02/19/23 Got mad and was verbally aggressive towards staff in the dining room and threw his drink on staff. 3/15/23 verbally aggressive with staff in dining room. 7/18/23 (R20) was noted being physically aggressive with staff. 9/9/2023 (R20) became physically aggressive towards another resident. 09/26/2023 - physically aggressive. R20's Nurses Notes dated 05/01/24 at 9:40 PM documents Per stated res was in dinning threw and hit resident (R31) with a chair, unknown why, called police report # 2024-025107, V18, NP (Nurse Practitioner), (V19) POA (Power of Attorney) aware at this time. Facility's Abuse Report dated 05/01/24 documents Resident (R20) tossed chair in dining room in the direction of resident (R31). She was assessed for injury and notifications made to respective RP's and doctors. Resident separated and ADM notified. Investigation started. Final report to follow. Based on resident and staff interviews and statements from residents involved, the allegation was substantiated. The perpetrator admitted that he threw the chair but gave no reason for the action. However, due to his diagnosis and the circumstance surrounding the incident, he gave no indication that he intended to harm the victim. It is possible that he tossed the chair in her direction because the other resident was merely in the dining room. R20's Nurses Note dated 12/22/24 at 3:50 PM documents The resident hit another resident with the caution floor sign. I redirected the resident to his room. I notified the on-call nurse at 1555 pm and she returned my call at 1611 pm. I notified the resident's POA (V19) at 1615 pm. Facility's abuse investigation dated 12/22/24 documents Res to Res incident. (R59) walked into (R20's) room to talk to his roommate and (R20) got upset. (R20) hit (R59) with the floor sign. Nurse assessed (R59) and he denied pain. No bruising or injury noted. QA (Quality Assurance) team met and will discuss with (R59) to not enter that room and to ask the roommate to go to his room. 2. R30's EMR undated documents that the resident was admitted to the facility on [DATE]. R30's EMR dated 4/12/19 documents a diagnosis of Schizophrenia, unspecified. R30's MDS dated [DATE] documents that a BIMS score could not be completed because resident is rarely/never understood. The MDS documents that the resident has not exhibited physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, or other behavioral symptoms not directed towards others. R30's Care Plan dated 5/10/24 documents (R30) is at risk for abuse and/or neglect related to Dx: Schizophrenia, psychotropic medications, diagnosis of dementia, confusion/disorientation/forgetfulness, poor judgement skills, difficulty in communication, history of verbal and physical aggression and poor personal hygiene. (R30) will mumble at times while walking around the facility. (R30) will curse at staff and peers. 9/29/23 resident was reported to have had an incident with peer. 10/5/23 chair was pushed into this resident's arm by peer. 5/1/24 resident physically aggressive with peer. There is no progress note for this incident. Facility's Abuse Investigation dated 12/14/24 documents (R30) went to grab (R31) cup of water and (R31) started to yell at her. (R30) punched (R31) in the face. No injuries noted. (R31) denied any pain. No swelling noted. Resident immediately separated by staff. 3. Facility's Abuse Investigation dated 07/05/24 documents (R92) a 60 y/o male whom is A/O to self with the following DX: other schizophrenia, diffuse traumatic brain injury without loss of consciousness, subsequent encounter. (R62) a 48 y/o female whom is A/O to person, place and situation with the following DX: Major depressive disorder, undifferentiated schizophrenia. (R92) made contact with (R62) to obtain attention causing (R62) to become agitated making contact back. Both residents moved to different tables to prevent further incidents. Both interviewed and both feel safe in facility. Both will remain in facility with no further incidents. Behavior tracking already in place and will continue. MD and POA notified. Care plan updated. There is no progress note noted for this incident. R62's EMR undated documents that the resident was admitted to the facility on [DATE]. R62's EMR dated 7/31/19 documents a diagnosis of undifferentiated schizophrenia. R62's MDS dated [DATE] documents a BIMS score of 13 out of 15. The MDS documents that the resident has not exhibit physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, or other behavioral symptoms not directed towards others. R62's Care Plan 7/12/24 documents (R62) is at risk for abuse and/or neglect related to DX: Schizophrenia, Major Depression, and Cognitive impairment, psychotropic medication use, poor judgement skills. 02/02/2022 resident was involved in an altercation with peer. 7/5/24 resident was physically aggressive with peer as well as a recipient. On 3/14/25 at 12:15 PM, V22, Social Worker stated that if residents are being aggressive with each other than we split them up. We have the residents sign a behavioral contract. With the behavioral contract the resident knows that there are consequences to their actions. The social workers will also do a 1 to 1 psychosocial meeting with the residents. We do behavior tracking on the residents. On 3/14/25 at 12:20 PM, V23, LPN (Licensed Practical Nurse) stated that the first thing she does is contact the administrator if there is an incident between two residents. She stated that the staff will try to de-escalate the situation. We separate the individuals. We are not allowed to touch the residents. We fill out an incident report. We notify the MD (Medical Director) and the guardian or POA. Sometimes we do room moves but that must be approved by administration. She stated they monitor all residents across the board. All residents are treated the same. She stated that with R20 it's all about tone. She stated that he is usually verbally aggressive. She stated that they monitor individuals that are prone to aggression a little closer. Facility's Abuse Prevention Program dated 9/2017 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents.

Based on observation, interview and record review the facility failed to assess and document a head to toe skin assessment upon readmission to the facility for 1 (R44) of 1 resident reviewed for pressure wounds in the sample of 39. This failure resulted in the deterioration of the pressure ulcer from a stage II to a stage III. R44's Undated Face Sheet documents initial admitted [DATE] diagnoses of spina bifida and pressure ulcer of sacral region unspecified stage. R44's Annual Minimum Data Set (MDS) dated [DATE] documents she is alert and no pressure ulcers, not at risk for pressure ulcers, no unhealed pressure ulcers. R44's Care Plan, addresses resident at risk for skin complications r/t (related to) skin spina bifida. Goal: area to right buttock will remain stable/heal. Interventions: assess and document progress of areas weekly, assist and encourage resident to turn and reposition every one to two hours and PRN (when needed) and skin assessment weekly. R44's Hospital Discharge Paperwork, dated 8/14/2024 documents sacral stage 2 pressure ulcer. R44's Nurses Note, dated 8/14/2024 at 6:12 PM, documents resident returned to the facility at 6p via ambulance. Resident transferred from stretcher to bed by 2 EMT workers. No c/o pain or discomfort at this time. Resident has a Foley catheter, suprapubic catheter, and cecostomy tube. The resident has a breakdown to her right butt. 97.6 120/74 20 82. Resident laying in bed with call light within reach. No documentation of readmission skin assessment documented. R44's Braden Scale for Predicting Pressure Ulcer Risk dated 8/15/2024 documents moderate risk. R44's Dietary Note, dated 8/15/2024 at 2:59 PM documents resident readmitted on [DATE]. Per staff, resident has 2 pressure wounds on buttocks. Recommend Prostat BID (twice a day) r/t wound healing. R44's NRSG Admission Observation, dated 8/15/2025 documents no skin assessment. R44's Dietary Evaluation, dated 8/15/2024 documents no skin issues and recommend Prostat 30 ml (milliliters). R44's Medication Administration Record (MAR) dated 8/15/2024 documents no physician's order for Prostat BID. R44's Treatment Administration Record (TAR), dated 8/17/2024 through 8/31/2024 documents staff initial treatment administered to buttocks one time a day and PRN to promote wound healing calcium alginate, medihoney wound gel and foam bordered dressing. R44's Skin Screen dated 8/20/2024 documents stage 3 pressure ulcer. No other assessment documented. R44's Wound Evaluation, dated 8/20/2024 documents stage 3 pressure ulcer right ischial tuberosity 6 days old present on admission measured 6.11 centimeters (cm) x 3.01 cm x 2.77 cm. Wound bed assessment: 60% slough, 40% eschar, no exudate (drainage), periwound area attached, surrounding tissue intact. R44's Wound Assessment Report, dated 8/21/2024 documents right ischium Stage 3 pressure ulcer date wound acquired 8/14/2024, present on admission. Wound status: 90% granulation, 10% slough, wound edges attached, periwound: intact, exudate: moderate, exudate amount: serosanguineous drainage, no odor. Treatment: daily and PRN (when needed) cleanse with wound cleanser, medical grade honey, collagen particles, calcium alginate and bordered foam. R44's Physician's Order Sheet (POS), dated 8/2024 documents staff administered wound treatment start date 8/16/2024 calcium alginate, medihoney and a foam dressing apply to buttocks topically one time a day/PRN (when needed) to promote wound healing. No physician's order for Prostat 30 ml twice a day documented. R44's POS dated 9/2024 documents a physician's order dated 9/4/2024 Prostat two times a day for wound healing 30 ml. Staff documented it was administered 9/5/2024 through 9/30/2024. On 3/12/2025 at 8:36 AM V12, Wound Nurse/LPN provided wound care to R44. V12 entered room washed hands and donned gloves. He assisted R44 to roll to her left side and removed the intact dressing to her right buttocks/ischium area. Wound bed was approximately 30% slough and had serosanguinous drainage that measured approximately 4.0 centimeters (cm) x 5 cm. No concerns regarding infection control noted during treatment. R44 lying on a low air loss mattress and had a wedge pillow under her left side. The Facility's Pressure Injuries Policy, last reviewed date 4/2024 the facility will ensure that all residents have necessary assessments completed in a timely manner at the point of admission in order to provide the best possible, person-centered care. All new and re-admissions that have been out of the facility longer than 24 hours should be assessed within 1 day of arriving to the facility by a licensed nurse to ensure stability and safety of resident. Within 24 hours of admission, the following forms should be completed NRSG: Admission Observation, Braden's Scale for Predicting Pressure Sore Risk and NRSG: Interim Baseline Care Plan.

Based on interview and record review the facility failed to ensure 1 of 4 residents (R2) was protected from another resident with known sexually inappropriate behaviors resulting in the sexual abuse of R2. This failure has the potential to affect all 123 residents residing at the facility. The Immediate Jeopardy began on 01/07/25 at 2:12 PM, when R3 was admitted back into the facility and the facility failed to initiation a plan of care and interventions to address how residents would be kept safe and free from sexual abuse, resulting in R2 being sexually abused by R3. V2, Director of Nursing (DON) and V7, Minimum Data Set (MDS) Coordinator were notified of the Immediate Jeopardy on 01/17/25 at 09:36 AM. The Immediacy was removed on 01/17/25, but noncompliance remains at Level II due to time needed to evaluate the implementation and effectiveness of the in-service training. Findings include: On 01/15/25 at 2:00 PM, The Illinois Department of Public Health (IDPH) Detailed Incident Summary of the 1/10/25 incident was reviewed and documented the following: January 13, 2025(1/10/25 incident), Final Investigation While staff were helping residents into dining room, they noticed R3 standing over another resident R2 and she was yelling at him to stop. They noted that he had his penis out and was making her rub it with her hand. Assessment completed on R2 by nurse. No injuries noted. R2 stated that she is upset about the incident but feels safe knowing he is not coming back. R2 is a bed bound alert and oriented x4 (times 4) resident. She is total assist with all ADLs (Activities of Daily Living). R3 is alert and oriented x4 resident with a diagnosis of schizophrenia and MDD (Major Depressive Disorder) with psychosis. He has been refusing his medication here at facility. He was sent out to a local hospital in January, and he was admitted . They returned him to this facility on January 4, 2025, still with refusal of medication. We then initiated a behavior contract in which he signed and agreed to. He has broken his contract numerous times. R2 is pressing charges against R3, in which we have issued an IVD (Involuntary Discharge) for 1/10/25. The ombudsman made aware of IVD, V1 LNHA (Licensed Nursing Home Administrator), RN (Registered Nurse) On 01/22/25 at 9:30 AM, The Police Investigation was reviewed and documented Field interview with V17, Nursing/Staffing Coordinator said she was approached by staff members who reported an incident that occurred in the dining area earlier. They reported R3 was sitting next to R2 and R2 told staff R3 was feeling on her. V17 spoke with R2 who told her R3 put R2's hand on his penis. R3 knows right from wrong and has been sexually harassing other female patients/employees. R3 has been seen coming in and out of female patient rooms and grabs his genitals while speaking to female employees. V18, Police Officer then spoke with R2 who told V18 R3 grabbed her hand and put it on his penis (on outside of his pants))**this is inconsistent with other eyewitness interviews**. R2 then told V18 a nurse came over to them and stopped R3. R2's Face Sheet, original admitted [DATE], documented R2 has diagnoses of but not limited to schizoaffective disorder, bipolar type, chronic obstructive pulmonary disease (COPD), Myelodysplastic syndrome, muscle weakness, and abnormal posture. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 12 out of 15 and R2 is dependent on staff for dressing, showers/bathe, bed mobility, and transfers. R2 also is dependent on staff for all of her other ADLs. R2's Care Plan, last care plan review date of 12/26/24, documented Problem: R2 is at risk for abuse and/or neglect related to bipolar disorder, psychotropic medications, poor judgement skills, history of verbal aggression, isolation/withdrawn behavior (may not report abuse), and history of resisting care interventions. On 1/10/25 resident was the recipient of sexual inappropriate behaviors from peer. Goal: Resident will not be abused and/or neglected thru next review date. Interventions include but not limited to 1/10/25 staff intervene residents separated. staff stayed present until Emergency Medical Services (EMS) arrived. Local Police department called to report, Abuse coordinator made aware, psychosocial follow up will continue and keep resident safe from harm at all times. R2's Progress Notes, dated 1/10/2025 at 06:30 AM, documented This nurse received notification from staff that resident was sitting in dining room and another resident (male) came up to her and began sexually assaulting her; the resident was immediately removed from scene to safety; 911 notified; administrator notified; nursing supervisor notified of situation; resident assessed and has no skin issues at this time; resident stated that she does not need to go to the hospital for further evaluation; resident in room at this time with belongings in reach; plan of care continues. R3's Face Sheet, original admitted [DATE], documented R3 has diagnoses of but not limited to schizophrenia, major depressive disorder, recurrent, sever with psychotic symptoms, and generalized anxiety disorder. R3's MDS dated , 10/07/24, documented R3 is cognitively intact with a BIMS of 15 out of 15, he requires supervision/touching assistance with his ADLs, he is occasionally incontinent of bladder, he has a colostomy and is always continent of bowel. R3's Care Plan, last care plan review date of 10/24/24, was reviewed and documented Date Initiated: 01/14/25, R3 has diagnosis of Schizophrenia and may display symptoms that include but not limited to being out of touch with reality (delusional or hallucinations, may have disorganized speech or erratic behavior, decrease in activities. Diagnosis of mental illness 01/10/25 resident sexually inappropriate with peer. 11/26/24- verbally aggressive, 12/25/24- Physical and verbal aggression. Interventions are but not limited to 1/10/25 staff intervene residents separated. Resident was sent to Local hospital for evaluation and treatment. Staff stayed present until EMS arrived. Local Police Department called to report, Abuse coordinator made aware, notify psychiatrist of any change in behavior, and staff to intervene if experiencing any aggressive/delusional behaviors, staff will continue to monitor R3 closely at all times to intervene when he becomes psychotic and physically aggressive. R3's care plan did not document R3 was displaying sexually inappropriate behavior and had no interventions in place to prevent sexual abuse of other residents. R3's Physician's Orders, dated 05/03/24, documented R3 was to get Invega Sustenna Suspension prefilled syringe 234 milligrams (mg)/1.5 milliliters (ml) inject intramuscularly (IM) once a month for schizophrenia. The Invega was discontinued in November 2024. R3's Physician's Orders, documented R3 started on Abilify 5mg one tablet by mouth one time a day for schizophrenia on 03/31/24. Then on 11/14/24 his Abilify was decreased to 2.5mg. On 11/26/24 there was a new order to increase R3's Abilify to 10mg daily and then on 12/03/24 it was again increased this time to 15mg once a day. R3 was then sent out to the hospital in late December 2024 and when he returned to the facility on [DATE] there was a new order to increase his Abilify to 20mg once daily. R3's Physician's Orders, dated 12/02/24, documented R3 was getting Depakote 250mg delayed release one tab twice a day related to (r/t) schizophrenia and when he returned from the hospital on 01/07/25 it had been changed to Depakote Sodium 500mg Extended Release (ER) one tablet at bedtime for schizophrenia. R3's Physician's Orders, dated 01/07/25, also documented when R3 returned from the hospital he was to get Zyprexa (Olanzapine) oral tablet 10mg every six hours as needed for psychosis and Zyprexa (Olanzapine) Intramuscular (IM) Solution Reconstituted 10mg IM every six hours as needed for psychosis. R3's Medication Administration Records (MARs) for the Months of August 2024, September 2024, October 2024, November 2024, December 2024, and January 2025 were reviewed and have no documentation of R3 taking his once-a-month antipsychotic injection in August, September, October, and November of 2024. R3's MAR for the month of December 2024 documented he refused his oral Abilify 15mg on 12/03/24, 12/05, 12/06, 12/10, 12/11, 12/12, 12/13, 12/14, 12/16, 12/19, 12/20, 12/23, 12/24, 12/25, and 12/26/24. He refused his oral Depakote 250mg twice a day on 12/03, 12/03, 12/16, 12/17, 12/24, and 12/25. He refused his morning dose on 12/05, 12/06, 12/10-12/14, 12/19, 12/20/24, and his evening dose on 12/18/24. R3's Electronic Medical Record (EMR) was reviewed, and his progress notes documented the following entries: On 12/25/24 at 3:30 PM, Social Service staff member reported to this nurse that the resident had asked to speak with her. She had gone into her office and the resident had locked the door behind him and refused to open it, but after a moment, the resident moved out of her way, and she was able to exit the office. The staff member also reported that the resident had once again entered her office, locked the door behind him and this time would not allow her to exit the room. Resident then approached her, getting in her face and made some threatening remarks towards her. The staff member was able to remove herself from the office and immediately reported this to this nurse. Social services staff member had requested that the resident be sent out for evaluation due to increased aggressive and threatening behaviors. On 12/25/24 at 6:15 PM, This nurse entered the resident's room to offer his roommate his medication, which his roommate was not in the room at the time. Upon attempting to exit the room, the resident stated, hold up, wait. When this nurse turned to face the resident, at which time, the resident jumped up out of his bed and got up in this nurse's personal space and face and said, what? Then the resident grabbed this nurse's left arm tightly and got closer to this nurse's face and said, what you going to do? This nurse jerked the arm away from the resident and began to quickly exit the resident's room when the resident stated, why'd you grab my d**k? This nurse attempted to redirect the resident and instruct him to stay in his room and that his comments and threats were inappropriate. Resident then started saying, man, you bogus. This nurse then instructed the resident to shut the door to his room to which he did comply once two other male residents got close to his doorway. On 12/25/24 at 8:49 PM, A nurse assigned to the 500 hall reported R3 grabbed her arm and made threatening and inappropriate sexual remarks to her. On 12/25/24 at 8:58 PM, Two residents reported R3 made threatening and aggressive remarks to them. On 12/26/24 at 1:34 AM, Resident physically and verbally aggressive towards residents and staff. Police were called and involuntary discharge was issued after as resident was a threat to staff and other residents. On 12/26/24 at 3:48 AM, Resident walking up and down the hallway with his cell phone in his hand with music blaring. R3 refused to turn down the music and he was unable to be redirected. Behaviors noted on shift report for possible medication changes or other interventions. On 01/07/2025 2:12 PM, Resident arrived at facility via company transportation. Resident ambulates without assistance. Resident has no complaint of pain or discomfort. Resident is own responsible party. DON and Administrator notified of return. Plan of care will continue. On 01/08/25 at 9:12 PM, R3 was standing behind the 400 nurse's station and another resident was yelling at R3 to stop following the nurse around and leave the 400 hall. On 1/10/2025 at 06:58 AM, This nurse entered dining room to witness a verbal altercation between this resident and a female resident that stated he used her hands to touch his genitals without her consent. The residents were separated immediately; incident was reported to abuse coordinator, DON, and local Police Department. Statements were taken and reported to appropriate parties. Survey Team Interviews: On 01/15/25 at 1:25 PM, On the day of the incident R2 said she was going down for breakfast when R3 came up and sat down beside her. She said she thought he was just trying to be friendly and come to find out he was a pervert. R2 said R3 pulled his penis out of his underwear and tried to make her touch it. She said he didn't try anything else, and it made her feel afraid when he did that. R2 said when R3 did that she started yelling help and the staff came and stopped R3. She said it's affected her because now she doesn't go out to the dining room early, she waits until everyone is seated then she will pick where she wants to sit so she can see if anyone is trying to sit down by her. R2 said she is a little bit worried it will happen again, but she doesn't think it will. She said she is a little leery about going out to the dining room, but she's been going. R2 said there is no reason he or anyone else should be touching his penis. The police came and took a report. R2 said she sits in a geriatric chair, she must have help with everything, and she has never felt afraid until now. On 01/16/25 at 10:05 AM, R7 who is cognitively intact with a BIMS of 15 out of 15 said she witnessed the incident between R2 and R3. She said R3 kept turning the lights off and then someone would turn them back on. She said R2 was sitting out in the dining room at the table and one of the nurses told R3 to get away from R2. R7 said R3 then started feeling on R2's breast and groin areas and R2 was yelling no. R7 said she ran and helped R2 by grabbing R2's chair and was trying to move it away from R3. She said R3 grabbed it also and they were fighting over the chair. She said if you ask me what he did was rape. R7 said she hollered for the nurse, and they came. On 01/16/25 at 10:12 AM, R8 who is cognitively intact with a BIMS of 15 out of 15 stated she was in the dining room on the day of the incident between R2 and R3. R8 said R3 kept turning the light off in the dining room and then others would turn it back on. R8 stated R3 was grabbing R2 by the arms and touching her around the chest area. R8 said R2 kept telling R3 to go away, and R8 feels like he (R3) kept turning the light off to keep it dark to stop people from seeing what was going on and so he could attack her again. R8 stated R2 can't defend herself and R3 trying to hurt R2 is not okay. R8 said since this happened the staff have been close by R2 and when R2 is out in the dining room she will look around all the time because she is scared. On 01/16/25 at 10:30 AM, V5, Licensed Practical Nurse (LPN) stated R3 had been having inappropriate behaviors for a few months prior to the incident involving R2. She said they had tried to get R3 sent out to the hospital, but they wouldn't take him due to the right paperwork not being sent with him. She said R3 had been inappropriate with other staff members, but he hadn't been inappropriate with her. V5 said yes R2 is scared to go back out to the dining room, and she will let you know. She said as far as she knows there have been no new interventions put into place after R3 came back from the hospital the last time. On 01/16/25 at 11:25 AM, V1, Administrator said R3 has been having behaviors on and off since about October. She said it truly started about mid-November about the 15th or 16th. She said she had staff who have known him for a while tell her his behavior just wasn't right. He was real paranoid and would follow people around. He also became aggressive with staff. V1 said his sexually inappropriate behavior started in December a couple of weeks before his last hospital stay. She said he was being sexually inappropriate with staff 100% and female staff specifically. V1 said a lot of the staff were fearful R3 would do something. V1 said R3 was sent to a local hospital and was there for about a week and when he came back to the facility, he was the same. There was no change in his behavior. She said he was still refusing his medication. V1 said while R3 was at the hospital they increased his medications, but he wasn't taking them and then he came back, and this incident happened. On 01/16/25 at 11:58 AM, V6, Social Service said she had an incident with R3. V6 said R3 never took his medications. She said she was talking with another resident in her office and when that resident left the office R3 started to come in her office then turned around and acted like he was leaving but then he came in and locked the door. She said she was able to get the door unlocked and then he locked it again on her. She said R3 was making threats towards her, trying to touch her a few days earlier, and wouldn't let her get to the door. She said she was screaming and yelling trying to get someone's attention. V6 said she was able to make it to the door was holding it open and was able to get someone to help her. V6 said R3 had been following her around the building and he was hearing voices. She said a lot of the staff are scared of R3. She said when he tried to touch her a few days earlier she told him that it wasn't appropriate for him to do that. On 01/16/25 at 2:00 PM, V10, Nurse Practitioner (NP) said they have had issues with R3 for months. She said R3 doesn't follow the rules and hasn't been taking his meds. she said he has been talking to people who aren't there. V10 said they have sent R3 out to the hospital several times due to his behaviors. She said she even talked with the emergency room (ER) doctor and told them about his behaviors, he is scaring people, and the hospital will send him right back stating R3 isn't a threat to anyone. V10 said R3 can stare at you and it's like he can see right into your soul. V10 said she was scared of R3 and wouldn't assess him with even two other people in the room because he had no control over what he was doing. V10 said when the hospital sent him back, she told the facility not to take him back. She said he would approach people, just wander around, stare at you, and then just walk away. She said she doesn't know what interventions the facility would put into place for him. R3 is very unpredictable, and she feels he is a danger to staff and other residents. She said she told them before Christmas not to take him back because he scared a lot of residents. On 01/17/25 at 9:09 AM, V2, DON stated that she didn't know R3 had touched and groped R2. She said she knew he had taken his penis out and put it in her (R2) hand. She said that he picked someone out who couldn't tell anyone, and she couldn't stop him. V2 continued to state that the facility had attempted to send R3 out multiple times to the hospital but when he got to ER, the ER would return him. On 01/17/25 at 9:42 AM, V7, MDS coordinator, in conference room, state she went through his (R3) medical record, and she could not find any documentation that R3 was sexually inappropriate prior to this incident. On 01/21/25 at 10:10 AM, R2 was sitting up in her reclining chair watching television (TV). 1:1 sitter sitting in the room with her. Follow up interview conducted at this time. R2 said she was sitting out in the dining room and R3 pulled out his penis and tried to make her touch it. R2 said she doesn't remember somethings about that day because she was kind of blacking out when it was all happening. She said he could have touched her breast and groin area, and he could have told her to put his penis in her mouth she just doesn't remember. She said she was scared when it happened and it's hard to think about. She said most of the time she has a 1:1 with her but that didn't start until after the incident happened with R3. The facility's daily census sheet, dated 01/16/25, documented the facility had 123 residents currently residing at the facility. The facility's Abuse Prevention Program, reviewed date of 09/2017, documented POLICY This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. It further documented Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault by a licensee, employee, or agent (77 Ill. Adm. Code 300.330). Sexual abuse is non-consensual sexual contact of any type with a resident. It also documented Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including, but not limited to, the separation of the residents. It also documented Resident Protection Investigation Paths Option 2: Possible Sexual Abuse Determine if the allegation involves either physical sexual contact involving penetration, or verbal harassment or physical contact that did not involve penetration. If an allegation of physical sexual contact with penetration is involved: The facility shall immediately contact local law enforcement authorities (e.g., telephoning 911 where available) as required in Section 300.695 in the following situations: For sexual abuse ? sexual penetration, intentional sexual touching or fondling, or sexual exploitation (i.e., use of an individual for another person's sexual gratification, arousal, advantage, or profit); or For sexual abuse of a resident by a staff member, another resident, or a visitor. The Immediate Jeopardy that began on 01/07/25 was removed on 01/17/25 when the facility took the following actions to remove the immediacy. 1. Affected resident corrective actions: A. Administrator/Designee immediately ensured the safety and well-being of the resident. B. Administrator/Designee initiated abuse investigation. C. The resident who was noted in the allegation was assessed by the DON/Designee. The result of the assessments will be documented in the resident's EHR (electronic health records), and the attending physician will be notified. D. The Following actions were taken to prevent alleged aggressor from perpetrating additional abusive behaviors. a. Resident was issued an Involuntary Discharge (IVD) b. Police were notified of incident. c. IDT will review, and revise R2 care plan, implement interventions to ensure R2's safety. E. Social Service will complete Trauma Assessment on R2 and anyone who experiences abuse completed on 1/17/24. F. Social Service will review behavior tracking sheets daily for all residents with behaviors and if noted, complete a new abuse and neglect risk assessment on them, the resident care plan will be updated by MDS with the intervention of enhanced monitoring initiated until behaviors subside. Enhanced Monitoring includes but not limited to q15, 30, 1-hour rounds per physician order. G. All residents have the potential to be affected by the alleged deficiency. 2. Immediate Actions: Initiated 1/17/2025 The facility took the following immediate actions to address the citation and prevent any additional residents from suffering an adverse outcome. Resident assessments for risk of abuse. The DON and Social Service will complete a facility-wide assessment of residents and review of care plan interventions to ensure no residents are abused. The Abuse and Neglect Risk assessment determines if the resident is at risk for being a victim or perpetrator of abuse. Any questions with a yes answer are care planned for at risk for abuse and inventions will be implemented per resident needs. A. Administrator and DON Education. RDO/Designee will provide training to Administrator and DON. The Training will include but not limited to the following: i. Abuse Prevention Policy ii. Allegation of Abuse Checklists iii. Reporting Abuse within required timeframe iv. Completing investigation per policy and protocols. v. Reporting and investigating injuries of unknown origin vi. care plan interventions to prevent abuse B. Staff Education. The Administrator/Designee will provide training to all staff. The training will include but not limited to the following: i. Abuse prevention including who the Abuse Coordinator is ii. Reporting Abuse and who to report Allegations to iii. Abuse Investigation procedures and documentation process. iv. Reporting and investigation of injuries of unknown origin v. Care plan interventions to prevent abuse. C. The training will be started on 1/17/2025. D. All staff who are not available and/or currently on vacation will also receive the same education upon their return to work. The Administrator/Designee will provide the same training. E. Agency staff. The facility will provide similar training to agency staff. The Administrator/Designee will provide similar training to an agency staff prior to the start of their shifts. F. Interviewable Residents. Residents were interviewed to identify if they felt safe and/or if they have experienced of any/all forms of abuse while living in this facility. No concerns identified completion: 1/17/25. G. A Regional Consultant Team Member will visit facility weekly x 4 weeks to provide oversight, complete audits and provide additional training as needed. H. As part of monitoring, the Administrator/Designee will monitor through facility audit tools five (5) residents daily for 1 week and then weekly x 4 weeks to ensure any allegations of abuse are reported to Abuse Coordinator and investigated and reported to appropriate organizations. The audits will ask the residents if they feel safe in the facility and if not, what is making them feel unsafe. I. Administrator and Regional Team reviewed current policies and procedures of Abuse Program. No revision needed at this time.

Based on interview and record review the facility failed to monitor and supervise 1 of 3 residents (R4) reviewed for elopement in a sample of 10. This failure resulted in R4 leaving the facility unattended, on 12/20/2024 from 2:00 AM to 3:30 AM, falling outside the facility, sustaining multiple abrasions to both lower extremities, a dislocated left wrist, and a laceration to R4's forehead and left cheek that required sutures. The Immediate Jeopardy began on 12/20/2024 when R4 eloped from the facility without staff knowledge. R4 was last seen in the facility on 12/20/2024 2:00 AM and was found outside the facility on the ground. Due to R4 physical and cognitive vulnerabilities, R4 had the likelihood of serious harm and injury when R4 eloped. V1, Administrator, and V30, Regional Clinical Nurse, were notified of the Immediate Jeopardy on 1/3/2025 at 2:50 PM. Surveyors confirmed by observation, record review, and interview, the Immediate Jeopardy was removed 1/7/2025 but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of staff's in-service training, and implementation of interventions for those at risk for elopement. Findings include: R4's diagnoses are Unspecified Injury of Head, subsequent encounter, Bipolar Disorder, History of Falling, Violent Behavior. R4's Care Plan, dated 10/17/2024, documents Resident is at risk for elopement r/t (related to) increased confusion. 10/17/2024 15-30 min checks as needed (PRN). Monitor where abouts PRN. 12/20/24 resident assessed, BPD called resident sent to (local) hospital for eval and treatment. Medication review upon return to facility. R4's Minimum Data Set, dated dated [DATE], documents that R4 is severely cognitively impaired. R4's August and November 2024 Elopement Assessments, documented R4 was at high risk for elopement. The facility's Elopement Book, located at the 300/400 hall nurse's station, documents Elopement Evaluation, dated 8/20/2024 High Risk, R4's Picture on Resident Elopement Risk Information with description of R4 and Admission Record. Per National Weather Service on 12/20/2024 from 2:00 AM to 4:00 AM it was 32- 36 degrees Fahrenheit. R4's Incident Report, dated 12/20/204, documents that R4's mental status was confused/forgetful, not oriented. Predisposing Physiological Factors: poor trunk control, gait imbalance, impaired memory. Predisposing Situation Factors: Active Exit Seeking R4's Progress Note, dated 12/20/2024 at 3:30 AM, documents Nurses Notes Note Text: This nurse was on break and I then received a phone call from 300 hall CNA(Certified Nursing Assistant) stating that resident eloped and was found outside the building by staff; resident confused and forgetful; resident has a laceration to the forehead and abrasions to his arms and legs; 911 immediately notified; DON (Director of Nursing) notified; Administrator notified; Resident transferred to (local) Hospital in Belleville; plan of care continues. R4's Local Hospital Emergency Department report, dated 12/20/2024, documents History of Present Illness Chief Complaint Patient presents with Fall 9:16 AM (R4) is a 65 y.o. (year old) male presenting to the ED (emergency department) c/o (complaints of) fall onset PTA (Prior to Arrival). EMS (emergency medical service) states pt (patient) came from NH (nursing home) where he hit staff there. He ran away, tripped, and hit his head on the ground. He has multiple abrasions to BLE (bilateral lower extremities). Also has a few lacs (lacerations) to his left side of face. Sutures to R4's forehead and cheek. R4's Progress Note, dated 12/20/2024 at 10:37 AM Nurses Notes Note Text: Resident returned from (local) hospital r/t fall with laceration to face. Resident is up with walker. Skin w/d to touch. Rest(sic) even unlabored. No c/o pain or SOB noted. Resident agreed to take a shower and after will speak to his ex-wife via phone. R4's State of Illinois Department of Public Health Long-Term Care Facility & 110 - Serious Injury Incident and Communicable Disease Report, dated 12/20/2024, documents staff noted resident was agitated all evening shift. nurse stated that she tried to redirect him from doors and when she did this, he tried to hit staff. staff noted the last time seen was 2:30am. around 3:00-3:30am staff noted resident outside of facility and resident had fallen. staff brought him into facility. nurse completed assessment. he had multiple lacerations on face and abrasions on legs. staff denied hearing any door alarms going off. resident was sent to ER for evaluation and returned with sutures in one laceration. R4's Progress Note, dated 12/21/2024 at 5:19 PM, documents Nurses Notes, Note Text: Resident Left wrist is bruised and swollen and will point to the left wrist area when you ask where it hurts. Resident has kicked one staff member and another resident. NP (Nurse Practitioner) notified, (local) ambulance and (Local) pd notified. R4's Local Hospital After Visit Summary, dated 12/21/2024, documents Reason for visit: Altered Mental Status. Diagnosis Dislocation of wrist and aggressive behavior. It also documented Patient Education for Preventing falls in adults. V15's, CNA, written statement, dated 12/20/24, documents between 3 to 4:45 AM R5 pointed out that he seen someone outside of his window. V15 entered R5 room and looked out the window and saw another resident on the ground with a walker struggling to get up. V15 ran outside and assisted R4 up and other staff came and helped. V15 stated that he assisted with getting R4 back into the building. V15 then went back to his workstation. V11's, Licensed Practical Nurse (LPN), written statement, dated 12/20/2024, documents Did you see (R4) leave his unit? Yes, he was wandering all night long. I redirected him from the front door multiple times. He was being aggressive. On 12/31/2024 at approximately 11:30 AM R4 stated that he left the facility and was trying to go home. R4 stated that he used his bike, pointing to his walker. R4 stated that he made it off the property and up the street. R4 stated that he was outside for a long time. R4 stated that he was so cold. R4 stated that he fell and hurt himself badly. When asked how did R4 leave the facility? R4 refused to answer. On 1/2/2025 at 1:00 PM R5 stated that he saw someone outside his window with a walker. R5 stated that he told the staff. R5 stated that he did not see R4 fall but that R4 was wobbly. R5 stated that he couldn't sleep that night and could not tell who it was but did see a man that was wobbly outside his window. On 1/2/2025 at 2:56 PM V8, LPN, stated that she came in to work and observed R4's hand was swollen and bruised. V8 stated that R4 was pointing to the area and complaining of pain. V8 stated that she called and sent R4 to the emergency room . V8 stated that she received a call from the hospital of R4 being combative and having to be placed in 4-point restraints while at the hospital. V8 stated that she was informed that R4 had fallen outside the day before and of him being combative and kicking staff and other residents. V8 stated that R4 was being monitored because of his exit seeking prior to the elopement. V8 stated that R4 was on 1 on 1 and was taken off the day prior to the elopement. V8 stated that she had not received or performed in servicing with staff on elopement or fall prevention since the incident. On 1/2/2025 at 4:04 PM V14, CNA, stated that she came in on the end of it. V14 stated that R4 was sitting in a chair bleeding from his head, face, and legs. V14 stated that R4 was cold to touch. R4 stated that the concern was that R4 was cold and had been out of the facility for a couple of hours. On 1/2/2025 at 4:18 PM V12, CNA, stated that R4 was having behaviors and attempting to leave the facility throughout the shift. V12 stated that there were several attempts to redirect without success. V12 stated that V13 put R4 to bed and V12 thought that everything was ok. V12 stated that she last saw R4 around 2 AM to 230 AM. V12 stated that she was in a room with another resident and was told that R4 was outside the building. On 1/3/2025 at 10:15 AM V16, Nurse Practitioner, stated that she was notified of R4's swelling and injury to the left wrist. V16 stated that she was notified by V2 or V3. V16 stated that the injury was related to the fall that occurred the night before. V16 stated that if R4 was having behavior and exit seeking she would expect the staff to monitor the resident and not leave them alone. V16 stated with R4's severe cognitive impairment and cold weather it would not be safe for R4 to be outside for a long period of time. On 1/3/2025 at 10:48 AM V13, CNA, stated that she was there when R4 fell outside. V13 stated that R4 was having behaviors and was trying to leave the building. V13 stated that this was several times throughout the shift. V13 stated that she had taken R4 to his room several times and he would go back to the door. V13 stated that she had taken R4 back to his room. V13 stated that she did not stay with R4. V13 stated that she did not increase supervision but did address the behaviors when she was aware. V13 stated that the last time she saw R4 was around 2 AM. V13 stated that she was told that R4 was outside about 3:30 AM. V13 stated that she went outside to help. V13 stated that R4 was on the side of the building. V13 stated that she put R4 in her truck and drove R4 around to the entrance. V13 stated that R4 did not say what happened he would just keep saying he was so cold. On 1/3/25 at 4:52 PM V15, CNA, stated that R5 notified him he saw someone outside his window. V15 stated that he looked out R5's window and saw R4 outside on the ground. V15 stated that R4 was struggling trying to get up off the ground. V5 stated that he went up and got help and went outside and helped R4 up and inside the building. V15 stated that R4 did not say how he got out or what happened. V15 stated that once R4 was in the building he went back to his work area. The facility's Elopement Policy, dated 9/2022, documents DEFINITION/GENERAL: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Elopement Risk: If the cause of the alarm is the resident attempting to leave the unit, the following measures will be taken: a. Resident will be redirected to the unit b. Additional monitoring of the resident as appropriate c. Update care plan as appropriate. The facility presented an abatement plan to remove the immediacy on 1/3/2025. During the validation of the abatement by the survey team on 1/7/2025, review of enhanced monitoring revealed that monitoring was not being completed per abatement plan, multiple interviews with staff indicated that they were not in-serviced, inspection of exit doors and alarms revealed that they were not working properly. At 3:07PM, the facility provided an updated abatement plan to reflect the exit doors and alarms were monitored and working; and documentation that all staff were in-serviced as of 1/7/2024. The Immediate Jeopardy that began on 12/20/2024 was removed on 1/7/2025, when the facility took the following actions to remove the immediacy. The facility provided an abatement plan that included the following: 1. Affected resident corrective actions RESIDENTS: A. R4 placed on Enhanced Monitoring. B. Any Residents with High Elopement Risk Assessment will be placed on Enhanced Monitoring. a. Enhanced monitoring will include but not limited to behavior monitoring every shift and 15 to 30 min location checks on residents that are exhibiting exit seeking behaviors. C. All residents have the potential to be affected by the alleged deficiency. 2. Immediate Actions: Initiated 1/3/2025 The facility took the following immediate actions to address the citation and prevent any additional residents from suffering an adverse outcome. A. Assessments. Administrator/Designee to complete Elopement Assessments on All Residents Completed 1/3/2025. B. Elopement Binders. Elopement binders will be updated with any resident that is moderate to high elopement risk and placed at Nurses stations and reception Area. Social Services Staff will be responsible for updating binders as needed. C. Door Alarms. Maintenance Director to complete 100% Audit on Door alarms to ensure working Properly Completed 1/3/2025. 1. Q 15 min monitoring of doors until alarms repaired D. Administrator and DON Education. RNC/Designee will provide training to Administrator and DON. The Training will include but not limited to the following: i. Elopement Policy and Procedures ii. Elopement Drills iii. Training provided to staff to place resident on enhanced monitoring when exhibiting exit seeking behaviors. E. Staff Education. The Administrator/Designee will provide training to all staff. The training will include but not limited to the following: i. Elopement Policies and Procedures ii. Elopement Drill iii. Training provided to staff to place resident on enhanced monitoring when exhibiting exit seeking behaviors. F. The training will be started on 1/3/2025 and will finish on 1/7/25. G. All staff who are not available and/or currently on vacation will also receive the same education upon their return to work. The Administrator/Designee will provide the same training. H. Agency staff. The facility will provide similar training to agency staff. The Administrator/Designee will provide similar training to an agency staff prior to the start of their shifts. I. A Regional Consultant Team Member will visit facility weekly x 4 weeks to provide oversight, complete audits and provide additional training as needed. J. As part of monitoring, the Administrator/Designee will monitor through facility audit tools daily x 5 days for 1 week and then weekly x 4 weeks to ensure any resident with moderate to high elopement risk assessment are monitored and supervised appropriately. K. New Admit residents will be assessed upon admission and residents exhibiting new onset exit seeking will be reassessed and based on assessment findings will be added to elopement binders and behavior monitoring. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: Completion Date: 1/7/25

Based on interview and record review, the facility failed to report verbal abuse allegations to Illinois Department of Public Health for 1 of 3 residents (R2) reviewed for abuse. This failure resulted in R2 becoming upset, crying, refusing medications and refusing to eat. Findings include: R2's Face Sheet which is undated documents that R2 was originally admitted to the facility on [DATE] with diagnosis of weakness, need for assistance with personal care, major depressive disorder, anxiety disorder, persistent mood disorder, borderline personality disorder, schizoaffective disorder, unspecified psychological disorder. R2's Minimum Data Set (MDS) dated [DATE] documented R2 is cognitively intact. R2's mood is often down with little pleasure in activities. She has impairment to bilateral upper extremities and uses a wheelchair for mobility. She requires touching assistance or verbal clues with eating. R2's Care Plan dated 9/23/2024 documented problems that R2 can be socially isolative when she is in a bad mood. The goal is that she will increase social interaction with interventions that staff will encourage resident to spend more time in social activities. On 11/20/2024 at 9:55 am, R2 stated she had gone to shock treatments (on 11/13/2024) and had come back to the facility feeling excited afterwards because she felt better by feeling more confident and feeling less prone to outbursts. At about 4:30 or 5:00 pm, R2 asked V9, Medical Records, if she could lie down and eat in her room because she was tired. V9 stated that she could. V4, Certified Nurse Assistant (CNA) then came into the room and yelled at me and stated that I could not eat in my room. R2 stated she told V4 that V9 had said she could. R2 stated that she then started crying and told V4 that this was abuse. V4 started looking at her and laughing at her. R2 stated that she (R2) used to buy V4 sodas, but she (V4) has always been hateful to me. R2 added that she doesn't get along with her. R2 stated that V4 began laughing at her and making fun of her. R2 stated that she was so upset and mad that she didn't eat supper. R2 stated that it really hurt her feelings. R2 added that V4 often tells her she can't eat in her room, causing her to start crying and refuse to eat if she must go to the dining room for her meal when she doesn't want to on that day. R2 stated that this makes her feel really bad. R2 stated that she told the next nurse on the night shift, and she said she would call V1, Administrator and V2, Director of Nurses (DON) and told me not to worry about it. R2 stated that V4 told one her friends in the facility that R2 had lied on her. R2 is unable to remember which friend in the facility this was. On 11/20/2024 at 10:35 am, V5, CNA stated that the day after the incident V5, was told by staff that R2 got in wheelchair and went up front and spoke with V2, Director of Nursing (DON). V5 stated that V2 did nothing and did not send V4 home. V5 stated V4 came in to work the day after the incident and would walk in the hall past R2's room antagonizing her and laughing at her. When V4 would walk past R2's room, R2 would yell out that that was the staff member who was mean to her. V5 stated that staff do not have the same assigned halls that they work on all halls. V5 worked with R2 the next day after the incident and stated that R2 wouldn't take her medications or get out of bed because she was still upset. V5 stated that she has seen and heard V4 talk to some residents roughly in the past but is unable to remember which residents this was. V5 overheard V4 tell a resident down the 400-hall loudly that she was not going to get the resident up and down up because that means she is doing double the work, and she don't get paid enough for that. Facility Staffing sheets for November 14, 2024, documented that V4 was assigned for fifteen-minute checks on residents. Daily staffing sheets also documented V7 assigned to the 200-hall for the day and evening shifts on 11/14/24. On 11/20/2024 at 1:30 pm V6, Receptionist, stated she was aware of the incident on 11/13/2024. The next day after this, on 11/14/2024, V6 stated that R2 was pushed in a wheelchair to the receptionist desk and V6 witnessed her pointing at V4 and yelling that's her, that's her. V6 stated that R2 was very upset and crying hard. V6 stated that V2 was there talking with R2 also. V6's daily notebook was reviewed, and a page dated 11/14/2024 and line number four documented that R2 was very upset about V4. On 11/20/2024 at 2:50 pm, V7, Licensed Practical Nurse (LPN) stated she was working on 11/14/2024 and was assigned to the 200-hall. V7 stated that R2 was crying and wouldn't take her 11:00 medications. V7 stated R2 kept crying and wouldn't talk to me. V7 stated that R2 did get in a wheelchair and said that V4 was being mean to her and yelling at her (R2). Later that day, R2 would not take her medications. R2 would see V4 walk by and yell out that's her, that's her. V7 stated that R2 said she wanted to leave the facility and that she didn't feel safe. V7 stated that R2 received a one-time intramuscular (IM) injection for Zyprexa ordered because of R2's recent behaviors. V7 stated that she hadn't seen R2 exhibit this type of behavior in a long time. V7 stated that this only occurs when someone makes her very upset. V7 also stated that she had worked the evening shift on 11/13/2024 and R2 was lying in her bed crying and repeating it's over, it's over. V7 tried to console R2 and to ask her to talk about what was bothering her but R2 refused to talk with her about it. R2 stated that she didn't want to be here, she wanted to leave. On 11/20/2024, V2 stated via telephone that she was told that R2 had come back from her electroconvulsive therapy (ECT) treatment and went to the dining room. R2 then decided to go lie down. R2's tray had been delivered to the dining room and V4 told R2 she would have to go out in the dining room to eat. V2 said that she was then told that R2 refused her tray. V2 then asked other CNAs if they had ever refused to go get a tray or refused to bring it to a resident. An in-service was provided on customer service. V2 stated she was new to the DON position and had the guidance of V8, Regional Nurse Consultant. V2 stated that she didn't know anything about the events of 11/13/2024 until the next day, 11/14/024. Once she learned this, V2 stated that she assigned V4 to perform fifteen-minute checks on the 300 and 500 halls. On 11/20 /2024 at 2:30 pm, V1, Administrator stated that V2 called her on 11/14/2024 to tell her about the allegation of customer service incident involving R2 and V4. On 11/20/24 at 4:00 pm V10, transportation stated that R2 goes to ECT treatments the third Wednesday of every month. V10 stated that last Wednesday on 11/13/3024 that he and R2 left the facility around 8 am and returned about 11:30 am. He stated that R2 told him she felt great. V10 added that (R2) hadn't been that good in a long time. On 11/20/204 at 4:35 pm, V4 stated via telephone that she had been notified by one of the staff that people are there lying on me. V4 stated that on 11/13/2024 she worked the evening shift from 2:00 pm until 10:00 pm on the 200-hall. V4 stated that she had just left the dining room and came to help pass trays on the hall. V4 stated that she saw that R2 was in bed and went to V11, CNA who was assigned to R2 and told her that the nurses are wanting the residents to eat in the dining rooms. V4 stated that she told V11 that R2 was not going to eat. V4 stated that she never went back into R2's room. V4 stated that V11 verified with R2 that she was not going to eat supper that night. On 11/21/2024 at 10:50 am V11, agency CNA stated that she was working on the 200-hall on 11/13/2024. She stated that the time was around 5:00 pm and when she walked out of another resident's room, V12, CNA, told her that R2 was ready for bed. V11 told R2 that she would go get some gloves and come right back. When V11 returned, R2 had already put herself to bed. V11 told her that dinner was ready. R2 stated that she was not going to go to dinner because she was tired from getting up so early for her treatment today. V11 stated that she offered to bring a tray to her, but R2 refused. R2 told her that she wanted to sleep. V11 then went to the dining room to help pass out trays. When she returned to the 200-hall, V4 told her that R2 was not happy and was having behaviors. When V11 went into the room, R2 was crying and told her that V4 was mean to her. R2 said that V4 had told her if she wanted to eat, she needed to get up and go down to the dining room. R2 stated that she was upset because V4 was mean to her. V11 offered to go get her tray but she said she didn't want to eat. V11 stated that shortly after telling her she didn't want to eat, R2 went to sleep. On 11/20/2024 at 12:50 pm V1, Administrator, stated that she is the abuse coordinator. V1 was aware of an incident between R2 and V4 and stated that she was on vacation during that time. V1 stated that she did receive a phone call from V2 telling her about the situation. V1 stated that V2 had told her that R2 had reported that V4 was refusing to give her food and yelling at her. V4 told V2 that R2's meal tray was in the dining room, and she was going to get it for her. V2 had told her that she had interviewed the staff on the hall and the other residents who stated they hadn't heard anything. V1 was not told by V2 if V4 was sent home. The customer concern and feedback form were signed by V1 on 11/19/2024 since there were no findings reported and customer in-service regarding tray delivery had been performed. On 11/20/2024 at 3:40 pm spoke with V8, Regional Nurse Consultant by phone. V8 remembered that V2 had called her regarding the incident between R2 and V4. V8 had been told this was a customer service issue and she recommended that V2 perform an in-service regarding customer service for meal trays. V8 stated that no allegations of abuse had been reported to her. V8 stated that if this had been reported as any type of abuse that the employee would be suspended until the investigation was complete. Abuse prevention program policy reviewed last on 9/2017 was reviewed. It stated that the facility desires to prevent abuse, neglect, exploitation, mistreatment, and misappropriation of resident property by establishing a resident sensitive and resident secure environment. It stated that employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property is unsubstantiated.

Based on interview and record review, the facility failed to investigate verbal abuse allegations for 1 of 3 residents (R2) reviewed for abuse. This failure resulted in R2 becoming upset, crying, refusing medications and refusing to eat. Findings include: R2's Face Sheet which is undated documents that R2 was originally admitted to the facility on [DATE] with diagnosis of weakness, need for assistance with personal care, major depressive disorder, anxiety disorder, persistent mood disorder, borderline personality disorder, schizoaffective disorder, unspecified psychological disorder. R2's Minimum Data Set (MDS) dated [DATE] documented R2 is cognitively intact. On 11/20/2024 at 9:55 am, R2 stated she had gone to shock treatments (on 11/13/2024) and had come back to the facility feeling excited afterwards because she felt better by feeling more confident and feeling less prone to outbursts. At about 4:30 or 5:00 pm, R2 asked V9, Medical Records, if she could lie down and eat in her room because she was tired. V9 stated that she could. V4 then came into the room and yelled at me and stated that I could not eat in my room. R2 told V4 that V9 had said she could. R2 stated that she then started crying and told V4 that this was abuse. V4 started looking at her and laughing at her. R2 stated that she used to buy V4 sodas, but she has always been hateful to me. R2 added that she doesn't get along with her. R2 stated that V4 began laughing at her and making fun of her. R2 stated that she was so upset and mad that she didn't eat supper. R2 stated that it really hurt her feelings. R2 added that V4 often tells her she can't eat in her room, causing her to start crying and refuse to eat if she must go to the dining room for her meal when she doesn't want to on that day. R2 stated that this makes her feel really bad. R2 stated that she told the next nurse on the night shift, and she said she would call V1, Administrator and V2, Director of Nurses (DON) and told me not to worry about it. R2 stated that V4 had told one of her friends in the facility that R2 had lied on her. R2 is unable to remember which friend in the facility this was. On 11/20/2024 at 2:50 pm, V7, Licensed Practical Nurse (LPN) stated she was working on 11/14/2024 and was assigned to the 200-hall. V7 stated that R2 was crying and wouldn't take her 11:00 medications. V7 stated R2 kept crying and wouldn't talk to me. V7 stated that R2 did get in a wheelchair and stated that R2 was being mean to me and yelling at me. Later that day, R2 would not take her medications. R2 would see V4 walk by and yell out that's her, that's her. V7 stated that R2 said that she wanted to leave the facility and that she didn't feel safe. V7 stated that R2 received a one-time intramuscular (IM) injection for Zyprexa ordered because of her recent behaviors. V7 stated that she hadn't seen R2 exhibit this type of behavior in a long time. V7 stated that this only occurs when someone makes her very upset. V7 also stated that she had worked the evening shift on 11/13/2024 and R2 was lying in her bed crying and repeating it's over, it's over. V7 tried to console R2 and to ask her to talk about what was bothering her but R2 refused to talk with her about it. R2 stated that she didn't want to be here, she wanted to leave. R2 did take her evening medications that night. On 11/20/2024 at 2:30 pm, V1 stated that V2 called her on 11/14/2024 to tell her about the allegation of customer service incident involving R2 and V4. On 11/20/2024 at 12:50 pm V1, Administrator, stated that she is the abuse coordinator. V1 was aware of an incident between R2 and V4 and stated that she was on vacation during that time. V1 stated that she did receive a phone call from V2 telling her about the situation. V1 stated that V2 had told her that R2 had reported that V4 was refusing to give her food and yelling at her. V4 told V2 that R2's meal tray was in the dining room, and she was going to get it for her. V2 had told her that she had interviewed the staff on the hall and the other residents who stated they hadn't heard anything. V1 was not told by V2 if V4 was sent home. The customer concern and feedback form were signed by V1 on 11/19/2024 since there were no findings reported and customer in-service regarding tray delivery had been performed. On 11/20/2024 at 3:40 pm spoke with V8, Regional Nurse Consultant by phone. V8 remembered that V2 had called her regarding the incident between R2 and V4. V8 had been told this was a customer service issue and she recommended that V2 perform an in-service regarding customer service for meal trays. V8 stated that no allegations of abuse had been reported to her. V8 stated that if this had been reported as any type of abuse that the employee would be suspended until the investigation was complete. There was no abuse investigation provided by the facility for R2 and V4. Abuse prevention program policy reviewed last on 9/2017 was reviewed. It stated that the facility desires to prevent abuse, neglect, exploitation, mistreatment, and misappropriation of resident property by establishing a resident sensitive and resident secure environment. It stated that employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property is unsubstantiated.

Based on interview, observation, and record review the facility failed to ensure wound treatments were consistently provided for 1 of 3 residents (R2) reviewed for wound care. This failure resulted in R2 requiring transfer to the hospital, maggots developing in R2's wound, a diagnosis of osteomyelitis and needing IV antibiotics therapy. Findings include: R2's face sheet, dated 8/28/24, documented R2 has diagnoses of unspecified open wound on right lower leg, osteomyelitis, local infection of the skin and subcutaneous tissue, type 2 diabetes, bipolar disorder, coronary angioplasty implant and graft, traumatic compartment syndrome of right lower extremity, hypertension, and depression. R2's MDS (Minimum Data Set), dated 7/29/24, documented R2 is cognitively intact. R2's MDS, dated [DATE], documented R2 has not exhibited any rejection of care behaviors. R2's MDS, dated [DATE], documented R2 has not exhibited any rejection of care behaviors. R2's weekly skin assessment of right lower leg wound, dated 8/14/24, documented surgical wound with delayed closure wound. Wound has moderate serosanguinous drainage present. Wound bed appearance is red with 80% granulation and 20% slough. Wound edges are attached. Peri wound is fragile and red. Wound is undermining 0.3 cm from 12 o'clock to 2 o'clock. Zero odor observed. Zero complaint of pain voiced. R2's TAR (Treatment Administration Record), dated August 2024, documented an order for xeroform petrolatum dressing to right lateral calf topically one time a day every Monday, Wednesday, and Friday to promote wound healing with a /start date of 8/16/24 and discontinue date of 8/19/24. R2's TAR documented wound care was completed on 8/16/24, however the facility was unable to provide documentation of when the treatment was signed off since V16, Licensed Practical Nurse (LPN) in an interview stated the treatment was not signed off on 8/16/24 when she worked on 8/18/24. R2's progress note, dated 8/18/24 at 10:37 am, documented another resident came to the nursing station being very aggressive toward this nurse demanding that resident's dressing be changed daily. R2 has an order for the dressing to be changed Monday, Wednesday, and Friday. This nurse and another staff went to observe the resident. This nurse removed the ace wrap and inspected the dressing. The dressing is securely intact and dry. The resident was educated on the importance of keeping the dressing intact and covered for the number of days in order to promote wound healing. R2's progress note, dated 8/19/24 at 5:55 am, documented nurse was called to resident room by CNA to assess resident; maggots were found in the sheets; upon further investigation, nurse found a maggot on resident dressing on RLE (right lower extremity), dressing was then unwrapped and found maggots within wound bed; on call MD (Medical Doctor) made aware, order to send to ED (Emergency Department) for eval (evaluation) and tx (treatment). Wound was then cleaned with wound cleanser per order and wrapped with kerlix. EMS (Emergency Medical Service) was called for transport to local hospital. R2's local hospital progress note, dated 8/19/24, documented R2 presented to the ED with complaint of worsening pain to RLE wound and maggots in wound. She states dressing is to be changed every MWF (Monday, Wednesday, Friday), but staff hadn't changed since last Wednesday. Maggots were noted in her wound this morning, so she was brought to the ED for further evaluation. It continues, Patient to be admitted for further evaluation and management of acute on chronic OM (osteomyelitis) as well as vascular and ID (Infectious Disease) consultations. R2's local hospital progress note, dated 8/19/24, documented XR (x-ray) of tibia and fibula date of service 8/19/24 at 7:52 am provided clinical information: [AGE] years, female, pain, this morning there were maggots found in her bed and when looking at her leg maggots were found there. Procedure and materials: AP (anterior to posterior) and lateral view of the right tibia and fibula. Comparison studies: April 23, 2024. Observations: there is a large soft tissue defect that is present about the lateral aspect of the right lower leg. Severe soft tissue swelling is present. The soft tissue swelling is increased compared to prior examination. The soft tissue defect now extends through to the underlying fibula. There are lucent areas that are present within the fibula concerning for areas of osteomyelitis. R2's local hospital progress note, dated 8/22/24, documented right leg wound culture positive for MRSA (methicillin-resistant staphylococcus aureus), pseudomonas aeruginosa, and proteus klebsiella. R2's re-admission orders to facility, dated 8/23/24, documented orders for cefepime 2 grams in sodium chloride IV (intravenous) every 12 hours for 42 days and vancomycin 1.5 grams IV daily for 42 days. On 8/27/24 at 4:25 pm R2 stated that the facility Wound Nurse V3 was on vacation the week that she developed the maggots in her leg wound. R2 stated that no staff changed nor offered to change her dressing on Friday, August 16, 2024. R2 stated that she could feel the maggots moving over the weekend and she asked a nurse to look at it, but none did. Observed many flies in resident's room during this interview. On 8/28/24 at 11:02 am R2 stated that the DON nor any nurse changed her dressing on 8/16/24. R2 stated that she tried to get her nurse to change the dressing over the weekend and that she even told the nurse that she had creepy crawlies in her leg. R2 stated that the leg wound was oozing, and her dressing was saturated. R2 stated that her nurse on Sunday, 8/18/24 was rude, rolled her eyes at her, and replied that is not my job in response to her complaint of feeling creepy crawlies in her leg and to her request of getting her wound looked at and her dressing changed. R2 stated that her nurse looked at her dressing but did not remove the dressing to assess the wound. R2 stated that her friend, R7, a fell ow resident, even tried to get the nurse to change her dressing to her leg but she still didn't get the wound assessed nor the dressing changed. On 8/28/24 at 9:50 am V2 DON (Director of Nursing) stated that she changed R2's RLE dressing on 8/16/24 and that she did not observe any maggots on the wound at this time. V2 stated that R2 has a history of being noncompliant with dressing changes and with keeping the dressings on the wound but that the facility does not have any of this documented. V2 stated that she would have expected her nurse to remove the dressing and assess the wound when R2 complained of discomfort in her wound on 8/18/24. On 8/29/24 at 10:07 am V16 LPN (Licensed Practical Nurse) stated that she was R2's nurse on 8/18/24 and that another resident, R7, became verbally aggressive with her and stated that R2's dressing needed to be changed daily. V16 stated that she informed R7 that is a HIPPA issue. V16 stated that she looked at R2's TAR (Treatment Administration Record) and she saw that R2's dressing did not get changed on Friday, August 16, 2024, and that the TAR was red for that date because it was not completed. V16 stated the last time it had been signed off was on 8/14/24. V16 stated that R2 told her that her leg dressing had not been changed since Wednesday, August 14, 2024. V16 stated that she looked at the dressing but did not change it because R2 did not complain to her about any discomfort. On 8/28/24 at 12:45 pm R7 stated that on 8/18/24 around 8:45 am he went to R2's nurse and asked her to change R2's right leg dressing because the dressing was saturated and that R2 told him she was having discomfort and could feel something crawling in the wound. R7 stated that it was obvious that the dressing needed changed because he could see the drainage on the outside of the dressing. R7 stated that R2's nurse told him that he needed to mind his own business. R7 stated that he was outside of R2's room in the hallway at 10:30 am waiting in line to go out and smoke on that same day. R7 stated that he observed R2's nurse in her room looking at R2's leg dressing. R7 stated that he heard the nurse tell R2 it's not due to be changed until Monday, I am not changing it. R7 stated that the nurse slammed the door shut when she saw him looking at her. R7's MDS, dated [DATE], documented that R7 is cognitively intact. On 8/28/24 at 1:58 pm V2 DON stated that she gave R2 her personal cell phone number in case she ever has issues again with getting her dressing changed. V2 stated that R2 told her that the weekend nurse on 8/17/24 and 8/18/24 refused to assess her wound and change the dressing even after R2 informed the nurse that she felt something crawling on the wound. V2 stated that she will be providing 1:1 education with that nurse because that was not appropriate for her not to look at the wound. V2 stated that R2 was moved to a different room today because she had been in a room next to the exit door where the residents go out to smoke resulting in more flies in R2's previous room. The facility Skin Management: Monitoring of Wounds and Documentation policy, dated 1/2022, documented it is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. Responsible party: All nursing staff. General guidelines: An evaluation of the PU/PI (pressure ulcer/pressure injury), if no dressing is present. An evaluation of the status of the dressing, if present (whether it is intact and whether drainage, if present, is or is not leaking); The status of the area surrounding the PU/PI. The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection (for example: increased redness or swelling around the wound or increased drainage from the wound); and whether pain, if present, is being adequately controlled.

