Every finding on record at Oak Park Oasis

Based on observation, interview, and record review, the facility failed to ensure a functioning Gastrostomy Tube (GT) was available for a GT resident to administer bolus feed and free water flush as ordered by the physician. The facility also failed to follow its Gastrostomy or Jejunostomy Feeding policy by not administering the GT free water flush before and after feeding as ordered by the physician. This applies to 1 of 2 residents (R3) reviewed for GT care in a sample of 5.The Findings include:R3 is a [AGE] year-old male admitted on [DATE] with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE].R3 was admitted with an admitting diagnosis of gastrostomy, dehydration, seizure, and anoxic brain damage.A review of the progress notes dated 4/2/26 documented that R1 was sent for an appointment with his mother, and, upon being seen by the MD, became agitated, with his heart rate elevated, and was admitted to the county hospital.A review of the hospital/Medical Intensive Care Unit (MICU) consult note dated 4/2/26 documented that R3's labs on admission to the county hospital showed an elevated sodium level (Hypernatremia) of 161, and MICU was consulted for further management given the complexity of the patient's issues.On 5/20/26 at 12:00 PM, observed V6 (Registered Nurse/RN) performing a 200 ml free water flush with R3's GT. Observed the GT port leaking onto R3's stomach, and V6 was unable to administer the bolus feeding and free water flush. V6 stated that she was supposed to give a free water flush of 200 ml altogether.A review of the R3's POS (Physician Order Sheet) documented that the physician placed an enteral feed order three times per day, 475 (ml), and a 300 ml free water flush before and after feeding at 0800, 1200, and 1600.On 5/20/26, at 1:10 PM, V2 (Director of Nursing/DON) attached an extension to the current GT port, and it was still leaking. V2 stopped feeding, saying that The port is leaking, and I need to consult with our nurse consultant.On 5/20/26 at 2:00 PM, V2 stated, Nurses are supposed to verify the physician orders and flush GT with the amount of water the MD ordered. R3 had a history of hypernatremia, so the MD ordered 300 ml before and 300 ml after feeding. Insufficient amount of feeding & flush can cause dehydration.The facility presented an undated Gastrostomy/Jejunostomy Feeding policy documented: Refer to MAR (Medication Administration Record) for orders for feeding amount, frequency, and water flush before beginning.

Based on observation, interview, and record review, the facility failed to administer medications within the expected timeframe. This failure affected five (R3, R5, R6, R8 and R9) residents reviewed for medication administration in the total sample of 9 residents. Findings include:On 04/17/2026 at 11:30am, V5 (Registered Nurse) stated she was getting ready to pass (R3) 9:00am medications. Informed V5 this surveyor was going to observe V5 with medication administration. On 04/17/2026 at 11:40am after passing R3's medications, V5 checked cloud-based electronic health record platform per this surveyor's request and stated she still had to pass medications to four (R5, R6, R8, and R9) residents scheduled at 9:00am. V5 stated the expectation is to pass medications one hour before and one hour after the scheduled time. On 04/17/2026 at 4:11pm, V2 (Director of Nursing) stated staff are expected to follow the rights of medication administration which include right dose, medication, person, time, and route. V2 stated the right time is one hour before and one hour after the scheduled time. V2 stated if medication is scheduled to be given two, three, or four times daily, and there is a schedule to give at 9am, then the medication should be given between 8a and 10am, so the next dose is not too close from the 9am dose. V2 stated the medication is ordered to be given on scheduled time for it to work properly so the resident will benefit from the therapeutic effect of the medication.R3'S (Active Order as Of: 04/17/2026) Order Summary Report documented, in part Diagnoses: (include but not limited to) Type 2 Diabetes Mellitus with diabetic neuropathy, chronic idiopathic constipation, and embolism and thrombosis of deep veins. buPROPion HCl ER (SR) Oral Tablet Extended Release 12 Hour 150 MG (Bupropion HCl) Give 1 tablet by mouth two times a day, Coreg Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day, Gabapentin Capsule 100 MG Give 2 capsule by mouth two times a day, Polyethylene Glycol Powder (Polyethylene Glycol 1450) Give 17 gram by mouth two times a day, prednisoLONE Acetate Ophthalmic Suspension 1 % (Prednisolone Acetate (Ophth)) Instill 1 drop in left eye two times a day. R3'S (04/17/2026) Medication Administration Audit Report documented, in part Polyethylene glycol powder 17gram by mouth two time a day for constipation dissolve in 8oz water, gabapentin 100mg 2 capsule by mouth two times a day, prednisolone ophthalmic suspension 1 drop to left eye two times a day, lactulose 15ml by mouth two times a day, bupropion 150mg by mouth two times a day, Coreg 12.5mg by mouth two times a day. Schedule Date: 04/17/2026 9:00am. Administration Time: 04/17/2026 at 11:30am - 11:43am. Documented by: V5.R3's (03/03/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 12. Indicating R3's mental status as moderately impaired.R3's (Effective Time Range: 04/16/2026 - 04/18/2026) Progress notes was reviewed with no notes to may give medications late. R5's (Active Order as Of: 04/17/2026) Order Summary Report documented, in part Diagnoses: (include but not limited to) hypertension, disorder of skin and subcutaneous tissue, pruritus, and Type 2 Diabetes Mellitus with polyneuropathy. metFORMIN HCl Oral Tablet 500 MG (Metformin HCl) Give 500 mg by mouth two times a day for Diabetes, Triamcinolone Acetonide External Cream 0.1 % (Triamcinolone Acetonide (Topical)) Apply to Itchy skin areas topically two times a day for skin inflammation, Gabapentin Oral Capsule (Gabapentin) Give 100 mg by mouth two times a day for Pain.R5's (04/17/2026) Medication Administration Audit Report documented, in part metformin 500mg two times a day, triamcinolone cream apply topically two times a day, Gabapentin 100mg two times a day. Scheduled time: 04/17/2026 9:00am. Administration time: 11:55am - 11:56am. Documented by: V5. R5's (02/02/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R5's mental status as cognitively intact.R5's (Effective Time Range: 04/16/2026 - 04/18/2026) Progress notes was reviewed with no notes to may give medications late.R6's (Active Order as Of: 04/17/2026) Order Summary Report documented, in part Diagnoses: (include but not limited to) hypertension, COPD (Chronic Obstructive Pulmonary Disease), and Type 2 Diabetes Mellitus. Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal)) 1 spray in both nostrils two times a day for nasal allergies. Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1tablet by mouth two times a day for Heart Failure. R6's (04/17/2026) Medication Administration Audit Report documented, in part carvedilol 12.5mg give one tablet by mouth two times a day, fluticasone nasal spray 1 spray in both nostrils two times a day. Schedule date: 04/17/2026 9:00am. Administration Time: 12:03pm - 12: 05pm. Documented by: V5. R6's (03/02/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R6's mental status as cognitively intact.R6's (Effective Time Range: 04/16/2026 - 04/18/2026) Progress notes was reviewed with no notes to may give medications late.R8's (Active Order as Of: 04/17/2026) Order Summary Report documented, in part Diagnoses: (include but not limited to): constipation, epistaxis, and hypertension. Artificial Tears Ophthalmic Solution 1 % (Carboxymethylcellulose Sodium (Ophth) instill 1 drop in both eyes three times a day, Ocean Nasal Spray Nasal Solution 0.65 % (Saline) 1 spray in both nostrils three times a day, Senna S Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 1 tablet by mouth two times a day. R8's (04/17/2026) Medication Administration Audit Report documented, in part Artificial Tears Instill 1 drop in both eyes three times a day for Dry Eyes, Ocean Nasal Spray three times a day, Senna S Tablet 8.6/50mg 1 tablet two times a day. Schedule Date: 04/17/2026. Administration Time: 04/17/2026 12:19(pm) -12:23(pm). Documented by: V5 (Registered Nurse)R8's (01/19/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R8's mental status as cognitively intact. R8's (Effective Time Range: 04/16/2026 - 04/18/2026) Progress notes was reviewed with no notes to may give medications late.R9's (Active Order as Of: 04/17/2026) Order Summary Report documented, in part Diagnoses: (include but not limited to) shortness of breath, COPD (Chronic Obstructive Pulmonary Disease), and heart failure. Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation)) 2 milliliter inhale orally two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Active 12/05/2025. Furosemide Oral Tablet 20 MG (Furosemide) Give 20 mg by mouth two times a day related to ACUTE RESPIRATORY DISTRESS SYNDROME. Active: 12/04/2025. R9's (04/17/2026) Medication Administration Audit Report documented, in part Budesonide Inhalation suspension 2ml inhale orally two times a day, furosemide 20mg two times a day: Schedule date: 04/17/2026 9:00am. Administration time: 04/17/2026 12:09pm - 12:13pm. Documented by: V5. R9's (01/07/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 03. Indicating R9's mental status as severely impaired.R9's (Effective Time Range: 04/16/2026 - 04/18/2026) Progress notes were reviewed with no notes to may give medications late.The (04/18/2026) email correspondence with V1 (Administrator) documented, in part The expectations of administration of medication in accordance with frequency prescribed by physician, ie., within 60 minutes before or after prescribed dose time. The (undated) RN/LPN Job Description documented, in part Job Summary: The primary purpose of your job position is to provide direct nursing care to the residents and to supervise the day to day nursing activities performed by the nursing assistants. Essential Duties and Responsibilities: Prepare and administer medications and treatments as ordered by Physician.The (undated) Medication Administration Policy documented, in part II. ADMINISTRATION OF MEDICATIONS. Medications must be administered in accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time. The (undated) Physician Orders documented, in part These guidelines are to ensure that: Any orders given by Physician are carried out. NURSE RESPONSIBILITIES. Orders are to be transcribed into the electronic charting system. Medication and/or treatment orders are to be scheduled to MAR/TAR as appropriate. NURSING DOCUMENTATION. Any calls to or from physician will be documented in the nurse's notes indicating information conveyed and received.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to document medication administration, failed to ensure prescribed medications were administered timely to three residents (R10, R37, R102) residing on 2nd floor in a sample of 25 residents. The facility further failed to ensure timely and appropriate emergency medical response and failed to follow facility's hypoglycemic protocol. These facility failures affected one (R116) of one resident reviewed for quality of care and resulted in R116 experiencing a blood sugar level of 40 (critical) and hospitalization requiring intensive care services.Findings include: R116 is a closed record. R116 was transferred to the hospital on [DATE]. R116's diagnoses include but are not limited to adult failure to thrive, chronic respiratory failure, dependence on supplemental oxygen, type 2 diabetes, hypertension, chronic obstructive pulmonary disease, malignant neoplasm of unspecified part of unspecified bronchus or lung, and obesity. R116's BIMS (brief interview mental status) score, dated 9/22/2025, is 13 which indicates R116 is cognitively intact. R116's physician order, ordered date 6/10/25, documents, in part, POLST: Attempt resuscitation/CPR (selecting CPR means intubation and mechanical ventilation). R116's progress note, per V23 (Registered Nurse), dated 10/19/25 at 6:11am, documents, in part, Writer entered room around 4:30 am. Resident (R116) would not respond to any verbal or physical stimuli. Writer called residents (R116) name loudly while shaking her shoulders, no response. Pupils dilated round and reactive to light assessed after raising eyelids. Mucus membranes moist. O2 NC 3LPM patent. Foley draining amber colored urine. Bowel sounds hypoactive. Lung sounds clear bilaterally. Compromised skin integrity, dryness, breakdown over arms, legs and perineal area. BP 132/64, P 65 T 95.4 O2 Sat 94% without 3L NC, 98% w/ 3L NC. BS 59 initially, Sugar given by mouth BS 63, Writer & Supervisor unable to get IV access for dextrose. 911 called around 4:50 am. MD (medical doctor) called no answer NP (nurse practitioner) called no answer. BS dropped down to 40 before EMS (emergency medical services) arrived. EMS arrived around 5:05 am, (R116) taken to hospital. R116's progress note, per V18 Licensed Practical Nurse/LPN), dated 10/19/25 at 1:27pm, documents, in part, Called (hospital) and spoke to with nurse in emergency department she (R116) is admitted in the ICU (intensive care unit), who then transferred me to ICU and spoke with nurse, she (R116) is still hypoglycemic and having some respiratory issues as well. R116's hospital records, admission date 10/19/25, documents, in part, Pt (R116) arrives via EMS (emergency medical services) from Nursing Home, pt (R116) was unresponsive on arrival in NH (nursing home) reported to have sugar of 50. Blood sugar 25 by EMS and given glucagon repeat 20. Not responsive on arrival. In the ED (emergency department), pt (R116) was initially hypothermic to 96.1F. Pt (R116) on 3L Nasal Cannula for COPD (chronic obstructive pulmonary disease). Initial labs were remarkable f glucose 42, Albumin 1.5, lactate 2.5 -> 3.8, WBC 14.95K. Arrived with foley placement, scant urine output, cloudy and clumpy output. Foley bag was noted to have grossly tenacious component. Foley leaking purulent urine malodorous. Her (R116) Foley catheter was exchanged that also had thick clumps debris and dark urine with concern for infectious etiology. Spoke to the patient's daughter and updated her in regards to her being at Rush Oak Park. She specifies that she would like her mother to be full code and receive chest compressions as well as intubation if she decompensates. During the ICU (intensive care unit) stay the patient (R116) was treated for ESBL (Extended-Spectrum Beta-Lactamase) bacteremia and UTI (urinary tract infection) with meropenem and MRSA bacteremia with vancomycin and pneumonia, as well as candida intertrigo with fluconazole. Patient mental status remained poor with severe pain given diffuse skin wounds. Patient family ultimately made a decision to make the patient DNR (Do Not Resuscitate) and today made a decision to transition the patient to inpatient hospice here in the unit. Presents with toxic metabolic encephalopathy. admitted with PNA (pneumonia) and Sepsis= 2/2 complicated UTI. See past medical history below. Extensive skin breakdown and? Abrasions present on admission-see photos. Moaning/crying throughout care. Four-eye skin assessment completed: under abdominal folds, breasts, back, bilateral outer and inner thighs, Left heel DTI and cracked and dry, sacrum, and perineal area. Report to IDPH (Illinoi Department of Public Health) for concerns of neglect from (nursing home) where patient has been a resident since June 10th, 2025. Pt appears un-cared for. Unbathed and skin was extremely dirty and dry. Back side reddened and with multiple areas of skin break down. Foley appears unchanged and extremely dirty. Sepsis--hypothermia, leukocytosis: Likely 2/2 R-sided PNA (pneumonia), suspect aspiration component; +/- component of GU infection, at risk given indwelling foley catheter though pyuria and mixed flora colonization expected. During the ICU stay the patient was treated for ESBL bacteremia and UTI with meropenem and MRSA bacteremia with vancomycin and pneumonia, as well as candida intertrigo with fluconazole. Patient family ultimately made a decision to make the patient DNR and today made a decision to transition the patient to inpatient hospice here in the unit. This patient has a high probability of sudden, clinically significant deterioration, which requires the highest level of physician preparedness to intervene urgently. R116's MAR (Medication Administration Record), dated October 2025, documents, in part Accu-Chek QID (4 times a day) AC & HS before meals and at bedtime for DMII (Diabetes Mellitus II). R116's care plan, dated 7/09/25, documents, in part, (R116) has diabetes mellitus & the potential for complications related to: Elevated blood sugar., History of uncontrolled diabetic status., The resident is: Insulin dependent, with interventions that document, in part, Assess for signs of hyperglycemia or hypoglycemia; Provide medication as ordered. On 12/16/25 at 2:14pm, V23 (Registered Nurse/RN) stated, Yes, I was familiar with the patient (R116). During my rounds, the patient (R116) was found unresponsive. I was unable to obtain vital signs, and the patient's (R116) blood sugar was low. I attempted to administer dextrose but was unable to obtain IV (intravenous access). The patient (R116) was sent out. V40 (Registered Nurse/RN) tried to give R116 sugar in her (R116) mouth to bring up R116's blood sugar. The sugar was regular table sugar. R116 wasn't given a lot of sugar because the patient's (R116) mouth was not open. I am not sure why this method (oral table sugar to an unresponsive resident) was used, and I understand that administering anything orally to an unresponsive patient is unsafe due to the risk of choking. When a patient is unresponsive, the first action should be to call 911, and it should be done in a timely manner. The patient felt cold to the touch, and a temporal thermometer was used. I was a new nurse at the time and was doing my best to the best of my ability. I immediately called for help by contacting my supervisor to determine the next plan of action. On 12/17/25 at 10:46am, V40 (Medical Director) said, For an unresponsive resident, the resident should be sent to the hospital immediately. The first step is for another nurse to evaluate the resident, and another nurse call 911, and ensure the resident is transported to the emergency room without delay. Administering oral sugar to an unresponsive resident who cannot swallow is ineffective and should not be done. A Foley catheter not being changed routinely can increase the risk of developing a urinary tract infection if not properly managed. Sorry, I am not familiar with R116. On 12/17/25 at 11:18am, V2 (Director of Nursing/DON) said, R116 was in and out of the hospital. She (R116) came in June 2025), but I didn't start until September (2025). Before my time. Based on the documentation, she (R116) came in June (2025) with a Foley catheter. The Foley was never changed in-house and there is no documentation that she (R116) refused to have the foley changed. Not changing a foley can cause infection. I would need to review her (R116) notes for more details. On 12/17/25 at 12:05pm, V40 (Registered Nurse/RN) said, I was called V23 (Registered Nurse/RN) who stated that she (V23) went to do routine care and found her (R116) unresponsive. At that moment I knew she (R116) was diabetic and check sugar and tried placing sugar in her (R116) mouth. Checked her (R116) sugar and sugar went up but then came right back down. Yes, I tried putting in and IV (intravenous) in her (R116) and was unsuccessful. When a resident is unresponsive, you do an assessment and call a code immediately. Yes, Call 911 immediately, but I knew it was hypoglycemia, so we (V40 and V23) were trying to get sugar up. If glucagon was available I would have given it to her (R116). If I remember, I don't recall exactly, I usually call 911 from my cellphone. I don't recall exactly. I do agree that 911 should be called immediately. Oral sugar is not safe when a resident is unresponsive, but I placed the sugar in between her (R116) lips and gums, because time was of the essence, and we were trying to bring the sugar up. We do have glucagon in the emergency carts, but we just didn't have it (glucagon) that morning. All I know is I asked V23 for some glucagon and V23 said V23 didn't have none. Each emergency cart has glucagon, so I don't know why she (V23) said she (V23) have any. On 12/17/25 at 12:43pm, V2 (Director of Nursing/DON) said, Glucagon is in the emergency kit. Yes, glucagon is always available. It (glucagon) should be given for hypoglycemia. Glucagon should have been given for a blood sugar less than 60 if the resident was unresponsive. The 12/14/25 census includes 72 (2nd floor) residents. On 12/15/25 at 10:50am, twenty (20) residents were affirmed to be highlighted red (indicating late administration) on the (2nd floor) EMAR (Electronic Medication Administration Record). Surveyor inquired why 20 residents were highlighted red on the EMAR V6 (LPN/Licensed Practical Nurse) stated Its highlighted red cause it needs signed out. I (V6) have to sign the medications that I give as I give it out, it got kinda busy today. We (staff) normally sign em out as we go. 12 of em (residents) are mine. Surveyor inquired which residents did not receive their 9am medications V6 responded Everybody got they're 9am meds. Surveyor inquired whose medications were in the cup - that V6 was holding V6 replied (R10's name). On 12/15/25 at 11:11am, V6 administered R10's medications (scheduled for 9am administration) therefore not within regulatory requirements (within one hour; before or after the scheduled time). On 12/16/25 (the following day) at 9:41am, surveyor relayed that AM medication administration was being observed today V19 (LPN) stated I'm (V4) finished with my morning meds already. Surveyor inquired why R11's name was highlighted red on the EMAR V19 responded I (V19) just need to check her (R11) blood sugar before I give it. Surveyor inquired why R11's insulin (scheduled for 8am administration) was not administered V19 replied This is my second day working here. Surveyor inquired about the regulatory requirement for medication administration V19 stated An hour before and an hour after, so yes, I'm late to her (R11). On 12/16/25 at 10:01am, R37 and R102 were highlighted red on the 2nd floor EMAR. V6 affirmed that medications (scheduled for 9am administration) were not administered to R37 and R102 therefore late. The (8/15) medication administration policy states medications must be administered in accordance with a physician's order ant his/her discretion (the right resident, right medication, right dosage, right route, and right time). Documentation of medication administration is recorded on the MAR (Medication Administration Record) and includes the date, time and initials of the licensed nurse who administered the medication. Record review of facility policy titled, Hypoglycemia, dated 9/14, documents, in part, Nursing Intervention: Give some form of glucose if resident is conscious: Mild reaction -small amount of food 10-15 gm carbohydrates (such a 4 oz. orange juice 6 oz. regular soda, 8 oz. 2% skim milk) repeat in 10-15 minutes if needed. Moderate reaction (drowsy, profuse perspiration, blood glucose 30-50 below normal) 20-30 gm. Carbohydrate, 4 oz. orange juice followed by food in 10 – 15 minutes. May give orange juice instead of food if still symptomatic. Contact physician if blood sugar is below 60 unless there are specific call parameters. Take vital signs Repeat finger-stick fifteen (15) minutes after first item of food is given. If unable to swallow notify physician and prepare glucagon from emergency drug kit for administration as ordered. Prepare to send to emergency room if condition worsens per MD order. Document findings, interventions, and M.D. contact in resident's clinical record. Record review of facility document titled, (Name of Facility) (Medication Dispensing Cabinet) List, undated, documents, in part, Glucagon Emergency Kit 1mg powder for injection D-Utility drawer 16. Record review of facility policy titled, Change In Condition Physician Notification Overview Guidelines, dated 4/14, documents, in part, These guidelines were developed to ensure that: 1. All significant changes in resident status are thoroughly assessed and physician notification is based on assessment findings and is to be documented in the medical record. 2.Medical care non-emergency problems are communicated to the attending physician and family in a timely, concise, and thorough manner (generally with twenty-four (24) hours or sooner). 3. Medical care emergency problems are communicated to attending physician and family immediately. The nurse should not hesitate to contact the attending physician at any time for a problem which in his or her judgment requires immediate medical intervention. Should the physician not be available, the alternate physician should be contacted. If neither of these physicians are available, the Medical Director should be notified. A. Any calls to or from physician will be documented in the nurse's notes indicating information conveyed and received. B. All orders taken from the physician, the Physician's Assistant or Nurse Practitioner to be carried out. C. The nurse receiving telephone verbal orders should write it on the POS. Acute and subacute problems are to be communicated shift-to-shift by verbal report and highlighting or discussing the problems listed on the 24 Hour Shift Report to facilitate communication and Quality Assessment and Improvement follow-up. E. The nurse shall indicate in the nurses notes ongoing conversations with the physician regarding response to notification(s) (faxes, phone calls, and verbal conversations) of changes in condition, laboratory. F. Responsible Party is to be notified of change in condition. The attending physician is responsible for responding in a timely manner to nurses regarding prompt notification calls, or emergencies. In addition, the physician is responsible for communicating the results of assessments and medical plans to a licensed nurse when appropriate. Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually. Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike. You may participate in developing a person-centered care plan which states all the services your facility will provide to you and everything you are expected to do. This plan must include your personal and cultural choices. Your facility must make reasonable arrangements to meet your needs and choices. You should receive the services and/or items included in the plan of care.

Based interview and record review facility failed to follow its abuse prevention policy and did not prevent an incident of resident-to-resident abuse. This deficient practice affected two of three residents (R1 and R2) reviewed for abuse. This failure resulted in R2 directing a racially derogatory term at R1 and spitting on R1. R1 was unavailable for interview during the survey; however, based on the Reasonable Person Concept, a reasonable person in R1's situation would likely experience humiliation, emotional distress, fear, and a sense of being unsafe because of the incident.R1 is not available for observation or interview. R1 MDS dated [DATE] denotes BIMS score of 10 (cognitive impairment). R1 care plan dated 7/28/28 with revision date of 8/12/25 denotes in-part R1 comprehensive assessment reveals history of suspected abuse or neglect or factors that may increase her susceptibility to abuse/neglect. R1 will be treated with respect, dignity and reside in the facility free of mistreatment, ongoing. R1 progress note dated 8/4/25 denotes R1 accused another resident of spitting on her and calling her the N word when she walked by him in the hallway. R2 face sheet shows diagnosis of delusional disorder, schizophrenia, unspecified psychosis.Facility final incident report dated 8/8/2025 denotes in-part on 8/4/25 the resident allegedly called a co-peer a name and spit in her face. R2 put on 1:1 monitoring until sent to hospital for psych evaluation. Investigation initiated. On 8/4/25 at approximately 3:30am, R2 and R1 were waking past each other on two main hallways. The resident calls R1 a black nxxxxx bxxxxx and spits in her face. R1 goes to the nurse's station to report incident to the nurse. R1 states she said nothing to provoke the incident. When asked why he called the resident a name and spat on her, R2 replies by speaking gibberish and off topic. R2 is put on 1:1 monitoring, sent to the hospital for psych evaluation. Witness statements dated 8/6/25 denotes in-part, on Sunday after handing R1 some linen from the cart for her bedding, while she was walking back to her room I heard R1 say don't spit on me and I looked up and told R2 to go back to his room. R2 progress notes dated 9/1/25 denotes in-part resident spit on one of the female residents without apparent reason. Writer tried to assess the resident why he spit on the resident, got no good reason except bad words coming from his mouth. Writer tried to talk to the resident to avoid getting near him because of his behavior issues.R2 plan of care dated 10/18/2024 with revision date of 9/2/25 denotes in-part for moderate to intense anger, related to poor listening skills, often becoming angry, defensive calling staff names, calling residents and staff Nxxxxx. R2 has history of spitting on other residents. Interventions are to encourage resident to talk about his feelings during support groups, work with the resident on improving listening skills, encourage resident to talk about anything that might be on his mind, anything that bothers him. There are no updated interventions noted for 9/1/2025, spitting incident. There are no intervention updates noted for the 8/4/25 spitting incident. R2 care plan has no updated intervention for the identified behaviors noted on the comprehensive quarterly assessment dated [DATE].R2 MDS dated [DATE] denotes BIMS score of 14, section E for behaviors denotes R2 has physical, verbal, and other behaviors directed towards others 1-3 times a week.9/15/25 at 10:59am V2 (Administrator) stated investigation was conducted he had no findings, administrator agreeable that spitting on resident is an assault. Resident right policy, date 11/2018, denotes in-part employees shall offer all resident privacy and treat all residents with respect, kindness and dignity. To provide an environment of care that supports a positive self-care.Facility policy abuse prevention and reporting effective date 6/7/2013 denotes in-part; the facility affirms the right of our residents to be free from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion. Abuse is willful infliction. The Resident Rights for People Living in the Long-term care denotes in-part, you must not be abused, neglected, or exploited by anyone, financially, physically, verbally, mentally or sexually.