Based on observation, interview, and record review the facility failed to ensure residents do not have access to chemicals for 1 of 3 residents (R3) reviewed for supervision to prevent accidents in the sample of 5. This failure resulted in R3 drinking a liquid containing bleach, being transported to the hospital for evaluation and medical treatment. R3, as a person with altered mental status and Schizophrenia would be afraid and apprehensive of being sent to the hospital. Findings include: R3's Admission Record, not dated, documents R3 was admitted on [DATE] and lists Major Depressive Disorder, Recurrent, Mild Unspecified Severe Protein-Calorie Malnutrition, Catatonic Disorder Due to Known Physiological Condition, Unspecified Psychosis not due to a Substance or known, Mood Affective Disorder, Altered Mental Status, Undifferentiated Schizophrenia as diagnoses. R3's Care Plan, dated 4/26/23, documents that R3's memory is impaired, and he has difficulty with decision-making, insight, logic, planning, and organization of thoughts. R3 ' s Care Plan documents R3 will put paper in his mouth and staff must get it out of his mouth. It also documents staff should provide clear explanations regarding expectations and procedures prior to providing care. Provide orientation to the immediate environment to enable the resident to be aware of surroundings and, provide reality-based orientation throughout the day to help the increase his/her comfort level and awareness of the environment. R3's Minimum Data Set, dated dated [DATE], documents that R3 is rarely/never understood, requires assistance with activities of daily living (ADL's). R3's MDS documents R3 and has short and long term memory problems with modified independence for decision regarding tasks of daily life. It also documents that R3 does not wander. R3's Late Entry Nurses Note, created date 4/23/2024 at 12:45 PM for effective date 4/17/2024 at 1:38 PM, documents This nurse was notified by CNA (certified nurse's assistant) that Resident was sitting in his room with a bottle of unknown liquid, Resident normal baseline is A&0 (alert and oriented) x 1, therefore he is unable to verify if any amount was ingested, vs (vital signs) 98.0 (temperature) 76 (pulse) 20 (respirations) 128/72 (blood pressure), Resident sent out to (local hospital) for evaluation. This Nurse attempted to contact Residents Daughters to advise them of the occurrence and their phone numbers were no longer in service. Resident was transported via stretcher in an Ambulance to (local hospital). R3's Progress Note-Acute Care, dated 4/17/2024, documents that (R3) is a [AGE] year old male with a pmhx (past medical history) of Drug induced parkinsonism, Schizophrenia with catatonia, orthostatic hypotension, MDD (Major Depressive Disorder), psychosis, HLD (hyperlipidemia), HTN (hypertension), protein calorie malnutrition, and weakness. He is a LTC (long-term care) resident at (facility). Resident seen today after receiving notification that he ingested an unknown substance assumed to be chemical. At approximately 1341 received notification that resident was observed drinking from a bottle which contained an unknown chemical substance. Nursing given order to call EMS (emergency medical service) for transport to hospital for potential poisoning. On assessment resident was at baseline orientation of A/O (alert/oriented) x1- at baseline he's minimally verbal- he made no verbal communication at time of assessment when he was asked what he was drinking or if he had any pain. Observed drooling excessive amount. Responded and complied with command to open mouth for assessment, no redness or swelling to tongue or throat noted on exam. Resident was not having any respiratory issues at time of assessment. EMS arrived during assessment. Resident transferred to stretcher- alert and stable upon exit from facility. Nursing unaware of amount consumed or identity of chemical substance. Admin (V1 Administrator), DON (V2, Director of Nursing), and appropriate parties notified of incident. R3's After Visit Summary from (Local Hospital), dated 4/17/2024, documents Today you were seen and evaluated for your consuming of bleach. Your labs and imaging were reassuring. Follow the instructions provided. Follow-up with your doctor as below. If you have any worsening or concerning symptoms, please return to the emergency room . It also documents Reason for Visit: Ingestion. Diagnosis: Ingestion of bleach, accidental or unintentional initial encounter. It also documents EXAM DESCRIPTION: CT SOFT TISSUE NECK W CONTRAST, dated 4/17/2024, documents REASON FOR STUDY: other, liquefactive ingestion. Pt (patient) BIBEMS (brought in by emergency services) from (facility) for ingestion of unknown substance PTA (prior to admission). Pt was seen drinking unknown substance out of water bottle that was labeled do not drink Pt AAO (alert and oriented) x1-2. Per EMS patient at baseline. Pt unable to answer all questions but following some commands. RR (respirations) even/nl (not labored). Pt speaking in garbled speech unsure if baseline. EMS unable to give exact baseline from healthcare facility. Denies pain at this time when asked. R3's Nurse's Notes, dated 4/18/2024 at 9:25 PM, documents Note Text: Cont (continue) IFU (incident follow up) day 2/3 without further occurrences noted. 0 acute distress noted. Resting quietly at this time with call light in reach. Clear po (oral) fluids offered, encouraged and made available. R3's Progress Note-Follow Up, dated 4/18/2024, documents that History of Present Illness: (R3) is a [AGE] year old male with a pmhx (past medical history) of Drug induced parkinsonism, Schizophrenia with catatonia, orthostatic hypotension, MDD, psychosis, HLD, HTN, protein calorie malnutrition, and weakness. He is a LTC resident at (facility). Resident seen today seen today after return from hospital ED for ingestion of bleach/ accidental or unintentional and constipation. Resident is at baseline orientation and functional status. no acute distress noted at time of assessment. He denies any pain. in hospital blood work, EKG- NSR- CT of neck-no abnormality's [sic] of neck and CT of abdomen- stomach distended (possible delayed gastric emptying), Severely increased amount of stool in entire colon- no obstruction, small hiatal hernia diffuse bladder wall thickening (d/t overdistention vs cystitis), Paget's disease of the right hemipelvis, mild subcutaneous induration overlying the coccyx ( potential to developing decub- no fluid collection) preformed- results noted accordingly. Resident returned to facility with no new orders and stable per hospital documentation. R3's Nurse's notes, dated 4/19/2024 at 2:36 AM, documents Note Text: Cont IFU day 2/3 without further occurrences noted. 0 acute distress noted. Resting quietly at this time with call light in reach. Clear po fluids made available. On 4/24/2024 at 8:16 AM R3 was sitting in wheelchair in room. R3 was sitting in front of the bedside table rummaging through drawer. On 4/24/2024 at 12:07 PM there was a 1-pound 3ounce container of bleach wipes in R3's bedside table door to bed side table was opened and visible. The container had multiple bleach-soaked wipes and liquid in the container. Microdot Bleach wipes container documents Keep out of reach of children caution. Precautionary statements: Hazards to humans and domesticated animals. On 4/24/2024 at 12:08 PM V12, Housekeeper, verified that the bleach wipes were in R3's bedside table. On 4/24/2024 at 12:11 PM V11, Licensed Practical Nurse, LPN, verified that the bleach wipes were in R3's bedside table in R3's reach. V11 stated that the wipes are supposed to be locked in a cabinet and not in R3's room. V11 stated that this puts R3 at risk for significant injury from ingesting, skin irritation and eye problems. On 4/23/2024 at 1:23 PM V5, Certified Nurse's Aide, CNA, stated that he was not working the hall on the day of the incident. V5 stated that he is normally assigned to R3. V5 stated that R3 eats and drinks anything in front of him. V5 stated that R3 is always hungry and thirsty. V5 stated that R3 is normally total care. V5 stated that R3 does not roam into others room and if it was in their it would have had to be brought into the room. V5 stated that R3 is alert to name only. V5 stated that R3 would not know if a liquid was harmful. V5 stated that if it is in his (R3) reach, he will grab it and drink it. V5 stated that R3 grabs at things and in the dining room they make sure nothing is in front of him. V5 stated that the staff feeds him. V5 stated that as soon as he gets to the dining room a staff member is always with him to keep him from grabbing things and eating them. V5 stated that R3 eats plastic and Styrofoam cups. V5 stated that this has always been the case with R3. V5 stated that when in his room they don't bring things into his room and lay him down. On 4/23/2024 at 1:26 PM V6, CNA, stated that she took care of R3 on the day of incident. V6 stated that she was walking the hall checking on her residents and saw R3 sitting in his room drinking out of a water bottle. V6 stated that it struck her odd because the liquid was yellow. V6 stated at that time V8, Restorative Aide, came past and looked as well. V6 stated they took the bottle away. V6 stated that she did not smell the liquid. V6 stated that R3 was drinking the liquid out of the bottle. V6 stated that R3 was initially in the dining room and had previously returned. V6 stated that she had not seen R3 with this water bottle at all that day. V6 stated that R3 does not roam into other rooms. V6 stated that she is not sure how it got into R3's room but someone would have had to bring it in there. On 4/23/2024 at 1:32 PM, V8, Restorative Aide, stated that she was walking past R3's room and saw R3 drinking from a clear water bottle. V8 stated that she thought it odd because water is clear. V7 stated that she and V6 entered the room. V8 stated that she took the water bottle from R3 and smelled it, and it smelled like bleach. V8 stated that when she observed R3 he was actively drinking the liquid. V8 stated that then V9, LPN, checked R3 out and he went to the hospital. V8 stated that she does not know how R3 got a hold of the bottle of bleach. V8 stated that R3 is total care, and the bottle would have to be brought into his room and placed in his reach. On 4/23/2024 at 1:35 PM, V9 stated that she was told by V8 that R3 was drinking a yellow liquid out of a water bottle. V9 stated that V8 at that time was not sure if it was urine or what. V9 stated that she smelled it, and it smelled like bleach. V9 stated that she went down and assessed R3. V9 stated that she did not know how much R3 drank and felt he needed to go to the emergency room . V9 stated that R3 was sent out at that time. V9 stated that she is not aware of how R3 got a hold of the bleach. V9 stated that the CNAs have a history of bringing bleach and cleaning products in the building from outside the facility. On 4/23/2024 at 8:36 AM, V14, Restorative Aide, stated that she does not work the floor. V14 stated that at lunch she did feed R3. V14 stated that he ate all his food. V14 stated that his drinks were in cups and R3 did not have a bottle while eating in the dining room. On 4/24/2024 at 12: 40 PM V2, Director of Nursing, DON, stated that she is aware of the incident that occurred with R3. V2 stated that nursing notified management that R3 was drinking a chemical substance. V2 stated that they felt that R3 needed to go to the hospital for evaluation and treatment. V2 stated that R3 returned without new orders and the facility monitored him. V2 stated that she is not for sure how R3 got the liquid. V2 stated that during the investigation she was able to determine that the liquid was brought in by staff. V2 stated they were unable to identify the specific person. V2 stated that no one would admit to it. V2 stated that the chemical should not have been in the facility let alone in R3's room and in reach. V2 stated that could have caused R3 serious injury. V2 stated that she was made aware by her staff that R3 had bleach wipes in his bedside tables today. V2 stated that R3 does not have access to the bleach wipes. V2 stated that staff have access. V2 stated R3 sits in front of the bedside table. V2 stated that the wipes in the bedside table would be considered in R3's reach. V2 stated that this puts R3 at risk for bleach being ingested, get in his eyes, and cause significant injury to R3. V2 stated that the bleach wipes were placed inside R3's beside table and R3 does not have the mental compacity to do so. On 4/24/2024 at 3:41 PM V20, Nurse Practitioner, stated that she was at the facility, lower level seeing patients, at the time of the event. V20 stated that she was called and notified that R3 had drank an unknown chemical substance. V20 stated that she assessed R3 at that time. V20 stated that because it was not sure at that time how much of the chemical was consumed, she felt R3 needed to go to the emergency room for evaluation and treatment as needed. V20 stated that she received confirmation from the hospital that the liquid was bleach. V20 stated that she did not see the liquid herself. V20 stated that she would expect that the facility and staff would not have bleach and chemicals in resident's room. V20 stated that if this liquid was in the room, she would expect the resident to be supervised. V20 stated that access to these chemicals puts residents at risk for serious and significant injury. The facility's Management of Hazardous Chemicals, dated 10/2023, documents that POLICY: Hazardous Chemicals shall be handled in a manner which poses no substantial hazard to human health, and shall not be deliberately discarded with the general waste or by any route into the sanitary sewer system. The handling and disposal of these materials shall be in compliance with this policy and Federal and State regulations to ensure that hazardous materials generated at this facility do not pose a substantial hazard to human health or the environment. It also documents Storage: 1. All chemicals shall be dated when opened. Excess Hazardous Chemicals: I. The contents of all containers must be clearly identified.

A. Based on interview and record review, the facility failed to ensure residents were free from abuse for 9 of 25 residents (R30, R35, R36, R39, R50, R63, R64, R85 and R88) reviewed for abuse, in the sample of 59. This failure resulted in R30 biting R50 and R50 being treated for a human bite and seeing the wound nurse for treatment. This failure also resulted in R85 being thrown out of wheelchair by R39, and R39 attempting to smash R85's head with the wheelchair causing an abrasion to R85's left ear, upper left arm, and face. Findings include: 1.R30's Physician Order Sheet (POS) for February 2024 documented a diagnosis of Unspecified psychosis not due to a substance or known physiological condition, unspecified asthma, morbid obesity, hypertension, major depression disorder, anxiety disorder, Schizophrenia, legal blindness, and post-traumatic stress disorder. R30's Minimum Data Set (MDS), dated [DATE], documented that R30 was severely impaired for cognition for activities of daily living. R30 was able to walk ten feet and required supervision or touching assistance. R30 had no impairments on the upper or lower extremities. R30' Care Plan, with multiple dates, documented, (R30) is at risk for abuse and/or neglect related to anxiety and major recurrent due to suicidal ideations and significant mental health issues. On 10/11/2022, it documented, (R30) was physically and verbally aggressive towards another resident that he shared a room with. (R30) will destroy his own property, i.e., guitar. Resident has diagnosis of Schizophrenia and may display symptoms that include but are not limited to; being out of touch with reality (delusional or hallucinations), may have disorganized speech or erratic behavior, decrease in activities. Diagnosis of mental illness. On 2/16/23 it documented, Having delusional thoughts. It continued, dated 09/30/23, Experienced delusions. On 10/12/2023, it continues, Experienced delusions. R30's care Plan did not address the altercation on 2/1/2024. R30's Care Plan, dated 8/2/2023, documented, (R30) is legally blind. He stated he was born with blindness in both eyes. (R30) qualifies for Subpart S programming to diagnosis major depression disorder, recurrent, sever, focus areas include community living, medication management and self-maintenance. Diagnosis of mental illness. At risk for abuse and neglect related psychosis, anxiety, and schizophrenia. R30's Initial Incident Report, dated 2/1/2024 at 8:30 AM, documented, Resident (R30) and (R50) entered into a verbal disagreement about (R50) working for a seed company that (R30) used to work for. The verbal argument became physical and (R30) bit (R50) on the right hand. Puncture wound/bite marks that drew blood to right hand of resident (R50). On 4/11/2024 at 9:22 AM, R30 stated, (R50) and I were roommates. (R50) was aggressive, and I am legally blind. (R50) was always threatening me and stealing my chips and candy bars. (R50) came right up into my space and I had to do something, so I bit him. I can see shadows and he was threatening me, so I bit him on the arm. They moved me downstairs now and I like it better. (R50) was always threatening me and they never did anything about it. When (R50) got close to me on my side of the room, I bit him to defend myself, he said he was going to beat me up. I did not do anything wrong. An Incident Report, dated 2/14/2024, documented, (R50) got into a verbal disagreement with roommate (R30) about working at the same seed company in the past then (R30) bit him on the right hand. Root cause: Both residents are cognitively impaired and became agitated resulting in (R50) being bit by (R30) on the right hand. Intervention: Residents were moved to separate rooms on a different hall. Supervision provided to both residents for change in status. R30's Progress Notes/Nurse's Notes did not document anything related to R30 biting R50. On 4/11/2024 at 9:32 AM, V18, Licensed Practical Nurse (LPN) stated, (R30) use to be upstairs but they moved him down here with me now. He is legally blind, and he can see shadows. When he was upstairs, he bit (R50) and then they moved him down here and I have not had any issues with him. He told me (R50) was taking his stuff and threatening him and he was defending himself. (R50) has a history of starting stuff with residents. On 4/9/2024 at 8:00 AM, all abuse investigations were requested for the past year. On 4/9/2024 at 5:15 PM, V21, Corporate Nurse stated, We had a change in Administration, and we were only able to find one abuse investigation. At this point, we do not have any other abuse investigations in the building, and we have looked in multiple places and this is all we have. I do not have any other abuse investigations. No abuse investigation for R30 was provided by the facility for the incident on 2/1/24. 2. R85's POS for April 2024, documented a diagnosis of dissociative and conversion disorder, chronic obstructive pulmonary disease, idiopathic aseptic necrosis of bone, psychoses, hypertension, peripheral vascular disease bipolar disorder, major depression, and suicidal ideations. R85's MDS, dated [DATE], documented that he was cognitively intact for decision making of activities of daily living (ADL). R85's Care Plan, dated 10/27/2022, documented, (R85) has an alteration in comfort related to idiopathic aseptic necrosis of the bone in his hip. R85's Care Plan Focus Area, dated 7/30/2022, documented, Resident reported being the recipient of verbal/physical aggression. On 8/19/2023, it documented, (R85) was on the receiving end of peer-to-peer incident. It continues, Intervention: Both residents separated and had psychosocial follow-up. On 4/16/2024 at 3:35 PM, R85 stated, I got thrown out of my wheelchair and onto the floor. (R39) is a hot head and he was mad at me in the dining room, and he can walk but I can't, and he got mad, he rushed me and threw me out of my chair. I think he would have killed me if he would have had more time. R85's Nurse Notes, dated 8/19/203 at 4:53 PM, As told by the 400 hall CNA, resident was thrown out of his wheelchair by another resident to the floor. As told by the resident he was thrown out of his wheelchair by another resident. Both residents separated from each other by staff. 911 was called. R85's Incident Report, dated 8/19/2023, documented, As told by the 400 hall CNA, resident was thrown out of his wheelchair by another resident to the floor. Both residents were separated by staff. Abrasion to left ear, upper left arm, and face. On 4/17/2024 at 3:12 PM, V2, Director of Nursing stated, We have had a lot of staff changes and I was not working at the time or the interim Administrator when this happened. On 4/17/2024 at 3:23 PM, V27, Certified Nursing Assistant (CNA), stated, I was in the dining room and (R85) bumped into (R39) and (R39) turned around and picked (R85) up and threw him out of his wheelchair and then he picked up the wheelchair and was going to try and smash his head in and I got there in time and stopped him from hitting him with the wheelchair but (R85) was slammed on the floor. It happened a while ago, and I do not remember all of the other details, but I know he wanted to smash his head in and would have if I would have not got there in time. 34964 3. R39's Progress Note, dated 8/19/2023 at 5:38 PM, documented, Approximately 1530 (3:30 PM) this said RN (Registered Nurse) was down the hall when I heard loud voices coming from the 300 hall. I ran to assist, and that is when I saw (R85) on the floor with CNA holding (R85's) wheelchair. CNA stated that he stopped (R39) from hitting (R85) with the wheelchair, and that (R39) had thrown/knocked (R85) out of his wheelchair. I assessed the situation and called 911 believing that (R39) was still a threat to others. While on the 911 call, I notified the Administrator, DON, NP (Nurse Practitioner) for DR (doctor). The Facility's Incident Report, dated 8/19/24 at 4:19 PM, documented, Nursing Description: As told by the 400 Hall CNA resident (R85) was thrown out of his w/c (wheelchair) by another resident (R39) to the floor. Resident Description: As told by the resident he was thrown out of his w/c by another resident. Immediate Action Taken: Both residents were separated from each other by staff. No other information regarding investigation of this resident-to-resident altercation was provided by the facility when requested. R39's Face Sheet, printed 4/10/24, documented that his diagnoses were Schizophrenia, Vitamin D Deficiency, Hyperlipidemia, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Bipolar Disorder and Hypertension. R39's MDS, dated [DATE], documented that he was cognitively impaired, and has rejected care daily. R39's Care Plan, dated 11/26/18, documented, (R39) is at risk for abuse and/or neglect related to history of physical/verbal aggression, use of psychotropic medications, hallucinations/delusions, confusion/disorientation/forgetfulness, offensive anti-social habits, poor personal hygiene and DX; SCHIZOPHRENIA, BIPOLAR DISORDER, and DEMENTIA. It continues, Interventions: 1:1 counseling as needed and as resident allows. Administer medications as per MD orders. Notify MD if behaviors are worsening. If resident becomes aggressive attempt to remove resident from situation and assist him/her to a quiet place. Encourage resident to vent his/her feelings about situation. Remind resident that behavior is not acceptable. Resident is involved in anger management focus groups learning different techniques on maintaining his anger. Resident was sent to the ER for evaluated. He was admitted . Staff to encourage resident to attend daily group therapy. On 04/12/24 at 12:57 PM, V1, Administrator, stated that he has not been able to locate the investigations surveyors have requested of the resident-to-resident abuse investigations and abuse investigations. He stated he has reached out to the two previous administrators who stated the investigations should be here, but he has looked in all the file cabinets and closets and the abuse investigations are not here anywhere. 4. On 4/11/24 at 11:18 AM R50 was lying on his bed. He had a crusty yellow scab at the base right first finger with no dressing or drainage noted. R50 shook his head when asked if he had any pain in his right hand from being bit. R50's Wound Physician Note, dated 2/6/24, documented the description of the bite wound to his right hand as a full thickness open ulceration wound measuring 6-centimeter (cm) x 1.3 cm x 0.2 cm with light serous exudate that is being treated with Augmentin (antibiotic). R50's Treatment order, dated 2/6/24, documented, Silver Sulfadiazine, apply twice daily, cover with bordered gauze and wrap with kerlix. R50's Wound Physician Progress note, dated 4/9/24, documented, (R50's) wound is now a scab and he removes his dressings, so treatment was changed to skin prep daily. R50's Face Sheet, print date 4/10/24, documented that he was initially admitted to the facility on [DATE] and his diagnoses included Schizophrenia, Maxillary Fracture, Left Side, Fracture of Nasal Bones, Fracture of Orbit, Unspecified Psychosis Not Due to a Substance or Known Physiological Condition, Paranoid Personality Disorder, Unspecified Lack of Coordination, Major Depressive Disorder, Anxiety Disorder, and Insomnia. R50's MDS, dated [DATE], documented that he was severely cognitively impaired, and had no behavior symptoms during the look-back period for that assessment. R50's Care Plan, dated 8/20/20, documented, (R50) is at risk for abuse and neglect related to use of psychotropic medication, physical/verbal aggression, isolation, resistive to care, poor hygiene and diagnosis of Anxiety, Schizophrenia, Depression, and Psychosis. It continued, Interventions: 1:1 visits for emotional support as needed. It continues, Administer medications as directed by MD and monitor for possible side effects and for effectiveness. If resident becomes difficult during care, make sure resident is safe and walk away. Allow resident time to calm down, then reapproach. Keep resident safe from harm at all times. Report any suspected abuse and/or neglect immediately to Administrator. Social Services to provide information regarding Hotline, Ombudsman, Community resources and residents rights as needed. Social services to review/assess resident history and assess risk factors for Abuse/Neglect quarterly and PRN. Staff to provide education/counseling if behaviors are noted. Staff will demonstrate respectful/non-threatening approaches. R50's Progress Note, dated 2/1/2024 at 12:08 PM, documented, Resident noted with blood stains on his coat. Resident assessed for injuries and noted abrasion to right hand. MD (Medical Doctor) notified new orders clean with wound cleaner and apply Triple Antibiotic Ointment daily until healed. Resident is own responsible party. R50's Progress Notes, dated 2/4/2024 at 12:05 PM, documented, Resident on abt (antibiotic) therapy r/t (related to) bite to hand; no ase (adverse side effects) noted. Will continue to monitor. R50's Progress Notes, dated 2/9/2024 at 2:50 PM, documented, Resident changed rooms; resident notified and aware; resident own responsible party; attempted to call (R50's family) but the number was disconnected; called placed to (R50 family) with no answer; (R50 family) called and notified of room change; said he would let the family know; no concerns voiced. R50's Order Summary Report, dated 4/11/24, documented, Silvadene External Cream 1 % (Silver Sulfadiazine) Apply to Right Hand topically every day shift for To Promote Wound Healing; Telfa Non-Adherent Pad (Gauze Pads & Dressings) Apply to right hand topically every day shift for To Promote Wound Healing; Kerlix Gauze Roll Medium Miscellaneous (Gauze Pads & Dressings) Apply to right hand topically every day shift for To Promote Wound Healing. R50 Physicians order, dated 4/10/24, documented, Skin Prep Wipes Miscellaneous (Ostomy Supplies) Apply to Right Hand topically everyday shift for To Promote Wound Healing for 30 Days. On 4/10/24 at 3:00 PM, V2, Director of Nursing, stated that she has not been able to find any abuse investigations regarding abuse allegations or resident to resident physical altercations involving R50. R50's Incident Report, dated 2/1/24 at 8:30 AM, documented, Nursing Description: Resident was bit by peer RB (R30). Refused to go to the hospital. Resident Description: Resident unable to give description. Immediate action taken: Description: Immediately separated, both refused to go to the hospital. Both skin assessed. NP (Nurse Practitioner) notified. Injuries Type: No injuries observed at time of incident. This incident report also documented that R50 was alert and ambulatory without assistance. R50's Incident Report, dated 9/30/23, documented, Nursing Description: Resident was seen in bed laying down with his roommate standing over him yelling about being hit. Resident description: Stated he did not do anything to that man. Immediate Action Taken: Resident was put on a one to one; and rooms are being changed. Mental status: Oriented to person; Predisposing Environmental Factors: Other; Predisposing Physiological Factors: Non-compliant with safety guidance, recent change in cognition, and Predisposing Situation Factors: Recent room change. R50's Incident Report, dated 9/28/23 at 2:01 AM, documented, Nursing Description: CNA (Certified Nursing Assistant) shouted out to this nurse that they were fighting. This nurse entered the room and observed this resident and another punching each other in the face and chest area while in the bathroom. I attempted to close the bathroom door to cease the fighting and this resident put his feet in the door in attempts to reopen. The other resident has sat down and calmed himself at this this time. this resident was then screaming, I said turn off the lights, turn them off. I asked the resident to if he could stop screaming in attempts to not awake other sleeping residents. He then responded, Fuck you, you, you, you I will kill all you guys. Several attempts were made to redirect/calm this resident by it only agitated him even more so I allowed him space to calm himself. Resident still at this time continued screaming, making gestures and threats. Resident Description: Unable to give description. Immediate Action Taken: Residents were separated. The aggressor was escorted from the room to ensure safety of other residents. MD called/texted. Management contacted. EMS (Emergency Medical Services/Police contacted. Resident sent to Gateway for a psych eval. The incident report documented R50 is ambulatory without assistance, oriented to person, place, time and situation. Predisposing Environmental Factors: other, poor lighting. Predisposing Situation Factors: Dislikes roommate, recent room change. R50's Incident Report, dated 9/9/23 at 4:00 PM, documented, Nursing Description: resident was seen by a staff member blood on resident masked. This nurse examined all that I could. Resident was angry yelling. A scratch examined on resident nose and under eye. Resident description: Resident states a guy hit him and he fell . Resident stated he does not know who hit him. Immediate Action Taken: Skin assessed. 2 small scratches noted under his eye near his nose. Skin cleansed with normal saline. Physician, police, and resident's responsible party resident sent to ER (emergency room ) for eval and treatment. Predisposing Environmental Factors: other. Predisposing Physiological Factors: confused, gait imbalance. Predisposing Situation Factors: Ambulating without assist. R50's Progress Note dated 9/9/2023 at 3:07 PM, documented, Note Text: resident was seen by a staff member blood on resident masked. This nurse examined all that I could. resident was angry yelling. a scratch was examined on resident nose and under eye. R50's Progress note dated 9/30/23 at 7:11 AM documented, Resident roommate c/o being physically assaulted by him. Resident denied allegations of abuse. Resident was yelling w/ roommate; roommate stated that he was struck by (sic); MD was notified, order was given to send resident to ED for eval of altered mental status; [NAME] PD were called to assist EMS; resident's roommate filed report; this resident refused to go to ED for eval; residents were separated immediately, this resident remains on one to one; MD made aware of changes. On 4/11/24 at 11:08, V16, LPN/Scheduler stated that she did the incident report on 2/1/24 when (R30) bit R50 on his hand but she did not witness what happened and could not remember who reported it to her. She also stated that she did provide wound care to R50's bite and that the bite did break the skin and it was bleeding. She also stated that he was followed by the wound nurse practitioner for a while because of the wound. V16 continued to state she did not know anything about R50 being hit by another resident on 9/9/23 causing facial fractures. On 4/11/24 at 11:25 AM V21, Corporate Nurse and V22, Corporate Travelling Administrator, both stated that they do not have any investigations for abuse allegations or resident to resident altercations for R50. V21 stated, We have given you (surveyors) everything we can find. We have looked everyplace for investigations and have not found them. On 4/11/24 at 11:40 AM V23, Nurse Practitioner stated that she assessed R50's wound from another resident biting him on the day after it happened. She stated the bite did break his skin and they always treat a human bite with antibiotics, but she did not feel that the wound from the bite was ever infected. She stated that R50 had prolonged healing from the bite because he is non-compliant with treatment and refuses hygiene most of the time. 04/12/24 at 12:57 PM, V1, Administrator, stated that he has not been able to locate the investigations surveyors have requested of the resident-to-resident abuse investigations and abuse investigations. He stated he has reached out to the two previous administrators who stated the investigations should be here, but he has looked in all the file cabinets and closets and the abuse investigations are not here anywhere. 5. The facility report to the State Agency, dated 3/30/24 at 12:23 PM, documented, Resident/ Victim/Perpetrator: (R63/R64) Initial Incident Description: Resident reported that he got into an argument with another resident over the food cart and the other resident poked him and hit him. Residents were separated and assessed for injury and minor injury was treated. Residents monitored to prevent recurrence. The Initial Report documents R63, as the victim and R64, as the perpetrator. The facility's Follow-up Investigation Report, undated, documented, The victim describes the incident as a disagreement over the access to the hallway meal cart during lunch. The victim states that he asked the other party to close the door to the cart and not to take food out of it. This discussion escalated to a verbal argument followed by the other resident approaching the victim and, with cupped hands, shoving his hands into the neck area of the victim and lightly poking him with a fork. Victim said there were no staff or residents present as the location was out of view of the nursing staff at the time. The victim stated that the other resident said he was allowed to access the cart. The victim displayed no expression of distress after the incident and during the follow up discussion with the Administrator on 4/1 and 4/2. He appeared to be in good spirits and expressed understanding of the other residents' initial actions due to the misunderstanding of the access allowed to the meal cart by residents. Under interview of alleged perpetrator, it documented, The resident is not cognitively able to express himself as to the intent of his actions due to a past brain injury but is alert. It continues, Based on staff interviews there were no additional reports of similar incidents uncovered involving these or other residents. A staff member did indicate that the victim has a history of directing other residents and that the alleged perpetrator coincidentally does not take direction well from other resident. It continued, Conclusion statement, Not verified. Unsubstantiated. It continues, The facility residents have diagnosis of bipolar, depressive disorders and behavior histories. The investigation uncovered the source of the altercation as a misunderstanding of the facility procedures for access to the hallway meal cart rather than a deliberate attempt by the alleged perpetrator to willfully harm the victim. The victim expressed this in his statements as well. The injury sustained by the victim were relatively minor and required basic first aid and apparently resulted from an initial verbal disagreement. Upon further discussions, the victim expressed no fear or feelings of being unsafe. Based on review of the medical records, resident history, as well as the disagreement involved and related to his need for behavior intervention plan, which is in place. At this point the police report has not been received but has been requested by the facility. If there are changes to the results of the investigation based on the content of the police report, the final report will be adjusted. R63's Face Sheet, undated, documented diagnoses included Bipolar Disorder, Current Episode Mixed, Moderate, Major Depressive Disorder, Single Episode, Unspecified and Anxiety Disorder, Unspecified. R63's MDS, dated [DATE], documented that R63 was alert and oriented and had no behaviors. R63's Care Plan dated 5/18/23, documented, Has symptoms such as mood swings, impulsive behavior and attention seeking behavior related to a diagnosis of bipolar disorder and major depression disorder. Goal: Resident will demonstrate an ability to manage affect/mood swing without difficulty at least twice/week; Resident will not have a relapse of symptoms through the next review. Interventions: Administer Medication as prescribed by the physician. Encourage and counsel on the importance of medication compliance as needed. Encourage participation in activities. Encourage participation in recommended programming. R63's Care Plan, dated 5/18/23, documented, ABUSE: (R63) is at risk for abuse and neglect r/t Bipolar Disorder, MDD, and Anxiety. It continues, Assess resident for abuse and neglect upon admission and quarterly. Continue to in-service the staff about abuse and neglect. 6. R64's Face Sheet, printed 4/12/24, documented diagnoses of Type 2 Diabetes Mellitus, Aphasia Following Non-Traumatic Subarachnoid Hemorrhage; Mixed Receptive-Expressive Language Disorder; Epilepsy, Unspecified, Intractable, with Status Epilepticus; Muscle Weakness; Bipolar Disorder; Cognitive Communication Deficit; Major Depressive Disorder; Personal History Traumatic Brain Injury; and Alcohol Abuse. R64's MDS, dated [DATE], documented that he was alert and oriented. R64's Care Plan, dated 3/30/24 documented, (R64) is at risk for abuse and/or neglect related to: history of TBI, Schizoaffective, depression, history of chemical/substance abuse, persistent anger/fear/anxiety, confusion/disorientation/forgetfulness, and poor judgement skills. Has difficulty in communications, history of verbal and physical aggression. It continues, Administer medications as directed by MD and monitor for possible side effects and for effectiveness. If resident becomes difficult during care, make sure resident is safe and walk away. Allow resident time to calm down, then reapproach. Keep resident safe from harm at all times. Provide resident with psychosocial programming for anger management. Report any suspected abuse and/or neglect immediately to Administrator. Social Services to provide information regarding Hotline, Ombudsman, Community resources and residents rights as needed. Social services to review/assess resident history and assess risk factors for Abuse/Neglect quarterly and PRN. Staff to provide education/counseling if behaviors are noted. Staff will demonstrate respectful/non-threatening approaches. It continues, 1:1 Anger management counseling with social services when res is aggressive. 1:1 counseling as needed and as resident allows. If resident becomes aggressive attempt to remove resident from situation and assist him/her to a quiet place. Encourage resident to vent his/her feelings about situation. Remind resident that behavior is not acceptable. If resident becomes upset, give him/her time to calm down before re-approaching. If resident refuses care, care giver should leave room and try again later. Separate residents as needed. Staff will ensure that each resident is safe. Staff to encourage resident to attend daily group therapy. Will be encouraged to attend Reality Awareness group. On 4/16/24 at 12:50 PM, V9, Social Service Designee, stated that they did have a point system for attending groups, but they no longer have any funding for groups and therefore there is no country store to offer the residents a place to spend their points. She stated attendance in groups has declined since they no longer have incentives to offer for attending them. She stated after residents are involved in 1:1 altercation with other residents she or her psycho-social staff do 1:1 with those residents to see if there is any post-traumatic stress following the incident and they make sure they are staying separated. She stated they are encouraged to attend psycho-social groups. V9 also stated that R63 does not attend psycho-social groups and R64 rarely attends them. On 4/17/24 at 2:55 PM V1, Administrator, stated that he did not feel abuse was substantiated in regard to the incident between R63 and R64 because, based on the facility's population, there was no willful intent to cause harm. V1 also stated that R63 likes to tell others what to do and R64 does not like anyone to direct him. V1 stated that there was superficial harm when R64 scratched R63 on the right cheek, but due to there being no intent, abuse was not substantiated. 33110 7. Resident to resident Initial Investigation, dated 2/26/24, documented that V34, LPN heard yelling coming from the dining area. She then went to assess and noted R36 laying on her back against a chair with staff in between her and a peer. R36 then voiced that R35 had taken her bag from a table in the dining room and when R36 attempted to retrieve her belongings, R35 pushed her away and hit her. Then R35 voiced that R36 grabbed R35's hair resulting in them falling back on to chair. Attempted to call V34, LPN without answer and R36 refused interview. When R35 was asked about the incident, he didn't remember the incident. An Investigation was requested from the facility, and V1, Administrator, stated that he has called the former staff, and they were not helpful. The final report staff and resident interviews were not provided during this investigation. R35's Care Plan, dated 2/3/24, documented that R35 can be verbally and physically aggressive. R35's intervention was to remove resident from the situation and administer medications. R35's Electronic Health Record, undated, documented that R35 has the diagnoses of Schizophrenia, Unspecified Dementia, and Unspecified Psychosis. R36's MDS, dated [DATE], documented that R36 was cognitively intact. R36's Care Plan, dated 3/14/24 documented that R36 qualified for subpart S. R36 displayed difficult behavior when dealing with peers and/ or staff and by the next review, R36 will not insult or direct vulgar behavior toward staff or peers. R36's Electronic Health Record Diagnoses list, undated, documented that R36 was bipolar disorder and Schizoaffective. On 4/17/24 at 12:50 PM, V2, DON stated that if one resident takes the other residents belongings then they would Initially separate the residents and assess them for injuries and then we would monitor them for 72 hours. The Facility Abuse Policy and Prevention Program, dated 2022, documented, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, and misappropriation of property, deprivation of goods, and services by staff or mistreatment. The facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his and her safely as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including but not limited to the separation of residents. B. Based on interview and record review, the facility failed to investigate injuries of unknown origin for 2 of 2 residents (R36 and R88), reviewed for abuse of unknown origin. This failure resulted in R88's fracture of T9 and T10 not being investigated as to the cause. Findings Include: 8. R88's Nurses Note, dated 8/12/23, documented, Resident complained of lower back pain, NP (Nurse Practitioner) notified. N.O (New Order) for lidocaine patch and Xray- Lumbar and sacral spine 4 view. R88's Nurses Note, dated 8/14/23, Resident came to nurses' station and stated that she is having back pain. R88's Nurses Note, dated 8/13/23, documented, Resident returned to facility with new orders for hydro-acet 5-325 PRN q6 d/t (Hydrocodone/Acetaminophen 5milligrams (mg)-325mg) Cat Scan results fracture vertebrae. R88's Clinical Record was reviewed on 4/16/24, and No investigation for injury of unknown found and no investigation to injury of unknown was provided by V1 Administrator or V2 Director of Nursing. 9. R36's Initial Report, dated 5/9/23, documented, This writer was made aware by the assistant administrator that resident reported being physically touched by a staff member, resident states a staff member physically touched her. Bruising noted with bright red blood to right lower extremity. Reside[TRUNCATED]

A. Based on observation, interview, and record review, the facility failed to ensure resident's coffee was served at temperatures that would not burn aresident for 1 of 12 residents (R30) reviewed for accidents in the sample of 59. This failure resulted in hot coffee being spilled on R30 and R30 sustaining burns to thigh and abdomen. Findings include: 1. R30's Physician Order Sheet (POS) for February 2024 documents diagnoses of unspecified psychosis not due to a substance or known physiological condition, unspecified asthma, morbid obesity, hypertension, major depression disorder, anxiety disorder, Schizophrenia, legal blindness, post-traumatic stress disorder. R30's POS has an order dated 3/12/2024 at 3:07 PM, Silvadene external cream 1%, apply to abdomen topically every day shift for blister. Clean with wound cleaner then apply Silvadene and cover with dry dressing daily until healed. Apply to abdomen topically every day shift to promote wound healing. R30's Minimum Data Set (MDS) dated [DATE] documents R30 was severely impaired for cognition. R30's Care Plan date initiated of 8/2/2023 documents, (R30) is legally blind. He stated he was born with blindness in both eyes. (R30) qualifies for Subpart S programming to diagnosis major depression disorder, recurrent, severe, focus areas include community living, medication management and self-maintenance. Diagnosis of mental illness. At risk for abuse and neglect related psychosis, anxiety, and schizophrenia. R30's Nurse's Notes dated 2/20/2024 at 3:52 PM, documents Resident witnessed with open red area to upper left abdomen. (Medical Doctor) notified new orders Silvadene and dry dressing to affected area until healed. Resident is own responsible party. Plan of care will continue. (Draft). There was no documentation to how R30 sustained this wound. R30's Progress Notes dated 2/26/2024 at 3:52 PM, Resident witnessed with open area to upper low left abdomen. MD (Medical Doctor) notified, new order Silvadene and dry dressing to affected area until healed. R30's Wound Report dated 2/27/2024 documents, Burn wound of left abdomen partial thickness, wound size 13 (length) x 15 (width) x 0.1 cm (centimeters), surface area 195.00 cm2, cluster wound open ulceration area of 78.00 cm2, no exudate, skin 60%. Silver sulfadiazine apply twice daily for 30 days. Secondary dressing, gauze island w/ bdr apply twice daily for 30 days. Burn Wound of the left thigh, partial thickness, etiology, burn, further etiology detail, 'hot liquid', duration less than four days, wound size Length 0.8 L x 0.6 w x d 0.1 c. Incident Reports provided by the facility do not document any incident for R30. R30's Nurse's Notes do not document when R30's accident/burn occurred or how the incident occurred. R30's Wound Notes dated 3/1/2024 at 9:00 AM, Resident has reddened area on left abdomen upper and lower, scabbed over, purulent drainage noted, cleansed area, applied Silvadene and a bordered gauze, applied Silvadene to left upper leg at this time, resident is scratching at wound at this time. R30's Wound Report dated 3/5/2024 documents hot liquid burn, wound size 13 (length) x 9 (width) x 0.1 cm. Patient has a wound on his left abdomen, left thigh. Further etiology detail: Hot liquid. Silver sulfadiazine apply twice daily for 30 days. Secondary dressing, gauze island w/ bdr apply twice daily for 30 days. R30's Skin and Wound Evaluation dated 3/5/2024 at 9:28 AM, Burn, second degree, front left thigh, New, Wound measurement area 3.2 cm (centimeters), length 2.3 cm, width 2.1 cm. On 4/11/2024 at 9:22 AM, R30 stated, I got that area on my belly from coffee that spilled on me. I can hold the cup and the (V20, certified nursing assistant CNA) spilled the coffee on me and it burned me on my stomach and thigh. I was in my room when the coffee was spilled. I burnt my stomach and thigh. On 4/11/2024 at 9:24 AM, R30 had a wound on his left stomach approximately 4 inches in length and 2 inches in width, pinkish in color, appearing as old wound, with an area in the center the size of a dime that had healed over. No exudate or pus was present, or foul odors. R30's thigh was healed over and had no open areas. On 4/11/2024 at 9:32 AM, V18, Licensed Practical Nurse (LPN) stated, (R30) use to be upstairs but they moved him down here with me now. He is legally blind, and he can see shadows. He has that area on his belly that is almost healed up. I can do treatments on him without any issues. He got burnt when coffee was spilled on him. I am not sure when this happened. He had an area on his thigh and stomach from the coffee burn. On 4/11/2024 at 9:52 AM, V20, Certified Nursing Assistant (CNA) stated, (R30) had a cup of coffee that he tipped over and it burnt him. I was not there but that is what (R30) told me. (R30) had a burn on his thigh and stomach. On 4/11/2024 at 8:02 AM, V10, Dietary Manager stated, The coffee machine breaker part has been ordered and we are waiting for the part for the coffee hot water machine to work. It was not working correctly. On 4/11/2024 at 4:30 PM, V1, Administrator stated there was no policy on heat/burns. B. Based on observation, and interview the Facility failed to provide supervision to residents to ensure they do not have access to areas of facility under construction for 1 of 3 residents (R63) reviewed for potential accident hazards in the sample of 59. Findings include: On 4/16/2024 at 8:00 AM, on the 400-halls, there was a sign posted on the two doors upon entering the hall not to proceed and not to enter the area. The doors did not lock and opened with no issues. On 4/16/2024 at 8:05 AM, no staff was observed sitting at the nurse's station or monitoring the 400-hall entrance for residents. On 4/16/2024 at 8:07 AM, V2, Director of Nursing (DON) stated, We are in the process of redoing the floors and remodeling on the 400-hall. The 400 hall is closed off for residents. We do not allow residents on that hall. On 4/16/2024 at 8:09 AM, construction work is being conducted on the 400-hall. There were various tools, and instruments being used for the flooring sitting in the unoccupied rooms. On 4/16/2024 at 2:24 PM, R63 entered the area walked down the hall into the conference room. On 4/16/2024 at 2:29 PM, R63 stated, I knew that state was in the building and so I was looking around trying to find where they put you. I just came through those doors and had no issues. On 4/16/2024 at 5:15 PM, the 400-hall at the end of the hall there was an exit door. When the door was open, the alarm did not sound or go off. On 4/16/2024 at 5:18 PM, V1, Interim Administrator stated, We have a construction crew that are putting in new floors and painting the 400- hall. We have moved all of the residents on the 400-hall and once everything is done, they will be moved back to the 400-hall. Residents are not allowed on the 400-hall until the work is completed. Staff are monitoring them.

Based on observation, interview and record review, the facility failed to provide interventions to address weight loss for 1of 9 residents (R108) reviewed for weight loss in the sample of 59. This failure resulted in R108 losing 45.5 pounds (#s), a 16.98% loss of body weight in less than 2 months. Findings include: R108's Face sheet documents R108's admitted [DATE] with diagnoses of Hemiplegia, Hemiparesis following Cerebral Vascular Accident, Weakness, Dysphagia, Gastronomy tube status. R108's hospital discharge records dated 2/15/2024 documents R108's discharge weight of 268 pounds (#s). R108's Admission Observation dated 2/16/2024 documents Formula 250 milliliters every 6 hours. R108's order sheet dated 2/16/2024 documents Nepro at (@) 250 milliliters (ml) every 6 hours via gastric tube. Discontinued 4/11/2024. R108's Minimum Data Set, MDS, dated [DATE] documents R108 cognition is severely impaired. R108's MDS documents upper extremity left side impairment and is dependent on staff for all Activities of Daily Living. R108's Care Plan dated, 3/7/2024, documents R108 is nutritionally compromised as evidenced by obesity. The Care Plan documents R108 is at risk for further compromise in nutrition and hydration status due to diagnosis of dysphagia, aphasia, hypertension, and dependence on tube feeding for all nutrition and hydration. R108's Progress notes dated 2/23/2024 at 4:18PM, written by V24, Registered Dietician, RD, documents Note Text: Nutrition at Risk Review Monitoring for admission, 2/15, and Tube Feeding. Weights. Diet: Jevity 1.5 Cal/Fiber Oral Liquid. Give 250 ml/hour via G-Tube four times a day until Nepro comes in. R108 is Nothing by Mouth, NPO, No weight/height in chart. Plan/Monitoring: Recommend adding height/weight to chart for complete assessment. Will follow with weekly weights. Continue plan of care. Registered Dietician available as needed. R108's Dietary Nutrition at Risk Initial dated 2/27/2024 documents weight at 240#. Will follow up with weekly weights. Recommend clarifying tube feed order, continue plan of care. Registered Dietician available as needed. R108's Dietary Evaluation dated 3/7/2024, written by V58, RD, documents no known weight loss, and no weight changes. R108's facility weight log documents weights dated 2/28/2024 240#, 3/5/2024 240#, 3/14/2024 230.2#, 3/21/2024 236#, 3/27/2024 234#, 4/5/2024 221.5#, and 4/9/2024 222.5#. R108's Progress notes dated 3/21/2024 at 2:29PM, written by V58, documents Nutrition at Risk Review. Monitoring for admission, 2/15, and Tube feeding, TF. Weights: 236# (3/21), 230.2# (3/14), 240# (2/28), 240# (3/5) BMI: 33.9 Diet: Nothing by Mouth, NPO; Nepro @ 250 ml/hour via G-Tube four times a day Skin: intact Review: Tolerating TF well, will continue to follow. Plan/Monitoring: Continue with weekly weights. Continue plan of care, Registered Dietician available as needed. R108's order sheet dated 4/11/2024 documents Six times a day for nutritional support 250ml. Nepro bolus via g tube every 4 hours for nutrition. R108's progress notes dated 4/11/2024 at 2:28PM documents Monitoring for Tube Feeding. BMI 31.9. Diet: Nothing by Mouth. Nepro @ 250milliliters an hour via G tube four times a day. Skin intact. Review R108 has had -7.7% weight loss since admission. Current order meeting caloric needs yet weight loss occurring, no tolerance issues noted. Plan/monitoring: Recommend changing tube feed order to Nepro 55ml/hour times 20 hours, 350ml flushes every 4 hours (providing 2004kcals, 95g PRO, 177g carbs, 106g fat, 2900mL total fluids). Continues with weekly weights. Continue plan of care, Registered Dietician available as needed. On 4/11/2024 at 12:00PM V11, Licensed Practical Nurse, LPN, provided nutritional supplement to R108 with no issues. V11, LPN, stated R108 has lost weight. V11 stated I am not sure why he has been losing weight. On 4/11/2024 at 11:00AM V23, Nurse Practitioner, stated R108 had a lot of edema when he first arrived. Some of his weight loss is probably related to the edema. His supplement was just increased from every 6 hours to every 4 hours. On 4/11/2024 at 2:45PM V24, Registered Dietician, stated A resident on a tube feeding should not be losing weight. I was not notified of (R108's) weight loss. We had a meeting today and changed his feeding to 55ml an hour for 20 hours a day with 50cc of water three times daily. Facility Tube Feeding policy with a review date of 4/2024 states Continuous tube feedings are based upon a 22-hour consumption period or other time frame based on individual resident need per Registered Dietician assessment and delivered over a 24-hour period. All residents admitted on a tube feeding will be reviewed at the first care conference and quarterly to determine if the tube feeding is till congruent with the resident and family goals for care.

Based on interview and record review the Facility failed to monitor/assess and treat a wound and monitor the resident's overall condition related to wound infection for 1 of 3 residents (R4) reviewed for wounds in the sample of 9. This failure resulted in R4 developing a swollen leg on [DATE] with V22, Physician/Medical Director, prescribing an antibiotic on [DATE] which was not given for 5 days. There was no documented monitoring of R4's leg until [DATE] at which time, R4 had an infected necrotic left leg wound measuring 20 centimeters (cm) by (x) 12 cm x .6 cm and a necrotic left foot wound measuring 10 cm x 8 cm x diameter 0.9 cm requiring surgical debridement by V31, Wound Physician. Subsequently, there was no monitoring of R4's medical condition while receiving antibiotics for his wound infection including vital signs from ,d+[DATE] through [DATE]. On [DATE], R4 was sent to the hospital and admitted with sepsis and expired on [DATE] from septic shock and bacteremia. The Immediate Jeopardy began on [DATE] when R4 developed a swollen left leg and the facility failed to initiate an antibiotic as ordered. R4's left leg deteriorated resulting in a large infected necrotic wound on his left leg and an infected necrotic wound on his left dorsal foot. On [DATE], at 11:18 AM, V1, Administrator V3, Assistant Director of Nursing (ADON), V7, Wound Nurse, and V33, Corporate Nurse were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R4's [DATE] Physician Order Sheet, POS, documents R4 has diagnoses of a Cerebral Infarction due to unspecified occlusion or stenosis of unspecified cerebral artery; Generalized anxiety disorder; Alcohol abuse, insomnia; Anemia; hyperlipidemia; Vitamin deficiency; Hypertension, Schizoaffective disorder; Major depression disorder, and other skin changes. R4's Care Plan, undated, documents: (R4) is at risk for skin complications related to anemia, psychotropic medications. (R4) has no open areas of skin [DATE]. R4's Minimum Data Set (MDS) dated [DATE] documents R4 was cognitively intact for decision making. R4's Nurse's Note, dated [DATE] at 11:34 AM. documented Late Entry: Note Text: Resident noted with swollen lower left leg. MD (Medical Doctor) notified new order venous doppler lower left leg. R4's Nurse's Notes dated [DATE] at 1:56 PM, Note Text, Medical diagnostic services arrived. Venous doppler lower leg completed. R4's Nurse's Notes dated [DATE] at 2:15 PM Note Text: Medical diagnostic faxing results of venous Doppler lower leg. R4's Radiology Results dated [DATE] document Left lower extremity venous doppler ultrasound, Reason: Swelling, left lower leg. Findings: There is no intraluminal filling defect demonstrated. Findings: Negative for DVT (deep vein thrombosis). R4's Nurse's Notes dated [DATE] at 3:12 PM, Note Text: results negative for DVT, Doctor notified, new order cefixime (antibiotic) 200 milligrams (mg) by mouth two times a day for 10 days. There was no documentation on R4's [DATE] Medication Administration Record (MAR) for cefixime 200 mg by mouth two times a day, for 10 days with a start date of [DATE]. There was no documentation R4 started receiving this medication on [DATE]. On [DATE] at 1:15 PM, V18, Licensed Practical Nurse (LPN) stated, When I talked with (V17, Nurse Practitioner) she gave me an order and I received the order for the antibiotic (cefixime) but when I went to put it on the system, I got a red flag because of possible drug allergy, and I could not enter the medication in the system. I called (V17) back to let her know what was going on and I told (V7), Wound Nurse that I could not put the order in and (V7) told me not to worry about and he would take care of it. I only did treatment on (R4's) leg once before it had opened up. The wound actually started on his foot. Any wound notes would be documented in the Nurse's Notes. There was no documentation on R4's [DATE] MAR, that R4 received Cefixime, 200 mg, twice daily from ,d+[DATE] through [DATE]. This would be 10 doses of antibiotic. R4's Nurse's notes do not document any communication/notification to V22 (Medical Director) regarding R4 not receiving cefixime from ,d+[DATE] through [DATE]. R4's Nurse's Notes dated [DATE] at 11:48 AM, documents, The system has identified a possible drug allergy for the following order: Cefixime Oral Tablet chewable, give 200 milligrams (mg) two times a day for to promote wound healing for 10 days. On [DATE] at 11:01 AM, V7, Wound Nurse stated, I was out the week of [DATE] and I only remember vaguely of what happened. In our computer system PCC (Point Click Care) if an allergy pops up the system will not let you enter that particular order, and it is not transferred to the MAR. We were waiting for confirmation from the physician because of the drug allergy. Again, I vaguely even remember that week. I would expect all notes and wound notes and descriptions and doctor conversations to be documented in the Nurse's Notes. I can see there are no notes for the reason the antibiotic was not given timely. R4's Nurse's Notes does not document any wound notes or description of R4's left leg from [DATE] to [DATE]. R4's Nurse's Notes dated [DATE] at 11:54 AM, Late Entry: Note Text: Resident has discoloration to left lower leg and weeping dorsal left foot. Resident states he does not know how his leg became discolored. MD (Medical Doctor) notified new order resident started on Cefixime 200 mg BID x 10 days to promote wound healing. This Nurse's Note was created on [DATE] as a late entry at 11:58 AM by V7, Wound Nurse. R4's [DATE] MAR documented R4's antibiotic order for Cefixime oral tablet chewable, 200 mg, give 200 mg by mouth two times a day to promote wound healing for 10 days. This was the same order which was given by V22 on [DATE]. R4's original order was not initiated and therefore, the antibiotic was not started, and was reordered again on [DATE]. On [DATE] at 12:55 PM, V30, Pharmacist stated, We did not receive any order for cefixime until [DATE] and then we filled that order. I looked at all of the faxes and orders and we did not receive this order until [DATE]. I do not have an order for cefixime on [DATE]. R4's Nurse's Notes dated [DATE] at 7:28 PM, documents, Note Text, Cefixime oral started on this day due to medication in refrigerator, not aware that medication was in refrigerator. R4's Medication Administration Records (MAR) for [DATE] documents Cefixime was given on [DATE] at 8 AM, but no dose was given at 8 PM. On [DATE], R4 missed his 8:00 PM dose. On [DATE], R4 missed both his 8:00 AM and 8:00 PM dose. On [DATE] at 2:37 PM, V18, Licensed Practical Nurse (LPN) stated, I saw (R4) had an order for the antibiotic and I was looking everywhere for it and could not find it. The POS documents an oral tablet chewable. I called the pharmacy, because I could not find it anywhere and they said the medication had been delivered. Finally, we figured out the medication was not in a pill form but rather it was in a liquid. There was a delay in the medications because of the confusion and the order did not say it was in liquid form, but rather oral form and it was in the refrigerator. There was no documentation in R4's medical record from ,d+[DATE] to [DATE] as to the condition of R4's leg. R4's Nurse's Notes dated [DATE] at 12:07 PM, Late Entry: Note Text: MD (Medical Doctor) notified r/t (related to) left lower leg deteriorating. Awaiting orders. R4's Wound Evaluation and Management Summary Report dated [DATE] (11 days later) documents Patient has wound on his left anterior leg, left dorsal foot. Etiology (quality: infection), Wound of the left, anterior leg full thickness, etiology: Infection, duration: less than 7 days; wound size Length 20 x width 12 x Diameter 0.6 centimeters (cm), Surface area 250.00 CM2; exudate moderate serous, thick adherent devitalized necrotic tissues: 100 %. Dressing treatment plan Sodium hypochlorite solution (Dakin's) apply twice daily for 30 days: ,d+[DATE]. Secondary dressing (s) Gauze roll (kerlix) 4.5 inches apply twice daily for 30 days. A surgical excisional debridement procedure was performed that day to the left, anterior leg. The Report also documents a wound of the left, dorsal foot, Etiology (quality) infection, full thickness, etiology: Infection, duration: less than 7 days; wound size length 10 x width 8 x diameter 0.9 cm, exudate: moderate serous, thick adherent devitalized necrotic tissues 100%. Primary dressing Sodium hypochlorite solution (Dakin's) apply twice daily for 30 days, Secondary dressing gauze roll (kerlix) 4.5 apply twice daily for 30 days. Recommendations: Antibiotic choice Bactrim DS (double strength) 1 tablet by mouth two times a day for 14 days. A surgical excisional debridement procedure was performed that day to the left dorsal foot. On [DATE] at 11:18 AM, V31, Wound Doctor stated, By the time I was notified of (R4's) wound it was already really bad. I am not sure why they even waited so long for me to see him. The size of this wound was not something that would just appear overnight. His whole left leg was a big bag of pus. I had never seen anything like it. I started seeing him and ordered a culture and was trying to treat it. I only saw him twice and I was supposed to see him again, but he was out at the hospital at that time. I would expect that all my orders to be followed including medication, monitoring, vital signs, temperatures all of that should have been done. If temperatures were being done it could have been an indication that the infection was progressing, and he could have been sent out sooner. I think in this case there was a delay in treatment. I remember even speaking with (V2) about how bad the wound was on (R4) and to watch for signs of infection. The facility should have been monitoring (R4) more closely. R4's Nurse's Note dated [DATE] at 2:58 PM, Note Text: MD was notified of open area to left lower leg and dorsal foot new orders Bactrim DS (double strength) BID (two times a day) x 14 days, and Clean open areas with wound cleaner apply soaked Dakin's ,d+[DATE] strength 4x4 to wound bed and cover with ABD (abdominal gauze pad) and kerlix BID x 14 days. R4's [DATE] Treatment Administration Record (TAR) documents an order for Dakin's (,d+[DATE] strength) external solution (sodium hypochlorite), Apply to left leg and foot topically two times a day related to other skin changes for 14 days. R4's [DATE] TAR documents R4 did not receive this treatment at 5:00 PM on ,d+[DATE], 8:00 AM and 5:00 PM on ,d+[DATE] and ,d+[DATE] and at 8:00 AM on [DATE]. The order regarding a 4 x4 to R4's wound bed and cover with ABD and kerlix BID x 14 was not transcribed to R4's [DATE] TAR and therefore was not documented as completed. R4's [DATE] TAR, documented an order for Dakin's (,d+[DATE] strength) external solution (sodium hypochlorite), apply to left leg and foot topically two times a day related to other skin changes for 14 days. There was no documentation R4 received this treatment at 8:00 AM on ,d+[DATE] and on [DATE] at 5:00 PM. The order regarding a 4 x4 to R4's wound bed and cover with ABD and kerlix BID x 14 was not transcribed to R4's [DATE] TAR and therefore was not documented as completed. There was no documentation in R4's medical record that V22 or V31 were notified that R4 did not receive the treatments in September and [DATE]. R4's Wound Evaluation and Management Summary Report dated [DATE], documents, Patient has wounds on his left anterior leg; left dorsal foot; right second toe. At the request of the referring provider, V22, Medical Director, a thorough wound care assessment and evaluation was performed today. He has condition(s) as listed above. Details about current wound(s) and any skin conditions are outlined below. There is no indication of pain associated with this condition. (Site 1 was not documented), Focused Wound Exam (Site 2); Wound of the left, anterior leg full thickness. etiology: Infection, duration: less than 13 days; wound size Length 15.5 x width 8 x Diameter 0.6 centimeters (cm), Surface area 124.00 CM2; exudate moderate serous, thick adherent devitalized necrotic tissues: 70 %, granulation tissues 30%. Dressing treatment plan Sodium hypochlorite solution (Dakin's) apply twice daily for 23 days: ,d+[DATE]. Secondary dressing (s) Gauze roll (kerlix) 4.5 inches apply twice daily for 23 days. A surgical excisional debridement procedure was performed that day to the left, anterior leg. Site 3, Wound of the left, dorsal foot full thickness, etiology: Infection, duration: less than 13 days; wound size Length 5 x width 7.5 x Diameter 0.9 centimeters (cm), Surface area 37.50 cm2; exudate moderate serous, thick adherent devitalized necrotic tissues: Wound progress: improved by decreased surface area. Site 4: Arterial wound of the right, second toe full thickness. Etiology arterial, duration less than 2 days, wound size length 0.5 x width x1 x diameter 01.cm. Surface area .50 cm2, exudate moderate serous, granulation tissue 100%. Alginate calcium apply once daily for 30 days, Betadine apply once daily for 30 days. Secondary dressing Gauze roll (kerlix) 4.5 inches apply once daily for 30 days. R4's wounds were documented as improved evidenced by decreased necrotic tissue, and decreased surface area. However, R4 had a new wound to his right second toe. R4's [DATE] does not document any treatment regarding the new wound to R4's right second toe although V31 saw R4 on [DATE] and ordered Alginate calcium to be applied once daily for 30 days, Betadine applied once daily for 20 days with gauze roll (kerlix). There is no documentation that this treatment was being completed by the facility. R4's [DATE] POS documents an order for Bactrim DS (double strength), oral tables ,d+[DATE] mg, 1 tablet by mouth two times a day, related to other skin changes for 14 days, with an order date of [DATE]. The MAR documents R4 did not receive the Bactrim on [DATE] at 8:00 AM. R4's Nurse's Notes dated [DATE] at 12:56 PM, Note Text: Call placed to (contracted lab company) r/t (related) results of wound culture collected on [DATE]. Staff at (contracted lab company) informed this writer sample was destroyed due to no sticker on sample. This writer collected another sample with sticker in place and notified (contracted lab company) that wound culture was awaiting pick up. MD (Medical Doctor) notified no new orders at this time. R4's Lab Report with a collection date of [DATE] documents the reported date of [DATE] that a culture was received after a 14 day, delay due to the culture not collected timely. R4's Nurse's Notes dated [DATE] at 12:13 PM, Note Text: Received wound culture results facility medical team (V17) notified. R4's Nurse's Notes dated [DATE] at 1:50 PM, Note Text: Received wound culture results facility medical team (V17) notified. R4's Nurse's Notes dated [DATE] at 2:00 PM, Note Text: Culture faxed to (V22, Medical Director) office awaiting orders. R4's September and [DATE] MAR and TAR does not document any order for vital signs to be being taken daily or for R4 to be monitored for infection and antibiotic use. R4's vital signs were not documented in R4's medical record every day for R4 even though he had an infection. For [DATE], R4's temperatures were taken on [DATE] and [DATE]. No vitals were available from [DATE] to [DATE] in R4's medical record. No blood pressure, oxygen saturations, pulse, or temperature were documented for seven days prior to R4 going to the hospital. R4's Progress Notes dated [DATE] at 7:13 AM, This nurse upon entering patient's room noted resident eyes closesd and restless. Spoke to resident good morning, resident moaning, noting being lethargic, decreased verbalization, no clear speech, mumbling. Resident baseline is alert and orientated x 3. Able to make needs known. Resident made no eye contact at this time. Does not verbalize and physical stimuli; notes pale color unable to obtain vitals, patient movements. Management team notified transferring resident to the hospital for evaluation. Facility medical team notified. Transferring resident to the hospital. Emergency Report given to nurse at hospital. On [DATE] at 10:33 AM, V6, Licensed Practical Nurse (LPN) stated, (R4) was usually alert and oriented x 3. He transferred to my side of the building on Friday. On Friday he was doing good, sitting on the side of the bed, making jokes. The last time I saw him was on Friday around 3:20 PM and he was fine. I don't work the weekends and when I came in on Monday, he had a change of condition and I sent him out. Nobody told me anything about his decline and I don't know when it started but when I started my shift and went to say hello he was not responding. I immediately sent him out. Because I don't work the weekends, I did not do his wound treatments. We have a wound nurse, and he does the treatments. He had just recently been sent to my hall. (R4) was on the 300-hall before that. I am not sure how the wound even started. On [DATE] at 9:24 AM, V21, Hospital Nurse stated, When patients come into the hospital it is very important for us to know if they are not cognitively intact or confused, to know if this is the normal or if this not their normal, how long have they been like this. This is a good indicator of a stroke for example, so we need to know whenever there is an altered mental status. When (R4) arrived, he was not able to answer any questions and was not alert. We were told this was not his baseline and he is normally alert x 3. I personally called the facility to try and find out how long and when this condition started that he was no longer alert and orientated. I talked with 3 different staff members, and nobody could tell me the last time anybody laid eyes on him and how long he had been like this, when this started. I find this very concerning because staff should know these things. R4's Hospital Records dated [DATE] at 9:12 AM, [AGE] year old male, NH (Nursing Home) resident with past medical history significant for HLD (hyperlipidemia), CAD (Coronary Artery Disease), HTN (Hypertension), psychiatric history, schizoaffective disorder, CVA (Cerebral vascular accident), (no motor deficits, baseline AO (alert and orientated) at baseline now x 1 on arrival, hypoglycemia with initial glucose recorded at 42, severe macrocytic anemia, hypotension, hypothermia and other lab findings, consistent with severe sepsis. On admission he was initially responding to painful stimuli only, now AO x 1, moving all extremities. R4's Admission Hospital Records document on [DATE] at 9:00 AM, (R4) is a [AGE] year-old male with history of hypertension, CAD, HLD, schizoaffective disorder, history of CVA. He was sent from nursing home yesterday with AMS (Altered Mental Status); it was reported that he is AAOx3 (alert and oriented times 3) at baseline and was AAOx1 prior to transfer. He also was hypoglycemic with Blood sugar of 42 and has been anemic with hypotension/hypothermic. On admission HG (hemoglobin) at 5.5, PH 7.1, LA was around 5, noted AKI with CR of 4.2 He is lethargic/sleeping and not much communicative. He has a bad wound over the left leg. His BP (Blood pressure) when I saw him this AM blood pressure was ,d+[DATE] (Normal ,d+[DATE]). Reason for Admission: Shock. R4's Death Certification dated [DATE] documents R4's cause of death as septic shock and bacteremia. On [DATE] at 3:36 PM, V2, Director of Nursing (DON) stated I am not aware of any issues with (R4's) wounds. After (R4) went out to the hospital we went through his medical records/chart, and everything was fine. On [DATE] at 8:33 AM, V7, Wound Nurse stated, (R4's) leg issue started as a bump and then an abscess. His foot was always dry, and he had bad dry skin. I am not sure what happened with his foot. I did not notice anything before he was sent out. I did his last treatment on Friday, and he was sent out to the hospital on Monday. When I am not here the floor nurse will do the treatments. I was not aware he was having any issues before he was sent out. On [DATE] at 11:01 AM, V32, LPN stated, I did wound treatments on (R4) over the weekend before he was sent out. I am not aware of any issues. I don't remember anything. V32, Licensed Practical Nurse (LPN) was documented as the charge nurse working on Saturday, [DATE], and Sunday, [DATE]. On [DATE] at 9:12 AM, V17, Nurse Practitioner stated, If a resident has an infection/wound we would turn that over to the Wound Doctor and expect the facility to be following the Wound Doctor's orders. With any infections I would expect staff to actually be looking at the wound, applying the treatments, changing the dressings, monitoring the wound, taking vitals and temperatures every day to ensure and documenting in the TAR and watching for any changes. I cannot get into (R4's) chart from here as I am not at the facility, but if we sent an order, I would expect it be followed and communicated to us if it was not given in a timely manner. The Facility's Skin Management: Pressure Injury Treatment/General Wound Treatment Policy with a revision date of [DATE] documents, All nursing staff are the responsible party. Document routine and PRN (As Needed) treatments in the treatment administration record of the EHR (electronic health record). Document all significant observations in the Nursing Progress Note. Pressure injuries will be evaluated and the following areas documented weekly (minimum every 7 days): Location, Stage, Size: perpendicular measurement of the greatest extent of length and width of the injury using a disposable measuring device, Depth: insert sterile swab in wound and gloved finger at end, then measure in centimeters, Presence and location (based on the clock) of undermining/tunneling/ sinus tract; Exudate: type, color, odor, and approximate amount, Pain: nature and frequency, Wound bed: color and type of tissue/character including evidence of healing (granulation tissue) or necrosis, description of wound edges and surrounding tissue (rolled edges, redness, maceration, etc.) The Facility's Change of Condition Policy with a revision date of ,d+[DATE] documents, It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician, and resident's responsible party of a change in condition. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the Immediacy: A. Identification of Residents Affected or Likely to be Affected: 1. R4 expired. 2. Currently 5 residents in the facility have wounds. 3. The facility will initiate skin assessments on every resident to assess all wounds for appropriate treatments. This will be completed by V2, Director of Nursing/DON, V3 ADON, V24 MDS nurse, V37 MDS nurse, and V36 Infection Preventionist IP nurse by [DATE]. All treatments ordered by the physician will be completed and documented by a nurse manager or charge nurse. The physician will be notified of residents overall change of condition related to wounds by the wound nurse, nurse manager or charge nurse. All new residents will have a skin assessment completed and physician's orders received for appropriate treatment. The DON, ADON, and MDS nurses will ensure that physician orders are transferred to the MAR/TAR. 4. Care plans will be updated with interventions to address identified wounds with appropriate treatments orders by V24 MDS nurse and V37 MDS nurse on [DATE] and to be ongoing including all new residents as needed for wound care. 5. The facility will initiate a review to identify residents receiving antibiotics. Assessment will include daily vital signs, mental or physical change in status, change in wound status by the Infection Preventionist, V36, or charge nurse by [DATE]. B. Actions to Prevent Occurrence/Recurrence: 1. The Regional Director of Operations, V43, reviewed and revised the wound care policy on [DATE]. Revisions were made to include monthly skin assessments on every resident monthly by wound nurse as well as charge nurses completing assigned skin assessments weekly. The Regional Director of Operations, V43, reviewed and revised policy related to antibiotic use to include an assessment of daily vital signs, mental or physical change in status, or change in wound status. The facility Infection Preventionist or designee should ensure that all antibiotics are prescribed for the correct indication, dose, duration and administered to treat the resident by on [DATE]. The Regional Director of Operations, V43 reviewed the Change of Condition policy with no changes on [DATE]. 2. The Regional Director of Operations, V43 educated V1 Administrator, V4 Assistant Administrator, V2 DON, V3 ADON, V24 MDS nurse, V37 MDS nurse, V7 Wound nurse, and V36 IP nurse educated on revised policies and procedures on [DATE] and to be ongoing for new hires and agency staff. 3. The Regional Director of Operations, V43, will provide training to V7, wound nurse on proper policy and procedure of wound care [DATE]. 4. The training will also include providing monitoring to identify wounds promptly and receive physician's orders for appropriate treatment for residents by Corporate Consultants or Nurse Mangers of the facility. 5. The LPN/RN nursing staff will be educated on completing skin assessments, wound care treatments, identifying wounds promptly, administering antibiotics, assess for change in daily vital signs, mental or physical status, or wound condition, and notifying physician of any change of condition on [DATE] and ongoing by Corporate Consultants or Nurse Managers. 6. CNA staff were educated on notifying charge nurse, ADON, DON, or Wound nurse of any skin changes by CNA Supervisor, V8 on [DATE] and to be ongoing for new hires and agency staff. 7. All agency and new hires will be educated on the above policies and processes prior to beginning their shift by V2 DON and V3 ADON or designee. 8. The DON V2, ADON V3 and IP nurse will evaluate physician's orders pertaining to wound care and antibiotic use to identify concerns including abnormal vital signs, change in wound condition, change in mental or physical condition by [DATE]. The concerns will be addressed, and additional staff training will be completed on an ongoing basis by Corporate Consultants or Nurse Managers. 9. The clinical leadership team, V2 DON, V3 ADON, V24 MDS nurse, V37 MDS nurse, V7 Wound nurse, and V36 IP will review residents on antibiotics and order listing to ensure residents are receiving per physician's orders during daily clinical meetings Monday-Friday, the weekend on-call nurse will review on Saturday and Sunday. 10. An Ad-Hoc QAPI meeting was completed on [DATE] to review the alleged deficiency and plan of removal. An Ad-Hoc QAPI meeting will be held weekly for four weeks by the QAPI team to discuss this removal plan and identify if additional interventions are necessary to be ongoing. 11. V1, Administrator notified the Medical Director of the discussion related to the deficiency and removal plan on [DATE]. 12. Monitoring/auditing of ongoing education of staff for appropriate wound care, administering antibiotics, condition change with physician notification and ongoing assessments of new residents and residents with newly identified issues regarding wound care and antibiotic use by V1 Administrator or designee will continue for a minimum of three months to be ongoing and will be part of the QAPI process. On ,d+[DATE] and [DATE], the surveyor did the following to validate the abatement/removal plan: Three additional residents R11, R12 and R13 were reviewed for wounds and treatment. Five residents were identified by the facility as having wounds. R9, R10, R11, R12 and R13. All TAR, MAR, Care Plans and Wound Care Orders were reviewed for R9, R10, R11, R12 and R13's. V1- Administrator, V24- Care Plan Coordinator, V3- Assistant Director of Nursing, were all interviewed, and they all stated all staff with the exception of three staff members on leave, had all been in-services and updated. Staff were interviewed regarding in-services on policy and procedures and V1- Administrator, V3- ADON, V34- Regional Nurse were all interviewed regarding with role that had in the abatement plan. V4- CNA, V23- LPN, V42,-LPN, V38- LPN V39- CNA, all stated they had been in-serviced by V7, Wound Nurse then again two days later by V3 - Assistant Director of Nursing.