Based on interview, observations, and record review the facility failed to ensure that resident floors are free from hazards. Water noted on the floor near door entry ways. Water was observed in a puddle with a white towel over it in R3's room entry way. This failure affected five residents (R3-R7) of 6 residents reviewed for safe environment.The findings include:On 8/13/25 at 10:45AM surveyor walked past R3's room and saw wet floor, towel on the floor near liquid, and no wet floor sign in the room. Air conditioning grill above the wet area near entry door. R3 sitting in her wheelchair in the room.On 8/13/25 at 10:47AM V1, CNA, said I have seen leaking from the ceiling in this room, R4's-R7's. V1 said I saw it a week or two ago. V1 said it was leaking a lot.On 8/13/25 at 10:55AM surveyor walked past R3's room, the floor remains wet with a towel over it. R3 sitting in the wheelchair. R3 pointed to the ceiling air conditioner grill when asked where the water was coming from. R3 said they know about it. It's been like this for a while. V8, ADON, was walking past in the hall and surveyor requested she call maintenance. V6, Administrator, arrived while V8 was placing a wet floor sign and drying the floor with the towel. V6 said maintenance has been working on this. V6 said sometimes the humidity makes it drip. While talking to V6 the grill dripped 2 drops. The water on the floor was approximately 3 floor tiles wide and long.On 8/13/25 at 11:10AM V2, Maintenance, said the air conditioner is working in R3's room making the condensation that is leaking to the floor. V2 said the pipe needs to be opened. V2 said yesterday the leaking was in room [ROOM NUMBER], above R3's room. V2 said I need to clean the main pipe out and put pressure in it, 2-3 times a year. V2 said last week I cleaned it out in the administration office and room [ROOM NUMBER] (currently empty). V2 said today the leak has been in R3's room for about 2 hours. V2 said I have only been working here about 6 weeks and when I asked, no one knew about the pipes needing to be cleaned. V2 said they told me they had not been doing this. V2 said I have been cleaning the pipes as the problems are reported. V2 said the pipes get build up in them and I need flush them with the air compressor. V2 said they get clogged, and the water has no where to go but to leak.On 8/13/25 at 2:03PM R6 said about a week ago the ceiling was leaking, (pointed to ac vent). The floor was getting wet. They had a bucket, but it was overflowing and full. No one was emptying it. The water was spilling onto the floor and it was slippery to walk past.R6 fall risk assessment was completed on 7/14/25 and he is identified at risk for falls due to his unsteady gait and medications.R6's care plan dated 1/25/24 states at risk for falls related to unsteady gait.On 8/13/25 at 2:07PM V9, LPN, said I have seen the dripping from there, indicating the ceiling grill in R6's room. V9 said the CNA and maintenance are in charge of emptying the water bucket. V9 said if there is water on the floor, the residents are at risk for falls. All the residents in that room (R4-R7) ambulate independently and are in and out of the room.On 8/14/25 at 11:56AM V3 said residents with unsteady gait can be ambulating independently. V3 said for all residents we ensure nothing on the floor, nothing in their path, like furniture, other residents, keep paths clear, and spills are supposed to be cleaned up right away. V3 said every week we do team rounding to make sure all rooms are clean and no hazards. V3 said everything in the facility is designed for safety. Census identifies R4-R7 residing in the same room with the leak.Review of work orders first floor on 7/16/25 123 room leaky from AC, please check. 7/11/25 122 room water dripping from the ceiling. [Illegible month] /8/25. 7/24/25 3:55AM room [ROOM NUMBER] ceiling by bathroom (vent) leaking causing huge puddle making hole in the wall bigger. Put something to catch it. 7/24/25 4:20AM room [ROOM NUMBER] leak by bathroom door and head od bed. Garbage bin catching leak now. Undated Rooms 203, 205, 207, and 206 leaking air conditioning condensation. On 8/8/25 room [ROOM NUMBER] water in middle of floor.The facility fall policy dated 2/28/14 states the standard fall safety precautions for all residents in part states the residents environment will be kept clear of clutter Which would affect ambulation and remove hazards.

Based on interviews and records reviewed the facility failed to ensure staff followed the facility practice of nurses not leaving the unit at the end of a shift without a relief. This failure resulted in the unit not having a nurse on unit for at least 1 hour. This failure has the potential to affect 36 residents residing on the unit.The findings include:On 8/13/25 at 12:06PM V3, Restorative Nurse, said on the second floor there is normally 2 nurses, 1 on main unit and 1on pavilion unit. V3 said 8/9/25 there was a call off for day shift I was notified at 8:45AM that there was a missing nurse on 2 main. V3 said I took over the cart about 9:15AM. V3 said I found out because I was coming in as Manager on Duty. V3 said I didn't clock in or out that day. V3 said the off going nurse is supposed to wait until the next nurse comes in before leaving. V3 said V12, LPN, called in. V3 said when I got to the facility the staff told me there was no nurse on 2 main. V3 said the call ins go to the DON or ADON. V3 said the unit was without a nurse for about 2 hours. V3 said CNAs can't pass medications. V3 said I don't even know what time I finished the morning medication pass, we had a code, reports of an alleged smoking violation I had to look into, and the Manager on Duty responsibilities.On 8/13/25 at 1:59PM V7, CNA, said we are supposed to call in 4 hours before our shift. We call into the DON to notify her.On 8/13/25 at 2:00PM V5, LPN, said we give verbal report to the oncoming nurse and we do a narcotic count with them. V5 said we are not supposed to leave the shift without a relief.On 8/13/25 at 12:42PM V6, Administrator, said I was made aware when V3 notified me on 8/9/25 that there was not a nurse for the 2nd floor unit. V6 said V3 took the cart. V3 said calls offs are to go to the on call person and DON. V6 said it is not the facility practice for the nurses to leave before a relief arrives. On 8/14/25 at 9:50AM V6 said we are a skilled nursing facility, we provide nursing care 24 hours a day.On 8/14/25 at 8:02AM V10, LPN, said I was not told there was a call off for the morning of 8/9/25. I was not asked to stay over on 8/9/25.On 8/14/25 at 12:45PM V14, Director of Nursing, said V12 text me last minute on 8/9/25. V14 said it was 6:50something in the morning when she text. V14 said I didn't even hear the text, I didn't know V12 wasn't in the building until V3 notified me. V14 said if I had known, I would have come in and had the nurse wait for me. V14 said call off should be 4 hours before the shift, staff should call the on call number. V14 said this is told to them at hire and is in the handbook. At 12:57PM V14 presented the unit census for 8/9/25 and said the unit has 36 assigned residents for the nurse.Review of time cards includes 8/9/25 V11 clocked in at 7:33AM; V13, LPN, clocked in at 6:51AM; V9, LPN, clocked in at 6:59AM. V12 is designated absent on 8/9/25. V10 clocked out the morning of 8/9/25 at 7:32AM.Review of Controlled Substances Check Form dated 8/9/25 unit 2 Main has no day shift on nurse or off nurse signature.The facility attendance policy in part states it is an employee's responsibility to notify their supervisor promptly of their absence for any scheduled work day. Employees should call at least 4 hours in advance of their scheduled start times.The Facility assessment dated [DATE] identifies on day shift (1st shift) 4 nurses will provide direct care to the residents.

Based on interviews and records reviewed the facility failed to follow their policy to provide Discharge Instructions and Medications to one resident (R1)upon her planned transfer from the facility to another skilled facility. This failure affected 1 of 3 residents reviewed for discharge/transfers.The findings include:R1 admitted to the facility on [DATE] and discharged to another facility on 8/9/25.On 8/13/25 at 12:06PM V3, Restorative Nurse, said R1 had a planned discharge, I was working the cart. V3 said R1's family came and got her. V3 said the Secretary at the front desk told them to speak with a nurse, but the family just took R1. V3 said they did not speak with me. V3 said only the secretary saw the family. At 12:54PM V3 said the admitting facility called me around 12:31PM on 8/9/25, V3 checked her phone for times. V3 said that is when I became aware R1 had left. V3 said they called when R1 arrived saying no medications were sent with R1. V3 said I faxed the paper work to the facility after they called. The family said they spoke with me, but then said I thought it was you. V3 said she didn't know when R1 left so no medication was sent or discharge instructions were given. V3 said she had see R1 sometime after 9:00AM on 8/925 when she administered medications. V3 said R1 was in her room with her suitcase. On 8/13/25 at 2:00PM V5, LPN, said when a resident is a planned discharge we review the discharge instructions and medications with them. We send them the instructions, medication list, and any referrals they might have with them.R1's progress notes dated 8/8/25 states R1 requested to be transferred to another facility. R1's family will transport. On 8/9/25 progress notes at 12:02PM states writer notified via phone that R1 arrived to accepting facility. Nurse did not speak to the family, medication did not go with R1 at the time she left the facility.A Transfer Discharge Report dated 8/8/25 was presented. R1 transferred to another nursing home. Medications are listed. A Discharge Planning Review dated 8/8/25 was presented stating will be returning to the facility she came from before facility.No document presented for R1 has a signature on the day of discharge. No Discharge Instructions with R1 or representative signature was presented.Facility Discharge/Transfer of Resident policy dated 11/18 states in part, purpose to provide safe departure from the facility period to provide for continuity of care and treatment. Provide additional health education or medication instruction information for resident or family as indicated. Have resident or sponsor signed personal inventory of effects form. Heat transfer form accurately and completely including vital signs. Assist resident into wheelchair and escort to vehicle if necessary or assist attendance with transport. Document discharge summary. Include notes on specific instructions given such as medications to resident and responsible parties.

Based on observation, interview, and record review, the facility failed to follow its Urinary Catheter Care policy to provide catheter care to residents. This applies to 3 of 4 residents (R2, R3, and R4) reviewed for indwelling catheter care in a sample of 4.1.R2 is an [AGE] year-old female admitted with moderate cognitive impairment as per the MDS dated [DATE]. On 7/16/25 at 9:00 AM, R2 was observed in her bed with an indwelling catheter bag with one-fourth urine placed flat on the bed. On 7/16/25 at 9:03 AM, V3 (Licensed Practical Nurse/LPN) stated that the indwelling catheter bag shouldn't be on the bed to prevent urine backflow, which could cause infection. A review of the indwelling catheter care plan document interventions including to position catheter bag and tubing below the level of the bladder.On 7/16/25 at 11:25 AM, observed V5 (Certified Nursing Assistant/CNA) providing catheter care to R2, who was on a geriatric chair. V5 used soap and water to wipe down the catheter without cleaning the labia. On 7/16/25 at 11:30 AM, V5 stated that she usually cleans the labia when R2 is in bed. V5 added that since R2 was on the chair, it was hard to spread out her legs to clean the labia. 2.R3 is a [AGE] year-old female admitted on [DATE] and having mild cognitive impairment as per the MDS dated [DATE]. On 7/16/25 at 9:10 AM, R3 was in her bed with an indwelling catheter in place, and V4 (Registered Nurse/RN) and V5 were checking R3's catheter. R3 was observed with an indwelling catheter not secured to her thigh with no stat lock or tape in place.3.R4 is a [AGE] year-old male admitted on [DATE] with moderate cognitive impairment as per the MDS dated /16/25. On 7/16/25 at 9:15 AM, observed R4 lying on his bed with a urine leg bag tied to his thigh and without having the catheter secured. On 7/16/25 at 11:45 AM, observed V7 providing catheter care to R4 (uncircumcised). V7 used soap and water to wipe down the indwelling catheter without retracting the foreskin to clean the catheter-meatal junction. On 7/16/25 at 2:00 PM, V2 stated, For uncircumcised male residents, the staff should retract the foreskin to cleanse the catheter-meatal junction while providing the catheter care. For female residents, staff should have clean labia while providing catheter care. The indwelling catheters should be secured to avoid tension, and also the bag should be kept to drain under gravity to prevent urine backflow. The facility presented the Urinary Catheter Care policy (5/14) document:5. Indwelling catheters will be secured to prevent trauma and tension.6. Catheters shall be positioned to maintain a downhill flow of urine to prevent a backflow of urine into the bladder or tubing during transfer, ambulation, and body positioning.16.Male residents who are uncircumcised shall have the foreskin retracted and the catheter-meatal junction cleansed, replacing the foreskin over the penis when the procedure is completed.

Based on interview and record review, the facility failed to provide adequate supervision to a high fall risk resident for one (R1) of four residents (R1, R2, R3 and R4) reviewed for falls in the sample of four. This failure resulted in R1's left hip fracture, emergent hospitalization, and subsequent left hip surgery. Findings include: R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including bit not limited to Ataxia; Epilepsy; Unspecified Abnormalities of Gait and Mobility; Abnormal Posture; Muscle Wasting and Atrophy; Schizoaffective Disorder, Bipolar Type; Schizophrenia; Bipolar Disorder; Essential (Primary) Hypertension; Type 2 Diabetes Mellitus with Diabetic Neuropathy; and Heart Failure. According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section C, R1 has BIMS (Brief Interview of Mental Status) score of 12 indicating moderate cognitive impairment. According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section GG, R1 uses a walker as a mobility device and requires supervision or touching assistance during bed-to-chair transfers and walking. According to R1's Fall Risk Review dated 03/12/2025, R1 is at high risk for falls. R1's care plan initiated on 12/23/2021 reads in part, (R1) is at risk for falls r/t (related to) confusion, gait/balance problems, poor communication/comprehension, on statin, hypoglycemic and psychotropic medications, unaware of safety needs, vitamin D deficiency, ataxia, DM II with neuropathy. Interventions: Be sure (R1's) call light is within reach and encourage the (R1) to use it for assistance as needed. [NAME] needs prompt response to all requests for assistance; Anticipate and meet the (R1's) needs; Ensure that (R1) is wearing appropriate footwear when ambulating or mobilizing in wheelchair; (R1) needs a safe environment with even floors free from spills and/orclutter; adequate, glare-free light; a working and reachable call light, handrails on walls, personal items within reach. R1's care plan initiated on 03/21/2023 reads in part, (R1) presents with: Decreased strength., Poor balance., Impaired ambulation., General deconditioning., Symptoms/problems are manifested by increased risk for falls. Interventions: Implement fall precautions per facility protocol (keep areas clear, well lit & accessible). On 6/30/2025 at 11:48 AM Surveyor observed R1 laying in the bed. R1 clean and dressed appropriate, no shoes observed at this time. R1's room dark, call light out of R1's reach, no clutter observed. R1 said, Yeah I fell, I hurt my hip. I'm not sure when or how it happened. R1 unable to recall circumstances of the incident, sounds confused and forgetful. On 06/30/2025 at 11:54 AM V6 (Licensed Practical Nurse) said, I wasn't here when R1 fell (04/06/2025). R1 ambulated with a walker, had steady gait back then; however, still required supervision prior to the fall. R1 is forgetful, there are times when you can have a conversation with him and other times when you cannot. R1 forgets to use a call light despite staff reminding him to do it. R1 was moved to a room closer to the nursing station after the fall for easier monitoring. On 06/30/2025 at 3:23 PM V9 (Registered Nurse) said, I worked on 04/06/2025, I don't remember what shift. I don't remember the time of R1's incident, but I think it was after breakfast. I heard R1 calling for help while I was passing medications. I went up to R1, R1 was sitting on the hallway floor, right by his room, leaning against the wall, with one of his legs stretched forward. R1 said he saw spilled water on the floor and was trying to wipe it. I don't remember if R1 was wearing shoes. R1 was not able to get up on his own. I called someone for help, I don't remember who came, we placed R1 in the wheelchair and put him in the bed. I notified the doctor, who recommend an x-ray. Upon my assessment, R1 was not able to move his left leg and it was in extended position. R1 was in a lot of pain, especially when trying to move his leg. I gave R1 pain medication, but I don't remember if I documented. After I received an x-ray order, I called the diagnostic company, and I was told they'll come out to do an x-ray but didn't say when. I don't remember whether this was a regular or STAT order. I didn't check on R1 nor reassessed R1's pain before the end of my shift. The x-ray company didn't come before I left. I didn't follow up with the diagnostic company. R1 would always use a call light when he needed anything. I don't know why he attempted to get up that day (04/06/2025). R1 would normally walk around the unit, he looked stable. I don't know if he used any mobility devices. R1 was walking like a normal person, so I'm not sure if R1 was at high risk for falls before the incident on 04/06/2025, so I'm not sure if R1 had any fall prevention interventions. Per record review, V9 (Registered Nurse) was scheduled to work 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM on the 2 Main unit on 04/06/2025. On 07/01/2025 at 10:45 AM V7 (Licensed Practical Nurse) said, When I came in to work on 04/07/2025 7:00 AM - 3:00 PM, it was reported to me that R1 fell the day before. I wasn't told any details of the fall. I looked at the report, and it showed that the x-ray was ordered per doctor's order. Once I noticed the diagnostic company didn't come around midday, I called them, and they said they had no order for R1's x-ray. I placed a STAT x-ray order, and they came out after 3:00 PM (04/07/2025). R1 usually wakes up early and walks around with a walker. On 04/07/2025, during my initial rounds, I noticed R1 was in pain and couldn't move his left leg. R1 was not able to get up but wasn't able to rate the pain. I'm pretty sure I gave R1 pain medication and document it in the progress. I was thinking we were just waiting for an x-ray, and everything was arranged. I was trying to keep R1 comfortable, I gave R1 some ice. When I returned to work on 04/08/2025 (7:00 AM - 3:00 PM), I was told that the x-ray showed that he had a fracture, and I was supposed to send him out to the hospital and not wait for the x-ray. R1 was a fall risk resident, and we were supposed to make sure we assist and supervise R1 when he gets in and out of bed and that he has a walker with him. R1 would always use a call light but also, he would try to get up by himself. On 07/01/2025 at 11:07 AM V2 (Director of Nursing/ Fall Coordinator) said, R1 had a fall in an early April (2025). I received a call from V9 (Registered Nurse) close to 3:00 PM notifying e of R1's fall. V9 (RN) said that R1 had a fall, while he was trying clean up a spilled water in the room. R1 didn't have a walker at the time of a fall. V9 (RN) said that R1 didn't have any injuries but complained of leg pain. V9 (RN) said he gave R1 pain medication and called V13 (Attending Physician) to get an x-ray order. It was a Sunday, so I didn't do anything else in relation to the fall, just spoke to V9 (RN). When I came in on 04/07/2025, V7 (Licensed Practical Nurse) told me that they are still waiting for an x-ray. I advised V7 (LPN) to follow up with the diagnostic company. V7 (LPN) told me that the diagnostic company will be coming in before the end of the day. I don't know what time they came in. When I came into the facility the next day (04/08/2025), I made my rounds and heard that R1 didn't come out of the bad. I had words with V7 (LPN), I told her that when a resident has a change in condition and cannot walk whereas he walked before, nurses should send them out to the hospital. I then started the process of sending R1 to the hospital and he was picked up around 10:20 AM (4/8/2025). R1 was a fall risk resident before the incident (04/06/2025). R1 required constant redirection. One of the issues was that R1 has OCD (obsessive compulsive disorder), trying to clean and rearrange the room all the time. R1 didn't use a call light or ask for assistance. We would find him walk without the walker all the time. R1 was already walking around or stayed in one of the dining rooms; however, Certified Nurse Assistant should monitor residents at least every two hours. R1's fall occurred because R1 was trying to clean up after his roommate and there was spilled water on the floor. R1 has an obsession with cleanliness. One of the reasons why R1 was moved to another room is to make sure the room is clean and close to the nursing station. Surveyor asked if V8 (Certified Nurse Assistant) was the only working CNA despite the need for two CNAs on the on the 2 Main unit on 04/06/2025, V2 (Director of Nursing/ Fall Coordinator) did not confirm nor deny it. On 07/01/2025 at 12:02 PM V13 (Attending Physician) said, I don't recall getting notified of R1's call, I might have gotten a call. When the facility nursing staff call me, they emphasize if a resident hit the head, vital sign status, how a fall occurred, and based on that I give orders. The first step is in-house diagnostic. If there is a change in resident's mental status, head trauma, loss of consciousness, or complaining of severe pain, I send them out to the hospital. Surveyor asked what some of the signs and symptoms of a broken hip are, V13 (Attending Physician) stated, Some of the signs of broken hip is complaining of pain, bruising, deformity, and affected ROM (range of motion), such as extended leg. The nurse should try to obtain a STAT image order to determine if there is a fracture and need for hospitalization. If a resident has a mild pain, we start at over-the-counter pain medication, if it's excruciating pain we would send them out to the hospital. It a resident has continuous pain, not managed by the over-the-counter medications, they should be sent out to the hospital. Surveyor asked what some are of long-lasting results of a broken hip, V13 (Attending Physician) said, A broken hip with a subsequent surgery would affect a resident acutely, example: bed rest and physical therapy. There could also be long lasting effect, such as chronic pain and change in the ROM (range of motion). On 07/01/2025 at 12:19 PM V8 (Certified Nurse Assistant) said, On 04/06/2025, R1 was assigned to me. I don't recall R1 falling on my shift (7:00 AM - 3:00 PM). I was the only CNA on the main portion of the second floor on 04/06/2025, normally it's two. We do rounds are at least every two hours. R1 was not monitored in any special way, I don't think he was at risk for fall. I don't remember any special interventions that we had to do for R1. R1 was always adjusting and cleaning his room. Per record review, V8 (Certified Nurse Assistant) was an only CNA scheduled to work 7:00 AM - 3:00 PM on the 2 Main unit on 04/06/2025. R1's progress note written by V9 (Registered Nurse) dated 04/06/2025 02:42 PM reads in part, Full body assessment done, no open injuries or active bleeding noted, able to move all extremities but with a lot of pain voiced when moved the left knee and unable to stand up. v/s bp 134/67, r 20 p 71, DON (V2) aware, on call md order Knee x-ray. R1's progress note written by V7 (Licensed Practical Nurse) dated 04/07/2025 03:38 PM reads in part, (R1) immobile due to pain to injury from recent fall; (R1) unable to come to an upright sitting position without assistance, greenish purple bruise noted on the left hip; pain level 5/10; Ambulatory status pre-change: ambulated with walker; Ambulatory status post-change: non ambulatory due to injury from previous fall. R1's progress note written by V2 (DON/Fall Coordinator) dated 04/08/2025 09:30 AM reads in part, Manager follow up: Writer made aware by floor nurse that (R1) was observed lying in bed awaiting x ray results, but (R1) continues to c/o pain to Left leg and is not getting out of bed as per his baseline. Writer observed (R1) in room lying in bed stating, it's hard for me to stand up it hurts. Floor nurse made aware and instructed to call MD and have (R1) sent out for further evaluation, no further issues at this time, call remains within reach and resident given pain medication as per MD order. will continue to monitor as needed. R1's progress note written by V7 (Licensed Practical Nurse) dated 04/08/2025 09:53 AM reads in part, The writer received (R1) in bed complaining of pain in left hip due to recent fall. The resident unable to come to a standing position. Md updated; orders given to send the resident to (local hospital). Currently awaiting transportation to arrive. R1's progress note written by V7 (Licensed Practical Nurse) dated 04/08/2025 10:20 AM reads in part, (Local) transportation arrived and transported (R1) via stretcher to (local medical center) per (R1's) request. (R1) received all scheduled medication and prn (pain medication) before leaving the facility and consumed 100% of his breakfast tray. Vitals upon (ambulance) arrival were (blood pressure): 138/76 (pulse): 86 (oxygen): 96% (temperature): 97.7 (pain): 6/10. Hospital record initiated on 04/08/2025 11:30 AM reads in part, [AGE] year-old male with a (past medical history) of anemia, CAD (coronary artery disease), schizoaffective disorder, bipolar disorder, GERD, epilepsy, hypothyroidism, heart failure, hypertension, T2DM (diabetes mellitus type 2) presented to the ER due to a fall. (R1) unsure when he fell but thinks that he fell on Sunday (04/06/2025) on his left side. Since the fall, (R1) has been having left-sided hip and knee pain as well as adnominal pain. CT of the hip showed a moderately displaced and angulated fracture of the left femoral neck along with enlargement of the left iliac muscle. (R1) was admitted for further management. Left femoral neck hemi-arthroplasty on 04/09/2025. Tolerated procedure well. The facility Fall policy (no date) reads in part, It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Standards: Safety interventions will be implemented for each resident identified at risk using a standard protocol. Standard Fall/Safety Precautions for All Residents: The resident's environment will be kept clear of clatter which would affect ambulation and remove hazards. Lighting will be appropriate for the time of day and in accordance to the resident's desire and the plan of care; Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet; All nursing personnel will be informed of residents who are at risk of falling. The fall risk classification will be identified on the care plan.