Based on interviews, and record reviews the facility failed notify the physician of changes related wound infections including failure to give medications and treatments as ordered for 1 of 3 residents (R4) reviewed for notification in the sample of 13. This failure resulted on [DATE], R4 was sent to the hospital and admitted with sepsis and expired on [DATE] from septic shock and bacteremia. Findings include: R4's [DATE] Physician Order Sheet, POS, documents R4 has diagnoses of Cerebral Infarction due to unspecified occlusion or stenosis of unspecified cerebral artery; Generalized anxiety disorder; Alcohol abuse, insomnia; Anemia; hyperlipidemia; Vitamin deficiency; Hypertension, Schizoaffective disorder; Major depression disorder, and other skin changes. R4's Care Plan with a Focus Area of Skin: documents, (R4) is at risk for skin complications related to Anemia, psychotropic medications. (R4) has no open areas to skin. Date [DATE]. (R4) has open areas, are to left lower leg and left dorsal foot dated, [DATE]. No open area was documented in the Care Plan before [DATE]. R4's Nurse's Notes dated [DATE] at 11:34 AM. Late Entry: Note Text: Resident noted with swollen lower left leg. MD (Medical Doctor) notified new order venous doppler lower left leg. R4's Nurse's Notes dated [DATE] at 1:56 PM, Note Text, Medical diagnostic services arrived. Venous doppler lower leg completed. R4's Radiology Results dated [DATE] document Left lower extremity venous doppler ultrasound, Reason: Swelling, left lower leg. R4's Nurse's Notes dated [DATE] at 3:12 PM, Note Text: results negative for DVT, Doctor notified, new order cefixime (antibiotic) 200 milligrams (mg) by mouth two times a day for 10 days. There was no documentation on R4's [DATE] Medication Administration Record (MAR) for cefixime 200 mg by mouth two times a day, for 10 days with a start date of [DATE]. There was no documentation R4 started receiving this medication on [DATE]. There was no documentation V22, R4's Physician, was notified of why R4's antibiotic was not initiated on [DATE]. On [DATE] at 1:15 PM, V18, Licensed Practical Nurse (LPN) stated, When I talked with (V17, Nurse Practitioner) she gave me an order and I received the order for the antibiotic (cefixime) but when I went to put it on the system, I got a red flag because of possible drug allergy, and I could not enter the medication in the system. I called (V17) back to let her know what was going on and I told (V7), Wound Nurse that I could not put the order in and (V7) told me not to worry about and he would take care of it. I only did treatment on (R4's) leg once before it had opened up. The wound actually started on his foot. Any wound notes would be documented in the Nurse's Notes. There was no documentation on R4's [DATE] MAR that R4 received Cefixime, 200 mg, twice daily from ,d+[DATE] through [DATE]. This would be 10 doses of antibiotic. There was no documentation of R4's physician, V22, being notified that R4 missed 10 doses of Cefixime from ,d+[DATE] through [DATE]. R4's Nurse's Notes dated [DATE] at 11:54 AM, Late Entry: Note Text: Resident has discoloration to left lower leg and weeping dorsal left foot. Resident states he does not know how his leg became discolored. MD (Medical Doctor) notified new order resident started on Cefixime 200 mg BID x 10 days to promote wound healing. This Nurse's Note was created on [DATE] as a late entry at 11:58 AM by V7, Wound Nurse. R4's [DATE] MAR documented R4's antibiotic order for Cefixime oral tablet chewable, 200 mg, give 200 mg by mouth two times a day to promote wound healing for 10 days. This was the same order which was given by V22 on [DATE]. R4's original order was not initiated and therefore, the antibiotic was not started, and was reordered again on [DATE]. There was no documentation in R4's medical record that V31, Wound Physician, was notified of the deterioration R4's left leg. R4's Nurse's Notes dated [DATE] at 12:07 PM, Late Entry: Note Text: MD (Medical Doctor) notified r/t (related to) left lower leg deteriorating. Awaiting orders. R4's Wound Evaluation and Management Summary Report dated [DATE] (11 days later) documents Patient has wound on his left anterior leg, left dorsal foot. Etiology (quality: infection), Wound of the left, anterior leg full thickness, etiology: Infection, duration: less than 7 days; wound size Length 20 x width 12 x Diameter 0.6 centimeters (cm), Surface area 250.00 CM2; exudate moderate serous, thick adherent devitalized necrotic tissues: 100 %. Dressing treatment plan Sodium hypochlorite solution (Dakin's) apply twice daily for 30 days: ,d+[DATE]. Secondary dressing (s) Gauze roll (kerlix) 4.5 inches apply twice daily for 30 days. A surgical excisional debridement procedure was performed that day to the left, anterior leg. The Report also documents a wound of the left, dorsal foot, Etiology (quality) infection, full thickness, etiology: Infection, duration: less than 7 days; wound size length 10 x width 8 x diameter 0.9 cm, exudate: moderate serous, thick adherent devitalized necrotic tissues 100%. Primary dressing Sodium hypochlorite solution (Dakin's) apply twice daily for 30 days, Secondary dressing gauze roll (kerlix) 4.5 apply twice daily for 30 days. Recommendations: Antibiotic choice Bactrim DS (double strength) 1 tablet by mouth two times a day for 14 days. A surgical excisional debridement procedure was performed that day to the left dorsal foot. On [DATE] at 11:18 AM, V31, Wound Doctor stated, By the time I was notified of (R4's) wound it was already really bad. I am not sure why they even waited so long for me to see him. The size of this wound was not something that would just appear overnight. His whole left leg was a big bag of pus. I had never seen anything like it. I started seeing him and ordered a culture and was trying to treat it. I only saw him twice and I was supposed to see him again, but he was out at the hospital at that time. I would expect that all my orders to be followed including medication, monitoring, vital signs, temperatures all of that should have been done. If temperatures were being done it could have been an indication that the infection was progressing, and he could have been sent out sooner. I think in this case there was a delay in treatment. I remember even speaking with (V2) about how bad the wound was on (R4) and to watch for signs of infection. The facility should have been monitoring (R4) more closely. On [DATE] at 8:33 AM, V7, Wound Nurse stated, (R4's) leg issue started as a bump and then an abscess. His foot was always dry, and he had bad dry skin. I am not sure what happened with his foot. I did not notice anything before he was sent out. I did his last treatment on Friday, and he was sent out to the hospital on Monday. When I am not here the floor nurse will do the treatments. I was not aware he was having any issues before he was sent out. On [DATE] at 9:12 AM, V17, Nurse Practitioner stated, If a resident has an infection/wound we would turn that over to the Wound Doctor and expect the facility to be following the Wound Doctor's orders. With any infections I would expect staff to actually be looking at the wound, applying the treatments, changing the dressings, monitoring the wound, taking vitals and temperatures every day to ensure and documenting in the TAR and watching for any changes. I cannot get into (R4's) chart from here as I am not at the facility, but if we sent an order, I would expect it be followed and communicated to us if it was not given in a timely manner. The Facility Notification Intervention and Reporting Policy with a Revision date of ,d+[DATE] documents, The center will notify the resident's physician and the resident's representative whenever: there is a significant change in the resident's health, mental or psychosocial status there is a change in the resident's condition that although not significant is prudent to report using good nursing judgment. There is a need to significantly alter or discontinue treatment because of adverse consequences. Document in the nurse's notes: A description of the change in condition/incident/accident/unusual occurrence. Results of any assessment performed. Description of any care or emergency measures performed. Notification of the physician including what was reported to the physician and physician response including whether new orders were received. Notification to resident and/or resident's representative. Follow up assessment and care as appropriate.

Based on interview and record review the facility neglected to ensure residents were receiving timely assessment, monitoring, and treatment to address wounds and wound infections for one of three residents (R4) reviewed for neglect in the sample of 13. This failure resulted in R4 not receiving an antibiotic as ordered on [DATE] which delayed treatment of an infection, not receiving ordered wound treatments, not having timely assessments, and monitoring of his left leg which resulted in the development of two large infected necrotic wounds, and not monitoring the overall condition of R4 during his treatment of the infection. On [DATE], R4 was sent to the hospital and admitted with sepsis and expired on [DATE] from septic shock and bacteremia. Findings include: The Abuse Policy 2022 documents The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods, and services by staff or mistreatment. The facility prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. The policy documents Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, or mental anguish. (42 CFR 483.5). Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish or mental illness of a resident. R4's [DATE] Physician Order Sheet, POS, documents R4 has diagnoses of Cerebral Infarction due to unspecified occlusion or stenosis of unspecified cerebral artery; Generalized anxiety disorder; Alcohol abuse, insomnia; Anemia; hyperlipidemia; Vitamin deficiency; Hypertension, Schizoaffective disorder; Major depression disorder, and other skin changes. R4's Nurse's Notes dated [DATE] at 11:34 AM. Late Entry: Note Text: Resident noted with swollen lower left leg. MD (Medical Doctor) notified new order venous doppler lower left leg. R4's Radiology Results dated [DATE] document Left lower extremity venous doppler ultrasound, Reason: Swelling, left lower leg. Findings: There is no intraluminal filling defect demonstrated. Findings: Negative for DVT. R4's Nurse's Notes dated [DATE] at 2:15 PM Note Text: medical diagnostic faxing results of venous Doppler lower leg. R4's Nurse's Notes dated [DATE] at 3:12 PM, Note Text: results negative for DVT (deep vein thrombosis), Doctor notified, new order cefixime (antibiotic) 200 milligrams (mg) by mouth two times a day for 10 days. There was no documentation on R4's [DATE] Medication Administration Record (MAR) for cefixime 200 mg by mouth two times a day, for 10 days with a start date of [DATE]. There was no documentation R4 started receiving this medication on [DATE]. On [DATE] at 1:15 PM, V18, Licensed Practical Nurse (LPN) stated, When I talked with V17, Nurse Practitioner she gave me an order and I received the order for the antibiotic (cefixime) but when I went to put it on the system, I got a red flag because of possible drug allergy, and I could not enter the medication in the system. I called (V17) back to let her know what was going on and I told (V7), Wound Nurse that I could not put the order in and (V7) told me not to worry about and he would take care of it. I only did treatment on R4's leg once before it had opened up. The wound actually started on his foot. Any wound notes would be documented in the Nurse's Notes. There was no documentation on R4's [DATE] MAR, R4 received Cefixime, 200 mg, twice daily from ,d+[DATE] through [DATE]. This would be 10 doses of antibiotic. On [DATE] at 11:01 AM, V7, Wound Nurse stated, I was out the week of [DATE] and I only remember vaguely of what happened. In our computer system PCC (Point Click Care) if an allergy pops up the system will not let you enter that particular order, and it is not transferred to the MAR. We were waiting for confirmation from the physician because of the drug allergy. Again, I vaguely even remember that week. I would expect all notes and wound notes and descriptions and doctor conversations to be documented in the Nurse's Notes. I can see there are no notes for the reason the antibiotic was not given timely. R4's Nurse's Notes does not document any wound notes or description of R4's left leg from [DATE] to [DATE]. R4's Nurse's Notes dated [DATE] at 11:54 AM, Late Entry: Note Text: Resident has discoloration to left lower leg and weeping dorsal left foot. Resident states he does not know how his leg became discolored. MD (Medical Doctor) notified new order resident started on Cefixime 200 mg BID x 10 days to promote wound healing. This Nurse's Note was created on [DATE] at 11:58 AM by V7, Wound Nurse. R4's [DATE] MAR documented R4's antibiotic order for Cefixime oral tablet chewable, 200 mg, give 200 mg by mouth two times a day to promote wound healing for 10 days. This was the same order which was given by V22 on [DATE]. R4's original order was not initiated and therefore, the antibiotic was not started, and was reordered again on [DATE]. On [DATE] at 12:55 PM, V30, Pharmacist stated, We did not receive any order for cefixime until [DATE] and then we filled that order. I looked at all of the faxes and orders and we did not receive this order until [DATE]. I do not have an order for [DATE]. R4's Nurse's Notes dated [DATE] at 7:28 PM, documents, Note Text, Cefixime oral started on this day due to medication in refrigerator, not aware that medication was in refrigerator. R4's Medication Administration Records (MAR) for [DATE] documents Cefixime was given on [DATE] at 8 AM, but no dose was given at 8 PM. On [DATE], R4 missed his 8:00 PM dose. On [DATE], R4 missed both his 8:00 AM and 8:00 PM dose. On [DATE] at 2:37 PM, V18, Licensed Practical Nurse (LPN) stated, I saw (R4) had an order for the antibiotic and I was looking everywhere for it and could not find it. The POS documents an oral tablet chewable. I called the pharmacy, because I could not find it anywhere and they said the medication had been delivered. Finally, we figured out the medication was not in a pill form but rather it was in a liquid. There was a delay in the medications because of the confusion and the order did not say it was in liquid form, but rather oral form and it was in the refrigerator. There was no documentation in R4's medical record from ,d+[DATE] to [DATE] as to the condition of R4's left leg. R4's Nurse's Notes dated [DATE] at 12:07 PM, Late Entry: Note Text: MD (Medical Doctor) notified r/t (related to) left lower leg deteriorating. Awaiting orders. R4's Wound Evaluation and Management Summary Report dated [DATE] (11 days later) documents Patient has wound on his left anterior leg, left dorsal foot. Etiology (quality: infection), Wound of the left, anterior leg full thickness, etiology: Infection, duration: less than 7 days; wound size Length 20 x width 12 x Diameter 0.6 centimeters (cm), Surface area 250.00 CM2; exudate moderate serous, thick adherent devitalized necrotic tissues: 100 %. Dressing treatment plan Sodium hypochlorite solution (Dakin's) apply twice daily for 30 days: ,d+[DATE]. Secondary dressing (s) Gauze roll (kerlix) 4.5 inches apply twice daily for 30 days. A surgical excisional debridement procedure was performed that day to the left, anterior leg. The Report also documents a wound of the left, dorsal foot, Etiology (quality) infection, full thickness, etiology: Infection, duration: less than 7 days; wound size length 10 x width 8 x diameter 0.9 cm, exudate: moderate serous, thick adherent devitalized necrotic tissues 100%. Primary dressing Sodium hypochlorite solution (Dakin's) apply twice daily for 30 days, Secondary dressing gauze roll (kerlix) 4.5 apply twice daily for 30 days. Recommendations: Antibiotic choice Bactrim DS (double strength) 1 tablet by mouth two times a day for 14 days. A surgical excisional debridement procedure was performed that day to the left dorsal foot. On [DATE] at 11:18 AM, V31, Wound Doctor stated, By the time I was notified of (R4's) wound it was already really bad. I am not sure why they even waited so long for me to see him. The size of this wound was not something that would just appear overnight. His whole left leg was a big bag of pus. I had never seen anything like it. I started seeing him and ordered a culture and was trying to treat it. I only saw him twice and I was supposed to see him again, but he was out at the hospital at that time. I would expect that all my orders to be followed including medication, monitoring, vital signs, temperatures all of that should have been done. If temperatures were being done it could have been an indication that the infection was progressing, and he could have been sent out sooner. I think in this case there was a delay in treatment. I remember even speaking with V2 (Director of Nursing-DON) about how bad the wound was on (R4) and to watch for signs of infection. The facility should have been monitoring (R4) more closely. R4's Nurse's Note dated [DATE] at 2:58 PM, Note Text: MD was notified of open area to left lower leg and dorsal foot new orders Bactrim DS (double strength) BID (two times a day) x 14 days, and Clean open areas with wound cleaner apply soaked Dakin's ,d+[DATE] strength 4x4 to wound bed and cover with ABD (abdominal gauze pad) and kerlix BID x 14 days. R4's [DATE] Treatment Administration Record (TAR) documents an order for Dakin's (,d+[DATE] strength) external solution (sodium hypochlorite), Apply to left leg and foot topically two times a day related to other skin changes for 14 days. R4's [DATE] TAR documents R4 did not receive this treatment at 5:00 PM on ,d+[DATE], 8:00 AM and 5:00 PM on ,d+[DATE] and ,d+[DATE] and at 8:00 AM on [DATE]. The order regarding a 4 x4 to R4's wound bed and cover with ABD and kerlix BID x 14 was not transcribed to R4's [DATE] TAR and therefore was not documented as completed. R4's [DATE] TAR, documented an order for Dakin's (,d+[DATE] strength) external solution (sodium hypochlorite), apply to left leg and foot topically two times a day related to other skin changes for 14 days. There was no documentation R4 received this treatment at 8:00 AM on ,d+[DATE] and on [DATE] at 5:00 PM. The order regarding a 4 x4 to R4's wound bed and cover with ABD and kerlix BID x 14 was not transcribed to R4's [DATE] TAR and therefore was not documented as completed. There was no documentation in R4's medical record that V22 (Medical Director) or V31 were notified that R4 did not receive the treatments in September and [DATE]. R4's Wound Evaluation and Management Summary Report dated [DATE], documents, Patient has wounds on his left anterior leg; left dorsal foot; right second toe. At the request of the referring provider, V22, Medical Director, a thorough wound care assessment and evaluation was performed today. He has condition(s) as listed above. Details about current wound(s) and any skin conditions are outlined below. There is no indication of pain associated with this condition. (Site 1 was not documented), Focused Wound Exam (Site 2); Wound of the left, anterior leg full thickness. etiology: Infection, duration: less than 13 days; wound size Length 15.5 x width 8 x Diameter 0.6 centimeters (cm), Surface area 124.00 CM2; exudate moderate serous, thick adherent devitalized necrotic tissues: 70 %, granulation tissues 30%. Dressing treatment plan Sodium hypochlorite solution (Dakin's) apply twice daily for 23 days: ,d+[DATE]. Secondary dressing (s) Gauze roll (kerlix) 4.5 inches apply twice daily for 23 days. A surgical excisional debridement procedure was performed that day to the left, anterior leg. Site 3, Wound of the left, dorsal foot full thickness, etiology: Infection, duration: less than 13 days; wound size Length 5 x width 7.5 x Diameter 0.9 centimeters (cm), Surface area 37.50 cm2; exudate moderate serous, thick adherent devitalized necrotic tissues: Wound progress: improved by decreased surface area. Site 4: Arterial wound of the right, second toe full thickness. Etiology arterial, duration less than 2 days, wound size length 0.5 x width x1 x diameter 01.cm. Surface area .50 cm2, exudate moderate serous, granulation tissue 100%. Alginate calcium apply once daily for 30 days, Betadine apply once daily for 30 days. Secondary dressing Gauze roll (kerlix) 4.5 inches apply once daily for 30 days. R4's wounds have increased from one area to three or four areas. R4's wounds were documented as improved evidenced by decreased necrotic tissue, and decreased surface area however, R4 now had a new wound on his right, second toe. R4's [DATE] does not document any treatment regarding the new wound to R4's right second toe although V31 saw R4 on [DATE] and ordered Alginate calcium to be applied once daily for 30 days, Betadine applied once daily for 20 days with gauze roll (kerlix). There is no documentation that this treatment was being completed by the facility. R4's [DATE] POS documents an order for Bactrim DS (double strength), oral tables ,d+[DATE] mg, 1 tablet by mouth two times a day, related to other skin changes for 14 days, with an order date of [DATE]. The MAR documents R4 did not receive the Bactrim on [DATE] at 8:00 AM. R4's September and [DATE] MAR and TAR does not document any order for vital signs to be being taken daily or for R4 to be monitored for infection and antibiotic use. R4's vital signs were not documented in R4's medical record every day for R4 even though he had an infection. For [DATE], R4's temperatures were taken on [DATE] and [DATE]. No vitals were available from [DATE] to [DATE] in R4's medical record. No blood pressure, oxygen saturations, pulse, or temperature were documented for seven days prior to R4 going to the hospital. R4's Progress Notes dated [DATE] at 7:13 AM, This nurse upon entering patient's room noted resident eyes closed and restless. Spoke to resident good morning, resident moaning, noting being lethargic, decreased verbalization, no clear speech, mumbling. Resident baseline is alert and orientated x 3. Able to make needs known. Resident made no eye contact at this time. Does not verbalize and physical stimuli; notes pale color unable to obtain vitals, patient movements. Management team notified transferring resident to the hospital for evaluation. Facility medical team notified. Transferring resident to the hospital. Emergency Report given to nurse at hospital. On [DATE] at 10:33 AM, V6, Licensed Practical Nurse (LPN) stated, (R4) was usually alert and oriented x 3. He transferred to my side of the building on Friday. On Friday he was doing good, sitting on the side of the bed, making jokes. The last time I saw him was on Friday around 3:20 PM and he was fine. I don't work the weekends and when I came in on Monday, he had a change of condition and I sent him out. Nobody told me anything about his decline and I don't know when it started but when I started my shift and went to say hello he was not responding. I immediate sent him out. On [DATE] at 9:24 AM, V21, Hospital Nurse stated, When patients come into the hospital it is very important for us to know if they are not cognitively intact or confused, to know if this is the normal or if this not their normal, how long have they been like this. This is a good indicator of a stroke for example, so we need to know whenever there is an altered mental status. When (R4) arrived, he was not able to answer any questions and was not alert. We were told this was not his baseline and he is normally alert x 3. I personally called the facility to try and find out how long and when this condition started that he was no longer alert and orientated. I talked with 3 different staff members, and nobody could tell me the last time anybody laid eyes on him and how long he had been like this, when this started. I find this very concerning because staff should know these things. R4's Hospital Records dated [DATE] at 9:12 AM, [AGE] year old male, NH (Nursing Home) resident with past medical history significant for HLD (hyperlipidemia), CAD (Coronary Artery Disease), HTN (Hypertension), psychiatric history, schizoaffective disorder, CVA (Cerebral vascular accident), (no motor deficits, baseline AO (alert and orientated x 3) at baseline now x1 on arrival, hypoglycemia with initial glucose recorded at 42, severe macrocytic anemia, hypotension, hypothermia and other lab findings, consistent with severe sepsis. On admission he was initially responding to painful stimuli only, now AO x 1, moving all extremities. R4's Admission Hospital Records document on [DATE] at 9:00 AM, (R4) is a [AGE] year-old male with history of hypertension, CAD, HLD, schizoaffective disorder, history of CVA. He was sent from nursing home yesterday with AMS (Altered Mental Status); it was reported that he is AAOx3 at baseline and was AAOx1 prior to transfer. He also was hypoglycemic with Blood sugar of 42 and has been anemic with hypotension/hypothermic. On admission HG (hemoglobin) at 5.5, PH 7.1, LA was around 5, noted AKI with CR of 4.2 He is lethargic/sleeping and not much communicative. He has a bad wound over the left leg. His BP (Blood pressure) when I saw him this AM blood pressure was ,d+[DATE] (Normal ,d+[DATE]). Reason for Admission: Shock. R4's Death Certification dated [DATE] documents: Cause of death septic shock and bacteremia. On [DATE] at 8:33 AM, V7, Wound Nurse stated, (R4's) leg issue started as a bump and then an abscess. His foot was always dry, and he had bad dry skin. I am not sure what happened with his foot. I did not notice anything before he was sent out. I did his last treatment on Friday, and he was sent out to the hospital on Monday. When I am not here the floor nurse will do the treatments. I was not aware he was having any issues before he was sent out. On [DATE] at 11:01 AM, V32, LPN stated, I did wound treatments on (R4) over the weekend before he was sent out. I am not aware of any issues. I don't remember anything. V32, Licensed Practical Nurse (LPN) was documented as the charge nurse working on Saturday, [DATE], and Sunday, [DATE]. On [DATE] at 9:11 AM, V7 stated, I was not here working when (R4) went out to the hospital so I cannot say what happened. I know, I get a lot of complaints from residents when I do not work but I cannot be here 24 hours a day, seven days a week. I have been told by the residents, multiple times that nobody is doing wound treatments over the weekends. I would consider missing wound treatments to be a bad thing and not good for the resident. On [DATE] at 9:12 AM, V17, Nurse Practitioner stated, If a resident has an infection/wound we would turn that over to the Wound Doctor and expect the facility to be following the Wound Doctor's orders. With any infections I would expect staff to actually be looking at the wound, applying the treatments, changing the dressings, monitoring the wound, taking vitals and temperatures every day to ensure and documenting in the TAR and watching for any changes. I cannot get into (R4's) chart from here as I am not at the facility, but if we sent an order, I would expect it be followed and communicated to us if it was not given in a timely manner.

Based on observation, interview, and record review the Facility failed to provide supervision to prevent elopement for 1 of 41 residents (R88) reviewed for elopement in the sample of 75. This failure resulted in R88 eloping from facility and the facility not being aware of when R88 left. R88 was found by the local police department on 1/18/2023 at 11:23 PM and taken to the hospital where he was diagnosed with chronic schizophrenia, noncompliance, and elevated blood pressure. The failure to provide supervision and monitoring and implement care plan interventions to prevent R88 from eloping resulted in an Immediate Jeopardy to the health and safety of R88. Without having access to supervision, medical and psychiatric monitoring, R88 has a likelihood for mental health complications resulting in psychiatric hospitalization s, decline in overall health and possible harm. This has the potential to affect 40 other residents (R7, R9, R15, R17, R19, R20, R21, R23, R26, R27, R36, R37, R39, R40, R42, R43, R44, R45, R46, R49, R50, R52, R56, R66, R69, R70, R72, R74, R83, R85, R93, R103, R104, R106, R107, R110, R122, R123, R126, and R232) who have been identified by the facility at risk for elopement. The Immediate Jeopardy began on 1/18/23 when R88 eloped from the facility at an unknown time and was found 2.2 miles away from the facility by the local police department. On 3/10/23 at 2:50 PM V1, Administrator, V52, Corporate Regional Director of Operations, V49 Corporate Nurse Consultant, V3, Assistant Administrator were notified of the Immediate Jeopardy. The surveyors confirmed through observation, interview, and record review, that the Immediate Jeopardy was removed on 3/10/23, but noncompliance remains at Level two because additional time is needed to evaluate the implementation and effective ness of the in-service training and quality assurance. Findings include: R88's Progress Notes document R88 was admitted to the facility on [DATE] at 6:32 PM. R88's previous facility's Physician Order Sheets (POS) dated 9/26/2022 to 10/26/2022 documents he had a (resident monitoring device), and staff were to evaluate the device every shift, twice a day 6 AM, 6 PM, and 6 AM. R88's POS dated March 2023 document R88 had diagnoses of Schizophrenia, delusional disorder, Psychotic disorder with hallucinations due to known physiological condition. R88's March 2023 POS document he was taking the following medications: Ativan (an anxiety medication) 1 milligram (mg) 1 tablet by mouth two times a day for anxiety, Invega Sustenna Suspension Prefilled syringe 234 mg/1.5 milliliters (Paliperidone Palmitate ER, an antipsychotic medication) inject 1 syringe intramuscularly one time a day starting on the 23rd and ending on the 23rd every month for prophylaxis related to schizophrenia, and Haloperidol (an antipsychotic medication) Tablet 10 gm, give a tablet a day for anxiety related to schizophrenia. R88's Minimum Data Set (MDS) dated [DATE] documents R88 was severely impaired for cognition, has a presence of behavioral symptoms, and had no wandering tendencies. R88's Care Plan, dated 1/10/2023 document, Resident is a high risk for elopement. R88's Care Plan Goal dated 1/10/2023, documented Will remain free from making elopement attempts throughout next review. R88's Care Plan Interventions to address elopement, dated 1/10/23, documented RESOLVED: 15-30 min (minute) checks as needed; Allow concerns to be expressed; Encourage resident to keep busy with activities; MD (medical doctor) notification PRN (as needed); Monitor where abouts PRN; and Reality orientation if appropriate. The Care Plan dated 11/30/2022 documents, Resident has diagnosis of Schizophrenia and may display symptoms that include but not limited to: being out of touch with reality (delusional or hallucinations), may have disorganized speech or erratic behavior, decrease in activities. Diagnosis of mental illness. R88's Care Plan dated 1/16/2023 documents, (R88) is at great to moderate risk for self-harm. R88's Care Plan, dated 1/5/23, documents that he is a moderate risk criminal offender. The Care Plan Intervention, dated 1/5/23, documents Evaluate the resident's ability to control impulses, document according. Teach impulse control strategies. R88's Nurse's Notes dated 1/18/2023 at 8:30 PM, This nurse was going to the resident room to administer bedtime medications and did not locate him in the room. This nurse asked staff assigned to the hall if they could help locate resident. This nurse was made aware that resident could not be found. This nurse performed a complete patient head count of each room on the hall. The nurse notified other staff on hall to help assist with a complete room search of each room, closet, and bathroom in the hall. The resident still could not be located at this time. Nurse Manager on duty notified at this time and alerted Administrator of the resident. Resident head count and search was extended to other halls of the building, still not located. Search begins to extend to the outside of the building and other surrounding areas near the facility by foot. Some employees went by car to search in this area. At this time resident still could not be found. Police notified of the resident. The resident was last physical seen approximately around 7 PM standing in the smoke line by this nurse. Staff continue to search for resident. R88's Nurse's Notes dated 1/18/2023 at 9:30 PM, documents The search for the resident continues. Will continue to monitor. R88's Nurse's Notes dated 10:00 PM documents (V34), Mother returned call, stated she haven't spoken with (R88) today. (V34) informed me to call (V67) who is a close family friend and stated that's where he might be headed (town listed). R88's Nurse's Notes dated 10:04 PM, documents Staff contacted (V67), close family friend informed staff that (R88) doesn't know anyone in the area and if he had money he would attempt to travel to (town listed). R88's Nurse's Notes dated 1/18/2023 at 11:06 PM, documents Received a call to facility stating resident has been found on a bus. Will follow up. R88's Nurse's Notes dated 1/18/2023 at 11:15 PM, documents The nurse was made aware that the person found on the bus was not the resident. Resident still not found at this time. The oncoming nurse is aware of the situation and will continue to follow up. R88's Nurse's Notes dated, 1/18/2023 at 11:45 PM, documents Resident returned to facility accompanied by local Police wearing a coat, t-shirt, necklace, socks, and black tennis shoes. Resident is smiling, happy stating he went to get a soda, some cigarettes and intended to get a ride to Centralia to see his mom. Resident aware it is late at night. Police received a call from dispatch resident was at Metro Link Station (2.2 miles from facility). Upon return resident stated that he did not know he was supposed to leave the facility without signing out he just wanted to see his mom because she is sick. Interviews with mom indicate resident has mental capacity to travel unassisted to (Centralia). Administrator educated resident on the proper process for signing out with staff when he wishes to go on a leave. Resident agreeable and states he will go to his room downstairs if he can't go to his mom's tonight. Resident escorted to room. Alert and orientated x 3. Resident 1:1 enhanced supervision will continue to follow. (draft). R88's Police Report dated 1/18/2023 at 9:23 PM, On January 18, 2023, at approximately 9:23 PM. I was dispatched to (Facility) for a report of a resident missing from the facility. I arrived on scene with (V58), Local Police Officer. We made contact with (V60), Front desk worker. She provided me with a document labeled admission record for (R88). (V58) took a photo of (R88's) intake photo and uploaded it to this report. I met with (V18, Certified Nursing Assistant CNA) in the facility basement, where (R88's) room was. She stated (R88) was last seen at 7:00 PM, during a smoke break facilitated by employees. (V18) did not realize (R88) was missing from the facility until her room checks at 8:30 PM. (V18) said (R88) was last seen wearing a white shirt, blue jeans, and red and black jacket, a necklace made of [NAME] teeth. (R88) had just received 30 dollars in cash, and she believed (R88) was heading to the Metro Link Station. Officers checked the area with staff and were unable to locate (R88). I completed the missing paperwork and turned it to dispatch so (R88) could be entered. At 11:57 PM, (V58) was disported to (Metro Link) and located (R88). This report was documented by V59, Local Police Officer. The Police Report documents R88 was found at a Metro Station 2.2 miles from the facility at 11:57 PM. The World Weather Services documents on 1/18/2023 at 7 PM in the city where the facility is located, it was raining and 37 degrees Fahrenheit. R88's Nurse's Notes dated 1/19/2023 at 12:32 AM, Made aware resident was returned to the facility/staff. R88's emergency room visit with an encounter date of 1/19/2023 documents, Chief complaint: Manic Behaviors. [AGE] year old white male with a history of schizophrenia, hypertension, reflux hyperthyroidism, currently has been living in a nursing home for six months or so was sent by the nursing home staff because of increasingly manic behavior, increasing hallucinations and tonight eloped from the nursing home, and he was found and brought back to the nursing home staff sent him here for evaluation, and medical clearance, and if he is cleared he may return back to the nursing home. Patient does report auditory and visual hallucinations, but he is vague. Physical Exam: At times speaks relatively clearly and other times he is rambling and does not make a lot of sense. However, when he settles down, he is able to provide a good history. He then just goes off on other tangents and has to be redirected. Patient arrived to ED (Emergency Department) via EMS (Emergency Medical Systems) from nursing home for complaints of maniac behavior. Per nursing home, he has been having more hallucinations, both auditory and visual. Patient reports he was locked out of the facility, and he was going to walk to [NAME] and get his truck. Patient is alert and orientated, calm and agreeable. He did have multiple blood pressures that were elevated, we did give him amlodipine and clonidine to control his pressure, he is scheduled for his morning dose AM and recommending his blood pressure be followed closely and his primary care physician be notified. R88's Facility Incident Report Form, undated, documents Family notified 1/18/2023 and Physician notified, documents, (R88) left the facility without notifying staff. Physician and Family notified immediately. Resident's mother stated that (R88) spoke of coming to visit her in (town). Resident did not mention this to staff. She provided phone number of his close friend that she stated he was also in contact with on a regular basis. Facility immediately began search for resident. Local police department was notified and assisted with locating resident. The Report Form Section Occurrence Resolution documented Facility began immediate search for resident with assistance of the local police, facility staff and regional staff. Facility spoke with resident's friend who stated that (R88) mentioned going to (City) and that he knows his way and has means to get there. Resident was located at the Metrolink station. Resident was assessed by staff with no injury or changes in status. Resident was dressed appropriately. Upon interview resident stated, 'I was going to see my mom'. Staff encouraged resident to speak to mother via phone and/or face time. Offered relocations closer to mother. Resident educated on the sign in/out process when leaving the facility. Resident was placed on enhanced monitoring and care plan updated. On 3/8/2023 at 4:27 PM, R88 stated, I left here because I don't like it here. I wanted to go back to my apartment. I don't like living here. I used to live downstairs on the 500- hall in the basement. I went out the basement door during the smoke break. I was trying to get back to (city name) to my apartment. I told them I did not like it here. On 3/8/2023 at 4:35 PM, V31, Maintenance Director stated, I am in the process of getting a new door frame for this door. When you open this door there is another door here and it is alarmed. Sometimes staff and residents will go out this door to smoke. (R88) was a smoker. He would fidget a lot. I was told they think he got out this door during the smoke break. On 3/8/2023 at 4:45 PM, V19, Certified Nursing Assistant (CNA) stated, (R88) liked to play and guitar, sing and do music. He was all over the place and he liked to walk around. I was not here when he eloped, but I heard he had wandered off during the smoke break. On 3/9/2023 at 5:00 PM, V34, R88's Mother, stated, I was not informed that (R88) was sent out to the hospital today. I know he constantly has behaviors, and it happens quite often that is why he is in the facility. He eloped from the facility last month. I do not think he can make good decision on his own. He gets confused and sometimes he sees things that are not there. I do not think he could make it to my home safely on his own. I am [AGE] years old and (R88's) birthday is coming up and I am so worried about him. I never told anyone that he had the mental capacity to be on his own or that he could make it home safely to see me. R88's MDS dated [DATE] document R88 severely impaired for cognition for decision for activities of daily living. R88's MDS documents R88 can walk in room supervision only and wandering occurred daily. On 3/9/2023 at 1:24 PM, V34, Licensed Practical Nurse (LPN) stated, I think (R88) went out to smoke at 7 PM for a smoke break. The guy, I don't know his name, but he was in charge of the smoke break said he let (R88) back into the building again. When I went to give out my pills later that night (R88) he was not in the building. I alerted everyone and we did a search and could not find him. At first, they thought they found him on a bus, when I left my shift at 10:30 PM, (R88) was still missing. I work with agency I had never worked with (R88) before, so I was not sure what was or was not normal for him. They said they let them out to smoke and are supposed to watch and monitor and then let everyone back inside of the building. Nobody told me any information about any of the residents. I did not get any report sheet, I just got a sheet with resident names but no information. A lot of staff are supposed to have one 1:1 and one night I did not have any aides I charted that and the ADON (Assistant Director of Nursing) got mad at me and yelled at me because I charted in the charts that there was no sitter. I think that building is risky and scary. If they are supposed to be on 1:1, then I would expect staff to be there for 1:1. I can't do my job and do 1:1. That's just an accident waiting to happen. On 3/10/2023 at 10:54 AM, V35, emergency room (ER) Attending Physician stated, (R88) had increased behavior and increased hallucination. The Police found (R88) and brought him back to the nursing home where they then send him to the ER. (R88) did not want to be in a nursing home and I was told he had a history of non-compliance. (R88) wanted to be in the outside world but with his psychiatric mental illness and medical problems and to keep him safe he needed to be in the nursing home with supervision. (R88) was healthy enough to figure out how to get out of the facility but not healthy enough to make safe decision and be aware of his environment, road, dangers, things that I would expect a healthy person to be aware of and able to navigate on their own. I do not believe (R88) was capable of making this safety decisions on how own and that would put him at risk for dangers. On 3/14/2023 at 12:37 PM, V1, Administrator stated, I interviewed all staff and could not get anyone to admit to me that they did not do a head count and/or anything to determine how (R88) got out of the building and when he got out of the building. We still do not know how he got out of the building. On 3/14/2023 at 1:03 PM, V68, Social Service Director stated, Nobody is really in charge of smoke breaks. Staff hold on to their cigarettes and hand them out. Staff are to supervisor residents when they smoke. I would expect all staff to do a head count and ensure everyone comes back into the building and is accounted for. After (R88) eloped (V1) moved the smoking so nobody staff and residents can smoke on the 500 hall that is where (R88) eloped on. (V69) was in charge of the smoke break when (R88) eloped. The elopement book observed at the Nurse's station on the 300-hall identified the following residents as elopement risk: R7, R9, R15, R17, R19, R20, R21, R23, R26, R27, R36, R37, R39, R40, R42, R43, R44, R45, R46, R49, R50, R52, R56, R66, R69, R70, R72, R74, R83, R85, R88, R93, R103, R104, R106, R107, R110, R122, R123, R126, and R232. The elopement Policy with a review dated of 9/2022 and 3/14/2023 documents, Elopement occurs when a resident occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. This does not include alert and orientated resident who handle themselves outside the facility and choose to leave the facility, even if against medical advice and sometimes, common sense. While presenting different care challenges, these alert residents are not in the same category of potential danger as the residents with impaired cognition trying to leave the facility, and their absences from the facility are not considered to be an elopement. All residents will be assessed for elopement risk upon admission, with significant change in condition, and quarterly. Residents who are at risk to elope are closely supervised to keep them safe in their environment, while allowing to move freely about the safe environment. Residents at risk to elope will be closely monitored. The Immediate Jeopardy that began on 1/18/23 was removed on 3/10/23 when the facility took the following actions to remove the immediacy: A. Identification of Residents Affected or Likely to be Affected: 1. R88 was assessed on 1/18/2023 by V49 Regional Nurse/Registered Nurse. Resident is currently out of facility. V2, DON will reassess R88 upon return to facility. 2. All residents were assessed for elopement risks by, V70, Previous MDS Coordinator, V55, MDS/Care Plan, V47, LPN/MDS, V4, RN/ICP, on 1/19/2023 and reassessed by V55, V2, V47, and V4 on 3/10/2023 to be ongoing for new residents will be assessed for elopement risk and residents with newly identified exit seeking behaviors will be reassessed for elopement risk. 3. Enhanced monitoring orders will be obtained by V49 and V4 for any residents identified to be at moderate or high risk for elopement on 3/10/2023 and to be ongoing for any newly identified exit seeking behavior and new admissions with identified exit seeking behavior. 4. Care plans were updated with interventions to address identified risks by V49, V47, V70, and V55 on 1/19/2023 ongoing to include all new residents and as needed for newly identified exit seeking behaviors. B. Actions to Prevent Occurrence/Recurrence: 1. The corporate and leadership team V49, V50, Corporate Clinical Nurse Consultant, V51, Corporate [NAME] President of Clinical Operations, V52, Corporate Regional Director, V1 and V3 reviewed policies and procedures regarding elopement on 1/18/2023 and 3/10/2023. 2. The interdisciplinary team including V1, V3, V4, V2, V55, V47, V26/CNA, V53, Human Resource Director, V54, Therapy Director, V37, Medical Records, V27, Admissions, V42 Dietary Manager, V60 Front Desk/Receptionist, V10 CNA/Staffing Coordinator, and V31 Maintenance Supervisor, will provide training to the staff related to the above-mentioned policy to be completed on 1/19/2023 and 3/10/2023 to be ongoing for new hires and agency staff. 3. The training will also include providing supervision/monitoring to prevent elopements and recognizing when a resident exits the facility or has newly identified exit seeking behaviors to be ongoing to include new hires and agency staff. 4. All agency staff and new hires will be educated on the above policies prior to beginning their shift by V10, V53, and V1 to be ongoing. 5. Safety checks of all potential exits daily to ensure they are secure. This will be done by the maintenance supervisor V31 and V56 to be ongoing. 6. V31 and V56 will conduct elopement drills at least three (3) times a month, at different shifts to ensure compliance to be ongoing. 7. The elopement drill will be evaluated by the Administrator, V1 and any identified concern will be addressed. Additional staff training will be completed as needed. 8. An Ad-Hoc QAPI meeting will be held weekly for four (4) weeks by the QAPI team to discuss this removal plan and identify if additional interventions are necessary to be ongoing. 9. Monitoring/auditing of ongoing education of staff for elopement policy and procedures, daily safety checks of all potential exits, and elopement drills and ongoing assessments of new residents and residents with newly identified issues regarding elopement by V1 will continue for a minimum of three months to be ongoing and will part of the QAPI process. Date Facility Asserts Completion of Abatement: 3/10/2023. B. Based on observation, interview, and record review, the facility failed to provide supervision, progressive interventions, and ensure bed in safe position to prevent falls for 3 of 6 residents (R34, R38, R74) reviewed for falls in the sample of 75. This failure resulted in R38's fall sustaining a hip fracture requiring surgical repair. Findings include: 1.R74's Physician Order Sheet (POS) documents diagnoses of psychosis, paranoid Personality, Dementia, Bipolar disorders, Personal history of transient ischemic attack and cerebral infarction without residual deficits. 1. R74's MDS dated [DATE] document R74 was moderately impaired for cognition and transfers with independent set up only with no impairments. R74's Care Plan dated 11/15/2022 document R74 is a 'high risk' for falls related to the use of psychotropic medication use and history of falls. R74's Nurse's Notes dated 2/2/2023 at 4:02 AM, Resident returned to facility following ED (Emergency Department) visit. Diagnosis Unwitnessed fall, closed head injury, Eyebrow laceration, left. No new orders. Liquid bandage applied. Area intact, no drainage, no odor and peri wound clear. No pain or discomforts voiced. Call placed to (V33, Medical Doctor, no answer no return phone call. Will continue to follow. R74's Nurse's Note, dated 2/2/2023 at 1:50 PM, documents Note Text: this nurse noted resident having dried red area above left eyebrow while communicating with resident. Resident stated he fell out of bed this morning round 5 o'clock. Resident stated he needed a new bed because his was too high, this nurse assessed resident no injury noted other than 1cm (centimeters) skin tear above Left eyebrow, no pain expressed. Resident eyebrow cleaned. Resident stated he is fine. Nurse on duty made aware of situation. NP (Nurse Practitioner) notified awaiting response. Resident received a new bed and was educated to call for assistance when needed. R74's Incident Report dated 2/22/2023 at 1:00 PM, Incident Description: This nurse noted resident having dried blood above left eyebrow. Resident description: Resident stated I fell this morning out of bed. It was too high. Orientated to person and situation. Intervention: Self-reported fall from bed. Intervention: Resident unable to put bed in lowest position. New bed given to resident that will raise and lower. On 3/14/2023 at 10:30 AM, R74 stated, Yes, I fell and hit my eye. I could not get the bed down it was too high, and I fell . On 3/14/2023 at 4:12 PM, V1, stated, I am not really sure what happened with (R74's) fall. I can only go by the incident report I am not sure what happened with his bed. On 3/14/2023 at 4:15 PM, V4, Registered Nurse (RN), stated, I am not sure about why (R74's) bed was replaced but it is fixed now. 43794 2. R34's Face Sheet, undated, documents that R34 has diagnoses of difficulty in walking, other abnormalities of gait and mobility, muscle weakness, lack of coordination, syncope, and collapse. R34's Physician Order (PO) dated 04/04/22 documents other abnormalities of gait and mobility. R34's PO dated 07/28/21 documents other lack of coordination. R34's PO dated 07/28/21 documents muscle weakness (generalized). R34's Fall Risk Evaluation dated 12/14/22 documents a score of 17.0. R34's Care Plan dated 12/21/22 documents (R34) is at high risk for falls related to use of psychotropic medication, some visual loss and DX (diagnosis): Seizure Disorder and Syncope. 12/14/2022 - fall while going to restroom. R34's Care Plan Interventions document the following: 11/29/22 Education done with (R34) on taking his time while he is up walking. 12/14/22 Education to (R34) to wear non-skid socks when not wearing shoes. R34's Nurse's Note dated 11/29/22 at 6:53 PM documents Resident lost his balance and fell to his knees in hallway upon assessment both knees were scraped moves all extremities WNL (within normal limits) or him this nurse and CNA (Certified Nursing Assistant) assisted resident back up on his feet fall was witnessed resident denies pain will continue to monitor POA (Power of Attorney) and DON (Director of Nursing) notified. R34's Nurse's Note dated 12/14/22 at 2:20 AM documents 0150 CNA informed nurse that resident had fallen and hit his head. 0157 (V33) was called and an order was given to [sic] to (local hospital) for evaluation and treatment. 0200 (local ambulance service) was called and report was given. 0205 Report was called to RN at (local hospital). 97.3 (temperature) 80 (pulse) 20 (respirations) 150/94 (blood pressure). R34's Nurse's Note dated 12/14/22 at 9:30 AM documents (R34) returned from Local hospital) Ed (emergency department) at this time post fall, he has 2 stitches noted above right eye cover with dry dressing. He is alert and orient x 3. Skin impairment noted. (R34's POA) called and made aware, thankful for call. R34's MDS dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS documents R34 requires supervision with no setup or physical help from staff for bed mobility and toilet use, requires supervision with setup help only for transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, eating, and personal hygiene. R34's MDS documents R34 is steady at times. R34's Nurse's Note sated 02/11/23 at 12:58 PM documents Resident was noted in room on the floor of the bathroom, states he did not hit his head. Resident had no loss of consciousness. Called report to (local hospital). Blood pressure 138/80, pulse 100, resp 18. Called EMS (Emergency Medical System) for transport. Initiated neuro checks. The facility did not document a root cause analysis of R34's fall on 2/11/23 and did not implement any progressive interventions to address this fall. R34's Nurse's Note dated 02/17/23 at 11:32 AM documents Resident is A & O (alert and oriented) x2/3; verbal & able to make needs known. VS (vital signs) stable/WNL: RR 18 even, unlabored, no SOB (shortness of breath) /cough noted, LS (lung sounds) CTA (clear to auscultation) bilaterally, O2 98% on RA (room air), HR (heart rate) 77, BP 128/72, ABD (abdomen) soft, non-tender & no distention noted, BS (bowel sounds) active & present all 4 quadrants, Pedal pulses present bilaterally, PERRLA (pupils equal round, reactive to light, accommodation), afebrile @ 97.7 & no complaints of pain reported. Resident had a witnessed fall this shift; reported to NP (Nurse Practitioner) (V32), NNO (no new orders) @ this time. No injuries noted. Resident did not hit his head. Resident resting with call light within reach while in room, no other concerns @ this time. There was no documentation that the facility assessed R34 for potential root cause after R34 fell on [DATE]. There was no documentation R34's Care Plan was not revised with progressive interventions after R34 fell on [DATE]. R34's MDS dated [DATE] documents R34 requires supervision with setup help only for transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, eating, toilet use, personal hygiene. The MDS documents R34 is not steady, but able to stabilize without staff assistance. On 03/09/23 at 3:00 PM, R34 observed ambulating by himself from the 400-hall to the dining room. On 03/14/23 at 10:00 AM, R34 observed ambulating by himself down the 400-hall. On 03/14/23 at 11:18 AM, V2 state that she would expect residents to have progressive interventions for each fall. She stated, I know that sometimes it's hard to come up with interventions, but you got to try. Facility's policy Fall Prevention and Management dated 05/2015 documents This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. 42834 3. R38's Facesheet documents an admitted [DATE] with diagnosis of Alzheimer's Disease, Diabetes Mellitus, Lack of Coordination, Drug Induced Subacute Dyskinesia, Paranoid Schizophrenia. R38's Fall Risk assessment dated [DATE] documents score 4.0. Quarterly fall risk assessment, 1-2 falls in past 3 months, ambulatory/continent, gait balance normal, alert and oriented to person, place, and thing. R38'S Fall Risk Assessments dated 2/1/2023 at 12:56PM documents: Score 16.0. High risk for falls. Reason for assessment: post fall, unsteady gait and/or use of ambulatory device, alert and oriented to person, place and thing, history of falls, continent. R38's Care Plan updated 1/10/2023 documents (R38) is at high risk for falls related to impaired safety awareness, use of psychotropic medication and DX (diagnosis): DM (diabetes mellitus) II and Alzheimer's Disease. Goal Falls/injuries will be minimized through management of risk factors thru next review. Interventions include 2/18/23 Brightly colored visual cues to ask for assistance. 2/1/23- Staff to provide frequent monitoring when up ambulating thru the facility. Assess for fall risk quarterly and as needed. Encouraged (R38) to get up out of bed slowly to avoid dizziness. Encourage (R38) to take rest breaks in between activities. Monitor (R38)'s safety during activities and anticipate needs, describe activities to (R38). Ensure (R38) is wearing proper fitting shoes. Keep frequently used items by (R38) within easy reach to avoid overreaching. Encourage (R38) to use call light and wait for assist. Keep call light within easy reach. Observe gait while ambulating for unsteadiness, SBA (stand by assist) as needed. Provide a safe environment free from clutter or safety hazards. Provide an environment with adequate lighting, free or glare. Transfers and ambulates independently. R38's fall investigation dated 2/1/2023 at 10:40PM states Writer made aware of (R38) lying supine on the floor in front of clean utility closet. No injuries observed at time of incident. Alert and ambulatory with assistance. Oriented to person and place. Predisposing factors include gait balance and ambulating without assist. MDS (Minimum Data Set) dated 2/8/2023 documents R38 has severe cognitive impairment, requires supervision of two+ persons physical assist for locomotion on unit, and has impairment on one side lower extremity. R38's Progress No [TRUNCATED]

Based on interview, observation, and record review, the Facility failed to supervise and implement progressive interventions to prevent resident to resident physical abuse. This failure has the potential to affect all 142 residents living in the facility. The Immediate Jeopardy began on 4/25/22 when R2 became physically aggressive throwing objects which hit R8. This same day, he threatened to kill R9. Subsequently, R2 continued to have impulsive aggressive behaviors and physical abused R1, R6 and R11. Due to the facility's failure to address R2's ongoing impulsive aggressive behaviors and provide supervision to prevent these aggressive behaviors, this has the potential to affect all residents in the facility. V1, Administrator, V20, Regional Clinical Nurse, and V6, Social Service Director, were notified of Immediate Jeopardy on 1/26/23 at 8:46 AM. The surveyor confirmed by record review and interview that the Immediate Jeopardy was removed on 1/27/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: 1. R2's Admission Record, dated 1/12/23, documents that R2 was admitted to the facility on [DATE]. R2's Diagnosis include: Schizophrenia, Major Depressive Disorder, and Bipolar. R2's Illinois PASRR (Preadmission Screening and Resident Review) Summary of Findings, dated 4/17/22, documents R2 has been diagnosed with an Intellectual Disability. R2's Electronic Medical Record under Weights/Vitals, documents that on 10/14/22, R2 was 72 inches tall, and on 1/11/23 R2's weight was 350 pounds. R2's Care Plan, dated 12/5/22, documents (R2) can become verbally and physically aggressive when he does not get his way. R2's Minimum Data Set (MDS), dated [DATE], documents that R2's Brief Interview of Mental Status (BIMS) is 15, which means that R2 is cognitively intact. R2's MDS documents that he is independent for all of his (Activities of Daily Living (ADL's), including ambulation. R2's MDS, documents R2's Physical Behavioral symptoms directed towards others occurred one to three days. R2's Verbal Behavioral symptoms directed towards others occurred four to six days. R2 has Overall Presence of Behavioral Symptoms that put the resident at significant risk for physical illness or injury significantly interferes with resident's care and significantly interferes with resident's participation in activities or social interactions. R2's Behavioral Symptoms put others at significant risk of physical injury, significantly intrudes on the privacy or activity of others, and significantly disrupts care or living environment. R2's Wandering Behavior occurred daily, places the resident at significant risk of getting to a potentially dangerous place and significantly intrudes on the privacy or activities of others. R2's Change in Behavior or Other Symptoms are worse than the prior assessment. R2 acknowledged feeling down, depressed, or hopeless, feeling bad about himself, or that he was a failure or have let himself or his family down. R2 denied thoughts that he would be better off dead, or of hurting himself in some way. R2's Nurse's Note, dated 4/24/22 at 3:37 PM, documents Resident became verbally aggressive with another resident (R8), resident was asked to go down the hall to separate residents. Neither resident became physical with each other. This nurse (V21, Licensed Practical Nurse/ LPN) and other staff defused situation before resident began punching walls and throwing objects down the hall. Resident then eloped from facility with staff member right behind and was redirected back to the building by staff member. This nurse called (V19, Physician) and was given orders to send resident to (Regional Hospital). This nurse called residents guardian made aware. EMS (Emergency Medical Service) as well as three (Local Police Department) officers arrived and escorted resident out by stretcher. Resident left A&O x3 (Alert and oriented times three). Resident had no bruising noted at the time. R2's Nurses Note, dated 4/24/22 at 6:50 PM by V21, LPN, documents Resident returned from (Regional Hospital). Did not meet criteria to be admitted per ER (emergency room ) staff. Resident returned with no new orders. Guardian (V4) notified of his returning. There is no documentation that 1:1 was implemented upon R2's return to the facility. There is nothing further documented on this day. R2's Nurse's Note, dated 4/25/22 at 12:32 PM, documents This nurse (V21, LPN) notified resident exited building with 1:1 staff following behind him. This nurse went outside to meet resident and staff. This nurse was able to redirect resident back to the facility with difficulty. Resident was suicidal in the process of walking back to facility. Resident also stated he was homicidal and wanted to burn the building down after he leaves. Resident was placed in the administrator office while guardian was called and (Local Ambulance) and waiting for (Local Police Department) to arrive. Resident being homicidal to resident and staff. Order was given to send resident to (Regional Hospital). Resident guardian made aware. There was nothing further documented after arrival back to facility. R2's Nurses Note, dated 4/25/22 at 2:21 PM, documents Resident was sent to ER per (V19, Physician) for aggressive behavior toward residents and staff, throwing objects down hall, eloped outside to parking lot, hitting and beating on staffs' cars in the parking lot, unable to redirect, (Local Ambulance) and police called to transfer resident to (Regional Hospital) for evaluation and treat. Report given to ER at (Regional Hospital) prior to resident's arrival. POA (Power of Attorney) notified. (Documented by V9, LPN). No further documentation. R2's Nurses Note, dated 4/26/22 at 11:21 AM, documents Resident came back into facility via stretcher. Resident went into (room #). Resident told staff he would slap someone. Resident became upset after phone call with family member. Resident threw phone down while in administrator's office. Hall monitor redirected resident to calm down because he would not be able to go into hallway while being aggressive. Resident threw himself against wall. (V19, Physician) was notified, gave order to send resident to (Regional Hospital) and Guardian was also notified. Police came to assist. Ambulance came as well. Resident was sent out via stretcher. R2's Care Plan, dated 12/5/22, documents (R2) can become verbally and physically aggressive when he does not get his way. R2's Care Plan revised on 4/25/22 documented 4/25/22 Physical altercation (R2) threw a picture frame in the hallway and hit another resident. 4/25/22 Verbal aggression in the evening time. R2's Care Plan Interventions, initiation date of 4/25/22, document the following: Encouraged to use phone in the privacy of his room; Resident was informed that it is unacceptable behavior to throw objects; Resident transferred to Hospital for evaluation and upon return from hospital, discussed with resident to contact his guardian about placement at a facility. R2's Nurses Note, dated 4/27/22 at 9:59 AM, documents Resident arrived to facility via EMS on stretcher. R2's Nurses Noted, dated 4/27/22 at 10:37 AM, documents (V19, Physician) made aware of arrival, NNO (No New Orders). Guardian (V4) made aware. The Facility's Final IDPH (Illinois Department of Public Health) Incident and/or Abuse Notification, dated 4/25/22, documents On 4/25/22 staff reported a physical altercation between (R2), a [AGE] year-old male resident with a diagnosis of Schizophrenia and (R8), a [AGE] year-old male resident with a diagnosis of Paranoid Schizophrenia. Staff reported (R2) threw a picture frame down the hallway causing it to make contact with (R8) who was sitting in hallway with no injury. Resident (R8) voiced no complaints of pain. Administrator initiated an investigation. Interviewable residents and staff were interviewed. Medical Records were reviewed for both residents including medication review. On 1/18/23 at 3:10 PM, R8 stated I remember when (R2) was down here with us. (R2) was very upset about something one day and hitting the walls and tearing things up. He took a picture frame off the wall and threw it down the hall and I happen to be hit by it. I believe my neighbor (R9) had an issue one day with (R2). You might want to talk to him. On 1/18/23 at 3:15 PM, R9 stated When (R2) first came down here, he was being loud in the hall and when I asked him to quiet it down, he became verbally aggressive towards me and threatened to kill me. I told the staff and they sent him out to the hospital. I wasn't afraid of him until he threatened to kill me. Then I was afraid of him because I wasn't sure if he would follow through with it. R2's Nurse's Note, dated 5/2/22 at 9:47 PM, documents Resident became verbally and aggressive (sic). resident expressed he wanted a blanket and pillow sooner. Resident set off door alarm and walked away from door, resident knocked off covering to exit sign. This nurse tried to redirect resident. resident back verbally aggressive again. Resident expressed self-harming thought. Resident was given the items he wants resident went back to room. This nurse gave resident a few minutes to get situated in room and calm down then this nurse entered the room to speak with resident. The resident appeared calmer, this nurse asked resident what was wrong. The resident stated he was mad he wanted the items, but he didn't know that the hall monitor had already went to get them items for him. This nurse asked resident if he still had self-harming thoughts. The resident stated no I'm not going to do anything to myself, I was just mad. This nurse proceeded to address behaviors with resident and let resident know that was the proper way to handle things, resident was educated on how to handle situations when he does not feel things are being handled correctly. Resident voiced understanding and stated I just was mad at the time. I'm okay now I'm just going to get some sleep. Thanks man. Resident will continue on frequent checks throughout the night. Psych (Psychiatric) DR. (Physician). made aware resident guardian. R2's Care Plan was revised on 5/02/22 and documented verbal and physical aggression towards staff. R2's Care Plan Interventions, initiated on 5/2/22 documented Encourage resident to allow staff time to retrieve items he is requesting. R2's Nurse's Note, dated 5/4/22 at 8:08 PM, documents (R2) sitting at nurse's station charging his cell phone, peer (R6) also at nurses' station yelling B* N****, peer (R6) directed focus to this nurse. (R2) being [sic] to voice to peer don't disrespect a woman, this nurse redirected (R2) voicing that he didn't need to intervene, peer then focused in on (R2) and being to propel self to (R2), peer (R6) being [sic] to swing in a slapping motion, (R2) being [sic] to punch peer. This nurse (V10, LPN) attempted to separate the two, while yelling for help. Another nurse came to help, that nurse was able to get (R2) in his room, 911 called. Other staff came to assist, peer (R6) continuously knocked hard on (R2) door. (V19, Physician) called gave orders to send to (Local Hospital) ED (Emergency Department), police arrived, got peer (R6) to calm down and leave (R2's) door. No injuries noted, (R2) denies pain at this time. Guardian called after directed to after hours phone line, Representative took message on the events occurred and voiced that the on-call guardian will be made aware, EMS here Face Sheet, POLST (Physicians Orders for Life Sustaining Treatment) form and transfer sheet sent with resident. (Local Hospital) ED called to give report. DON (Director of Nursing) made aware. The Facility's Final IDPH Incident and/or Abuse Notification, dated 5/4/22, documents On 5/4/22 an altercation occurred involving (R2), a [AGE] year-old male with a diagnosis of Bipolar, and (R6), a [AGE] year-old male with a diagnosis of Schizophrenia. (R2) was sitting at the nursing station talking with nurse while charging his phone. At the same time, (R6) wheeled up and started being verbally aggressive towards the nurse. It was reported that when (R6) became aggressive with the nurses, (R2) told him 'You shouldn't talk to women that way'. (R6) reacted to (R2) comment and became aggressive towards him, resulting in a physical altercation with both residents making contact with each other. Nursing assessed both residents. No injuries noted. The Administrator was notified. An investigation immediately began. Interviewable residents have been interviewed. Staff interviews have been completed. Medical record reviews which included medication reviews for both residents were completed. R2's Care Plan was reviewed on 5/4/22 and documented R2 was verbally aggressive with staff/peer. R2's Care Plan Intervention, initiation date of 5/4/22, documented If resident becomes upset, give him time to calm down then re-approach, Staff to allow resident to vent feelings. Administer medications as per MD (Medical Doctor) orders. Notify MD if behaviors are worsening. Call resident guardian to see if he can assist in calming (R2). Staff to encourage resident to attend daily group therapy. If resident becomes aggressive attempt to remove resident from situation and assist him/her to a quiet place. Encourage resident to vent his/her feelings about situation. Remind resident that behavior is not acceptable. If resident refuses care, care giver should leave room and try again later. Separate residents as needed. Staff will ensure that each resident is safe. On 1/24/23 at 9:05 AM, V10, LPN, stated I remember (R2) was sitting at the nurse's desk (5/4/22) when (R6) walked by and started saying things to (R2). That triggered (R2) which started a verbal argument which then turned into a physical altercation. I remember that (R2) was hitting (R6) and then they got separated and (R2) got sent to the hospital. On 1/12/23 at 2:23 PM, V6, Social Service Director, stated (R2) is supposed to be attending groups, such as Life Skills, Anger Management, and Community Living, but (R2) will come into the meeting, become very vocal and disruptive, and leave within a few minutes of being there. Sometimes what we are doing for (R2) just doesn't work. Right now, the only thing we are doing for him is one on one. (R2) knows that if he says something suicidal or homicidal, that we will send him out for an evaluation, so he gets out of the building. When he returns, he is put on a 72-hour one-on-one watch. It seems like as soon as his watch/evaluation period is done, he starts to act up again, especially when he doesn't get his way. R2's Nurse's Note, dated 5/24/22 at 5:53 PM, documents This nurse (V10, LPN) in hallway passing dinner trays when (R2) brought dinner tray back to serving cart, peer (R6) seen (R2) and began to yell loudly YEAH as he propelled self toward (R2). this nurse attempted to move (R2) out of the way before peer (R6) could grab him, unsuccessful. Peer (R6) grabbed (R2) by the shirt and they both exchanged several punches to the face, staff intervened separating the two, as (R2) is walking to room peer (R6) broke free and being to propel self to (R2) again, (R2) turned around and grabbed a wet floor sign and began to hit peer (R6), the two separated again by staff. This nurse went to assess (R2), blood noted to his face, after cleaning area, blood coming from nose, instruct him to pinch nose and hold head down until bleeding stop. (Local Police Department) arrived, this nurse called (V19) at this time gave orders to send to (Local Hospital) to Evaluate and Treat. Guardian on call made aware. MOD (Manager on Duty) made aware. There was no documentation of any additional supervision such as 1:1. On 01/12/23 at 2:50 PM, V2, Regional Clinical Operations stated, I know you have concerns with resident safety, and I have to tell you that not only do we have the 1:1 CNA, but we also have hall monitors that help keep an eye on residents and can help if the person doing 1:1 needs assistance. I can tell you that (R2) will be a 1:1 from now until he is discharged from here. The incident when he pushed another resident in the dining room, the staff member who was doing 1:1 with him was probably walking next to him when he did that. There is not much they could have done. R2's Care Plan, revised on 5/24/22 documents (R2) got into a verbal and physical altercation with another resident. R2's Care Plan Interventions, revised on 5/24/22 documented Staff to encourage (R2) when he has problem with peer to notify staff to assist. Resident moved to another hall. R2's Social Service Note, dated 5/24/22 at 7:04 PM, documents (R2) was involved in a physical altercation with another resident this evening. His state appointed guardian was contacted. On 1/24/23 at 9:10 AM, V10, LPN, stated On 5/24/22, we were passing food trays in the hall when (R2) walked past (R6's) room and exchanged words, which triggered (R2) and then a fist fight began. I believe (R6) was punched in the head and because of his traumatic brain injury, and being hit in the head, he was sent to the hospital to be looked at. (R2) was also sent to the hospital and when he came back, I believe they put him in another room. R2's Nurses Note, dated 5/25/22 at 11:33 AM, documents Resident guardian notified that resident has to be moved to (a different room). Resident has been moved with no complaint or concerns. R2's Nurse's Note, dated 5/28/22 at 8:36 PM, documents Staff reported Resident was asked to put mask on, he became upset verbal aggressive toward staff, broke a plate, pulled hand sanitizer off the wall throwing things, unable to redirect, called (V13, MD) new order to send to (Regional Hospital) ER for evaluation. There was nothing documented in R2's Care Plan related to his aggressive behavior on 5/28/22 and no additional interventions. R2's Nurses Note, dated 6/11/22 at 8:11 PM, documents Resident told this nurse (V22, MDS/Care Plan Coordinator) that he called police because he did not want to be here. At 5:20 PM, Resident was lying on the floor telling other residents he could not breathe. When this nurse went to assess him, he became verbally abusive and started breaking the sanitizer dispensers on the wall on 400-hall. At 5:23 PM, Resident went out of 400-hall exit door and started exiting through the doors in the building. Resident was walking around the parking lot while staff was trying to get him back into the building. At 5:25 PM, Director of Nursing was called and informed of resident's behavior and that he was being sent out to another hospital. At 5:30 PM, (V19, Physician) was called and informed of this behavior and order was given to send to (Local Hospital). At 5:35 PM, (Local Ambulance) was called and report was given. At 5:36 PM, Report was given to (Local Hospital). At 5:37 PM, (Local Police) arrived and was talking to resident outside. (Local Police) said he was taking resident to ( Hospital) because resident requested (Hospital). At 5:38 PM, Guardian was call and no message could be left. R2's Care Plan, dated 11/22/22, documents 6/11/22 Verbal and Physical Aggression. There were no interventions documented after this altercation. R2's Nurses Note, dated 6/20/22 at 11:14 PM, documents IDT (Interdisciplinary Team) has met and reviewed (R2's) behaviors and need for one on one. Pattern noted that (R2) has more behaviors on the weekend's so he will be provided a one on one for weekends. On 1/23/23 at 1:35 PM, V20, Regional Clinical Nurse, stated If the IDT got together in June 2022 regarding (R2), that was before us. We were not here then so cannot answer for what happened then. I do know that (R2) tends to call 911 and act out more when the Administration is gone and that is typically at night and/or the weekends. R2's Nurses Note, dated 6/22/22 at 3:08 PM by V23, LPN, documents Staff report Resident is in the dining room throwing tables around hitting at the windows, threatening staff members. No easily redirected. Call placed to (Local Ambulance) to transport Resident to (Local Hospital). R2's Nurse's Note, dated 7/2/22 at 9:22 PM, documents Resident yelling loudly cussing at staff, walking up and down the hallway to the dining room, pulling pictures off the wall, slamming tables down in the dining room unable to redirect, 1:1 in place, call placed to (Local Ambulance) and Police. The Facility's Final IDPH Incident and/or Abuse Notification, dated 7/8/22, documents On 7/8/22, (R2) a [AGE] year-old male resident with a diagnosis of Bipolar, Schizophrenia DO (Disorder), was physically aggressive with (R11), a [AGE] year-old male resident with a diagnosis of Schizoaffective DO. Residents were immediately separated. (R11) was interviewed and stated that (R2) open handed made contact with the side of his face. (R2) was interviewed and stated that (R11) was in his way while he was upset. (R11) was assessed, with no redness or swelling was found. Interviewable residents have been interviewed with no finding. Staff interviews have been completed. Medical records for both residents have been reviewed including medication review. It continues The Facility has taken the following actions based on the facts and conclusions of the investigation: Psych Dr. was notified. (R2) was sent to (Local Metropolitan Hospital) for Psychiatric evaluation, upon return, 1:1, and skills anger management was provided. (R11) continues his daily activity with no signs of mental anguish, IDT has reviewed and updated care plans on both residents accordingly. It continues Brief description of Occurrence based on known facts at this time prior to a comprehensive investigation: Resident to Resident physical altercation. Residents immediately separated. Administrator notified. Final to follow. The Facility's Resident Interview, undated, unsigned, documents (R11) was asked what occurred between him and (R2) which he replied, I don't know, he slapped me across my face. When (R11) was asked if he was hurt, he said no. When (R11) was asked if he felt safe or was scared of (R2) or anyone at the facility, he stated Hell No, they don't bother me. The Facility's Resident Interview, undated, unsigned, documents When (R2) was asked what occurred between him and (R11), he stated He was in my way. When (R2) was asked if he slapped (R11), he refused to answer and walked away. R11's Admission Record, dated 1/19/23, documents that R11 was admitted to the facility on [DATE] and was discharged from the facility on 7/21/22 and therefore, unable to interview. There is nothing further documented in neither resident's medical record regarding this incident. R2's Care Plan, revised on 7/8/22 documented (R2) was verbally aggressive towards staff. There were no interventions to address his physical altercation with R11. R2's Care Plan revised on 7/09/22 documented (R2) punched a staff member in the face. No new interventions were added. There was no documentation in R2's medical record regarding this incident. There was no facility investigation regarding this incident. On 1/12/23 at 11:20 AM, V2, Regional Clinical Operations, stated We do not need to do an investigation when a resident hit a staff member as it is not a reportable incident. R2's Nurse's Note, dated 7/25/22 at 2:21 PM, documents Resident was in the dining room flipping table and chairs and knocking things off the table due to being mad that he overheard a staff member ask if it was okay for resident to be off the hall due to COVID isolation restriction. this nurse and two other staff members were able to redirect residents and calm him down and address his concerns. R2's Nurses Note, dated 7/25/22 at 6:15 PM, documents Resident in dining room this nurse heard commotion and this nurse immediately went to dining area resident was actively throwing chairs and tables chasing staff being combative this nurse asked resident to calm down and explain what happened to him to make upset, stated staff asked him to return to room and he got upset this nurse redirected resident to calm down and to come to management anytime he has and issues this nurse called (V19) gave orders to send resident to (Local Hospital) this nurse called (Local EMS) currently waiting for transport to arrive to take resident hospital for psychiatric evaluation. R2's Care Plan, revised on 7/25/22, documented (R2) was throwing chairs at staff members on evening shift and was chasing staff members. (R2) was sent out to hospital for evaluation. The facility did not implement progressive interventions at that time to address this behavior and to prevent R2 from future aggressive behaviors. R2's Nurses Note, dated 8/5/22 at 5:26 PM, documents (V13, Physician) made aware of resident sitting himself on the floor and running out of facility multiple times. Resident observed hitting walls in hallway and threatening to kick residents' teeth out. Orders received to send resident to ER for psychiatric evaluation and treat. (Local Ambulance) made aware of transportation needed. Resident made aware of MD orders and requested to go to ( Hospital). Notified guardian via voicemail of resident occurrence and MD orders. Ambulance arrived with two EMTs (Emergency Medical Technicians). Documentation and report given to paramedics. Resident cooperative with transfer to stretcher. Exited facility without incident. R2's Care Plan, dated 11/22/22, does not document the incident on 8/5/22, nor does it document any new interventions to be done. R2's Nurse's Note, dated 9/5/22 at 3:30 PM, documents Writer (V24, Registered Nurse/ RN) having a conversation with another nurse when resident interrupted wanting to talk to writer in office; explained to him writer was working floor as nurse when resident became loud walked away screaming no one here cared about him, as writer attempted to talk to resident he became loud and verbally aggressive walked over the stairway exit opened door and went downstairs as writer walked around to check on resident he was yelling loudly, cursing and had his fist balled up and pulled back to hit aide in her face. Writer interrupted him and attempted to talk to him when he bolted out the exit door yelling how no one cares about him. Two Staff members with resident. (Local Police) called about resident behavior and walking off. (V19, Physician) notified awaiting return call. R2's Nurses Note, dated 9/5/22 at 5:35 PM, documents When writer (V24, RN) observed resident with aide also observed him with his chest making contact with aide yelling at her and pushing her backwards with his chest. R2's Nurses Note, dated 9/6/22 at 10:37 PM, documents Resident sent to (Local Hospital) per (V19) related to aggressive behavior toward staff and destroying facility property, also trying to cut wrist with glass from broken picture frame which resident broke by throwing pictures onto floor. (Local Ambulance) and (Local PD) responded to facility for transfer, POA and DON (Director of Nursing) notified. R2's Nurses Note, dated 9/13/22 at 9:54 PM, documents Resident returned to facility by two EMS drivers, no complaints at this time, resident able to ambulate from the stretcher, resident currently resting in bed with no complaints. R2's Care Plan, dated 9/7/22, documents (R2) displays behavioral Symptoms, and will call 911. 9/6/22, Verbal and Physical behavior and destruction of property. R2's Care Plan Interventions, were not updated after this incident. There were no new interventions in place. R2's Nurse's Note, dated 9/24/22 at 9:24 AM, documents Resident sent out to hospital due to behaviors and throwing chairs, threatening to harm self and staff, and notified resident was sent to( Local Hospital) and admitted . There is no documentation of R2 returning to the Facility and there is no documentation of R2's Care Plan updated with new interventions. R2's Nurses Note, dated 12/4/22 at 11:30 AM, documents (R2) voiced that he was using his personal phone on the phone with his Dad, roommate (R3) self-talking and (R2) assumed that roommate (R3) threaten his dad, (R2) became homicidal toward roommate, voicing that he's going to kill him. (R2) called 911 from his personal phone, voicing that he wants to go to (Hospital). (R2) transferred to (Hospital), facesheet and POS (Physician Order Sheet) sent. State guardian on call made aware. The Facility's Incident Report Form - Final Report, dated 12/5/22, documents Description of Occurrence: Resident told nurse he was having homicidal thoughts against residents and family member. Residents were immediately separated from the room. 1:1 support given. (R2) stated that he became upset with his roommate for talking to himself and threatened to harm (R3) and his father. No physical contact was made. (R2) was sent to ER for evaluation. A nursing assessment shows no injuries. Staff and other residents were interviewed with no negative findings. Occurrence Resolution: Care Plans and medical records were reviewed and updated. Resident carried out normal daily routine without signs of distress. R2's Care Plan, dated 12/5/22, documents (R2) has a history of self-harming as a form of attention seeking. 12/4/22, (R2) was having homicidal thoughts against his roommate. There were no new interventions documented in his Care Plan after the 12/5/22 incident. R2's Nurse's Note, dated 12/11/22 at 6:03 PM, documents Resident was walking through dining room and pushed another resident (R1) onto floor and walked away, stated she yelled at him, this nurse received order to send resident to (Psychiatric Hospital) for evaluation and treat per MD, Guardian notified. R2's Nurse's Note, dated 12/11/22 at 11:00 PM, documents Resident returned to facility via (Local Ambulance)/stretcher accompanied by two attendants. Resident reintroduced to assigned room. R2's Care Plan, updated on 1/12/23, documents Aggression Care plan continues: 12/11/22 (R2) noted in altercation with another resident. R2's Care Plan Interventions, updated on 1/12/23, documents Per (V19, Physician) send resident out to the hospital, See aggression Care Plan Interventions. There are no other interventions put into place for the incident on 12/11/22. R1's Nurses Note, dated 12/11/22 at 6:16 PM, documents Resident was in dining room and was pushed onto floor by another resident (R2), upon assessment no injury noted resident got herself up from floor and used her walker to walk back to her room. MD, Administrator and POA notified, will continue to monitor. The Facility's Incident Report Form - Initial Report, dated 12/11/22, documents Description of Occurrence: (R1) was sitting in the dining room with another resident when (R2) walked through. (R1) was complaining about her salad. (R2) made a comment to her about always complaining. (R1) began to raise her voice and stood up losing her balance and falling backwards. Residents were immediately separated and 1:1 support was given. A nursing assessment reveals no injuries. Other residents and staff were interviewed with no negative findings. Occurrence Resolution: (R2) sent out for evaluation related to behaviors shortly after the incident. Care Plans and medical records were reviewed and updated. (R1) carried out her normal daily routine after the altercation without any signs of distress. On 1/12/23 at 3:20 PM, R1 stated (R2) pushed me purposely. (R2) was standing in the doorway in the dining room and people were trying to get through so I told him he needed to move. (R2) started to yell at me and when I stood up, he walked over to me and pushed me. I went into a chair and me and the chair fell to the floor with the chair on top of me. My leg was hurting me afterwards and I believe they did do an x-ray. I have seen (R2) hit and push other people too. (R2's) very violent and nobody does anything about it. I don't recall seeing a worker walking around next to him. He was by himself when he pushed me over. (R2's) always yelling and cursing at everyone. I am scared of him, and I think some of the staff are scared of him too. R2's Care Plan, revised on 12/11/22 documented (R2) note[TRUNCATED]