Based on interview and record review, the facility failed to timely administer a PRN (as needed) pain medications for post fall onset of pain for a one of one (R1) resident reviewed for pain in the sample of four. This failure resulted in R1 having ongoing, unaddressed pain for 44 hours before R1 was hospitalized for left hip fracture, and subsequent surgery of the left hip fracture. Findings include: R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Ataxia; Epilepsy; Unspecified Abnormalities of Gait and Mobility; Abnormal Posture; Muscle Wasting and Atrophy; Schizoaffective Disorder, Bipolar Type; Schizophrenia; Bipolar Disorder; Essential (Primary) Hypertension; Type 2 Diabetes Mellitus with Diabetic Neuropathy; and Heart Failure. On 6/30/2025 at 11:48 AM Surveyor observed R1 laying in the bed. R1 clean and dressed appropriate, no shoes observed at this time. R1's room dark, call light out of R1's reach, no clutter observed. R1 said, Yeah I fell, I hurt my hip. I'm not sure when or how it happened. R1 unable to recall circumstances of the incident, sounds confused and forgetful. 06/30/2025 11:54 AM V6 (Licensed Practical Nurse) said, If a resident complains of pain and has difficulty moving, I make sure the doctor knows all the details and gives order to send a resident to the hospital for further evaluation. On 06/30/2025 at 3:23 PM V9 (Registered Nurse) said, I worked on 04/06/2025, I don't remember what shift. I don't remember the time of R1's incident, but I think it was after breakfast. I heard R1 calling for help while I was passing medications. I went up to R1, R1 was sitting on the hallway floor, right by his room, leaning against the wall, with one of his legs stretched forward. R1 said he saw spilled water on the floor and was trying to wipe it. I don't remember if R1 was wearing shoes. R1 was not able to get up on his own. I called someone for help, I don't remember who came, we placed R1 in the wheelchair and put him in the bed. I notified the doctor, who recommend an x-ray. Upon my assessment, R1 was not able to move his left leg and it was in extended position. R1 was in a lot of pain, especially when trying to move his leg. I gave R1 pain medication, but I don't remember if I documented. After I received an x-ray order, I called the diagnostic company, and I was told they'll come out to do an x-ray but didn't say when. I don't remember whether this was a regular or STAT order. I didn't check on R1 nor reassessed R1's pain before the end of my shift. The x-ray company didn't come before I left. I didn't follow up with the diagnostic company. R1 would always use a call light when he needed anything. I don't know why he attempted to get up that day (04/06/2025). R1 would normally walk around the unit, he looked stable. I don't know if he used any mobility devices. R1 was walking like a normal person, so I'm not sure if R1 was at high risk for falls before the incident on 04/06/2025, so I'm not sure if R1 had any fall prevention interventions. Per record review, V9 (Registered Nurse) was scheduled to work 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM on the 2 Main unit on 04/06/2025. On 07/01/2025 at 10:45 AM V7 (Licensed Practical Nurse) said, When I came in to work on 04/07/2025 7:00 AM - 3:00 PM, it was reported to me that R1 fell the day before. I wasn't told any details of the fall. I looked at the report, and it showed that the x-ray was ordered per doctor's order. Once I noticed the diagnostic company didn't come around midday, I called them, and they said they had no order for R1's x-ray. I placed a STAT x-ray order, and they came out after 3:00 PM (04/07/2025). R1 usually wakes up early and walks around with a walker. On 04/07/2025, during my initial rounds, I noticed R1 was in pain and couldn't move his left leg. R1 was not able to get up but wasn't able to rate the pain. I'm pretty sure I gave R1 pain medication and document it in the progress. I was thinking we were just waiting for an x-ray, and everything was arranged. I was trying to keep R1 comfortable, I gave R1 some ice. When I returned to work on 04/08/2025 (7:00 AM - 3:00 PM), I was told that the x-ray showed that he had a fracture, and I was supposed to send him out to the hospital and not wait for the x-ray. R1 was a fall risk resident, and we were supposed to make sure we assist and supervise R1 when he gets in and out of bed and that he has a walker with him. R1 would always use a call light but also, he would try to get up by himself. On 07/01/2025 at 11:07 AM V2 (Director of Nursing/ Fall Coordinator) said, The nurses should assess residents' pain, establish source, administer a PRN pain medication or order one if there is no order for it, and check within 30 minutes if administered pain medication was effective. If the medication is not effective, nurses should follow-up with a physician. The nurses should sign the medication out in a resident's MAR (Medication Administration Record) or document it in the progress note. The pain should be assessed at the time of a fall or if a resident exhibits pain. Other than that, pain should be assessed every shift and documented in a resident's MAR (Medication Administration Record). On 07/01/2025 at 12:02 PM V13 (Attending Physician) said, I don't recall getting notified of R1's call, I might have gotten a call. When the facility nursing staff call me, they emphasize if a resident hit the head, vital sign status, how a fall occurred, and based on that I give orders. The first step is in-house diagnostic. If there is a change in resident's mental status, head trauma, loss of consciousness, or complaining of severe pain, I send them out to the hospital. Surveyor asked what some of the signs and symptoms of a broken hip are, V13 (Attending Physician) stated, Some of the signs of broken hip is complaining of pain, bruising, deformity, and affected ROM (range of motion), such as extended leg. If a resident has a mild pain, we start at over-the-counter pain medication, if it's excruciating pain we would send them out to the hospital. It a resident has continuous pain, not managed by the over-the-counter medications, they should be sent out to the hospital. R1's progress note written by V9 (Registered Nurse) dated 04/06/2025 02:42 PM reads in part, Full body assessment done, no open injuries or active bleeding noted, able to move all extremities but with a lot of pain voiced when moved the left knee and unable to stand up. v/s bp 134/67, r 20 p 71, DON (V2) aware, on call md order Knee x-ray. R1's progress note written by V7 (Licensed Practical Nurse) dated 04/07/2025 03:38 PM reads in part, (R1) immobile due to pain to injury from recent fall; (R1) unable to come to an upright sitting position without assistance, greenish purple bruise noted on the left hip; pain level 5/10; Ambulatory status pre-change: ambulated with walker; Ambulatory status post-change: non ambulatory due to injury from previous fall. R1's progress note written by V2 (DON/Fall Coordinator) dated 04/08/2025 09:30 AM reads in part, Manager follow up: Writer made aware by floor nurse that (R1) was observed lying in bed awaiting x ray results, but (R1) continues to c/o pain to Left leg and is not getting out of bed as per his baseline. Writer observed (R1) in room lying in bed stating, it's hard for me to stand up it hurts. Floor nurse made aware and instructed to call MD and have (R1) sent out for further evaluation, no further issues at this time, call remains within reach and resident given pain medication as per MD order. will continue to monitor as needed. R1's progress note written by V7 (Licensed Practical Nurse) dated 04/08/2025 09:53 AM reads in part, The writer received (R1) in bed complaining of pain in left hip due to recent fall. The resident unable to come to a standing position. Md updated; orders given to send the resident to (local hospital). Currently awaiting transportation to arrive. R1's progress note written by V7 (Licensed Practical Nurse) dated 04/08/2025 10:20 AM reads in part, (Local) transportation arrived and transported (R1) via stretcher to (local medical center) per (R1's) request. (R1) received all scheduled medication and prn (pain medication) before leaving the facility and consumed 100% of his breakfast tray. Vitals upon (ambulance) arrival were (blood pressure): 138/76 (pulse): 86 (oxygen): 96% (temperature): 97.7 (pain): 6/10. R1's April 2025 Medical Administration Record pain assessment shows: 04/06/2025 (evening) pain 3/10; 04/07/2025 (day) pain 4/10; 04/07/2025 (evening) pain 1/10. R1's progress note written by V7 (Licensed Practical Nurse) dated 04/07/2025 03:38 PM shows R1's pain 5/10. Absent are any documents to show that R1 received pain medication between 04/06/2025 2:40 PM (time of the incident) and 04/08/2025 10:20 AM (as per progress note) indicating 44-hour delay in pain management. Hospital record initiated on 04/08/2025 11:30 AM reads in part, [AGE] year-old male with a (past medical history) of anemia, CAD (coronary artery disease), schizoaffective disorder, bipolar disorder, GERD, epilepsy, hypothyroidism, heart failure, hypertension, T2DM (diabetes mellitus type 2) presented to the ER due to a fall. (R1) unsure when he fell but thinks that he fell on Sunday (04/06/2025) on his left side. Since the fall, (R1) has been having left-sided hip and knee pain as well as adnominal pain. CT of the hip showed a moderately displaced and angulated fracture of the left femoral neck along with enlargement of the left iliac muscle. (R1) was admitted for further management. Left femoral neck hemi-arthroplasty on 04/09/2025. Tolerated procedure well. The facility Pain policy (no date) reads in part, It is the policy of the Nursing Department to respect and support the resident's right to optimal pain management. General Guidelines: A Pain Assessment tool will be used as a guide in determining a resident's pain level in addition to their descriptive words, and/or physical signs and behaviors; Assessments will be performed at the time of admission, quarterly in conjunction with the MDS schedule. admission diagnosis and other events during the resident's stay may initiate additional pain assessments, i.e., post falls or new or increased pain medications; Pain control effectiveness will be measured after PRN pain medication is administered and during each medication pass; Once pain rate scale is determined, all staff members are instructed to use the resident's identified scale for all assessments; Interventions for pain will be balanced with adequate response to provide comfort while maintaining functional status, when possible, in accordance with the residents; Documentation of each pain assessment will be recorded on the Pain Assessment form, in the nurses' notes or on the MAR.

Based on observation, interview, and record review, the facility failed to adhere to sanitary requirements by not following its own hair restraints policy when a dietary aide was found not wearing a hair restraint while inside the facility's kitchen. This failure has the potential to affect the quality of food served to all residents at the facility. Findings include: On 07/01/2025 at 12:00 PM, This Surveyor visited the facility kitchen to verify if kitchen staff were wearing hair restraints. This Surveyor introduced himself to V14 (Dietary Supervisor). Before entering the kitchen, this Surveyor asked V14 for a hair restraint to wear, was given one, and placed it over his head. Both V14 and this Surveyor then proceeded to enter the kitchen. Upon entering the kitchen, this Surveyor observed V15 (Dietary Aide) to the immediate left, sitting by the wall, and not wearing a hair restraint. This Surveyor then observed V14 instruct V15 to place his hair restraint over his head. V15 was then seen walking outside the kitchen, holding a hair restraint in his hand, then returning to the kitchen a few seconds later, now wearing a hair restraint over his head. This Surveyor then left the kitchen. On 07/01/2025 at 1:15 PM, V14 told this Surveyor that, technically, V15 was not supposed be without his hairnet in the kitchen. When this Surveyor asked V14 what she meant by, technically, V14 said, it was not correct because I didn't want you to see it. V14 also said that V15 told her he had just sat down in the kitchen because it got hot, then wiped the sweat off his brow, and the hairnet slipped off. V14 reiterated that, technically, V15 was not supposed to be in the kitchen without wearing a hairnet, but because he was hot, she gave him the leeway. The facility's Hair Restraints policy, dated 2021, states in part, Food and nutrition services employees shall wear hair restraints. The facility's Hair Restraints procedure states in part, hairnets will be worn at all times in the kitchen.

Based on interview and record review, the facility failed to ensure diagnostic testing order was carried out and diagnostic testing results were reported in a timely manner for a resident with acute fracture for one of four (R1) residents (R1, R2, R3 and R4) reviewed for diagnostic testing in the sample of four. Findings include: R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including bit not limited to Ataxia; Epilepsy; Unspecified Abnormalities of Gait and Mobility; Abnormal Posture; Muscle Wasting and Atrophy; Schizoaffective Disorder, Bipolar Type; Schizophrenia; Bipolar Disorder; Essential (Primary) Hypertension; Type 2 Diabetes Mellitus with Diabetic Neuropathy; and Heart Failure. On 6/30/2025 at 11:48 AM Surveyor observed R1 laying in the bed. R1 clean and dressed appropriate, no shoes observed at this time. R1's room dark, call light out of R1's reach, no clutter observed. R1 said, Yeah I fell, I hurt my hip. I'm not sure when or how it happened. R1 unable to recall circumstances of the incident, sounds confused and forgetful. 06/30/2025 11:54 AM V6 (Licensed Practical Nurse) said, As far as an x-ray service, we use external diagnostic service. When the doctor gives an x-ray order, we call the x-ray company and order an x-ray. If it is a regular order, the company comes out within 24 hours, if it's a STAT order, the company comes out within 2 hours. On 06/30/2025 at 3:23 PM V9 (Registered Nurse) said, I worked on 04/06/2025, I don't remember what shift. I don't remember the time of R1's incident, but I think it was after breakfast. I heard R1 calling for help while I was passing medications. I went up to R1, R1 was sitting on the hallway floor, right by his room, leaning against the wall, with one of his legs stretched forward. R1 said he saw spilled water on the floor and was trying to wipe it. I don't remember if R1 was wearing shoes. R1 was not able to get up on his own. I called someone for help, I don't remember who came, we placed R1 in the wheelchair and put him in the bed. I notified the doctor, who recommend an x-ray. Upon my assessment, R1 was not able to move his left leg and it was in extended position. R1 was in a lot of pain, especially when trying to move his leg. I gave R1 pain medication, but I don't remember if I documented. After I received an x-ray order, I called the diagnostic company, and I was told they'll come out to do an x-ray but didn't say when. I don't remember whether this was a regular or STAT order. I didn't check on R1 nor reassessed R1's pain before the end of my shift. The x-ray company didn't come before I left. I didn't follow up with the diagnostic company. R1 would always use a call light when he needed anything. I don't know why he attempted to get up that day (04/06/2025). R1 would normally walk around the unit, he looked stable. I don't know if he used any mobility devices. R1 was walking like a normal person, so I'm not sure if R1 was at high risk for falls before the incident on 04/06/2025, so I'm not sure if R1 had any fall prevention interventions. Per record review, V9 (Registered Nurse) was scheduled to work 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM on the 2 Main unit on 04/06/2025. On 07/01/2025 at 10:45 AM V7 (Licensed Practical Nurse) said, When I came in to work on 04/07/2025 7:00 AM - 3:00 PM, it was reported to me that R1 fell the day before. I wasn't told any details of the fall. I looked at the report, and it showed that the x-ray was ordered per doctor's order. Once I noticed the diagnostic company didn't come around midday, I called them, and they said they had no order for R1's x-ray. I placed a STAT x-ray order, and they came out after 3:00 PM (04/07/2025). R1 usually wakes up early and walks around with a walker. On 04/07/2025, during my initial rounds, I noticed R1 was in pain and couldn't move his left leg. R1 was not able to get up but wasn't able to rate the pain. I'm pretty sure I gave R1 pain medication and document it in the progress. I was thinking we were just waiting for an x-ray, and everything was arranged. I was trying to keep R1 comfortable, I gave R1 some ice. When I returned to work on 04/08/2025 (7:00 AM - 3:00 PM), I was told that the x-ray showed that he had a fracture, and I was supposed to send him out to the hospital and not wait for the x-ray. R1 was a fall risk resident, and we were supposed to make sure we assist and supervise R1 when he gets in and out of bed and that he has a walker with him. R1 would always use a call light but also, he would try to get up by himself. On 07/01/2025 at 11:07 AM V2 (Director of Nursing/ Fall Coordinator) said, The nurse should call the diagnostic company once they receive an order. Next, they should print an order and a resident face shift and get all documents ready. When we call the diagnostic company, we need to specify whether it is a regular or stat order. Regular x-ray is usually done within 24 hours, and STAT should be done with 4 hours. On 07/01/2025 at 12:02 PM V13 (Attending Physician) said, The nurse should try to obtain a STAT image order to determine if there is a fracture and need for hospitalization. On 07/01/2025 at 1:40 PM In the follow up interview, V2 (Director of Nursing/ Fall Coordinator) said, If an x-ray order was STAT, it would be indicated on the order, R1's x-ray it was a regular order. If there is an abnormality in the radiology report, the diagnostic company supposed to call the facility; however, all results are posted in the electronic medical record, as the company process them. The nurses should check for any posted results at least once per shift. R1's x-ray result was posted on 04/07/2025 at 5:48 PM, that means, at least night nurse should have caught it. I was never aware of R1's x-ray result. I don't know if any nurses saw the result. It was not reported to me. I don't know if nurses didn't check and were not aware of it or they just didn't report it to nor anyone else. I initiated R1's hospitalization on the morning of 04/08/2025 based on R1's declined condition. R1's progress note written by V9 (Registered Nurse) dated 04/06/2025 02:42 PM reads in part, Full body assessment done, no open injuries or active bleeding noted, able to move all extremities but with a lot of pain voiced when moved the left knee and unable to stand up. v/s bp 134/67, r 20 p 71, DON (V2) aware, on call md order Knee x-ray. R1's progress note written by V7 (Licensed Practical Nurse) dated 04/07/2025 03:38 PM reads in part, (R1) immobile due to pain to injury from recent fall; (R1) unable to come to an upright sitting position without assistance, greenish purple bruise noted on the left hip; pain level 5/10; Ambulatory status pre-change: ambulated with walker; Ambulatory status post-change: non ambulatory due to injury from previous fall. New orders: x-ray ordered by writer, currently awaiting x-ray tech to arrive. R1's progress note written by V2 (DON/Fall Coordinator) dated 04/08/2025 09:30 AM reads in part, Manager follow up: Writer made aware by floor nurse that (R1) was observed lying in bed awaiting x ray results, but (R1) continues to c/o pain to Left leg and is not getting out of bed as per his baseline. Writer observed (R1) in room lying in bed stating, it's hard for me to stand up it hurts. Floor nurse made aware and instructed to call MD and have (R1) sent out for further evaluation, no further issues at this time, call remains within reach and resident given pain medication as per MD order. will continue to monitor as needed. R1's x-ray physician order dated 04/06/2025 03:20 PM created by V2 (DON/Fall Coordinator) reads in part, x-ray left knee bil. R1's Radiology Results Report reads in part, Examination Date: 04/07/2025 1:50 PM; Reported Date: 5:48 PM; Procedure: L-HIP W/PELVIS & FEMUR; Interpretation: Impacted transcervical fracture of the left neck with varus deformity. Hospital record initiated on 04/08/2025 11:30 AM reads in part, [AGE] year-old male with a (past medical history) of anemia, CAD (coronary artery disease), schizoaffective disorder, bipolar disorder, GERD, epilepsy, hypothyroidism, heart failure, hypertension, T2DM (diabetes mellitus type 2) presented to the ER due to a fall. (R1) unsure when he fell but thinks that he fell on Sunday (04/06/2025) on his left side. Since the fall, (R1) has been having left-sided hip and knee pain as well as adnominal pain. CT of the hip showed a moderately displaced and angulated fracture of the left femoral neck along with enlargement of the left iliac muscle. (R1) was admitted for further management. Left femoral neck hemi-arthroplasty on 04/09/2025. Tolerated procedure well. Diagnostic company ordering procedure (no date) reads in part, All non-stat orders are performed the same day, unless requested to be done another day. Results will also be available to you the same day the procedure was performed (please note that this is 100% possible if the orders are placed early, preferably before 5 pm.

Based on interview and record review, the facility failed to follow their policy to conduct a contraband search on one (R1) of three residents reviewed for contraband possession. This failure resulted in R1 falling and hospitalized with a diagnosis of opioid overdose, and laceration of right eyebrow. Finding include: On 5/28/2025 at 11:52 AM, V3 (LPN) said that R1 did not fall on V3 shift. V3 said R1 is alert and oriented and makes his needs known. V3 said that R1 has a pass to go with relatives. V3 said that R1 went out with relative today about 8:30 am and was expected to be back to the facility around 2:00 PM. V3 said that the social service told V3 that R1 must be checked by the social service before R1 can get back into R1's room. V3 said that the social services are responsible for checking the residents before the residents return to their rooms. On 5/28/2025 at 12:04 PM, V4 (LPN) said that when V4 initially rounded on R1, R1 was alert and oriented and conversing. V4 said about less than ten minutes while V4 was walking the hall, V4 saw R1 on the floor in another resident's room. V4 called out to V2 (Director of Nursing) for help. V4 assessed the resident, V4 said that R1 was unresponsive, and 911 was called to transport to ER. On 5/28/2025 at 12:58 PM, V5 (Director of Social Services) said that R1 has never been out by himself. V5 said R1 is always accompanied by a family and friends. V5 said that R1's family comes and takes R1 out. V5 said that if R1 has not had any visitor to stay with him in the facility, but if he does have a visitor who wants to spend time with him in the facility, V5 said that the visitation will happen in the day room and monitored by the staff. V5 said that V5 was informed that R1 was unresponsive and was sent out to the hospital. Prior to 5/19/2025 incident, V5 said on 4/14/25 V5 observed R1 who appeared to be asleep, upon entering the room and getting closer R1, V5 observed a rolled-up dollar in R1's hand. V5 said that R1 was breathing, V5 shouted out R1's name and received no response. V5 said V5 notified the nurse and V5 removed the dollar from R1's hand, unrolled it and notice a white powdery substance on the dollar. V5 said that R1 was aroused and asked to identify the substance on the dollar in-which R1 refused to do so. V5 said that R1 was asked the question if there was any more of this white powdery substance in R1's possession and R1 stated I don't know what you are talking about. V5 said that R1's living area was searched and there was no contraband found. V5 said that after the incident, R1 was only allowed to go out with responsible party. V5 said that R1's belongings were supposed to be searched upon return from outing. V5 said that social services are supposed to search R1 belongings when he returns from outing. V5 said that V5 was not in the facility when R1 went out on pass on 5/19/2025. V5 said that V5 was not made aware that R1 was back into the facility. V5 said that V5 is not sure if any social worker searched R1 belongings when he returned from pass. On 5/2 /2025 at 2:17 PM, V2 (Director of Nursing) said that V2 was called down to R1's room in April because resident was sitting in the chair and nodding. V2 said that V1 and V5 informed V2 that a dollar rolled up with white substance was found in R1's hand. V2 said that V2 gave R1 a sternal rub which woke R1 up but R1 continue to go in and out. V2 said that after the incident occurred, R1 was moved to a room closer to the nurses' station so that R1 will be monitored more closely. V2 said R1 was made aware that R1 will have supervised visit only. V2 said that R1's emergency contact was notified that R1 can only have supervised visit. V2 said that R1 also notified that he can only go out with his emergency contact. V2 said that social services are also supposed to search R1 when he returns from the community outing. V2 said that on 5/19/2025, V4 (LPN) came to V2 to talk about R1 staying in another resident's room more frequently than usual. V2 said that V2 came down with V4 to go talk to R1. V2 said that R1 was observed on the floor with face down. V2 said that V2 observed small amount of blood on the floor. V2 said that R1 was unresponsive but was breathing. V2 said that V2 perform sternal rub, V2 said that V2 placed a pillow underneath R1 head and log rolled R1 to observe where R1 was bleeding from. V2 said that R1 was administered with Narcan and 911 was called. V2 said that V2 notified V1 (Administrator), and R1 nephew was called by (V1) to determine if he at any point left R1 alone. V2 said that R1's nephew admitted leaving R1 alone in the car for few minutes while he went to reactivate his phone. V2 said that V1 searched R1 pocket before the ambulance transported him to ER and found a bag of white substance in R1's pocket. V2 said that V2 called the cooperate office and notify them and also notified the IDPH. V2 said that the social service should have searched R1 when R1 returned from outing to the facility. V2 said that the social services failed in that area for not searching R1. On 5/28/2025 at 3:12 PM, V1 (Administrator) said that V1 was aware of R1 drug abuse incident in April. V1 said R1 was unresponsive, and the facility tried to wake him up and after shaking R1, R1 finally woke up. V1 said that R1 was placed on a pass restriction where R1 was only allowed to go out on pass with his nephew, and random room search to be conducted on him. V1 said that social service will search R1 when he returns from outing. V1 said that on 5/19/2025, R1 went out with his nephew. V1 said that R1's nephew assured the facility that he will keep a close watch on R1. V1 said that it wouldn't have hurt for the social service to search R1 when R1 returned from the outing with the nephew. V1 said that after the incident happened, V1 said that V1 called R1 nephew to ask if R1 was left alone at any time during his outing. V1 said that R1's nephew said that he left R1 alone in the car while he went to a phone store. V1 said that V1 found a packet of white powder in R1 pocket. R1 is a [AGE] year-old-male admitted on [DATE]. The social service note dated 4/16/2025, indicated that R1 was found unresponsive on 4/14/2025 and a dollar found in R1's hand when unrolled had white powdery substance on the dollar. On 5/19/2025, it was documented that R1 was also found on the floor unresponsive, and when R1 pockets were searched by V1 (Administrator), a bag with white substance in the bag was found in the left pocket. 5/19/2025 nurses note indicated that R1 was transferred to the hospital by 911 attendees. It was also documented that R1 went out on a pass with his nephew earlier on 5/19/2025. R1 after hospital visit summary indicated that R1 admission diagnosis was Opioid overdose, accidental or unintentional, and laceration of right eyebrow. Facility Policy: Policy on Contraband Materials, Inspection of Rooms and Use of Recording Devices Introduction: This organization reserves the right to conduct inspections if there is reason to suspect/believe that a resident has contraband items/materials in his/her possession. Procedure 1. Residents may be asked to empty and show the content of their pockets at any time if reasonable suspicion exists. 2. Residents may be asked to reach into concealed (Clothing) areas and remove any items and place these items on a horizontal surface. Staff are instructed to have the resident hand items to the staff member or place the items on the horizontal surfaces.