Based on interview and record review, the facility failed to provide supervision and progressive interventions to address threats of suicide and self-injurious behaviors for 1 of 3 residents (R2) reviewed for supervision in the sample of 11. This failure has resulted in R2 expressing suicidal ideations and self-injurious behavior resulting in recurrent emergency room evaluation and treatment. The Immediate Jeopardy began on 4/25/22 when R2 was suicidal and homicidal and sent to local emergency room . Subsequently, from 4/25/22 through 1/13/23, R2 has had 12 documented episodes of elopement/exit seeking behavior, 10 documented episodes of suicide/self-harm including attempting to cut himself and beating his head against objects, and 3 documented episodes of homicidal ideation without progressive interventions to address R2's behaviors or his need for increased supervision after each incident. V1, Administrator, V6 Social Service Director, and V20, Regional Clinical Nurse, were notified of Immediate Jeopardy on 1/26/23 at 8:46 AM. The surveyor confirmed by record review and interview that the Immediate Jeopardy was removed on 1/27/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R2's Admission Record, dated 1/12/23, documents that R2 was admitted to the facility on [DATE]. R2's Diagnosis include: Schizophrenia, Major Depressive Disorder, and Bipolar Disorder. R2's Electronic Medical Record under Weights/Vitals, documents on 1/11/23, R2's weight of 350 pounds, and on 10/14/22, R2 height of 72 inches. R2's Care Plan, dated 12/5/22, documents (R2) has a history of self-harming as a form of attention seeking. (R2) uses a bell in place of a call light due to self-harming behaviors. 5/22/22 resident used a plastic knife to place superficial cuts on arms. 10/2/22 walked outside of the building over the weekend multiple times and had self-harming behavior. 12/4/22 (R2) was having homicidal thoughts against his roommate. It continues (R2) is at high risk for elopement. He has a history of leaving home when he is upset. 12/5/22 (R2) ran out of the building Dr. (Doctor) wonder was announced immediately over the intercom and staff went out and immediately brought him back into the facility. R2's Minimum Data Set (MDS), dated [DATE], documents that R2's Brief Interview of Mental Status (BIMS) is 15, which means that R2 is cognitively intact. R2's MDS documents that he is independent for all of his (Activities of Daily Living (ADL's), including ambulation. R2's MDS documents R2's physical behavioral symptoms directed towards others occurred one to three days and verbal behavioral symptoms directed towards others occurred four to six days. R2's MDS documents R2 has overall presence of behavioral symptoms that put the resident at significant risk for physical illness or injury significantly interferes with resident's care and significantly interferes with resident's participation in activities or social interactions. R2's MDS documents R2's behavioral symptoms put others at significant risk of physical injury, significantly intrudes on the privacy or activity of others, and significantly disrupts care or living environment. R2's MDS documents R2's wandering behavior occurred daily, places the resident at significant risk of getting to a potentially dangerous place and significantly intrudes on the privacy or activities of others. R2's MDS documents R2's change in behavior or other symptoms are worse than the prior assessment. R2's MDs documents R2 acknowledged feeling down, depressed, or hopeless, feeling bad about himself, or that he was a failure or have let himself or his family down. R2's MDS documents R2 denied thoughts that he would be better off dead, or of hurting himself in some way. R2's Care Plan Interventions regarding self harming behavior, dated 4/21/22 documents Document all episodes of suicidal ideations; provide experience/interactions that enhance self esteem, sense of personal power; conduct appropriate interdisciplinary assessments upon admission. Review transfer forms, including screening material to determine any history of self harm; and assess seriousness of suicidal ideation, noting behaviors such as gestures, threats giving away possessions. R2's Nurse's Note, dated 4/25/22 at 12:32 PM, written by V21, Licensed Practical Nurse (LPN), documents This nurse notified resident exited building with 1:1 staff following behind him. This nurse went outside to meet resident and staff. This nurse was able to redirect resident back to the facility with difficulty. Resident was suicidal in the process of walking back to facility. Resident also stated he was homicidal and wanted to burn the building down after he leaves. Resident was placed in the administrator office while guardian was called and (Local Ambulance) and waiting for (Local Police Department) to arrive. Resident being homicidal to resident and staff. Order was given to send resident to Local Hospital). Resident guardian made aware. R2's Nurses Note, dated 4/25/22 at 2:21 PM, written by V9, LPN documents Resident was sent to ER (emergency room ) per (V19, Physician) for aggressive behavior toward residents and staff, throwing objects down hall, eloped outside to parking lot, hitting and beating on staffs' cars in the parking lot, unable to redirect, (Local Ambulance) and police called to transfer resident to (Regional Hospital) for evaluation and treat. Report given to ER at (Local Hospital) prior to resident's arrival. POA (Power of Attorney) notified. There is no documentation in R2's medical record that any interventions were implemented after R2 was sent to hospital for suicidal ideations and homicidal allegations on 4/25/22 including addressing R2's need for increased supervision. R2's Care Plan was not revised after the 4/25/22 incident. R2's Nurses Note, dated 4/26/22 at 11:21 AM, documents Resident came back into facility via stretcher. Resident went into (room xxx). Resident told staff he would slap someone. Resident became upset after phone call with family member. Resident threw phone down while in administrator's office. Hall monitor redirected resident to calm down because he would not be able to go into hallway while being aggressive. Resident threw himself against wall. (V19, Physician) was notified, gave order to send resident to (Local Hospital) and Guardian was also notified. Police came to assist. Ambulance came as well. Resident was sent out via stretcher. There was nothing further documented after arrival back to facility regarding if R2 was receiving increased supervision from staff. There is no one-on-one documentation as they started on 5/6/22. R2's Nurse's Note, dated 4/28/22 at 1:22 PM, documents Resident stated to this nurse he was having suicidal ideations and was going to start knocking M***** F****** out and he wanted to be sent out to the hospital. This nurse called DR., received order to send to (Local Hospital), (Local Ambulance) arrived with (Local Police Department) for transfer to hospital. Resident calmly put himself onto stretcher, left facility, A/OX3 (alert and oriented times three), responding upon command, POA made aware. R2's Care Plan was not revised with progressive interventions to address R2's suicidal ideations and if R2 was receiving increased supervision after he was sent to the hospital on 4/28/22. R2's Nurse's Note, dated 5/2/22 at 9:47 PM, documents Resident became verbally and aggressive. resident expressed he wanted a blanket and pillow sooner. Resident set off door alarm and walked away from door, resident knocked off covering to exit sign. This nurse tried to redirect resident. resident back verbally aggressive again. Resident expressed self-harming thought. Resident was given the items he wants resident went back to room. This nurse gave resident a few minutes to get situated in room and calm down then this nurse entered the room to speak with resident. The resident appeared calmer, this nurse asked resident what was wrong. The resident stated he was mad he wanted the items, but he didn't know that the hall monitor had already went to get them items for him. This nurse asked resident if he still had self-harming thoughts. The resident stated no I'm not going to do anything to myself, I was just mad. This nurse proceeded to address behaviors with resident and let resident know that was the proper way to handle things, resident was educated on how to handle situations when he does not feel things are being handled correctly. Resident voiced understanding and stated I just was mad at the time. I'm okay now I'm just going to get some sleep. Thanks man. Resident will continue on frequent checks throughout the night. Psych (Psychiatric) DR. made aware and resident guardian. R2's Nurse's Note, dated 5/9/22 at 9:46 AM, documents A SAD (Seasonal Affective Disorder) assessment was conducted and completed on (R2) to determine if he is suicidal. (R2's) SAD scale score was 4. The score of 4 suggest that (R2) should continue to be closely monitored and any objects that he can use to harm himself should be removed from his room and possession. There was no documentation in R2's medical record that based upon the SAD assessment the facility implemented any progressive interventions to address R2's self harming behaviors and suicidal ideations. R2's Nurse's Note, dated 5/15/22 at 1:22 PM, documents (R2) got upset this afternoon because the kitchen wouldn't give him a banana. He talked to me about the matter, and he was told to give me some time to get to kitchen to find out what happen. (R2) did not allow this staff enough time to investigate what happen. He went back to the kitchen and attempted to make kitchen staff give him a banana. They refused, he became angry and exploded. This social worker had to escort (R2) back to his room whereas he made suicidal threats. He did eventually calm down. Incident recorded in his behavior tracking sheet. There was no documentation in R2's medical record the facility implemented any progressive intervention after R2's incident of expressing suicidal threats or implement any type of increased supervision to monitor for R2's safety on 5/15/22. R2's Care Plan was not revised with any progressive interventions at that time. R2's Nurse's Note, dated 5/21/22 at 7:49 PM, documents (R2) eloped out of the dining room exit door, alarms didn't sound. Hall monitor voiced that he attempted to go out of the smoke door on 100-hall redirected by staff to come back to 300-hall, as (R2) walked back to this side, he exited out of the dining area door. Staff members saw (R2) from 100-hall exit door walking across the parking lot, while walking away from the building (R2) began to cut his right arm with a butter knife, staff followed him and redirected him back into the facility as he's walking back into the facility, he threw the knife. Once in the facility he's placed on 1:1, multiple superficial cuts noted to the right arm, areas cleaned with wound cleanser and triple antibiotic cream applied, no bleeding noted. (R2) sat down and talked with this nurse and voiced that he's just frustrated that he's not able to see his pregnant girlfriend, this nurse asked him if he used any coping skills when he gets upset and emotional like this he voiced no, this nurse gave suggestions on things he can do, he voiced understanding. (R2) voiced that he's still feeling suicidal, and he wants to go to the hospital. (V19, Physician) called gave orders to send to (Local Hospital) to evaluate and treat. Message left for on call guardian. DON (Director of Nursing) made aware. R2's Nurse's Note, dated 5/21/22 at 8:00 PM, documents (Local Ambulance) called, ETA (estimated time of arrival) two to three hours. Facesheet, POLST (Physicians Orders for Life Sustaining Treatment), orders and transfer made for hospital and EMS (Emergency Medical Service). R2's Nurse's Note, dated 5/21/22 at 10:00 PM, documents (Local Ambulance) here. (R2) transported to (Regional Hospital) at this time. (Local Hospital) called, report given. R2's Nurse's Note, dated 5/22/22 at 10:04 AM, documents (R2) returned from (Local Hospital) at this time. NNO (No New Orders). On call Guardian called and made aware. R2's Care Plan, dated 5/6/22, documents (R2) is at high risk for elopement. He has a history of leaving home when he is upset. 12/5/22 (R2) ran out of the building, Dr. Wonder was announced immediately over the intercom and staff went out and immediately brought him back into the building. The facility did not revise R2's care plan with progressive interventions to address R2's self-injurious behavior of cutting. There was no documentation in R2's medical record that the facility provided R2 with increased supervision after R2 displayed self injurious behavior on 5/21/22. There was no documentation of one-on-one done for R2 during 5/21/22 incident. On 1/24/23 at 9:15 AM, V10, LPN, stated (R2) was in the dining room on 5/21/22 and I don't recall him being a one-on-one at that time. (R2) then walked out the dining room door to the outside parking lot. We followed him outside and he had a butter knife that he must have gotten off his table. (R2) actually cut his wrist with the knife and he was sent to the hospital. I do not recall what triggered him that day, but it can be anything. Anytime (R2) does not get what he wants, it's a trigger. For example, if (R2) wants ice cream and the kitchen is out of ice cream, that triggers him, and he has a behavior and can become verbally and physically violent to himself and others. R2's Care Plan Intervention, revised on 5/23/22 documents Dietary to provide resident with metal spoon only with meals. R2's Nurse's Note, dated 6/20/22 at 11:14 PM, documents IDT (Interdisciplinary Team) has met and reviewed (R2s') behaviors and need for one on one. Pattern noted that (R2) has more behaviors on the weekends so he will be provided a one on one for weekends. On 1/23/23 at 1:35 PM, V20, Regional Clinical Nurse, stated If the IDT got together in June 2022, regarding (R2), that was before us. We were not here then so cannot answer for what happened then. I do know that (R2) tends to call 911 and act out more when the Administration is gone and that is typically at night and/or the weekends. The Facility's One-On-One Documentation Sheet, dated 9/5/22 through 9/7/22, documents every ten-minute check were completed on R2, indicating his whereabouts. R2's Nurse's Note, dated 9/6/22 at 10:37 PM, documents Resident sent to (Local Hospital) per (V19) related to aggressive behavior toward staff and destroying facility property, also trying to cut wrist with glass from broken picture frame which resident broke by throwing pictures onto floor. (Local Ambulance) and (Local PD) responded to facility for transfer, POA and DON notified. There was no documentation in R2's medical record that the facility provided R2 with increased supervision after R2 displayed self injurious behavior on 9/6/22. There was no documentation if staff were directly supervising him at the time of the 9/6/22 incident. R2's Nurse's Note, dated 9/13/22 at 9:54 PM, documents Resident returned to facility by two EMS drivers no complaints at this time resident able to ambulate from the stretcher resident. Resident currently resting in bed with no complaints. There is no documentation in R2's medical record that the facility implemented any new interventions to address R2's self-injurious behavior of increased supervision to prevent R2 from self-injuring. R2's Nurse's Note, dated 9/15/22 at 9:37 PM, documents Resident in reception area yelling staff, was told that resident called the police. Resident stated he did not call police. This nurse was headed to speak with resident, then resident proceeded to run out of the door. This nurse, along with other staff, went out to stop resident from leaving property. Resident became aggressive punched facility van window, then punched out facility window. This nurse and staff tried to intervene, resident then picked up glass from the ground and attempted to cut himself. This nurse was able to get resident to drop the glass, then he began banging his head against the building. This nurse redirected resident to sit in chair and talk about what happened. Resident stated he wanted to go and not be at facility anymore, and he wanted to harm himself. (Local EMS) and Police were called, and this nurse gave report to EMTs (Emergency Medical Technicians). Resident sent to (Local Hospital) for evaluation. MD (Medical Doctor) notified guardian was called left voice message. The Facility's One-On-One Documentation Sheet, dated 9/13/22 through 9/15/22, documents every ten-minute check were completed on R2, indicating his whereabouts. R2's Nurse's Note, dated 9/24/22 at 9:24 AM, documents Resident sent out to hospital due to behaviors and throwing chairs, threatening to harm self and staff, and notified resident was sent to (Local Hospital) and admitted . There was no documentation the facility implemented progressive interventions to address R2's behaviors or to increase supervision after R2's incidents of attempting to self-harm on 9/15/22 and 9/24/22. R2's Nurse's Note, dated 10/1/22 at 10:28 AM, documents Resident being sent to (Local Hospital) per (V19) for evaluation and treat related to threatening behavior towards staff and eloping to outside to parking lot. Staff one-on-one with resident awaiting (Local Ambulance) for transfer, POA and DON notified. R2's Nurses Notes dated 10/14/22 at 6:18 PM documents This nurse was notified that resident stated he was hearing voices and he wrapped a sheet around his neck. This nurse attempted to contact (V19) with no answer. Report then called to (V26) NP with new order to send for psych eval. Call placed to guardian and message left. DON and Administrator made aware. (Local Ambulance Service) called and awaiting transportation. 1 to 1 continues. Will continue to follow. R2's Nurse's Note, dated 10/24/22 at 1:11 PM, documents At this time (R2) is yelling through the hallway that he wants to get out of here. This nurse asked (R2) if he wants to talk about what got him so upset, he voiced no, and stormed off into the dining area, he walked up to the dining cabinet and punched the glass out, he then picked up a piece of the glass and proceeded to attempt to cut right arm, staff intervened taking the glass away. Superficial cut noted to arm, (R2) then walks over to dining room exit door and walks out, staff with him. Door alarm didn't sound. (R2) redirected back into the facility by staff. Arm cleaned with wound cleanser and TAO (Triple Antibiotic Ointment) applied and dry dressing, NP (Nurse Practitioner) here and is aware. DON is aware. (R2) placed on 1:1. R2's Nurse's Note, dated 10/24/22 at 1:52 PM, documents Resident could not be seen by (V27, Physician) due to active behaviors, exiting the building, hitting head on wall, verbal aggression. R2's Nurse's Note, dated 10/25/22 at 6:18 PM, documents (R2) continues on 1:1 for exit seeking and suicidal. He's been calm and cooperative this shift. He's been using coping skills to help with increased anxiety and is effective. He took medications without difficulties. No behaviors noted this shift. R2's Nurses Note, dated 10/26/22 at 1:49 PM, documents (R2) continues on 1:1 related to exit seeking, he's been calm throughout this shift. No behaviors this shift. He's able to make needs known. no distress noted. The Facility's One-On-One Documentation Sheet, dated 10/24/22 through 10/28/22, documents every ten-minute check were completed on R2, indicating his whereabouts. R2's Nurse's Note, dated 11/1/22 at 5:51 PM, documents (R2) voiced to this nurse that he's feeling suicidal and he's hearing voices. (R2) said the voices are telling him to kill himself, (R2) denies having a plan at this time. 1:1 initiated at this time. (R2) encouraged to use coping skills such as music therapy, walking and a snack. (R2) agreed at this time. Will continue to follow up. R2's Care Plan was not revised after R2's incidents on 10/24 and 11/1/22 of verbalizing suicidal ideations and self-injurious behaviors. The Facility's One-On-One Documentation Sheet, dated 11/1/22, documents every ten-minute check were completed on R2, indicating his whereabouts for the twenty-four-hour period. R2's One to One Sheet date starting at 12/05/22 at 3:00 PM and ending 12/05/22 at 11:10 PM. No Progress Notes noted for any behaviors on 12/05/22. R2's Nurse's Note, dated 12/6/22 at 00:45 AM, documents At 00:40 AM, Resident came and asked for his HS (bedtime) medications and this nurse told him she could not give them to him and then he started cursing at this nurse. At 00:42 AM, (Local Police Department) called and informed this nurse that resident had called 911 and was talking about committing suicide. (Local Ambulance) arrived to transport resident. There were was no 1:1 sheet noted for 12/06/22. There was no documentation in R2's medical record that the facility implemented progressive interventions to address R2's suicidal ideations and need for increased supervision. R2's Care Plan was not reviewed after the incident on 12/6/22. R2's had a One to One Sheet date starting on 12/20/22 at 6:00 AM and ending 12/24/22 at 12:40 PM. R2's Social Service Note, dated 12/23/22 at 10:10 AM, written by V28, Social Service Assistant, documents This staff interviewed (R2) to determine if he was still in need of a 1:1. During the interview, (R2) stated that he was no longer angry. He stated that he understands that whenever he gets angry, he can't bolt out of the facility. He knows what resources are available to him when he gets angry. He stated that when it comes to things he wants or want to do, he has to learn not accept that he can't have them, and not get angry. It is this staff opinion that (R2) no longer needs a 1:1. The Facility's One-On-One Documentation Sheet, dated 12/20/22 through 12/25/22, documents every ten-minute check were completed on R2, indicating his whereabouts. R2's Nurse's Note, dated 1/13/23 at 10:28 PM, documents Late Entry: Note Text: Resident made staff aware that he was having chest pain and stomach was bothering him. staff let resident know that they would notify the nurse. While staff went to go get this resident's nurse resident proceeded to call 911. Resident called stating he was having chest pain and wanted to go to the hospital. This nurse arrived after resident made phone call to PD. Resident stated he called because he needed to go and did not want to be treated at the facility he wanted to go to the hospital for treatment. Two EMS arrived at 9:20 PM, as well as two (Local Police) Officers. Resident became agitated with EMS questions and became homicidal towards staff members and suicidal towards self. Resident walked to stretcher and exited facility with no bruises noted A&Ox3 when resident sat on stretcher resident began hitting self with phone in the head and then proceeded to throw phone to the groundbreaking the front screen to the phone. The nurse made resident aware of screen being broken due to resident throwing it resident examined phone and stated he didn't care. Phone was locked away in med cart on 400-hall. Resident exited facility headed to (local hospital) for evaluation and treatment. Administrator and NP made aware. R2's One to One Sheet date starting on 01/12/23 at 6:00 AM and ending 01/16/22 at 6:15 AM, documents every ten-minute check were completed on R2, indicating his whereabouts. On 1/12/23 at 2:23 PM, V6, Social Service Director, stated (R2) is supposed to be attending groups, such as Life Skills, Anger Management, and Community Living, but (R2) will come into the meeting, become very vocal and disruptive, and leave within a few minutes of being there. Sometimes what we are doing for (R2) just doesn't work. Right now, the only thing we are doing for him is one-on-one. (R2) knows that if he says something suicidal or homicidal, that we will send him out for an evaluation, so he gets out of the building. When he returns, he is put on a 72-hour one-on-one watch. It seems like as soon as his watch/evaluation period is done, he starts to act up again, especially when he doesn't get his way. On 1/12/23 at 2:50 PM, V2, Director of Nursing stated I know you have concerns with resident safety, and I have to tell you that not only do we have the 1:1 CNA (Certified Nursing Assistant), but we also have hall monitors that help keep an eye on residents and can help if the person doing 1:1 needs assistance. I can tell you that (R2) will be a 1:1 from now until he is discharged from here. The incident when (R2) pushed another resident in the dining room, the staff member who was doing 1:1 with him, was probably walking next to him when he did that. There is not much they could have done. On 01/18/23 at 2:05 PM, V15, Certified Nursing Assistant (CNA) stated, I have been here with (R2) since 6:00 AM this morning. I document where (R2) is or what he is doing every 15 minutes. If (R2) has any behaviors, I really don't do anything but notify the supervisor. On 01/19/23 at 11:50 AM, V4, State Guardian, stated, (R2) has never been on one-on-one that I know of. Every time I visit, I don't see him with a one-on-one. The facility does not let me know when (R2) does things. They usually wait until I get here and fill me in. On 1/23/23 at 1:50 PM, V9, LPN, stated (R2) wanted to get out so he complained of suicidal ideations and he was just sent out. (R2) doesn't really give specifics as to what he may want to do to himself, but I know he will try something because he has done it before. For now, we are just keeping him on 1:1 observation. On 1/27/23 at 10:50 AM, V19, Psychiatrist, stated In my professional opinion, (R2) is in best place for him right now. He has no place to go. He is not appropriate for a group home, and he cannot survive on the street. (R2) has spent many many years in the system. We have tried therapy, several different medications, and different outpatient resources. (R2) has a lot of attention seeking behaviors and will act up at the facility, and then when he gets to the emergency room , is calm and quiet. The Facility's Residents Rights & Residents Safety, dated 7/8/20, documents These guidelines emphasize a proactive intervention promoting enhanced physical, psychosocial well-being and person-centered care while promoting resident/resident representative care participation. The facility recognizes that there may be occasions in which standard approaches of Q (every) 2 hour rounds may need to be increased to more frequent, enhanced observation. Enhanced supervision should take the form of positive interaction, in line with the patient's therapeutic goals. It continues Q15-minute, Q30-minute, hourly checks - the staff will check observe the resident's status/whereabouts every 15 or 30 minutes, or hourly. One to one observation - one staff member will be scheduled to provide one to one observation. The scheduled staff member will not have other resident in his/her care assignment. This is an integral part of a therapeutic plan and ensures the safe and sensitive monitoring of the patients physical and psychological well-being, whilst at the same time developing positive therapeutic interactions. It should consider interactions and engagements with the patient that maintains a balance between intrusion and safety. The Facility's Suicide Policy, undated, documents It is the policy of this facility to act quickly and appropriately if a resident express thought of suicide. It continues Policy Explanations and Compliance Guidelines: 1. All staff members will immediately report any suicidal ideation to the resident's charge nurse and facility social worker. 2. Immediately notify the resident's physician if the resident presents with suicidal ideation, even if he or she isn't specific about a plan or intent. 3. If applicable, notify the resident's responsible party of the resident's suicidal ideation and any orders received from the resident's physician. 4. The resident will not be left alone. One-on-one care will be provided until arrangements can be made for the resident to receive emergency psychiatric care, or until the resident's physician determines that the risk of suicide is no longer present. 5. Objectively and thoroughly document the resident's mood and behaviors, as well as all actions taken, in the medical record. 6. If the resident requires inpatient psychiatric services, State specific guidelines and requirements will be followed. The Facility's Elopement Policy, dated 9/2022, documents Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. This does not include alert and oriented residents who handle themselves outside the facility and choose to leave the facility, even if against medical advice and sometimes, common sense. While presenting different care challenges, these alert residents are not in the same category of potential danger as the residents with impaired cognition trying to leave the facility, and their absences from the facility are not considered to be an elopement. It continues Residents who are at risk to elope are closely supervised to keep them safe in their environment, while allowing them to move freely about the safe environment. The Immediate Jeopardy that began on 4/25/22 was removed on 1/27/23 when the facility took the following actions to remove the immediacy. A. Identification of Residents Affected or Likely to be Affected: 1. R2 will remain on 1:1 until Administrator (V1), Social Services Director (V6), Medical Director (V13) and Psychiatrist (V19) deem appropriate to discontinue or R2 discharges from facility. 2. All residents were reassessed for suicidal and/or self-injurious behaviors for potential causative factors by (V6), (V29, MDS Coordinator), (V21, LPN), and (V28, Social Service Assistant) to be completed on 1/26/2023 and ongoing to include all new residents and as needed for newly developed issues regarding suicidal and/or self injurious behaviors. 3. Care plans were reviewed and revised with progressive interventions to address identified risks by (V30, MDS Coordinator), (V21), (V29), and (V6) to be completed on 1/27/2023 and ongoing to include all new residents and as needed for newly developed issues regarding suicidal and/or self injurious behaviors. B. Actions to Prevent Occurrence/Recurrence: 1. The corporate and leadership team (V31, [NAME] President of Clinical Operations), (V20, Regional Clinical Nurse), (V32, Clinical Nurse Consultant), (V2, Regional Clinical Operations), (V14, Administrator of sister facility), and (V1) reviewed policies and procedures regarding policy for self-injurious and suicidal behavior and enhanced monitoring on 1/26/2023. 2. The interdisciplinary team including (V1), (V14), (V33, Staffing Director), (V16, CNA Supervisor), (V34, RN/Charge Nurse), will provide training to the staff related to the above-mentioned policies to be completed on 1/26/2023. 3. The training will also include providing enhanced supervision and self-injurious and/or suicidal behavior and recognizing when a resident exhibits newly identified self injurious and/or suicidal behaviors to be reassessed as needed on ongoing basis. 4. All agency staff and new hires will be educated on the above policies prior to beginning their shift by (V34), (V16), (V33), and (V1) to be ongoing. 5. An Ad-Hoc QAPI (Quality Assurance and Performance Improvement) meeting will be held weekly for four (4) weeks by the QAPI team to discuss this removal plan and identify if additional interventions are necessary to be ongoing. 6. Monitoring/auditing of ongoing education of staff for enhanced monitoring and self-injurious and/or suicidal behavior policy and procedures identifying staff ability to identify progressive interventions to deescalate residen [TRUNCATED]

Based on interview and record review, the facility failed to provide behavioral health service for mental illness to maintain/improve resident's psychosocial well-being for 1 of 3 residents (R2) reviewed for behavioral health services for mental illness in the sample of 14. This resulted in R2 having ongoing behaviors of self-harm, suicidal ideations, impulsive and explosive verbal and physical aggression resulting in recurrent emergency room evaluation and treatment. Findings include: R2's Face Sheet documents that resident was admitted on [DATE]. R2's Illinois PASRR (Preadmission Screening and Resident Review) Summary of Findings, dated 4/17/22, documents R2 has been diagnosed with an Intellectual Disability. R2 was approved for short term/120 days at this Nursing Facility Level of Care. The PASRR also documents that R2 will require Rehabilitative Services and/or Supports of Pharmacotherapy, including administration and monitoring of the effectiveness and side effects of medications which have been prescribed to change inappropriate behavior or to alter manifestations of psychiatric illness. This further explains that Medication Management can help the resident take medication correctly. The provision of a structured environment for those individuals who are determined to need such structure (e.g., structured socialization activities to diminish tendencies toward isolation and withdrawal). It further explains that a resident should take part in social activities to help with depression and anxiety. The development, maintenance, and consistent implementation across settings of those programs designed to teach individuals daily living skills necessary to become more independent and self-determining including, but not limited to, grooming, personal hygiene, mobility, nutrition, vocational skill, health, drug therapy, mental health education, money management, and maintenance of the living environment. It further explains that Psychiatric education on your disorder and medications, Crisis intervention services or plan, a safety and crisis plan will help your nursing home staff if you have thoughts of hurting yourself, Individual, group, and family psychotherapy, Counseling from a therapist or counselor could help you learn coping skills. It further explains that you enjoy sports, such as, football and kickball, you like playing games, a good day is Good things make my day good. Nice day walking outside stuff like that. R2's Physician Order dated 8/14/18 documents Unspecified recurrent Major Depressive Disorder, unspecified Schizophrenia, and unspecified bipolar disorder. R2's Physician Order dated 04/19/22 documents Major Depressive Disorder, single episode, unspecified. R2's Physician Order dated 09/14/22 and discontinued 12/07/22 documents May be seen by Psychiatrist/Psychologist. R2's Minimum Data Set (MDS) dated [DATE] documents that resident has Brief Interview for Mental Status (BIMS) score 15 out of 15 indicating R2 is cognitively intact. R2's MDS documents R2 had the following behaviors 1 to 3 days: physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, and abusing others sexually). R2's MDS documents R2 had behavior of this type occurred 4 to 6 days: verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). The MDS documents that R2 is at significant risk for physical illness or injury, significantly interfere with the resident's care, and significantly interfere with the resident's participation in activities or social interactions. The MDS documents that R2's symptoms put others at significant risk of physical injury, significantly intrude on the privacy or activity of others, and significantly disrupt care or living environment. The MDS documents that R2 had the following behaviors 4 to 6 days: rejection of evaluation or care. The MDS documents that R2 had the following behavior daily: wandering. The MDS documents that R2's wandering places the resident at significant risk for getting to a dangerous place (e.g., stairs, outside of the facility) and the wandering significantly intrude of the privacy or activities of others. R2's Care Plan dated 11/22/22 documents (R2) can become verbally and physically aggressive when he does not get his way. 05/02/22 verbal and physical aggression towards staff. 05/04/2022 (R2) was verbally aggressive with staff/peer. 05/07/2022 res was Verbally aggressive with staff. 05/24/22 (R2) got into a verbal and physical altercation with another resident. 04/25/22 Physical altercation (R2) threw a picture frame in the hallway and hit another resident. 04/25/22 Verbal aggression in the evening time 06/04/22 (R2) will call 911 06/07/22 (R2) punched a hole in the wall on 400-hall. 06/11/22 verbal and physical aggression 07/08/22 (R2) was verbally aggressive towards staff. 07/09/22 (R2) punched a staff member in the face. 07/25/22 (R2) was throwing chairs at staff members on evening shift and was chasing staff members. (R2) was sent out to hospital for evaluation. 10/25/22 (R2) became upset and punched the glass cabinet. Interventions: 04/25/22 Encouraged to use phone in the privacy of his room. 04/25/22 R2 was informed that it is unacceptable behavior to throw objects. 1:1 counseling as needed and as resident allows. 4/25/22 R2 transferred to Hospital for evaluation. Upon return from hospital, discussed with R2 to contact his guardian about placement at facility. 5/2/22 Encourage R2 to allow staff time to retrieve items he is requesting. 5/24/22 Staff to encourage (R2) when he has problem with peer to notify staff to assist. R2 moved to another hall. 5/4/22 If R2 becomes upset, give him time to calm down then re-approach. Staff to allow R2 to vent feelings. Administer medications as per MD (physician) orders. Notify MD if behaviors are worsening. Call R2's guardian to see if he can assist in calming (R2). Staff to encourage R2 to attend daily group therapy. If R2 becomes aggressive attempt to remove resident from situation and assist him/her to a quiet place. Encourage R2 to vent his/her feelings about situation. Remind R2 that behavior is not acceptable. If R2 refuses care, care giver should leave room and try again later. Separate residents as needed. Staff will ensure that each resident is safe. R2's Care Plan does not address engaging R2 in activities that interest him as identified on PASRR to proactively occupy R2 or use those activities to distract and engage R2. No new interventions added for aggression noted on 05/28/22, 06/22/22, 07/02/22, 07/25/22 x 2, 08/05/22, 09/05/22, 09/06/22, 09/24/22, 12/04/22, 12/11/22, and 01/05/23. R2's Nurse's Note, dated 4/24/22 at 3:37 PM, documents an incident of verbal aggression with R8 and they were separated. R2 began punching walls and throwing objects down the hall. R2 then eloped from facility with staff member right behind and was redirected back to the building by staff member. R2 sent out to hospital per V19, Physician, orders. R2's Nurses Note, dated 4/24/22 at 6:50 PM, documents R2 returned from hospital with no new orders, did not meet criteria to be admitted . R2's Nurses Note, dated 4/25/22 at 12:32 PM, documents R2 exited building with 1:1 staff following behind him. Able to redirect resident back to the facility with difficulty. R2 made suicidal and homicidal statements. R2 sent to ER (emergency room ) per MD order. There was nothing further documented after arrival back to facility. R2's Nurses Note, dated 4/25/22 at 2:21 PM, documents R2 sent to ER per (V19, Physician) for aggressive behavior toward residents and staff, throwing objects down hall, eloped outside to parking lot, hitting and beating on staffs' cars in the parking lot, unable to redirect, ambulance and police called to transfer resident. R2's Nurses Note, dated 4/26/22 at 11:21 AM, documents R2 returned to facility. R2 told staff he would slap someone. R2 became upset after phone call with family member and threw phone down while in administrator's office. Hall monitor redirected resident to calm down because he would not be able to go into hallway while being aggressive. R2 threw himself against wall. R2 sent to ER per V19, Physician, order with assist of police. R2's Nurse's Note, dated 5/2/22 at 9:47 PM, documents R2 became verbally and aggressive. R2 expressed he wanted a blanket and pillow sooner. R2 set off door alarm and walked away from door, R2 knocked off covering to exit sign. Attempts to redirect resident resulted in R2 verbally aggressive again. R2 expressed self-harming thought. Upon R2 receiving the items he wanted, went back to room. R2 more calm. R2 stated he was mad he wanted the items, but he didn't know that the hall monitor had already went to get them items for him. R2 stated he wasn't going to do anything to himself, he was just mad. Behaviors addressed with R2 and discussed the proper way to handle things. R2 will continue on frequent checks throughout the night. The Facility's Final IDPH Incident and/or Abuse Notification, dated 5/4/22, documents On 5/4/22 an altercation occurred involving (R2), a [AGE] year-old male with a diagnosis of Bipolar, and (R6), a [AGE] year-old male with a diagnosis of Schizophrenia. (R2) was sitting at the nursing station talking with nurse while charging his phone. At the same time, (R6) wheeled up and started being verbally aggressive towards the nurse. It was reported that when (R6) became aggressive with the nurses, (R2) told him You shouldn't talk to women that way. (R6) reacted to (R2) comment and became aggressive towards him, resulting in a physical altercation with both residents making contact with each other. R2 was sent out to ER. R2's One to One Sheet, dated 05/06/22 started at 6:00 AM and ended at 5:40 am on 05/07/22. R2's Nurses Notes dated 05/06/22 at 2:03 PM documents R2 returned from hospital via cab. R2's Nurses Notes dated 05/07/22 at 8:07 PM documents (R2) voiced to this nurse that CNA was lying on him, he voiced that the CNA asked him to stop taking pictures of her, (R2) voiced that he wasn't taking pictures. Became verbally aggressive voicing that she is picking on him and he wants to leave, he doesn't feel safe here with female staff, asked this nurse if he could go to the hospital because he doesn't want to be here. This nurse called (V19), Psychiatrist gave orders for 1:1 with male staff. There was no documentation in R2's medical record of a One to One Sheet for 05/07/22. R2's Nurses Note dated 05/21/22 at 7:49 PM documents (R2) eloped out of the dining room exit door, alarm didn't sound. Hall monitor voiced that he attempted to go out of the smoke door on 100-hall redirected by staff to come back to 300-hall, as (R2) walked back to this side he exited out of the dining area door. Staff members saw (R2) from 100 hall exit door walking across the parking lot, while walking away from the building (R2) being to cut his right arm with a butter knife, staff followed him and redirected him back into the facility as he's walking back into the facility he threw the knife. Once in the facility he's placed on 1:1, multiple superficial cuts noted to the right arm, areas cleaned with w/c and triple antibiotic cream applied, no bleeding noted. (R2) sat down and talked with this nurse and voiced that he's just frustrated that he's not able to see his pregnant girlfriend, this nurse asked him if he used any coping skills when he gets upset and emotional like this he voiced no, this nurse gave suggestions on things he can do, he voiced understanding. (R2) voiced that he's still feeling suicidal, and he wants to go to the hospital. R2 was sent to ER to evaluate and treat. There was no documentation in R2's medical record of a One to One Sheet for 05/21/22. R2's Nurse's Note, dated 5/28/22 at 8:36 PM, documents R2 became upset when asked to put mask on, verbally aggressive toward staff, broke a plate, pulled hand sanitizer off the wall throwing things, unable to redirect, sent to ER for evaluation per V13, MD. There was nothing documented in R2's Care Plan related to his aggressive behavior on 5/28/22. R2's Nurses Notes dated 06/06/22 at 10:42 AM documents R2 on 1:1 for behaviors. There was no documentation in R2's medical record of a One to One Sheet for 06/06/22. R2's Nurses Note, dated 6/7/22 at 3:05 PM, documents R2 brought cell phone with V19, Physician, on the line. R2 sent to ER for evaluation and treatment related to suicidal thoughts per V19 order. R2's Nurses Note, dated 6/11/22 at 8:11 PM, documents Resident told this nurse that he called police because he did not want to be here. At 5:20 PM, Resident was lying on the floor telling other residents he could not breathe. When this nurse went to assess him he became verbally abusive and started breaking the sanitizer dispensers on the wall on 400-hall. At 5:23 PM, Resident went out of 400-hall exit door and started exiting through the doors in the building. Resident was walking around the parking lot while staff was trying to get him back into the building. R2 sent to ER per V19, Physician. R2's Nurses Notes dated 06/15/22 at 10:54 AM documents R2 continue on 1 to 1 observation. There was no documentation in R2's medical record of a One to One Sheet for 06/15/22. R2's Nurses Note, dated 6/22/22 at 3:08 PM, documents R2 throwing tables in the dining room, hitting the windows, threatening staff members. Unable to redirect. Sent to ER. R2's Nurse's Note, dated 7/2/22 at 9:22 PM, documents R2 yelling cursing at staff, walking up and down the hallway to the dining room, pulling pictures off the wall, slamming tables down in the dining room unable to redirect, 1:1 in place, called ambulance and police. There was no documentation in R2's medical record of a One to One Sheet for 07/02/22. R2's Nurses Notes dated 07/05/22 at 2:37 PM, documents R2 arrived at facility as readmit from hospital. R2's One to One Sheet documents starting 07/05/22 at 6:00 AM through 07/06/22 at 5:40 AM. R2's Nurse's Note, dated 7/25/22 at 2:21 PM, documents R2 flipping tables and chairs in the dining room, knocking things off the table. R2 mad that he overheard a staff ask if it was okay for R2 to be off the hall due to COVID isolation restriction. Was able to redirect residents and calm R2 down and address his concerns. R2's Nurses Note, dated 7/25/22 at 6:15 PM, documents R2 in dining room throwing chairs and tables, chasing staff, and being combative. R2 stated staff asked him to return to room and he got upset. Sent to ER for psychiatric evaluation per V19. R2's Nurses Notes dated 07/28/22 at 8:03 PM, documents This nurse notified that (R2) was attempting to leave from exit door in the kitchen, this nurse noted that (R2) was running away from the exit door and slipped on a wet spot. He got up in a hurry and picked up a chair and swung it multiple times at staff. (R2) threw the chair down and exited from kitchen door, alarm sounded, staff stayed with (R2) this nurse called 911, (R2) redirected back on to the facilities parking lot. (local police department) arrival, (R2) is calm and voiced that he's upset about his Dad's house flooding, he voiced he wants to go to (Regional hospital). R2 sent to ER per V19 orders. R2's Nurses Notes dated 08/05/22 at 5:26 PM, documents R2 sitting himself on the floor and running out of facility multiple times. R2 hitting walls in hallway and threatening to kick teeth out of other resident. Sent to ER per V13 order. R2's Nurses Notes dated 08/06/22 at 6:01 PM, documents R2 returned to facility. R2's Nurses Notes dated 08/08/22 at 11:04 AM, documents R2 threatening to leave facility having behaviors. Sent to ER. R2's Nurses Notes dated 08/08/22 at 6:32 PM, documents R2 returned from hospital. R2's One to One Sheet documents starting 08/05/22 at 6:00 AM and ending 08/09/22 at 5:40am although R2 out of facility for 2 different trips to the ER. R2's One to One Sheet documents starting 08/29/22 at 6:00 AM and ending 09/02/22 at 5:40 AM. R2's Social Service Note dated 08/29/22 at 11:42 AM, documents (R2) has been reminded constantly to remain behind the door of the quarantine floor of 400. He gets highly upset and curses at staff. R2's Social Service Note dated 08/29/22 at 11:46 AM, documents (R2) was discovered walking around on the 100-hall floor. He was reminded again that he is on quarantine and should not be off of his assigned floor (400). (R2) became upset began to curse and make threats that he would kill himself. R2's Nurses Notes dated 08/31/22 at 12:07 PM, documents R2 flipping table and chairs and knocking things off the table was in the dining room due to being mad that over covid isolation restriction. able to redirect residents and calm him down. R2's Nurse's Note, dated 9/5/22 at 3:30 PM, documents R2 became loud walked away screaming no one here cared about him, he became loud and verbally aggressive walked over the stairway exit opened door and went downstairs. R2 was yelling loudly, cursing and had his fist balled up and pulled back to hit aide in her face. R2 was interrupted and attempted to talk to him when he bolted out the exit door yelling how no one cares about him. Two Staff members with resident. Police notified about resident behavior and walking off. V19 notified awaiting return call. R2's Nurses Note, dated 9/5/22 at 5:35 PM, documents when observed R2 with aid, R2 yelled at aid and pushed aid backwards with his chest. R2's Nurses Notes dated 09/05/22 at 9:49 PM, documents Resident tried to elope and leave facility this nurse called 911 and along with other staff redirected resident back down the street to building resident was transported to (local hospital) and returned at approx. 6pm this nurse spoke with him trying to find ways to cope. The resident took medication for anxiety and was able to go to bed this nurse assisted him to room will continue to monitor. R2's Nurses Note, dated 9/6/22 at 10:37 PM, documents R2 sent to ER per V19 related to aggressive behavior toward staff, destroying facility property, and trying to cut wrist with glass from broken picture frame which R2 broke by throwing pictures onto floor. R2's One to One Sheet documents date starting 09/05/22 at 6:00 AM and ending 09/07/22 at 5:40 AM. R2's Nurses Notes dated 09/13/22 at 9:54 PM, documents resident returned to facility by two ems drivers no complaints at this time resident able to ambulate from the stretcher resident. resident currently resting in bed with no complaints. R2's One to One Sheet documents date starting 09/13/22 at 6:00am and ending 09/15/22 at 5:40 AM. R2's Nurses Notes dated 09/15/22 at 9:37 PM, documents Resident in reception area yelling staff was told that resident called the police resident stated he did not call police this nurse was headed to speak with resident then resident proceeded to run out of the door this nurse along with other staff went out to stop resident from leaving property resident became aggressive punched facility van window then punched out facility window this nurse and staff tried to intervene resident then picked up glass from the ground an attempted to cut himself this nurse was able to get resident to drop the glass then he began banging his head against the building this nurse redirected resident to sit in chair and talk about what happened resident stated he wanted to go and not be at facility anymore and he wanted harm himself. Ambulance and police were called. R2 sent to ER. R2's Nurses Notes dated 09/15/22 at 11:45 PM, documents R2 returned from hospital. R2's Nurse's Note, dated 9/24/22 at 9:24 AM, documents R2 sent out to hospital and admitted due to behaviors and throwing chairs, threatening to harm self and staff. R2's One to One Sheet documents date starting 09/27/22 at 6:00 AM and ending 09/30/22 at 5:40 AM. R2 in the hospital during this period. R2's One to One Sheet documents date starting 10/03/22 at 6:00 AM and ending 10/11/22 at 10:40 PM. R2's Nurses Notes dated 10/11/22 at 10:25 AM, documents R2 left at this time with a guardian for court date. R2's Nurses Notes dated 10/11/22 at 11:32 AM, documents R2 returned from court visit at this time. There was no documentation in R2's medical record of a One to One Sheet for 10/14/22. R2's Nurses Notes dated 10/14/22 at 6:18 PM, documents R2 stated he was hearing voices and he wrapped a sheet around his neck. Contacts made to send to ER. 1 to 1 continues. R2's Nurses Notes dated 10/24/22 at 1:11 PM, documents At this time (R2) is yelling through the hallway that he wants to get out of here. This nurse asked (R2) if he wants to talk about what got him so upset, he voiced no and stormed off into the dining area, he walked up to the dining cabinet and punched the glass out, he then picked up a piece of the glass up and proceeded to attempt to cut right arm, staff intervened taking the glass away. Superficial cut noted to arm, (R2) then walks over to dining room exit door and walks out, staff with him. Door alarm didn't sound. (R2) redirected back into the facility by staff. R2 placed on 1:1. R2's One to One Sheet documents date starting 10/24/22 at 6:00 AM and ending 10/28/22 at 5:40 AM. R2's One to One Sheet documents date starting 11/01/22 at 5:00 PM and ending 11/02/22 at 8:10 AM. R2's Nurses Notes dated 11/01/22 at 5:51 PM, documents (R2) voiced to this nurse that he's feeling suicidal and he's hearing voices. He said the voices are telling him to kill himself, (R2) denies having a plan at this time. 1:1 initiated at this time. (R2) encouraged to use coping skills such as music therapy, walking and a snack. (R2) agreed at this time. Will cont. to follow up. R2's Nurses Notes dated 11/01/22 at 7: 48 PM, documents (Local Police Department) here at this time, voiced they received a call from a resident here, (R2) came to the nurses station voicing that he called and wanted to go to (local hospital) because he isn't feeling any better. (Local Police Department) dispatched EMS. R2's Nurses Notes dated 11/01/22 at 8:00 PM, documents Ambulance here at this time to transport R2 to local hospital. R2's Nurses Notes dated 11/02/22 at 8:31 AM, documents This nurse received report from off going nurse that (R2) was transported to (local hospital) from (local hospital) and orders and face sheet was faxed to (hospital staff). Spoke with nurse from (Psych Unit) at (local hospital) voiced that (R2) was admitted from suicidal ideation. R2's Nurses Note, dated 12/4/22 at 11:30 AM, documents (R2) voiced that he was using his personal phone on the phone with his dad, roommate (R3) self-talking and (R2) assumed that roommate (R3) threaten his dad, (R2) became homicidal toward roommate, voicing that he's going to kill him. (R2) called 911 from his personal phone, voicing that he wants to go to (Regional Hospital). R2 transferred to hospital. R2's One to One Sheet documents date starting at 12/05/22 at 3:00 PM and ending 12/05/22 at 11:10 PM. No Progress Notes noted for any behaviors on 12/05/22. The Facility's Incident Report Form - Final Report, dated 12/5/22, documents Description of Occurrence: Resident told nurse he was having homicidal thoughts against residents and family member. Residents were immediately separated from the room. 1:1 support given. (R2) stated that he became upset with his roommate for talking to himself and threatened to harm (R3) and his father. No physical contact was made. (R2) was sent to ER for evaluation. A nursing assessment shows no injuries. There was no documentation in R2's medical record of a One to One Sheet for 12/06/22. R2's Nurses Notes dated 12/06/22 at 12:45 AM documents (12:40 AM) Resident came and asked for his HS (evening) meds and this nurse told him she could not give them to him and then he started cursing at this nurse. (12:42 AM) (Local Police Department) called and informed this nurse that resident had called 911 and was talking about committing suicide. (Local Ambulance Service) arrived to transport resident. R2's One to One Sheet documents date starting 12/08/22 at 2:40 PM and ending 12/11/22. No Progress Notes noted for behaviors during this period. R2's Nurse's Note, dated 12/11/22 at 6:03 PM, documents R2 was walking through dining room and pushed R1 onto floor and walked away, stated she yelled at him. R2 sent to psychiatric hospital for evaluation and treat per MD. R2's One to One Sheet documents date starting 12/11/22 at 6:00 AM and ending 12/15/22 at 5:40 AM. R2's Nurses Notes 12/11/22 at 6:03 PM, documents Resident was walking through dining room and pushed another resident onto floor and walked away stated she yelled at him this nurse received order to send resident to (local hospital) for eval and treat per (V13). R2's Nurses Notes dated 12/11/22 at 11:00 PM, documents Resident returned to facility via (local ambulance service) accompanied by 2 attendants. Resident reintroduced to assigned room. R2's Social Service Note dated 12/15/22 at 11:53 AM, documents (R2) has successfully completed his 72-hour psych evaluation. No behaviors were previously noted or mentioned. The 1 on 1 does not need to continue. R2's One to One Sheet documents date starting on 12/20/22 at 6:00 AM and ending 12/24/22 at 12:40 PM. R2's Social Service Note dated 12/23/22 at 10:10 AM, documents This staff interviewed (R2) to determine if he was still in need of a 1 on 1. During the interview, (R2) stated that he was no longer angry. He stated that he understands that whenever he gets angry, he can't bolt out of the facility. He knows what resources are available to him when he gets angry. He stated that when it comes to things he wants or want to do, he has to learn not accept that he can't have them, and not get angry. It is this staff opinion that (R2) no longer needs a 1 on 1. On 1/12/23 at 3:20 PM, R1 stated, (R2) pushed me purposely. (R2) was standing in the doorway in the dining room and people were trying to get through so I told him he needed to move. (R2) started to yell at me and when I stood up, he walked over to me and pushed me. I went into a chair and me and the chair fell to the floor with the chair on top of me. My leg was hurting me afterwards and I believe they did do an x-ray. I have seen (R2) hit and push other people too. (R2's) very violent and nobody does anything about it. I don't recall seeing a worker walking around next to him. He was by himself when he pushed me over. (R2's) always yelling and cursing at everyone. I am scared of him, and I think some of the staff is scared of him too. R2's Nurse's Note, dated 1/5/23 at 11:22 PM, documents R2 upset about not getting a second ice cream started punching the walls knocking down hand sanitizer stations an also ripping up facility decor. R2 called police from his personal cell phone and stated he wanted to leave and not come back here and also that he is homicidal. EMS arrived and resident requested to go to hospital. On 1/18/23 at 3:10 PM, R8 stated I remember when (R2) was down here with us. (R2) was very upset about something one day and hitting the walls and tearing things up. He took a picture frame off the wall and threw it down the hall and I happen to be hit by it. I believe my neighbor (R9) had an issue one day with (R2). You might want to talk to him. On 1/18/23 at 3:15 PM, R9 stated When (R2) first came down here, he was being loud in the hall and when I asked him to quiet it down, he became verbally aggressive towards me and threatened to kill me. I told the staff and they sent him out to the hospital. I wasn't afraid of him until he threatened to kill me. Then I was afraid of him because I wasn't sure if he would follow through with it. R2's Care Plan dated 12/05/22 documents (R2) has a history of self-harming as a form of attention seeking. (R2) uses a bell in place of a call light due to self-harming behaviors. 5/22 resident used plastic knife to place superficial cuts on arms. 10/02/22 Walked outside of the building over the weekend multiple times and had self-harming behavior 12/4/22 (R2) was having homicidal thoughts against his roommate. Interventions: Assess seriousness of suicidal ideation, noting behaviors such as gestures, threats, giving away possessions. Conduct appropriate interdisciplinary assessments upon admission. Review transfer forms, including screening material to determine any history of self-harm. Dietary to provide resident with metal spoon only with meals. Document all episodes of suicidal ideations. Provide experience/interactions that enhance self-esteem, sense of personal power. R2's Care Plan dated 08/05/22 documents (R2) is at high risk for elopement. He has a history of leaving home when he is upset. Interventions: 1:1 as needed. Divert resident's attention to another subject or activity. Place resident's picture in elopement books kept at nurse's stations. Redirect resident when she is exit seeking. Interventions dated 04/21/22 and 08/05/22. No interventions added for elopements on 04/24/22, 04/25/22 x 2, 06/11/22, and 09/05/22. On 01/12/23 at 11:45 AM, R2 was lying in bed, propped up by blankets, plate of food on his stomach while he eats. V3, CNA, sitting in chair next to his bed documenting his behaviors. R2's One to One Sheet documents date starting on 01/12/23 at 6:00 AM and ending 01/16/22 at 6:15 AM. R2's Nurses Notes dated 01/13/22 at 10:28 PM documents resident made staff aware that he was having chest pain and stomach was bothering him. staff let resident know that they would notify the nurse. while staff went to go get this resident's nurse resident proceeded to call 911. resident called stating he was having chest pain and wanted to go to the hospital. this nurse arrived after resident made phone call to PD. resident stated he called because he needed to go and did not want to be treated at the facility he wanted to go to the hospital for treatment. 2 EMS arrived at 9:20 as well as 2 (local police department) officers. resident became agitated with EMS questions and became homicidal towards staff members and suicidal towards self. resident walked to stretcher and exited facility with no bruises noted A&Ox3 when resident sat on stretcher resident began hitting self with phone in the head and then proceeded to throw phone to the groundbreaking the front screen to the phone. the nurse made resident aware of screen being broken due to resident throwing it resident examined phone and stated he didn't care. phone was locked away in med cart on 400-hall. resident exited facility headed to (local hospital) for eval and treatment. admin and NP (V26) made aware. R2's Nurses Notes dated 01/13/22 at 11:59 AM documents res returned fromER on stretcher with 2 AMB (ambulance) attendants. in pleasant mood, has no c/o (complaint of). all test at hospital came back neg for Dx (diagnosis): chest pain. On 01/17/23 at 8:50 AM, R2 lying in bed. V8, Hall Monitor, sitting in room. On 01/19/23 at 9:30 AM, R2 lying in bed with hall monitor sitting in his room with him. On 01/24/23 at 10:10 AM, R2 sitting outside on the patio with hall monitor standing next to him. R2's Care Plan/Behavior Tracking Record dated May 2022 documents Resident has a history of homicidal ideations. Resident is at risk for harm to others. Resident had issues on 05/17/22 and 05/18/22 during the day shift. Resident has a history of being verbally aggressive. Resident had issues on 05/02/22, 05/04/22, 05/17/22, 05/20/22, and 05/28/22 during the day shift. Resident had issues on 05/02/22, 05/04/22, 05/09/22, 05/15/22, and 05/23/22 during the evening shift. Resident is at risk for elopement. Resident had issues on 05/02/22, 05/10/22 during the day shift. Resident had issues on 05/17/22 and 05/24/22 during the evening shift. Resident has a history of calling 911. Resident had issues on 05/07/22 during the day shift. Resident had issues 05/01/22, 05/21/22, and 05/29/22 during the evening shift. (R2) has history of suicidal ideations. He is at risk for self-harm. Resident had issues on[TRUNCATED]

Based on observation, interview and record review the Facility failed to supervise/monitor and prevent elopement for 1 of 3 residents (R2) reviewed for elopement in the sample of 42. This failure resulted in R2 eloping the facility, being found by local police on 7/27/22 and being hospitalized for seven days. The failure to provide supervision and monitoring and implement care plan interventions to prevent R2 from eloping resulted in an Immediate Jeopardy to the health and safety of R2. Without having access to supervision, medical and psychiatric monitoring, R2 has a likelihood for mental health complications resulting in psychiatric hospitalization s, decline in overall health and possible harm. This failure has the potential to affect 39 other residents (R1, R2, R3, R7-R42) who have been identified by the facility at risk for eloping. The Immediate Jeopardy began on 7/27/2022 when R2 was found missing from the facility by the local police department approximately two miles from the facility. The Immediate Jeopardy was identified on 8/5/22. V1, Administrator, V2, Director of Nursing, and V21, Corporate were notified of the Immediate Jeopardy on 8/5/22 at 11:11 AM. The surveyors confirmed by observation, record review and interview that the Immediate Jeopardy was removed on 8/8/22 but non-compliance remains at Level 2 because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: On 7/28/2022 at 1:35 PM, R2 was not in the facility. R2's Face sheet documents R2 was admitted to the facility on [DATE]. R2's July 2022 Physician Order Sheets (POS) documents diagnoses of unspecified [CONDITION(S)] due to a substance or known psychosocial condition, paranoid personality disorder, unspecified dementia, and depression. R2's Care Plan document with a date initiated of 6/14/2022 document, (R2) is at high risk for elopement related to dementia, paranoid personality disorder, and [CONDITION(S)]. Will not leave the facility unsupervised throughout the next review. Interventions: Staff to do frequent checks on (R2). R2's Minimum Data Set signed 6/24/2022 document R2 was moderately impaired for cognition. R2 has no physical impairments and can walk independently. R2's Facility assessment dated [DATE] document R2 is a high risk for elopement. The Assessment form also documents, Complete on admission there was no date on the form or date of R2's admission (6/13/2022). The only date was 7/27/2022 of the date the form was completed. On 7/28/2022 at 1:10 PM, V1, Administrator stated, (R2) did elope from the facility but he was checked off at 6:30 AM by the hall monitor and when staff did their rounds an hour later, they could not find him, so we called the police and did an elopement search and hour later the police found him and brought him back. (R2) had only been gone an hour at the most. We are not sure how he got out. R2's Police Report documents, Wednesday, July 27, 2022, at approximately 11:12 AM hours, I, Officer (V8) responded to the area of State Street and West van Buren Street to attempt to locate a white elderly male wearing a black shirt and pajama pants and no shoes. Furthermore, dispatch advised the caller and stated the subject appeared confused. Officer (V9) responded to assist. I located the above-described individual sitting on a sidewalk behind The Edge near the intersection of State St. and W. van Buren St. Upon contacting the subject, he identified himself as (R2), and while speaking with him he was able to provide his birth date, Social Security number, and Illinois Driver's License number. (R2) was talkative, he spoke with me about his military background. His clothing appeared to be wet but not dripping wet, there was what appeared to be mud on the lower portion of his pant legs and had no explanation of where his shoes were. I photographed (R2). (R2) made the following statements written in essence not verbatim: I've been at (Facility) for five months; I don't like how I'm taken care of. I walked away from there last night (7/26/22) right before dark; I'm trying to get back home to [NAME] IL. I'm prescribed multiple medications but the only one they give me is my blood thinner and I have not taken it since I left. I could have a pulmonary embolism if I don't have it. I contacted dispatch providing (R2's) information and requested an ambulance to respond to my location; dispatch advised he was clear with no alerts and (ambulance company) EMS was dispatched. Additionally, I requested dispatch to contact (Facility) to find out if (R2) was a patient and if they were aware he had walked away. Dispatch advised when they attempted phone contact, no one answered. (V14, Officer) and (V15, Officer) were dispatched to Integrity to make contact. (V14, Officer) made contact at (Facility) and advised me that (R2) is a resident there and that they were not aware he had walked away. Additionally, he stated an employee would be responding to our location. Ambulance arrived on scene. A short time later, (V16) (Business Office Manager) and (V17) Social Services Director) arrived on the scene. (V16) signed a refusal with ambulance for transport of R2 and stated they had one of their vans in route to transport (R2) back to (Facility). Shortly thereafter, an (Facility) transport van arrived and (R2) walked into the van. On 7/29/2022 at 4:01 PM, V8, Officer of Local Police Department stated, I was with Officer (V9) when we were contacted because we got a call that there was a confused resident, wandering around. (R2) was able to tell us that he was from (Facility). He was dirty, no shoes, clothes were wet, mud on his feet and ankles. (R2) told us he had left the night before and been wandering around. We took him to the facility and staff were not even aware that he had left. Nobody from the facility alerted us or notified us at any time on 7/26/2022 or 7/27/2022 that any resident was missing from the facility. On 8/2/2022 at 11:41 AM, V9, Officer of Local Police Department stated, I was at State Street and West van Buren in [NAME] Illinois. This is a very busy area and is close to interstate 15 and North Belt streets which are both very busy and unsafe for people walking. When I saw (R2) he was confused, wearing pajamas, and no shoes and was wandering the streets. We had had a big storm the night before and (R2's) clothes appeared wet. He was not wearing any shoes, was bare foot and had dried mud around his ankles. He told me had had walked out of the facility the night before and wanted to go to his home ([NAME], Illinois). We also have a creek in that area, and it floods. (R2) was able to tell me his name, and social security number. Initially he did not want to give the name of the facility because he did not want to go back. He told me he had been at the facility for five months and was not getting the correct medication. He went on to say that he was on blood thinners and had not taken any since the night before and was worried that he could have a pulmonary embolism. He said the facility was not giving him his correct medications. We tried to call the facility but at first, we could not get anybody to answer. Then when they finally responded they were able to confirm that he was a resident there and when we asked to speak to him, they said just in minute, they left then they came back and then they told us they could not find him and that was when we told the facility he was in our custody. The facility was not even aware that he was gone. I did an internet search of past weather conditions and for [NAME] IL indicated an overnight low air temperature of 72 degrees Fahrenheit with 10mph winds and thunderstorms. Additionally, the most direct path by road from the facility to our location was two miles as indicated by an internet search. I was also told they door alarms were not working at that time. The facility had no clue when he left the facility and or how long he had even been gone. We found (R2) on 7/27/2022 at around 11:12 AM. There were no entries in R2's Progress Notes documented on 7/25/2022 or 7/26/2022. R2's Progress Notes dated 7/27/2022 at 9:13 AM, document Staff unable to locate resident, breakfast served in resident room, not there, staff believed resident was out for smoke break as he does like to go out with the smokers for fresh air or visiting with peers as he likes to do this. Immediately staff-initiated search for resident in facility and surroundings. Resident was located walking down a road. (local) Police with resident and staff picked up and transported to (hospital). R2's Incident Report dated 7/27/2022 at 9:13 AM, 'Staff unable to locate resident was not in his room, facility and immediate surrounding searched initiated following elopement, protocol. Resident taken to Hospital. No injuries observed at time of incident. (Filed out by V2, Director of Nursing). R2's July 2022 Medication Administrator Record (MAR) documents R2 received and/or refused medications on 7/28/22 and 7/30/22 although he was in the hospital during this time, in addition, staff were documenting R2's pain level on 7/28, 7/30 and 7/31, although R2 was in the hospital during this time. R2's Emergency Record document he was admitted to the hospital on 7/27/2022 at 1:00 PM. R2's emergency room Report documents R2's Mental Status: Cognitively he has some deficits of his intelligence, fund of knowledge, insight, and judgement. R2's Hospital Records dated 7/27/2022 document, Patient is [AGE] year-old gentlemen admitted through the Emergency Department (ER) for psychotic agitation after eloping out a window of his psychiatric nursing home. History of Present Illness: Emergency Department Documentation, Residential staff members' states patient has been increasingly agitated, trying to escape. States he even jumped out of a window today. Patient stated he is unhappy there and wants to return home. On 7/28/2022 at 3:03 PM, V5, Nurse Manager stated, Staff are constantly checking on residents during medication pass, and we have hall monitors continuously checking. I am not aware of any issues with staffing or not having enough hall monitors. The hall monitors check off a list every hour for every resident. We found out (R2) was not here because I was going to do a room change and he wasn't in his room. I went and saw nurse (V6, Licensed Practical Nurse, LPN) and she had not seen him either, so we all spread out or started looking for him. We were looking for him for about 15-20 minutes on property and then we called the police and the police found him about 15-20 minutes later and brought him back and then we sent him out to the hospital, and he is still there. I never, personally talked with the police. On 7/28/2022 at 3:23 PM, V6, Licensed Practical Nurse (LPN), stated, stated, I was working the day (V5) approached me and told me (R2) was missing. I think it was about 2 days ago. I am not sure I have heard 2 different stories, so I am not sure what really happened. I heard (R2) wandered out the night before and then I heard he only wandered out this morning I don't know which one is right. (R2) can ambulate by himself and he is independent and alert and orientated x 3. He can answer questions and tell you what happened. The nurse manager came to me and asked me if I had seen (R2) because he was going to do a room check and he wanted to know the last time I had seen (R2), which I could not remember. We started a search because I could not remember when I had last seen him. He has two roommates, and they were not able to provide any information. That is all I really remember. I did not contact the police but cannot say if anyone else did. The police were the ones that brought (R2) back into the facility and then he was sent out to the hospital. On 7/31/2022 at 8:00 PM, V11, Hall Monitor stated, I am not aware of anybody eloping the facility in the last 3 months. Nobody told me about anything. I have a clipboard and I must go and check off residents every hour. There is supposed to be three of us, but I am the only one working tonight. I have the whole building to do. Staffing schedules document V11 and V16, Business Office Manager, were both working as hall monitors on 7/26/2022. On 8/4/2022 at 10:03 AM, V13, Certified Nursing Assistant stated, I worked on 7/27/2022 but (R2) was already missing. Everybody was talking about (R2) and they told me he had left on 7/26/2022 at night. We did not do any room search or anything because he was already gone. I worked the 300 halls but (R2) was already gone. I heard staff talking about it when I started my shift at 6:30 AM on 7/27/2022 but again he was already gone, and they said he had left the night before. Nobody was doing any searches because he had gone the night before. Staffing schedules were reviewed for 7/27/2022 for the day shift for the 300 hall and V6 was documented as the nurse working the 300 halls for the day shift, and V12 was documented as the certified nursing assistant working on the 300 halls. On 8/4/2022 at 1:43 PM, V17, Social Service Director stated, The police contacted the facility and they told us they had (R2). I am not sure who took the call. This was on 7/27/2022. I am not sure about the time. We didn't know how long (R2) had been gone and or when he had left. I cannot really say as I don't know. (V16, Business Office Manager) and I got in my car, and we drove out to the (Family entertainment business) where the police said (R2) was at. (V5) the nurse told us to send (R2) to (hospital). We waited for the facility bus and had (R2) sent out to the hospital per (V5). (R2) was in his Pajamas and he had mud on PJ's and was not wearing any shoes and was barefoot. He is still in the hospital and has not returned. On 8/4/2022 at 1:55 PM, V4, LPN, Nurse Manager stated, Once we knew (R2) was not at the facility then I had staff send him directly to the hospital to get an evaluation on him. No, I do not know how long he had been missing and/or when he had left the facility. (V16) and (V17) both went out to where the police had found him and had the van send him to the hospital. On 8/4/2022 at 1:05 PM, V18, Hall Monitor stated, I was working the day (R2) got out of the facility. Nobody knows when he got out and or how long he had been out. When I was doing my hour checks. We have a clip board with names of residents who are at risk, and we are supposed to go around every hour and lay eyes on the residents at risk and check them off on the clip board. When I went into (R2's) room he has two other roommates and when I opened the door, I saw 3 people laying in each bed, so I checked it off. Later, the police came and brought (R2) back. I am not sure what time. But when I went and checked (R6) was laying in (R2's) bed. (R6) had apparently been sleeping in his bed all night so I did not realize it was not (R2) and checked him off as being in the facility. On 8/4/2022 at 3:35 PM, R2 was in his room, clothes clean sitting on his bed. R2 was missing some teeth on his lower jaw. At 3:37 PM, R2 stated, Yes, it is true I tried to run away from here. I jumped out of the window here a week ago because I was trying to go home. I hate it here! I have no life here. People here do not really care about you. I told them I was not happy here, but nothing changed. Day after day everything the same. I guess I don't matter to anybody here. I left at night when everyone was sleeping. It was raining when I left. I fell and hurt my back. I used to work at an automotive shop and had a herniated disk. I think I hurt it again my herniated disk because it hurts now. It still hurts. I used to live by myself, and I want to do that again. I could not sleep that night, so I left through the window in my bedroom. I don't like it here and they brought me right back here. On 8/4/2022 at 5:13 PM, V16, Business Office Manager stated, I received a phone call from the police telling me that they had (R2). I do not recall any of the details. At the time of the call, we did not know he was missing and or when he had gotten out or when he had left. On 8/5/2022 at 9:48 AM, V2, Director of Nursing stated, (V5) was making rounds on 7/27/2022 as he wanted to do a move change. He went to check with (R2) and (R2) was not there and was missing. I do not believe our cameras work in the front so we really cannot say when or we are not exactly sure when (R2) left the facility. On 8/5/2022 at 9:51 AM, V1, Administrator stated, I do not have anything on camera showing when (R2) left the facility. The cameras do not even work on the halls. I have no way of showing or knowing exactly when (R2) left the facility. On 8/5/2022 at 8:41 AM, V19, Hospital Physician stated, (R2) when he was admitted to us, he had neurocognitive disorder, dementia, possibility of the mixed type with Alzheimer and vascular contributions with [CONDITION(S)] and behavioral features. He was having delusions and was confused, and he was not able to fully understand reality. He was more than likely not able to understand safety awareness including traffic, and inclement weather and reduced awareness of his environment. He was admitted to our facility and was here for a week. On 8/5/2022 at 9:02 AM, V20, Medical Director stated, I cannot recall who (R2) is as a patient. If (R2) was admitted in June, then I have not personally seen him as I have been out of the country. I cannot say or testify as I do not know him. We need to know how (R2) got into the facility in the first place. Was he living alone before? We never want to see any resident get out of the facility without staff knowing. On 8/5/2022 at 9:32 AM, V12, Certified Nursing Assistant (CNA), stated, I know I was working on 7/27/2022 and I usually pass out meal trays. (R2) does not eat in the dining room he takes his meals in his rooms. (R2) is also a smoker and so when I passed out his breakfast tray, he was not in his room but that was normal for him because he is a smoker. There is a smoke break around breakfast time and that is usually where you will find him. Nobody came to me and asked me if I had seen him or told me that he was missing. I did not learn about it until a few days later when I returned to work. I did not help with any search or was even aware that anybody was looking for (R2) that day. On 8/5/2022 at 10:23 AM, V24, CNA stated, I heard about (R2) eloping because all of the staff was talking about how he got out of the building. Nobody knows when or what time he got out. On 7/22/2022 at 1:32 PM, the facility provided an elopement risk dated 7/27/2022 and document the following residents at risk, R1, R2, R3, R7-R42. The surveyor requested the Elopement policy on 8/4/22 and was provided Elopement/Missing Resident Procedure Policy with a revision date of December 2020. The policy documents, Staff shall investigate and report all cases of missing residents. Staff shall promptly report a resident who tries to leave the premises or is suspected of being missing to the Charge Nurse of Director of Nursing. Staff shall promptly report any resident who tried to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. If an employee observes a resident leaving the premises, he/she should a. attempt to prevent the departure in a courteous manner, b. get help from other staff members in the immediate vicinity, if necessary, and instruct other staff member to inform the Charge Nurse or Director of Nursing that a resident has left the premises. When a departing individual returns to the facility, the DON or charge nurse shall a, examine the resident for injuries, b, notify the attending physician, c, notify the residents legal representative (sponsor) of the incident, d. document the event. If an employee discovers that a resident is missing from the facility, he/she shall: a. determine if the resident is missing from the facility, he/she shall b. if the resident was not authorized to leave, initiate a search of the building (s) and premises; c. if the resident is not located, notify the Administrator and the DON, the resident's legal representative, the Attending Physician, law enforcement officials and (as necessary) volunteer agencies. Provide search teams with resident identification information and initiate an extensive search of the surrounding area. When the Resident returns to the facility, the DON shall A, examine the resident for injuries, B, Contact the Attending Physician, and report finding and conditions of the resident. C, Notify the legal representative A (sponsor). D, notifies search teams that the resident has been located. E. document relevant information and update plan of care. The facility took the following actions to remove the Immediate Jeopardy: 1.On 07-27-2022, R2 was sent to the hospital for immediate medical and psychiatric evaluation. DON, Administrator and POA/Family notified.07/27/2022 2.Facility immediately initiated education on elopement policy to all staff by administrator 07/27/2022 3.All windows were checked by maintenance daily.07/27/2022 4.Door alarms were checked by maintenance daily.07/27/2022 5.R2 was readmitted into the facility on [DATE] with no injuries. 6. R2 care plan has been updated accordingly.07/27/2022 7.All current residents were re-assessed for Elopement by social services 07/27/2022. This will be an on-going process to include admissions and residents exhibiting exit seeking behaviors. 8.All Care Plans reviewed and updated accordingly by MDS 07/27/2022. This will be an on-going process to include admissions and residents exhibiting exit seeking behaviors. A staff have been re-educated on the Elopement policy and procedure by DON on 07/27/2022. Agency staff will be notified prior to the start of each shift. This will be an ongoing process. Monitoring/Surveillance Daily Review of elopement binder will be reviewed by staff at the start of each shift to ensure that all current at-risk residents and assessments are in binder by social services. Social services will update with any new resident that has been deemed to be at risk. This will be an ongoing process. Hourly Checks by 3 hall monitors per shift of residents that are high risk for elopement. Hall monitors per shift will complete hourly checks visually checking the identity of the resident. Nurses will Review high risk resident at shift change, this will be an ongoing process. If resident is exhibits exit seeking behaviors, they will be placed on 1:1 until the resident is evaluated by social services to determine if the resident is at risk. If a resident is assessed to be at risk 1:1 will remain. This will be an ongoing process. QAPI All audit results will be reviewed by the Quality Assurance Committee to determine if any further staff education or facility policy changes are needed. All above measures will be subject to review, assessment, and modification. The Administrator will review elopement binder, hall monitor documentation and door alarm checks 3x weekly and ongoing as needed. Completion Date: 7-27-2022

Based on interview and record review the Facility failed to supervise, assess, and implement progressive interventions for 1 of 7 residents (R12) reviewed for elopement in the sample of 35. This failure resulted in R12 eloping the facility on 4/22/2021. R12 has not been found after she eloped on 4/22/2021 and is still missing as of 5/27/2021. The failure to develop and implement progressive interventions to address R12's need for increased supervision to prevent elopement resulted in an Immediate Jeopardy to the health and safety of R12. R12 has diagnoses including [CONDITION(S)] disorder, [CONDITION(S)] type, Cocaine Abuse with cocaine induced psychotic disorder, [CONDITION(S)] not intractable without [CONDITION(S)], Type 2 diabetes mellitus with diabetic [CONDITION(S)], muscle weakness, complete traumatic amputation of left lower leg and alcohol abuse. Without having access to R12's psychoactive, diabetic and [CONDITION(S)] medications and not being medically monitored, R12 has a high risk for increased psychiatric episodes with the likelihood of mental health complications, seizures and possible hospitalization . The Immediate Jeopardy began on 4/22/2021 when R12 eloped from the facility. R12 eloped from the facility and has not been found. The IJ was identified on 5/19/2021 at 3 PM. V1 (Administrator) and V48 (Corporate Nurse) were notified of the Immediate Jeopardy on 5/19/2021 at 3:18 PM. The surveyors confirmed by observations, record review and interview that the Immediate Jeopardy was removed on 5/21/2021 but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: R12's Face Sheet documents R12 was admitted to the facility on [DATE]. R12's Face Sheet also documents V34 as the Family of R12. On 5/14/2021 at 8:13 AM, the facility provided The Midnight Census Form that documents R12's room as a Bed hold (paid). R12's electronic records document R12 as being an active resident. R12's Minimum Data Set (MDS) dated [DATE] documents R12 was moderately impaired with cognition with supervision and set up needed for transfers. R12's Physician Order Sheet (POS) for April 2021 documents (R12) has a diagnoses including [CONDITION(S)] disorder, [CONDITION(S)] type, cocaine abuse with cocaine induced psychotic disorder, [CONDITION(S)] not intractable without [CONDITION(S)], Type 2 diabetes mellitus with diabetic [CONDITION(S)], muscle weakness, complete traumatic amputation at knee level of left lower leg, and alcohol abuse. R12's POS for April 2021 also documents R12 is taking 25 milligrams (mg) of [MEDICATION(S)] tablets two times a day for anxiety. R12's POS documents she was taking [MEDICATION(S)] ([MEDICATION(S)]) 30 mg daily for [CONDITION(S)], [MEDICATION(S)] 250 mg three times a day for [CONDITION(S)], [MEDICATION(S)] (Seroquel) 50 mg two times a day and 200 mg once daily at bedtime. R12's POS also documents Blood Glucose Monitoring check and record at 6:00 AM, before breakfast. R12's Elopement Wandering Risk assessment dated [DATE] does not identify R12 as being at risk for elopement and or wandering. On 5/14/2021 at 9:35 AM, V1 (Administrator) was questioned if any residents had attempted to elope from the facility. At that time, V1 stated, I am not sure if we have had anyone elope in the last 3 months; let me check. R12's Care Plan, with a target date of 2/12/2021, documents, (R12) requires healthcare monitoring related to Diabetes Mellitus. The Care Plan documents R12 received blood sugar finger sticks and insulin daily to manage symptoms. R12's Care Plan documents, (R12) is at risk for episodes of hypo/hyperglycemic reactions. R12's Care Plan documents, (R12) healthcare monitoring related to diagnosis of [CONDITION(S)] Disorder. (R12) is at risk for injury due to uncontrolled [CONDITION(S)] activity. She is at risk for aspiration of respiratory secretions or vomiting during [CONDITION(S)] and suffocation. R12's Care Plan documents, (R12) is at risk for decrease of functional mobility in lower extremities related to above the knee left leg amputation, inactivity resulting from loss of limb. R12's Care Plan documents, (R12) has a diagnosis: [CONDITION(S)]. She is at risk for impaired social interaction, disturbed sensory perception, defensive coping and disturbed thought processes. (R12) displays conflictual, difficult behavior with peers and roommates. She likes to antagonize her peers, related to Diagnosis of [CONDITION(S)] and Psychotic Disorder. R12's Care Plan does not document she was always saying she wanted to leave the Facility. R12's medical records had no documentation related to R12's elopement on 4/22/2021 in her electronic or paper chart. On 5/14/2021 at 9:48 AM, R17 stated, (R12) was no longer happy here in the Facility. Her room was in the basement and she was not happy here and she said she was going to leave so she crawled out of the window in the middle of the night. She crawled out of the window out of (R9's) room. They never found her; nobody knows where she went or where she is at now. She was going around checking the windows and (R9') window was open and she crawled out of it. On 5/14/ 1 at 9:59 AM, R19 stated, (R12) used to be on our hall, but she was moved down into the basement. (R12) was not happy here; she was miserable and said she was going to leave, and she did. She went into (R9's) room and crawled out at night a couple of weeks ago. They never found her; she is still missing. I hope she is okay. On 5/14/2021 at 10:54 AM, V34 (Family of R12) stated, The facility called me and told me (R12) had left out of the window in the middle of the night. I have no clue where (R12) is at or if she is even safe. She does not have any money and I do not know if her medical needs are being met and if she is getting her medication. She has no access to money, and I have called the facility several times to get updates. Nobody knows nothing. I don't know if the police are even looking for her, and I am really worried about her and want to know if she is safe. I live in Kentucky and we are really sick about it. On 5/14/2021 at 11:02 AM, R21 stated, I am now in the room where (R12) was living. They took all of her stuff out of the room. I think it is in storage because (R12) left in the middle of the night and never came back. They say she crawled through the window in the middle of the night. On 5/14/2021 at 11:03 AM, R22 stated, I know (R12). She was down here with us. She said she was sick of this place and in the middle of the night she crawled out of the window and that is something because she only had one leg. They never found her, and nobody knows where she is at. On 5/14/2021 at 11:04 AM, V19 (Certified Nursing Assistant/CNA) stated, I was not working that night. It was a Thursday and when I came into work they told me (R12) was no longer here and had went out the window in the middle of the night. On 5/14/2021 at 11:06 AM, V20 (Licensed Practical Nurse/LPN) stated, All I know is that (R12) got out of the facility and is no longer here and is still missing. On 5/14/2021 at 11:07 AM, V22 (Housekeeping) stated, When I came to work, they told me (R12) had escaped through the window in the middle of the night. (R12) was always up and down in her moods and was always saying she was going to leave. On 5/14/2021 at 11:08 AM, V24 (Activity Director) stated, (R12's) belongings are in storage. She eloped. I heard about it when I got to work on Friday morning; that would have been April 22, 2021 around 10 PM. I have a text, so it was 4/22/2021. (R12) crawled out of the window in (R9's) window as we think it was opened. We think she had on her prosthetic leg because we did not find it, but her wheelchair was right by the window. (R12) was always saying she was going to leave the Facility. On 5/14/2021 at 11:11 PM, V23 (Maintenance Director) stated, (R12) crawled out of the window and broke the screen and escaped. I know we documented everything in her nurse's notes. We think she was going room to room and checking windows and found a window that was open, and she could crawl out of and left. On 5/18/2021 at 1:32 PM, V2 (Director of Nursing/DON) stated, I heard (R12) had some issues in the past. Staff were telling me she wanted to leave, every so often. She had had an episode that night and was threatening to leave. Later on that night, I got a call from staff telling me they could not find her and so we called the police and started looking for her. They said she crawled out of the window. On 5/18/2021 at 2:33 PM, V35 (Hall Monitor) stated, (R12) came up to the nurse's station that night and was talking and saying stuff like if she could do things all over again what she would do different. At 10:20 PM, I did my rounds and (R12) was in bed. Some of the windows on the 500 hall do open and I was told the next day that (R12) had left out of the window and the screen was messed up and she was no longer here. (R12) was constantly saying she wanted to leave the Facility, but I did not take her seriously. We have not found her, and she is still missing. On 5/18/2021 at 2:38 PM, V33 (Pharmacist) stated, Looking at (R12's) diagnoses and medications, (R12) has 2 significant medications that could cause her harm by not receiving them. The [MEDICATION(S)] 30 milligrams (mg) daily one time a day which could cause her withdrawals and the [MEDICATION(S)] 250 milligrams three times a day which would increase her likelihood of having seizures. Both of these drugs could be harmful to (R12) if she was not taking them. On 5/18/2021 1t 4:31 PM, R9 stated, (R12) came into my room and I did not see or hear her, but (R12's) wheelchair was by my bed and they told me she had crawled out of my window. The next day my window was broken, and the screen was missing. On 5/19/2021 at 4:45 PM, V5 (Assistant Director of Nursing/ADON) stated, I was new to this position and had only been here for a few days. I came to do a follow up and (R12) was in a frenzy and was all upset and was belligerent and said she wanted to leave the facility. I told her, 'Look it is 9:00 PM at night.' I talked with her for about 30 minutes and I thought she was fine, and I left about 9:40 PM. Then I got a call later about 11:00 PM telling me (R12) was gone and we (V5, V1 and V6 Assistant Administrator) went out looking for her. I did not get home until about 2:00 AM. On 5/18/2021 at 10:40 PM, V30 (LPN) stated, (R12) was upset that night and was screaming and hollering. V5 (ADON) was talking to her. (R12) was saying that she wanted to leave the facility. On 5/18/2021 at 10:43 PM, V38 (Hall Monitor) stated, I was just coming into work the night (R12) escaped from the building. We were changing shifts and the CNA called upstairs and asked us to look for (R12) because she was missing. I started at 10:30 PM, and (R12) was already gone. We went outside and did a perimeter check but could not find her. I had received a report from (V35, Hall Manager) that (R12) had been acting up all night and to keep an eye on her. (R12) has good days and bad days. We found (R12's) wheelchair next to (R9's) window and the window was opened, and the screen had been off, so we think that is how (R12) got out. On 5/18/2021 at 10:44 PM, V39 (Hall Monitor) stated, As I was coming in and starting my shift (R12) was already gone. We were looking for her, but she had already left. On 5/18/2021 at 10:46 PM, V40 (CNA) stated, (R12) always had something to say and was always saying she wanted to leave. She had good days and bad days. On 5/18/2021 at 10:47 PM, V41 (LPN) stated, (R12) has her moments; she was up and down and sometimes she would say she wanted to get out of here. On 5/18/2021 at 11:45 PM, V42 (Police Officer) stated (R12) was still missing and had not been found and the case was still active. On 5/18/2021 at 1:32 PM, V2 (Director of Nursing) stated, I heard (R12) had some issues in the past. Staff were telling me she wanted to leave every so often. She had had an episode that night and was threatening to leave. Later on that night I got a call from staff telling me they could not find her and so we called the police and started looking for her. They said she crawled out of the window. R12's paper and electronic records were reviewed and there was no documentation related to her being upset, stating she wanted to leave the facility and/or any documentation related to her eloping on 4/22/2021. There was no assessment or interventions related to stating she was unhappy with placement. R12's Elopement Investigation, undated, documents the following: R12 was last seen by V35, Hall Monitor, at 10:20 PM on 4/22/21. The Investigation documented at 10:40 PM, the night Shift CNA reported for shift. At that that time, CNA noted that R12 was not in her room and she/he continued to search the remainder of the rooms on 500-hall searching for R12. The Investigation documents that at 10:55 PM, the nurse and physician were notified R12 was missing. The facility staff were notified, and all completed a facility wide search including the facility outside grounds. The Investigation documented during the search it was discovered that R12's wheelchair was found in (Room XXX) next to the window. In this room the window was opened, and the screen was pushed outward, R12's wheelchair was noted to be in the room next to window. R12's prosthesis was not in the room nor in any of the rooms of the facility. R12's Behavior Tracking for April 2021 does not document R12 wanted to go home, leave the Facility or was exit seeking. The Facility's Elopement Policy dated March 2015 documents, Staff shall investigate and report all cases of missing residents. The surveyors verified through observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. The Facility Administrator, Assistant Director of Nursing, Social Services Director, and the Business Office Manager along with all key personnel have continued the search for R12 and will continue to do so daily. Ongoing until found. 2. The Facility Administrator/Designee will continue to reach out to R12's friend whose telephone number was on the resident's phone and will continue to do so daily. 3. The Facility Administrator/Designee will continue to contact the Local Police Department for any further updates and will continue to do so daily. 4. The Facility Administrator/Designee will continue to contact the Local Hospitals for further updates and will continue to do so daily. 5. On 05/19/2021 Facility reviewed, revised, and implemented the following policies by Chief Operating Officer, Regional Director of Operations, VP of Clinical Services, and the Facility Administrator. Elopement/Missing Resident Procedure. Completion date 5/19/2021 6:30 p.m. 6. On 05/19/2021 Administrator and Assistant Administrator implemented the revised Elopement/Missing Resident Procedure which includes implementation of: a) Attempt to redirect resident who communicates a desire to leave facility except current, ongoing planned discharges. b) Notify Administer and/or Director of Nursing. c) Notify Attending Physician or Medical Director. d) Staff to remain with resident with increased monitoring implemented until further orders, direction received with focus on resident centered care. e) Notify resident's Legal Representative (Sponsor). Completion date 05/19/2021. 7. Facility has reviewed, revised, and implemented the following policies by Chief Operating Officer, Regional Director of Operations, VP of Clinical Services, and the Facility Administer: Behavioral Assessment, Intervention and Monitoring. Completion date 5/20/2021 8. On 05/20/2021 Administrator, Assistant Administrator implemented the Behavioral Assessment, Intervention and Monitoring policy. Completion date 5/20/21 9. On 5/20/2021 the Behavioral Screening Tool was developed and implemented as part of the Behavioral Assessment, Intervention and Monitoring Policy. Completion date 05/20/2021. 10. On 05/19/2021 Facility reviewed, revised, and implemented the following policies by Chief Operating Officer, Regional Director of Operations, VP of Clinical Services, and the Facility Administer. Elopement/Missing Resident Procedure. Completion date 5/19/2021 6:30 p.m. 11. On 05/19/2021 Administrator, Assistant Administrator implemented the Revised Elopement/Missing Resident Procedure which includes implementation of: a) Attempt to redirect resident who communicates a desire to leave facility excluding Planned Discharges. b) Notify Administer and/or Director of Nursing. c) Notify Attending Physician or Medical Director. d) Staff to remain with resident with increased monitoring implemented until further orders, direction received with focus on resident centered care. e) Notify resident's Legal Representative (Sponsor). Completion date 05/19/2021. 12. On 05/20/2021 Staff education was initiated by the Facility Administrator and Assistant Administrators on the Behavioral Assessment, Intervention and Monitoring. Completion date 5/20/21. 13. On 5/20/21 Interdisciplinary Facility staff were educated on the Behavioral Assessment, Intervention, and Monitoring. Completion date 5/20/21. 14. Social Service Director and PRSC's have been educated on the Behavioral Screening Tool. The tool is developed for root cause analysis to identify triggers to behaviors in order for staff to be able to identify those triggers with the de-escalation of the behavior to prevent resident communicating the desire to leave the facility or any attempt in elopement. Completion date 5/20/2021. 15. Facility staff who were on vacation, sick leave, etc. will receive education on the revised Elopement/Missing Resident Procedure and the Behavioral Assessment, Intervention, and Monitoring Policy before returning to facility on next scheduled shift. 16. On 05/19/2021 Social Services Director and PRSC's have assessed and identified all residents who are at high risk for elopement including those residents who communicate the desire to leave Facility, except those residents with current, ongoing discharge plans. Completion date 05/19/2021 7:20 p.m. 17. On 05/19/2021 Social Services Director and PRSC's reviewed and updated accordingly the Plan of Care based off the Elopement Assessment. 18. The Social Services and PRSC's reviewed and updated accordingly the Elopement Binders located at each Nursing Station and Reception area. Completion date of 5/19/21. 19. Staff who are in the facility will be notified immediately via verbal communication, of any resident identified as exit seeking or an elopement risk. Facility staff will also receive communication of any resident identified as exit seeking or an elopement risk through one the following means of communication: shift to shift report, PCC communication board, written communication. Completion date 5/21/2021. 20. Administrator/Director of Nurse/Designee will perform random Medical Record Reviews including Elopement Assessments and care plans of residents at risk for elopement, including any residents who have communicated the desire to leave the Facility, except those residents with current, ongoing discharge plans, three times a week for eight weeks, then weekly times eight weeks to ensure compliance. 21.Administrator/Director of Nurse/Designee will perform random Medical Record Reviews including the Behavioral Monitoring Tool and care plans of residents at risk for behaviors including but not limited to elopement, including any residents who have communicated the desire to leave the Facility, except those residents with current, ongoing discharge plans, three times a week for eight weeks, then weekly times eight weeks to ensure compliance. 22. Residents will be assessed upon Admission, Readmission, as needed, Quarterly and upon Significant Change in condition for Elopement risk including any residents who have communicated the desire to leave the Facility, except those residents with current, ongoing discharge plans, to ensure compliance. 23. Residents will be assessed upon Admission, Readmission, as needed, Quarterly and upon Significant Change in condition for behaviors including but not limited to Elopement risk, including any residents who have communicated the desire to leave the Facility, except those residents with current, ongoing discharge plans, to ensure compliance. 24. Results of the reviews will be discussed in the Quarterly QA Meeting times 3 Quarters with educational needs discussed as needed by the facility Administrator/DON and or designee.

Based observation, interview, and record review the facility failed to treat, assess or provide services to address and treat behaviors related to mental disorders for 2 (R6, R8) of 5 residents reviewed for behavioral health services in the sample of 35. This failure resulted in R6 and R8 displaying self-injurious behaviors resulting in hospitalization s. Findings include: 1. R6's Face Sheet documents he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Care Plan, dated 3/30/21, documents, (R6) has a dx (diagnosis): Paranoid [CONDITION(S)], depression with psychotic symptoms, and [CONDITION(S)] disorder [CONDITION(S)] type. He is a risk for impaired social interaction, disturbed sensory perception, defensive coping and disturbed though processes. R6's Interventions, dated 3/30/21, document, As resident allows introduce strategies that can minimize anxiety and behaviors such as meaningful activities replacing negative thoughts with constructive thoughts, deep breathing exercise, seeking support from families and outside agencies and listening to music or other activities that assist resident in staying calm. The Interventions document, Offer supportive group therapy. R6's Care Plan, dated 4/9/21, documents, (R6) has history of [CONDITION(S)]. He is at risk for self-harm. The Interventions, dated 4/9/21, document, Assess seriousness of suicidal ideation, noting behaviors such as gestures, threats, giving away possessions. Conduct appropriate interdisciplinary assessments upon admission. Review transfer forms, including screening material to determine any history of self harm. The Care Plan did not address any interventions to prevent R6 from self harming. R6's Progress Note dated 5/3/21 at 10:48 AM documents R6 was sent out to the hospital for drinking body wash. R6's Care Plan, dated 5/4/21, documented, When res (resident) wants to go out to the hospital, he will conduct abnormal behavior. 05/4/21, res drank soak because he wanted to go out to the hospital. The Interventions documented, Soap was taken out of resident room and res was sent out to hospital for exam. There was no documentation in R6's medical record that facility reassessed R6 upon readmission to the facility to determine appropriate behavioral health services and interventions to address his wanting to be sent out to the hospital using self-injurious behavior to do so. R6's Progress Note dated 5/7/21 documents Resident complained of his chest hurting and he was sent out to the hospital. R6's Progress Note dated 5/8/21 at 3:24 PM documents R6 complained of chest pain and wanted to be sent out to the hospital. R6's Progress Note dated 5/8/21 at 3:58 PM documents R6 drank some soap to kill himself. He was sent out to the hospital. R6's Care Plan, dated 5/20/21, documents, Resident has behaviors such as drinking soap. The Interventions, dated 5/20/21, document, Educate resident on the importance of not drinking soap. Notify the nurse on hall. Remove soap from residents view. On 05/21/21 at 8:15 AM V5 (Assistant Director Nurses/ADON, stated, He complains of chest pain to leave the facility. He knows how to play the system. He knows we have to send him out if he complains of chest pain. He was on his way back to the facility in the ambulance and he complained of chest pain. He was rerouted to another hospital. R6's Behavior Care Plan/Behavior Tracking Record dated 5/21 documents R6 has behaviors of drinking soap. R6's interventions were documented as 1). Notify the nurse on the hall and 2) Remove soap from the resident's view. R6's Behavior tracking dated 5/3/21 documents frequency 1, with the use of their intervention remove soap from the resident's view. The behavior stopped. R6 drank soap on 5/8/21, but his behavior tracking did not document any behaviors. The Care Plan/Behavior Tracking Interventions did not address what behavioral health services or interventions the facility staff should implement to prevent R6 from self-injurious behavior. R6's Self harm Care Plan/Behavior Tracking Record dated May 2021 documents R6 has a history of Suicidal Ideation and is at risk for self-harm. R6's interventions were documented as 1. Assess the seriousness of the suicidal ideation through the next review date and 2. Conduct appropriate interdisciplinary assessment upon admission. R6's Interventions did not address what types of behavioral health services the facility staff should implement to prevent R6 from attempting self-harm/injurious behavior. R6's Elopement Care Plan/Behavior tracking Record dated 5/21 documents R6 is at risk for elopement. The Care Plan documents R6 voices desire to leave facility and has a history of leaving the facility unescorted. On 03/09 the resident attempted to leave the facility. The care plan did not document the year in which he (R6) left the facility. R6's interventions for this problem was documented as allow the resident to vent concerns frustrations when exhibiting exit seeking behaviors. Divert the resident's attention to another subject or activity. Follow the facility protocol should the resident exit the facility. Notify the family and physician as needed. R6's Interventions did not address what types of behavioral health services the facility staff should implement to prevent R6 from attempting to elope. R6's undated SAD (Sex Age Depression) Scale documents R6 scored a 5 which means strongly consider follow-up. On 5/13/21 at 8:50 AM V8 (Social Service Director/SSD) stated, For him (R6) we took the soap out of all the residents' rooms. Even their personal soap. They are given soap when they are going to use it, because (R6) will get it and drink it. During his one to one counseling (R6) stated that he wants to live on the streets. He does not want to be here, and he thinks going to the hospital will help him get to the streets. He likes being homeless, because he can do whatever he wants. He has a guardian, and his guardian will not allow him to be homeless. We have had meetings with him and his guardian. There was no documentation in R6's medical record he received any one-to-one counseling regarding his use of self-injurious behavior to leave the facility and his desire to leave the facility. There is no documentation in R6's medical record he is currently receiving mental health services to address those behaviors. On 5/21/21 at 12:43 PM R6 was lying on his bed in his room watching television. R6 stated, I'm getting out of here. I'm going to another facility. That's my plan. I've got to go and get out of here. The facility policy Behavioral Assessment, Intervention, and Monitoring revised May 2021 documents, 1. Behavioral symptoms will be identified using facility approved behavioral screening tools. 2. Residents who do not display symptoms of or have not been diagnosed with a mental, psychiatric, psychosocial adjustment or post-traumatic stress disorder will not develop a pattern of decreased social interaction or increased withdrawn, angry, or depressive behaviors that cannot be explained or attributed to a specific clinical condition that makes the pattern unavoidable. Residents will have minimal complications associated with the management of altered or impaired behavior. The interdisciplinary team (IDT) will thoroughly evaluate new or changing behavioral symptoms to identify underlying causes and address modifiable factors that may contribute to the residents change in conditions. The Interdisciplinary Team (IDT)will monitor the progress of individuals with impaired cognition and behavior until stable. 2. R8's Face Sheet, undated, documents she was admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's Minimum Data Set, dated dated [DATE], documents she has no cognitive impairment. R8's Care Plan, dated 4/14/2017 with revisions on 9/3/20, documented, (R8) has self harm behaviors and utilizes her personal items to hurt herself. i.e. earrings, CD cases, tack, pen, pencil, etc. Her guardian is in approval of parameters to remove personal items from (R8's) possession in order to assist in assuring her safety. 2/18/19 Guardian expressed desire to continue keeping items out of resident's room. 9/2/20 res used her nails to self harm herself. Personal items were removed from her room per guardian. R8's Intervention, dated 9/25/17, documented, Discuss positive influences/coping skills. R8's Care Plan Intervention, dated 8/26/17, documented, Social Service to meet 2 times weekly to discuss coping skills and handling stressful situations. R8's Nurse's Notes dated 5/11/2021 at 2:40 PM, documents R8 was readmitted to the facility from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R8's Care Plan, Behavior Tracking Record, dated May 2021, documents, Resident has a history of self harm behavior, and will use her personal items to hurt herself. The Interventions documented, One to one to understand why resident wants to self harm and validate resident's feelings. The Intervention documented, Encourage socialization through participating in an activity and/or psychosocial groups. On 5/18/2021 at 9:00 AM, R8 stated, I do not want to be here anymore. I want them to tell my guardian that I want to be sent out to the hospital. They have a television there and I can pick my own food. It's better there at the hospital than here at this place. My room has bugs and mice and it's a dump here. I want to be sent to the hospital because I am bulimic, and I threw up my lunch. Please tell them to ask get approval from my guardian to go out to the hospital. My guardian has to approve for me to go out to the hospital and she will not let me have anything in my room. I only have one set of clothes and one pair of underwear. R8's Nurse's Note dated 5/18/2021 at 5:56 PM stated, Feelings of depression and bulimia no vomit noted, upon assessment will not answer questions. Notified (Psychiatrist) of the above, no orders received to send out; stated 'will follow-up on Friday with resident.' No one on one was documented as being provided to R8 and no interventions were documented regarding R8's feelings of depression and/or bulimia. No SAD scale was documented for being completed for R8 on 5/18/2021. R8's Nurse's Notes labeled draft dated 5/18/2021 at 7:22 PM, documents, 7:05 PM, resident attempted suicide by stealing a knife off another resident tray and cut wrist and left forearm; one on one initiated STAT (instantly). On 5/19/2021 at 10:00 AM, V14 (Licensed Practical Nurse/LPN) stated, (R8) is not here anymore. She went out to the hospital because she took out a plastic knife and tried to cut herself. On 5/13/21 at 8:50 AM V8 (Social Service Director) stated, (R8) cannot have anything in her room. I spoke with her and her guardian and the guardian does not want anything in her room, because she will use almost anything to try and kill herself. She can have crayons during her one to one only, because of safety. V8 stated, According to her guardian she once used (Name brand) chips to cut her wrist. There is no documentation in R8's medical record she is receiving any ongoing behavioral health service to address her bulimia and self-injurious behavior related to her mental illness. Statement of Education Training dated 5/6/2021 document, Interventions for resident behaviors are located on the care plan and on the resident behavior/tracking. These interventions are in place to help decrease behaviors. If a resident stating that they are feeling down or depressed a SAD scale shall be conducted to determine the safety of a resident; it is not just social service responsibility to conduct a SAD scale and all staff can do a sad scale. How to conduct a SAD (if further education please see SSD). After a staff member has conducted a sad scale and resident exhibits alarming behaviors, then social service and/or nursing should be notified immediately. Sad scales are kept at each nurse's station in the social services office.

These failures resulted in two deficient practice statements. A. Based on interview and record review, the facility failed to provide supervision and progressive interventions to prevent falls for 1 of 5 residents (R3) reviewed for falls in the sample of 23. This failure resulted in R3 having multiple falls and sustaining a fracture to the maxillary and nasal bones. B. Based on interview and record review, the facility failed to provide supervision to prevent elopement for 1 of 3 residents (R1) reviewed for elopement in the sample of 23. Findings include: A. The physician's orders [REDACTED]. The Minimum Data Set (MDS), dated [DATE], documented R3 was moderately cognitively impaired and required extensive assist of one for bed mobility, transfers, walking, dressing, toileting and hygiene. The MDS, dated [DATE], documented R3 required limited assist of one for walking, dressing, hygiene and bathing and was independent with transfers, bed mobility and toileting. The care plan, dated 08/19/20, documented R3 was identified as a fall risk. It documented R3 had a fall on 08/01/20 resulting in maxillary and nasal fractures. On 02/03/20, it documented to remove tube socks from R3's room and replace with gripper socks. On 02/04/20, it documented to instruct R3 to look at surroundings before walking and stepping. On 08/12/20, the care plan documented R3 placed in wheelchair for safety, therapy evaluating and treating as per physician orders, monitored for transferring/walking on own. There were no orders or assessments provided by the facility that R3 was evaluated or being treated by therapy services. The Fall Risk Assessment, dated 01/02/20 was 10, indicating high risk. On 04/04/20, it was 7, indicating at risk. On 05/24/20, there were two separate scores of 17 and 9, one indicating high risk and the other at risk. On 07/29/20, the score was 8, indicating at risk. From 12/16/19 to 08/01/20, nurse's notes, incident/accident log and Situation Background Assessment Recommendation (SBAR) reports documented R3 had eight falls. On 07/29/20 and 08/01/20, R3 was sent to the hospital due to falls where he hit his head. On 08/01/20, the fall resulted in maxillary and nasal fractures. There were no new interventions put into place after the falls on 12/26/19, 01/13/20, 04/04/20, 05/24/20 or 06/30/20. There were no immediate interventions put into place after the fall on 07/29/20 to prevent the fall on 08/01/20. There were no incident/accident reports presented by the facility for 12/16/19 or 01/13/20. All of these falls were documented as R3 self-ambulating in his room, in hallway or at the nurse's station. Multiple nurse's notes documented R3 was impulsive and had an unsteady gait. On 08/28/20, a nurse's note documented R3 had [MEDICAL CONDITION] activity and was subsequently sent to the hospital. On 09/02/20, R3 was discharged from the facility. On 09/18/20 at 12:20 PM, V21 (Regional Director of Operations) stated R3 was discharged from the hospital to another facility and had not returned to this facility after the [MEDICAL CONDITION] activity on 08/28/20. On 09/24/20 at 10:10 AM, V13 (Licensed Practical Nurse/LPN) stated R3 was impulsive and had an unsteady gait at times. V13 stated he was alert and oriented and could make his needs known. V13 stated R3 mostly kept to himself and slept a lot during the day. V13 stated staff tried to keep a close eye on him while he was up and moving around to try to prevent him from falling. On 09/24/20 at 10:20 AM, V6 (Certified Nursing Assistant/CNA) stated R3 was independent with care and at times was unsteady on his feet. V6 stated R3 was quiet and stayed in his room most of the day. V6 stated R3 would walk around without shoes and socks on sometimes and staff would remind him to put some on. The policy and procedure titled, Fall Management was reviewed. It documented under, Policy: It is the policy of the facility to have a Fall Prevention Program to assure the safety of all resident in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions which include any assistive devices are utilized as necessary. B. R1's face sheet, dated 9/22/20, documents R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's MDS, dated [DATE], documents R1 has severe cognitive impairment. R1's Elopement/Wandering Risk Assessment, dated 9/4/20, documents R1 is at risk for elopement. R1's Care Plan, dated 7/30/20, documents R1 is at risk for elopement and has a history of leaving the facility unescorted. R1 is alert and oriented to name only. Interventions include providing 1 on 1 and redirection if attempting to exit. It further documents that on 9/14/20, resident eloped from the building, there was an all staff search and (R1) was brought back to the building (revision date of 9/17/20). Intervention for this occurrence was social services to provide 1 on 1 for 3 days and R1 was moved to a different room. R1's Behavior Tracking, dated 9/14/20, documents R1 eloped from the facility and the intervention attempted was 1 on 1 with social services for increased monitoring. R1's Progress note dated 9/14/20 at 5:20 AM, documents V32 (Hall Monitor) went to check lower level and heard the door alarm sounding, V32 went out the door and saw no one. V32 then checked on R1 and noticed she was missing. A search of the building and surrounding area was completed and R1 was not found. V21 (Regional Director of Operations/RDO) was notified. Staff continue to search outdoors by foot and car. Police arrived, took resident information and began searching for R1. R1's Progress note dated 9/14/20 at 5:40 PM, documents R1 was found by an employee and is safe without noted harm or acute distress. The facility's timeline, dated 9/14/20, documents the following: 3:30 AM - Hall monitor completing walking rounds on high risk elopement residents, entered 500 hall and heard exit door alarm sounding. Hall monitor immediately went to area, searched outside area with no one seen. He completed a room search and noted R1 was not in her room. Hall monitor informed nurse and the facility was searched but R1 was not found. 4:08 AM - Charge nurse notified RDO, police and family. 5 AM - R1 located by V11 (Housekeeping Supervisor). On 9/24/20 at 1:40 PM, V11 stated he found R1 on 9/14/20 at 4:45 AM on 28th Street. V11 stated R1 was standing on the side of the road. On 9/29/20 at 8:43 AM, V32 stated on 9/14/20 at 3:50 AM, he heard the 500 hall alarm sounding and he stuck his head out the door but did not go outside. V32 stated he did not see anyone, so he did a head count on the 500 hall where R1 resided and noticed she was not in her room. V32 stated he notified the nurse and the other halls were searched but R1 was not found. V32 stated he last saw R1 in her bed on 9/14/20 at 2:50 AM. V32 stated he checks on all residents at risk for elopement hourly. On 9/18/20 at 1:15 PM, V2 (Director of Nurses) stated R1 was on the 500 hall when she eloped. R1 was moved to the 100 hall after the elopement to be monitored closer. On 9/24/20 at 12 PM, V2 stated the facility is ensuring the floors are adequately staffed and they have hall monitors on each shift to ensure adequate supervision is provided to prevent residents from eloping. The facility policy titled Elopements dated March 2015, documents to initiate a search of the entire building, premises and surrounding area.

Based on interview and record review, the facility failed to provide supervision to prevent elopement for 1 of 3 residents (R3) reviewed for elopement in the sample of 3. Findings include: 1. R3's Admission record, dated 06/02/2020, documents that R3 was admitted to the facility on [DATE]. R3's Physician order [REDACTED]. R3's Elopement/Wandering Risk Assessment, dated 5/20/2020, documents that R3 was at risk for elopement. R3's Care plan/Behavior Tracking Record, dated 06/2020, documents that on 06/17/2020 on the Evening shift R3 attempted to elope twice; the intervention attempted was to divert resident's attention to another subject or activity and the outcome was that R3's behavior increased. R3's Care Plan, dated 05/11/2020, documents, Provide one on one should resident attempt exit seeking behaviors. Redirect resident when she is exit seeking. R3's Minimum Data Set (MDS), dated [DATE], documents that R3 was independent with all Activities of Daily living and did not require the use of an assistive device to ambulate. It also documents R3 has intact cognition. The Local Police Report, dated 06/17/2020 at 9:47 PM, documents that the last time R3 was seen in her room was at 8:30 PM. In R3's Progress note, dated 06/18/2020 at 8:00 AM, V12 (Former Administrator/RN) documents, This writer received a phone call from facility nurse (V14) on 06/18/2020 around midnight stating they did not place eyes on resident (R3) during rounds. This writer instructed facility nurse to conduct a facility head count and also initiate a facility grounds check. If resident was not found, staff member was instructed to call 911 to make a missing person report and to contact resident responsible party. V12 continued to document on 06/18/2020 at 10:00 AM, This writer contacted resident (R3) guardian, (V15), about resident eloping. R3's Progress note, dated 6/19/2020 at 10:00 AM, shows V12 documented, Facility nurse (V13) contacted this writer on 6/18/2020 around 5:15 PM and notified the writer she placed eyes on resident in East St. Louis on 15th St. Resident stated to facility nurse she eloped facility because of her birthday and she had a new residency in the (specified apartment building) in East St. Louis, IL. Resident stated to facility nurse she did not want to come back to facility. This writer and the Director of Nursing contacted (Local Police Department) and spoke to the officer in charge of resident missing report case. Resident guardian called (times) 4 with no reply. On 08/31/2020 at 11:45 AM, V13 (former employee of the facility) stated that she happened to see R3 in East St. Louis, so she stopped and talked to R3 on 6/18/2020, and that R3 told her that she left the facility because it was her birthday and she didn't want to be at the facility for her birthday. V13 continued to state that R3 told her she was going to return to the facility in a day or 2 and that she was staying with someone in East St. Louis. V13 stated she couldn't remember who it was. V13 stated that she called the facility and spoke with V12 (Former Administrator) and reported where R3 was. On 09/01/2020 at 3:40 PM, V1 (Administrator) stated that she would expect the staff to follow the interventions of one to one observation and redirecting a resident who is trying to elope and she would expect the facility to follow the elopement policy. The facility's Elopements policy and procedure, dated 03/2015, documents, 4. e. Initiate an extensive search of the surrounding area.

Based on observation, interview and record review the Facility failed to supervise, reassess, and implement progressive interventions for 1 (R2) of 23 residents reviewed for elopement in the sample of 43. This failure resulted in R2 eloping the facility on 5/26, 6/25 and 7/8/20. R2 has not been found after he eloped on 7/8/20. The failure to develop and implement progressive interventions to address R2's need for increased supervision to prevent elopement resulted in an Immediate Jeopardy to the health and safety of R2. R2 has a [DIAGNOSES REDACTED]. Without medications and medical monitoring, R2 has a high risk for increased psychiatric episodes with the likelihood of mental health complications resulting in psychiatric hospitalization . This failure has the potential to affect 22 other residents (R1, R5, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, and R29) who have a risk of eloping and require medications and medical monitoring. The Immediate Jeopardy began on 5/26/20 when R2 eloped from the facility. R2 returned to the facility on [DATE]. R2 eloped from the facility on 6/25/20 and was found by local police and taken to the hospital. On 7/8/20 R2 eloped from the facility and has not been found. After each elopement attempt, the facility did not reassess or revise R2's care plan with progressive interventions to address his need for increased supervision to prevent elopement. The IJ was identified on 7/29/2020. V1 (Administrator), V27 (Corporate) and V28 (Corporate) were notified of the Immediate Jeopardy on 7/29/2020 at 2:15 PM. The surveyors confirmed by observations, record review and interview that the Immediate Jeopardy was removed on 7/30/2020 but non-compliance remains at Level 2 because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: R2's Face Sheet document R2 was admitted to the facility on [DATE]. R2's Face Sheet also document V26 (R2's mother) is the guardian of R2. R2's Care Plan, initiation date 7/24/2018, documents (R2) has a [DIAGNOSES REDACTED]. R2's Care Plan documents R2 is at risk for changes in his cognition and behaviors related to his use of [MEDICAL CONDITION] medication. R2's Clerk of the Circuit Court Guardianship papers dated 7/7/2020 documented R2 was a disabled adult and V26 was authorized as R2's Court Appointed guardian. R2's Physician order [REDACTED]. R2's Elopement Risk form, dated 3/4/2020, document R2 was at risk for elopement, ambulated independently and was cognitively impaired with poor decision-making skills. The Risk Form documented R2 had a wandering behavior or pattern or routine, history of elopement, history of leaving without informing staff and recent change in the resident's status or routine. R2's Care Plan Problem, initiation date of 3/4/2020, documents, History of exit seeking. The intervention documented Divert resident's attention to another subject or activity. Place resident's picture in elopement book and keep at nurses' station, and redirect resident when he is exit seeking. On 7/24/2020 at 12:20 PM, at the 400-hall nurse's station there was no elopement book present. V20 (Licensed Practical Nurse/LPN) stated she was not sure where the book was at. On 7/24/2020 at 12:23 PM, at the 200-hall nurse's station there was no elopement book present. V7 (LPN) stated the elopement book was usually kept at the nurse's station but she was not sure where it had gone to. R2's Progress Notes dated 5/27/2020 at 11:59 PM, document, This writer asked if anyone from the facility had contacted her (V26) to inform her that her son the resident (R2) had eloped from the facility on yesterday evening (5/26/20) around 8:00 p.m. She replied 'No'. There is no documentation or investigation in R2's medical record prior to the 5/27/20 Progress Note regarding R2's elopement. There is no documentation as to when R2 was found to have eloped and what was done. R2's Progress Note Text dated 5/28/2020 at 4:47 PM documents, This writer received a call from this resident's mother (V26). This writer expressed that she wants to know why she was not notified. R2's Progress Notes dated 5/30/2020 at 2:36 PM, document, Resident walked up to the front door by himself; no visible sign of injury noted; no distress. R2 returned to the facility after 4 days. On 7/28/2020 at 2:40 PM, V17 (Police Officer) stated, We were called in on 5/27/2020 at 8:37 PM, because (R2) was missing. The facility reported to us (R2) had been missing for about 30 minutes; they were unable to find (R2) so they contacted us because they did not know where he was at. He had eloped. R2's Care Plan was not updated to address R2's elopement on 5/26/2020. There were no new progressive interventions to address his elopement or address his need for increased supervision after he returned on 5/30/20. R2's Elopement Risk form, dated 6/3/2020, documented R2 continued to be at risk for elopement. The form documented the same information provided in the 3/4/20 Elopement Risk form. R2's Social Service Notes dated 6/8/2020 document, QUARTERLY NOTE: This resident eloped from the facility and was gone for about three or four days. Resident stated he was at his sister's. R2's emergency room Visit and General History Notes, dated 6/15/20, documented he was sent to the Emergency Department after making homicidal threats to staff and residents. R2's Progress Notes dated 6/16/2020 at 5:58 PM, documented R2 returned to facility via stretcher. R2's Situation Background Assessment Recommendation Communication Form (SBAR) dated 6/25/2020 at 11:42 AM, documents (R2) was transferred to hospital via ambulance; resident was located by local police. Resident was found on (street name). Resident was in distress and was transported via ambulance to the hospital. There was no other documentation in R2's medical record as to when staff found R2 missing, what time R2 was last seen and what facility staff did when they noted he was gone. On 7/28/2020 at 4:14 PM, V18 (Licensed Practical Nurse/LPN) stated, Yes, I remember (R2) eloping and I filled out the SBAR for 6/25/2020. (R2) has a history of eloping and always wanting to leave the facility. I remember working that night and the alarms going off. We did room checks and discovered (R2) was missing. He had eloped. We searched the building and could not find (R2) so we called the police. The police later found him downtown. He was missing for about a half an hour before we called the police. The police found him later that same night a couple hours later. R2's Care plan was not updated after his 6/25/20 elopement with progressive interventions to address his need for increased supervision to prevent him from eloping. R2's Police Report dated 7/8/2020 at 8:46 AM, documents, On the above date at 8:46 AM, I (V17, Police Officer), responded to the facility in reference to a missing adult male (R2). Upon arrival I made contact with (V4 - LPN). (V4) stated she discovered (R2) had not been seen by staff as of 8:00 AM on 7/8/2020. (V4) believes (R2) could have been missing since the night before around 11:00 PM on 7/7/2020. (R2) does suffer from mental illness and is unknown where he goes when he leaves. R'2s Progress Notes dated 7/8/2020 at 11:42 AM, Guardian mother is aware of resident leave of absence (LOA) from facility .police aware of resident LOA from facility. This Progress Note did not document that R2 eloped from the facility and the facility was not aware of leaving the premises. R2's Investigation Report dated 7/8/2020 did not document that the facility attempted to search outside of the facility for R2 when this incident occurred. No time was documented as to what time the facility was unable to find R2. On 7/17/2020 at 12:50 PM, V1 (Administrator) stated, I spoke with (R2's) mom regarding (R2) eloping. V1 stated the facility has not been able to confirm where R2 is or if he is safe or injured. V1 stated, No, we are not sure how he got out of the building or what time he exited. On 7/17/2020 at 12:58 PM, V3 (Social Service Director) stated, (R2) eloped in July. The family has called about it and the mom (V26) is his guardian and she is upset. V3 stated V26 thinks R2 is at a family member's house. V3 stated, V26 keeps calling the facility saying 'We have to find him.' She has called 3 times last week. V3 stated R2 has eloped before but he usually comes back within a day or two. V3 stated the last time R2 eloped he returned to the facility. V3 stated this was during the COVID-19 outbreak, so the facility sent him to the hospital to get tested . V3 stated the facility does not know where R2 is or where he went. V3 stated We think it was in the wee hours of the morning. I clock in and check the halls and when I had already clocked in the nurse told me he had eloped, and they had called the police. On 7/17/2020 at 12:41 PM, V6 (Minimum Data Set Coordinator) stated, (R2) would be okay for a while, then he would start to get anxious and say he has business he would need to take care of. He has a history of drugs. V6 stated, Yes, he has left before, this is not the first time he has just left. Yes, this is the longest he has stayed away. No one is sure where he is at. On 7/17/2020 at 1:34 PM, V7 (LPN) stated, (R2) liked to stay in his room; he did not come out much. V7 stated, He has left before, but he came back. This is the longest he has been away. I think he has left 2 times maybe. I can't say where he goes. I know he came back during COVID outbreak, so we had to get him tested but I am not sure of the exact date. On 7/17/2020 at 1:40 PM, V8 (Training Nurse Assistant) stated, (R2) stays in his room. He will wave back at you if you wave at him. He came up here the other day, he was short-fused and angry. It was not like him at all. One day he would be fine, the next day he would not be okay and short tempered. I have only been working here for about 6-8 weeks, but something was bothering (R2) right before he went missing. On 7/22/2020 at 2:44 PM, V4 (LPN) stated, I worked the night shift on 7/7/2020 and day shift on 7/8/2020. My co-worker gave his medication on 7/7/2020 at around 7:00 PM on 7/7/2020. V4 stated, Around 8:00 AM, the next morning as I walked the hall I realized (R2) wasn't in his room. We searched the building and we couldn't find him. We called the police and reported (R2) gone. The CNAs are supposed to check on all the residents at least every 2 hours. V4 stated, I know no alarms went off on the night shift on 7/7/2020. The doors are all alarmed. V4 stated again, I don't know how he would have got out of the building. I guess the door alarm may not have worked. I don't know. No, I never heard any alarms going off alerting us that he had left the building. On 7/23/2020 at 10:28 AM, V14 (CNA) stated, Yes I know (R2). I work the night shift. I come in at 10:30 PM. I saw (R2) that night (7/7/20) about 10:50 PM or 11:00 PM pacing the halls. I was not assigned to his hall that night. (R2) did seem distressed and had an angry look on his face. I went to the nurse and let her know you better check on (R2) because he is pacing, and he is about to go off. I think the nurse was either (V7, LPN) or (V18, LPN). We are supposed to go to the charge nurse when anything unusual is going on. (R2) is usually quiet but sometimes he will get an angry look, and pace when he is about to go out the door. I didn't hear any door alarms go off that night. If the door alarm goes off everybody runs to see what is going on. I heard about (R2) missing the next day by another CNA. No one from the facility asked me any questions about him. We do bed checks every 2 hours to make sure all the residents are dry. We check and make sure they are accounted for. I would check at 12:00 AM, 2:00 AM, 4:00 AM and 6:00 AM. (R2) did not need to be checked frequently unless he was having some behavioral issues. He was usually quiet and stayed in his room. On 7/23/2020 at 11:00 AM V16 (CNA) stated, Yes, I know (R2), and I worked his hall on the 7/7/2020. I came in and worked at 2:30 PM until 6:30 AM. The last time I saw (R2) was about 5:00 AM or 6:00 AM and (R2) was laying down in his bed. There were not any alarms going off letting us know a resident had left the building. I am not sure when he went missing. On 7/28/2020 at 3:30 PM, V26 stated, (R2) can't make his own decisions, that's why I have guardianship of him. He lived with me, and he would get himself beat up on the street, he wouldn't pay his bills, and he wouldn't take his medication. He became combative and I couldn't take care of him anymore. That is why we put him at the facility. I have court appointed Guardianship. V26 confirmed R2 eloped on 6/25/20. V26 stated, He has eloped at least 4 times this past 3 months. I believe they sent him to the hospital that time because he was so upset, and he had hit someone. On 7/23/2020 at 3:20 PM, V19 (Physician/Medical Director) stated, I go the facility every Saturday and that facility in particular has a population that has a lot of psych patients and they have tendency to run out the door, but I was never informed that (R2) had eloped from the facility and was still missing and could not be found. I was never informed of (R2) leaving the building and missing. (R2) needs supervision and especially with his history of eloping the facility should have something in place. The facility should have a working alarm system in place so no one can get out of the facility without staff knowing about it. They should be checking on (R2) and monitoring him. (R2) has behaviors and I do not believe he can make good judgements about his surroundings and environment. No, I do not believe (R2) can make good decisions. I was never contacted regarding (R2) becoming agitated, was distressed and/or angry. I would expect the facility to notify me of his behaviors and of his elopement. As of 7/24/2020 at 12:00 PM an onsite was made to the facility and R2 was not in the facility. R2 had not returned to the facility and his whereabouts were still unknown. On 7/25/2020 at 4:35 PM, V1 (Administrator) stated there was no policy on how to address elopement behaviors and she had already given this surveyor everything on their elopement policy. Facility's Elopement Policy Statement, dated March 2015 documents, Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation documents, 1. Staff shall promptly report any resident who tries to leave premises or is suspected of being missing to charge nurse or Director of Nursing. The Policy documented If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if resident is authorized to be out on leave or pass. b. If the resident was not authorized to leave, initiate a search of the building(s). c. If the resident is not located, notify the Administrator and Director of Nursing Services, Residents legal Representative (sponsor), the attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. emergency management, rescue squads, etc.). d. Provide search teams with resident's identification information; and e. Initiate an extensive search of the surrounding area. On 7/24/2020 at 1:00 PM, V3 provided the Elopement book to surveyor. Inside the book was a list of residents at risk for elopement and the following residents were documented as being at risk for elopement R1, R2, R5, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, and R29. The Immediate Jeopardy that began on 5/26/20 was removed on 7/30/2020 when the facility took the following actions to remove the immediacy: 1. Facility has reviewed, revised and implemented the following policies by Chief Operating Office, Regional Director of Operations, Regional Clinical Director and the facility Medical Director regarding Safety and Supervision of Residents, Elopements, and Wandering, Safety of Resident. Completion date 7/29/2020 at 6:00 PM 2. Facility implemented one staff member to be assigned to hall monitor duties per shift, seven days a week. The hall monitor's duties consist of visually checking on residents at high risk for elopement hourly, checking to assure all doors are closed and secure hourly, and general hall monitoring. To be assigned daily each shift by the facility Administrator and or Assistant Administrator. Completion date 7/29/2020 5:00 PM 3. Elopement Drills have been initiated and will be conducted the evening and midnights of 7/29/20 and morning of 7/30/20 for day shift by the facility Maintenance Director. Completion date 7/30/20 at 2:00 PM 4. Staff education has been initiated by the facility Administrator and Assistant Administrator. Interdisciplinary facility staff will be educated on the Safety and Supervision of Residents policy by the facility Administrator and Assistant Administrator. Interdisciplinary facility staff will be educated on the Elopement policy by the facility Administrator and Assistant Administrator. Interdisciplinary facility staff will be educated on the Wandering, Safety of Resident Policy by the facility Administrator and Assistant Administrator. Interdisciplinary facility staff will be educated on the Elopement Drill protocol by the facility Maintenance Director. Completion dated 7/30/20 2:00 PM 5. The Interdisciplinary Team has assessed and identified all residents that are at high risk for elopement by the facility MDS Coordinator and Social Service Director. Completion date 7/29/20 at 8:00 PM 6. The Interdisciplinary Team is updating the elopement books at each nursing station and reception area with current and accurate information by facility MDS Coordinator and Social Service Director. Completion dated 7/30/20 at 2:00 PM 7. Facility is currently reviewing all care plans of residents at high risk for elopement to assure individualized and current interventions re in place by facility MDS Coordinator and Social Service Director. Completion date 7/30/20 at 2:00 PM 8. Facility has verified all delayed egress doors are functioning properly by the facility Maintenance Director. Completion date 7/29/20 at 5:00 PM