Based on interview and record review the facility failed to notify the residents representative psychotropic medications were prescribed. This applies to 1 of 3 residents (R1) reviewed for resident rights in the sample of 4. The findings include: On 5/16/25 at 10:37 AM, V9 (R1's Guardian) said the facility reported R1 was receiving psychotropic medications with my knowledge or consent. V9 said she did not consent for him to receive those medications. When she asked the facility why he was on the medications she was told, R1 would be uncontrollable without the medications. R1's face sheet shows V9 is R1's Guardian. R1's Physician Order Sheets dated May 2025 shows orders including Haloperidol 5 mg (milligrams) every 6 hours as needed for behavior disturbance and Lorazepam 1 mg every 6 hours as needed for behaviors (both order date of 3/4/25). R1's Consent for Psychotropic Medications dated 3/5/25 shows Haloperidol 5 mg and Ativan (Lorazepam) 1 mg listed. The informed consent is signed by V3 (ADON) and signed signature above the resident/authorized Representative/Guardian. On 5/16/25 at 12:10 PM, V3 (Assistant Director of Nursing-ADON) said she over sees psychotropic medications. Consent should be obtained from the resident or resident representative prior to the use of psychotropic medications. At 1:57 PM, V3 said R1 signed his own consent, and she was not aware of R1 having a guardian. V2 (Director of Nursing) confirmed R1 has a guardian, and consents should be signed by the authorized representative. The facility's undated Psychotropic Drug Therapy Policy states, Psychotropic drug therapy will be used only to treat a specific condition .Obtain informed consent. PSYCHOTROPIC MEDICATION SHALL NOT BE PRESCRIBED OR ADMINISTERED WITHOUT THE INFORMED CONSENT OF THE RESIDENT, THE RESIDENTS GUARDIAN OR OTHER AUTHORIZED REPRESENTATIVE .

Based on interview and record review the facility failed to ensure prescribed medications were administered as ordered for 1 of 3 residents (R2) reviewed for medication administration in the sample of 4. The findings include: R2's Medication Administration Record dated April 2025 shows orders including Benztropine Mesylate 0.5 mg (milligram) give one tablet at bedtime. The M.A.R. shows on 4/10/25 this medication was not administered. Divalproex Sodium tablet 500 mg ER (extended release) give two tablets at bedtime related to bipolar disorder. The M.A.R. shows this medication was not administered on 4/10/25 and 4/13/25. Olanzapine 10 mg give one tablet daily for mood disorder. The M.A.R. shows this medication was not administered on 4/10/25. Trazadone 50 mg give 1.5 tablet daily for insomnia. The M.A.R. shows this medication was not administered on 4/10/25 and 4/13/25. On 5/16/25 at 9:28 AM, V5 (Registered Nurse) said medications should be administered as ordered. If the medication is given it is documented on the M.A.R. If the M.A.R. shows no entry the medication was not administered. The facility's undated Medication Administration Policy states, Documentation of medication administration is recorded on the Medication Administration record (MAR) or Treatment Record and includes the date, time and initials of the licensed nurse who administered the medication .

Based on interview, and record review the failed to ensure stop dates for residents with prn (as needed) psychotropic medications were in place for 2 of 3 residents (R1, R3) reviewed for psychotropic medications in the sample 4. The findings: R1's Physician Order Sheets dated May 2025 shows orders including Haloperidol 5 mg (milligrams) every 6 hours as needed for behavior disturbance and Lorazepam 1 mg every 6 hours as needed for behaviors (both order date of 3/4/25). R3's Physician Order Sheets dated May 2025 shows orders including Lorazepam Injection 0.5 ml every 8 hours as needed for agitation (order date 4/29/25). On 5/16/25 at 12:10 PM, V3 (Assistant Director of Nursing-ADON) said psychotropics prn medications should have a stop date of 14 days. The facility's Psychotropic Drug Therapy undated policy states, Psychotropic drug therapy will be used when necessary to treat a specific condition .PRN (as needed) psychoactive medications will be ordered with a time limit of 14 days. After that time, Physicians may re-evaluate and reroder at 14 day intervals. There must be documentation to support the continued use.

Based on observation, interview, and record review the facility failed to provide a clean, comfortable, and homelike environment for 9 (R3, R4, R5, R6, R7, R8, R10, R11, and R12) of 12 residents reviewed for environment. The findings include: On 3/22/25 at 10:04AM R8's room has four tiles missing from the main room floor. R8 was observed in the bed, opened her eyes but did not respond to the surveyor's question. On 3/22/25 at 10:06AM R3's room was observed. The top veneer finish lifts off to expose plywood/particle board underneath. A round hole was [NAME] key lock fell out. 2 window curtains in the room, one is hung and can slide to open and close, but second curtain is partially hung. Curtain hooks/clips observed on the window ledge. Trim boards look dirty with discolored, dark black/brown grime. Black, dark, spotted discoloration along floor trim and floor that is along wall. R3 said her window curtains have been like that for a couple weeks. R3 said she is unable to open or close the windows, they stay like that. R3 said the dresser in the room was her room mates, it's been like that for some time. R3 said housekeeping has not been in to clean her room today. R3 said that was my roommate's dresser. R3 showed surveyor her bathroom. R3 turned on the cold-water faucet and then the faucet for hot water. Only a dribble of hot water came out. R3 said it makes it hard to wash up. There are four missing tiles in R3's bathroom. R3 said the floor has a lot of wear and tear, it's been like that so long as I can remember. R3 said some rooms are better than others. R3 said yes, she has reported the faucet, curtain, and tiles, but the staff have a lot to do. On 3/22/25 at 10:13AM R4-R7 are roommates. Three residents were in the room during observation. No window curtain in the room. On 3/22/25 at 10:15 R12's room has 1 square tile near bathroom door lifted up and some pieces cracked. On 3/22/25 at 10:23AM R10's bathroom is observed and the toilet seat has a brown substance smeared on it. On 3/22/25 at 10:30AM V2 (Certified Nurse Assistant-CNA), said R12 walks into the bathroom and uses the toilet, but she still needs staff assistance with toilet hygiene. V2 said R11 walks around but needs staff assist with toilet cares. V2 said R2 is bed-bound and won't use the bathroom. R2, R10 and R11 are roommates. On 3/22/25 at 10:40AM V6 (Assistant Administrator) was asked about missing tiles in R12's room. V6 said I don't know what the plan is for flooring. At 10:44AM V6 said if R3's window curtains were up, we could close them, but it is not up (the hanging curtain mentioned above). V6 opened the hot water faucet in R3's bathroom and saw the water trickle. V6 saw the missing floor tiles in the bathroom. On 3/22/25 at 10:46AM V6 saw R4-R7's room without window curtains and said all rooms should have window curtains. On 3/22/25 at 10:48AM V3, Housekeeping, said all rooms are swept, mopped, and bathrooms cleaned every day. V3 said I have the 2nd floor until 1:00PM, the other housekeeper called off. V3 said when we do a deep cleaning of a room, we take the window curtains down to wash them. V3 said he has not gotten to clean any rooms on R10's side. On 3/22/25 V4 (Licensed Practical Nurse-LPN) observed R10's bathroom. V4 said it is not acceptable, housekeeping is responsible to clean it. V4 said we would clean the toilet before using it. On 3/22/25 at 11:59AM via phone interview, V7 (Housekeeping Director) said the resident rooms are to be cleaned daily. V7 said we should have two housekeepers on each floor. V7 was asked if the housekeepers are expected to use water from the resident sinks to clean. V7 said yes, they need the sink to wet the cloths. V7 said housekeeping should report when a water faucet needs repair. V7 said I take down the window curtains and wash them when we deep clean a room. V7 said we have extra and enough window curtains for all rooms. V7 said I can get curtains from the empty floor and use them in a needed room. V7 said if a curtain falls then housekeeping should fix it. There are communication sheets at each nurses' station for us to let maintenance know if something needs to be fixed, like faucets. On 3/22/25 at 1:17PM V9 (Maintenance Director) said work order forms are kept at each end of the hall. V9 said we pick them up or staff calls us to let us know of something that needs fixed. V9 said we check daily for hot water, cold water, and air temperatures. V9 said we can replace furniture with furniture from unoccupied floor/room. V9 said I was aware tiles need to be replaced. V9 said there are no tiles here, none are available in the facility to replace. V9 said the CNAs are supposed to let us know if furniture is damaged or if there are plumbing issues, because they would see it during patient care. V9 said we don't check every room everyday for plumbing problems, I have never checked that room. V9 said I don't keep the work request, we take care of the issue and don't keep the paper. On 3/22/25 at 2:08PM V6 was asked if the staff have a responsibility to make sure the residents have a clean and homelike environment. V6 responded absolutely. V6 was asked if missing curtains, missing floor tiles, feces smeared on toilet seats, and no hot/warm water available meets the criteria of clean and homelike environment. V6 responded absolutely not. The facility resident rights booklet page 3 states Your facility must be safe, clean, comfortable, and homelike.

Based on interview and record review, the facility failed to notify a physician that a resident was not being administered a steroid topical ointment and an immunosupressive medication as ordered and missed 15 doses of the steroid topical ointment and 14 doses of the immunosupressive medication for one out of three residents (R1) reviewed for physician notification in a total sample of three. Findings Include: R1 is a [AGE] year old with the following diagnosis: rheumatoid arthritis, dermatomyositis, herpes vesicular dermatitis, and chronic ulcer of skin. On 2/26/25 at 11:30AM, R1 was only available by phone for interview due to being hospitalized at the time of the investigation. R1 stated R1 does not the get medication for R1's autoimmune disease. R1 was unable to remember the name of the medication but knew it started with an M. R1 reported the medication is supposed to be taken twice a day (once in the morning and once around dinner time) but it is only given usually once a day or not at all. R1 was unable to report the number of doses that were missed but R1 stated it was more than ten a month. R1 was unaware why the medication was not being given as scheduled. R1 stated the medication is used for healing the lesions on R1's hands from the autoimmune disease. R1 stated the lesions are painful but have not gotten any worse from not taking the medication as scheduled. On 2/26/25 at 12:30PM, V1 (Nurse) stated R1 takes a medication for an autoimmune disease because R1's fingers swell. V1 could not remember the names of the medications, but reported R1 also uses topical creams. V1 denied R1 refusing any medication. V1 reported R1 has a condition that causes swelling and lesions to the hands and fingers. V1 stated medications need to be administered as they are ordered. V1 denied being aware of R1 having multiple missed doses of the topical steroid cream and the immunosupressive medication. V1 reported that if a medication is not signed out on the MAR, then it is considered not to have been given. V1 stated if a resident misses a dose of a medication the physician or the director of nursing are notified, and the nurse follows up with any further orders. On 2/26/25 at 1:23PM, V2 (DON) stated R1 admitted to the facility with lesions to the hands and arms. V2 could not state what medications R1 was taking for the autoimmune disease. V2 reported all medication should be administered as ordered. V2 stated the nurse should document the medication when it is administered in the MAR. V2 denied R1 making any reports that R1 was not getting the topical steroid cream or the immunosupressive medication. V2 reported a physician needs to be notified when a resident is missing an ordered medication because the physician needs to be aware of what is going on with the resident. On 2/26/25 at 3:37PM, V6 stated R1 has rheumatoid arthritis and dermatomyositis and both conditions are autoimmune. V6 reported R1 has lesions on both hands and arms due to dermatomyositis. V6 stated the lesions present as swollen, inflamed, sores. V6 reported the physicians at an outside hospital put R1 on the immunosupressive medication and the topical steroid cream. V6 stated the immunosupressive medication helps decrease the swelling and prevent any further lesions from occurring. V6 reported the topical steroid cream helps with inflammation and healing of the lesions. V6 denied making any changes to the medication and reported the physicians at the outside hospital are responsible for managing both medications. V6 stated R1 reported being given medications late, but denied R1 reporting any missed doses of medication. V6 denied being aware of any missed doses of the topical steroid cream or the immunosupressive medication. V6 reported if either medication is not given as ordered the lesions could potentially become worse. V6 reported if a medication is not given for more than one dose as ordered than V6 would expect to be notified by staff to see if there is an alternative medication that should be prescribed instead. V6 stated the physician wants to be aware if R1 is taking the medication or not to see if the medication is working properly with R1's auto immune disease. The Physician Order Summary documents a medication order for a topical steroid cream (clobetasol) to be applied two times a day for dermatitis and an immunosupressive medication (mycophenolate mofetil) to be given twice a day for rheumatoid arthritis. The topical cream was ordered on 12/23/24 and the immunosupressive medication was ordered on 12/25/24. The Medication Administration Record (MAR) dated 01/2025 documents the topical steroid cream is to be given at 6 AM and 6 PM and applied to both hands. During 01/2025, six doses were not documented as being administered on the MAR. The following are the dates and times the topical steroid cream was not administered: 1/8/25 at 6AM, 1/8/25 at 6PM, 1/9/25 at 6AM, 1/15/25 at 6AM, 1/27/25 at 6PM, and 1/30/25 at 6PM. The immunosupressive medication is ordered to give three tablets by mouth two times a day at 9 AM and 5 PM. A total of four doses are not documented as being administered during this month. The following are the dates and times the immunosupressive medication was not administered: 1/20/25 at 9AM, 1/27/25 at 5PM, 1/30/25 at 9AM, and 1/30/25 at 5PM. The Medication Administration Record dated 02/2025 documents eleven doses of the steroid cream were not administered as ordered. The following are the dates and times the topical steroid cream was not administered: 2/10/25 at 6PM, 2/13/25 at 6PM, 2/14/25 at 6PM, 2/18/25 at 6PM, 2/19/25 at 6PM, 2/20/25 at 6AM, 2/20/25 at 6PM, 2/22/25 at 6AM, 2/23/25 at 6PM, 2/24/25 at 6AM, and 2/24/25 at 6PM. It also documents that ten doses of the immunosupressive medication were not administered as order. The following are the dates and times the immunosupressive medication was not administered: 2/4/25 at 5PM, 2/10/25 at 5PM, 2/13/25 at 5PM, 2/14/25 at 5PM, 2/18/25 at 5PM, 2/19/25 at 5PM, 2/20/25 at 9AM, 2/20/25 at 5PM, 2/23/25 at 5PM, and 2/24/25 at 5PM. The Hospital Records dated 2/3/25 document R1 presented to the hospital with bilateral hand ulcerations, pain, and swelling. Rheumatology was consulted and stated to continue the immunosupressive medication. Plan is to continue the immunosupressive medication and topical steroid cream. The Minimum Data Set, dated dated dated [DATE] documents a Brief Interview for Mental Status score as 15 (no cognitive impairment). The policy titled, Medication Administration Policy, dated 08/2015 documents, Policy: Level of Responsibility: . Documentation of medication administration is recorded on the medication administration record or treatment record and includes the date, time, and initials of the licensed nurse who administered the medication . Administration of Medications: Medication must be administered in accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time. The policy titled, Physicians Orders, dated 06/2017 documents, These guidelines are to ensure that: 1. Changes in resident status/condition are assessed and physician notification is based on assessment findings and is to be documented in the medical record. 2. Any orders given by the physician are carried out. Nurse Responsibilities: .6. Medication and/or treatment orders are to be scheduled to MAR/TAR as appropriate .Nursing Documentation: A. Any calls to or from physician will be documented in the nurse's notes, indicating information conveyed and received. B. The nurse shall indicate in the nurse's notes, ongoing conversations with the physician regarding response to notifications of changes in condition, laboratory, etc. The policy titled, Change in Condition Physician Notification Overview Guidelines, dated 04/2014 documents, . Nurse Responsibilities: The nurse should not hesitate to contact the attending physician anytime for a problem which is in his or her judgment requires immediate medical intervention. The frequency of physician contacts is based on nursing judgment and the following guidelines . Nursing Documentation: A. Any calls to or from physician will be documented in the nurse's notes, indicating information conveyed and received .E. The nurse shall indicate in the nurse's notes, ongoing conversations with the physician regarding response to notifications of changes in condition, laboratory.

Based on interview and record review, the facility failed to administer a topical steroid ointment and an immunosupressive medication as ordered causing the resident to miss 15 doses of the topical steroid ointment and 14 doses of the immunosupressive medication over a two month period for one resident (R1) out of three reviewed for medication administration in a total sample of three. Findings Include: R1 is a [AGE] year old with the following diagnosis: rheumatoid arthritis, dermatomyositis, herpes vesicular dermatitis, and chronic ulcer of skin. On 2/26/25 at 11:30AM, R1 was only available by phone for interview due to being hospitalized at the time of the investigation. R1 stated R1 does not the get medication for R1's autoimmune disease. R1 was unable to remember the name of the medication but knew it started with an M. R1 reported the medication is supposed to be taken twice a day (once in the morning and once around dinner time) but it is only given usually once a day or not at all. R1 was unable to report the number of doses that were missed but R1 stated it was more than ten a month. R1 was unaware why the medication was not being given as scheduled. R1 stated the medication is used for healing the lesions on R1's hands from the autoimmune disease. R1 stated the lesions are painful but have not gotten any worse from not taking the medication as scheduled. On 2/26/25 at 12:30PM, V1 (Nurse) stated R1 takes a medication for an autoimmune disease because R1's fingers swell. V1 could not remember the names of the medications, but reported R1 also uses topical creams. V1 denied R1 refusing any medication. V1 reported R1 has a condition that causes swelling and lesions to the hands and fingers. V1 stated medications need to be administered as they are ordered. V1 denied being aware of R1 having multiple missed doses of the topical steroid cream and the immunosupressive medication. V1 reported that if a medication is not signed out on the MAR, then it is considered not to have been given. On 2/26/25 at 1:23PM, V2 (DON) stated R1 admitted to the facility with lesions to the hands and arms. V2 could not state what medications R1 was taking for the autoimmune disease. V2 reported all medication should be administered as ordered. V2 stated the nurse should document the medication when it is administered in the MAR. V2 denied R1 making any reports that R1 was not getting the topical steroid cream or the immunosupressive medication. On 2/26/25 at 3:37PM, V6 stated R1 has rheumatoid arthritis and dermatomyositis and both conditions are autoimmune. V6 reported R1 has lesions on both hands and arms due to dermatomyositis. V6 stated the lesions present as swollen, inflamed, sores. V6 reported the physicians at an outside hospital put R1 on the immunosupressive medication and the topical steroid cream. V6 stated the immunosupressive medication helps decrease the swelling and prevent any further lesions from occurring. V6 reported the topical steroid cream helps with inflammation and healing of the lesions. V6 denied making any changes to the medication and reported the physicians at the outside hospital are responsible for managing both medications. V6 stated R1 reported being given medications late, but denied R1 reporting any missed doses of medication. V6 reported if either medication is not given as ordered the lesions could potentially become worse. The Physician Order Summary documents a medication order for a topical steroid cream (clobetasol) to be applied two times a day for dermatitis and an immunosupressive medication (mycophenolate mofetil) to be given twice a day for rheumatoid arthritis. The topical cream was ordered on 12/23/24 and the immunosupressive medication was ordered on 12/25/24. The Medication Administration Record (MAR) dated 01/2025 documents the topical steroid cream is to be given at 6 AM and 6 PM and applied to both hands. During 01/2025, six doses were not documented as being administered on the MAR. The following are the dates and times the topical steroid cream was not administered: 1/8/25 at 6AM, 1/8/25 at 6PM, 1/9/25 at 6AM, 1/15/25 at 6AM, 1/27/25 at 6PM, and 1/30/25 at 6PM. The immunosupressive medication is ordered to give three tablets by mouth two times a day at 9 AM and 5 PM. A total of four doses are not documented as being administered during this month. The following are the dates and times the immunosupressive medication was not administered: 1/20/25 at 9AM, 1/27/25 at 5PM, 1/30/25 at 9AM, and 1/30/25 at 5PM. The Medication Administration Record dated 02/2025 documents eleven doses of the steroid cream were not administered as ordered. The following are the dates and times the topical steroid cream was not administered: 2/10/25 at 6PM, 2/13/25 at 6PM, 2/14/25 at 6PM, 2/18/25 at 6PM, 2/19/25 at 6PM, 2/20/25 at 6AM, 2/20/25 at 6PM, 2/22/25 at 6AM, 2/23/25 at 6PM, 2/24/25 at 6AM, and 2/24/25 at 6PM. It also documents that ten doses of the immunosupressive medication were not administered as order. The following are the dates and times the immunosupressive medication was not administered: 2/4/25 at 5PM, 2/10/25 at 5PM, 2/13/25 at 5PM, 2/14/25 at 5PM, 2/18/25 at 5PM, 2/19/25 at 5PM, 2/20/25 at 9AM, 2/20/25 at 5PM, 2/23/25 at 5PM, and 2/24/25 at 5PM. The Hospital Records dated 2/3/25 document R1 presented to the hospital with bilateral hand ulcerations, pain, and swelling. Rheumatology was consulted and stated to continue the immunosupressive medication. Plan is to continue the immunosupressive medication and topical steroid cream. The Minimum Data Set, dated dated dated [DATE] documents a Brief Interview for Mental Status score as 15 (no cognitive impairment). The policy titled, Medication Administration Policy, dated 08/2015 documents, Policy: Level of Responsibility: . Documentation of medication administration is recorded on the medication administration record or treatment record and includes the date, time, and initials of the licensed nurse who administered the medication . Administration of Medications: Medication must be administered in accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time. The policy titled, Physicians Orders, dated 06/2017 documents, These guidelines are to ensure that: 1. Changes in resident status/condition are assessed and physician notification is based on assessment findings and is to be documented in the medical record. 2. Any orders given by the physician are carried out. Nurse Responsibilities: .6. Medication and/or treatment orders are to be scheduled to MAR/TAR as appropriate .Nursing Documentation: A. Any calls to or from physician will be documented in the nurse's notes, indicating information conveyed and received. B. The nurse shall indicate in the nurse's notes, ongoing conversations with the physician regarding response to notifications of changes in condition, laboratory, etc.

Based on interview and record review, the facility failed to follow their abuse policy by not preventing a resident to resident physical assault. This affected two of three residents (R1, R2) both reviewed for physical abuse. This failure resulted in R1 being punched in the face and being transferred to the local hospital for evaluation Findings include: R1 was admitted to the facility on [DATE] with a diagnosis of heart failure, dementia, schizophrenia, depression and auditory hallucinations. R1's brief interview for mental status score dated 11/8/24 documents score 10/15 which indicates moderate cognitive impairment. On 12/31/24 at 2:22PM, R1 who was alert and oriented was asked if he recalls the incident with his roommate. R1 said yes. R1 said there was something wrong with the toilet in his room that it wasn't flushing. R1 said R2 punched him in the face two times. R1 was unsure where it happened or why. R1 unable to recall if he went into bathroom with R2. R1 does not recall any injury or any other details. On 12/31/24 at 2:52PM, V6 (nurse) said she witnessed R2 punching R1 in the face in the hallway. V6 said she immediately went and separated the residents. R2 was upset about something in the bathroom. R2 had hit R1 a couple times in the face. R1 did not hit R2 back. R1 face was red but does not recall any injury. R2's progress note dated 12/10/24 documents: Writer went to the hallway area and stopped R2 from hitting resident R1 more. Alert and oriented x3. Resident very aggressive and angry and constantly hitting R1. Facility final abuse report form dated 12/10/24 documents: R2 was using the bathroom, his roommate R1 kept opening bathroom door. R2 exited bathroom and hits R1 in the face below right eye. Staff immediately separate residents. R2 was asked what happened and said R1 keeps messing with him by opening the door while using the bathroom. Both residents assessed for injury with R1 having swelling below right eye and redness to right eye. R2 has diagnosis of hunting's disease and violent behavior. Symptoms include mental confusion, compulsive behaviors, irritability, lack of restraint, anxiety, mood swings as evident by resident becoming irritable and acting impulsively towards his roommate. R1's hospital record dated 12/10/24 documents eye pain/injury for reported assault. Facility abuse prevention program policy undated documents: the facility affirms the right for our residents to be free from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion. The facility therefore prohibits the mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrence of mistreatment, abuse or neglect by: implementing systems to investigate all reports promptly and making the necessary changes to prevent further occurrences; identifying occurrences and patterns of mistreatment; establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching and kicking.

Based on interview and record review, the facility failed to protect a resident identified to be at risk for abuse from a resident-to-resident sexual abuse. This affected one of three residents (R1) reviewed for resident-to-resident sexual abuse. This failure resulted in resulted in R1 feeling sad, scared, and powerless. Findings include: On 11-14-23 at 9:55 AM, R1 said she went with R2 to his room to get a pop. R1 said R2 did not touch R1 and moments later said R2 touched R1's genitals with his hands. R1 said R2 touched between my legs under my clothes. R1 said they were in R2's bed. R2 asked R1 to sit on his bed and R1 said R2 is big, and she didn't have a choice. R1 said R2 put 2 hands under the skirt and R2's 2 fingers penetrated R1's vagina. R1 said she did not fight R2 and did not tell R2 to stop. R1 said R2 put R1 in her wheelchair and pushed R1 out of his room. R1 said she told R1 told V4 (Certified Nursing Assistant/CNA) who told V3 (Licensed Practical Nurse/LPN). R1 said V3 called the local police. R1 said she did not talk to the police. R1 said R2 is no longer at the facility however said she still feels scared at the facility. R1 said she feels safer since R2 is not here anymore. R1 said she is satisfied with the facility handling this situation. R1 said R2 has not touched R1 before. R1 said R2 did not try to be romantic with R1. R1 said R2 was able to lift her up and place her on his bed and this happened in the afternoon. On 11-16-23 at 8:54 AM, R1 said R2 pushed R1's wheelchair to his room R2 did not say what they would do in his room. R1 said R2 told R1 to get on the bed, R2 assisted (lifted) R1 on the bed, R2 flipped R1 over on the bed, R2 pulled R1's skirt and panties down, and R2 slapped his penis on R1's vagina. R1 said R2 did not penetrate me with his penis. R1 said she did not consent to any of this. R1 said she did not put up a fight because he was a big guy. R1 said this lasted 3 minutes. R1 said after, R2 put panties back on and skirt on. R2 threw me in the chair and wheeled me out. R1 said she did not tell anyone because she did not like the nurse. There are no previous altercations or encounters with R2 prior to this. R1 denies any previous abuse concerns prior to this incident. On 11-14-23 at 9:30 AM, V2 (Director of Nursing/DON) said on 11-12-23 around 8:00 AM, R1 informed V3 informed R1 made sexual assault allegation against (R2). V2 said she was on her way to facility and said the staff kept R1 and R2 separated. On the phone, R1 told V2 that R2 pushed R1's wheelchair into his room around 2:00 PM on Saturday (11-11-23). R1 said R2 told R1 to get on R2's bed. R1 needed assistance to transfer on to his bed. R1 said she transferred herself onto R2's bed. While on his bed, R2 vaginally penetrated R1 with his penis. V2 asked R1 if she yelled or screamed for help and R1 said no. V2 asked R1 why she didn't scream for help and R1 said R2 was big. R1 said she was scared of R2. R1 told V2 that she went back to her chair and she left out of R2's room. When V2 arrived at facility, R1 was interviewed by 2 other staff ( V12 Assistant Administrator and V5 Social Services). V2 talked with V12 (Assistant Administrator) and V5 (Social Services). V2 said local police were called by Assistant Administrator and they arrived at the same time ambulance was bringing R1 to hospital. MD was notified and gave order to send R1 for hospital evaluation and rape kit. Emergency contact was called however no response and message left. Facility called R2's psych MD and family. MD gave order for R2's psych evaluation. V2 said R2 can show behaviors of flirtation and making inappropriate sexual comments towards staff residents. V2 said R2 may attempt to touch an arm but has not seen R2 grab or sexually touch a resident or staff. V2 said she would not condone R2 taking a female to his room knowing R2's sexual behaviors and mental illness for a safety measure. V2 said R2 requires standard rounding because he is out and about. V2 said when she is around and sees R2's door closed, she would make it a point to knock on the door to check on his due to his behaviors. On 11-14-23 at 11:08 AM, V3 (LPN) said on 11-12-23 around 7:15 AM, R1 told V3 R2 raped her (R1). V3 immediately asked if R1 was OK and did a visual inspection. V3 said R1 did not complain of any pain or discomfort. V3 appeared to be OK at that time. V3 said R1 did not show any signs of abuse. V3 said she did not check R1's genitals. V3 asked when this happened and R1 said it happened yesterday at 2:00 PM (11-11-23). R1 said R2 raped her and did not give any detail. V3 said R1 did not mention any penetration or finger activity. V3 immediately notified social worker, V2 (DON), (Administrator was on vacation), V11 (MD), and no family was listed. V3 said V5 (Social Worker) called police. V3 said local police met R1 at the hospital. V3 said R2 was sent out for hospital evaluation and has not returned. On 11-14-23 at 11:51 AM, V4 (CNA) R1 is alert, oriented, and able to make her needs known. V4 said R1 would be able to report abuse if it happened to her. V4 said R2 is alert, oriented, and able to make his needs known. V4 said she is not aware of R2 being capable of sexual abuse towards others. V4 said she has not seen R2 have any sexual behaviors towards other residents. V4 said she arrived to work on Sunday (11-12-23) at around 7:15 AM, R1 saw V4 at the elevator and took V4's hand and lead V4 around the corner. R1 told V4 R2 raped R1. R1 did not give details however V4 immediately reported to V3 (LPN). V3 arrived and R1 told V3 the same allegation. V3 reported it to necessary administration. V4 said R1 was tearful, emotional, and scared. On 11-14-223 at 12:18 PM, V5 (Social Service Director/SSD) said R1 is alert, oriented, and able to make her needs known. V5 said R1 is capable of reporting abuse if it happened to R1. V5 said R2 is alert, oriented, and able to make his needs known. V5 said R2 is known for inappropriate jokes which can be very personal or sexual at times. V5 said staff will report inappropriate touch from R2. V5 said R2 can be difficult to redirect and R2 has poor respect of other people's boundaries and can be impulsive. V5 said she would separate R2 from female peers due to his joking and sexually inappropriate behaviors. V5 said if she would see a female with R2 going to his room, she would suggest they meet in a common area of the floor. This way staff can monitor and ensure resident safety. On 11-16-23 at 9:30 AM, V5 said R1 is vulnerable for abuse because of confusion related to CVA, Hemiplegia, Psychiatric History, and Depression. R1's Minimum Data Set/MDS (ARD 9-11-23) documents: BIMS = 11. Active Diagnoses (not limited to): Cerebrovascular Accident. R1's Progress Note dated 11-12-23 documents: Upon checking rooms this a.m., resident came out to nurses' station and stated to writer and CNA that she had been raped by R2. Resident stated that (R2) pushed her wheelchair into his room and told her to get on the bed and she did. She stated, He pulled my dress up and raped me. When writer asked where roommate was, she stated, he was in his bed. Writer asked why you didn't scream. She stated, I was scared, he is a big guy, and I was afraid of him. T 98 P 84 R 18 B/P 162/111. Rapid Covid 19 complete. Results are negative. Dr. [NAME] called and notified. Order sends to ER (emergency room ). EMS (Emergency Medical System) called and ETA (Estimated Time of Arrival) within 30 minutes. At 9:00 a.m. EMS arrived EMTs (Emergency Medical Technicians) x2 with stretcher to pick up resident. DON notified and present. Assistant Administrator notified. Social Service notified. R1's Social Service Note dated 11-12-23 documents: Writer was made aware that resident made an alleged statement against peer, writer informed SSD. DON (Director of Nursing) and Assistant Administrator were made aware. Resident was sent out for observation. Writer gathered witness statement and room change was made because resident felt unsafe. Staff will continue to monitor resident needs upon return from hospital. R1's Comprehensive Assessment Care Plan documents: R1 is susceptible for abuse/neglect. R2's Social Service Note dated 11-12-23 documents: Writer provided resident with a wellness check due to resident being named in an alleged incident. Writer took residents' statement, during which time resident appeared nervous due to labile (shaking) affect. Also, during intake of statement resident held a blank stare. Due to the nature of the incident resident was sent out for observation (around noon) and writer will provide an update upon residents' return. R2's Care Plan documents: Focus: Comprehensive assessment reveals history of suspected abuse and/or neglect or factors that may increase his/her susceptibility to abuse/neglect. Intervention: Assure the resident that he is in a safe & secure environment with caring professional. Explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse, CNA, peer) and by verbalizing thoughts, needs & feelings. R2's Care Plan documents: Focus: (R2) exhibits sexually inappropriate behavioral symptoms related to Severe Mental Illness. Intervention: Intervene & redirect when any inappropriate behavior is observed. Communicate assertively that the resident must exercise control over impulses &behavior (Social skills training). Remind the resident to refrain from hostile and inappropriate touching. Initial State Reportable dated 11-12-23 documents: Circumstances of alleged incident: It was reported to the nurse by the resident that she was allegedly sexually assaulted by another resident. The victim evaluated and sent out for further evaluation. The alleged perpetrator sent out as well. The police were called, and a report was filed. MD made aware. Family made aware and administration made aware. R1's Hospital Record dated 11-1-223 documents: HPI: (R1) female with medical history as noted who presents with call for sexual assault. R1 is a resident at a nearby nursing home. She states that another resident brought her into his bedroom against her will. States he slapped his penis on her unclothed vagina. Denies penetration, did not see bodily fluids. This interaction was brief lasting couple seconds to minutes. She was able to leave shortly after. She denies sustaining any other injury during this event. She is low concern for STDs. Of note, the patient does have history of hypertension and had a stroke last year which is why she is now living in a nursing home. She denies any pain. Denies any skin changes. Denies any trauma or injury. Police called by NH (nursing home) and present in dept (department). Pt does not want to discuss with police does not want a SA (sexual assault) kit. Medical Decision Making: Initial Assessment and Plan: female with medical history as noted above who presents with report of sexual assault. No penetration. No apparent involvement of bodily fluid. There was skin to skin contact between this man's penis and the skin over her vagina. She denies any vaginal discharge, bleeding, lesions. This occurred within the past 24 hours. Patient initially refusing to make a police report. Has gone back and forth. Multiple discussions with (R1), SANE (Sexual Assault Nurse Examiner). Sexual assault kit catered to exposures and desires of the patient. Please see SANE full documentation. Reviewed this work-up with the patient and she does not feel comfortable with this plan. We also called the nursing home to confirm that this individual is no longer living there he has been sent to another institution nursing supervisor aware and she will be living on a different floor from here on out according to the nursing supervisor. All questions answered patient does feel safe to go back to the institution. No further needs at this time will discharge in stable condition.

Based on observation, interview, and record review, the facility failed to follow its abuse prevention policy to prevent an incident of staff to resident sexual assault. This affected 1 of 3 residents (R1) reviewed for sexual abuse. This failure resulted in V3 being found in bed on top of R1. Using the reasonable person concept, R1 would be scared and traumatized. Findings include: On 4/5/23 at 3:35pm, R1 was observed to be alert, confused, oriented to name only. This surveyor's conversation with R1 was nonsensical. On 4/6/23 at 1:30pm, R1 was more alert. R1 was able to answer simple questions appropriately. R1 did not recall any staff coming into her room at night on 3/26/23. On 4/5/23 at 2:08pm, V6 (Certified Nursing Assistant/CNA) stated that V6 was working 3/26/23 from 10:30pm-6:30am on R1's nursing unit. V6 stated that V6 rounded on all her assigned residents; R1 was asleep in R1's bed. V6 stated that V3 (Registered Nurse/RN) was working on another nursing unit during the evening shift, 3:00pm-11:30pm, on 3/26/23. V6 stated that V8 (Licensed Practical Nurse/LPN) had gone down to the first floor nursing unit. V6 stated that at 10:50pm, V6 observed V3 (RN) walking down hall towards V6, V3 checked to see if V8 (LPN) was at the nurses' station, and then proceeded to enter R1's room. V6 stated that it took a while, about 15 minutes, for V8 to return to the nursing unit. V6 stated that when V8 exited the elevator, located on this nursing unit, V8 sensed something was wrong with V6. V6 stated that V6 informed V8 that V3 was in R1's room. V6 stated that V8 looked in R1's room briefly then shut R1's door leaving V3 in room with R1. V6 stated that V8 informed V6 that V3 said he was giving R1 a pop. V6 stated that V3 only had a book in his hand when he came onto R1's nursing unit. V6 denied V3 had any pop with him. V6 stated that V8 took the elevator to the first floor nursing unit and came back onto unit with V7 (LPN/Nurse Supervisor). V6 stated that V7 and V8 were both standing at the nurses' station. V6 stated that V7 instructed V6 to go into R1's acting like she was making resident rounds. V6 stated that V6 pushed R1's door open and witnessed V3's feet were off the floor. V6 stated that V3's whole body was on top of R1's body, and V3 was holding R1's arm. V6 stated that V3 didn't look back to see who came in R1's room; V3 jumped out of R1's bed. V6 stated that V6 informed V7 and V8 what she witnessed. V3 exited R1's room at 11:30pm, made small talk with V7 and V8 and then left the nursing unit. V6 stated that V3, V7, and V8's conversation did not involve what happened or any allegation of abuse. V6 stated that R1 was still asleep. V6 stated that V7 stated he was contacting V2 (Director of Nursing/DON) as he picked up his personal cellular phone. V6 stated that V6 did not call V1 (Administrator/Abuse Coordinator) to report the allegation of abuse, because V6 did not have V1's phone number and V7 was notifying V2. On 4/5/23 at 3:30pm, V7 (Nurse Supervisor) stated that V7 was working on first floor nursing unit for the 3:00pm-11:00pm and 11:00pm-7:30am shifts on 3/26/23. V7 stated that V7 was also the nurse supervisor on both shifts that day. V7 stated that between 11:00pm and 11:30pm, V8 (LPN) informed him that V3 (RN) was on V8's nursing unit. V7 stated that V8 did not say anything else. V7 stated that V6 (CNA) informed him V3 was in R1's room. V7 stated that V7 did not see V3 in R1's room; only saw V3 coming out of R1's room. V7 stated that V3 will walk into residents' rooms when not providing care for them during his shift. V7 stated that V7 spoke with V3 after V3 exited R1's room. V7 stated that V7 asked V3 How is everything, is everything okay? V7 stated that V3 informed him that R1 is calm now. V7 denied asking V3 who called V3 to inform him that R1 needed to be calmed down or what behaviors was R1 exhibiting that R1 needed to be calmed down. V7 denied asking V3 the length of time V3 was in R1's room or reason door was closed. V7 stated that R1 will stand in R1's doorway with bags waiting for a bus. V7 stated that V7 has only witnessed this on one occasion. V7 denied checking on R1 afterwards. V7 denied notifying V1 (Administrator) or V2 (DON) of an allegation of abuse on 3/26/23. Surveyor asked V7 why V7 was not concerned that V3 left the residents on his nursing unit unattended to go to R1's room late in the evening with R1's door closed and calming down a resident that was asleep. V7 replied, V3 is a nice guy and V3 was just being V3. On 4/6/23 at 9:30am, V1 (Administrator) stated that V8 (LPN) was interviewed after the alleged incident on 3/26/23 involving R1 and V3 (RN). V1 stated that V8 informed V1 that V6 (CNA) informed V8 that V3 was in R1's room. V8 went into R1's room to check on R1, saw V3 by R1's bedside, and then V8 walked out of R1's room and closed the door. V1 stated that V1 reviewed the video tapes from 3/26/23. V1 stated that he saw V3 enter R1's room about 11:25pm. V1 stated that R1's door was partially closed. V1 stated that he saw V8 enter R1's room briefly and when V8 exited she closed the door. V1 stated that V3 left R1's room shortly afterwards. V1 stated that V3 spoke briefly to V7 and V8 and then left facility. V1 stated that he could not tell what they were saying on the video. This surveyor requested to view the video tapes from 3/26/23. V1 stated that he would have to speak with the corporate office regarding request. This surveyor was not able to view the video recording during this survey. On 4/6/23 at 9:17am, V8 (LPN) stated that V8 was informed by V6 (CNA) that during V6's rounds, V6 saw V3 (RN) going into R1's room. V8 stated that V8 was not present on the nursing unit at the time V3 came onto nursing unit and went into R1's room. V8 stated that the event occurred around 11:20pm on 3/26/23. V8 stated that V8 was downstairs and was getting off the elevator. V8 stated that V8 went to R1's room and stood in doorway. V8 stated that V8 observed R1 and V3 speaking to each other. V8 stated that V3 was standing by R1's bathroom door and R1's bed is next to bathroom. V8 denied closing R1's door while V3 was still in R1's room. V8 denied asking V3 reason for being in R1's room as V3 was assigned to another nursing unit. V8 stated that V7 (Nurse Supervisor) came onto R1's nursing unit and V8 informed V7 that V3 was in R1's room. V8 stated that R1 does not need to be calmed down. V8 stated that R1 is a wanderer and needs to be re-directed. V8 stated that V8 did not think anything of this event. V8 stated that V3 was always visiting with residents on other nursing units during V3's work hours. V8 denied previously observing V3 enter any resident's room or visiting residents that late in the evening. V8 was unable to articulate reason V8 was not concerned with V3 visiting R1 in R1's room at 11:20pm when R1 had been asleep. V6's (CNA) written statement, dated 3/28/23, was reviewed. V6's statement correlates with V6's interview on 4/5/23. V7's (Nurse Supervisor) written statement, dated 3/27/23, was reviewed. V7 noted at approximately 11:00pm, V7 went to R1's nursing unit. V7 was made aware V3 was in R1's room. V7 had conversation with V8. V7 then instructed V6 (CNA) to round on R1. V7 saw V3 exiting R1's room and asked V3 if everything was okay. V3 replied Yes. V7 and V3 talked for a couple of minutes and then V3 left to go back on his assigned nursing unit. V8's (LPN) written statement, dated 3/27/23, was reviewed. Inconsistencies were noted in V8's written statement, interview, and video tapes. Video tape and staff interviews note V8 closed R1's door. There were also inconsistencies with V8's timeline of events. V3's (RN) written statement, dated 3/29/23, was reviewed. V3's statement included One of the ideas of being a nurse is, in my opinion, to console residents. With R1, I have given her hugs and tried to make R1 feel loved. V3 also wrote, R1 is a woman with dementia, and I've learned to help keep R1 in the moment R1 is in. So I believe I only went to R1's room to console R1. Attempts to interview V3 were unsuccessful during this survey. Review of R1's medical record, dated 3/27/23 at 4:29pm, documents V13 (Director of Clinical Services) noted: V13 was informed earlier by human resources of an allegation that a staff member, V3, had been seen lying in bed with R1 last night. Stated both R1 and V3 were fully dressed and that R1 was asleep. Administrator immediately made aware. Went to R1's room where she was observed walking independently in room, confused as per her baseline, oriented to name only as per her baseline. Talking incoherently when questions asked. R1 did allow body check without difficulty and no obvious evidence of trauma, redness, drainage, signs of pain or discomfort or injury noted with focus on vaginal area. Review of R1's BIMS (Brief Interview for Mental Status) score, dated 3/28/23, documents R1's score is 4 out of 15, indicating severely impaired cognition. Review of V3's timecard, dated 3/26/23, documents V3 did not clock out until 11:45pm. The facility's investigation into an allegation of sexual abuse involving V3 (RN) and R1 was reviewed. Summary of findings documented V3 left his assigned nursing unit and entered R1's room. Several minutes later, V8 (LPN) looks in R1's room and sees V3 standing by R1's bed. Several minutes later, V6 looked into R1's room and alleges seeing V3 in R1's bed on top of R1. When asked why V3 went in R1's room, V3 replied, To tell R1 good night. V3 stated V3 was in the room for 1-2 minutes and that R1 was asleep. When asked why did V3 stay in the room if R1 was asleep, V3 replied, I don't know. Facility Abuse Prevention policy, undated, documents this facility affirms the right of our residents to be free from abuse. Abuse means any sexual assault inflicted upon a resident other than by accidental means. All instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. According to the Association for the treatment and Prevention of Sexual Abuse, sexual abuse is defined as any sexual or sexually motivated behavior that is done to someone without that person's consent. This includes a continuum of intrusive behaviors ranging from hands-off offending, such as voyeurism and verbal comments, up to and including sexual penetration with or without violence. The key is that there is no consent.

Based on interview and record review, the facility failed to effectively monitor, cue and assist a resident that required aspiration (aspiration occurs when contents such as food, drink, saliva or vomit enters the lungs) precautions during a meal for one resident of three residents (R2) reviewed for aspiration precautions and special diets. This failure resulted in R2 choking on a cookie, having a syncopal episode, and being sent to the hospital. Findings Include: R2 is an [AGE] year old with the following diagnosis: dysphagia and vascular dementia with behavioral disturbance. R2 admitted to the facility on [DATE]. A Nursing note dated 6/22/22 at 1:22 PM documents R2 was sitting at the nurse's station eating lunch. R2 is alert to self at baseline. R2 started eating a cookie and was observed unresponsive to verbal stimuli. R2 had no reaction with a sternal rub and eyes remained closed. R2 had no movement. R2 began desaturating quickly to 83% so oxygen was administered at 4L. 911 was called and R2 was sent to the hospital. The Hospital Records dated 06/22/22 document R2 presented from the nursing home after a witnessed syncopal event (medical term for fainting or passing out) R2 was eating a cookie and started choking and subsequently vomited up the food. R2 had a brief loss of consciousness but regained consciousness spontaneously. Per EMS, R2 was hypotensive (low blood pressure) and initially only responsive to painful stimuli but came back to baseline mental status upon arrival to the ED. R2 was hypotensive as low as the 60s systolic with EMS. R2 has diminished breath sounds but otherwise normal. R2 has excessive salivation. R2's blood pressure improved with IV fluid resuscitation. R2 was admitted to the hospital for syncope, hypokalemia, and metabolic acidosis. On 08/02/22 at 11:45AM, V2 (DON) stated, The nurse went on break, and I was sitting at the nurses station. R2 was being monitored there. The CNA called me and told me that R2's head had dropped over. R2 wasn't responding. I tried doing a sternal rub and I couldn't get a response from R2. We brought R2 back to the room and put R2 back in the bed and that's when R2 began vomiting. We first put the pulse ox on R2, and she was desaturating quickly. We moved R2 to the bed to put oxygen on R2 and in case we needed to do anything else to R2. While all this was going on people were also calling 911. R2 did still have food in R2's mouth before R2 started vomiting. R2 was on a mechanical soft diet. R2 has a history of dementia and pocketing food along with difficulty swallowing. I didn't see what R2 was eating but I was told by the CNA that R2 was eating a cookie. I didn't see it happen. The CNA is the one who brought it to my attention. On 08/02/22 at 12:22PM, V3 (Nurse) stated, R2's on a mechanical soft diet because R2 can't swallow and chew very well. All the staff watch R2. If R2 is in R2's room, then staff watch R2 from a distance. As we pass by R2's room then we will look in on R2. If R2's not in the mood to eat R2 will keep the food in R2' mouth, and not swallow it. R2 is on aspiration precautions because of R2's swallowing problems and dementia. On 08/02/22 at 12:55PM, V5 (CNA) stated, I was sitting with R2 and helping feed R2 when I got up to go collect some trays. I came out and I saw R2's head back in the chair. I told the nurse because the nurse was at the nurse's station. R2 was sitting maybe 3 or 4 feet in front of the nurse's station. I don't know why the nurse didn't see R2. V2 was doing something else. I was gone about 3 minutes. I picked up trays in two different rooms. That's when I came out and saw R2. R2 is on aspiration precautions. I don't think there's any safety concerns when R2 eats. If they are pocketing food in their mouth then you need to sit there with a whole meal with them to make sure that they are swallowing. I don't know if R2 had anything in R2's mouth. I didn't see into R2's mouth; R2 was just slobbering. We put R2 back in bed and then R2 vomited. On 08/02/22 at 2:12PM, V9 (Speech Therapist) stated, R2 was evaluated by speech, and we worked with R2 to make sure R2 was safe while eating. The dysphasia was caused from R2's dementia. R2 needs reminders to swallow and to be set up while eating. R2 is someone who is easily distracted so R2 needs to be re-focused when eating. We also worked on only putting one bite of food in R2's mouth at a time and waiting for R2 to swallow that. Then we would follow up with a liquid for her to rinse your mouth out. The limiting factor for R2 was R2's cognition. The dementia really had caused R2 to have some issues with eating that weren't caused by other physical diagnoses. For someone on aspiration precautions we have them sitting up at a 90 angle for all meals, take small bites or sips, and making sure they're not shoving anything in their mouth or pocketing food. R2 did need verbal cues to remind R2 to swallow the food R2 had in her mouth. R2 just had a habit of kind of holding it in R2's mouth or R2 would just keep chewing it. On 08/03/22 at 2:45PM, V11 (Primary Physician) stated, Someone is put on aspiration precautions because there is a concern for them swallowing food into their lungs versus their stomach. For aspiration precautions, you want them to be sitting up straight during the meal instead of in the bed. For someone with dementia you would want to make sure that you are monitoring them swallowing and making sure that they're not pocketing any food because as dementia advances those are things that happen. When the body is choking the first natural instinct is to cough up the food if you can't do that then usually the body will vomit to try to get it open out. The Care Plan dated 01/22/22 documents R2 is at risk for aspiration. The Care Plan dated 01/22/22 documents R2 demonstrate some or high risk to potentially choke, aspirate food or liquids. This problem is related to a diagnosis of dysphasia. Interventions include: observe the resident during meal times for any signs or symptoms of aspiration or difficulty swallowing. Utilize safe swallowing techniques. The Care Plan dated 04/15/22 documents R2 has nutrition concerns related to dementia, poor appetite, pocketing food and intermittent refusal for food intake. R2 was downgraded to a mechanical soft diet. Interventions include: assist as needed with meals. The Minimum Data Set (MDS) dated [DATE] documents the Brief Interview for Mental Status score as a 6 (severe cognitive impairment). The Speech Therapy Evaluation dated 6/4/22 documents R2 was referred to speech therapy for dysphasia and services due to new onset of functional activity tolerance during oral intake, need for assistance from others, and prolonged mastication (chewing) with solids. The Speech Therapy note dated 6/4/22 documents and the plan of care was developed on this date. R2 was instructed on use of strategies to address swallowing dysfunction with focus on alternating bites and sips and body positioning to increase safety with intake and alternating liquids/solids to increase pharyngeal clearance. R2 was successful with follow through 26% of attempts due to limitations in safety awareness. The Speech Therapy note dated 6/14/22 documents R2 poorly recalled strategies and required cues to take smaller bites and to alternate between liquids and solids. R2 inconsistently followed commands. The Speech Therapy note dated 6/16/22 documents R2 benefits from assistance to alternate liquids and solids to help with oral clearance. The Speech Therapy note dated 6/19/22 documents R2 took small bites of food with mild increased manipulation time. R2 required a liquid wash to clear mouth. R2 does have a precaution of confusion, aspiration, and cognition listed in each speech therapy session. The Physician Order Sheet dated 7/29/22 documents R2 receives a mechanical soft diet with thin liquids due to vascular dementia. The policy titled, Feeding and Assisting Residents to Eat, dated 06/2014 document, 10. Encourage chewing. 11. Encourage swallowing - after each mouthful, praise. Gentle pressure upward on the chin will stimulate tongue to start swallowing pattern. Look and listen for swallowing. The policy titled, Aspiration Precautions, dated 12/2014 documents, 1. Residents assessed to be at risk to aspirate will be fed in the following manner: A. Sitting upright during meals for approximately 30 minutes after meals. B. Feed small bites and cue to swallow if needed. C. Check mouth for food not swallowed.