Based on interview, observation and record review, the facility failed to provide care and services for the provision of [MEDICAL TREATMENT] for 2 of 2 residents (R1, R3) reviewed for [MEDICAL TREATMENT] services in a sample of 9. This failure resulted in R3 missing 2 [MEDICAL TREATMENT] treatments within a week which resulted in hospitalization for End Stage [MEDICAL CONDITIONS] and the need for emergency [MEDICAL TREATMENT] treatment. Findings include: 1. R3's current Care Plan documented R3 was a [AGE] year-old male admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R3's Minimum Data Set ((MDS) dated [DATE] documents that R3 was alert and oriented, independent with bed mobility and transfers and utilized a wheelchair to independently propel himself in and out of the facility. R3's Nurse's note dated [DATE] at 9:38 AM entered by V7 (Licensed Practical Nurse/LPN) documents that R3 was having diarrhea and R3's Primary Care Physician (PCP) was in the building and gave a new order to send R3 to the nearest emergency room for evaluation. R3's Hospital History & Physical (H&P) dated [DATE] documents that R3 presented to the emergency room with complaints of a fall, nausea, vomiting, diarrhea and chest pain. Problem list includes: Acute on [MEDICAL CONDITIONS], Lactic Acidosis,[MEDICAL CONDITION], and Pneumonia. R3's Hospital Discharge Summary dated [DATE] documents that R3 was admitted with a [DIAGNOSES REDACTED]. The Hospital Discharge Summary documented R3 received emergency [MEDICAL TREATMENT] at the hospital. R3's [MEDICAL TREATMENT] (undated) Care Plan documents R3's goal will be to have no complications associated with [MEDICAL TREATMENT] through the next review. Interventions include: Arrange transportation to and from [MEDICAL TREATMENT] center; Assess bruit and thrill every shift; Assess for [MEDICAL CONDITION]; Check lab values as ordered - notify MD/NP/[MEDICAL TREATMENT] of abnormal values; Monitor shunt site for signs and symptoms of infection or free bleeding. R3's Nurse's Note, dated [DATE] at 10:10 PM entered by V2 (Director of Nurses/DON) documents R3 returned from the hospital with a [DIAGNOSES REDACTED]. The Note documented [MEDICAL TREATMENT] was set up for three times weekly on Tuesday, Thursday and Saturday and a new fistula was placed in R3's left arm for [MEDICAL TREATMENT]. R3's Physician order [REDACTED]. At that time there was no documented physician's orders [REDACTED]. R3's (MONTH) 2019 Medication Administration Record [REDACTED]. There is no documentation that R3 attending on those days. R3's TAR documents that the fistula site will be monitored daily during the day shift for thrill/bruit. The TAR did not document staff were monitoring R3's fistula site for thrill/bruit on all shifts. R3's Nurse's Note dated [DATE] at 12:57 PM entered by V4 (LPN) documents rescheduled [MEDICAL TREATMENT] appointment for tomorrow ([DATE]) at 0600. Will be transported by company van. Transportation director at facility aware of appointment. R3's Nurse's note dated [DATE] at 12:57 PM entered by V6 (LPN) documents that the facility received a [MEDICAL TREATMENT] holiday schedule for the holiday (Thanksgiving Holiday). The Nurse's Note did not document what changes were made and what days R3 would be receiving [MEDICAL TREATMENT]. R3's Nurse's Notes dated [DATE] and [DATE] (Saturday) documented R3 received [MEDICAL TREATMENT] on these days. R3's Nurse's Note dated [DATE] (Tuesday) at 10:54 AM entered by V4 document that a call was received from the [MEDICAL TREATMENT] center and R3 had missed his [MEDICAL TREATMENT] appointment on Monday [DATE]. Nurse asked if there were any available chairs for [DATE], there were none available. R3's next appointment was on Wednesday [DATE]. The Nurse's Note documented R3's [MEDICAL TREATMENT] schedule had changed from Tuesday, Thursday, Saturday to Monday, Wednesday, Friday due to the holiday. The Note documented the transportation coordinator was made aware of situation/change in schedule and that a ride needed to be scheduled or provided so R3 could attend the [MEDICAL TREATMENT] appointment on [DATE] at 5:30 AM. The Note documented Call made to PCP with no new orders. V1 (Administrator) provided a copy of a (MONTH) 2019 calendar on [DATE] at 11:14 AM for R3. This calendar documents that R3 missed [MEDICAL TREATMENT] appointments on [DATE] and [DATE]. V1 stated the information on the calendar was compiled after reviewing transportation records, nurse's notes and staff interviews. Review of the [MEDICAL TREATMENT] center's post treatment notes on R3 dated [DATE] & [DATE] confirms that R3 missed the [MEDICAL TREATMENT] appointments on those days. R3's Nurse's note dated [DATE] entered by V5 (Licensed Practical Nurse (LPN)/Unit Manager) documents that a family member came to the nurse's station with concern about R3. The Nurse' Note documented R3's blood pressure was ,[DATE]; Pulse 72; and Temperature 97.2 degrees Fahrenheit. The Nurse's Note documented R3 was transported to the emergency room . R3's Hospital History & Physical (H&P) dated [DATE] documents that R3 was admitted to the hospital with [REDACTED]. The H&P documented R3 had missed several [MEDICAL TREATMENT] sessions and his prognosis was poor. The H&P documented R3 received emergency [MEDICAL TREATMENT] and during [MEDICAL TREATMENT] R3 became unresponsive and CPR was performed. R3 was subsequently placed on a ventilator. The H&P documented on [DATE] at 6:21 PM, R3 continued to deteriorate. R3 expired on [DATE] and death certificate documents the cause of death [MEDICAL CONDITIONS], and Wound Infection. On [DATE] at 12:12 PM, V15 (R3's sister) stated that she visits R3 ,[DATE] times per week. V15 stated on [DATE], she went to the facility to take R3 shopping and to bring him food. V15 stated that after telling the nurse that R3's wound was bleeding and the nurse reapplying a dressing, she took R3 shopping. V15 stated that R3 had complained that he was sick to his stomach, so he bought some 7-up. V 15 stated that when she brought R3 back to the facility, V9 (Transportation Coordinator/Certified Nurse's Assistant/CNA) stated that R3 had missed his [MEDICAL TREATMENT] appointments on Monday and Wednesday because transportation wouldn't pick him up due to insurance and the facility van was broken and in the shop. V15 stated on [DATE], she went to the facility and upon arriving, R3 was still in bed which V15 stated was unusual and his food was still on his table that was brought to him on [DATE]. R3 stated he wasn't feeling well, had missed 2 appointments at [MEDICAL TREATMENT] and needed to go to the hospital to get [MEDICAL TREATMENT]. V15 stated that R3 was confused, slow to respond, stated he hadn't eaten, left leg was bleeding and his voice was raspy. V15 stated she went to the nurse's station and spoke with V5 regarding R3 not feeling well and he needed to be sent to the hospital. V15 then left the facility. V15 stated on [DATE] she received a call from her mother and was told that R3 was in the hospital. V15 visited R3 in the hospital that afternoon and she was hopeful that he would recover in a few days. On [DATE], V15 received a phone call from her mother stating R3 had deteriorated and she needed to get to the hospital. V15 stated that R3 was unresponsive and expired [DATE] at 6:31 PM. V15 stated that R3 had never refused his [MEDICAL TREATMENT] treatments. On [DATE] at 10:58 AM, V13 (R3's Nephrologist) stated he would expect the facility to monitor a [MEDICAL TREATMENT] patient's blood pressure, signs of fluid overload (i.e.: [MEDICAL CONDITION], shortness of breath), weigh daily, monitor for any change that would warrant an office visit. V13 stated he would expect to be notified of a missed [MEDICAL TREATMENT] appointment or change in condition. V13 stated he was not notified of R3 missing any [MEDICAL TREATMENT] appointments or change of condition. On [DATE] at 8:30 AM, V5 stated that he was the nurse on duty [DATE] when R3 was sent to the emergency room . V5 stated that R3's daughter was here and wanted him sent out. V5 stated that R3's leg was bleeding, and he wasn't messing around with a [MEDICAL TREATMENT] patient so he sent him to the hospital. V5 stated he did not assess R3 prior to and it would have been a good idea, but the sister was demanding that he be sent out, and he did not notify R3's PCP or Nephrologist. V5 was unaware of how many [MEDICAL TREATMENT] appointments R3 had missed. V5 stated, I almost sent him out the day before ([DATE]) because of his leg, I had to put a new dressing on it even though I don't do wounds. On [DATE] at 10:00 AM, V9 stated that she is responsible for setting up the initial transportation for [MEDICAL TREATMENT] patients. V9 stated she was aware of the holiday schedule for [MEDICAL TREATMENT] and had set up transportation for [DATE] & [DATE]. V9 stated she was notified by [MEDICAL TREATMENT] on [DATE] that R3 had missed his appointment on [DATE] and V9 contacted R3's insurance company regarding the transportation. V9 stated that if she been notified that transportation didn't come, she would have taken R3 in the facility van. V9 stated the facility van's lift was broken; however, R3 could have gotten into the van without the lift and the facility could have borrowed a sister facility's van if necessary. On [DATE] at 1:15 PM, V6 (LPN) stated that R3 had not missed any [MEDICAL TREATMENT] appointments prior to [DATE]. V6 stated that the hospital or [MEDICAL TREATMENT] center will set up the initial transportation and once it is set up the facility transportation person lets the insurance company know of any changes. V6 stated the transportation company will not make any changes until the insurance company approves it. V6 stated the facility is not notified if the change has been approved, the transportation company just doesn't show up or shows up at the regularly scheduled time. V6 stated that R3 missed his [MEDICAL TREATMENT] appointment on [DATE] and the facility attempted to reschedule him for [DATE] but the [MEDICAL TREATMENT] facility did not have a chair time available. On [DATE] at 9:10 AM, V4 (LPN) stated she would monitor R3's shunt/fistula for thrill and bruit at the beginning of the shift and when R3 would return from [MEDICAL TREATMENT]. V4 stated the facility would send a communication form with R3 to [MEDICAL TREATMENT] but he wouldn't return with it. V4 stated there was no communication between the facility and [MEDICAL TREATMENT] regarding R3's condition before or after the [MEDICAL TREATMENT] treatments. On [DATE] at 9:45 AM, V1 stated she was not notified that R3 had missed [MEDICAL TREATMENT] appointments or of any transportation issues until Wednesday ([DATE]). V1 stated V1 was notified that R3 missed Wednesday and it was rescheduled for Saturday and no one knew about him missing Monday ([DATE]). On [DATE] at 2:15 PM, V11 (Registered Nurse/RN/Regional Nurse) stated the facility does not have a policy and procedure for [MEDICAL TREATMENT]. V11 stated they would follow the standard of practice. The facility contract with the [MEDICAL TREATMENT] center, last signed on [DATE] stated that The facility shall have the responsibility for arranging suitable transportation of the Designated Resident to and from Center, including the selection of the mode of transportation, qualified personnel to accompany the Designated Resident and transportation equipment usually associated with this type of transfer. The facility shall ensure that all appropriate information accompany all Designated Residents at the time of transfer including any information that will facilitate the adequate coordination of care. The facility policy titled Change in a Resident's Condition or Status dated (YEAR) stated the facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. The policy continues to state that the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been a significant change in the resident's physical/emotional/mental condition; A need to alter the resident's medical treatment significantly, and a need to transfer the resident to a hospital/treatment center. The policy defines a significant charge as a condition that is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, impacts more that one area of the resident's health status, requires interdisciplinary review and/or revision to the care plan and is ultimately based on the judgement of the clinical staff. 2. The MDS dated [DATE] identifies R1 to be a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 was identified on [DATE] as receiving [MEDICAL TREATMENT] treatments off campus by V1 (Administrator). R1's (MONTH) 2019 physician's orders [REDACTED]. The Care Plan (undated) documents R1 has end stage [MEDICAL CONDITION] and receives [MEDICAL TREATMENT] 3 times per week but fails to document when those times are. The Care plan documents his [MEDICAL TREATMENT] access/shunt is located on his right upper extremity and identifies which [MEDICAL TREATMENT] center he attends. The care plan also documents R1 has a history of refusing to go to [MEDICAL TREATMENT] at times. He will state that he doesn't feel like it. The goal is for R1 to have no complications associated with [MEDICAL TREATMENT] thru next review with interventions being: arrange transportation to and from [MEDICAL TREATMENT] center, assess for [MEDICAL CONDITION], dressings to be changed at [MEDICAL TREATMENT], encourage resident to rest upon return, in case of bleeding hold pressure until EMS (emergency medical services) arrive, make sure resident is ready to go to [MEDICAL TREATMENT], monitor shunt site for signs and symptoms of infection or free bleeding, staff are to encourage to attend all [MEDICAL TREATMENT] appointments, nurses to educate resident on the risk of missing [MEDICAL TREATMENT] treatments, utilize communication form and phone conversation to optimize coordination of care and limit complications related to treatments in part. On [DATE] at 1:10 PM, R1 was out of the building at [MEDICAL TREATMENT] per V5. V5 stated they always send information with the resident but they do not always come back with information or they do not give it to the nurses. The Medication Administration Records (MAR) and the Treatment Administration Records (TARs) for October, (MONTH) and (MONTH) 2019 were reviewed and found to have no information regarding when R1 is scheduled to go to [MEDICAL TREATMENT] and when he went. The progress note dated [DATE] entered by V7 (LPN) at 11:32 AM documents R1 returned from [MEDICAL TREATMENT] and starting on [DATE] [MEDICAL TREATMENT] will move to Tuesday, Thursday and Saturday at 11:20 AM. Progress notes dated [DATE] entered by V8 (Psychiatric Rehab Service Director) at 1:17 PM documents [DATE] 13:17 (1:17PM) a Social Service Note text Due to transportation issues, resident was unable to go to [MEDICAL TREATMENT] on this date. The note continues This writer phoned ([MEDICAL TREATMENT] Center) to inquire of transportation and or to gain knowledge if [MEDICAL TREATMENT] social worker (SW) arranged, however SW was off on this date. This writer spoke w (with)/Nurse who shared information on chair-time. Residents' chair-time is from 11:,[DATE]:20p on T-TH-Sa (Tuesday-Thursday-Saturday) Nurse shared would leave a message for SW to return call on Monday, [DATE]. This writer attempted to contact (Transportation Service) (per resident this is his transportation) to no avail. Will continue to follow up on res and offer supportive services. There is no follow-up to this conversation documented in the progress notes or Social Service Notes. Progress notes dated [DATE] at 1:52 PM, written by V6 (LPN) documented waiting [MEDICAL TREATMENT] holiday schedule up ad lib no s/s (signs/symptoms) distress, denies discomfort, shunt positive bruit/thrill, no abnormal bleeding. Progress Notes dated [DATE] documents at 10:22 AM, R1 was picked up by (transportation service) to transport to [MEDICAL TREATMENT]. There are no further notes in the progress notes regarding the holiday schedule or problems with [MEDICAL TREATMENT] following this entry. On [DATE] at 11:00 AM, V4 (LPN) stated R1 was out of the building at [MEDICAL TREATMENT]. At 5:10 PM, R1 was walking up to the building after being let out by transportation following [MEDICAL TREATMENT]. On [DATE] at 8:30 AM, V1 was unable to provide any documentation as to when R1 went to [MEDICAL TREATMENT] and when he did not. V1 stated they were checking their transportation book and with [MEDICAL TREATMENT] to determine how many sessions he attended and had [MEDICAL TREATMENT]. V1 also stated the facility does not currently have a policy/procedure on [MEDICAL TREATMENT]. On [DATE] at 12:11PM, V14 ([MEDICAL TREATMENT] Clinical Manager) stated R1 usually comes empty handed when asked about if he brought any information with him from the facility. V14 stated R1 usually makes his appointments but confirmed that he did not make the appointment on [DATE] and that the facility was going to call back to tell them why but never did. V14 also stated R1 missed his appointments during the holiday week between ,[DATE] and ,[DATE]. V14 stated the [MEDICAL TREATMENT] center provides the holiday schedule well in advance to the facility and the transportation company so arrangements can be made. V14 stated after R1 missed [DATE] and [DATE], they notified the facility again but didn't get any explanation back. V14 stated they notified V16 (R1's nephrologist) of the missed appointments. On [DATE] at 11:10 AM, V1 provided a calendar of [MEDICAL TREATMENT] treatments that R1 received which she stated she compiled from nurses' notes, transportation notes and 24-hour report sheets. The [MEDICAL TREATMENT] treatment calendar shows R1 missed his [MEDICAL TREATMENT] session on [DATE] with a notation transportation wouldn't wait for him to come and on [DATE] it documents transportation did not come and p/u (pickup.) The Calendar documents R1 also did not attend his [MEDICAL TREATMENT] on [DATE]. There is no documentation in the clinical record or that V1 could provide that shows the facility notified, V16 and/or the [MEDICAL TREATMENT] team of any of R1's missed [MEDICAL TREATMENT] treatments. On [DATE] at 2:15 PM, V11 (Nurse Consultant) confirmed the facility has no policy/procedure, but they would expect nurses to follow standards of practice and send a sack lunch with them if they are there over a mealtime. The Contract dated ,[DATE] entitled Nursing Home Outpatient [MEDICAL TREATMENT] Agreement which was written under another ownership documents it was written [DATE]. The agreement documents the facility agrees to provide [MEDICAL TREATMENT] treatments to those patients as ordered by each patient's nephrologist. The contract continues under services to document Nursing Home shall schedule [MEDICAL TREATMENT] treatments for designated residents as mutually agreed by the parties. Nurse Home shall have sole responsibility for transporting or arranging transportation of the designated residents to and from the above referenced clinic. The policy documents The RAI (Resident Assessment Instrument) with cooperation from the nursing home, will for its use, develop, implement, and maintain appropriate care plans for each designated resident.

Based on observation, record review and interview, the facility failed to assess, provide and medicate for pain for 4 of 4 residents (R96, R39, R45, R86) reviewed for pain management in the sample of 50. This failure resulted in R96's pain level rising to a 10 on a 1/10 scale causing him difficulty to actively participate in his rehabilitation after a severe motor vehicle accident in (MONTH) 2019. Findings include: 1. R96's Minimum Data Set ((MDS) dated [DATE] documents a BIMS (brief interview for mental status) score of 14, which is cognitively intact with decision making. The MDS documents R96 is nonambulatory and requires extensive assistance with bed mobility and all ADL's (activities of daily living) except eating. The MDS documents R96 has limited range of motion to both lower extremities. R96's Care Plan, dated as revised 1/24/2019, documents diagnoses, in part, as Displaced [MEDICATION NAME]-Posterior Fracture of Right Acetabulam, Fracture of parts of Lumosacral Spine and Pelvis, Fracture of Nasal Bones, Collapsed Vertebra-Thoracolumbar Region, Collapsed Vertebra Lumbar Region, Pneumothorax, Laceration of the Scalp and Spleen, Displaced Comminuted Fracture of Shaft of Left and Right Femur, Collapsed Vertebra of Sacral and Sacrococcygeal Region. On 2/24/19 at 10:24 AM R96 stated, My pain medication isn't working. After about an hour or an hour and a half it wears off. They doubled it, and it still doesn't work. R96 was lying in bed. He reported his surgical sight to the right hip had become infected after admission to the facility, and he had to return to the hospital for treatment and further surgery. R96 removed the sheet covering his hip revealing a 10 inch surgical site with numerous sutures and steri-strips. R96 moaned and grimaced during movement in the bed. On 2/24/2019 at 1:00 PM, R96 stated, I have another hour to wait for my pain medication. My pain scale is at a '7'. I was hit by a semi truck on 1/05/2019. I had 37 broken bones in my ribs, lumbar spine and pelvis. My nose was broken. When I arrived, I was taking [MEDICATION NAME] 10 mg (milligram), [MEDICATION NAME] every 72 hours. I puked yesterday 3 times because I was in so much pain. It was a '10'. I'm not on [MEDICATION NAME] now. I only had those one time orders twice because they didn't have my [MEDICATION NAME] here. I asked the nurse and she told me (V25, Physician) said no. The nurse (V11, Licensed Practical Nurse) has been trying to help me. I've had no good pain management since I've been here. I can't sit up straight. The therapist said I can't participate in therapy until I get my pain under control. I've been in bed for 5 weeks. They told me (V25) must be afraid I'll get addicted. They don't ask me my pain scale. At that time, R96 turned himself very slowly from the left to the right side, moaning and grimacing. R96's physician's orders [REDACTED]. The Nurses Note, dated 2/06/2019 at 8:50 AM documents R96 was sent by ambulance to the hospital. The Nurses Note, dated 2/11/2019 at 4:37 PM, documents R96 returned to the facility. The Note documents, in part, (V25) notified, POS faxed to pharmacy. The POS after readmission, dated 2/12/2019, documents a one time order of [MEDICATION NAME] 25 mcg today. The Medication Administration Record [REDACTED]. There is no documentation or assessment related to R96's pain in the Nurses Notes or on the MAR for 2/12/19 dose of [MEDICATION NAME]. R96's Pain Questionnaire, dated 2/12/2019, documents a score of 8, indicating a comprehensive pain assessment is needed. No Comprehensive Pain Assessment could be located in R96's clinical record. R96's POS (physician's orders [REDACTED]. R96's Medication Administration Record [REDACTED]. There was no pain assessment documented on the back of the MAR. There was no follow-up of its effectiveness documented on the back of the MAR. There is no documentation where the [MEDICATION NAME] was applied or when it was removed. There is no documentation in the Nurses Notes of R96's pain level on 2/19/2019. The Review of Discharge Summary for R96, dated 2/11/2019, documents, in part, Internal fixation of a comminuted left sacral ala fracture with 2 screws, mild persistent widening of the right sacro-illiac joint. Unchanged fixation of a right acetabular fracture and a left superior pubic ram fracture. Comminuted and displaced fractures of the right superior and inferior pubic rami. Poly trauma following a truck versus pedestrian accident complicated by pelvic and lumbar fractures as well as splenic lack and right pneumothorax. Patient has presumed surgical site infection now s/p (status [REDACTED]. Non-weight bearing bilateral lower extremities. Slide board for transfers only. Out of bed to chair at least three times a day. [MEDICAL CONDITION] ([MEDICAL CONDITION] [MEDICATION NAME]. [MEDICATION NAME] injections once daily for 2 weeks. The PO for R96, dated 1/14/2019, documents, [MEDICATION NAME] 25 mg patch to skin every day. V25's PO (physician's orders [REDACTED]. The PO dated 1/14/2019 documents [MEDICATION NAME] 25 mg patch to skin every day. On 2/28/2019 at 1:50 PM, V22 (Lead Pharmacy Consultant) stated, His (R96's) [MEDICATION NAME] ([MEDICATION NAME]/APAP) was sent 2/23/2019 of 30 tabs, and sent again on 2/25/19 of 30. R96's MAR for 1/2019 documents he received a [MEDICATION NAME] Patch 25 mcg on 1/15, 1/24, and 1/30/19. There is no documentation R96's pain was assessed, where the patch was applied or when it was removed. The 1/19 MAR indicated [REDACTED]. The back of the MAR indicated [REDACTED]. There is no follow-up for the effectiveness for these doses of narcotic pain medication. R96's MAR for 2019, documents, in part, he received [MEDICATION NAME]/APAP ([MEDICATION NAME]) 5/325 mg 1 to 2 tabs by mouth every 4 hours twice on 2/13, 3 times 2/14, once 2/5, once 2/16, 3 times 2/18, none on 2/19, 2/10, 2/21, twice 2/22/2019, once 2/23, 3 times 2/24, twice 2/25 and once on 2/26/2019. The back of R96's MAR for 2/2019 only documents the [MEDICATION NAME] was given 2/16 once for generalized pain, 2/22 once for generalized pain, once 2/23 for pain generalized and once 2/25/2019 for body pain. During these administration times, there is no pain assessment for level of pain documented for R96. R96's Controlled Substance Log is dated as received 2/23/2019 of 30 tablets with none used and another Controlled Substance Log dated as received 2/23/2019 of 30 doses, with 5 doses remaining on 2/26/2019 at 6:00 AM. V25's physician progress notes [REDACTED]. V25 could not be reached for comment after multiple attempts. R96's Care Plan, dated as revised on 1/23/2019, documents, in part, Is at risk for pain related to diagnosis; multiple pelvic fractures and vertebra fractures, fractures of the left and right femur. Administer medication as per MD (medical doctor) orders, Notify MD/NP (Nurse Practitioner) if pain medication is not effective. Assess location, duration, intensity and frequency of pain, observe for signs and symptoms of pain or discomfort such as moaning, yelling, crying, favoring a body part, rocking, rubbing a body part, wringing hands or facial grimacing. Pain assessment every 3 months and PRN. Use pain scale to identify pain level and intensity. On 2/28/2019 at 3:30 PM, V28 (Physical Therapy Assistant/PTA) stated, I see (R96) is scheduled 3 or 4 times a week. I only have him for 30 or 40 minutes. We kind of sit and he'll shift his weight. He can only put so much pressure on his arms and can't sit on his buttocks due to the pain. On 2/28/2019 at 3:45 PM, V29 (Occupational Therapy Assistant/OTA) stated, I talked to him (R96) this morning after his orthopedic appointment. He said the ortho told him he has 6 obvious fractures in his pelvis. He said he's got 8 more weeks before he can bear weight on his legs. The fractures are through his tailbone. You can see he's in pain when holding himself up with his arms. His pain shoots up through his groin. He complains less in bed. It was really bad after the accident first happened. The Orthopedist gave him a [MEDICATION NAME] prescription to help with the break through pain. When he went to the hospital with the infection, he came back with only [MEDICATION NAME]. We are trying to get something for him from V25 and so was the DON (V2). Multiple people did. He said today the [MEDICATION NAME] helps, but he needs something extra to have before therapy for when he is moving. We've met with resistance with V25. The PO dated 2/27/2019, for R96 has an order, for [MEDICATION NAME] 50 mg po q 6 hours from V30 (Orthopedic Physician Consult) for break through pain. 2. The MDS for R39, dated 1/01/2019 documents a BIMS score of 15, which is cognitively intact with no problems with decision. The POS for 2/2019 documents R39 has the [DIAGNOSES REDACTED]. The POS for 1/2019 documents he has orders for the scheduled pain medications: [REDACTED]. R39's MAR for 1/2019 has no documentation R39 was given the [MEDICATION NAME] on the evening dose of 1/6, 1/17 and 1/18/2019. There is no documentation R39 received the 6:00 AM complete dose of [MEDICATION NAME] 900 mg on 1/01, 1/14, 1/16, 1/21, and 1/22/2019. There is no documentation R39 received the 6:00 PM complete dose of [MEDICATION NAME] on 1/02, 1/03, 1/09, 1/10, 1/16, 1/20, 1/21, 1/22, 1/24 and 1/30/2019. R39's MAR for 1/2019 has no documentation R39 received the prescribed doses of [MEDICATION NAME]/APAP 7.5-325 mg on 1/02, 1/08, 1/07, 1/08, 1/20, 1/21, 1/22 and 1/25 through 1/30/2019. There is no documentation of why he failed to receive the medication anywhere on the MAR, including on the back of each page of the MAR. R39's MAR for 1/2019 fails to document the reason for the PRN dose of [MEDICATION NAME] 600 mg on 1/07 and 1/09/2019, the pain scale or if the medication was effective. R39's MAR for 2/2019 has no documentation R39 received the complete dose of [MEDICATION NAME] 900 mg at 6:00 AM on 2/01, 2/06, and 2/20/2019. The MAR for 2/2019 has no documentation R39 received the complete 2:00 PM dose of [MEDICATION NAME] 900 mg on 2/02, 2/17 ad 2/20/2019. R39's MAR for 2/2019 has no documentation R39 received the 5:00 PM dose of [MEDICATION NAME]/APAP 7/5-325 mg on 2/14 and 2/16/2019. There is no documentation R39 received the 9:00 PM dose of [MEDICATION NAME]/APAP on 2/05, 2/11 and 2/24/2019. There is no documentation on the MAR indicated [REDACTED]. There is no documentation R39 received the 5:00 AM dose of [MEDICATION NAME]/APAP on 2/01, 2/06, 2/09, 2/12, 2/13, 2/15 through 2/19, 2/22, 2/23 and 2/24/2019. There is no pain assessments or followup for the effectiveness of this narcotic pain medication documented as well. On 2/24/19 at 11:10 AM, R39 stated, I've been out of my narcotic pain medication for up to 3 days. I have pain in my hands and feet. On 2/27/19 at 3:49 PM, R39 stated, They finally got me my Narco just 2 hours ago. My pain level was at a 10. My whole body hurt. At 3:30 last night the nurse (V32/LPN) said she had no pain pills for me, and there was nothing in the E-kit. (emergency kit). R39's Care Plan, dated as revised 2/23/19, documents, in part, Is at risk for pain related to the [DIAGNOSES REDACTED]. Administer medication per MD (medical doctor) orders. Monitor for side effects and effectiveness. Assess and document the frequency and intensity pain symptoms. Use the resident's verbal reports and staff's clinical judgement for the assessment. On 2/28/19 at 1:50 PM, V22 (Lead Pharmacist Consultant) was called. V22 stated, His [MEDICATION NAME] was last sent 1/23/2019, a quantity of 60. It was sent again on 2/27/2019 for 60. 3. The MDS for R45 dated 1/04/2019, documents a BIMS score of 15, which is cognitively intact. R45's EHR (electronic health record) documents diagnoses, in part, as Psoriatic Arthritis, and Pain in Left Knee. R45's Comprehensive Pain Assessment, dated 1/09/2019 documents R45 has a daily pain level at a minimum of 5 in the right knee, left knee, and right wrist intermittently. R45's Pain Questionnaire, dated 2/10/2019, documents R45 is alert and has daily pain. On 2/24/19 at 12:04 PM, R45 stated, I've been out of [MEDICATION NAME] for 5 days now. They are offering me Tylenol. When I get up and walk around I hurt due to psoriatic arthritis. On 2/26/19 at 8:00 AM, V18 (LPN) stated, The pain assessments are documented on the back of the MAR. The PO (physician's orders [REDACTED]. R45's MAR's for 12/18, 1/19 and 2/19 have no documentation of assessments of pain level prior to or after giving [MEDICATION NAME]/APAP7.5/325 mg as ordered PRN. On 2/26/19 at 10:55 AM, R45 stated, My pain level is at a 7 in my knees and my hips. I asked for [MEDICATION NAME] last night and they told me it hasn't come yet. It was V33 (LPN). He didn't offer me anything else. Tylenol doesn't touch the pain. I had trouble sleeping for the last 4 or 5 days. I do take [MEDICATION NAME]. It keeps the [MEDICAL CONDITION] in my feet quiet. I took it last night. I toss and turn. It kind of wears you out. On 2/26/2019 at 11:00 AM, V26 (LPN) checked med cart for R45. V26 stated, No [MEDICATION NAME]/APA 7.5-325 mg tablets were available. The pharmacy just told me they just received a script for (25), and they are sending it over by noon today. R45's MAR for 2/19 documents his last dose was on 2/11/19 at 8:00 PM. This dose was verified by V26. On 2/28/19 at 1:15 PM, R45 stated, I still don't have my pain medication. I don't know what's going on. On 2/28/19 at 1:41 PM, V22 (Pharmacist) stated, (R45) doesn't have a script for [MEDICATION NAME] to refill. The last [MEDICATION NAME] was sent 1/16/2019. We have sent out notices to sign a refill order to (V25) on 2/26/2019. We have not gotten any complaints. I talked to my supervisor about this, and no issues have been reported. The (facility) Pharmacist (V24) said the nurse would have to bring it to her (V24) attention if there was a problem. I got a note from (MONTH) that the NP wrote a script on 1/16/2019. On 2/28/19 at 2:00 PM, V12 (Care Plan Coordinator) stated, (V25) swears he sent the pharmacy a signed script for (R45) the day before yesterday. I asked V11 (LPN) if it ([MEDICATION NAME]) came in, and she said it wasn't here. (V25) was supposed to come here today, and he called and cancelled. He told me to text him again and when he got home this evening, he would refax it to the pharmacy. I also asked him to fax it to the facility. The problem is (V25's) NP (V27), used to come here. She quit coming to nursing homes. He wants to do the building himself. He's over extended. The nurses come to me when they are not getting prescriptions signed from (V25). He has every resident in this facility but 2. R45's current Care Plan, dated as revised 2/06/2017, documents, in part, Is at risk for pain related to [DIAGNOSES REDACTED]. Administer pain medications as ordered. Evaluate the effectiveness of pain interventions, Is able to call for assistance when in pain, reposition self and ask for medication, tell you how much pain is experienced, and tell you what increases or alleviates pain. 4. R86's POS for (MONTH) 2019 documents in part [DIAGNOSES REDACTED]. R86's MDS dated [DATE] documents a BIMS score of 15 out of 15 (cognitively intact). On 02/26/2019 at 9:37 AM, R86 stated, I do not always get my pain medication; they are always running out of it. I am supposed to get it 4 times a day. R86's POS (MONTH) 2019 document R86 was prescribed (2) 50 mg [MEDICATION NAME] tablets with a start date of 11/21/2018, 4 times a day, 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM. [MEDICATION NAME] 2 tablets (650 mg) by mouth every 4 hours as needed. R86's Care Plan with an initiated date of 10/16/2018 documents (R86) is at risk for pain related to his [DIAGNOSES REDACTED]. R86's Care Plan also documents Administer medication as per Physician Orders. Notify Physician if medication is not effective. R86's MAR indicated [REDACTED]. MAR for 01/2019 document no pain assessment before or after medication administration for 01/10/2019, 01/16/2019, 01/17/2019 and 01/24/2019. (MONTH) and February's MAR indicated [REDACTED]. The Facility's Pain Management Policy (2015) documents in part, Purpose: To facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. General Guidelines: The facility will achieve these goals through - Promptly and accurately assessing and managing pain to the greatest extent possible - Encouraging residents to self-report pain - Aggressively assessing pain in non-verbal and cognitively impaired residents - Optimizing the resident's ability to perform activities of daily living

Based on observation, interview, and record review, the facility failed to develop and operationalize a Disaster Preparedness and Evacuation Plan for bariatric residents over 1000 pounds. This deficient practice resulted in an Immediate Jeopardy affecting one of one resident (R3) reviewed for Disaster Preparedness and Evacuation Plan in the sample of 3. The Immediate Jeopardy began on 8/14/15 when R3 was placed in a bed that is larger than his room door dimensions. Findings include: On 3/5/16 at 2:00 PM, R3 was in bed in a sitting position with the back of the bed raised supporting R3's back. R3 is massively obese and was in a wide bariatric bed. R3 was unable to get out of bed. He was on a vent. He stated, Z1 is my primary (care physician). He changed the order that I must go to the hospital [MEDICAL CONDITION]. No ambulance around here can move me cause I'm too big. The administrator found an Ear, Nose and Throat (ENT) doctor that said he would [MEDICAL CONDITION]. That doctor has concerns that if there are complications there won't be the right set up here. On 3/13/16, at 9:34AM, Z3, R3's mother, was interviewed by telephone. She stated she had just talked to Z2 on the telephone and he said he was still willing to perform [MEDICAL CONDITION] procedure in the facility. She stated R3 had been in another facility before going to this one for about 3 or 4 years. He was moved by ambulance. She stated the facility had to get a new bed for R3 a few months ago because he gained so much weight. R3 refused at first because he is afraid to be in the mechanical lift, but finally agreed to move to the new bed. Z3 stated a lot of people that worked in the facility helped stabilize R3 when he was moved. Z3 stated that R3 wears a hospital gown all the time. He doesn't have any clothes except for the ones he had when he went to the facility, but they didn't fit him. On 3/10/16, R3's bed dimensions were measured. R3's bed was 52 inches wide by 87 inches long. The door opening from R3's room into the corridor measured 43.5 inches wide. Therefore, R3's bed could not fit through the door to exit his room. The fire exit door closest to R3's room measured 45.5 inches wide. As you exit the building there is a wooden ramp. There is a gate as you enter to the ramp which measures 49 inches wide. The wooden ramp is 57 inches wide rail to rail . E1 was interviewed on 3/14/16 and stated that R3 was placed in the 52 inch wide bed on 8/14/15. R3's March 2016 physician's orders [REDACTED]. R3's Minimum Data Set, dated dated [DATE], documents he requires extensive assistance of two staff members for bed mobility and is bedfast. R3's Nutritional Record, dated 8/6/14, documents R3's weight as 768.9 pounds (lbs). R3's Daily Skilled Nurse's Note, dated 6/25/15 at 10:00 PM, documents Bed bath given, wt (weight) 1032 lbs. Res (Resident) tolerated weighing with terrible anxiety noted. Dietary Assessment, dated 8/6/15 documents Last recorded wt was 1032 #'s (pounds) in June 2015. (Up) 263.1 pounds since August 4th, 2014, admit weight of 768.9 pounds. 3/10/16, at 2:18 PM, E12, I was here the night they got the 1230 pounds. Two CNAs used a hoyer. I was standing in the doorway. The weight came out 1230 pounds on the scale. The capacity of the hoyer said 1000 pounds but the weight part can go up higher and is not limited. Once we figured out he was over the weight limit for the hoyer, we couldn't use it again. We know he got bigger because his sides started to touch the edge of the bed. We got him a new bed. On 3/14/16 at 2:40 PM, E13, CNA stated that she weighed R3 using the hoyer lift with the built in scale in June 2015. It took 6 people to steady him because he panics alot and moves around. She stated it is difficult to keep him steady. R3's Physician's Progress Report, dated 1/13/16, documents Diagnoses: [REDACTED]. It is caused by a constant intake of food that goes well beyond what the body requires) which is [MEDICAL CONDITION] requiring ventilatory support. A hand written document located in the front of R3's medical record, dated 1/25/16, documented (R3) - If Resident is in Respiratory distress call 911 & inform 911 operator that Z16, Local Ambulance Company, ambulance needs to send bariatric ambulance and resident's weight is greater than 1400 lbs and is dependent on assist control Ventilator. On 3/7/16, E1 confirmed that this was an Emergency Plan for R3. On 3/14/16 at 11:08AM, E7, Licensed Practical Nurse, LPN; at 11:12AM, E5 LPN; at 1:30PM, E3, LPN, ADON; and at 1:35PM, E8, LPN were interviewed regarding emergency procedures that are in place to take R3 out of the building if there was a medical emergency or a disaster. They stated that a plan was developed on 2/28/16 and was not in writing. The plan involved a cart with tools which included a large crowbar, an electric saw that cuts through metal and wood, an extension cord and a large hammer, locked in the Respiratory Therapy room. Each nurse has a key. The walls in R3's room are sheet rock. The plan would be to use the tools to knock the wall out in R3's room and take him, in his bed, down the hall to the double front doors. The doors are wide enough to accommodate R3's bed. Once he was out on the sidewalk call Z14, Bariatric Ambulance,and the Fire Department. They assume Z14 and the Fire Department would take over from there. They have not determined how many people it would take to complete this transfer. On 3/14/16 at 11:15AM, E9, Certified Nurse Aid, CNA, stated, I don't know how to get him out, nobody told me. At 11:55AM, E10, CNA, stated, I would not know how to get R3 out of his room. I have not been instructed on an emergency plan. On 3/9/16 at 11:25 PM, Z7, Hospital Emergency Medical Service (EMS)Coordinator/Regional Emergency Service Coordinator, stated he was the coordinator for the local emergency service and was the coordinator for four local counties. He said he and his director were responsible for assisting these ambulance companies with their policies and procedures and licensing. Z7 stated he was contacted by Z16, local ambulance, on 2/28/16. He was told by Z16 they were unable to transport R3 due to his size. Z7 stated after receiving this information, he contacted Z15, other local ambulance, because this company had an ambulance that could accommodate a bariatric resident. When he contacted Z15, Bariatric ambulance, he was told the ambulance could accommodate a patient who was 1000 pounds or under. R3 was 1000 pounds plus and could not be transported by this ambulance. Z7 stated he then contacted Z14, bariatric ambulance, Z7 stated this company had an ambulance that had a two ramp system. He stated each ramp would hold 700 pounds. Z14 told Z7 they would not transfer R3 due to the inability to ensure that R3's weight would be evenly distributed on the two ramps. This would include his body weight, equipment and staff attempting to assist with the transfer. Z7 stated because R3 could not be transferred out of the facility for medical care he and his superiors at (Local Hospital) discussed possible alternatives. Z7 stated that on 3/1/16, Z1, Administrator notified him and said it was the facility's stance that R3 had to go to the hospital for this procedure. Z7 confirmed there was no ambulance service in the region that could transport this resident. Z7 stated at no time did the facility contact him regarding how to transport R3 if there was an emergency. 3/9/16 at 3:00 pm, Z13, City Fire Department Chief, said that the facility had not approached him or the Fire Department in regards to developing a Disaster Plan for R3. Z13 said recently the Local Ambulance Company contacted the Department to request assistance in transporting R3 from the facility. When arriving at the facility, R3 was in a bed that was at least 48 inches wide. Z13 stated the largest stretcher available to transport R3 was only 26 inches - 28 inches wide. Z13 stated In the case of a fire Emergency for (R3), it would be Shelter in Place. On 3/10/16, the Facility's Disaster Policy and Procedure book was reviewed. There was no documentation in the book to address how facility staff and emergency responders should implement emergency medical and disaster policy and procedures in regards to R3 and his inability to leave his room and the facility. 3/14/16 at 11:25AM, E1 stated I don't know of any other Evacuation Procedures for the building. E1 did not mention an evaluation plan for R3 at this time. At 11:26 E1 was asked about the drywall evacuation for R3, that nurses discussed and he stated, Oh yes, in an emergency we would knock the wall out. At 3:50 PM, E1 stated he did not address an overall comprehensive emergency plan for R3. He stated he just spoke to the County EMS regarding [MEDICAL CONDITION]. The Facility's Disaster Policy & Procedure, not dated, documents A disaster may be a fire, tornado strike, gas leak, flood, electrical power outage, heating failure, explosion, bomb threat, or any other situation that would warrant evacuation of the facility in order to protect the lives and safety of the facility's staff and residents. The Policy & Procedure documents This plan will be in cooperation with the American Red Cross, the County Emergency Government office, local Police and County Sheriff's Departments. The Facility's Evacuation Procedures for fire, not dated, documents The necessity for varying degrees of evacuation will be determined by the person in charge of the fire area as to the extent of the fire. Initial evacuation should be accomplished by horizontal movement if possible. Movement of people should always be away from the travel of heat and smoke. Utilize the nearest safety area under exit. The Procedure documents 4. Bedfast residents should be removed by moving beds out of the fire area if possible. The Immediate Jeopardy was identifed on 3/15/16. On 3/15/16 at 12:58PM, E1, E2 and E12 were notified of the Immediate Jeopardy. The Immediate Jeopardy began on 8/14/15 and was not removed at the time of the survey conclusion.

Based on observation, record review and interview, the Facility failed to assess and adequately monitor the necessary needs of a known insulin dependent resident with Type II diabetes for one of four residents (R2) reviewed for a change in condition in the sample of 4. This neglect resulted in R2 not receiving daily blood glucose monitoring and medication intervention to reduce R2's blood glucose levels from 3/01/2015 through 3/15/2015. As result of this neglect, R2 was hospitalized for [REDACTED]. Findings include: The physician's orders [REDACTED]. R2's Admission POS for 12/2014 documents an admission date of [DATE] with medication orders, in part, as "[MEDICATION NAME] 30 units SQ (subcutaneously) at HS (bedtime), Humalog insulin SQ per sliding scale at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM. Physician must contact consultant as needed for blood glucose less than 70." R2's POS for 1/2015 documents, in part, "[MEDICATION NAME] 1 mg (milligram) SQ PRN (as needed) for [DIAGNOSES REDACTED] (low blood glucose), [MEDICATION NAME] 30 units SQ at bedtime, (glucometer) check every 6 hours with sliding scale Humalog and [MEDICATION NAME] 50 % 50 ml (milliliter) intravenous injection PRN." R2's POS for 2/2015 documents, in part, "[MEDICATION NAME] 30 units SQ at bedtime, (Glucometer) check, sliding scale every 6 hours, 140-175=2 units, 176-200=3 units, 201-250=5 units, 251-300=7 units, 301-350=9 units, [MEDICATION NAME] 50 %-50 ml intravenous injection PRN, [MEDICATION NAME] 1 mg SQ PRN-[DIAGNOSES REDACTED]." R2's physician's orders [REDACTED]." The Discharge Medication Instructions from the local hospital sent to the Facility, dated 3/01/2015, have no PO's for any medication to treat and control R2's blood sugar levels or any orders for the blood glucose monitoring for a daily assessment for her insulin needs. The Facility's POS for R2, dated 3/01/2015, have no PO's documented to treat R2's diabetes at all. The medical information about R2 sent to the local hospital on [DATE] include the Admission Record (that includes a [DIAGNOSES REDACTED]. The Patient Transfer Form includes a [DIAGNOSES REDACTED]. The copies of R2's POS sent to the hospital fail to include any insulin orders or sliding scale orders for elevated blood glucose levels. On 3/24/2015 at 3:35 PM, E8 reported she was the task nurse the evening R2 was sent to the local hospital on [DATE]. E8 reported she could not remember exactly what she filled out or sent to the hospital with R2 and the ambulance staff. E8 stated, "I just can't remember." E8 confirmed R2 is diabetic. The Discharge Summary for R2 from the local hospital, dated 3/01/2015 documents, in part, "During the ten days, her only two issues were elevated blood pressures and elevated glucose readings. For her glucose readings, she was initially brought in without any need for insulin, however, her glucose levels remained high initially. We titrated insulin up slowly from initially using [MEDICATION NAME] 5 mg and low dose sliding scale to end with [MEDICATION NAME] 25 mg every HS and Mid dose sliding scale. She tolerated this well." A History and Physical (H&P) from Z2, Physician documents R2 was seen for a witnessed [MEDICAL CONDITION] and a follow up of an infection with a MDRO (multi-drug resistant organism). There is no documentation from Z2 included in the H&P to address R2's diabetes at all or if R2's medications at that time were reviewed. A Nurses Note, dated 3/02/2015 at 5:00 PM, written by E7, LPN documents speaking with Z2 to clarify R2's medications and status. No orders for insulin or daily glucometer checks were documented as received at that time. On 3/24/2105, at 4:20 PM, E7 confirmed she faxed R2's medication orders to the pharmacy and to Z2 on 3/02/2015. E7 stated, "Me personally, I don't work with (R2) on a regular basis, so when the transfer papers came from the hospital, I didn't question them. I didn't know she was diabetic. I have been here 7 months and never gave her insulin." The Nurses Note For R2, dated 3/15/2015 at 5:30 PM, written by E5, LPN, documents, "Check (glucometer) reading 'HI', above 600 (normal =70 to 99). Called (Z8, Physician) at 5:35 PM. New order to send to ER (emergency room ) for further evaluation. Called (ambulance) at 5:40 (PM) and (ambulance) arrived at 5:43 (PM). Called (local hospital) to give report. Family here with resident and aware. Left via stretcher at 6:00 PM." The Nurses Note for R2, dated 3/16/2015 at 6:30 AM, written by E14, LPN documents, "admitted with [DIAGNOSES REDACTED]." The diabetes.org website documents, in part, "Hyperosmolar Hyperglycemic Nonketoti[DIAGNOSES REDACTED], or HHNS, can happen to people with either type 1 or type 2 diabetes that is not being controlled properly, but it occurs more often in people with type 2. If HHNS continues, the severe dehydration will lead to [MEDICAL CONDITION], coma and eventually death. Warning Signs: blood sugar level over 600 mg/dl (milligrams per deciliter), dry parched mouth, extreme thirst, high fever, sleepiness or confusion, loss of vision, hallucinations, weakness on one side of the body." On 3/25/2105 at 1:15 PM, E5, LPN reported she works PRN at the Facility, but had checked R2's blood glucose levels before and had given her [MEDICATION NAME] insulin. E5 reported when she entered R2's room on 3/15/2015, she was carrying the glucometer machine to check R2's blood glucose as she had done previously. E5 reported Z7, family member was with R2 and asked her what her previous blood sugar levels had been. E5 reported when she left the room to check R2's chart, she discovered there was no PO for daily blood sugar levels or insulin ordered for R2. E5 reported Z7 then asked her to check R2's blood glucose level and the level was over 600. E5 reported she called Z2, but Z8 responded with an order to send R2 to the hospital. E5 reported she called the local hospital with a report of R2's vital signs and blood glucose level and sent R2 by ambulance to the hospital. The H&P for R22 from the local hospital, dated 3/15/2105, documents, in part, "Suspect 2/2 lack of insulin for two weeks, and dehydration. Glucose 737-high. Potassium-2.5 (normal=3.5-5.0) [MEDICAL CONDITION] hyperosmolar state due to lack of insulin for two weeks, and inability to increase fluid intake. Dehydration with acute kidney injury likely due to this. Marked [DIAGNOSES REDACTED]. Hydration with normal saline at 250 ml's (milliters) per hour. Control glucose levels with IV (intravenous) insulin drip. Supplemental potassium via IV route. Cardiac monitoring until potassium level better." On 3/26/2105, at 8:00 AM, Z7 reported when she visited R2 on 3/15/2105 she felt R2 "did not look right." Z7 reported R2 was sleeping a lot. Z7 reported, "Normally at her best, she would open her eyes and look at you. I asked (E5), the nurse to check her meds (medications) for me, and (E5) told me (R2) hadn't gotten any insulin from 3/01 through 3/15/2015. She has been hospitalized three times since she has been at the Facility." Z7 reported R2 has been diabetic for some time. On 3/24/2105 at 3:15 PM, Z2 stated, "I see quite a few patients. I would assume the nurses would look through the old charts to see what they (residents) are on. This is a significant medication error by the hospital and the nursing home. With the number of hires and fires, I don't know how they would remember what a patient takes. It should be a standard to look through the old orders. They shouldn't clean out the old history and progress notes. They have a lot of issues with documentation at the Facility. I am glad you (the Department) are here. It is quite frustrating and risky for patient's because of it. It is basic nursing to make sure diabetic residents are on the right regimen." On 3/25/2105 at 1:38 PM, E13, LPN reported R2 is a known diabetic since admission. E13 stated, "I have given her insulin and done glucometer checks. Recently when (R2) returned from the hospital, she had no insulin orders or orders for a glucometer. It never crossed my mind to wonder. I get moved around a lot." On 3/25/2015, at 1:05 PM, Z5, Pharmacist reported he normally does the monthly medication reviews for the Facility, but has been having Z3, Pharmacist doing them for the Facility in March . Z5 stated, "I would normally look at the hospital discharge orders as well as the current medications, and the meds they were on prior to leaving the Facility." Z5 reported he was unaware of any problems related to the pharmacy that the Facility was having or had had in the past. On 3/25/2105 at 10:40 AM, Z3 was asked if he routinely monitors the medications for resident with Type II Diabetes Mellitus. Z3 stated, "I just don't know. For me, when I would look at that and knew a patient went into the hospital with a change in condition and came back with no order for insulin, I would think the hospital took them off the insulin or diabetic meds." Z3 reported Z5 usually does the monthly pharmacy reviews for the Facility, but Z3 was filling in for March 2015. On 3/20/2015, at 1:40 PM, E1, Administrator stated, "We had a resident (R2) in the hospital who just came back. The hospital paperwork addressed the issue that we weren't giving her insulin. (E3, Assistant Director of Nursing) checked that out. What happened was when (R2) was discharged from the hospital, they failed to give discharge orders for insulin. I don't know how long she went without insulin." On 3/25/2015, at 2:43 PM, E11, LPN reported she works the same hall where R2 resides and was aware R2 was diabetic. E11 stated, "She is non responsive, a [DEVICE] (gastrostomy tube) and is diabetic. I have given her insulin before. The last time she was readmitted , I didn't give her insulin. I didn't question it. Typically, I would question if they are sent out with an insulin order and came back without one. I would check it out." On 3/24/2105 at 12:00 PM, R2 was in bed with a tracheotomy collar with tubing attached to a liquid oxygen tank. R2 had an indwelling urinary catheter and was receiving an enteral feeding through a gastrostomy tube, via a mechanical pump. R2 was non responsive to verbal stimuli, but would periodically open her eyes with no visual tracking of a voice or sound. E4, LPN was preparing to administer medication via the gastrostomy tube. E4 reported she is the nurse who often takes care of R2. E4 was asked if R2 had always received insulin, and E4 stated, "I can't say she was always on insulin before. I don't know really." R2's Care Plan, dated 12/29/2014 and updated 3/06/2015 documents, in part, "(R2) requires PROM (passive range of motion) as evidenced by the following limitations and potential contributing [DIAGNOSES REDACTED]." The revised Care Plan, dated 3/06/2105, documents, in part, (R2) requires tube feedings to maintain daily nutritional requirements and weight and receives diuretic medication daily. (R2) has [DIAGNOSES REDACTED]." Interventions include; "Monitor/document/report to MD (medical doctor) PRN signs and symptoms of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, [MEDICATION NAME] breath (smells fruity) stupor, coma." On 3/24/2015 at 2:55 PM, E9, Corporate Registered Nurse (RN) was asked why R2 had no intake and output (I&O) records for March 2015 to monitor her urinary output for increased or decreased output as a symptom of hyper or [DIAGNOSES REDACTED]. E9 stated, "One wasn't restarted when she came back from the hospital." No I&O records were documented in R2's clinical record. The Facility's Consultant Pharmacy Services Provider Agreement, updated 1/27/2104, documents in part, "The Consultant Pharmacist, or adjunctive licensed pharmacy personnel under the control of the Consultant Pharmacist provides consultant pharmacist services, including but not limited to the following: Reviewing the medication regimen of each resident at least monthly, utilizing federally mandated standards of care in addition to (company's name) applicable standards, and documenting the review and finding in the resident's medical record. Participating in the preparation of the resident care plan for each new resident or current resident with a change of status by reviewing the following information in collaboration with the operational pharmacist. The following examples of information may be reviewed to determine any potential problems related to the medication therapy of the resident, including the presence of a [DIAGNOSES REDACTED]. if this is the reason for the assessment."

A. Based on observation, record review and interview, the facility failed to assess and adequately monitor the necessary needs and provide necessary services for a known, insulin dependent resident with Type II diabetes for one of four residents (R2) reviewed for a change in condition in the sample of 4. This failure resulted in R2 not receiving daily blood glucose monitoring and medication intervention to reduce R2's blood glucose levels from 3/01/2015 through 3/15/2015. As result, R2 was hospitalized for [REDACTED]. Findings include: The R2's March 2015 physician's orders [REDACTED]. R2's Admission POS for 12/2014 documents an admission date of [DATE] with medication orders, in part, as "[MEDICATION NAME] 30 units SQ (subcutaneously) at HS (bedtime), Humalog insulin SQ per sliding scale at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM. Physician must contact consultant as needed for blood glucose less than 70." R2's POS for 1/2015 documents, in part, "[MEDICATION NAME] 1 mg (milligram) SQ PRN (as needed) for [DIAGNOSES REDACTED] (low blood glucose), [MEDICATION NAME] 30 units SQ at bedtime, (glucometer) check every 6 hours with sliding scale Humalog and [MEDICATION NAME] 50 % 50 ml (milliliter) intravenous injection PRN." R2's POS for 2/2015 documents, in part, "[MEDICATION NAME] 30 units SQ at bedtime, (Glucometer) check, sliding scale every 6 hours, 140-175=2 units, 176-200=3 units, 201-250=5 units, 251-300=7 units, 301-350=9 units, [MEDICATION NAME] 50 %-50 ml intravenous injection PRN, [MEDICATION NAME] 1 mg SQ PRN-[DIAGNOSES REDACTED]." R2's physician's orders [REDACTED]." The Discharge Medication Instructions from the local hospital sent to the Facility, dated 3/01/2015, have no PO's for any medication to treat and control R2's blood sugar levels or any orders for the blood glucose monitoring for a daily assessment for her insulin needs. The Facility's POS for R2 dated 3/01/2015, have no PO's documented to treat R2's diabetes at all. The medical information about R2 sent to the local hospital on [DATE] include the Admission Record (that includes a [DIAGNOSES REDACTED]. The Patient Transfer Form includes a [DIAGNOSES REDACTED]. The copies of R2's POS sent to the hospital fail to include any insulin orders or sliding scale orders for elevated blood glucose levels. On 3/24/2015 at 3:35 PM, E8 reported she was the task nurse the evening R2 was sent to the local hospital on [DATE]. E8 reported she could not remember exactly what she filled out or sent to the hospital with R2 and the ambulance staff. E8 stated, "I just can't remember." E8 confirmed R2 is diabetic. The Discharge Summary for R2 from the local hospital, dated 3/01/2015 documents, in part, "During the ten days, her only two issues were elevated bloods pressures and elevated glucose readings. For her glucose readings, she was initially brought in without any need for insulin, however, her glucose levels remained high initially. We titrated insulin up slowly from initially using [MEDICATION NAME] 5 mg and low dose sliding scale to end with [MEDICATION NAME] 25 mg every HS and Mid dose sliding scale. She tolerated this well." A History and Physical (H&P) from Z2, Physician documents R2 was seen for a witnessed [MEDICAL CONDITION] and a follow up of an infection with a MDRO (multi-drug resistant organism). There is no documentation from Z2 included in the H&P to address R2's diabetes at all or if R2's medications at that rime were reviewed. A Nurses Note, dated 3/02/2015 at 5:00 PM, written by E7, LPN documents speaking with Z2 to clarify R2's medications and status. No orders for insulin or daily glucometer checks were documented as received at that time. On 3/24/2105, at 4:20 PM, E7 confirmed she faxed R2's medication orders to the pharmacy and to Z2 on 3/02/2015. E7 stated, "Me personally, I don't work with (R2) on a regular basis, so when the transfer papers came from the hospital, I didn't question them. I didn't know she was diabetic. I have been here 7 months and never gave her insulin." The Nurses Note For R2, dated 3/15/2015 at 5:30 PM, written by E5, LPN, documents, "Check (glucometer) reading 'HI', above 600 (normal =70 to 99). Called (Z8, Physician) at 5:35 PM. New order to send to ER (emergency room ) for further evaluation. Called (ambulance) at 5:40 (PM) and (ambulance) arrived at 5:43 (PM). Called (local hospital) to give report. Family her with resident and aware. Left via stretcher at 6:00 PM." The Nurses Note for R2, dated 3/16/2015 at 6:30 AM, written by E14, LPN documents, "admitted with [DIAGNOSES REDACTED]." The diabetes.org website documents, in part, "Hyperosmolar Hyperglycemic Nonketoti[DIAGNOSES REDACTED], or HHNS, can happen to people with either type 1 or type 2 diabetes that is not being controlled properly, but it occurs more often in people with type 2. If HHNS continues, the severe dehydration will lead to [MEDICAL CONDITION], coma and eventually death. Warning Signs: blood sugar level over 600 mg/dl (milligrams per deciliter), dry parched mouth, extreme thirst, high fever, sleepiness or confusion, loss of vision, hallucinations, weakness on one side of the body." On 3/25/2105 at 1:15 PM, E5, LPN reported she works PRN at the Facility, but had checked R2's blood glucose levels before and had given her [MEDICATION NAME] insulin. E5 reported when she entered R2's room on 3/15/2015, she was carrying the glucometer machine to check R2's blood glucose as she had done previously. E5 reported Z7, family member was with R2 and asked her what her previous blood sugar levels had been. E5 reported when she left the room to check R2's chart, she discovered there was no PO for daily blood sugar levels or insulin ordered for R2. E5 reported Z7 then asked her to check R2's blood glucose level and the level was over 600. E5 reported she called Z2, but Z8 responded with an order to send R2 to the hospital. E5 reported she called the local hospital with a report of R2's vital signs and blood glucose level and sent R2 by ambulance to the hospital. The H&P for R22 from the local hospital, dated 3/15/2105, documents, in part, "Suspect 2/2 lack of insulin for two weeks, and dehydration. Glucose 737-high. Potassium-2.5 (normal=3.5-5.0) [MEDICAL CONDITION] hyperosmolar state due to lack of insulin for two weeks, and inability to increase fluid intake. Dehydration with acute kidney injury likely due to this. Marked [DIAGNOSES REDACTED]. Hydration with normal saline at 250 ml's per hour. Control glucose levels with IV (intravenous) insulin drip. Supplemental potassium via IV route. Cardiac monitoring until potassium level better." On 3/26/2105, at 8:00 AM, Z7 reported when she visited R2 on 3/15/2105 she felt R2 "did not look right." Z7 reported R2 was sleeping a lot. Z7 reported, "Normally at her best, she would open her eyes and look at you. I asked (E5), the nurse to check her meds (medications) for me, and (E5) told me (R2) hadn't gotten any insulin from 3/01 through 3/15/2015. She has been hospitalized three times since she has been at the facility." Z7 reported R2 has been diabetic for some time. On 3/24/2105 at 3:15 PM, Z2 stated, "I see quite a few patients. I would assume the nurses would look through the old charts to see what they (residents) are on. This is a significant medication error by the hospital and the nursing home. With the number of hires and fires, I don't know how they would remember what a patient takes. It should be a standard to look through the old orders. They shouldn't clean out the old history and progress notes. They have a lot of issues with documentation at the facility. I am glad you (the Department) are here. It is quite frustrating and risky for patient's because of it. It is basic nursing to make sure diabetic residents are on the right regimen." On 3/25/2105 at 1:38 PM, E13, LPN reported R2 is a known diabetic since admission. E13 stated, "I have given her insulin and done glucometer checks. Recently when (R2) returned from the hospital, she had no insulin orders or orders for a glucometer. It never crossed my mind to wander. I get moved around a lot." On 3/25/2015, at 1:05 PM, Z5, Pharmacist reported he normally does the monthly medication reviews for the facility, but has been having Z3, Pharmacist doing them for the facility in March . Z5 stated, "I would normally look at the hospital discharge orders as well as the current medications, and the meds they were on prior to leaving the facility." Z5 reported he was unaware of any problems related to the pharmacy that the Facility was having or had had in the past. On 3/25/2105 at 10:40 AM, Z3 was asked if he routinely monitors the medications for resident with Type II Diabetes Mellitus. Z3 stated, "I just don't know. For me, when I would look at that and knew a patient went into the hospital with a change in condition and came back with no order for insulin, I would think the hospital took them off the insulin or diabetic meds." Z3 reported Z5 usually does the monthly pharmacy reviews for the Facility, but Z3 was filling in for March 2015. On 3/20/2015, at 1:40 PM, E1, Administrator stated, "We had a resident (R2) in the hospital who just came back. The hospital paperwork addressed the issue that we weren't giving her insulin. (E3, Assistant Director of Nursing) checked that out. What happened was when (R2) was discharged from the hospital, they failed to give discharge orders for insulin. I don't know how long she went without insulin." On 3/25/2015, at 2:43 PM, E11, LPN reported she works the same hall where R2 resides and was aware R2 was diabetic. E11 stated, "She is non responsive, a [DEVICE] (gastrostomy tube) and is diabetic. I have given her insulin before. The last time she was readmitted , I didn't give her insulin. I didn't question it. Typically, I would question if they are sent out with an insulin order and came back without one. I would check it out." On 3/24/2105 at 12:00 PM, R2 was in bed with a tracheotomy collar with tubing attached to a liquid oxygen tank. R2 had an indwelling urinary catheter and was receiving an enteral feeding through a gastrostomy tube, via a mechanical pump. R2 was non responsive to verbal stimuli, but would periodically open her eyes with no visual tracking of a voice or sound. E4, LPN was preparing to administer medication via the gastrostomy tube. E4 reported she is the nurse who often takes care of R2. E4 was asked if R2 had always received insulin, and E4 stated, "I can't say she was always on insulin before. I don't know really." R2's Care Plan, dated 12/29/2014 and updated 3/06/2015 documents, in part, "(R2) requires PROM (passive range of motion) as evidenced by the following limitations and potential contributing [DIAGNOSES REDACTED]." The revised Care Plan, dated 3/06/2105, documents, in part, (R2) requires tube feedings to maintain daily nutritional requirements and weight and receives diuretic medication daily. (R2) has [DIAGNOSES REDACTED]." Interventions include; "Monitor/document/report to MD (medical doctor) PRN signs and symptoms of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, [MEDICATION NAME] breath (smells fruity) stupor, coma." On 3/24/2015 at 2:55 PM, E9, Corporate Registered Nurse (RN) was asked why R2 had no intake and output (I&O) records for March 2015 to monitor her urinary output for increased or decreased output as a symptom of hyper or [DIAGNOSES REDACTED]. E9 stated, "One wasn't restarted when she came back from the hospital." No I&O records were documented in R2's clinical record. The Facility's Consultant Pharmacy Services Provider Agreement, updated 1/27/2104, documents in part, "The Consultant Pharmacist, or adjunctive licensed pharmacy personnel under the control of the Consultant Pharmacist provides consultant pharmacist services, including but not limited to the following: Reviewing the medication regimen of each resident at least monthly, utilizing federally mandated standards of care in addition to (company's name) applicable standards, and documenting the review and finding in the resident's medical record. Participating in the preparation of the resident care plan for each new resident or current resident with a change of status by reviewing the following information in collaboration with the operational pharmacist. The following examples of information may be reviewed to determine any potential problems related to the medication therapy of the resident, including the presence of a [DIAGNOSES REDACTED]. if this is the reason for the assessment." B. Based on record review and interview, the Facility failed to adequately assess for pain, monitor the effectiveness of pain medication and provide narcotic pain medication when necessary for one of four residents (R1) reviewed for pain in the sample of 4. Findings include: Nurses notes document R1 was admitted to the facility on [DATE] at 5:28 PM. The Daily Skilled Nurses Notes, dated 3/9/15, document R1 being alert, oriented to person, place and time with unclear speech and voicing no pain at the time. Admitting orders included [MEDICATION NAME] 5/325 1 tab via [DEVICE] every 4 hours as needed, and Tylenol 650 mg every 6 hours as needed for pain. The Pain Assessment, dated 3/9/15, signed by E5, LPN, is incomplete. The Assessment failed to document R1's description of pain, intensity, duration, effectiveness of medication, and what increases pain. It documents R1 had no pain at the time of the assessment. The section for General information has Decubitus Ulcer Back written in form the resident describing cause of pain and checks resident does not verbalize pain. Under "Relief of Pain," medication is checked as what relieves pain, no adverse consequences of interventions is checked, and resident's acceptable pain level is documented as a "3." The Assessment lists the PRN [MEDICATION NAME]/APAP ([MEDICATION NAME]) 5/325 1-2 tabs every 4 hours PRN which directly conflicts with the admitting order that clearly documents one tab every 4 hours as needed not 2. The Assessment's conclusion is also blank. The Controlled Drug Receipt /Record/Disposition Form documents [MEDICATION NAME] 30 tabs were received on 3/10/15, the day after admission, with the first dose given at 2:30 PM on 3/10/15. This was 21 hours after R1's admission to the Facility. In addition, R1's Medication Administration Record [REDACTED]. R1's March 2015 MAR indicated [REDACTED]. The Controlled Drug Form documents R1 was given two tabs of [MEDICATION NAME], instead of the ordered one tab, on 3/12/15 and three times on 3/16/15 at midnight, 6 AM and 10 AM. The Controlled Drug Form also documents that the 10 AM dose was the last available [MEDICATION NAME]. Later that same day, 3/16/15 at 1 PM, the Nurses Notes document that R1 was "very anxious this shift et (and) constantly requesting [MEDICATION NAME] even after given." The Nurses Notes fail to consistently and routinely assessed R1 for pain management even though he was taking [MEDICATION NAME] regularly when it was available. On 3/17/15 at 2 AM, R1's Nurses Notes document "upset he is out of [MEDICATION NAME]. This nurse spoke c (with) pharmacy + he is out of refills. Pharmacy states will fax notification for Dr." Again, no pain intensity and no assessment is documented. At 10:35 AM, the Nurses Notes document R1 "was given Tylenol for complaints of pain" and they are "waiting for script (prescription)." The March 2015 MAR indicated [REDACTED]. The Nurse's Medication Notes documents "3/17 10 AM Tylenol 650 gen (general) pain," but no pain intensity assessment (scale information) or response documented. At 7:30 PM on 3/17/15, R1 was sent to the emergency room following a chest x-ray and admitted with [MEDICAL CONDITION] and skin ulcer. The Controlled Drug Form, dated 3/17/15, documents the Facility received 60 [MEDICATION NAME] at 11 PM on 3/17/15 after R1 left the Facility. On 3/25/15 at 2 PM, Z6 stated R1 informed her that he did not have the [MEDICATION NAME] available until the second day of his stay. Z6 also said R1 described the pain on the last two days before discharge as a "8" on a scale of 1-10 with 10 being the worst. R1 told Z6 that the Facility did give him Tylenol, but that he gets no relief from Tylenol. Z6 stated E1 Administrator was aware of the facility not getting the [MEDICATION NAME] timely upon admission and voiced to Z6 that it was unacceptable. On 3/25/15 at 1:15 PM, E5, LPN, stated she remembered R1 and that she had admitted him to the Facility. E5 described R1 as very intelligent, had unclear speech but could make all his needs known by writing them either on a pad of paper or with his communication board. E5 stated his communication board did not work the first night he was here, but did after that. E5 stated R1 denied pain the first night when she admitted him. On 3/24/15 at 3:26 PM, Z2, Medical Director stated R1 had a radical throat surgery and would need the [MEDICATION NAME] for pain management. Z2 described R1 as alert/oriented times three being fully capable of making his needs known. Z2 stated that having the medication unavailable as ordered was a significant error given R1's [DIAGNOSES REDACTED]. The Facility's Pain Management Policy, revised 2015, documents the purpose of the policy is to "help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain." The policy documents that pain management is a multidisciplinary care process that includes the following "a) assessing potential for pain, b) effectively recognizing the presence of pain, c) developing and implementing approaches to pain management, d) identifying and using different strategies for pain management, and e) modifying approaches as necessary." The policy continues to document that "During PRN pain medication administration, at a minimum, the location and intensity characteristics are to be gathered prior to administration of the as needed pain medication."