Based on observation, interview and record review the facility failed to assess a resident for injury in a timely manner following a suspected unwitnessed fall. This failure resulted in R1 not receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This applies to 1 of 3 residents (R1) reviewed for assessment in a sample of 3. The findings include: R1's Unusual Occurrence Report Form dated 3/21/22 states, Resident complained of left leg pain earlier today and [CONDITION(S)] noted to leg and foot. Resident denies falling per Charge Nurse. Portable x-ray showed impacted transcervical fracture of the left femoral neck with no recent fracture or dislocation of the femoral shaft with varus deformity. R1's Final Investigative Report Form states, Resident denies falling. No staff is aware of him falling. According to staff, if resident did have a fall, he would have been able to get up without staff assistance. Resident does have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Probable cause could be fall as a result of possible [CONDITION(S)]. V5's (Corporate Nurse) Summary of R1's Unusual Occurrence Report dated 3/23/22 states, Investigation upon talking to staff that worked with him yesterday revealed no staff with any knowledge of him falling. Staff say that he is able to walk but slowly. Some staff reported that they feel if he did fall and wasn't hurt at the time that he would be able to get himself up. Unable to talk to resident as he is out to the hospital at this time. Staff reports that prior to this, resident did not say or show any signs of pain or injury. Review of progress notes shows a raised area to forehead earlier in the week, but according to staff there was no change in his condition since then. Probable cause is likely an unwitnessed unreported fall. None of the staff had any knowledge of him falling recently. DON stated she investigated the raised area on his forehead which was reported to her by (V2-ADON). (V6-LPN) said she noticed the forehead area upon coming on duty that day. On 4/8/22 at 12:05 PM V2 (Assistant Director of Nursing) stated, Early in the morning the nurse addressed the bump on his head. I looked at it and then I tried to clean it up, but I didn't want to scrub it too much. It looked fresh but there was some dried blood on it right above his left eyebrow. It was pink, tender and there was a little swelling. The nurse that had him said it wasn't there the day before. I reported it to the DON (she resigned about 3 weeks ago). Then about 1 week later his left leg was swollen. I called the doctor and he ordered an x-ray and a doppler and it came back with a fracture. He didn't have any bruising, just the swelling. He could walk independently before that, but he wouldn't walk every day. I reported it to the DON and called the doctor and the doctor said to send him out. On 4/8/22 at 12:30 PM V5 (Corporate Nurse) stated, (V2) notified me of the swelling and pain to (R1's) left leg and that they were sending him out. I don't know the residents here. I was told he usually walks around but no one knew of any falls with him. I talked to a bunch of staff, but I didn't write down all the individual statements. None of them knew anything about what happened. I concluded that it is probable that he fell , and staff said if he fell he would have been able to get himself up. I was made aware of the bump on his head after I started the investigation. On 4/11/22 at 1:30 PM V8 (R1's son) stated, I asked him if he had pain in Russian and he shook his head up and down. When he got the bump on his head, they called me, and I went over there and I was trying to put his pants on and he couldn't stand up. His legs were shaking. I thought, 'what is going on?' and I told the nurse. Then they didn't do anything else. Then when he couldn't walk, they sent him out for the x-ray. There is a stairway across the hall from his room and that door is not locked. He doesn't know up from down and I think he fell on the stairs. R1's Progress Notes dated 3/14/22 state, While observing resident during morning rounds, small red area noted to left forehead. Area cleaned with normal saline and [MEDICATION(S)] applied to area. On 4/8/22 at 2:30 PM V6 (LPN) stated, I came in that morning, and I was doing my rounds. I saw the area on his left forehead was open and reddened. That was not there the day before when I worked. I told (V2) about it. He would usually sit in a chair in his room. That day he was trying to get out of the bed. He used to walk in the halls all the time but then even before this he started to slow down and wouldn't be out walking every day. R1's Progress Notes dated 3/16/22 state, Resident told son, who is visiting that he has leg pain. Resident cannot tell writer that he is in pain due to language barrier. Resident did not grimace or have any facial expressions of pain. Administered Tylenol without any issues will continue to monitor. R1's Progress Notes dated 3/17/22 state, Resident was noted to be moving slow to feed himself and missing his mouth. He was assisted to sit up by the side of the bed and was feed by the writer. Due meds given to time with 650mg Tylenol given for comfort. Shower given and will monitor closely. R1's Progress Notes dated 3/21/22 state, Writer (V2) was made aware that resident was observed with Left leg swelling and [CONDITION(S)] to Left foot, pitting 2+ pale warm to touch, complained of pain to leg over the weekend per son who visited and informed nurse. Writer placed call to (R1's physician) with order for Tylenol 650mg PO (by mouth) q (every) 6 hours as needed, x-ray to left leg and venous doppler. Orders noted and carried out. Resident remains at baseline with periods of confusion due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Progress Notes also dated 3/21/22 state, Per x-ray results resident has a left hip fracture. ADON informed, call placed to (R1's Physician) stated send him to (Local) hospital. Resident is in no apparent pain or discomfort at this time, in bed resting . R1's Radiology Results Report dated 3/22/22 states, Impression Left Hip: Impacted transcervical fracture of the left femoral neck. R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set assessment dated [DATE] shows that R1 requires limited assistance of 1 staff for transfers and walking in his room and in the corridor. R1's Care Plan dated 9/11/21 states, (R1) has an alteration in communication related to Dementia, Speaks Russian. R1's Care Plan dated 9/10/21 also states, (R1) is at risk for falls related to confusion, gait/balance problems, unaware of safety needs . The interventions include: 1/18/22: Monitor/document/report as needed x 72 hours to MD for signs/symptoms: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation R1's Hospital Orthopedic Progress Notes showing dated of 3/23/22 states, Hip fracture, left. Post-Operative Day 1 left hip hemiarthroplasty (half of the hip is replaced). Left leg DVT ([CONDITION(S)])

Based on observations, interviews, and records reviewed the facility failed to provide effective pain treatment for 2 residents (R55 and R58) reviewed for pain in a total sample of 21. The facility also failed to apply [MEDICATION(S)] 5% pain patches and pain medication prescribed by physician. These failures resulted in R55 and R58 complaints of unrelieved and in constant pain. Findings include: Record review for R58 documents a [AGE] year old male admitted to the facility on [DATE]. Minimum Data Sheet (MDS) dated [DATE] section C documents R58's mental status was intact as noted in the Brief Interview for Mental Status (BIMS) score of 14 out of 15. R58 was admitted to the facility on [DATE]. R8's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/22/22 at 11:54 AM R58 states he has pain to both legs. R58's legs were dry and red. V24 (Restorative Aid) stated R58 is always in pain. R58 stated I tell them I'm in Pain and, they don't take me to the doctor. Resident states he has been in pain since he had abdominal surgery and a stroke. Resident showed surveyor his legs and he did not have a pain patch on. R58 has a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/23/22 at 12:12 PM V8 (CNA) stated R58 complains now and then that his feet are sore. V8 states she tells the nurse and R58 makes sounds like he is pain when they are doing things with him. On 2/24/22 at 11:21am V20 (LPN) stated R58 always says he is hurting. He is on [MEDICATION(S)] and they just started him on [MEDICATION(S)]. R58 gets Tylenol for breakthrough pain. R58 says his pain level is 9/10 when he is in pain. On 2/24/2022 at 11:37 AM R58 Stated pain level is 8/10. R58 stated he has not seen a doctor, and nothing they have been giving him helps his pain. I don't know what they give me. They give me medication in the morning and at night. R58 states his left leg from knee to toes hurt and his right leg from right hip to toes hurts constantly. R58 states he tells staff all the time he is pain and that has not told a doctor because he hasn't seen one. There is no pain patch on resident's legs. On 02/25/22 10:06 AM R58 stated he has had pain in his lower legs since abdominal surgery. He believes he lost nerves in his legs. I feel F****ed up that they have not been controlling my pain. I don't curse, but they do me so bad. It makes me curse. I have not had a pain patch in at least 4 days. On 2/25/22 at 10:13 AM V20 (nurse) states R58 said his pain level was 8/10. V20 states she gave R58 [MEDICATION(S)] and [MEDICATION(S)] (anti-[CONDITION(S)]) this morning. V10 (RN) states R58 gets a pain patch, but he does not have any in the drawer. The night shift nurse gives the pain patch to him. Review of R58 progress notes is absent of any primary care physician notes or documentation of a visit with R58. On 02/25/22 at 10:54 AM V3 (DON) stated R58 has never been seen by a primary physician since he has been admitted . Pain Care plan created 1/8/2022 and has not been updated with any new interventions. Facility's Pain management Program documents the following: Purpose: To establish a program which can effectively manage pain in order to remove adverse physiologic and physiologic effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. The purpose of this policy is to accomplish that goal through an effective pain management program. On 2/22/2022 at 9:45am R55 said I spoke with my doctor last week over the phone myself about a stronger pain med, I have two broken ribs. The pain medication that was given to me does not work and she wrote me an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . My pain is about a seven. I don't like getting out the bed, and I feel terrible. The nurse this morning said he will check if my medication came in, but that was about hour ago. On 2/22/22 at 9:55am V5 (Licensed Practical Nurse-LPN) said I am giving R55 his pain medication it just came in. An observation of the pain medication card, date ordered 2/15/2022 and date delivered was 2/20/2022 thirty pills un-opened. V5 said I just saw that the medication was delivered this morning, he didn't complain about any pain to me. When the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the pharmacy is taking a while to send medication the nurses should call and inquire about the medication. On 2/22/22 at 2:30pm V3 (Director of Nursing-DON) said when the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses should follow up and transfer the medication over to the electronic record. A week is a long time for a medication to be delivered from pharmacy. I was not aware that it had been a week. The nurses should follow up and call the pharmacy to see why the medication has not been delivered. On 2/25/2022 at 9:50am V5 said, I did ask the resident about his pain, but I did not chart it, I should have charted the pain assessment when I gave the pain medication. I should be doing a pain assessment every shift or every time I give a pain medication. On 2/25/2022 at 10:10am V3 said it is not acceptable for the nurses not to complete a pain assessment, it should be completed as ordered. On 2/25/2022 at 10:20am V4(Assistant Director of Nursing-ADON) said on 2/18/2022 I spoke with R55 and he complained of not receiving his pain medication, I called the pharmacy and they had not received the prescription. I notified the physician and then the prescription was faxed over to the pharmacy. I did not take the medication out of the emergency supply box because pharmacy was in the process of changing the boxes out. I did not do a pain assessment, and I should have completed one. It's not acceptable for a resident to be in pain at any time. I expect all the nursing staff to assess for pain as ordered. On 25/2022 at 1:06pm V27 (Physiatrist/Pain) I know R55 and I did give him medication for rib pain. The resident did not call me, I do not know who called me. I don't know why it takes so long for the residents to receive their medication. On 2/25/2022 at a record review of the resident's order summary report that indicates R55 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A controlled drug receipt/record/disposition form drug dispensed on 2/20/2022 first dose administered on 2/22/2022 at 10am. There was no pain score until 2/24/22 on the medication administration record-(MAR) on evening shift of 0' and night shift 2. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (1:30 pm). No assessment for pain level on 2/15, 2/16, 2/17, 2/18, 2/19, 2/20, 2/21. A Pain Review (Nursing) dated on 12/26/2021 at 10:13 am section D no pain intensity scale in place. A (Minimum Data Set-MDS) section J , a 1' for pain assessment interview not completed. A care-plan dated for 12/23/2021 Focus-at risk for alteration in pain/comfort related to 8th and 9th rib fractures, Intervention-complete the pain assessment upon admission, re-admission, quarterly and as needed-prn, educate resident and significant other about pain/pain relief measures, administer analgesic medication as ordered per plan of care, offer as needed-prn analgesic medication prior to ADL-activity of daily living, activities/rehabilitation, wound care, as indicated for pain management, notify md-medical doctor for any new resident complaints of pain and/or S/S- signs and symptoms of pain to obtain new order for medication regimen or break0through pain management, focus-fracture if the 8th and 9th left ribs. Problems manifested by impaired mobility, problems manifested by pain upon movement, interventions-monitor and medicate for pain as needed, focus-at risk for altered respiratory status/difficulty breathing related to wheezing, intervention-use pain management as appropriate, monitor/document side effects and effectiveness.

Based on interview and record review the facility 1) failed to conduct a comprehensive assessment and accurately notify the physician of an acute decline of a resident's condition, 2) failed to immediately activate 911 emergency services for an unresponsive resident. This affected 1 of 3 (R1) residents reviewed for provision of care. These failures resulted in delayed treatment and delayed notification emergency transport services being activated for R1 who was transported to the local hospital and required intubation (mechancial respiratory assistance). Findings Include: R1 face facility face sheet shows R1 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 medical transportation report dated 01/11/22 shows in-part, narrative in summary, crew 92 dispatched to (nursing home name) for the unresponsive resident. Requested closest hospital is (hospital name) at 5 minutes. Per dispatch, facility accepted 60-90 minutes ETA, fall the other day, 155/108, 95 p, 18 Rr, 99Ra( room air). Responded immediately code 3, 18 minutes to scene. Upon arrival delay to door due to inability access ramp due to cars in the way on one-way road. We entered facility and waited for the elevator to take us to the second floor, we were directed down the hall to room, where we found the approximately 135 lb (pound) [AGE] year old male in the bed in supine and sleeping. Patient was unresponsive to verbal, eyes opened to sternal rub, no verbal response. Palpable carotid approximately 50, breathing spontaneously unlabored, snoring respirations. Patient's nurse entered room and informed us that since this morning, patient has not been himself. We asked for a last known normal and time for unresponsiveness, unable to obtain, Nurse said she got there today. No DNR paperwork given, unknown code status per paperwork and nurse. ALS assessment performed by paramedic, patient eyes opened to sternal rub, no verbal response, and flex to pain. Airway patent, nurse took a nasal swab for patient prior to our departure. Noted blood on end of swab, snoring respiration. Breathing was spontaneous and non-labored with clear lung sounds and symmetrical chest rise. Radial pulses not present, palpable carotid at a [CONDITION(S)] rate and regular. Skin parameters cool and dry, no pallor or cyanosis. Abdomen soft and non-tender. No JVD, trachea midline. Pupils equal and reactive to light. No signs of trauma on or around head, neck, chest. Patient has no known allergies and a history of [CONDITION(S)], [CONDITION(S)], dementia, [CONDITION(S)], GERD, [CONDITION(S)]. Initial vital signs obtained, 57/41, 50hr, 14R, 87RA, 138BS, 12 lead ECG obtained, sinus [CONDITION(S)] with bigeminal PACs at rate of 44. Patient was moved to stretcher via two man lift and was secured x5 in semi-fowlers. We successfully established 20g IV in patient left forearm WO (wide open). We administered 0.5mg [MEDICATION(S)] IV, heart rate increased to 62. We placed patient on 2LPM via nasal cannula, 93%. Patient was moved to ambulance for transport and continuation of ALS care. Hospital contacted prior to departure, no orders given for intervention. Patient was transported code 3 to hospital, 3 minutes to destination. Patient was continuously monitored while in-route, final vital signs 57/35, 45 HR, 15R, 94%, 3LPM. At destination, we moved patient to ER 6 where care and report were given to Nurse. We returned to ambulance to clean and return to service. No incidents or injuries. All time approximate. End of narrative. DC. R1's run report shows the dispatch was notified at 2:44p.m, the paramedics were on the scene at 3:04p.m and at the patient bedside at 3:09pm, 1.5 hours after V3 said she called for transportation. R1 emergency room records dated 01/11/22 shows diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .m in the emergency room . R1 progress notes dated 1/11/22 at 3:00pm completed by V3 (Nurse), shows in-part resident noted in bed unresponsive but breathing and moving. Attempted to give resident his medication and he refused. Refused to eat breakfast and lunch and DON notified. T 97.8 P 90 R 18 B/P 155/108 O2 sat 99% RA (room air). V4 notified. MD ordered resident to be sent to ER. Ambulance picked up resident via EMTs x2. Rapid Covid test Negative (-). On 1/27/2022 at 11:58am V3 (Nurse) said on 1/11/22 she was the nurse responsible for R1's care. V3 said she got report that morning that R1 was on 72 hour charting post a fall occurrence, and the nurse did not report that R1 had any injuries from the fall. V3 said when she did her morning rounds, just at the start of her shift (7:00AM) R1 was observed resting in bed, her goal was to make sure the resident was breathing and R1 was, and so she finished rounding on the other residents. V3 said around 8 AM/something (unsure of time) she did a set of vitals on R1 because she noticed R1 was not being himself and she wanted to medicate R1. V3 said R1 was just sleeping and R1 was a resident that would have sitting up at the bedside in his wheelchair, would communicate with her, and eat his meals. V3 said R1's blood pressures were running in the 130's, but she's not sure. V3 said she did not document the vitals because R1 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 made an attempt to feed R1, but R1 would hold his lips tight and go back to sleep. V3 said R1 even made a fist at her to get away which was not R1's usual behavior. V3 contacted V4(Physician) and V4 gave orders to send R1 to a local hospital for evaluation. V3 called the ambulance service and they said ETA (estimated time of arrival) of 1 hour. V3 said the ambulance arrived sooner than the time they gave. V3 then said R1 did not eat lunch. Then V3 stated R1 was still at the facility during lunch time. Later V3 said she called the ambulance for transportation after lunch. Asked if V3 completed any other assessments on R1 while she was waiting for the ambulance to arrive? V3 responded she did not complete any other assessments on R1 besides completing a rapid covid test on R1. V3 said there was no one in the room monitoring R1 while awaiting the ambulance service. R1's progress notes were reviewed with V3, V3 stated the vital signs that were documented at 3:00pm were the vital signs that she assessed at 9:40a.m that morning. V3 said she documented everything all together at 3:00pm. V3 said she doesn't remember the time that the physician gave the orders to send R1 to the hospital. V3 said R1 remained very sleepy, but would open his eyes and then close them when his name was called. V3 said she did not give a report to the hospital nurse because in emergency situation the paramedics usually give the hospital the information. V3 said she did give the report when she called the ambulance service and when the EMTs arrived to the facility she informed them that R1 was not himself and very sleepy. V3 said R1 was unresponsive since that morning. V3 stated she did not do any neurological checks on R1, and she doesn't know what R1's code status was on 01/11/22. V3 said she does not remember what she told the physician during the phone call, she just remembers that the physician gave orders to send R1 to the hospital. On 02/01/22 at 10:08a.m, during a follow up interview V3 stated the second set of vitals was taken at 1:45p.m, just before she called the paramedics. V3 checked on R1 several times from 8:30am to 1:45p.m. V3 would go into R1's room to make sure R1 was breathing and check R1's oxygen saturation. V3 did not document any of her observations of R1. V3 stated that a blood pressure of 155/108 was not a normal blood pressure for R1, but R1 was breathing and, he was okay. V3 stated she usually documents everything at the end of the shift, based on her memory of the events. V3 said it was not at 9:40 AM when she contacted the physician, the physician was called around lunch time at 1:45p.m. V3 informed the physician that R1 was not himself, she reviewed the vitals with the physician and the physician said to send R1 to the hospital for evaluation. There were no orders to send R1 out via 911, but V3 understood to send R1 out immediately. V3 said she did not assess R1's vitals again because the paramedics had arrived. V3 said V2 (Director of Nursing) came to the unit to try and feed R1 his lunch. V2 informed V3 to monitor R1, meaning to check R1's vitals and monitor for changes every 5 minutes, she guessed. V3 said she did not complete a full set of vital signs on R1 every 5 minutes, because she did not have time due to the paramedics arriving. V3 said she does not remember reporting to the medical transportation company that R1 was unresponsive. V3's progress note was reviewed with V3, and V3 stated she may have used the term of unresponsive wrong because R1 would open his eyes, and fall back asleep. R1 just would not respond back when she tried to talk to him, and would not eat his food, or take his medication. R1 was not sitting up in bed as he usually does. On 1/28/22 at 2:01p.m V6 CNA (Certified Nursing Assistant) said she was the aide assigned to R1 on 01/11/22. V6 stated R1 was lethargic and she informed the nurse. R1 did not eat breakfast or lunch when she attempted to feed R1. V6 said R1 could not keep his eyes open he would open his eyes, and then fall back to sleep. V6 said she does not usually work with R1 but the times that she was assigned to R1, R1 was the type of resident that would eat all his meals, sit up at the bedside in a wheelchair, and was awake and alert. V6 said she informed the nurse that R1 was not himself. On 01/27/22 at 12:44p.m V2 DON (Director of Nursing) said V3 reported to her that R1 was not himself and would not eat. V2 instructed V3 to call the physician and follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 would open his eyes and then close them. V2 said the physician was notified around lunch time and gave orders to the nurse to send R1 to the hospital for evaluation, and the paramedics arrived around 1:30-2:00pm. V2 said the nurse should use nursing judgement if a resident has a change in condition, and the resident vital signs should be assessed at least every 15 to 30 minutes. The nurse should contact the physician right away when a resident is observed with a change in condition. V2 said she believed R1 was a full code. Request was made to review R1 advance directive for his code status. V2 said R1 did not have an advance directive for his code status. However, when a resident does not have any documentation on file, the facility practice is to treat the resident as a full code which means all life saving measures will be implemented. V2 said a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/1/22 V2 said the nurse has to assess the vitals and monitor the resident's condition in order to determine if the resident is experiencing a decline. V2 said the nurse should do neuro checks, check level of consciousness, mental status, and keep monitoring until paramedics arrive. On 01/28/22 at 10:31a.m V4 (Medical Doctor) stated V3 contacted him and informed him that R1 was not himself, and he gave orders to send R1 to local hospital for evaluation. V4 said no one gave him any detailed information on R1's status. V4 said if he would have known that R1 was presenting in a very sleepy state he would have gave orders for neurological checks while the nurse waited for the ambulance. V4 said he should have been notified immediately when the resident was observed with a change in condition that morning, The nurse should have made an assessment, using nursing judgement and assessed vital signs as appropriate. V4 said a resident that is found to be unresponsive should be sent out 911. On 01/28/22 at 10:19a.m V5 (EMT) said he received the call that R1 was unresponsive. V5 said an unresponsive patient is an emergent situation and that's why they arrived before the hour ETA (expected time of arrival) given. V5 said when they arrived at the facility the nurse said R1 had been like this since this morning, V5 said R1 was observed in the bed, and unresponsive to verbal stimuli. R1 was not able to track with his eyes, R1 was snoring, would open his eyes but then close them. V5 said when he assessed R1's vital signs R1's blood pressure was 57/41, heart rate was 50, respiration was 14, and oxygen saturation level was 87% on room air. R1 was not wearing any oxygen when V5 arrived on the scene. Review of R1's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's progress notes, vital sign assessments were not documented except for the 3:00p.m vital signs. Facility policy Titled Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Any orders given by physician are carried out. The nurse should not hesitate to contact physician at any time for problems with orders or needed clarifications. Facility policy Titled Neurological assessment dated ,d+[DATE] shows in-part, residents will have neurological assessment completed when they have experience a head injury or a change in condition that deems it necessary or per physician order. Neurological assessments will be completed upon a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observe, assess and document the resident level of consciousness, speech, pupils, and hand grasp and vital signs. Unless otherwise ordered by the physician, neuro checks will be completed along the following schedule: Q (every) 15 minutes times 1 hour, Q30 minutes x2 hours, Q4 hours x 24 hours and then Q shift x 48 hours. Facility policy Tilted Change in condition physician notification overview guidelines dated 04/14 shows in-part, these guidelines were developed to ensure that all significant changes in resident stats are thoroughly assessed and physician notification is based on assessment findings and is to be documented in the medical records. Medical care emergency problems are communicated to attending physician and family immediately (generally within 2 hours or sooner). The nurse should not hesitate to contact the attending physician at any time for a problem which in his or her judgement requires immediate medical interventions. When contacting the physician the nurse in charge should have the following information and medical record available: age and sex, nature of problem or complaint with symptoms, signs, and results of current physical assessment, including vital signs and mental status, onset, duration of problems/illness, primary and active diagnoses, review of recent hospitalization , current medications.

Based on interview and record review the facility failed to monitor the a resident with a declining change in condition this affected 1 of 3 (R1) residents reviewed for monitoring a acute change in condition. This failure resulted in R1's change in condition not accurately & timely addressed. R1 was found to be unresponsive and R1 was transported to the local hospital and was intubated. Findings Include: R1 face facility face sheet shows R1 has diagnosis of [CONDITION(S)], [CONDITION(S)], hypertensive heart disease, dysphagia, acute kidney failure, mental and behavior disorders, [CONDITION(S)] heart disease, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], hypercalcemia, dementia, [CONDITION(S)], Parkinson disease, [CONDITION(S)], cerebral infraction, gerd, [CONDITION(S)], calculus of kidney, [CONDITION(S)], [CONDITION(S)], abnormal weight loss, vitamin D deficiency, contusion of knee, solitary pulmonary nodule, unspecified head injury, fracture nasal bones, unspecified fall. R1 medical transportation report dated 01/11/22 shows in-part, narrative in summary, crew 92 dispatched to ( nursing home name) for the unresponsive. Request and closet hospital is (hospital name) at 5 minutes. Per dispatch, facility accepted 60-90 minutes ETA, fall the other day, 155/108, 95 p, 18 Rr, 99Ra(room air). Responded immediately code 3, 18 minutes to scene. Upon arrival delay to door due to inability access ramp due to cars in the way on one-way road. We entered facility and waited for the elevator to take us to the second floor, we were directed down the hall to room, where we found the approximately 135 lb (pound) [AGE] year old male in the bed in supine and sleeping. Patient was unresponsive to verbal, eyes opened to sternal rub, no verbal response. Palpable carotid approximately 50, breathing spontaneously unlabored, snoring respirations. Patient nurse entered room and informed us that since this morning, patient has not been himself. We asked for a last known normal and time for unresponsiveness, unable to obtain, Nurse said she got there today. No DNR paperwork given, unknown code status per paperwork and nurse. ALS assessment performed by paramedic, patient eyes opened to sternal rub, no verbal response, and flex to pain. Airway patent, nurse took a nasal swab for patient prior to our departure. Noted blood on end of swab, snoring respiration. Breathing was spontaneous and non-labored with clear lung sounds and symmetrical chest rise. Radial pulses not present, palpable carotid at a [CONDITION(S)] rate and regular. Skin parameters cool and dry, no pallor or cyanosis. Abdomen soft and non-tender. No JVD, trachea midline. Pupils equal and reactive to light. No signs of trauma on or around head, neck, chest. Patient has no known allergies and a history of [CONDITION(S)], [CONDITION(S)], dementia, [CONDITION(S)], GERD, [CONDITION(S)]. Initial vital signs obtained, 57/41, 50hr, 14R, 87RA, 138BS, 12 lead ECG obtained, sinus [CONDITION(S)] with bigeminal PACs at rate of 44. Patient was moved to stretcher via two man lift and was secured x5 in semi-fowlers. We successfully established 20g IV in patient left forearm WO. We administered 0.5mg [MEDICATION(S)] IV, heart rate increased to 62. We placed patient on 2LPM via nasal cannula, 93%. Patient was moved to ambulance for transport and continuation of ALS care. Hospital contacted prior to departure, no orders given for intervention. Patient was transported code 3 to hospital, 3 minutes to destination. Patient was continuously monitored while in-route, final vital signs 57/35, 45 HR, 15R, 94%, 3LPM. At destination, we moved patient to ER 6 where care and report were given to Nurse. We returned to ambulance to clean and return to service. No incidents or injuries. All time approximate. End of narrative. R1's run report shows the dispatch was notified at 2:44p.m, the paramedics was on the scene at 3:04p.m and at the patient at 3:09pm, 1.5 hours after V3 said she called for transportation. R1 emergency room records dated 01/11/22 shows diagnosis unresponsive, [CONDITION(S)] and hypothermia, R1 was intubated at 4:44p.m in the emergency room . R1 progress notes dated 1/11/22 at 3:00pm completed by V3, shows in-part resident noted in bed unresponsive but breathing and moving. Attempted to give resident his medication and he refused. Refused to eat breakfast and lunch and DON notified. T 97.8 P 90 R 18 B/P 155/108 O2 sat 99% RA. V4 notified. MD ordered resident to be sent to ER. Ambulance picked up resident via EMTs x2. Rapid Covid test Negative (-). On 1/27/2022 at 11:58am V3 (Nurse) said on 1/11/22 she was the nurse responsible for R1's care. V3 said she got report that morning that R1 was on 72 hour charting post a fall occurrence, and the nurse did not report that R1 had any injuries from the fall. V3 said when she did her morning rounds, just at the start of her shift (7:00AM) R1 was observed resting in bed, her goal was to make sure the resident was breathing and R1 was, and so she finished rounding on the other residents. V3 said around 8 AM/something (unsure of time) she did a set of vitals on R1 because she noticed R1 was not being himself and she wanted to medicate R1. V3 said R1 was just sleeping and R1 was a resident that would have sitting up at the bedside in his wheelchair, would communicate with her, and eat his meals. V3 said R1's blood pressures were running in the 130's, but she's not sure. V3 said she did not document the vitals because R1 did not have an order for vital sign assessment. V3 stated around 9:40am the aide reported to her that R1 was not eating his breakfast, and the tray was just sitting at the bedside. V3 made an attempt to feed R1, but R1 would hold his lips tight and go back to sleep. V3 said R1 even made a fist at her to get away which was not R1's usual behavior. V3 contacted V4(Physician) and V4 gave orders to send R1 to a local hospital for evaluation. V3 called the ambulance service and they said ETA (estimated time of arrival) of 1 hour. V3 said the ambulance arrived sooner than the time they gave. V3 then said R1 did not eat lunch. Then V3 stated R1 was still at the facility during lunch time. Later V3 said she called the ambulance for transportation after lunch. Asked if V3 completed any other assessments on R1 while she was waiting for the ambulance to arrive? V3 responded she did not complete any other assessments on R1 besides completing a rapid covid test on R1. V3 said there was no one in the room monitoring R1 while awaiting the ambulance service. R1's progress notes were reviewed with V3, V3 stated the vital signs that were documented at 3:00pm were the vital signs that she assessed at 9:40a.m that morning. V3 said she documented everything all together at 3:00pm. V3 said she doesn't remember the time that the physician gave the orders to send R1 to the hospital. V3 said R1 remained very sleepy, but would open his eyes and then close them when his name was called. V3 said she did not give a report to the hospital nurse because in emergency situation the paramedics usually give the hospital the information. V3 said she did give the report when she called the ambulance service and when the EMTs arrived to the facility she informed them that R1 was not himself and very sleepy. V3 said R1 was unresponsive since that morning. V3 stated she did not do any neurological checks on R1, and she doesn't know what R1's code status was on 01/11/22. V3 said she does not remember what she told the physician during the phone call, she just remembers that the physician gave orders to send R1 to the hospital. On 02/01/22 at 10:08a.m, during a follow up interview V3 stated the second set of vitals was taken at 1:45p.m, just before she called the paramedics. V3 checked on R1 several times from 8:30am to 1:45p.m. V3 would go into R1's room to make sure R1 was breathing and check R1's oxygen saturation. V3 did not document any of her observations of R1. V3 stated that a blood pressure of 155/108 was not a normal blood pressure for R1, but R1 was breathing and, he was okay. V3 stated she usually documents everything at the end of the shift, based on her memory of the events. V3 said it was not at 9:40 AM when she contacted the physician, the physician was called around lunch time at 1:45p.m. V3 informed the physician that R1 was not himself, she reviewed the vitals with the physician and the physician said to send R1 to the hospital for evaluation. There were no orders to send R1 out via 911, but V3 understood to send R1 out immediately. V3 said she did not assess R1's vitals again because the paramedics had arrived. V3 said V2 (Director of Nursing) came to the unit to try and feed R1 his lunch. V2 informed V3 to monitor R1, meaning to check R1's vitals and monitor for changes every 5 minutes, she guessed. V3 said she did not complete a full set of vital signs on R1 every 5 minutes, because she did not have time due to the paramedics arriving. V3 said she does not remember reporting to the medical transportation company that R1 was unresponsive. V3's progress note was reviewed with V3, and V3 stated she may have used the term of unresponsive wrong because R1 would open his eyes, and fall back asleep. R1 just would not respond back when she tried to talk to him, and would not eat his food, or take his medication. R1 was not sitting up in bed as he usually does. On 1/28/22 at 2:01p.m V6 CNA (Certified Nursing Assistant) said she was the aide assigned to R1 on 01/11/22. V6 stated R1 was lethargic and she informed the nurse. R1 did not eat breakfast or lunch when she attempted to feed R1. V6 said R1 could not keep his eyes open he would open his eyes, and then fall back to sleep. V6 said she does not usually work with R1 but the times that she was assigned to R1, R1 was the type of resident that would eat all his meals, sit up at the bedside in a wheelchair, and was awake and alert. V6 said she informed the nurse that R1 was not himself. On 01/27/22 at 12:44p.m V2 DON (Director of Nursing) said V3 reported to her that R1 was not himself and would not eat. V2 instructed V3 to call the physician and follow the physician's orders. V2 said she went to R1's room and tried to feed R1, and R1 would hold his mouth tight and not take the food. R1 would open his eyes and then close them. V2 said the physician was notified around lunch time and gave orders to the nurse to send R1 to the hospital for evaluation, and the paramedics arrived around 1:30-2:00pm. V2 said the nurse should use nursing judgement if a resident has a change in condition, and the resident vital signs should be assessed at least every 15 to 30 minutes. The nurse should contact the physician right away when a resident is observed with a change in condition. V2 said she believed R1 was a full code. Request was made to review R1 advance directive for his code status. V2 said R1 did not have an advance directive for his code status. However, when a resident does not have any documentation on file, the facility practice is to treat the resident as a full code which means all life saving measures will be implemented. V2 said a physician order should be carried out right away when a resident has a change in condition. On 2/1/22 V2 said the nurse has to assess the vitals and monitor the resident's condition in order to determine if the resident is experiencing a decline. V2 said the nurse should do neuro checks, check level of consciousness, mental status, and keep monitoring until paramedics arrive. On 01/28/22 at 10:31a.m V4 (Medical Doctor) stated V3 contacted him and informed him that R1 was not himself, and he gave orders to send R1 to local hospital for evaluation. V4 said no one gave him any detailed information on R1's status. V4 said if he would have known that R1 was presenting in a very sleepy state he would have gave orders for neurological checks while the nurse waited for the ambulance. V4 said he should have been notified immediately when the resident was observed with a change in condition that morning, The nurse should have made an assessment, using nursing judgement and assessed vital signs as appropriate. V4 said a resident that is found to be unresponsive should be sent out 911. On 01/28/22 at 10:19a.m V5 (EMT) said he received the call that R1 was unresponsive. V5 said an unresponsive patient is an emergent situation and that's why they arrived before the hour ETA (expected time of arrival) given. V5 said when they arrived at the facility the nurse said R1 had been like this since this morning, V5 said R1 was observed in the bed, and unresponsive to verbal stimuli. R1 was not able to track with his eyes, R1 was snoring, would open his eyes but then close them. V5 said when he assessed R1's vital signs R1's blood pressure was 57/41, heart rate was 50, respiration was 14, and oxygen saturation level was 87% on room air. R1 was not wearing any oxygen when V5 arrived on the scene. Review of R1's POS (Physician Order Sheet) dated 01/11/22, there was no documented code status. Review of R1's progress notes, vital sign assessments were not documented except for the 3:00p.m vital signs. Facility policy Titled Physician Orders dated 6/2017 shows in-part, these guidelines are to ensure that changes in residents status/condition are assessed and physician notification is based on assessment findings and is to be documented in the medical records. Any orders given by physician are carried out. The nurse should not hesitate to contact physician at any time for problems with orders or needed clarifications. Facility policy Titled Neurological assessment dated ,d+[DATE] shows in-part, residents will have neurological assessment completed when they have experience a head injury or a change in condition that deems it necessary or per physician order. Neurological assessments will be completed upon a physician order when indicated for a change of residents' condition, after all head injuries and when nursing judgement deems necessary. Observe, assess and document the resident level of consciousness, speech, pupils, and hand grasp and vital signs. Unless otherwise ordered by the physician, neuro checks will be completed along the following schedule: Q (every) 15 minutes times 1 hour, Q30 minutes x2 hours, Q4 hours x 24 hours and then Q shift x 48 hours. Facility policy Tilted Change in condition physician notification overview guidelines dated 04/14 shows in-part, these guidelines were developed to ensure that all significant changes in resident stats are thoroughly assessed and physician notification is based on assessment findings and is to be documented in the medical records. Medical care emergency problems are communicated to attending physician and family immediately (generally within 2 hours or sooner). The nurse should not hesitate to contact the attending physician at any time for a problem which in his or her judgement requires immediate medical interventions. When contacting the physician the nurse in charge should have the following information and medical record available: age and sex, nature of problem or complaint with symptoms, signs, and results of current physical assessment, including vital signs and mental status, onset, duration of problems/illness, primary and active diagnoses, review of recent hospitalization , current medications. On 01/27/22 at 12:44p.m V2 DON (Director of Nursing) said V3 reported to her that R1 was not himself and would not eat, V2 said she instructed V2 to call the physician and follow the physician orders. V2 said she went to R1's room and tried to feed R1 and R1 would hold his mouth tight and not take the food. V2 said R1 would open his eyes and then close them back, R1 was very sleepy. V2 said the physician was notified around lunch time and gave orders to the nurse to send R1 to the hospital for evaluation. V2 said she instructed V3 to contact the physician around lunch time, and the paramedics came around 1:30-2:00pm. V2 said the nurse should use nursing judgement if a resident has a change in condition. V2 said the resident vital signs should be assessed at least every 15 to 30 minutes. V2 said the nurse should contact the physician right away when a resident is observed with a change in condition. On 01/28/22 at 10:31a.m V4 (Medical Doctor) said V2 contact him and informed him that R1 was not himself, and he gave orders to send R1 to local hospital for evaluation. V4 said no one gave him any detail information on R1 status, V4 said if he would have known that R1 was presenting in a very sleepy state he would have gave orders for neurological checks while the nurse wait for the ambulance, V4 said he should have been notified immediately when the resident was observed with a change in condition that morning, V4 said the nurse should have made an assessment, using nursing judgement and assessed vital signs as appropriately. V4 said a resident that is found to be unresponsive should be sent out 911. On 01/28/22 at 10:19a.m V5 (EMT) said he received the call that R1 was unresponsive, V5 said an unresponsive patient is an emergent situation and that's why they arrived before the hour ETA (expected time of arrival) given. V5 said when they arrive to the facility the nurse said R1 had been like this since this morning, V5 said he observed R1 was observed in the bed, R1 was unresponsive to verbal stimuli, R1 was not responding to any stimuli, R1 was not able to track with his eyes, V5 said R1 was snoring, R1 would open his eyes but then close them back. V5 said when he assessed R1 vitals R1 Blood pressure was observed to be 57/41, heart rate was 50, respiration was 14, and oxygen saturation level was 87% room air, V5 said R1 did not have on any oxygen when he arrived to the facility. On 01/27/22 at 12:44p.m V2 DON (Director of Nursing) said on 11/11/22 the nurse informed her that R1 was not himself and that he would not eat his food. V2 said she informed the nurse to call the physician and do whatever the physician tell you to do. V2 said she went to the unit and tried to give R1 some water and food also, and R1 would just open his eyes then close then back, and that R1 would [NAME] his lips. V2 said she believe R1 was a full code. Request was made to review R1 advance directives for his code status. V2 said R1 did not have an advance directives for his code status, however when a resident does not have any documentation on file, the facility practice is to treat the resident s a full code which means all life saving measure will be implemented. V2 said a physician order should be carried out right away when a resident has a change in condition. Review of R1 POS (Physician Order Sheet dated as of 01/11/22, there were no documented code status for R1. Review of R1 progress notes, there were no other vital sign assessments, documented for R1 on 1/11/22 besides the 3:00p.m documented vitals. Facility policy Titled Physician Orders dated 6/2017 shows in-part, these guidelines are to ensure that changes in residents status/condition are assessed and physician notification is based on assessment findings and is to be documented in the medical records. Any orders given by physician are carried out. The nurse should not hesitate to contact physician at any time for problems with orders or needed clarifications. Facility policy Titled Neurological assessment dated ,d+[DATE] shows in-part, residents will have neurological assessment completed when they have experience a head injury or a change in condition that deems it necessary or per physician order. Neurological assessments will be completed upon a physician order when indicated for a change of residents' condition, after all head injuries and when nursing judgement deems necessary. Observe, assess and document the resident level of consciousness, speech, pupils, and hand grasp and vital signs. Unless otherwise ordered by the physician, neuro checks will be completed along the following schedule: Q (every) 15 minutes times 1 hour, Q30 minutes x2 hours, Q4 hours x 24 hours and then Q shift x 48 hours. Facility policy Tilted Change in condition physician notification overview guidelines dated 04/14 shows in-part, these guidelines were developed to ensure that all significant changes in resident stats are thoroughly assessed and physician notification is based on assessment findings and is to be documented in the medical records. Medical care emergency problems are communicated to attending physician and family immediately (generally within 2 hours or sooner). The nurse should not hesitate to contact the attending physician at any time for a problem which in his or her judgement requires immediate medical interventions. When contacting the physician the nurse in charge should have the following information and medical record available: age and sex, nature of problem or complaint with symptoms, signs, and results of current physical assessment, including vital signs and mental status, onset, duration of problems/illness, primary and active diagnoses, review of recent hospitalization , current medications.