Based on observation, record review and interview the facility failed to supervise wandering residents with poor safety awareness who have access to an unsafe areas for five of five residents (R1, R11, R12, R13, R14) reviewed for wandering behaviors in the sample of 19. This failure resulted in R1 wandering through a stairway door and falling down the stairs to her death. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate and monitor the effectiveness of the Wandering Resident and Elopement policies and procedures. Findings include: On [DATE], at 5:30 AM, the door to the stairwell on ,[DATE] hallway was unlocked but alarmed with a squelch-type alarm. The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documents R1 is severely impaired with cognition, is non ambulatory, requires extensive assistance of 2 staff for transfers and bed mobility, has no limitations to both upper and lower extremities and uses a wheelchair. The current MDS documents R1 has unsteady sitting and standing balance. The Fall Risk Assessment, dated [DATE], documents R1 is chair bound with a device to prevent falls, is disoriented X 3 (person, place, time) at all times and is a moderate risk for falls. The Elopement Risk Assessment Form, dated [DATE], documents R1 is at risk for elopement from the facility. The Incident/Accident Report, dated [DATE] at 6:25 AM, documents R1 was confused and had a self releasing seatbelt while seated in a wheelchair.The Incident/Accident Report further documents R1 was observed on the landing of the stairwell and was unresponsive. The Report fails to document the staff involved in the accident or what had happened. The Nurses Note for R1, dated [DATE] at 6:30 AM, documents, "Summoned to 400 hall, nurse stated resident (R1) was in the stairwell. Noted resident face down with wheelchair on the top of resident. Non responsive to verbal and tactile stimuli, nail bed cyanotic, lips blue-911 (emergency response) in route." The Prehospital Care Report Summary for R1 from Z3, Paramedic, dated [DATE], documents a call from the facility was received on [DATE] at 6:32 AM, and the ambulance was on the scene at 6:35 AM. The Report Summary documents, in part, "Disposition: Dead prior to arrival. Unwitnessed cardiac arrest/trauma. Breathing: Apneic, absent lung sounds, pale, skin temperature-cool, capillary refill: absent. Left eye-non reactive, right eye-nonreactive, unconscious. EMS (emergency medical service) noted that the patient (R1) was asystole (state of no cardiac electrical activity/flatline, no blood flow) with a very occasional beat, EMS confirmed no pulse times 3. The nursing staff stated they saw the patient (R1) a little before 6:00 AM, and she was asleep in her wheelchair at the nurses station. The staff stated that after they did not find (R1) and around 6:30 AM, they found patient lying prone on a platform down a flight of about ,[DATE] stairs with a small puddle of blood around her head, and her wheelchair on top of her. Staff stated they called EMS right away. EMS noted upon arrival, the wheelchair was taken off (R1). EMS noted the patient was lying on her side and slightly rolled onto her back, with a towel over her forehead. EMS noted there was a large gash in her head. The patient was pale, cool and dry, had bruising around the eyes, with no pulse, was not breathing. The nursing staff stated (R1) was a DNR (do not resuscitate) and presented EMS with papers. EMS notified dispatch and notified the nurses they need to call the coroner. (R1) was left with the nursing home." On [DATE] at 12:10 PM, the facility's video/view of dining room north exit, dated [DATE], was observed. On [DATE] at 5:49 AM, R1 is seen leaving the dining room. The video/view of vending machine elevator, common area adjacent to the stairwell entry door was observed for [DATE]. On [DATE] at 5:56 AM, R1 is seen in a wheelchair facing the vending machines. At 5:58 AM, 6:02 AM and 6:07 AM, R1 remains in the vending area. On [DATE] at 6:08 AM, R1 is seen turning toward the stairway/hallway. At this time, the camera loses sight of R1. From 6:08 AM, R4, E12, Certified Nurses Aide (CNA), and R5 enters and exits the elevator with R1 not in sight of the camera. On [DATE] at 6:16 AM, R5 exits the elevator and walks toward the stairwell, then briefly goes out of view of the camera. At 6:37 AM, numerous facility staff are seen going to the stairwell, and then are out of the camera's view. Numerous attempts to contact E8, CNA by telephone on [DATE] at 10:48 AM, 2:49 PM and on [DATE], at 12:40 PM were unsuccessful. The written and signed statement for E8 dated [DATE] documents, in part, "I came in side entrance and found (R1). I felt for a pulse. I couldn't get one. I jumped over (R1) and ran to the door and screamed for a nurse. (R1) was face down. We were trying to get the wheelchair off her. A nurse gave me scissors to cut her seatbelt. We took the chair off and rolled her over. (E9, Registered Nurse/RN) and (E10, Licensed Practical Nurse/LPN) came to help. I layed down next to (R1) to see if I could get a pulse. Nurses came down the elevator to get to us. When I pushed the door to call for the nurse, the alarm sounded. It was working." On [DATE] at 7:00 AM, E9 reported she worked the midnight shift of [DATE]. E9 stated, "I saw (R1) sitting in the hallway between the lobby doors and ,[DATE] hall with a seat belt alarm on about 5:50 AM. I was coming off of 400 hall to pass med's (medications) on 300 hall about 6:20 AM and a day aide (E8) came in and yelled, 'I need a nurse. Call 911!' I saw (R1) lying on the landing face first with seatbelt on and no alarm sounding. I tried to get the seatbelt off, but couldn't. I yelled then to go get scissors. (E8) cut the seatbelt, removed it and pulled the wheelchair out of the way. I rolled her (R1) over and didn't get a pulse. I put a hand on her chest. No respirations, no pulse, no rise of the chest visually. Both hands were cyanotic. Blood was coming out of her mouth. Blood was on the left side of (R1's) forehead. I wiped all the blood off her face. Someone else called the coroner, but I took the return call. (E10) was actually the nurse assigned to (R1). Paramedics came and put an EKG (electrocardiogram) monitor on her. I came upstairs to see if I could help. E11, CNA stayed with (R1). I took the call back for the coroner . He asked who the deceased was. I gave him her name, birthday and next of kin, [DIAGNOSES REDACTED]. That was it. I don't remember his name. I just told him what he asked." On [DATE], at 12:55 PM, E10, LPN stated, "I was paged to the 400 hall. The nurse (E9) said (R1) fell down the stairs. Then I just went to the stairwell. (R1) was on the landing after the first set of steps, face down with the wheelchair on top of her. The alarm chimed when I opened the (stairway) door. At that time, I asked if I need to call 911. I was told it was already done. I checked (R1's) pulse-no pulse. I got the wheelchair off her and yelled for scissors. Someone pushed the belt to get it off her. The chair was removed to get access better. It was 6:30 AM, the change of shift. The ambulance arrived around 6:45 AM. They assessed (R1) with no vital signs and pronounced her expired. The ambulance staff called the coroner. They said they have to. I assumed they called the coroner. I called the family member and (Z2), Physician and notified the exchange. (Z2) called right back. I told him (Z2) it was an unfortunate incident and was asked to fax the H & P (history and physical) and face sheet. I gave (R1) medication that morning. (R1) is not known to be an elopement risk, but she did wander everywhere with the wheelchair with a seatbelt, usually with her feet. There were no problems with the chime alarm. I used that stairway during the night. It worked. The chime lasts seconds-you can hear the doorbell (chime)from the nurses station." On [DATE], at 12:10 PM, E15, LPN reported she had worked the night shift of [DATE]. E15 stated, "I seen (R1) when (E8) came up and said someone fell down the stairs. (E9) got there before me. I was busy with another resident who was in respiratory distress. The new shift was coming in. I took the steps, looked down to the landing, then called 911, a male dispatcher. I told them there was an accident, that someone fell down the stairs, and we need an ambulance. I asked if (R1) was still with us and was told she was unconscious. I hadn't seen (R1) that night. The last time I saw (R1) was a week ago. (R1) wanders around the facility in a wheelchair." On [DATE] at 11:00 AM, E11, CNA reported she was working the night shift of [DATE], and came from another resident's room when she saw staff running around. E11 reported she heard (E25), CNA state R1 had fallen down the stairs. E11 stated, "I went to the stairwell door to see and at that moment staff was bringing up the wheelchair. (E9) and someone else was there. I grabbed the wheelchair and helped pull it up the stairs. I saw (R1) rolled onto her back face up. (E10) was there assessing her and waiting for paramedics. (R1) had no response or respirations. A big gash was on the right aside of the forehead. Blood, a medium amount was there. (R1) might have had bruising. The paramedics got there around 6:25 AM. They hooked (R1) to a EKG to see if there was a heart rate and check her pulse. So then they said she was dead. The paramedics told me to stay with the body until the coroner gets there." E11 reported R1 propels herself in the wheelchair using her feet. E11 reported R1 is confused and very hard of hearing, but alert at times. E11 reported she did not hear the stairway door chime that morning. E11 stated, "I have heard it go off before-ding dong, and at other times it is a shrill sound. I usually use the elevator." On [DATE] at 12:20 PM, E14, Maintenance Director reported that prior to R1's fall, the alarm to the stairway door was set to chime. E14 reported he checks the door alarms every morning after he arrives at 8:00 AM. E14 reported the last time he had checked the stairway door alarm prior to the fall was the morning of [DATE]. E14 reported he arrived at the facility for work on [DATE] at 6:45 AM and went to the employees entrance downstairs on the 500 hall. E14 reported usually using the stairs to go upstairs, but someone told him the morning of [DATE] he couldn't use the stairs. E14 reported he checked the door alarm to the stairs after the accident at approximately 1:00 PM, and the alarm chimed. E14 reported the chime alarm "Ding-dongs" until the door automatically closes. E14 stated, "If no staff is located at the nurses station, it would depend on how far down the hall you are if you could here it." E14 reported R1 was known to be a wanderer. E14 reported usually only the employees use the stairs, and if a resident uses the stairs a staff member must accompany them for safety. On [DATE], at 8:50 AM E3, Vice President of Operations stated, "The alarm that was on the stairway door prior to [DATE] sound was different. It went ding dong and stopped as soon as you went through the door. The alarm was functioning when (R1) went down. (E7), CNA checked on (R1) prior to the accident. (R1) liked to sit in front of the vending machine. E7 said he rubbed her back. We have (R1) going into the vending area on tape. You see (E7) doing rounds. He's a night shift CNA. The stair door to the ,[DATE] hall only sounded once, then stopped." E3 reported R1 would wander throughout the facility in her wheelchair. On [DATE] at 10:00 AM, R5 was asked if she had witnessed R1 go through the door to the stairwell, or if she had heard an alarm sound on [DATE] between 6:15 AM and 6:20 AM. R5 refused to respond. On [DATE] the other residents, R4 and R7 who were viewed in the video of the vending, elevator and stairwell area were interviewed. Both R4 and R7 reported they did not see R1 or knew of R1's accident the morning of [DATE]. On [DATE] at 1:20 PM, Z1, Deputy Coroner reported the preliminary report of the cause of R1's death is blunt force trauma to the head and possibly a broken back. Z1 reported an autopsy will be performed on R1. Z1 reported if the facility calls 911, the call goes straight to the local police department dispatcher. Z1 reported the police would normally respond, but the information provided by E9 wasn't given properly, so only an ambulance responded. On [DATE] at 2:05 PM, Z2, Physician and the facility Medical Director reported R1's fall down the stairs could have caused her death. Z2 stated, "I was livid this happened." R1's Care Plan, dated [DATE] documents, in part, "(R1) is an elopement risk/wanderer. Resident wanders aimlessly, impaired safety awareness. Disoriented to place. Per Elopement Risk Assessment, (R1) is at risk for leaving facility unattended." Interventions documented include; Apply (attached safety monitor that alerts staff a resident has left the building) [DATE]. Check placement and function per policy. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television. Identify patterns of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor every 15 minutes until (attached safety alarm) obtained and then RN (as needed). R1's Care Plan revised on [DATE] documents, in part, (R1) is at risk for falls related to gait/balance problems. (R1) maintains bad posture while in chair. R1 slouches and slides forward in chair. (R1) wears a seatbelt for security and to remind her to push herself back. (R1) is able to release seatbelt herself." R1's Care Plan also documents she has impaired cognitive function/dementia with an intervention that includes; Needs assistance with all decision making. 2. On [DATE] at 2:00 PM, E1, Administrator reported and provided documentation that R11 through R14 have poor safety awareness and have the potential to wander to the stairwell. Throughout the survey R11, R12, R13, and R14 were observed wandering around the facility propelling themselves in wheelchairs. R11's Elopement/Wandering Risk Assessment, dated [DATE] documents R11 ambulates independently with or without the use of an assistive device, including a wheelchair, and is cognitively impaired with poor decision making skills. R11's Fall Risk assessment dated [DATE] documents R11 is disoriented X 1 and has a balance problem while standing and walking. R12's Elopement/Wandering Risk Assessment Form, dated [DATE], documents R12 ambulates independently and has a hearing, vision or communication problem. R12's last Fall Risk assessment dated [DATE] documents is a moderate risk for falls, requires a device to prevent falls, is disoriented X 3, and has balance problems while standing and walking. R13's Elopement/Wandering Risk Assessment Form, dated [DATE], documents R13 ambulates independently, is cognitively impaired with poor decision making skills, wanders without a sense of purpose, and is at risk for elopement. R13's Assessment of Fall Risk dated [DATE], documents R13 is chair bound and requires the use if assistive devices. R14's Elopement/Wandering Risk Assessment Form, dated [DATE] documents, in part, R14 ambulates independently with or without the use of an assistive device, has hearing vision or communication problems and is cognitively impaired with poor decision making skills. The Elopement Assessment documents "(R14) wanders through the facility, will not attempt to leave out doors." R14's Fall Risk Assessment, dated [DATE] documents R14 is a high risk for falls, is disoriented X 1, is legally blind and requires the use of an assistive device. On [DATE], at 10:46 AM, E1 reported the facility does not have a door alarm policy. E1 reported the facility does not have a policy to address wandering residents, but will immediately develop and implement one. The facility's policy and procedure, entitled, 'Fall Management' dated ,[DATE], documents, in part, "It is the policy of the facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Safety interventions will be implemented for each resident identified at risk using a standard protocol. Facility staff are responsible for assuring ongoing precautions are put in place and consistently maintained. The resident's environment will be kept clear of clutter and remove hazards. Residents will be observed every 2 hours to ensure the resident is safely in bed or chair." The Immediate Jeopardy began on [DATE] at approximately at 6:08 AM when R1 turns from the vending area and moves toward the stairway door and out of the sight of the camera. E1 was notified of the Immediate Jeopardy on [DATE] at 12:42 PM. On [DATE] the surveyor determined through observations and record review the facility took the following action to remove the Immediacy: 1. On [DATE], 4 residents, R11, R12, R13, and R14 were identified to have poor safety awareness, who have the potential to wander and open the stairwell door. Care Plans have been reviewed and updated accordingly. Completion [DATE] 2. On [DATE] the volume and intensity of the alarm for the stairwell door was immediately increased and change to an instant loud shrill that can only be tuned off by entering a numerical code on a key pad located at the top of the door. Completion date [DATE] 3. On [DATE] at 4:35 PM, Z1, Medical Director was notified of the Immediate Jeopardy. 4. The double doors on the main level leading to the stairwell were kept closed to deter the use of the stairwell door on [DATE]. 5. On [DATE], door guard stop banner with alarm were ordered for overnight delivery to be placed on the doors at the top of the stairwell and at the bottom of the stairwell. Completion date [DATE]. 6. ON [DATE], facility staff were educated and inserviced on responding to the door alarms, not using the stairwell doors except for emergencies and the facility wandering and elopement policies. Completion [DATE] 7. On [DATE], the facility developed and implemented a Wandering resident policy and educated staff accordingly. Completion [DATE] 8. On [DATE], the facility reviewed and revised the facility Elopement policy and reviewed and revised the facility Elopement Risk assessment to include wandering. If assessment is revised, all residents will be reassessed with [REDACTED]. All elopement risk assessments on current assessment forms completed and have been completed within the past 30 days. Completion [DATE] 9. The Administrator and/or Designee will perform functionality testing of stairwell door alarms 3 X per week times 12 weeks and will perform random observations of the door guard banner placement and double door closure compliance 3 X per week for 12 weeks. 10. All staff will be re-educated on education within the plan monthly for 3 months to assure compliance and safety requirements. 11. Results of the reviews will be discussed in the quarterly QA (quality assurance) meeting times 3 quarter with educational needs discussed as needed.

Based on interviews, observations and record review, the facility failed to development a preventative plan for pressure ulcers, identify, assess, monitor and treat pressure ulcers in a timely manner for 4 of 4 residents (R5, R7, R8 and R10) reviewed for pressure ulcers in a sample of 13. This failure resulted in R5 developing facility acquired unstageable pressure ulcer to her left heel, a Stage II pressure ulcer to her left ear and and an unstageable pressure ulcer to her coccyx. R5's pressure ulcer on her ear deteriorated to a Stage IV. This failure resulted in an Immediate Jeopardy which was identified to have begun on 1/28/15. While the Immediate Jeopardy was removed on 2/7/15, the facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and update the staff on Pressure Ulcer Prevention and Treatment policies and procedures. Findings include: 1. R5's January 2015, Physician order [REDACTED]. R5's BRADEN SCALE - For Predicting Pressure Sore Risk of 1/8/15 documents a score of 11 which is high risk and on 1/22/15 a score of 10 which is high risk. R5's Admission Resident - Data Collection report of 1/8/15 documents R5 has a reddened coccyx with skin intact. There is no other documentation of skin breakdown. R5's undated Interim Plan of Care documents R5 requires total care and has a reddened coccyx. R5's Care Plan approach is to keep R5 clean, dry and safe. R5's Comprehensive Admission Skin Assessment of 1/8/15 documents reddened area on the coccyx. The Assessment documents "Pressure ulcer prevention. Keep pt (patient) clean & dry, q (every 2 hours)." There are no other prevention interventions for pressure ulcers identified on the assessment. The TAR documents R5 was admitted on [DATE] and R5 was to have weekly skin assessment. R5's January 2015 Treatment Administration Record (TAR) documents the 1/17/15 Weekly Skin Assessment was completed and R5's skin was warm, dry and color fair. No [MEDICAL CONDITION]. The Assessment documented R5 had contractures to bilateral hands and foot drop to bilateral feet. No areas of concern were noted. Note of 1/28/15 documents "Skin warm dry, open areas noted on coccyx and left and right buttock, treatment ordered." The TAR documents skin checks were only done on 1/17/15 and 1/28/15 in the month of January. R5's WOUND CARE SPECIALIST INITIAL EVALUATION done by Z1, Wound Doctor, dated 1/28/15 documents the following pressure sores: 1. An unstageable DTI (Deep Tissue Injury) to the left heel measuring 3 centimeters (cm) x (by) 3 cm with recommendation for heel boot to be worn in bed and chair to off-load wound, float heels in bed and off-load wound. 2. Stage 2 pressure ulcer to the left ear measuring .5 cm x .5 cm x .1 cm with light sero sanguineous drainage. Dressing: Dry Protective Dressing - once Daily and PRN (as needed). Off-load wound. 3. Unstageable (Due to Necrosis) of the coccyx measuring 4 cm x 2 cm with depth not measurable. Light serous exudate. Noted as reddened area upon admission. Dressing: Santyl - Twice daily and PRN. Dry Protective Dressing twice daily and prn. Antifungal - twice daily and PRN. Off load wound, reposition per facility protocol. 4. Z1 ordered a pre-[MEDICATION NAME] for R5. The results of the pre [MEDICATION NAME] of 1/30/15 documents Pre-[MEDICATION NAME] of 17.5 mg/dl (milligrams)/dl (deciliter) with normal being (16-45). On 1/30/2015 at approximately 3:00 PM, R5's TAR was copied and did not have documentation on the TAR of the above pressure ulcers and treatment orders. On 1/30/15 at 11:17 AM, E3, Licensed Practical Nurse, LPN, completed a skin check while R5 was in bed. R5 had heel protectors on her feet but feet were not off loaded from the mattress. There was a purple pressure sore larger than an inch on her left foot. R5 had an open pressure sore with yellow center on her coccyx. R5 did not have a dressing on her coccyx and she had feces at the anal area. R5 had a scab and dried blood on her outer left ear that did not have a dressing. R5's right hand had red opened areas on her 1st finger and third finger and a scab on her thumb. At 11:20PM, E6 and E8, Certified Nurse's Assistants, CNA's, stated they were the CNA's that were caring for R5. They stated they had last given care to R5 at 8:00 AM and R5 did not have any dressing on her ear or coccyx at that time. There was no dressing in R5's bed or under the bed or in the surrounding area. E8 gave R5 incontinent care and using the same soiled gloves put barrier cream on R5's buttocks and coccyx. An observation was made with E1, Administrator, on 1/30/2015 at 2:30 PM. R5 was in bed and still had no dressing on her coccyx/buttock area or ear. R5 did have heel protectors on but her heels were not floated. There was no dressing on R5's ear and E1 was informed of the areas on R5's right hand. At 2:45 PM, E1 stated that they had found R5's bandage for her left ear in her bed but staff were not taping on the bandage and she didn't know why. On 2/4/2015, at 9:45 AM R5 was in bed. Skin check with E1 showed R5 did not have a dressing on her left ear and there was blood on her pillow case. E1 did not have heels floated. E1 did have a bandage over her buttocks and coccyx area and was incontinent of a large amount of feces. The bandage did not have a time or date documented as to when it was applied. On 2/4/15 at approximately 10:00 AM, E2, Director of Nursing (DON), was asked for a copy of R5's January TAR. The TAR documented an order for [REDACTED]. The TAR documents "Apply Skin Prep to left heel BID" with documentation that it was applied only one day, 1/29, but not applied on 1/28/15, 1/30/15 or 1/31/15. There was nothing on the TAR about floating the heels. The TAR showed order of 1/28/15 to apply dry dressing to the left ear every day and PRN with no documentation that this was being done. There is no documentation on the TAR for February 2015 that the above treatments were being done. Z1's WOUND CARE SPECIALIST EVALUATION done on 2/4/15 documents that R5's pressure ulcer on her left ear had increased in size to "1 cm x .5 cm x .1 cm and is a stage 4 with surgical excisional debridement of muscle. Continue dry protective dressing once daily and PRN. Mupirocin once daily and PRN. Off-load wound." Z1 stated on 2/4/15 at 11:35 AM, R5's wounds on her coccyx, ears and heel is from pressure and she would expect the dressings to be on. Z1 stated that the dressing on R5's ear should be taped. The pressure sore is chronic and down to the cartilage. Z1 stated R5 favors laying on her left ear and needs to be kept off the ear or it won't heel. Z1 stated she is ordering special ear protectors for R5. On 2/6/2015, at 2:20 PM, an interview was conducted with E10, Assistant Director of Nurses/Wound Nurse. E10 confirmed R5's TAR did not have any documented orders/ treatments for R5's ear or coccyx until 2/4/2015. E10 stated that the floor nurses would not know to do the treatments unless the orders were on the TAR. E10 stated if the treatments on the TAR are not initialed as completed then the treatment was not completed. E10 stated it is Nursing Standard of Practice to document/initial the TAR after completing a treatment. On 2/6/2015, at 2:30 PM, an interview was conducted with E3. E3 stated the nurses typically look at the TAR to see if a resident has a treatment. E3 stated once the treatment is complete, the nurse would initial the date and time the treatment was competed on the TAR. E3 stated if a physician gives an order for [REDACTED]. When questioned if a signature is missing on a TAR, E3 responded "It's either you forgot to sign it or you didn't do it." On 2/6/2015, at 2:45 PM, an interview was conducted with E12, Corporate Nurse. E12 stated the TARS should reflect the treatment orders for each residents. E12 stated "That's how you know." E12 stated if nurse's do not initial the TAR then you can assume the treatment was not done. R5's Care Plan of 1/22/15 and revised on 2/3/15 does not address R5's Pressure Ulcers. The Care Plan does not address R5's risks for pressure ulcers and interventions to aide in healing existing pressure sores or the prevention of developing new pressure ulcers. The Facility's Decubitus Care/Pressure Area Policy, reviewed January 2014, documents "To ensure a proper treatment program has been instituted and is being closerly monitored to promote the healing of any pressure ulcer, once identified." The Policy documents "1) The pressure area will be assessed and documented." The Policy documents "3) Notify the physician for treatment orders. The physician's orders [REDACTED]. The order must have specific frequencies; vi) Initiate physician order [REDACTED]. 2. The MDS dated [DATE] identifies R10 as totally dependent on staff for all activities of daily living. The MDS documents [DIAGNOSES REDACTED]. R10's POS documents R10 has a [MEDICAL CONDITION] and gastrostomy tube. The Braden Scale dated 1/9/15 identifies R10 at high risk for pressure ulcer development. The Braden Scale dated 12/29/14 identifies R10 as high risk for pressure ulcers. R10's laboratory results dated [DATE] reflects normal Protein 6.3 (Normal 6-8.2) and [MEDICATION NAME] 3.5 (Normal 3.5-5,5) and Pre-[MEDICATION NAME] dated 2/5/15 was also normal at 22 (normal 16-45.) The Weekly Pressure Ulcer Record dated 12/10/14 identifies R10 as having multiple pressure ulcers at that time and the Weekly skin reports also document a pressure ulcer on left heel. Treatment orders are present on the POS January and February 2015 for all three areas. The care plan dated 12/29/14 does not include a prevention plan nor a treatment plan for R10's pressure ulcers. R10's weekly wound documentation dated 12/10/14 identify it as the first evaluation by Z1 for R10's Elbow Ulcer. Measurements were "3.5 cm x 2.5 cm x 1cm stage 3 duration less than 6 days, undermining 1cm at 9 o'clock, moderate Serous exudate, 5% necrosis and 95% granulation." Weekly Skin Reports dated 12/17/14 and 12/24/14 show minimal change with Z1 documenting the area as "healing". Recommendation for all visits was to off load. On 1/14/15, R10's weekly wound report for the elbow ulcer continues to document it as a stage 3 with 100% granulation with the area measuring 2.5 cm x 2.5 cm x 1 cm. Weekly report narrative, dated 1/21/15, written by Z1 documents that R10's elbow pressure ulcer has deteriorated due to infection, wound not adequately off-loaded, measurements were 4 cm x 3 cm x1 cm, wound progress "deteriorated". The Weekly wound care notes, dated 1/28/15, by Z1 document the same measurements as before but indicates there is moderate purulent exudate with the elbow wound, 30% necrotic tissue. The report documents a surgical excisional debridement of the subcuteaneous tissue was done. On 2/4/15, Z1 documented R10's elbow pressure ulcer was stage IV with no other changes. On 1/30/15 at 10:00 AM, R10 was laying in bed on her back with her elbows resting on wedge cushions under both elbows. R10's knees were drawn up in contractures and her arms were pulled inward. At 10:30 AM, 11:05 AM, 11:35 AM, 12:00 PM, 12:30 PM and 1:00 PM, R10 remained in the same position with the head of the bed elevated until 1:30 PM. At 1:35 PM, a skin check was done with E3 LPN and E6,CNA. R10 was laying on her back, knees and arms contracted, with her left elbow resting directly on the wedge cushion to her left side. R10's elbow dressing was loose and saturated with a blood tinged drainage which had saturated the incontinent pad under R10's elbow as well. R10 had a incontinent brief under her which had smears of dried bowel movement on it along with a large area of urine which E6 CNA identified as urine from her leaking catheter. E6 stated she had been at 10:00 AM to change R10's position. R10 had no protective devices on her feet which layed directly on the mattress. On 2/5/15 at 10:30 AM, R10 was laying on her back with wedge cushions at both elbows. Her legs were laying to the right side. She had no protection on her feet which were laying directly on the mattress. There was no padding between her legs. R10's left elbow dressing was again hanging loose and was blood/drainage soaked. The dressing was dated 2/4/14. E10, Assistant Director of Nurses/Wound cleansed the wound, applied Alginate with Santyl after applying sureprep to the wound edge. She then applied the dressing and tucked the wedge cushion under R10's arm only to have it pop back out. E10 told E17, CNA, that R10's arm needs to be off the wedge and "off loaded." E10 also stated R10 needed to have EZ boots on which were in the laundry. As E10 did the treatments, R10's left heel ulcer did not have a dressing on and was laying directly on the bedsheet. E17 stated that R10's heel did not have a dressing on it when she turned R10 at 8:00 AM that morning. E10 cleansed the heel wound with wound cleanser then laid the heel back on the sheet before she applied the Alginate and Santyl dressing. E10 directed E17 to inform the nurse when she notices a dressing not on a wound. Wound documentation of R10's left heel documents that it was first identified on 12/10/14 as a deep tissue ulcer by Z1 with the plan of treatment to include skin prep and EZ boot to be worn in bed and chair to off-load wound, float heels in bed, off-load wound. Z1's weekly notes documented on 12/17/14 and 12/21/14 document no change in R10's heel ulcer. The note dated 1/14/15 and 1/21/15 identifies some improvement and on 1/28/15, no change noted. Recommendations continue to be off loading and float heels in bed. Wound documentation of the heel on 1/28/15 have measurements as 1.5 cm x 1 cm x 0.1 cm with 100% granulation, stage III, improvement noted. TARS for January and February 2015 document only one time daily for Skin Prep to the right heel and left lateral foot ordered BID (twice daily). The Elbow treatment of [REDACTED]. The TAR also includes a directive to check left elbow dressing every shift but is documented only twice daily. The left heel ulcer's treatment to cleanse with wound cleanser, apply hydrogel with a 4 x 4 dressing daily and PRN is documented daily with no PRN's initialed. On 2/11/15 at 10:15 AM, Z1 Wound Physician stated that R10's pressure ulcers on her heel and elbow were developed prior to her admission to the facility last fall. 3. The MDS dated [DATE] identifies R8 as being a [AGE] year old female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documents R8 to be totally dependent on staff for all activities of daily living (ADL) and interviewable with Spanish being her primary language. The MDS also indicates she has a [MEDICAL CONDITION], gastrostomy, and urinary catheter. The care plan of 11/14/14 identifies R8's bowel incontinence and immobility as a risk factor in skin breakdown with the goal for R8 to be free from skin breakdown. Interventions include incontinent check every 2 hours and as required, wash, rinse, and dry, monitor and document intake and output per facility policy, and encourage her to use a bedpan for bowel movements and offer pan every two hours. The plan does not include turning/repositioning. According to the Nurse's Notes, R8 was transfered to the emergency room late on 1/29/15 and returned to the facility on [DATE]. R8's TAR's, Nurse's Notes, Weekly Pressure Ulcer reports all fail to identify any pressure ulcers on R8 upon discharge to the hospital on [DATE]. However, hospital history and physical notes dated 2/3/15 document R8 to have "pressure sores on her back and buttock areas" with the Skin/Wound assessment dated [DATE] "sacrum, gluteals, and coccyx are red, blanchable, and intact." There is no evidence the facility was aware of these areas prior to R8's discharge. On 2/4/15 at 8:45 AM , R8 was in bed with the head of the bed elevated as she ate breakfast unattended. At 9:10 AM, 9:45 AM, 10:00 AM, 10:30 AM, 11:00 AM, 11:30 AM and11:45 AM to be sitting in the same position in bed with the head of the bed elevated. At 12:00 PM, R8's skin was observed with E10 and Z1. R8 had no redness or open areas on her coccyx and/or buttocks but was deeply creased. There were 3 incontinent pads under R8 along with a quarter folded bath blanket. Her heels were laying directly on the pads on the bed. E11, CNA, stated she last repositioned R8 right after breakfast when giving her the bedpan. R8 remained on her back with the head of the bed elevated through lunch and at 1:00 PM, 1:30 PM , 2:00 PM, 2:30 PM, and 3:00 PM. On 2/10/15 at 4:32 PM, E20 LPN stated she discharged R8 to the hospital the evening of 1/29/15. E20 stated R8 was able to shift her weight side to side with assistance and did not have any open areas on the coccyx or buttocks that she knew of. On 2/11/15 at 11:10 AM, R8 was interviewed with the assistance of E24, Respiratory Therapist, due to R8 only being speaking spanish. R8 stated she did have a sore on her coccyx and buttocks at the facility before her discharge to the hospital which the nurses were aware of but not treating. R8 stated the sores healed in the hospital before she returned to the facility. 4. R7's MDS, dated [DATE], documented diagnoses, in part, [MEDICAL CONDITIONS] and Diabetes Mellitus and total dependence of two plus persons physical assistance with mobility, transfer and hygiene. R7's Nursing Note, dated 1-6-2015, documented, in part, "Also noted pressure ulcers on buttocks." R7's Treatment Record, dated 1-2015, documented her treatment as "cleanse areas to coccyx with w/c (wound cleaner) apply hydrogel cover with dry dressing" which was documented as administered on 1-6-2015 and 1-8-2015 through 1-24-2015. R7's Treatment Record also documented on 1-9-2015, "area to coccyx dressed as ordered"; and on 1-16-2015, "area to coccyx has treatment in progress as ordered." R7's Treatment Record, dated 1/2015, and her Nursing Notes, dated 1-6-2015 to 1-25-2015, and her Care Plan, dated 1-2015, did not document her pressure sore measurements, to include decline or improvement, location, effectiveness of her pressure sore treatments or pressure sore prevention measures. R7's Nursing Notes, dated 1-25-2015, documented, in part, that R7 was sent to a local emergency room to evaluate her [DEVICE] displacement. R7's Comprehensive Admission Skin Assessment, dated 1-31-2015, documented that she returned to the facility with "Area to coccyx measures 11 cm (cubic meter) from East to West. The right buttocks measures 5 cm from North to South, left buttocks areas measures 7 cm from North to South." R7's Skin Issue Notification Tool to Treatment Nurse, dated 1-31-2015, documented, "pressure ulcer, blackened area, coccyx area, treatment in progress (see treatment book), blackened heels treatment in place," R7's Care Plan, admitted d 1-31-2015, did not document that R7 had pressure sores to include goals and interventions. R7's Treatment Record, dated 1-2015, did not document her pressure sore measurements, to include decline or improvement, location, effectiveness of pressure sore treatment or pressure sore prevention measures. Interview of E10, Assistant Director of Nursing (ADON), on 2-6-2015 at 2:00p.m., E10 stated that she could not find R7's pressure sore measurements, care planning, monitoring, assessments or pressure sore preventive interventions, other than what is documented in this narrative, for any of R7's pressure sore areas. The facility's Decubitus Care/Pressure Area Policy, reviewed January 2014, documents "4) Documentation of the pressure area must occur upon identification and at least once each week. The assessment may include: i) Characteristic (i.e. size, shape, depth, color, presence of granulation tissue, necrotic tissue, etc.); ii) Treatment and response to treatment. E1, Administrator, E12, E21, E22, and E23 Corporate Nurses were notified of the Immediate Jeopardy on 2/6/15 at 2:50 PM. On 2/10/2015, surveyors confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy on 2/7/15. The Immediate Jeopardy Removal Plan is as follows: 1. On 2/6/15 Facility has reviewed the Pressure Ulcer Policy and Procedures. The facility is currently performing a facility wide skin assessment on all residents who reside in the facility to remove the Immediate Jeopardy. Completion date 2/7/2015 2. On 2/6/15 Facility is currently performing education with nursing staff on the pressure ulcer policy and procedure, including identifying, assessing, monitoring and treating any resident at risk for pressure ulcers to remove the alleged Immediate Jeopardy. Completion date 2/7/15. 3. On 2/6/15 Facility is currently performing education with the licensed nursing staff on proper transcription of physician's orders [REDACTED]. Completion 2/7/15. 4. On 2/6/15 Facility is currently performing education with the licensed nursing staff on completion of treatments to remove the Immediate Jeopardy. Completed 2/7/15 5. On 2/6/15 Facility is currently performing education with the licensed nursing staff on physician's notification if pressure ulcers have declined to remove the alleged Immediate Jeopardy. Completion date 2/7/15. 6. On 2/6/15, Facility will assess all residents for pressure ulcers with plan of care updated accordingly. Completion date 2/7/2015. 7. Quality Assurance: DON/Designee will perform random observations of Residents at risk for Pressure ulcers, 4 times a week for 8 weeks, then weekly times 4 weeks to ensure appropriate identification, assessment, monitoring and treatment. 8. Quality Assurance: Residents' skin will be assessed upon Admission, Readmission, as needed, Quarterly and upon a Significant Change. 9. Results of the reviews will be discussed in the Quarterly QA Meeting times 3 Quarters with educational needs discussed as needed.

Based on record review and interview, the facility failed to follow their policy for use of mechanical lifts and 2 person transfers, and failed to ensure safety measures and proper transfer techniques were used during a mechanical lift transfer for 1 of 6 residents (R9) reviewed for safe transfers in the sample of 13. This failure resulted in R9's being improperly lifted and transferred, causing him to have his tracheotomy tube dislodged from his throat, suffer respiratory distress, become unresponsive and need emergency intubation and hospitalization . R9 is currently admitted to a local hospital and continues to be unresponsive. This resulted in an Immediate Jeopardy which was identified to have begun on 2/4/15. While the Immediacy was removed on 2/6/2015, the facility remains out of compliance at Severity Level 2 as the facility continues to; assess all residents for transfer needs; educate staff and provide inservice training on mechanical lift and 2 person transfers; evaluate and monitor the effectiveness of the facility policies and procedures; and initiate a system to assess, evaluate, monitor and reassess plans of care put into place to address individual transfer needs. Findings include: 1. R9's Minimum Data Set (MDS), dated [DATE], documented diagnoses, in part, of Multiple Sclerosis, Nasogastric Feeding Tube, Tracheostomy and Ventilator Dependant. The MDS documented R9 has total dependence of two plus persons for physical assistance, mobility and transfer needs. R9 is assessed with [REDACTED]. R9's Nursing Note, dated 2/4/2015 at 2035 (8:35 PM), documented, in part, "Resident became anoxic when care was being given. CNA (E13, Certified Nursing Assistant) reported to respiratory that he had lost his tracheostomy tube at time of transfer." It was also documented that R9 was sent to a local emergency room and admitted to a local hospital with respiratory distress. On 2/5/15 at 9:30 AM, E2, Director of Nursing (DON), stated she had not been informed of the incident with R9 until this morning (2/5/15) when she arrived at work. E2, began to investigate the incident at around 7:45 AM, that E13 had lifted R9 by herself and caused R9's tracheostomy tube to be dislodged and was sent to the hospital. E2 stated E10, ADON was on call last night (2/4/15), and should have been called by staff, and an incident report started. On 2/5/15 at 10:00 AM, E10, ADON, stated "No staff had called her and she knew nothing about R9's being sent to the hospital last night." The Facility Incident/Accident Report dated 2/4/15, written by E15, Licensed Practical Nurse, documented "Went down to resident's room where he was being bagged (manually ventilated with Ambu bag) by RT (respiratory therapist) and another RT assisting trying to replace dislodged trach. (Z3, Physician) at bedside assisting and she and RT was able to replace trach. Resident was still cyanotic, bagging continued until he was placed back on Vent. O2 sats began to improve. Residents color returned to normal. Physician gave orders to transfer resident to ER for further assist." R9's Hospitalist History and Physical, dated 2/4/2015, documents "52 YO (Year Old) with H/O (History Of) MS (Multiple Sclerosis), trach and vent dependent presented to the ED (Emergency Department) from his SNF with reported nonresponsive after trach tube dislodged. Pt (Patient) unresponsive at this time." The History and Physical documented "SNF (Skilled Nursing Facility reported that pt was found non responsive and his trach tube dislodged-replaced at SNF per staff - remained nonresponsive and sent for evaluation. Reportedly when found noted with O2 sats in the 40's - SNF stated that at baseline pt is A/O (Alert and Oriented ) x 3." On 2/5/15 at 8:30 AM, E2 in her investigative notes on 2/5/15 at 8:30 AM, documented: "Call to (Employee).... looking for incident report. Not aware of one, not in building when it occurred. 2/5/15 - 9:00 AM, (E15), called 2nd time, no incident report made. Was not in room with resident, will come in to make out report. 2/5/15 - 2:30 PM, Called (E13) back. admitted did transfer by herself." On 2/5/2015 at 11:55 AM, E1, Administrator, stated "It was the Facility's policy to use two person assistance when using the mechanical lifting device." E1, stated no incident report had been made regarding R9's dislodged trach tube. On 2/5/2015 at 11:10 AM, E13, Certified Nurses Aide, CNA, stated, "Last night, 2/4/2015, I put him (R9) from chair to bed. Yes, I did it by myself. He uses a (mechanical) lift . We are supposed to use 2 people when using the (mechanical) lift but last night we didn't have enough staff, so I used the (mechanical) lift by myself. His machine beeped so I got (E18, Respiratory Therapist). Yes, when the machine beeps it means a problem with his breathing and he did seem to have some problem breathing." On 2/5/2015 at 1:30 PM, Z4, Sitter for R9, stated that she was not present at time of R9's dislodged tracheostomy but "many times they (staff not identified) have transferred him by themselves (one staff only)." Z4 also stated R9 can only move his head and could not have pulled out his tracheostomy. On 2/5/2015 at 1:35 PM, R2 stated that she witnessed E13 transfer R9, by herself (only one staff), with a mechanical lift from chair to bed. R2 stated she witnessed R9's tracheostomy tube pulled out during the transfer after which E13 placed R9 on his back in his bed, with the mechanical lift sling under him, and left the room to get assistance. R2 stated R9's tracheostomy stoma was bleeding excessively, and there was blood all over the place, while he laid in bed. On 2/5/15 at 2:00 PM, in an additional interview with E 1 she stated "There are usually 3 CNA's assigned to the 300 hall, and 3 CNA's assigned to the 400 hall (6 total) on the evening shift. On 2/4/15 for the evening shift, only 4 CNA's had reported for duty and 1 CNA went home early. This left only 3 CNA's to cover both the 300 and 400 halls instead of the 6 usually scheduled on that side of the building." On 2/6/2015 at 2:20 PM, E18, Respiratory Therapist, stated on 2-4-2015 at 2025 (8:25 PM), E13, CNA, informed her that R9's machine was alarming. E18 stated that she entered R9's room and found him laying in bed with his tracheostomy out / dislodged, and a lot of blood at his stoma site. E18 stated R9 became cyanotic after which an staff began to ambu bag R9. R9's tracheostomy was re-inserted. E18 stated that "Prior to this event, R9's tracheostomy was securely attached with a collar and that his tracheostomy could not fall out from being rolled side to side and that it would have to be pulled out.". The Facility's "Lifting Machine, Using a Portable", policy and procedure, revised April 2007, documented, "The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, two (2) nursing assistants will be required to perform the procedure." On 2/5/2015 at 10:45 AM, E3, Licensed Practical Nurse, LPN, stated that R9 required two person assistance with the mechanical lift, that he could lift only his head and was totally dependent for all other movement. On 2/5/2015 at 1:00 PM, E19, Restorative Aide, stated that R9 was not able to move his arms. On 2/6/2015 at 2:20 PM, E18, stated R9 was not able to to move is hands to pull out his tracheostomy and that he was not having a seizure at that time his tracheostomy tube became dislodged from it's site. On 2/13/15 at 10:00 AM, in a phone interview, E1 stated the above incident report written by E15 was not written on 2/4/15 as documented, but written on 2/5/15. E1 stated that the report documents 2 CNA's assisted R9 on 2/4/15 when his tracheostomy became dislodged, however this is an error, there was only 1 CNA who transferred R9 at the time of the event on 2/4/15. The Immediate Jeopardy situation was identified to have began on 2/4/2015 when R9 was transferred with only one assist, E13 (CNA), and his tracheostomy was pulled out during transfer. R9 was sent to a local hospital for respiratory distress. The facility failed to transfer R9 with the assistance of two, as per policy and procedure. E1 and E2 were notified of the Immediate Jeopardy on 2-5-2015 at 3:30 PM. Through surveyor interviews, observation and record review, the facility took the following actions to remove the Immediacy on 2/6/15: 1. On 2/5/2015, the facility reviewed the (mechanical lift) policy. Any resident utilizing mechanical lift transfers will be done with 2 staff members regardless of resident's ability to assist. 2. On 2/5/2015, the facility performed education with nursing staff that any resident utilizing a (mechanical) lift for transfers must be done with 2 staff members. Completion date of 2/5/2015. 3. On 2/5/2015, the Interdisciplinary Team has identified all residents that require (mechanical) lift. Facility has educated all nursing staff on protocol on residents that need (mechanical) lift for transfer must utilize two persons. 4. On 2/6/2015, all residents were assessed for transfer needs with plan of care updated accordingly. Completed on 2/6/2015. 5. On 2/6/2015, Resident transfer policies were reviewed and adapted accordingly. 6. Quality Assurance- DON/Designee will perform random observation reviews of transfers 3 times a week for 8 weeks, then weekly times 4 weeks to insure safe and appropriate transfers. 7. Quality Assurance- Resident transfer status will be assessed upon Admission, Readmission, as needed, Quarterly and upon Significant Change. 8. Quality Assurance - Results of the reviews will be discussed in the Quarterly QA Meeting times 3 Quarters with educational needs discussed as needed. 1. All residents were assessed for transfer needs with plan of care updated. 2 Resident transfer policies will be reviewed for adapted accordingly. 3. Director of Nursing/Designee will perform random observation review of transfer 3 times a week, for 8 weeks, then weekly times 4 weeks to insure safe and appropriate transfer. 4. Resident transfer status will be assessed upon Admission, Readmission, Quarterly and Significant Change 5. Results of the reviews will be discussed in the Quarterly Quality Assurance Meeting times 3 Quarters with educational needs discussed. 6. Inservicing and education plan was initiated with all nursing staff.

Based on record review and interview, the facility failed to supervise residents to prevent resident to resident altercations between confused residents for 3 of 3 residents (R1, R2 and R6) reviewed for residents to resident altercations in the sample of 6. This failure resulted in R1's repetitive physical and verbal aggressive behaviors and R2 incurring a fracture shoulder during a incident involving R1. Findings include: R1's Minimum Data Set (MDS), dated [DATE], documented severe cognitive impairment and physical and verbal behavioral symptoms directed toward others. R1's Nurse's Notes documented that he was sent to a local emergency roiagnom on [DATE], for agitation and aggression. R1's Physician Order, dated 7/21/2014 documented an order for [REDACTED]." R1's Nurse's Notes documented that he was sent to a local emergency roiagnom on [DATE], for, in part, aggression and agitation. R1's hospital's Behavior Health Mental Status Report, dated 9/6/2014, documented, in part, "Aggressive and agitation. Grabbing, PPI (?), swinging w(with)/fists, cursing. Doesn't walk but rolls himself in the wheel chair and hits." R1's Care Plan, not dated, documented that he sometimes exhibited physical and verbal aggressive behaviors. R1's Care Plan documented, in part, the following behaviors: On 9/2/2014, "kicked another res (R6) when asked to leave her room; On 9/4/2014 "grabbed another res (resident - not documented) arm"; On 9/7/2014, "grabbed another res (resident - not documented) arm mumbling something to res"; On 9/21/2014, "(R1) refused to move when asked by another res (resident not documented) r/t (related to) confusion kicked at other res"; and on 10/1/2014, "aggressive with (R2)." R1's Situation Report, dated 10/4/2014, documented, in part, "Resident (R1) to resident (R2) resulting in fracture. (R1) reported to have pulled another resident (R2) from her wheel chair. Both residents were immediately separated and both were sent to hospital for evaluation. (R2) returned to facility with her left arm in sling and order to follow up with orthopedic related to fracture shoulder." Interview of R2, on 10/15/2014 at 1:30p.m., R2 stated that her shoulder was broken during the incident with R1. R1's Incident/Accident Reports, dated 9/2, 9/4, 9/6, 9/21 and 10/ , did not document behavioral interventions after each incident. R1's Nursing Notes, dated 9/2/2014 to 10/1/2014, documented R1's incidents of 9/2/2014, 9/4/2014, 9/7/2014, 9/21/2014 and 10/2/2014, but did not entirely document specific problem behaviors, interventions attempted or the outcomes associated with interventions. R1's Care Plan, not dated, documented dates of his behavioral incidents but did not document interventions other than separate, remove, redirect, provide notification, monitor his whereabouts, close doors and provide medication as ordered. These interventions remained the same after each of R1's altercations. R1's MDS, dated [DATE], documented activity preferences, in part, as showering, bathing, snacks between meals, listening to music, doing things with groups of people; however, R1's chart did not document his activity preferences as potential behavioral intervention(s). R1's chart did not document on going behavioral assessments to include assessing the effectiveness of behavioral interventions. During interview of E1, Administrator, on 10/14/2014 at 10:30a.m., E1 stated R1's physical and/or verbal behaviors were documented on his Behavior/Intervention Monthly Flow Record which was dated 7/2014. E1 also state that she could not find any other documentation. R1's Behavior/Intervention Monthly Flow Records, dated 7/2014, documented he was monitored for restlessness and hitting staff. It was also documented that his behaviors were not assess every shift from 9/1/2014 to 9/30/2014 or that he displayed any behaviors for the month of 9/2014. During interview of E2, Director of Nursing (DON), on 10/14/2014 at 2:15p.m., E2 stated that she would expect behaviors to be tracked and interventions put into place. The facility's Behavior Assessment and Monitoring policy and procedure, dated 4/2007, documented, in part, "Problematic behavior will be identified and managed appropriately. If the resident is being treated for [REDACTED]. The staff will document (either in progress notes, behavior assessment forms, or other comparable approaches) the following information about specific problem behaviors: a. Number and frequency of episodes; b. Preceding or precipitating factors; c. Interventions attempted; and, d. Outcomes associated with interventions."

Based on record review and interview, the facility failed to follow a Do Not Resuscitate (DNR) advanced directive for 1 of 3 residents (R1) reviewed for advanced directives in a sample of 6. This failure resulted in R1 receiving Cardiopulmonary Resuscitation (CPR) at the facility, was hospitalized for [REDACTED]. R1 expired on [DATE]. This failure resulted in an Immediate Jeopardy. . While the immediacy was removed on [DATE], the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication. Findings include: R1 was admitted to the facility on [DATE] with diagnoses, in part, of acute and chronic [MEDICAL CONDITION], acute [MEDICAL CONDITION], diabetes mellitus, dementia, [MEDICAL CONDITION], and [MEDICAL CONDITION] with ventilator support according to the "physician's orders [REDACTED]. 30, 2012. R1 has a Physician order [REDACTED]. R1 was assessed on the [DATE] Minimum Data Set (MDS) as able to usually understand in her ability to understand others. E8, Respiratory Therapist, (RT), stated in an interview on [DATE] at 10:20 AM that R1 could answer yes/no questions even though she couldn't talk. E8 stated R1 did watch television in her room in her recliner. E6, Licensed Practical Nurse, (LPN), stated on [DATE] at 10:07 AM that R1 would respond if spoken to even though she could not speak. E6 stated R1 would eat but had to be fed. The "Illinois Department of Public Health Uniform Do-Not-Resuscitate (DNR) Order Form" signed and dated on [DATE] by Z2, appointed Durable Power of Attorney for Health Care, documented Z2 had selected the following: "1. FULL CARDIOPULMONARY ARREST (When both breathing and heartbeat stop): Do Not Attempt Cardiopulmonary Resuscitation (CPR) (Measures to promote patient comfort and dignity will be provided) 2. PRE-ARREST EMERGENCY (When breathing is labored or stopped, and heart is still beating): ...Do Not Attempt Cardiopulmonary Resuscitation (CPR) (Measures to promote patient comfort and dignity will be provided)." Z1, Physician, signed the DNR order on [DATE]. The facility's "CPR Code Status" documented Z2 selected on [DATE] "No CPR: In the event of cardiopulmonary arrest, CPR (cardiopulmonary resuscitation) will NOT be initiated in the facility". Z2 did not select "NO TRANSFER: The resident will not be sent to the hospital. The resident will be given comfort and supportive measures at (Facility) as ordered by the physician". E6, LPN, stated in an interview on [DATE] at 10:45 AM that to check for a resident's advanced directive status the nurse would have to check in the resident's medical record. E6 stated the code status used to be on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. E7, Nurse Manager, stated in an interview on [DATE] at 10:47 AM that the residents have a red or green dot on the chart and on the resident's name by the outside door. Red means "Do Not Resuscitate" and green means full code. E6, who was present during this interview, stated she was not aware of the red and green dots. E1, Administrator, stated in an interview on [DATE] at 12:10 PM that there is no policy and procedure for the red and green dots on the door and chart. E32, Corporate Nurse, stated in an interview on [DATE] at 11:15 AM that there was no policy and procedures for the use of the red and green dots for code status. E32 stated there was no policy and procedure for what to do for an unresponsive resident. The "(Facility) Daily Ventilator Documentation Record" dated [DATE] documented by Z3, Respiratory student, and E3, RT, at 7:10 PM for R1 "found pt (patient) unresponsive, immediately notified respiratory, respiratory notified nursing. No reading on pulse ox (Oximetry), called ambulance, sent to hospital. Admitting dx (diagnosis): [MEDICAL CONDITION]". The nurses note by E10, LPN, dated [DATE] at 7:10 PM documented "Called to resident room...RT (related to) resident in chair unresponsive O2 (oxygen) 81 % RT (Respiratory Therapist) began to bag resident while this nurse called (ambulance) to transfer to ER (emergency room )". E3, RT, stated in an interview on [DATE] at 12:10 PM that R1 was unresponsive when she walked into the room and she shook R1 with no response. E3 stated the pulse ox had no reading and there was no pulse when she checked for a pulse. E3 stated she didn't know the code status so they did CPR on R1 and "bagged" her with the ambu-bag until the EMT's (emergency medical technicians) arrived. E3 stated the nurse did the chest compressions. E3 stated she did not recall any red or green dots on the door and the nurse went to check on the code status in the chart. E3 stated they had to do what was needed until they found out the code status. E3 stated R1 was a no code, but they got a heart rate and because R1 was a "transport" she had to be sent out. E3 stated the "No Transport" document was not signed so that meant R1 had to be transported to the hospital. E3 stated in an interview on [DATE] at 11:45 AM that Z3, Respiratory student, had found R1 and called her in. E3 stated she checked R1's pulse on her neck and wrist, there was no pulse, and no reading on the pulse oximetry machine. E3 stated she did not have a stethoscope to check for the pulse. E3 stated R1 was in a chair and she did do a few chest compressions on R1 in the chair. E3 stated they did not move R1 to a flat surface. E3 stated E13, LPN, started chest compressions and once they had a pulse they only bagged R1. E3 stated E10, LPN, went to check for the code status. E3 did not recall if there was a red or green dot on the door. E8, RT, stated in an interview on [DATE] at 11:40 AM that they usually start CPR on a resident found with no pulse until they can find out if the resident has a DNR status. E8 stated they have to check the chart to find out and would lose a few minutes finding out the status. If the resident was a full code that would mean a few minutes lost to start CPR. E8 stated there are "dots" on the door but they have to check the chart to be sure. E1, Administrator, stated, in an interview on [DATE] at 12:10 PM that there is no policy and procedure regarding the red or green dots to indicate code status. E1 stated there is no policy and procedure regarding what to do if an unresponsive resident is found by staff. E10, LPN, stated in an interview on [DATE] at 2:15 PM that she was called to the room for R1. E10 stated her pulse oximetry reading was zero and she was not sure she could hear a pulse. E10 stated she went to check for the code status. E10 stated she only saw staff "bagging" R1. E10 stated R1 was a DNR but the "No Transport" had not been checked so they had to send her out. E10 stated she did not see any staff do chest compressions. E13, LPN, stated in an interview on [DATE] at 12:25 PM that she did not have a stethoscope to check for a pulse for R1. E13 stated she felt the carotid pulse and "pushed deep" to feel it as R1 was a heavy person. E13 stated she was not sure if there was a faint pulse. E13 stated she was going to do chest compressions but R1 was in a chair and she needed to be on a flat surface and they did not put her on the floor. E13 stated E3 started chest compressions in the chair and it was back as far as it would go. E13 stated respiratory was bagging R1 and when E10 came back and said R1 was a DNR they had already stopped compressions and were just bagging her. E13 stated when the EMT's got there they were "getting on them" because R1 was a DNR but they had to send R1 out due to the transfer status. E13 stated they have to check the chart to make sure what the code status is. E28, Corporate Nurse, stated in an interview on [DATE] at 12:45 PM that she was not sure why this incident of resuscitating R1 when she was a DNR was an Immediate Jeopardy. E28 stated staff have to be "proactive" when there is a code and someone has to be in charge. E18 stated they don't have a lot of codes at the facility and it is "chaotic" during a code and staff just respond. Z1, Physician, stated in an interview on [DATE] at 11:30 PM that CPR should not have been done on R1. Z1 stated the staff were "stuck" because they had done CPR and got a heart beat before they found out R1 was a DNR. Z1 stated the family then had to make the decision at the hospital to discontinue treatment and take R1 off the ventilator. The hospital "emergency room Visit Report" dated [DATE] documented R1 was unresponsive at the facility. The "Clinical Impression" for R1 was documented as "[MEDICAL CONDITIONS] due to cerebral artery occlusion". The hospital "Pulmonary Consultation" [DATE] documented "This patient is an [AGE] year-old unfortunate female who was ventilator dependent at a chronic vent facility that evidently was in a code 3 status and had a [MEDICAL CONDITION], but was resuscitated and did have CPR". The "Assessment/Plan" documented R1 was "status [REDACTED]. The hospital "Neurological Consultation" dated [DATE] documented R1 had "presented to the emergency room by the EMS this early morning with unresponsiveness. The patient lives in a chronic ventilator facility (facility) and patient has been on a DNR status and apparently in the facility she was found by the student respiratory tech, who could not feel her pulse and the nurse started CPR in the facility because of pulselessness. The CPR was stopped and the EMS called. The EMS apparently first notified about the [MEDICAL CONDITION]. Upon arrival of the EMS, the pulse oximetry read 99% and the heart rate was 63. The EMS was informed that the CPR was started and subsequently stopped prior to their arrival...". The hospital "Discharge Summary" dated [DATE] documented R1 presented to the hospital with acute on chronic [MEDICAL CONDITION], with altered level of consciousness after having CPR at ECF (Extended Care Facility), though per family she was no-code". The summary documented "given her poor overall status and the diminished likelihood that she would be able to breath without the vent given her [MEDICAL CONDITIONS] the family decided to withdraw care. We initiated the process on [DATE], and the patient died later in the afternoon on comfort care measures". Z2, Power of Attorney, stated in an interview on [DATE] at 4:10 PM that R1 was on a vent at the facility. Z2 stated R1 was not suppose to be resuscitated but staff at the facility did resuscitate her and she went to the hospital. Z2 stated they had to make the decision to take her off the vent at the hospital. Z2 stated they shouldn't have resuscitated R1. The Facility "Do Not Resuscitate Order" policy states "Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect". The "Advance Directive" policy states "Advance directives will be respected in accordance with state law and facility policy. The policy defines "Do Not Resuscitate" as "Indicates that, in the case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used". The Immediate Jeopardy was identified to have begun on [DATE], after the facility failed to develop and operationalize policy and procedures to identify and follow Do Not Resuscitate policies. E1, Administrator was informed of the Immediate Jeopardy on [DATE] at 9:50 AM. . The Facility took the following actions to remove the Immediacy: 1. A House-wide assessment of all residents' code status was reviewed and updated on [DATE]. 2. Code Status Dots (Green-Full Code) and (Red-DNR) were initiated and appropriate dots related to the code status was placed on the resident door on [DATE]. 3. The DON or designee reviewed all residents' Physician order [REDACTED]. 4. All Care Plans have been updated to current code status for all residents on [DATE]. 5. The current Advanced Directive, Code Status, and DNR policies were reviewed and updated on [DATE]. 6. All new admission Advanced Directives will be initiated by social service with the review of the DON. It will be the responsibility of the Social Service Department with the assist of the DON to update the residents' chart, POS, MAR, and TAR and the door with the code dots. 7. The MDS Coordinator or her designee will update code status as implemented by Social Service, the DON, or her designee annually or as changes occur in the resident condition. 8. The Facility initiated new procedures of 1) Non-Nursing Procedure for Resident with a DNR code status; 2) Nursing Procedure for a Code status; 3) Non-Nursing Procedure for a Resident with a Full Code status on [DATE]. 9. Staff were re-inserviced on ,[DATE]//12 on the following topics: 1) Procedures for non nursing and nursing staff related; 2)Non-nursing Procedure for Resident with a DNR Code status; 3) Nursing Procedure for a Resident with a DNR code status; 4) Non-Nursing Procedure for a resident with a Full Code status. 10. Staff was in-serviced on the location of the code status dots and where to look for code status on the MAR, TAR, and resident chart on [DATE].

Based on record review, interview, and observation, the facility failed to assess, monitor and calculate sufficient calories and hydration according to actual body weight for nutrition provided by a gastrostomy tube feeding for 1 of 3 residents (R6) reviewed for gastrostomy tube feeding in a sample of 6. This failure resulted in R6 losing 24 pounds in a 5 month period (12 % significant weight loss), hospitalization for severe dehydration and development of a stage 4 pressure ulcer. The findings include: According to the physician's orders [REDACTED]. The Minimum (MDS) data set [DATE] assessed R6 as totally dependent for all activities of daily living and was receiving a gastrostomy tube feeding. E33, Registered Dietitian (RD), documented on 6/7/12 under " Dietitians Progress Record " that R6 was receiving a tube feeding of [MEDICATION NAME] 2.0 with 165 cc ' s (cubic centimeters) given every 4 hours with 100 cc ' s of water every 4 hours. E33 documented R6 ' s weight at 220 pounds. The note documented that E33 discussed R6's weight status with the Certified Dietary Manager (CMD) and would verify R6's weight prior to estimating his nutritional needs and she would monitor and refer R6 as needed. A Dietary Assessment was not done until 6/28/12 when E33 documented on that R6 ' s weight was 220 pounds with an ideal body weight as 154 pounds plus or minus 15 pounds. The assessment documented R6 ' s [MEDICATION NAME] as 2.8 g/dl (grams/deciliter) which indicates moderate visceral protein deficiency according to the " Enteral Feeding Assessment Guide " . E33 assessed R6's nutritional needs, based on an adjusted weight of 170.5 to 177.5 pounds instead of actual weight of 220 pounds. E33's calculations were 2170 calories, 93 grams of protein, and 2500 cc's (cubic centimeters) water per day. R6 ' s nutritional needs, based on actual weight of 220 pounds, were calculated by the Department as 2498-3123 calories, 120-150 grams of protein and 3000-3500 cc ' s water. According to the manufacturers ' nutritional information, [MEDICATION NAME] 2.0 that E33 recommended for R6 on 6/7/12 contained 1980 calories, 79 grams of protein and 1293 cc ' s of water. E33 did not reassess R6 ' s calorie, protein and fluid needs in the "Dietitian's Progress Record" or the "Dietary Assessment" again through 12/13/12. laboratory results dated [DATE], documented R6's Blood Urea Nitrogen (BUN) was 46 mg/dl (milligrams/decaliter) with normal 7-27 mg/dl. On 7/21/12 the Physician order [REDACTED]. 4 hours. laboratory results dated [DATE] documented R6's BUN was 23 and creatinine was 0.7 mg/dl (normal 0.5-1.5 mg/dl). laboratory results dated [DATE] documented BUN was 24 and the creatinine was 0.7. On 9/27/12, the BUN was 24 and the creatinine was 0.7. On 9/27/12 the tube feeding flushes were decreased to 200 cc's every 4 hours on the POS. On 10/11/12, E33 documented R6's BUN was 40 and to "monitor". On 10/25/12 E33 documented no information regarding the BUN and "will monitor status". E33 documented R6 ' s weight at 194.8 pounds. E33 did not calculate and document R6's nutritional needs based on his current weight. The "Weekly Pressure Ulcer QI Log" dated 10/22/12 documented R6 developed four facility acquired pressure ulcers on 10/1/12. On 10/22/12 the pressure ulcers on the right and left buttocks, and left ankle were stage 2. The right ankle was unstageable. On the pressure ulcer log dated 12/3/12 documented R6 had a stage 4 pressure ulcer to the right ankle, an unstageable pressure ulcer on the left ankle and a stage 2 pressure ulcer to the right ischium. There was no documentation that E33 was contacted to assess R6 for additional nutritional needs based on the development of pressure sores. On 11/8/12, E33 documented R6 ' s weight at 194.1 pounds and recommended a change in the tube feeding to [MEDICATION NAME] 60 cc's/hour for 23 hours with a 200 cc water flush every 4 hours. Per manufacturer this provided 2760 calories, 110 grams of protein, 2166 cc's water. According to the nutritional needs calculated by the Department, nutritional needs for R6 at 194 pounds were 1888-2360 calories, 114-132 grams of protein, 2645-3086 cc's of water which did not meet R6's hydration needs. The POS documented the physician ordered a "stat BMP" (blood metabolic panel) on 11/13/12. On 11/13/12 the physician ordered R6 sent to the emergency room due to abnormal labs. The lab results documented R6's BUN was 113, creatinine 1.2, sodium 168 (normal 135-145 mEq/L (milliequivalents/liter) and potassium was 5.2 (normal 3.5-5.3 mEq/L). The emergency room report documented R6 "presents from (facility) with severe dehydration and a UTI (urinary tract infection). The patient has a chronic indwelling (catheter), gtube and trach". R6 was admitted to the hospital and was discharged on [DATE]. The hospital "Discharge Summary" dated 11/23/12 documented R6 "presented from (facility) with severe dehydration and UTI". The summary documented as the "Hospital Course" that on admission R6 was hypernatremic with a "total water deficit of 9 L (liters) on admission" The summary documented "Nutrition was consulted for recommendations regarding his [DEVICE] feeds, as he was not being adequately given water, so specific recommendations were sent home with him when he left regarding his tube feeds to prevent further episodes of [MEDICAL CONDITION]." The summary documented R6 was septic due to a UTI with acute [MEDICAL CONDITION] which resolved with rehydration. On readmission to the facility on [DATE] the hospital "Discharge Instructions" documented under "Diet Comments" for R6 ' s tube feeding as "Oxepa 45 ml/hr with 50 ml water flushes per hour". According to the manufacturers information Oxepa which provides 1.5 calories per cc. This would provide 1552.5 calories per day according to manufacturer ' s information. The hospital tube feeding instructions was not followed by the facility. The 11/2012 POS documented an order for [REDACTED]. On 11/26/12 the lab report documented R6's BUN at 26, creatinine at 0.8 and sodium at 140. On 11/29/12 E33 recommended to increase his tube feeding to Fibersource HN 75 cc's per hour with 200 cc's flush every 4 hours and Prostat Supplement 30 cc's three times per day. E33 did not assess R6 ' s nutritional needs for calories, protein or water. This tube feeding recommendation would provide 2760 calories, 155 grams protein and 2766 cc's water per manufacturers information. On 12/5/12 lab report documented R6's BUN was elevated at 61 and creatinine was within normal limits of 1.4. R6's weight was documented at 184.6 by E33 on 11/29/12. On 12/11/12, E33 documented R6 had a 16.9% significant weight decrease in 6 months. The nutrition notes documented multiple pressure ulcers with a stage 4 on the right ankle, stage 2 to right ischium and unstageable to the left ankle. E33 documented R6's BUN was elevated at 61. E33 documented she would continue with feeding/flushes as ordered and as needed. There were no assessments done to address R6 ' s nutritional needs or any recommendations to change the tube feeding or flush. Observation on 12/11/12 at 2:40 PM was made on R6's tube feeding. The tube feeding of Fibersource HN for R6 was hung at 9:45 AM on 12/11/12 with a 1500 cc bag. The bag documented the tube feeding rate was 75 cc's per hour. At 2:40 PM there was 1300 cc's of tube feeding in the bag and there should have been only 1125 cc's. The tube feeding pump was off and E20, Licensed Practical Nurse, came in at 2:42 PM and saw the pump off and restarted it. E20 stated she was not sure why the pump was off. The "Intake Output Record" documented R6 received 600 cc's on the 7 AM -3 PM shift and 641 cc's for the 3 PM til 11 PM shift. The " Intake Output Record " did not reflect the decrease in tube feeding amount due to the pump being turned off. There is no documentation in the nurse ' s notes or on the Intake record regarding the discrepancy. R6 does not receive [MEDICATION NAME] or any other medication requiring the tube feeding be shut off for any length of time, according to the "Physician Orders". E32, Corporate Nurse, stated in an interview on 12/1312 at 3:30 PM that she was not sure why the tube feeding pump was off or why R6 had lost weight and was admitted to the hospital on [DATE] for severe dehydration. E32 stated she would check with the dietitian. The E33's Progress Record dated 12/13/12 E33 documented that she spoke with the corporate registered nurse regarding R6's status. E33 documented that she wanted to provide adequate nutrition without problems with tolerance. Changed R6's feeding to [MEDICATION NAME] 2.0 at 60 cc/hr and increase flushes to 300 cc every 4 hours. This will provide 2760 allegories, 110.4 gm protein and 966 fluids plus 1800cc from flushes. These calculation were not based on R6's weight of 184 pounds. The 12/13/12 assessment by E33 did not assess R6's calorie, fluid and protein needs. .

Based on observation, interview and record review, the facility neglected to identify, assess and implement interventions to prevent elopement for one of three residents (R1) reviewed for elopement in the sample of 9. On [DATE], R1 eloped from the facility between 7:30 PM and 8:15 PM. R1 was found by the police face down in a creek, expired, on [DATE]. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2 as the facility continued to educate staff and evaluated the effectiveness of the elopement policies and procedures and their system of communication. Findings include: 1. The facility's initial report to the Department dated [DATE] documented "This letter is to inform you of an elopement of one our residents (R1), a [AGE] year old male with [DIAGNOSES REDACTED]. The resident was found missing from the facility at 8:15 PM. He had last been seen at 7:30 PM while he was watching a movie with a group of residents in the Dining/Living Room area. The staff searched the building, the outer parameter of the facility and other staff got in their cars and searched the area blocks around the facility. The (city) police were notified as well during this search. The police came into the facility and took the report. They came back to the building at midnight and searched the building and were unable to find the resident. They sent a helicopter up around 2:30 AM to search further. Ongoing search is continuing. Further investigation of the incident will continue and a follow up on the results will be provided." The Coroner's Report dated [DATE] documented the Deputy Coroner, Z3, was notified by the city police of the death of R1 on [DATE] at 10:50 AM. The Report documented "He then led me to the creek viaduct that goes under 17th St., where I observed (R1), floating, face down, in the center of the creek." The Report documented R1 was wearing pajama bottoms, white underwear, a t-shirt, a sweat shirt, white socks and slippers. The Report documented Z3 pronounced R1 dead at 12:05 PM. The Report documented the cause of death was accidental "Hypothermia". The weather history from the wunderground.com website for the area on [DATE] at 7:55 PM documented a temperature of 28.2 degrees Fahrenheit (F) with a wind-chill of 23.1 degrees F with no precipitation. On [DATE] at 4:30 PM, the area around the facility and the site where R1 was found was observed. The facility was located on the west side of a three lane street. The speed limit on this street was 30 miles per hour. There were sidewalks located on each side of the street. R1 was found approximately one block south east of the facility in a creek which flowed through a viaduct under the street to the south of the facility. The following are a history of R1's elopement attempts : a. R1's Hospital Departure Summary dated [DATE] documented "[DATE] 1725 Triage Assessment, Complaint Related Notes via EMS (Emergency Service) c/o (complained of) combative and screaming with roommate and staff........Went on EMS stretcher ok. Believes he is here to be checked out. On Thursday ,[DATE] he decided he wanted to leave the facility and packed up his belongings and started to leave the facility." b. R1's Interdisciplinary Progress Notes dated [DATE] documented "(R1) believes that he is going home, and that his house needs tending to, he does have a grandson who visits with him weekly. (R1) will become verbally abusive with staff and other residents. He will try to leave the facility. (R1) has poor decision making skills." c. On [DATE] at 10:20 AM a telephone interview was conducted with E24, Certified Nurse's Aide (CNA). E24 stated he had taken care of R1 when R1 resided on the 100 hallway. E24 stated he caught R1 outside the facility in late [DATE]. E24 stated he saw R1 outside the facility through the window. He stated R1 was walking outside the facility in the front courtyard towards the front parking lot. E24 stated R1 was carrying his pants and shirts on hangers. E24 stated he went outside to retrieve R1. E24 stated R1 was upset; however, E24 was able to redirect R1 back into the facility. E24 stated he had questioned how R1 had walked past the receptionist at the front desk and walked out the front door. E24 stated R1 had a history of [REDACTED]. E24 stated he was working at the facility on [DATE] at the time R1 eloped from the facility. E24 stated he did not hear any door alarms sound indicating any resident was leaving the facility. d. R1's Nurse's Note dated [DATE] at 8:45 PM documented R1 walked out the front door , was not wearing a (patient monitoring device) and was redirected back inside the facility. The Note documented "Nurse initiated 15 min (minute) checks until he was sleeping." e. R1's Nurse's Note, dated [DATE] at 8:00 PM documented "CNA was looking for him he was gone from D/R (Dining Room) no one could tell where he went. q (every) one staff in building went by car & (and) on foot looking for him no trace of him. q (every) hall was (checked) over (and) over s (without) result." 8:30 PM Police notified came in to get information." On [DATE] at 3:25 PM an interview was conducted with E4, Licensed Practical Nurse (LPN). E4 stated she was R1's nurse on [DATE] when R1 eloped from the facility. E4 stated she went to give him his medications at 8:00 PM and he was not in his room. E4 stated she asked E28, (CNA) where he (R1) was and E28 said he was in the dining room watching a movie. E4 stated she looked in the dining room but he was not there. E4 stated that the staff in the building began to search for R1, but could not locate him. E4 stated the Administrator and Director of Nurses were notified and stated to call the police. On [DATE] at 3:40 PM an interview was conducted with E7, CNA. She stated R1 could ambulate independently. E7 stated she did not work on [DATE] when R1 eloped from the facility. E7 stated she was aware R1 had a history of [REDACTED]. On [DATE] at 10:30 AM a telephone interview was conducted E28 (CNA). E28 stated she worked on [DATE] when R1 eloped from the facility. E28 stated at 5:30 PM R1 was in the dining room eating his dinner. E28 stated she was passing through the Dining Room at around 7:30 PM, and she saw R1 watching a movie. E28 stated at 8:00 PM, E4 asked if I had seen R1, and I told her I had seen him watching the movie. E28 stated R1 had a history of [REDACTED]. E28 stated she was unsure if R1 wore a patient monitoring device. On [DATE] at 3:50 PM a telephone interview was conducted with E29, CNA. E29 stated she worked on [DATE], the evening R1 eloped from the facility. E29 stated at around 7:00 PM she saw R1 sitting in his room. E29 stated she asked R1 if he wanted to watch a movie. E29 stated R1 agreed and walked with her to the dining room. E29 stated around 7:45 PM she noticed R1 was not in his room. E29 stated she did not hear any door alarms indicating a resident had left the building. E29 stated R1 was normally quiet but it depended on his mood. E29 said R1 had a history of [REDACTED]. On [DATE] at 12:05 PM an interview was conducted with E1, Administrator. E1 stated R1 was admitted to the facility in [DATE] with Dementia, [MEDICAL CONDITION], Hypertension and Cardiac Issues. E1 stated R1 ambulated independently without assistive devices. E1 stated R1 had a history of [REDACTED]. E1 stated staff would intervene prior to him leaving. E1 stated R1 attempted to pack his belongings up and leave the facility in early [DATE]. E1 stated that on [DATE], R1 did not pack his belonging up prior to eloping the facility. E1 stated R1 was not wearing a patient monitoring device when he eloped from the facility on [DATE]. E1 stated she had been told by staff that R1 would not leave the patient monitoring device on his person, and therefore it had been removed. E1 stated Z4, R1's Psychiatrist, had seen R1 a few days prior to his elopement and did not feel R1 was an elopement risk. On [DATE] at 10:30 AM a telephone interview was conducted with Z4. Z4 stated he did not recall being told by the facility R1 had attempted to leave the building or had a history of [REDACTED]. Z4 stated he would have expected the facility staff to let him know if R1 was trying to leave the building. Z4 stated R1 was demented and didn't know what he was doing. On [DATE] at 12:20 PM a telephone interview was conducted with Z5, R1's Primary Care Physician. When asked if he was aware R1 had a history of [REDACTED]. He (R1) was not very happy with placement." Z5 stated R1 had dementia and his cognitive and mental abilities fluctuated. R1's physician's orders [REDACTED]. R1's Minimum Data Set, MDS, dated [DATE] documented under Section G0300 Balance During Transitions and Walking R1 was not steady, but able to stabilize without human assistance when moving from seated to standing position, walking, turning around and surface to surface transfers. The MDS documented he required supervision of staff for transfers and walking. R1's Fall Risk assessment dated [DATE] documented R1 had a fall risk score of 55. The Assessment documented "IF FALL SCORE 40 OR MORE THAN THEY ARE CONSIDERED A HALL FALL RISK AND SHOULD BE CARE PLANNED FOR FALL RISK." R1's Care Plan updated [DATE] documented under the Comment Section "(R1) tries to leave the facility frequently wears a (patient monitoring device)." The Care Plan does not address R1's exit seeking behaviors and elopement attempts, and goals and interventions to address these behaviors. On [DATE] at 8:30 AM an interview was conducted with E30, LPN/Care Plan/MDS Coordinator. E30 stated she started her position as Care Plan/MDS Coordinator the end of [DATE]. E30 stated she was not aware of R1's previous attempts to elope the facility, his behavior of packing his belongings, and saying he was going to leave. E30 stated R1's Care Plan was never revised to address those behaviors. R1's Initial Wandering Assessment Guide reviewed and revised on [DATE] documented "No" to the question "7. Is resident a candidate for (patient monitoring device) bracelet?" The facility's policy "Wandering Residents" revised [DATE] documented the following under the section Policy Interpretation and Implementation: "1. All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. 2. The resident's current MDS 3.0 will be reviewed to determine what changes have occurred that would trigger elopement episodes." 3. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. Staff will be informed at shift change of the modifications to the resident's care plan. 4. Interventions into elopement episodes will be entered onto the resident's care plan and medical record. 5. Should an elopement episode occur, the contributing factors, as well as the intervention tried, will be documented on the nurse's notes. 6. If a resident repeatedly wanders off the unit, a monitoring schedule will be implemented to ensure resident safety. The resident's care plan will be documented as to the implementation of the monitoring schedule." The Immediate Jeopardy was identified to have begun on [DATE] between 7:30 PM and 8:15 PM when R1 eloped from the facility without staff 's knowledge. E1 and E31, Director of Regional Operations, were notified of the Immediate Jeopardy on [DATE] at 3:31 PM. The surveyor confirmed through interview, record review, and observation that the Facility took the following actions to remove the Immediacy: 1. On [DATE], the facility conducted individual in-service training for all staff. All staff were in-services on the following policies and protocol: Elopements, Wandering Residents, Missing Residents, Head Checks and Drills, Elopement Drills, Door Alarms, Behavior Tracking, Tracking Sheets, Residents Currently on Tracking and/or (patient monitoring device) and the (patient monitoring device) System Policy. 2. On [DATE], the facility reassessed all current residents in the facility to determine wandering risk status. Following this, all high risk residents care plans were reviewed and changes made as necessary. 3. On [DATE], a Quality Assurance (QA) Meeting was held and all areas of the facility were reviewed to determine the possible exit route of the missing resident and other possible problem areas that exist. New preventative measures were implemented at that time as needed. 4. On [DATE], the QA committee reviewed all related policies and revisions were made as needed. 5. On [DATE] and on-going, secondary keyed door alarms were installed on all exit doors accessible to residents. 6. On [DATE], all high risk resident's information was placed in a binder at each nursing station and at the front desk. Each binder included the individual residents face sheet, a current picture, room number and specific interventions to be in place. 7. On [DATE], Receptionist's hours have been extended and are now from 8:00 AM until 9:00 PM to provide additional monitoring of our main entrance. 8. On [DATE] and on-going, all door alarms will be checked by Maintenance daily (Monday-Friday) and by the weekend manager on Saturday and Sunday to ensure they are in proper working order. These checks will be documented at the time they are completed. Batteries will be changed monthly and as needed. 9. On [DATE] and on-going, Elopement Drills will be conducted monthly, alternating shifts, and randomly per Director of Nurse's (DON) and/or designee. 10. On [DATE] and on-going, Head Check Drills will be conducted monthly, alternating shifts, and randomly per DON and/or designee. 11. On [DATE] and on-going, an initial Wandering Assessment will be completed on all new admits on the day of admission, in conjunction with their 14 day assessment, quarterly and PRN. Follow-up will be implemented based on the results of the assessment. 12. On [DATE] and on-going, patient monitoring devices will be checked daily by the MDS nurses Monday thru Friday and on the weekend by the weekend manager.

A. Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent elopement for three of three residents (R1, R2 and R9) reviewed for elopement in the sample of 9. On [DATE], R1 eloped from the facility between 7:30 PM and 8:15 PM. R1 was found by the police face down in a creek, expired, on [DATE]. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2 as the facility continued to educate staff and evaluated the effectiveness of the elopement policies and procedures and their system of communication. Findings include: 1. The facility's initial report to the Department dated [DATE] documented "This letter is to inform you of an elopement of one our residents (R1), a [AGE] year old male with [DIAGNOSES REDACTED]. The resident was found missing from the facility at 8:15 PM. He had last been seen at 7:30 PM while he was watching a movie with a group of residents in the Dining/Living Room area. The staff searched the building, the outer parameter of the facility and other staff got in their cars and searched the area blocks around the facility. The (city) police were notified as well during this search. The police came into the facility and took the report. They came back to the building at midnight and searched the building and were unable to find the resident. They sent a helicopter up around 2:30 AM to search further. Ongoing search is continuing. Further investigation of the incident will continue and a follow up on the results will be provided." The Coroner's Report dated [DATE] documented the Deputy Coroner, Z3, was notified by the city police of the death of R1 on [DATE] at 10:50 AM. The Report documented "He then led me to the creek viaduct that goes under 17th St., where I observed (R1), floating, face down, in the center of the creek." The Report documented R1 was wearing pajama bottoms, white underwear, a t-shirt, a sweat shirt, white socks and slippers. The Report documented Z3 pronounced R1 dead at 12:05 PM. The Report documented the cause of death was accidental "Hypothermia". The weather history from the wunderground.com website for the area on [DATE] at 7:55 PM documented a temperature of 28.2 degrees Fahrenheit (F) with a wind-chill of 23.1 degrees F with no precipitation. On [DATE] at 4:30 PM, the area around the facility and the site where R1 was found was observed. The facility was located on the west side of a three lane street. The speed limit on this street was 30 miles per hour. There were sidewalks located on each side of the street. R1 was found approximately one block south east of the facility in a creek which flowed through a viaduct under the street to the south of the facility. The following are a history of R1's elopement attempts : a. R1's Hospital Departure Summary dated [DATE] documented "[DATE] 1725 Triage Assessment, Complaint Related Notes Via EMS (Emergency Service) c/o (complained of) combative and screaming with roommate and staff...........Went on EMS stretcher ok. Believes he is here to be checked out. On Thursday [DATE] he decided he wanted to leave the facility and packed up his belongings and started to leave the facility." b. R1's Interdisciplinary Progress Notes dated [DATE] documented "(R1) believes that he is going home, and that his house needs tending to, he does have a grandson who visits with him weekly. (R1) will become verbally abusive with staff and other residents. He will try to leave the facility. (R1) has poor decision making skills." c. On [DATE] at 10:20 AM a telephone interview was conducted with E24, Certified Nurse's Aide (CNA). E24 stated he had taken care of R1 when R1 resided on the 100 hallway. E24 stated he caught R1 outside the facility in late [DATE]. E24 stated he saw R1 outside the facility through the window. He stated R1 was walking outside the facility in the front courtyard towards the front parking lot. E24 stated R1 was carrying his pants and shirts on hangers. E24 stated he went outside to retrieve R1. E24 stated R1 was upset; however, E24 was able to redirect R1 back into the facility. E24 stated he did tell the nurse; however, he could not recall what nurse. E24 stated he had questioned how R1 had walked past the receptionist at the front desk and walked out the front door. E24 stated R1 had a history of [REDACTED]. E24 stated he was working at the facility on [DATE] at the time R1 eloped from the facility. E24 stated he did not hear any door alarms sound indicating any resident was leaving the facility. d. R1's Nurse's Note dated [DATE] at 8:45 PM documented R1 walked out the front door , was not wearing a (patient monitoring device) and was redirected back inside the facility. The Note documented "Nurse initiated 15 min (minute) checks until he was sleeping." e. R1's Nurse's Note, dated [DATE] at 8:00 PM documented "CNA was looking for him he was gone from D/R (Dining Room) no one could tell where he went. q (every) one staff in building went by car & (and) on foot looking for him no trace of him. q (every) hall was (checked) over (and) over s (without) result." 8:30 PM Police notified came in to get information." On [DATE] at 3:25 PM an interview was conducted with E4, Licensed Practical Nurse (LPN). E4 stated she was R1's nurse on [DATE] when R1 eloped from the facility. E4 stated she went to give him his medications at 8:00 PM and he was not in his room. E4 stated she asked E28, (CNA) where he was, and E28 said he was in the dining room watching a movie. E4 stated she looked in the dining room but R1 was not there. E4 stated that the staff in the building began to search for R1, but could not locate him. E4 stated the Administrator and Director of Nurses were notified and and told her to call the police. On [DATE] at 3:40 PM an interview was conducted with E7, CNA. She stated R1 could ambulate independently. E7 stated she did not work on [DATE] when R1 eloped from the facility. E7 stated she was aware R1 had a history of [REDACTED]. On [DATE] at 10:30 AM a telephone interview was conducted E28 (CNA). E28 stated she worked on [DATE], when R1 eloped from the facility. E28 stated at 5:30 PM R1 was in the dining room eating his dinner. E28 stated she was passing through the Dining Room at around 7:30 PM, and she saw R1 watching a movie. E28 stated at 8:00 PM, E4 asked if I had seen R1, and I told her I had seen him watching the movie. E28 stated R1 had a history of [REDACTED]. E28 stated she was unsure if R1 wore a patient monitoring device. On [DATE] at 3:50 PM a telephone interview was conducted with E29, CNA. E29 stated she worked on [DATE] when R1 eloped from the facility. E29 stated at around 7:00 PM she saw R1 sitting in his room. E29 stated she asked R1 if he wanted to watch a movie. E29 stated R1 agreed and walked with her to the dining room. E29 stated around 7:45 PM she noticed R1 was not in his room. E29 stated she did not hear any door alarms indicating a resident had left the building. E29 stated R1 was normally quiet but it depended on his mood. E29 said R1 had a history of [REDACTED]. On [DATE] at 12:05 PM an interview was conducted with E1, Administrator. E1 stated R1 was admitted to the facility in [DATE] with Dementia, Hypotension, Hypertension and Cardiac Issues. E1 stated R1 ambulated independently without assistive devices. E1 stated R1 had a history of [REDACTED]. E1 stated staff would intervene prior to him leaving. E1 stated R1 attempted to pack his belongings up and leave the facility in early [DATE]. E1 stated that on [DATE], R1 did not pack his belonging up prior to eloping the facility. E1 stated R1 was not wearing a patient monitoring device when he eloped from the facility on [DATE]. E1 stated she had been told by staff that R1 would not leave the patient monitoring device on his person, and therefore it had been removed. E1 stated Z4, R1's Psychiatrist, had seen R1 a few days prior to his elopement, and did not feel R1 was an elopement risk. On [DATE] at 10:30 AM a telephone interview was conducted with Z4. Z4 stated he did not recall being told by the facility R1 had attempted to leave the building or had a history of [REDACTED]. Z4 stated he would have expected the facility staff to let him know if R1 was trying to leave the building. Z4 stated R1 was demented and didn't know what he was doing. On [DATE] at 12:20 PM a telephone interview was conducted with Z5, R1's Primary Care Physician. When asked if he was aware R1 had a history of [REDACTED]. He (R1) was not very happy with placement." Z5 stated R1 had dementia and his cognitive and mental abilities fluctuated. R1's physician's orders [REDACTED]. R1's Minimum Data Set, MDS, dated [DATE] documented under Section G0300 Balance During Transitions and Walking R1 was not steady, but able to stabilize without human assistance when moving from seated to standing position, walking, turning around and surface to surface transfers. The MDS documented he required supervision of staff for transfers and walking. R1's Fall Risk assessment dated [DATE] documented R1 had a fall risk score of 55. The Assessment documented "IF FALL SCORE 40 OR MORE THAN THEY ARE CONSIDERED A HALL FALL RISK AND SHOULD BE CARE PLANNED FOR FALL RISK." R1's Care Plan updated [DATE] documented under the Comment Section "(R1) tries to leave the facility frequently wears a (patient monitoring device)." The Care Plan does not address R1's exit seeking behaviors and elopement attempts, and goals and interventions to address these behaviors. On [DATE] at 8:30 AM an interview was conducted with E30, LPN/Care Plan/MDS Coordinator. E30 stated she started her position as Care Plan/MDS Coordinator the end of [DATE]. E30 stated she was not aware of R1's previous attempts to elope the facility, his behavior of packing his belongings and saying he was going to leave. E30 stated R1's Care Plan was never revised to address those behaviors. R1's Initial Wandering Assessment Guide reviewed and revised on [DATE] documented "No" to the question "7. Is resident a candidate for (patient monitoring device) bracelet?" The facility's policy "Wandering Residents" revised [DATE] documented the following under the section Policy Interpretation and Implementation: "1. All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. 2. The resident's current MDS 3.0 will be reviewed to determine what changes have occurred that would trigger elopement episodes." 3. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. Staff will be informed at shift change of the modifications to the resident's care plan. 4. Interventions into elopement episodes will be entered onto the resident's care plan and medical record. 5. Should an elopement episode occur, the contributing factors, as well as the intervention tried, will be documented on the nurse's notes. 6. If a resident repeatedly wanders off the unit, a monitoring schedule will be implemented to ensure resident safety. The resident's care plan will be documented as to the implementation of the monitoring schedule." On [DATE] at 1:00 PM, E5, Maintenance Director, was observed checking all exit doors to ensure the door alarms were working properly. At 1:45 PM, there were double exit doors in the 500 Hall Solarium. When E5 opened the right side exit door, the alarm did not sound. E5 stated "I don't know why." The Door Alarm and Locks check sheet for the facility were reviewed for the dates [DATE] through [DATE]. There were no Alarm check sheets for ,[DATE] and [DATE]. At 2:00 PM, E5 stated the maintenance only conducts door alarm checks Monday thru Friday and that was why there was no door alarm check sheet for [DATE]. 2. R9's Department of Health Services Assessment of Summary Information sheet, located in R9's medical record, dated [DATE], documented he was residing in a state operated mental hospital. The Summary documented prior to his admission to the state hospital "Reports walking away from a previous nursing home because ' people were talking about me.' The Behavior Assessment Summary section documented "(R9) has a history of impaired judgement, poor insight, substance use, and behavior that place him at risk". R9 was discharged from the state hospital on [DATE] and admitted to the facility. R9's POS dated [DATE] documented he had partial [DIAGNOSES REDACTED]. R9's physician's orders [REDACTED]. R9's Admission MDS dated [DATE] documented he had a BIMS (A brief screener that aids in detecting cognitive impairment) score of 15 (Score of ,[DATE]: cognitively intact). On [DATE] at 11:15 AM, R9 was pacing up and down the 500 hallway. At 11:20 AM, an interview was conducted with E36, LPN. E36 stated R9 had a history of [REDACTED]. On [DATE] at 3:30 PM an interview was conducted with E2. She said a facility-wide re-assessment of all residents had been completed on [DATE] to determine who required patient monitoring devices. E2 stated R9 was assessed as requiring a patient monitoring device, and therefore, he was taken off the 15 minute checks. The following are a history of R9's wandering behaviors and elopement attempts: a. R9's Nurse's Note dated [DATE], no time, documented "Res. (Resident) monitored by staff. Very sensitive. Sneaking up on elevator. Gait very rigid. Continues to want to leave to go to the Christian Center down the street. Adapt (On-Site Mental Health Care Provider) staff aware of behavior. Has (patient monitoring device) in place on arm." R9's Nurse's Note dated [DATE] at 1:00 PM documented "Res up walking halls all day (patient monitoring device) remain in place. Being monitored closely for wandering behaviors." R9's Nurse's Note dated [DATE] documented "Requires close monitoring due to attempting to go to upper level to go out of facility. Adapt staff re-directed res." b. R9's Nurse's Note dated [DATE] documented "Case Management: Transition Aftercare & Linkage, Chestnut Health Systems - Met w (with) client face to face, as well as staff of Adapt and (facility)........Staff report client continues to attempt to walk off the grounds. He will ask permission to attend activities upstairs then walk out the front door." c. R9's Nurse's Note dated [DATE] at 1:00 PM documented "Res attempted to walk out the front door of the facility, was able to redirect." d. R9's Nurse's Note dated [DATE] at 9:00 PM documented "Client noted not to be in room or sitting rooms. Search conducted throughout facility for client." R9's Nurses's Note at 9:15 PM documented " 911 called and staff dispatched to search for client on grounds and streets, on foot and in vehicle." R9's Nurse's Note at 9:55 PM "Client returned to facility c (with) police escort, ambulatory. Stated he had been @ (at) (local bar), approx (approximately) 15 blocks from facility drinking only H2O." R9 was sent to the hospital for evaluation. R9 returned to the facility that evening. On [DATE], E32's, LPN, statement regarding R9's elopement on [DATE] was reviewed. The statement documented "Approximately 7:00 PM I did the treatment on his (R9's) left foot, on healing open areas, as he had requested bandage. Approx 8:45 PM I noticed the he was neither in his room nor the TV room. I alerted one of my CNA's, (E33), who immediately went upstairs to look for him, returning back downstairs in ,[DATE] min., not having found him. After about 5 min further search in bathrooms and small rooms downstairs, I called (E3, Assistant Director of Nurse's), who affirmed that I should call 911, which I then immediately did." On [DATE], E33's, CNA, signed statement regarding R9's [DATE] elopement was reviewed. The statement documented ".....my last time seeing (R9) was around 7:30ish walking down the hall........(E32) was down on A hall passing meds. When she asked me have I saw (R9) I stated o not since earlier I preceded to look in his room then when I did not locate him I went upstairs to look for him. I started asking other co-workers have they seen him and they stated no. I looked down 100 hall. I searched all bathrooms down on 500 hall, from there the police was called in." On [DATE], E34's, LPN, signed statement regarding R9's [DATE] elopement was reviewed. The statement documented "This nurse observed resident (R9) walking from the ,[DATE] nurses station towards the dining room past the front entrance @ (at) 7:30 PM. We were told he was missing around 9:20 PM." On [DATE], a statement taken from R9 after he eloped from the facility on [DATE] was reviewed. The statement documented "He was asked which door did he leave out of. He stated 'The front door.' He also was asked did the alarm sound. He said 'No. I walked to (local bar) it took 30 minutes' and he stated he did not fall. He was asked if he drank anything He said water. He also was asked did he smoke anything. He said cigarettes. He stated Pam bought me a jacket. He stated he wanted to go to (local hospital) and wanted his medications." e. R9's Nurse's Note dated [DATE] at 1:45 PM documented "Resident attempting to elope from facility x 1 this shift. Resident redirected from front entrance walk per Adapt staff. 15 minute checks continued at this time. Will continue to monitor. 1 on 1 observation initiated." On [DATE], the facility provided the following letter to the Department: "This letter is a follow up letter in reference to (R9). (R9) eloped from our facility on [DATE] and walked 1.5 miles to (a local bar)......Our staff has decided that we can no longer meet (R9's) needs and has issued him an Involuntary Discharge Notice. We have provided (R9) with a one on one staff member and has implemented a 15 minute check list for any behavior issues that (R9) might encounter. In addition to that we have in-serviced our staff on residents that wander and the purpose of the (patient monitoring device)." R9's Care Plan dated [DATE] was not revised after his elopement attempts on ,[DATE] and [DATE] to provide interventions to assist staff in preventing R9's future attempts at elopements. R9's Care Plan was updated after he eloped from the facility on [DATE]; however, his Care Plan was not revised after R9 was placed on 15 minute checks after his elopement attempt on [DATE]. On [DATE] at 8:30 AM an interview was conducted with E30. E30 stated she was hired the last week of October as the MDS/Care Plan Coordinator. E30 stated she went through R9's chart and asked staff questions regarding R9. E30 stated she was not aware of R9's previous elopement attempts. She stated she revised R9's Care Plan after he eloped from the facility on [DATE]. E30 stated it is the nurse's responsibility to let her know what is going on with the residents so she can update their Care Plan. 3. R2's POS dated [DATE] documented she had a partial [DIAGNOSES REDACTED]. R2's MDS dated [DATE] documented severely impaired cognitive abilities. R2's Nurse's Note dated [DATE] at 11:00 AM documented "Res (Resident) trying to elope out of 200 hall door this is second elopement attempt. Res. re-directed back to room et explained to res this was her home where she stayed." R2's Care Plan was not revised after her elopement attempts on [DATE] to provide interventions to assist staff in preventing R2's future attempts at elopement. On [DATE] at 8:30 AM an interview was conducted with E30. E30 stated she was not aware R2 had attempted to elope the facility on [DATE] and had not revised R2's Care Plan. The Immediate Jeopardy was identified to have begun on [DATE] between 7:30 PM and 8:15 PM when R1 eloped from the facility without staff 's knowledge. E1 and E31, Director of Regional Operations, were notified of the Immediate Jeopardy on [DATE] at 1:33 PM. The surveyor confirmed through interview, record review and observation that the Facility took the following actions to remove the Immediacy: 1. On [DATE], the facility conducted individual in-service training for all staff. All staff were in-services on the following policies and protocol: Elopements, Wandering Residents, Missing Residents, Head Checks and Drills, Elopement Drills, Door Alarms, Behavior Tracking, Tracking Sheets, Residents Currently on Tracking and/or (patient monitoring device) and the (patient monitoring device) System Policy. 2. On [DATE], the facility reassessed all current residents in the facility to determine wandering risk status. Following this, all high risk residents care plans were reviewed and changes made as necessary. 3. On [DATE], a Quality Assurance (QA) Meeting was held and all areas of the facility were reviewed to determine the possible exit route of the missing resident and other possible problem areas that exist. New preventative measures were implemented at that time as needed. 4. On [DATE], the QA committee reviewed all related policies and revisions were made as needed. 5. On [DATE] and on-going, secondary keyed door alarms were installed on all exit doors accessible to residents. 6. On [DATE], all high risk resident's information was placed in a binder at each nursing station and at the front desk. Each binder included the individual residents face sheet, a current picture, room number and specific interventions to be in place. 7. On [DATE], Receptionist's hours have been extended and are now from 8:00 AM until 9:00 PM to provide additional monitoring of our main entrance. 8. On [DATE] and on-going, all door alarms will be checked by Maintenance daily (Monday-Friday) and by the weekend manager on Saturday and Sunday to ensure they are in proper working order. These checks will be documented at the time they are completed. Batteries will be changed monthly and as needed. 9. On [DATE] and on-going, Elopement Drills will be conducted monthly, alternating shifts, and randomly per Director of Nurse's (DON) and/or designee. 10. On [DATE] and on-going, Head Check Drills will be conducted monthly, alternating shifts, and randomly per DON and/or designee. 11. On [DATE] and on-going, an initial Wandering Assessment will be completed on all new admits on the day of admission, in conjunction with their 14 day assessment, quarterly and PRN. Follow-up will be implemented based on the results of the assessment. 12. On [DATE] and on-going, patient monitoring devices will be checked daily by the MDS nurses Monday thru Friday and on the weekend by the weekend manager. B. Based on observation, record review, and interviews, the facility failed to provide safe transfer technique and failed to assess for possible cause of fracture of unknown origin for one of one resident (R3) reviewed for a fracture of unknown origin in the sample of 9; and failed to provide progressive interventions for fall prevention of 1 of five residents (R5) reviewed for fall risks in the sample of 9. This failure resulted in R3's fracture of distal left tibial and fibular shafts. Findings include: 1. On [DATE] E2, Director of Nursing (DON) sent a report to the IDPH office which stated (in part), "I have conducted an investigation following the letter...sent to you on [DATE]. The report is in regard to R3, who was [DIAGNOSES REDACTED]. I have interviewed staff....The injury was noted by a CNA...was reported to the Nurse on duty....there were no complaints of pain prior to this....She (R3) was returned to our facility on Monday [DATE] with a soft cast to her lower leg.....I have concluded my investigation. It is still unknown when or how this injury occurred....". E2's report of [DATE] stated (in part), "...there were no complaints of pain prior to this." R3's Nursing Notes documented the following complaints of pain: a) On [DATE] at 7:50 PM, E17, Registered Nurse (RN) documented in R3's Skilled Nurses Note, "Resident yelling...CNA reports resident is complaining of pain. Given 650 mg. Tylenol via jelly.....". The Skilled Daily Nurses Note described the pain as "generalized" and intensity (0 -10) "crying". b) On [DATE] at 10:15 AM, E17 stated she remembered R3's complaint of pain on [DATE]. E17 stated she was preparing for medication pass when the CNA informed her of R3's complaint of pain. E17 was asked what was the source of the pain and stated she could not say. E17 did not assess R3 for the location of the pain. c) On [DATE] at 8:50 PM, E12, Licensed Practical Nurse (LPN), documented in R3's Skilled Daily Nurses Note, "Res. c/o (complaining of) pain in left leg. Gave PRN Tylenol....". On [DATE] at 11:15 AM, E12 stated in a telephone interview that she gave R3 the pain medication on [DATE]. E12 was asked if she looked at R3's legs and feet at that time. E12 stated R3's, "legs are always very swollen. I didn't see any difference". d) On [DATE] at 5 PM, E11, LPN, documented in R3's Skilled Daily Nurses Note, "C/o leg pain - given PRN Tylenol with evening medication - taken without difficulty with assistance from CNA (Certified Nursing Assistant). On [DATE] at 10 AM, E11 stated in a telephone interview that she remembered R3's daughter asked for the Tylenol for "pain in her legs" on [DATE]. E11 stated she did not look at R3's legs when she gave the pain medication on [DATE]. e) During a confidential staff interview on [DATE], at 3:10 PM, staff stated that on the previous Sunday, [DATE], R3's ankle was swollen and R3, "was definitely in pain. She was hollering out, voice was higher pitched than usual." Staff stated the nurse was informed on Sunday, [DATE]th, that R3's ankle was swollen and she was in pain. The facility's Monthly Incident Tracking form for [DATE] listed R3's incident dated [DATE], "Left ankle found swollen, in pain...... Type of injury: Fx (fractured) ankle. Investigation: Res. transferred via (mechanical) lift. Possible hit leg during transfer. Intervention: pad pole during transfer.". The Hospital Consultation Report dated [DATE] by Z6, Doctor of Osteopathy documented (in part), "She (R3)....evidently in the process of being transferred..The staff lost control of her and she struck the floor, sustaining an injury to her left ankle.....Radiographs....showed mildly angulated and displaced fractures of the distal left tibial and fibular shafts." On [DATE] at 11:45 AM, E2, DON,stated that she was at the facility on [DATE], when R3's fracture was first reported. E2 was asked why the hospital report stated that R3's injury was a result of a fall. E2 stated she was unaware of the hospital report and had no idea where the hospital obtained that information. On [DATE] at 12:10 PM, E1, Administrator, stated she had completed the [DATE] Accident Incident Log that attributed R3's cause as "...transferred via (mechanical lift) Possible hit leg during transfer." E1 stated, "That's my assumption of how the injury was caused. That was the only thing that I could think of - possibly she hit the lift. That is not a statement of fact.". E1 stated she had not reviewed the report that E2, DON, had sent to IDPH, which stated that the cause of injury was not known. On [DATE] at 10:22 AM, R3 was transferred from her bed to a loveseat/chair at her bedside. E13, and E26, CNA's, E25, LPN, and E27, Respiratory Therapist, were in the room to assist with the transfer. R3 was placed on the lift pad for a large mechanical lift. E25 supported R3's legs. E13 operated the mechanical lift, and E26 assisted in guiding R3 towards the chair. E27 was holding the ventilator tubing. As the lift moved R3 towards the chair, the base of the lift did not spread widely enough to face the front of the chair. The lift base was positioned around the side of the chair, which would require the CNAs to swing R3 either to the right or left to position her in the chair correctly. As E13 was turning R3 to lower her into her chair, R3's left leg and cast were moving towards the center support pole of the lift. E13 moved the lift base back from the chair, turned the chair in the opposite direction so R3's feet could clear the lift pole, and guided her towards the chair. E27 had to move the ventilator down to the foot of the bed until R3 was positioned in the chair. The staff involved in the transfer had to move furniture around, reposition the lift, reposition the chair, move the ventilator around the foot of the bed, all while R3 was suspended from the mechanical lift. R3 is assessed as totally dependent on staff for all Activities of Daily Living (ADL). R3's MDS dated [DATE] assessed her as totally dependent, requiring two or more staff for bed mobility, transfers, dressing, eating, toilet use, grooming. R3's Care Plan dated [DATE] identified Problem/Need: Total care for all ADL tasks and Fall risk r/t cognitive deficits. 2. R5's POS dated [DATE] indicated she had partial [DIAGNOSES REDACTED]. R5's MDS dated [DATE] documented she required limited assistance of two staff persons for transfers and was assessed as not steady, only able to stablize with human assistance when moving from seated to standing position. R5's Nurse's Note dated [DATE] at 6:28 AM documented "found resident on floor in room in sitting position @ (at) foot of bed stated she bumped her head. 0 injuries noted". R5's Nurse's Note dated [DATE] 3:50 AM documented "CNA went into res room @ 3:30 AM found resident in sitting position on floor beside the bed stated she was sitting on side of the bed and slid to the floor". R5's Nurse's Note dated [DATE] at 5:10 PM documented "Resident found on floor by this nurse sitting in front of w/c (wheelchair)on the floor on buttocks. Res denies having any pain. Res stating 'I was trying to go to the bathroom.' " R5's Fall Investigation Report dated [DATE] documented R5 was trying to get to the bed from her wheelchair and fell to the floor. R5's Care Plan dated [DATE] was not revised after R5 fell on [DATE], [DATE] and [DATE] to address R5's falls or progressive interventions to prevent R5 from future falls. On ,[DATE]/, ,[DATE] and [DATE] the surveyor requested the Incident Reports regarding R5's falls on ,[DATE], ,[DATE] and [DATE]. On [DATE] at 11:45 AM during an interview with E1 she stated no incident reports could be found regarding R5's falls on ,[DATE], ,[DATE] and [DATE].

A) Based on interview, observation and record review, the facility neglected to identify new pressure ulcers and or wounds and neglected to identify new pressure ulcers/wounds as ordered for 1 of 3 residents (R5) reviewed for pressure sores and/or wounds in the sample of 7. This neglect resulted in R5's developing pressure sores the facility was unaware of and having deteriorating sores they failed to identify, assess and treat. Findings include: According to nurses notes dated 9/26/11 at 2:30pm, R5 was sent to the emergency room after staff noted decreased alertness, increased blood sugars for 2 days and rapid progression of a sacral decubitus. Wound reports dated 9/26/11 indicate R5 was being seen by a wounds specialist who identified 8 pressure sores. The facility's "Weekly Pressure Ulcer QI Log" dated 9/26/11 shows the facility identifying 6 pressure ulcers, not 8 as identified by the wound specialist that same day. The weekly pressure ulcer report dated 9/19/11 identifies that R5 had 3 areas. There is no indication until 9/26/11, that the facility identified decline in the wounds he was admitted with on 9/12/11. Treatment records from September 12 through the 26th, 2011, show treatments were documented as being done 9 of the 13 days, with an order for [REDACTED]. Pictures and information obtained from the hospital, dated 9/26/11, indicate a wound consultant saw R5 due to numerous open areas on his skin. The areas were documented to include, "superficial blisters that have denuded revealing superficial pink open areas beneath on his right axilla, right lateral knee, right calf, left calf in several areas in addition to open sloughing areas on his right hip, coccyx that are very large, at leach 12-15cm each. The coccyx is butterfly shaped. The rt trochanter area is moist, sloughing and there is some purple discoloration around this. The left plantar foot has a pink, resolving area with scarring around it. The left heel has eschar that is coming off, removed. The rt (right) heel has some purple discoloration but intact skin at this time." The report continues to state that R5 "should be hospice and made comfortable" with palliative wound care provided. The coccyx wound was identified as a Kennedy ulcer. Hospital photographs dated 9/26/11 show R5 to have an open area on his abdominal fold measuring 5cm long and 1/2 centimeters wide, fatty tissue/slough at the wound base, and an open sore at the urethra opening. According to an consultant report dated 9/27/11, R5 had sores on his rectum described as, "The rectum has water filled blistering all around and there is ulceration on the outside, extending up into the rectum that shows sloughing." None of these areas were evident in any facility documentation. According to facility admission records, R5 was readmitted to the facility on [DATE] and placed on Hospice services. On 10/7/11, R5's skin was checked with E21, Licensed Practical Nurse (LPN) at 10:54am. R5 had no dressings on his right hip sore, no dressing/treatment on his coccyx and his coccyx/buttocks wounds were actively bleeding. He had a [MEDICATION NAME] dressing on his right outer leg dated 10/5/11 The pads underneath him were soiled with bloody drainage and his lower extremities dressings were on but soiled with bloody drainage. None were dated. E21 looked through the bedclothes for the dressings but was unable to locate them. A Certified Nurses Aide (CNA), E13 stated she removed the dressings at 9:30am. Review of the Treatment Administration Record for (TAR) for November 2011, R5 had no treatments done to his pressure sores since his return from the hospital on [DATE] as it was blank with no initials documented. Review of the Physician order [REDACTED]. On 11/1/11 at 12:30pm, E22 LPN stated she admitted R5 back into the facility on [DATE] and completed the TAR. E22 stated R5 returned from the hospital with no treatment orders. At that time E22 called and received orders for treatments. E2 stated she did the dressings the afternoon of 10/5/11 when she assessed R5's wounds but acknowledged that she didn't sign the TAR after completing them. E5 was asked why she didn't sign off the treatments and stated "sometimes she doesn't." On 11/1/11 at 11:55am, E4 LPN confirmed she worked on 10/6/11 and did not get R5's treatments done. E4 stated she "passed the information on to" the next nurse but did not document that R5's treatments were not done. This was confirmed in nurses notes written by E4 on 10/1/11. The first initials, on the TAR, for R5's treatments was on 10/7/11. On 10/28/11, a copy of R5's October 2011 TAR was obtained and noted to not only have the blanks for treatments done following his admission on 11/5/11 until 11/7/11, but to also have initials of treatments done on 10/3 and 10/4/11 when he was not in the facility. These initials were added after the first copy was obtained on 10/7/11. On 11/1/11, E2 Director of Nursing confirmed that documentation was a problem. E2 confirmed that treatments should be done as ordered by the physician and documented when done. E2 also stated that treatments not done should be initialed and circled. E2 confirmed that they have identified concerns with pressure ulcer treatment. In addition, Skilled Daily Nurses Notes for 9/23/11, 9/24/11, 9/25/11, 9/26/11, 10/5/11, 10/6/11 and 10/7/11 failed to identify any skin ulcers on R5. E2, E22, E4 and E19 were all unable to explain why this assessment conflicts with weekly wound documentation and treatment records. B) Based on interview, observation and record review, the facility neglected to meet nutrition and hydration needs and neglected to revise the plan of care for 1 of 4 residents (R5) reviewed for tube feeding in a sample of 7. Findings include: The care plan dated 8/4/11 identifies R5 to require tube feedings with goals to meet his hydration needs and maintain his weight within 5% by next review on 11/4/11. Interventions indicate staff are to follow physician's orders [REDACTED].), and position at 30 degrees minimum. The care plan does not reflect any weight loss although monthly weight records indicate R5 has had a substantial weight loss since his admission to the facility. R5's admission weight is recorded as 257.9 pounds on 5/5/11; his weight on 7/29/11 was 225.8; on 8/19/11, 245.7; and on 9/6/11, 226 pounds. E23, Registered Dietician's (RD), made a Note on admission in May 2011 that R5 had feedings set at 60cc/hr and flushes at 120cc every 4 hours. On 6/24/11, an RD note identified that his current flush rate did not meet his hydration needs and documented "wt (weight) (decreased), fluids do not meet needs but may not tolerate ^ (increase). Will suggest and monitor. Concur c (with) goal and plan." No changes were recommended. On 7/13/11, the RD assessment documents "6/28/11 flush ^ to 250cc q (every) 4 hours. Tube feeding the same." R5's weight is documented as 222.7 pounds. On 7/29/11, the RD again documents to increase R5's flushes to 250cc q 4 hours. R5 was not reviewed again by the RD until 8/4/11. At that time, no weekly weights were recorded and no additional interventions toward preventing further weight loss is noted or recommended by the nursing staff or the RD. On 9/12/11, R5 was readmitted to the facility following a hospitalization for pneumonia. His tube feeding was ordered at 60cc/hour with 120cc flushes every 4 hours even though the RD has identified that 120cc every 4 hours does not meet his hydration needs previously. An RD note dated 9/14/11 reflects the TF at 60cc/hour with water flushes at 120cc every hours. The note states readmission weight "to be clarified." R5 did not have weekly weights done following his readmission. The next entry by the RD was not until 10/14/11. Calculating intake for feedings at 60cc/hr, 12 hours shifts would be 720cc with 120cc flushes every 4 hours being 360cc per 12 hours shift. The I&O sheets for the feeding and flushes from 9/12/11 to 9/26/11 are inconsistently documented with many blanks. There is no intake documented on 9/12/11. On 9/13/11 for 7a-7p shift, 480cc is documented under "ORAL" even though R5 is NPO (nothing by mouth.) and 861cc for "OTHER." On 9/14/11, 240cc is documented for 3-11 shift, 491cc for feeding but has no documentation for the rest of the day. 9/15 has 240cc/flush for 7p to 7a, 570cc/feeding with 7a-7p 480cc and 936cc/feeding. On 9/16/11 7p-7a, R5 is recorded as only getting 240 cc flush and 580cc feeding with nothing recorded for 7a-7p shift. On 9/17/11, 7p-7a has 240cc recorded for flush and 500cc feeding, 7a-7p has 360cc recorded for flush and 702cc recorded for feeding. On 9/18/11, 7a-7p 408cc flush, 1330cc feeding and 7p-7a 240cc flush with 570cc feeding. From 9/19/11 through 9/25/11, documentation is absent for 6 of 15 shifts. According to nurses notes dated 9/26/11 at 2:30pm, R5 was sent to the emergency room after staff "noted decreased alertness, increased blood sugars for 2 days and rapid progression of a sacral decubitus." He was admitted with dehydration,[MEDICAL CONDITION] and numerous pressure ulcers/wounds that included extreme excoriation and open wound surrounding the gastric tube ([DEVICE]) insertion site. The facility did not have the [DEVICE] site wound identified prior to discharge on 9/26/11. The care plan shows no revisions to R5's interventions toward fluid intake/dehydration and/or weight maintenance since 5/26/11 despite his continued weight loss. On 11/1/11 at 2pm, E15, LPN, stated she worked with R5 on 9/24, 9/25 and 9/26 on 7am to 7pm shift. E15 stated she didn't know why she didn't document R5's intake for 9/23/11 but cleared the pump and wrote the amount down. The ORAL intake is the section she documents the flushes in. E15 stated R5 had no vomiting and/or diarrhea in the days prior to his hospitalization . On 10/5/11, R5 was readmitted to the facility. His admission weight was recorded as 230.6 pounds although his weekly weight was recorded as 199.3. On 11/1/11, R5's weight was 196.4. On 10/7/11 at 10:52am, R5's [MEDICATION NAME] 1000cc bag was hanging with 500cc left. The pump was running at 60cc/hour. The bag was not labeled. R5's mouth was in need of oral care as he had white substance in the roof of his mouth with sores evident. Lips were dry and peeling. At 10:54am, E21, Licensed Practical Nurse (LPN) stated she did not know when the bag of [MEDICATION NAME] was hung. R5's [DEVICE] site was noted to have no open sores evident but dark brown crusted substance underneath it. E21 stated "It just needs to be cleaned." On 10/28/11 at 1:30pm, E23, RD stated she bases all her feedings on 23 hour infusion. E23 stated no weekly weights were done until his last hospitalization . E23 stated she will look at the intake sheets occasionally and last saw R5 on 10/14/11. R5 was readmitted on [MEDICATION NAME] 60cc/hr and 250cc flush with med pass. The RD note dated 10/14/11 indicates R5's weights "fluctuate". On 10/12/11, an order to increase R5's flushes to 250cc with every med pass and every 4 hours was given. E23, RD, acknowledged on 10/28/11 at 1:30pm that the med passes would be every 4 hours so essentially, his flushes were not increased.

Based on observation, interview and record review, the facility neglected to identify, assess and implement interventions to prevent elopement for one of three residents (R1) reviewed for elopement in the sample of 9. On 1/14/2012, R1 eloped from the facility between 7:30 PM and 8:15 PM. R1 was found by the police face down in a creek dead on 1/16/2012. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 1/24/2012, the facility remains out of compliance at Severity Level 2 as the facility continued to educate staff and evaluated the effectiveness of the elopement policies and procedures and their system of communication. Findings include: 1. The facility's initial report to the Department dated 1/15/2012 documented "This letter is to inform you of an elopement of one our residents (R1), a [AGE] year old male with [DIAGNOSES REDACTED]. The resident was found missing from the facility at 8:15 PM. He had last been seen at 7:30 PM while he was watching a movie with a group of residents in the Dining/Living Room area. The staff searched the building, the outer parameter of the facility and other staff got in their cars and searched the area blocks around the facility. The (city) police were notified as well during this search. The police came into the facility and took the report. They came back to the building at midnight and searched the building and were unable to find the resident. They sent a helicopter up around 2:30 AM to search further. Ongoing search is continuing. Further investigation of the incident will continue and a follow up on the results will be provided." The Coroner's Report dated 1/16/2012 documented the Deputy Coroner, Z3, was notified by the city police of the death of R1 on 1/16/12 at 10:50 AM. The Report documented "He then led me to the creek viaduct that goes under 17th St., where I observed (R1), floating, face down, in the center of the creek." The Report documented R1 was wearing pajama bottoms, white underwear, a t-shirt, a sweat shirt, white socks and slippers. The Report documented Z3 pronounced R1 dead at 12:05 PM. The Report documented the cause of death was accidental "Hypothermia". The weather history from the wunderground.com website for the area on 1/14/2012 at 7:55 PM documented a temperature of 28.2 degrees Fahrenheit (F) with a wind-chill of 23.1 degrees F with no precipitation. On 1/17/12 at 4:30 PM, the area around the facility and the site where R1 was found was observed. The facility was located on the west side of a three lane street. The speed limit on this street was 30 miles per hour. There were sidewalks located on each side of the street. R1 was found approximately one block south east of the facility in a creek which flowed through a viaduct under the street to the south of the facility. The following are a history of R1's elopement attempts : a. R1's Hospital Departure Summary dated 5/6/2011 documented "05/06/11 1725 Triage Assessment, Complaint Related Notes Via EMS (Emergency Service) c/o (complained of) combative and screaming with roommate and staff........Went on EMS stretcher ok. Believes he is here to be checked out. On Thursday 5/5 he decided he wanted to leave the facility and packed up his belongings and started to leave the facility." b. R1's Interdisciplinary Progress Notes dated 6/6/11 documented "(R1) believes that he is going home, and that his house needs tending to, he does have a grandson who visits with him weekly. (R1) will become verbally abusive with staff and other residents. He will try to leave the facility. (R1) has poor decision making skills." c. On 1/24/12 at 10:20 AM a telephone interview was conducted with E24, Certified Nurse's Aide (CNA). E24 stated he had taken care of R1 when R1 resided on the 100 hallway. E24 stated he caught R1 outside the facility in late October 2011. E24 stated he saw R1 outside the facility through the window. He stated R1 was walking outside the facility in the front courtyard towards the front parking lot. E24 stated R1 was carrying his pants and shirts on hangers. E24 stated he went outside to retrieve R1. E24 stated R1 was upset; however, E24 was able to redirect R1 back into the facility. E24 stated he had questioned how R1 had walked past the receptionist at the front desk and walked out the front door. E24 stated R1 had a history of [REDACTED]. E24 stated he was working at the facility on 1/14/2012 at the time R1 eloped from the facility. E24 stated he did not hear any door alarms sound indicating any resident was leaving the facility. d. R1's Nurse's Note dated 1/2/12 at 8:45 PM documented R1 walked out the front door , was not wearing a (patient monitoring device) and was redirected back inside the facility. The Note documented "Nurse initiated 15 min (minute) checks until he was sleeping." e. R1's Nurse's Note, dated 1/14/12 at 8:00 PM documented "CNA was looking for him he was gone from D/R (Dining Room) no one could tell where he went. q (every) one staff in building went by car & (and) on foot looking for him no trace of him. q (every) hall was (checked) over (and) over s (without) result." 8:30 PM Police notified came in to get information." On 1/17/12 at 3:25 PM an interview was conducted with E4, Licensed Practical Nurse (LPN). E4 stated she was R1's nurse on 1/14/12 when R1 eloped from the facility. E4 stated she went to give him his medications at 8:00 PM and he was not in his room. E4 stated she asked E28, (CNA) where he (R1) was and E28 said he was in the dining room watching a movie. E4 stated she looked in the dining room but he was not there. E4 stated that the staff in the building began to search for R1, but could not locate him. E4 stated the Administrator and Director of Nurses were notified and stated to call the police. On 1/17/12 at 3:40 PM an interview was conducted with E7, CNA. She stated R1 could ambulate independently. E7 stated she did not work on 1/14/12 when R1 eloped from the facility. E7 stated she was aware R1 had a history of [REDACTED]. On 1/19/12 at 10:30 AM a telephone interview was conducted E28 (CNA). E28 stated she worked on 1/14/12 when R1 eloped from the facility. E28 stated at 5:30 PM R1 was in the dining room eating his dinner. E28 stated she was passing through the Dining Room at around 7:30 PM, and she saw R1 watching a movie. E28 stated at 8:00 PM, E4 asked if I had seen R1, and I told her I had seen him watching the movie. E28 stated R1 had a history of [REDACTED]. E28 stated she was unsure if R1 wore a patient monitoring device. On 1/24/12 at 3:50 PM a telephone interview was conducted with E29, CNA. E29 stated she worked on 1/14/12, the evening R1 eloped from the facility. E29 stated at around 7:00 PM she saw R1 sitting in his room. E29 stated she asked R1 if he wanted to watch a movie. E29 stated R1 agreed and walked with her to the dining room. E29 stated around 7:45 PM she noticed R1 was not in his room. E29 stated she did not hear any door alarms indicating a resident had left the building. E29 stated R1 was normally quiet but it depended on his mood. E29 said R1 had a history of [REDACTED]. On 1/17/12 at 12:05 PM an interview was conducted with E1, Administrator. E1 stated R1 was admitted to the facility in January 2008 with Dementia, [MEDICAL CONDITION], Hypertension and Cardiac Issues. E1 stated R1 ambulated independently without assistive devices. E1 stated R1 had a history of [REDACTED]. E1 stated staff would intervene prior to him leaving. E1 stated R1 attempted to pack his belongings up and leave the facility in early January 2012. E1 stated that on 1/14/12, R1 did not pack his belonging up prior to eloping the facility. E1 stated R1 was not wearing a patient monitoring device when he eloped from the facility on 1/14/12. E1 stated she had been told by staff that R1 would not leave the patient monitoring device on his person, and therefore it had been removed. E1 stated Z4, R1's Psychiatrist, had seen R1 a few days prior to his elopement and did not feel R1 was an elopement risk. On 1/19/12 at 10:30 AM a telephone interview was conducted with Z4. Z4 stated he did not recall being told by the facility R1 had attempted to leave the building or had a history of [REDACTED]. Z4 stated he would have expected the facility staff to let him know if R1 was trying to leave the building. Z4 stated R1 was demented and didn't know what he was doing. On 1/19/12 at 12:20 PM a telephone interview was conducted with Z5, R1's Primary Care Physician. When asked if he was aware R1 had a history of [REDACTED]. He (R1) was not very happy with placement." Z5 stated R1 had dementia and his cognitive and mental abilities fluctuated. R1's physician's orders [REDACTED]. R1's Minimum Data Set, MDS, dated 11/23/2011 documented under Section G0300 Balance During Transitions and Walking R1 was not steady, but able to stabilize without human assistance when moving from seated to standing position, walking, turning around and surface to surface transfers. The MDS documented he required supervision of staff for transfers and walking. R1's Fall Risk assessment dated [DATE] documented R1 had a fall risk score of 55. The Assessment documented "IF FALL SCORE 40 OR MORE THAN THEY ARE CONSIDERED A HALL FALL RISK AND SHOULD BE CARE PLANNED FOR FALL RISK." R1's Care Plan updated 12/2/2011 documented under the Comment Section "(R1) tries to leave the facility frequently wears a (patient monitoring device)." The Care Plan does not address R1's exit seeking behaviors and elopement attempts, and goals and interventions to address these behaviors. On 1/20/12 at 8:30 AM an interview was conducted with E30, LPN/Care Plan/MDS Coordinator. E30 stated she started her position as Care Plan/MDS Coordinator the end of October 2011. E30 stated she was not aware of R1's previous attempts to elope the facility, his behavior of packing his belongings, and saying he was going to leave. E30 stated R1's Care Plan was never revised to address those behaviors. R1's Initial Wandering Assessment Guide reviewed and revised on 10/6/11 documented "No" to the question "7. Is resident a candidate for (patient monitoring device) bracelet?" The facility's policy "Wandering Residents" revised March 2004 documented the following under the section Policy Interpretation and Implementation: "1. All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. 2. The resident's current MDS 3.0 will be reviewed to determine what changes have occurred that would trigger elopement episodes." 3. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. Staff will be informed at shift change of the modifications to the resident's care plan. 4. Interventions into elopement episodes will be entered onto the resident's care plan and medical record. 5. Should an elopement episode occur, the contributing factors, as well as the intervention tried, will be documented on the nurse's notes. 6. If a resident repeatedly wanders off the unit, a monitoring schedule will be implemented to ensure resident safety. The resident's care plan will be documented as to the implementation of the monitoring schedule." The Immediate Jeopardy was identified to have begun on 1/14/12 between 7:30 PM and 8:15 PM when R1 eloped from the facility without staff 's knowledge. E1 and E31, Director of Regional Operations, were notified of the Immediate Jeopardy on 1/19/12 at 3:31 PM. The surveyor confirmed through interview, record review, and observation that the Facility took the following actions to remove the Immediacy: 1. On 1/15/12, the facility conducted individual in-service training for all staff. All staff were in-services on the following policies and protocol: Elopements, Wandering Residents, Missing Residents, Head Checks and Drills, Elopement Drills, Door Alarms, Behavior Tracking, Tracking Sheets, Residents Currently on Tracking and/or (patient monitoring device) and the (patient monitoring device) System Policy. 2. On 1/16/12, the facility reassessed all current residents in the facility to determine wandering risk status. Following this, all high risk residents care plans were reviewed and changes made as necessary. 3. On 1/16/12, a Quality Assurance (QA) Meeting was held and all areas of the facility were reviewed to determine the possible exit route of the missing resident and other possible problem areas that exist. New preventative measures were implemented at that time as needed. 4. On 1/16/12, the QA committee reviewed all related policies and revisions were made as needed. 5. On 1/16/12 and on-going, secondary keyed door alarms were installed on all exit doors accessible to residents. 6. On 1/16/12, all high risk resident's information was placed in a binder at each nursing station and at the front desk. Each binder included the individual residents face sheet, a current picture, room number and specific interventions to be in place. 7. On 1/16/12, Receptionist's hours have been extended and are not from 8:00 AM until 9:00 PM to provide additional monitoring of our main entrance. 8. On 1/16/12 and on-going, all door alarms will be checked by Maintenance daily (Monday-Friday) and by the weekend manager on Saturday and Sunday to ensure they are in proper working order. These checks will be documented at the time they are completed. Batteries will be changed monthly and as needed. 9. On 1/16/12 and on-going, Elopement Drills will be conducted monthly, alternating shifts, and randomly per Director of Nurse's (DON) and/or designee. 10. On 1/16/12 and on-going, Head Check Drills will be conducted monthly, alternating shifts, and randomly per DON and/or designee. 11. On 1/16/12 and on-going, an initial Wandering Assessment will be completed on all new admits on the day of admission, in conjunction with their 14 day assessment, quarterly and PRN. Follow-up will be implemented based on the results of the assessment. 12. On 1/16/12 and on-going, patient monitoring devices will be checked daily by the MDS nurses Monday thru Friday and on the weekend by the weekend manager.

Based on observation, record review, and interview, the facility failed to prevent and timely treat pressure sores for 2 of 5 residents (R3, R7) reviewed for pressure ulcers in the sample of 9. Findings include: 1. R3's Care Plan dated 12/12/11 identified a Problem/Need of Pressure Ulcers: Potential for skin breakdown or pressure ulcers related to decreased mobility, vent dependence, leaky (indwelling catheter) and [MEDICAL CONDITION] bag. The goal of the care plan is, "Will maintain intact skin, free of redness, blisters or discoloration...". R3 was observed on 1/19/12 at 12:45 PM. E23 and E24, Certified Nursing Assistants (CNAs) were providing care to R3. R3 had a gauze dressing on her right buttock. E23 and E24 stated R3 "scratched" her buttock causing the open area. On 1/20/12 at 11:55 AM, Z1, POA for R3, was interviewed by telephone. Z1 stated she was unaware of any open areas on R3's skin. When asked if Z1 would be able to scratch herself, Z1 replied, "There's no way she could scratch her buttocks. Her hands are contracted. She can't even pick up a cup." . R3's Weekly Basic Skin assessment dated [DATE] documented, "Red areas - buttocks. superficial abrasion left buttock." There is no documentation of treatment obtained until 1/11/12, when the treatment sheet documented a new order, "Apply TAO (triple antibiotic ointment) & cover with dry drsg (dressing) to open area on R (right) buttocks daily.". Nursing staff initialed the order starting on 1/11/12. R3's Care Plan for potential for skin breakdown was not updated to identify the facility-acquired pressure ulcer and treatment ordered to treat the pressure ulcer. On 1/20/12 at 2:30 PM, E2, Director of Nursing, (DON), stated she was unaware that the "abrasion" had been documented on both the right and left buttock. E2 was unable to state if there were two separate areas, or just one that had been documented incorrectly. The area observed on 1/19/12 was on the right buttock. On 1/19/12 from 12:45 PM until 3:00 PM, R3 remained in the same position. She was in bed, on her back, with the head of her bed elevated, and R3's position was unchanged for 2 hours and 15 minutes. On 1/20/12 from 10:22 AM until 3:15 PM, R3 remained in the same position. R3 was seated in the chair next to her bed, and R3's position was unchanged for 4 hours and 53 minutes. R3's Care Plan dated 12/12/11 for potential for pressure ulcers documented an approach, "Turn, reposition at least every 2 hours, more often as needed or requested." The facility's Skin Care, Assessment and Maintenance Policy updated 9/2011, documented (in part), "Documentation will be recorded in the resident's medical record....All pressure ulcers are to be....on the TAR (Treatment Administration Record)....any assessment change noted, and any change noted with the resident.....". The Procedure documented an intervention "Decreased Pressure: Turn and position every two hours. Use supportive pillows or body aligner to redistribute body weight..." 2. Review of the Admission Sheet doucments R7 was originally admitted to the facility on [DATE] with diagnosis, in part, of [MEDICAL CONDITION], Acute [MEDICAL CONDITION], and Urinary tract infections. The Minimum Data Set, MDS, dated [DATE] indicates that R7 is totally dependent on staff for all activities of daily living (ADL) and is cognitively impaired. The Care Plan dated 1/16/12 identifies R7 at risk for pressure ulcers related to decreased movements and incontinent of bowel. There are no open areas identified currently on 1/19/12. The Skin Chart completed on admission 12/15/11 does not identify any open areas or pressure ulcers present on R7 at the time but does does identify some "excoriation." There is no further documentation present in the chart that includes an assessment of the excoriation. There is a physician's orders [REDACTED]. There is also no treatment records in the clinical record to review to see if the treatments were initialed as completed. On 12/17/11, R7 was transferred back to the hospital and returned on 12/24/11. A skin chart completed on 12/24/11 identifies R7 to have an open area stage II/excoriation on his left buttock and a "small open area on ear" (left and right). There is no further information on these areas in regards to measurements that included stages, etc. There is no treatment sheet that reflects that any orders were received for these areas or treatments were done. On 12/27/11, R7 was sent back to the hospital and returned on 1/3/12. A "skin issue notification tool to treatment nurse" sheet dated 1/3/12 was completed and identified an "open area" on the coccyx. The skin chart dated 1/3/12 had the coccyx circled, but included no further information, and no orders were noted on the physician's orders [REDACTED]. Review of the Dietary assessment dated [DATE] has "pressure ulcers" checked with "(on bil ears) - stage II on L (left) buttock." However, there is no documentation present in the chart including the physician's orders [REDACTED]. On 1/19/12 at 9:05am, R7 was observed to have a stage II ulcer on his right ear, outer auricle, left ear and right buttocks with scarring on his left buttock. E8, CNA, was assisting with the skin check and was aware of all the areas observed at the time. At 10:25am on 1/19/12, E9, Treatment Nurse, stated she was going in to assess R7's open area on his buttock. E9 rolled R7 to his right side with the assistance of E10, Registered Nurse. R7 had a large irregular shaped ulcer on his mid right buttock which had slough present on the upper half and active bleeding at the lower right edge. The dermis was completely gone. There was deep purple scarring on the mid left buttock but no open areas were noted. E9 measured the right buttock area then applied barrier cream and a gauze dressing. E9 had completed her treatment, and was ready to leave the room when asked about R7's ear sores. E9 stated she "didn't know about his ears" and proceeded to assess them. E9 stated she measured the left ear, but didn't measure the right ear "because it wasn't open. It was just dry and scabby." Measurements documented on the back of the treatment sheet dated 1//19/12 indicates the Right buttock was 4cm (centimeter) x 1cm and 26 cm x 0.5cm. The right ear ulcer measured 2cm x 0.5cm. There is no measurements for the left ear. No additional information is present that includes a description of the ulcers that reflects the slough and bleeding observed on the larger ulcer, and no stages were identified. E9 notified the physician and received orders for the buttock wound and right ear. The treatment sheet includes an order for [REDACTED]." On 1/20/12 at 1:15pm, R7's treatment records for December were requested from E19, Corporate RN with none provided. The facility's policy entitled "Skin Care, Assessment and Maintenance" documents that an assessment shall be performed at admission and quarterly. Any impairment in skin integrity shall be documented. Under General Statements, all pressure ulcers will be documented using DOCUMENTATION GUIDELINES that list the following information to be included: A. Stage & size: Measure using the metric system, width, length, and depth, B. Wound Description: Select all appropriate abbreviations from "Key" wound bed and surrounding wound., C. Odor present? D. Wound color E. Exudate or drainage present (if present) and amount and other including nutritional/hydrational needs, culture needs, preventative measures and progress, pain assessed.

Based on observation, interview and record review, the facility failed to ensure adequate hydration through tube feedings and flushes for 3 of 4 residents (R1, R2, R5) reviewed for tube feedings in a sample of 7. This failure resulted in R5 being admitted to the hospital for dehydration [MEDICAL CONDITION]. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] identifies R5 to be totally dependent on staff for all activities of daily living (ADL's). The MDS also indicates R5 has a gastrostomy tube, is vent dependent, and has a urinary catheter. The MDS indicates R5 has severe cognitive impairment. The care plan dated 8/4/11 identifies R5 requires tube feedings with goals to meet his hydration needs and maintain his weight within 5% by next review documented as being 11/4/11. Interventions indicate staff are to follow physician's orders [REDACTED].), and position at 30 degrees minimum. The care plan does not reflect any weight loss. The weight record indicate R5 has had weight loss with his admission weight recorded as 257.9 pounds on 5/5/11; on 7/29/11 he weighed 225.8; on 8/19/11 he weighed 245.7; and on 9/6/11 he weighed 226 pounds. The Registered Dietician's (RD), E23, Note on admission had feedings set at 60cc/hr and flushes at 120cc every 4 hours. On 6/24/11, a dietary manager's note written by E3, Dietary Manager,documents "no dietary changes. TF (tube feeding)/flush order same." On 6/24/11, an RD note documented "wt (weight) (decreased), fluids do not meet needs but may not tolerate ^ (increase). Will suggest and monitor. Concur c (with) goal and plan." On 7/13/11, the RD assessment documents "6/28/11 flush ^ to 250cc q (every) 4 hours. Tube feeding the same." R5's weight is documented as 222.7 pounds. On 7/29/11, the RD again documents to increase R5's flushes to 250cc q 4 hours. R5 was not reviewed again by the RD until 8/4/11 and no weekly weights are recorded and no additional interventions toward preventing further weight loss is noted. On 9/12/11, R5 was readmitted to the facility following a hospitalization for pneumonia. His tube feeding was ordered at 60cc/hour with 120cc flushes. An RD note dated 9/14/11 reflects the tube feeding at 60cc/hour with water flushes at 120cc every hours. The note states readmission weight "to be clarified." R5 did not have weekly weights done following his readmission. The next entry by the RD is 10/14/11. Calculating intake for feedings at 60cc/hr, 12 hours shifts would be 720cc with flushes every 4 hours being 360cc per 12 hour shift. The I&O sheets for the feeding and flushes from 9/12/11 to 9/26/11 are inconsistently documented with many blanks. There is no intake documented on 9/12/11. On 9/13/11 for the 7a-7p shift, 480cc is documented under "ORAL" even though R5 is NPO (nothing by mouth.) and 861cc for "OTHER." On 9/14/11, 240cc is documented for 3-11 shift, 491cc for feeding but has no documentation for the rest of the day. 9/15 has 240cc/flush for 7p to 7a, 570cc/feeding with 7a-7p 480cc and 936cc/feeding. On 9/16/11 7p-7a, R5 is recorded as getting 240 cc flush and 580cc feeding with nothing recorded for 7a-7p shift. On 9/17/11, 7p-7a has 240cc recorded for flush and 500cc feeding, 7a-7p has 360cc recorded for flush and 702cc recorded for feeding. On 9/18/11, 7a-7p 408cc flush, 1330cc feeding and 7p-7a 240cc flush with 570cc feeding. From 9/19/11 through 9/25/11, documentation is absent for 6 of 15 shifts. According to nurses notes dated 9/26/11 at 2:30pm, R5 was sent to the emergency room after staff "noted decreased alertness, increased blood sugars for 2 days and rapid progression of a sacral decubitus." He was admitted with dehydration,[MEDICAL CONDITION] and numerous pressure ulcers/wounds that included extreme excoriation and open wound surrounding the [MEDICAL CONDITION] tube ([DEVICE]) insertion site. The care plan shows no revisions to R5's interventions toward fluid intake/dehydration and/or weight maintenance since 5/26/11 despite his continued weight loss. On 11/1/11 at 2pm, E15, LPN, stated she worked with R5 on 9/24, 9/25 and 9/26 on 7am to 7pm shift. E15 stated she didn't know why she didn't document R5's intake for 9/23/11 but clears the pump and writes the amount down that is on the pump. The ORAL intake is the section she documents the flushes in. E15 stated R5 had no vomiting and/or diarrhea in the days prior to his hospitalization . On 10/5/11, R5 was readmitted to the facility. His admission weight was recorded as 230.6 pounds although his weekly weight was recorded as 199.3. On 11/1/11, R5's weight was 196.4. On 10/7/11 at 10:52am, R5's [MEDICATION NAME] 1000cc bag was hanging with 500cc left. The pump was running at 60cc/hour. The bag was not labeled. R5's mouth was in need of oral care as he had white substance in the roof of his mouth with sores evident. Lips were dry and peeling. At 10:54am, E21, Licensed Practical Nurse (LPN) stated she did not know when the bag of [MEDICATION NAME] was hung. R5's [DEVICE] site was noted to have no open sores evident but dark brown crusted substance underneath it. E21 stated "It just needs to be cleaned." On 10/28/11 at 1:30pm, E23, RD stated she bases all her feedings on 23 hour infusion. E23 stated no weekly weights were done until R2's last hospitalization . E23 stated she will look at the intake sheets occasionally and last saw R5 on 10/14/11. R5 was readmitted on [MEDICATION NAME] 60cc/hr and 250cc flush with med pass. The RD note dated 10/14/11 indicates R5's weights "fluctuate". On 10/12/11, an order to increase R5's flushes to 250cc with every med pass and every 4 hours was given. E23, RD, acknowledged on 10/28/11 at 1:30pm that the med passes would be every 4 hours so essentially, his flushes were not increased. As of 11/2/11, R5's care plan had not been revised to reflect any changes since 5/26/11. 2. The MDS dated [DATE] identifies R2 to be totally dependent on staff for all activities of daily living. The MDS indicates R2 is vent dependent, has a [DEVICE], and has a urinary catheter. According to the monthly weight records, R2's weight is stable around 184 pounds. The physician's orders [REDACTED]. The POS also includes an order "cleanse tube daily c (with) soap and H2O." The TARs also reflect this order to be done by evening staff. On 10/5/11 at 1pm, R2's tube feeding was running via a pump at 60cc/hour. He had 150cc left in his bottle of 1000cc. The bottle was labeled hung at 1pm on 10/4/11. According to calculations, R2's tube feeding was off by 275cc. R2 also was noted to have peeling skin on his tongue, inner cheeks with mucus membranes being dry, lips peeling. The pump was soiled with formula. R2's [DEVICE] site had dried dark red crusty drainage present under it with some moisture noted at the inner area. The TAR for October reflects the [DEVICE] site cleansing order and has only 17 of 29 days documented as having done the treatment. The Intake records were also noted to be inconsistently documented and incomplete. 3. According to the MDS dated [DATE], R1 is totally dependent on staff for all activities of daily living. The MDS indicates he is vent dependent and has a [DEVICE]. According to the RD notes of 8/19/11, R1 has "fluctuating weights" and weighed 196.4 on 8/19/11 and on 10/25/11, weighed 176.4 pounds. The POS indicates R1 receives 200cc water flush every 4 hours and Diabetisource 80cc/hour/pump. The dietary note dated 5/26/11 indicates R1 had a hospitalization for pneumothorax and also receives [MEDICATION NAME] which could contribute to the fluctuating weights. On 8/19/11, the dietary note identifies a goal to maintain weight within 5% ongoing and listed R1's current weight at that time as 196.4 pounds. The dietary manager made no recommendation but indicated they would continue to monitor. On 10/25/11, R1's weight was recorded as 176.4 pounds. There is no indication the facility made revisions to R1's plan of care to address the weight loss in an effort to prevent further loss. R1's tube feeding and flushes are inconsistently documented with many omissions present. Of 62- 12 hours shifts for October 2011, 18 shifts have no intake for formula or flushes recorded as occurring. On 10/5/11 at 12:30pm, R1's [DEVICE] site was noted to have dry drainage with chunks hanging around the tube. There was no dressing over the site. R1's pump was soiled with feedings. His lips were dry and peeling.