This deficiency resulted in two deficient practice statements: 1. Based on the coronavirus global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-,[DATE] revised on [DATE] and QSO-,[DATE]-NH dated [DATE], Nursing Home guidance from the Centers for Disease Control (CDC) and observation, interview and record review the facility failed to follow appropriate standard and transmission based infection control practices to prevent spread of COVID 19 for three (R1, R2, and R3) of three residents exposed to COVID 19 positive residents in the sample of five. These failures resulted in an Immediate Jeopardy to the health and safety of all residents in the facility. The IJ began on [DATE] at 4:20pm when the Social Service Designee (SSD) was observed to deliver R1's lunch tray to his room without proper PPE (Personal Protective Equipment). R1 was currently on standard and transmission based precaution. The SSD only had a mask and gloves on. The SSD was also observed to remove her gloves inside R1's room without performing hand hygiene, exited the room and donned a new pair of gloves outside R1's room. Shortly thereafter, Nurse Aide1 (NA1) was observed to enter R1's room with R2's (roommate of R1) lunch tray without PPE. NA1 only had a mask and gloves on. The facility had 10 residents positive for COVID-19 that were currently hospitalized and was located in a county with sustained community transmission, with many active COVID-19 cases and deaths. Findings include: According to the Centers for Disease Control and Prevention (CDC), Given the high risk of spread once COVID-19 enters a nursing home, facilities must take immediate action to protect residents, families, and healthcare personnel (HCP) from severe infections, hospitalization s, and death .Recent experience with outbreaks in nursing homes has also reinforced that residents with COVID-19 may not report typical symptoms such as fever or respiratory symptoms; some may not report any symptoms. Unrecognized asymptomatic and pre-symptomatic infections likely contribute to transmission in these settings .In addition to the actions described above, these are things facilities should do when there are COVID-19 cases in their facility or sustained transmission in the community. Healthcare Personnel Monitoring and Restrictions: Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is identified in the facility; this should also be considered when there is sustained transmission in the community . On [DATE] at approximately 10:30am, during the entrance conference with the Administrator and the Director of Nursing (DON), both were asked whether the facility had confirmed cases of COVID-19. The Administrator answered, Yes, we have 10 residents who tested positive for COVID-19 but they're in the hospital now. When asked if they have residents currently on isolation, the DON responded, Yes, we have few residents on isolation and most were roommates of the residents who tested positive for COVID-19. The DON explained, We put them on contact and droplet precautions that's why you see those isolation cart set-up outside their rooms. When asked about the facility's personal protective equipment inventory, the Administrator replied, We do not have problems with our inventory. We are fully stocked. During a tour with E2 at 4:30pm in the facility's Central Supply room. E2 stated, Look these are our gowns, masks and gloves over there (while pointing to a stack of boxes) I told you we are good. 1. Review of R3's electronic health record (EHR) revealed R3 (age 73) had [DIAGNOSES REDACTED]. R3 was on standard and transmission based precaution after she was exposed to her roommate (R5) who was diagnosed with [REDACTED]. Review of R5's EHR revealed R5 (age 65) had [DIAGNOSES REDACTED]. Further review of R5's EHR under Progress Notes revealed R5 was transferred to the hospital on [DATE] via ambulance wherein she was tested positive for COVID-19. On [DATE] at approximately 11:20am, E1 was observed exiting R3's room with gloves and mask on. E1 failed to remove his gloves upon exiting R3's room. E1 then proceeded to the housekeeper's cart in the hallway where he discarded the soiled gloves. Review of R3's Nursing Progress Notes dated [DATE] 15:59pm, revealed, Note text: Resident received in bed .observed experiencing dyspnea and confusion. Lungs were congested with sounds of wheezes. Writer assessed resident. vitals were ,[DATE] (blood pressure), 48% (oxygen saturation), 152bpm (beats per minute), 53rr (respiratory rate), 97.5 (tempearture) .immediately call 911 .upon arrival 911 refused to come into the facility stating that we had to bring the bed ridden resident down in a wheelchair ot in her bed. they also stated that they did not wish to come inside because they would have to put all of their gear on just to come inside. despite the emergent situation, 911 remained in the lobby forcing writing and other assisting staff members to have to bring her down in her bed .Resident was admitted to ICU (Intensive Care Unit) . Review of an email correspondence from the DIrector of Clinical Services (DCS) dated [DATE] 1:06pm indicated, .Today the Village Fire Chief notified us that resident (R3) was retested later and tested positive (COVID19). Hospital did not notify us of this. We are trying to verify . Review of an email correspondence from the Administrator dated Friday, [DATE] 2:19pm revealed, Resident is now deceased . Review of an email correspondence dated [DATE] 2:22pm from the DCS indicated, She (R3) expired same day she was taken to hospital. R3's hospital records were requested from the facility. There were no hospital records received prior to the survey's exit. 2. Review of R1's electronic medical record (EHR) revealed R1 (age 97) was admitted to the facility with [DIAGNOSES REDACTED]. R1 was moved to room ,[DATE] when his roommate R4 tested positive for COVID-19 and was transferred to the hospital. R1 then was placed on droplet precautions. Review of R4's (age 68) EHR revealed R4 had [DIAGNOSES REDACTED]. Further review of R4's EHR under Progress Notes revealed, XXX[DATE] .at approximately 1200 CNA (Certified Nurse Assistant)reported that resident was not acting himself. Writer went in to access. Resident was very confused, not able to follow simple commands, and had a constant shaking. Resident's vitals were as follows ,[DATE] (blood pressure), 100 (pulse rate), 22 (respiratory rate), 84% (oxygen saturation) RA (room air), 99.3 (temperature). Writer applied 2L O2 NC (2 liters of oxygen per nasal canula). O2 went up to 95. MD (name of physician) paged at 1215 . Review of the facility's list titled Residents tested COVID and Presumptive dated [DATE] provided by the facility revealed R4 was tested positive for COVID19 on [DATE] and was currently hospitalized . Review of an email correspondence with the Administrator on [DATE] at 1:32pm revealed R4 shared a room with R1 and R2 prior to his transfer to the hospital. On [DATE] at 12:10pm, the Social Service Designee (SSD) was observed delivering R1's lunch tray (R1 was on standard and transmission based precaution) to his room. The SSD did not have an isolation gown, only had her gloves and mask on. While inside the room, the SSD was observed to reposition R1's over bed table next to his bed. R1 did not have a mask on (for source control). On her way out the SSD removed her gloves and exited R1's room without performing hand hygiene. The SSD then retrieved a new pair of gloves from the infection control cart outside R1's room. The cart was observed to be fully stocked with PPEs (masks, isolation gowns and gloves). 3. Review of R2's EHR revealed R2 (age 66) had [DIAGNOSES REDACTED]. R2 was moved into room [ROOM NUMBER] and was on standard and transmission based precaution after he was exposed to his former roommate (R4) who tested positive for COVID-19 and was currently in the hospital. On [DATE] at approximately 12:15pm, Nurse Aide1 (NA1) was observed to deliver R2's (R1's roommate) lunch tray. NA1 only had her mask and gloves on. NA1 repositioned the over bed table while touching R2's bed and curtain in the process. R2 did not have a mask on (for source control). The Director of Nursing (DON) who observed the occurrence immediately asked NA1, Why are you not wearing an isolation gown? NA1 responded, I thought we are only using isolation gowns during resident cares. The DON replied to NA1 that staff should don complete PPE including gown when entering an isolation room especially when there were identified positive cases in the facility. On [DATE] at approximately 1:05pm, the DON was asked about the observations. The DON confirmed staff should have donned mask, gown, and gloves before entering the room even if they were only passing trays. The DON was asked about the isolation signage on the door. The DON went out of the conference room and viewed the isolation signage posted outside the rooms. The signage was only for droplet precaution. The DON stated, Honestly, this is the first time I've seen this. This is not the same signage we had yesterday. It should be for both. When asked what she meant by both. The DON explained, It's for contact and droplet. The DON continued, Regardless, staff should don complete PPE (mask, gown, gloves) when entering isolation rooms and that included wearing a gown. That's why we have the isolation cart set up right outside. When asked about the lack of hand hygiene in between glove changes, the DON confirmed the SSD should have performed handwashing or used alcohol gel prior to exiting the room and before donning a new pair of gloves. On [DATE] at approximately 3:30pm, the DON stated It's different if we have shortage of PPE but we do not- so no excuse at all (referring to staff not using the isolation gowns). On [DATE] at approximately 12:05pm, NA2 was observed delivering a lunch tray inside room [ROOM NUMBER] an isolation room. NA2 had a gown and mask on but did not have gloves. In addition, NA2 exited the room without first removing his isolation gown. When asked whether he had training about proper PPE usage, NA2 stated that he had attended one last week. When asked why he did not have gloves on and why he did not remove his isolation gown prior to exiting the R2's room, NA2 did not provide an answer. When asked if he followed the proper use of PPE when entering and exiting an isolation room, NA2 just shook his head and walked towards 1 pavilion's nurse's station. On [DATE] at approximately 12:20pm the Director of Clinical Services (DCS) was informed of the observation. The DCS stated, They just have (sic) their training and there's a sign posted on the door as guide. The DCS verbalized that not using the available PPE defeated the purpose of having a fully stocked isolation cart set up outside the isolation rooms. On [DATE] at approximately 12:50pm during unit observations with the RNC the following were observed: A. On the second floor NA3 and NA4 were observed standing next to each other in front of the dining cart. Both failed to observe the six feet social distancing recommendations. B. On the second floor a dietary aide (DA) was observed in the hallway carrying two plates of food with only his mask and gloves on. The DCS stopped the DA and asked the DA why he was not wearing his gown per their protocol. After the dialogue with the dietary aide, the DCS verbalized, They've been in-serviced and reminded. C. On the first floor E3 was observed to remove her isolation gown right in the hallway and placed the used gown on top of the isolation set up cart. E3 then took a new gown from the isolation cart and donned a new gown. The RNC stopped E3. E3 then asked the RNC what was the concern. The DCS explained to E3 the proper sequence in donning and doffing PPEs. Review of the facility's [MEDICAL CONDITION] Policy revised on [DATE] revealed under Policy: This policy is to educate, prevent, identify and treat the Coronavirus .Coronavirus in humans can cause the common cold and range to severe respiratory infections even leading to death. Symptoms: Generally manifest within ,[DATE] days after being infected .Signs/symptoms of lower respiratory illnesses: Fever, Cough, Shortness of Breath, Sometimes Pneumonia and [MEDICAL CONDITION] .Respiratory germs prevention spread WITHIN your facility: Make sure PPE, including gowns, gloves, masks, eye protection are available immediately outside door. Review of the facility's Infection Control policy dated ,[DATE] under Standards revealed, .14. All facility personnel are required to routinely wash hands and use appropriate barrier precautions to prevent transmission of infections. 15. All facility personnel shall adhere to the Infection Control Program in the performance of their daily assignments. Employees disregarding the facility's policies and procedures shall be retrained as necessary, disciplined, and may be discharged for repeated non-compliance. 16. The facility shall assure that necessary training, equipment and supplies are maintained to carry out an effective Infection Control Program. 17. The facility shall inform the public of the IL State Department of Health's Universal Precautions Rule by posting same in a location accessible to the public, residents and staff. The notice shall also be included in the resident admission informational packet. 18. Handwashing is essential. Alcohol based hand rubs/gels is the Gold Standard of Prevention. 19. Contact precautions in addition to standard precautions will be initiated as specified in the specific isolate policy . Based on the CMS QSO ,[DATE]-NH dated [DATE] revealed under Guidance fo limiting the transmission of COVID-19 for Nursing Homes .1. Cancel communal dining and all group activities, such as internal and external group activities .3. Remind residents to practice social distancing and perform frequent hand hygiene. Review of an article from CDC (Centers for Disease Control) revealed under In addition to the actions described above, these are things facilities should do when there are COVID-19 cases in their facility or sustained transmission in the community .these are things facilities should do when there are COVID-19 cases in their facility or sustained transmission in the community . Resident Monitoring and Restrictions: Encourage residents to remain in their room. If there are cases in the facility, restrict residents (to the extent possible) to their rooms except for medically necessary purposes . If they leave their room they should wear a cloth face covering or facemask, perform hand hygiene, limit their movement in the facility, and perform social distancing (stay at least 6 feet away from others) . Remind residents to practice social distancing and perform frequent hand hygiene . Educate residents and families including, information about COVID-19; actions the facility is taking to protect them and/or their loved ones, including visitor restrictions; and actions they can take to protect themselves in the facility, emphasizing the importance of social distancing, hand hygiene, respiratory hygiene and cough etiquette, and wearing a cloth face covering . https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fprevent-spread-in-long-term-care-facilities.html#cases-in-community In addition under Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings dated [DATE] reveaeld under Recommendations .2. Adhere to Standard and Transmission-Based Precautions .Personal Protective Equipment .The PPE recommended when caring for a patient with known or suspected COVID-19 includes: Respirator or Facemask (Cloth face coverings are NOT PPE and should not be worn for the care of patients with known or suspected COVID-19 or other situations where a respirator or facemask is warranted) Eye Protection - Put on eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use or reuse strategies to optimize PPE supply. Gloves - Put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene. Gowns - Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use . https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html The immediacy was removed on [DATE] at 4:41pm when the facility implemented the following: 1. The facility re-educated all staff on general infection control with emphasis on proper PPE use, accurate donning and doffing procedure and hand hygiene in between gloving. 2. Revised and replaced isolation door signage as appropriate 3. Revised its plan for staffs' gown distribution 4. Assigned the DON to be ultimately responsible in the close monitoring of staff in the first floor and the ADON in the second floor to ensure direct care staff followed appropriate PPE protocol 5. Both the DON and the Administrator will consistently monitor new memorandum and guidelines daily from CDC, DHHS and CMS and disseminate the information timely as needed. 2. Based on the unprecedented coronavirus global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-,[DATE]-NH revised on [DATE], Nursing Home guidance from the Centers for Disease Control (CDC), interview and record review, the facility failed to 1) establish a facility-wide Infection Control Prevention Program including standards, policies and procedures that are current and based on national standards; 2) develop and implement measures to contain the possible spread of COVID-19, as evidenced by failures to establish a facility-wide surveillance plan that used evidenced-based surveillance criteria to define infections, appropriately track and analyze resident infections to recognize possible trends or outbreaks; and 3) monitor for signs and symptoms to prevent the development of COVID-19 for four residents (R6, R7, R8, and R9) reviewed for infection control. These failures had the potential to affect all 97 residents in the facility. Findings include: Review of the facility's List of residents who tested positive (for COVID-19) provided by the Administrator via email on [DATE] at 12:34pm revealed that the facility had 10 residents who were hospitalized with COVID-19 and 19 residents as PUI (Person Under Investigation) or considered under the presumptive case. A. Review of the facility's Infection Control Summary dated February 2020 revealed that the facility had a census of 119, admitted with two residents with infections, six nosocomial infections, and had an infection rate of 2.3%. There were no additional surveillance logs provided by the facility other than the February 2020 Infection Control Summary. Interview with the DCS (Director of Clinical Services) on [DATE] at 12:24pm, when requested for the Infection Control Surveillance for January, March, and [DATE], the DCS indicated that she will check the DON (Director of Nursing) and ADON (Assistant Director of Nursing) computers and later revealed This is all (referring to the February 2020 Infection Control Summary) I found. I spoke with Nurses on units too and they don't remember anyone else being on isolation this year. In a follow-up interview with the DCS on [DATE] at 9:07am, the DCS stated that the ADON (Assistant Director of Nursing) was responsible in tracking infections and her DON (Director of Nursing) who started this month was doing it, and April is not even done yet. It is usually a month later when it gets to the QA. When asked if the facility had a working and ongoing surveillance tracking and trending, the DCS indicated I cannot answer that because I am not in the facility. I did not find anything. In the same interview when the DCS was asked about the facility's Infection Report and Surveillance Procedures that included the policies and procedures dated [DATE], the DCS confirmed that this was the current policy. Review of the facility's Infection Control Policy dated [DATE] revealed Purpose: To establish methods and criteria, necessary within the facility and its operation, to prevent and control infections and communicable diseases .Policy: It is the policy of 'this facility to maintain an infection control program designed to provide a safe, sanitary and comfortable environment, and to prevent or eliminate when possible the development and transmission of disease and infection .Standards .6. All infection control policies and procedures will be reviewed annually by the Quality Assurance Committee and revised as needed. Department Heads are responsible for assuring personnel are made aware of all revisions to respective policies and procedures .7. The program provides for the recording of each suspected infection and surveillance activities as they relate to individual resident infections. A log is maintained of suspected and actual infections . According to the CMS QSO Memo ,[DATE] NH dated [DATE] revealed .Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and to whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii)) . Review of the article titled The SHEA (Society for Healthcare Epidemiology of America)/APIC (Association for Professionals in Infection Control and Epidemiology) Guideline: Infection Prevention and Control in the Long-Term Care Facility, published in the [DATE] issue of AJIC (American Journal of Infection Control), stated: .To establish baseline infection rates, track progress, determine trends and detect outbreaks, site-specific rates should be calculated .Analysis and reporting of surveillance data: Analysis of absolute numbers is misleading; calculation of rates provides the most accurate information .Infection control data, including rates, then need to be displayed and distributed to appropriate committees and personnel (including administration) and used in planning infection control efforts. The data should lead to specific interventions such as education and control programs. B. Review of the facility's [MEDICAL CONDITION] Policy revised on [DATE] revealed under Policy: This policy is to educate, prevent, identify and treat the Coronavirus .Definition: COVID-19 is a beta coronavirus that rapidly developed into an epidemic centered in China. [MEDICAL CONDITION] is commonly found in bats, rabbits, camels and anteaters. Coronavirus in humans can cause the common cold and range to severe respiratory infections even leading to death. Symptoms: Generally manifest within ,[DATE] days after being infected .Signs/symptoms of lower respiratory illnesses: Fever, Cough, Shortness of Breath, Sometimes Pneumonia and [MEDICAL CONDITION] .Respiratory germs prevention spread WITHIN your facility: Make sure PPE, including gowns, gloves, masks, eye protection are available immediately outside door. Further review of the same policy did not include to actively monitor all residents at least daily for symptoms of COVID-19 (shortness of breath, new or change in cough, sore throat, muscle aches). Review of the document List of Positive Residents (for COVID-19) dated [DATE] revealed: i. R6's onset date of COVID-19 symptoms was on [DATE] and was hospitalized . Review of R6's SPO2 (stands for peripheral capillary oxygen saturation, an estimate of the amount of oxygen in the blood. More specifically, it is the percentage of [MEDICATION NAME] hemoglobin) readings were as follows: XXX[DATE] 12:04am 12:04am 94% room air [DATE] 2:56am 96% room air [DATE] 10:09pm 96% room air [DATE] 2:17pm 96% room air [DATE] 11:47am 98.0% room air . R6's EHR (Electronic Health record) under vital signs revealed that R6's SPO2 was not being monitored every shift since the implementation of the facility's COVID-19 policy on [DATE]. R6's progress notes revealed: [DATE] 4:01pm Social Service .note text: Writer spoke w Note Text: Writer spoke with daughter Elizabeth to provide her with an update regarding positive COVID19 resident in the facility. {Name of R6) is aware to contact the Administrator with any questions/concerns . [DATE] 4:05pm Nursing Progress Note .Resident was experiencing constant productive cough . vitals signs WNL (sic) and as follows ,[DATE], 71, 97.7, 18, 94% MD (physician) was contacted to inform of the change in condition. He ordered to send resident to (name of hospital) for evaluation. Daughter contacted. Nurse consultant aware. endorsed to evening nurse to follow up . [DATE] 5:27pm Nursing Progress Note: Resident is being admitted for UTI and tested positive for Covid-19. all appropriate staff made aware. belongings and meds packed and placed in med room . [DATE] 12:05pm Social Service Note: hospitalization : Resident was transferred to the nursing home due to changes in health. Social service will follow up . [DATE] 4:01pm Nursing Progress Note: Received Resident from (name of hospital) around 12:30 pm per stretcher accompanied by two paramedics of (name of hospital) ambulance in stable condition. Resident is Covid 19 positive per hospital report and is on droplet isolation. Resident also discharged from hospital. Resident noted to be A&O (sic) x ,[DATE] with periods of confusion. Resident's respiration noted to be regular and slightly labored. Bilateral lung fields noted to be moderately diminished. Resident presents no cough at present time. No SOB (sic)or respiratory distress. Resident ate his lunch meal and is currently resting in bed .T 98.8 P 72 R 18 BP ,[DATE] O2 sat 96% on RA (sic) . [DATE] 08:33am Nursing Progress Note .droplet isolation precautions maintained . [DATE] 12:40am Nursing Progress Note .droplet precaution maintained throughout shift . Review of R6's progress notes failed to reveal evidences that R6's respiratory status was being assessed and monitored every shift or at least daily since the implementation of the facility's COVID-19 policy on [DATE]. Review of R6's EMAR (Electronic Medication Administration Record) revealed R6's SPO2, temperatures, respiratory rates, presence of coughing and shortness of breath were only monitored on [DATE], and 23, 2020 since the implementation of the facility's COVID-19 policy on [DATE]. ii. R7's onset date of COVID-19 symptoms was on [DATE]. R7 was hospitalized and expired in the hospital on [DATE]. Review of R7's progress notes revealed: [DATE] 3:08pm Social Service Note .Writer spoke with brother (name of brother) to give update on resident during Shelter in Place Order. No questions or concerns at this time . [DATE] 10:05pm Nursing Progress Note .resident vital sign: 98.7 T, R17, P78, ,[DATE], 99% SAO2 (sic) . [DATE] 2:01pm Nursing Progress Note .Another staff member on unit informed writer that resident was on floor her bedroom. Writer observed resident on all fours next to bed. Vital signs taken: BP: ,[DATE]; P: 108; O2 Sat: 94% on room air; Temp: 96.3; Resp:22. No signs of injury, pain, or distress noted . [DATE] 2:35pm Nursing Progress Note .At about 2:30pm, charge nurse reported to writer that resident is in respiratory distress and hyperventilating at rest upon assessment, Responds to verbal/tactile stimuli, A/Ox2, but falls right back to sleep. She is noted to have general body weakness, her vitals as noted BP: ,[DATE] HR: 105 T: 98.9 RR:29 O2:90%RA .intermittent Non-productive cough/SOB noted. Increased effort in inspiration and expiration. denies any chest pain. diminished lungs sounds to bilateral lower lobes. NP (Nurse Practitioner) notified and gave orders to send to hospital for further eval. (sic) .ambulance called and report called to hospital, spoke to RN (Registered Nurse) facial mask provided to resident. will continue to monitor for any further changes . Review of R7's progress notes failed to reveal evidence that R7's respiratory status was being assessed and monitored every shift or at least daily since the implementation of the facility's COVID-19 policy on [DATE]. Review of R7's EMAR revealed that R7's respiratory rates, presence of coughing and shortness of breath were only monitored on [DATE], 10, 11, and 17, 2020 since the implementation of the facility's COVID-19 policy on [DATE]. iii. R8's onset date of COVID-19 symptoms was on [DATE]. R8 was hospitalized and expired in the hospital on [DATE]. Review of R8's progress notes revealed: [DATE] 3:27pm Social Service Note .Writer called (name of resident representative) to give update on resident during Shelter in Place Order. voicemail left . [DATE] 5:14pm Social Service Note .Writer left voicemail for State Guardian to give her an update regarding positive COVID19 resident in the facility . [DATE] 6:38pm Nursing Progress Note .At about 6pm, staff reported to writer that resident is out of his baseline and didn't eat his lunch nor dinner, upon assessment, his vitals as noted BP:,[DATE] HR;111 T:100.2 RR:20 O2 (sic):94%RA. No cough/SOB noted. denies any chest pain. Md notified and gave orders to send to hospital for further eval. ambulance called and given an ETA (sic) of 30 mins. VM (sic) left for POA (sic) .at about 6:48pm . [DATE] 7:00pm Nursing Progress Notes .2 attendants here to transport resident via stretcher. he remains awake, A/O (sic) x1 . [DATE] 10:14pm Nursing Progress Note .called placed to hospital, resident tested positive for Covid-19 and is being admitted . all belongings and meds packed and placed in med room. all appropriate staff made aware [DATE] 12:01pm Social Service Note .Resident was transferred to the hospital due to changes in health. Social service will follow up . [DATE] 4:25pm Social Service Note .Dr (name of physician) reviewed his records & gave medical ok for readmission. Per Dr (name of physician), pt is not on oxygen [MEDICATION NAME] or chloroquine . [DATE] 08:36am Nursing Progress Note .droplet isolation precautions maintained . Review of R8's progress notes failed to reveal evidences that R8's respiratory status was being assessed and monitored every shift or at least daily since the implementation of the facility's COVID-19 policy on [DATE]. Review of R8's EMAR revealed that R8's respiratory rates, presence of coughing and shortness of breath were only monitored on [DATE], 18, and 19, 2020 since the implementation of the facility's COVID-19 policy on [DATE]. iv. R9's onset date of COVID-19 s(TRUNCATED)

Based on interview and record review, the facility failed to supervise a resident who, while on the patio, lifted a metal grate and lowered himself into the patio sublevel/storm drain. This failure resulted in the resident having laceration to his hand, requiring transfer to the hospital, and receiving stitches to his hand. This failure affected 1 resident (R1) of 3 reviewed for accidents in a total sample of 8 residents. Findings include: On 6-11-19 at 9:43 AM, V1 (Administrator) stated on 5-26-19 around 4:00 PM, R1 was downstairs on the patio on his own accord. R1 has a right to be on the patio when he wishes. Per V1's interview with CNA, CNA was constantly going in and out of the dining room for supervision purposes. There was no staff sitting outside monitoring the patio. On 6-6-19 at 1:04 PM, V2 (Director of Nursing) stated R1 was on the patio and he lifted the grate by himself. He lowered himself into the lower level. R1 was unable to get himself up. Staff attempted to lift him out, however, they could not get him out. 911 was called and was able to get R1 out. R1 had a laceration to his hand and he went to local hospital for stitches. R1 returned to facility the same day. R1 has a history of [MEDICAL CONDITION] and [MEDICAL CONDITION]. R1 is alert and oriented x3 most of the time, however, he has periods of confusion. R1 can become more forgetful and have increased aggression. R1 requires redirection at times when his [MEDICAL CONDITION] is kicking in. R1 requires supervision during those periods. R1 was on the patio with staff present. Activities is now required to stand at the patio doors to monitor residents on the patio this is during smoke breaks and outside activities. On 6-6-19 at 11:06 AM, V6 (Psych Rehab Services Coordinator/PRSC) stated R1 is a psychiatric resident and seen by psychiatrist. R1 is alert oriented 1-3 (depending the day). R1 likes to go places where he knows he is not supposed to go. PRSC has not seen R1 attempt to lift grates. PRSC is not aware of previous incident/accident. R1 has history of behavior (aggression and altercation). R1 has a history of stealing. R1 has history of [MEDICAL CONDITIONS], and history of right tibia fracture. His mental status can vary day by day. Some days he will require cuing and redirection. Some other days, he is ok. R1 can be a safety risk due to impaired judgment which can fluctuate. V6 stated there are designated patio hours or upon request with supervision/chaperone. Staff present in the dining area would be scanning the enclosed patio. On 6-6-19 at 10:55 AM, V4 (Licensed Practical Nurse/LPN) stated R1 requires public supervision. LPN stated that she is unaware of R1 having any previous accident prior to patio incident. LPN stated R1 requires cuing and redirection (for example: getting up by himself and not using his walker). On 6-6-19 at 11:30 AM, V5 (Certified Nurse Aide/CAN) stated R1 is alert and oriented x 1-2. R1 has history of behaviors (going into other rooms, taking other resident belongings, and laying in other resident beds). The other resident might get upset and complain which would cause R1 to get upset. Staff would intervene and redirect R1. R1 will sometimes get up and forget to use his walker. R1 would have some poor safety awareness depending on his day. He can be forgetful. CNA has not seen R1 attempt to lift grates and lower himself down. CNA is not aware of any prior accidents or incidents before this incident. R1 would require supervision in the patio area. R1's Minimum Data Set (ARD 5-17-19) documents Transfers: Self Performance: 1 (supervision), Support:2 (one person physical assist), Active [DIAGNOSES REDACTED]. Order Summary Report documents orders for scheduled antipsychotic medications ([MEDICATION NAME] Sodium, Ziprasidone HCl, and [MEDICATION NAME] HCl) and antidepressants ([MEDICATION NAME] HCl). R1's Behavior Care Plan (dated 5-7-19) documents R1 has a history of acting impulsively and erratically. R1 has [DIAGNOSES REDACTED]. The care plan documents intervention when any inappropriate behavior is observed. R1's Hospital Medical Record dated 5-26-19 documents R1 had a y shaped laceration 1.5 cm in length with an additional 0.5 cm extension forming a Y on the left palm. R1 received 5 total sutures per hospital medical record.

Based on interview and record review, the facility failed to allow resident (R23) remain in the facility after returning late from being out on pass and failed to follow their policies on Outside Pass Policy and Against Medical Advice (AMA) for 1 (R23) of 2 closed records reviewed for leaving the facility AMA in the sample of 24 residents. This failure resulted in R23 becoming very irate along with verbal agitation when confronted by staff after returning late from an outside appointment. The findings include: R23, a [AGE] year old, non-ambulatory male was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. R23's brief interview mental status (BIMS) is a 15 which indicates he orient times three (person, place and time.) The MDS documents R23 exhibits verbal behavior one to three times a week and rejects care 4 to 6 times a week. R23's care plan dated 11/24/16 documents his problematic areas to be exhibiting attention-seeking behaviors, exhibiting manipulative behavior at times, such as, giving contradictory information on his history and therapy, exhibiting intermittent episodes of verbal outburst, hoarding food in his room, and has surgical wound to his right 5th toe which was amputated as a result from [DIAGNOSES REDACTED] of the right foot. The care plan addresses R23 receiving anti-psychotic medications for his [DIAGNOSES REDACTED]. On 12/15/16 at 10:35 AM via phone conversation with Z3 (outside advocate), Z3 stated R23 was 45 minutes late in returning to the facility on [DATE]. R23 had a 4 hour pass to come see Z3. Z3 stated she received a phone call from E3 (director of nursing) and E6 (Social Service Director) around 2 PM on 12/5/16 requesting to schedule a meeting with R23 and ombudsman to discuss a behavioral contract. Later that same day, Z3 states she receives a phone call from R23 all upset saying the facility is throwing him out of the facility for being late from out on pass. Z3 requested to talk to E1 (administrator) but E1 would not take call from R23's phone. Z3 stated she called the facility's phone line and eventually spoke to E1. Z3 stated that E1 stated R23 was leaving AMA per his choice. Z3 stated that she understood that R23 is being discharged due to returning late to the facility and was the facility sending him to another facility. Z3 stated that E1 stated that R23 was leaving on his own accord and it was not considered a discharge but an AMA. Z3 stated when she had concluded her conversation with E1, she was told that R23 had left the facility. Z3 stated R23 is homeless and has no identification cards or medical card. Z3 stated that R23 left 2 to 3 voice messages about being very distraught, scared, not knowing what was going to happened to him or where to go and it being very cold outside. Z3 stated that R23 was not happy at this nursing home but was trying to adjust. Z3 stated R23 went to the facility due to an infection in his foot after amputation of his 5th toe. Z3 stated R23 was still receiving antibiotic treatment and dressing changes to his foot. On 12/15/16 at 12:45 PM, E6 (Social Service Director) stated R23 was admitted for a foot infection. E6 stated that R23 would exhibit verbal aggression in regards to his medical treatment and would voice veiled threats toward staff but no actual physical harm or threats. E6 stated he had a good relationship with R23. E6 stated that R23 just wanted to be heard and to vent. E6 stated R23 is alert and orient times 3 (person, place and time). E6 stated R23 left the facility for a personal matter and was gone over 4 hours. E6 does not recall the exact time R23 returned. E6 stated R23 did speak to E6, E1(administrator) and the E19 (receptionist) about permission to leave facility prior to leaving the facility. E6 stated that the facility was planning on meeting with R23 and the ombudsman to develop a behavior contract regards to the 4 hour pass privilege and his foot infection. E6 stated R23 returned to the facility and became verbally aggressive toward E1, E3 and E6 when R23 was questioned about his whereabouts. E6 stated that R23 was exhibiting his base-line behavior of using vulgar language and was not re-directable as E1 and E3 explained the pass privilege. E6 stated he left the room [ROOM NUMBER] to 6 minutes into the conversation and left R23, E1 and E3 in the room. On 12/15/16 at 1:07 PM, E1 (administrator) stated that the meaning of being AMA is not returning on time from pass, not returning at all and/or family member taking resident out of facility without proper discharge plans in place. E1 stated R23 is alert and orient times three and left the faciity on [DATE] at 10 AM and returned sometime after 4 PM, not sure of the exact time. E1 stated she could not recall if R23 ever violated the PASS privilege before this time but believes there was one time when he returned 15 minutes late pass the curfew time. E1 stated that Z2, the nurse practitioner was here waiting to see his foot infection but R23 was not here. E1 stated she was aware of R23's visit into the community to see Z3. E1 stated when R23 returned to the facility, it was herself, E3 and E6 that explained the 4 hour pass is due to his foot being infected and requiring medical treatment. E1 stated that earlier in the day, E6 called Z3 to see where R23 was because Z2 (Nurse Practitioner) was in the facility and wanted to see him. E1 stated that E6 was told not to have R23 come to office because Z3 has no time to see R23. E1 stated that E6 was informed at that time that Z3 had not seen R23 yet. E1 stated that E6 informed E1 and E3 that R23 was back in the facility and to come to E6's office. E1 stated that as E6 was explaining the 4 hour pass privilege R23 starts screaming, he is an adult, this is not a jail, I am only here for rehab and awaiting to get his car back. E1 stated that R23 was allowed to vent and then E1 decided that the conversation was going nowhere because R23 saying he does not want to be here, the place is terrible, and he is on his way. E1 stated herself and E3 left conference room for something and R23 ends up in the lobby at the front desk. E1 states that R23 is making calls on a cell phone in the lobby and tries to hand the cell phone to E1 who says she does not take calls from resident's cell phone for whoever it is to call the facility's phone number. E1 stated that a call from Z3 comes to the facility and she takes it. E1 stated that Z3 asks why she did not take the call from R23, E1 stated that she only takes calls on the facility line. E1 stated she informed Z3 that she can not discuss R23 because he has made the decision to leave and is no longer a resident here at the facility. E1 stated that R23's belongings are still here and another nursing home called to say they want to pick up R23's belongings. After E1 read the facility's PASS Policy, E1 agreed that R23 did not violate the Pass policy. The policy documents that if not returning on time from out on pass, the pass privilege would be revoked. E1's response to this is that R23 never allowed this to come up due to his vulgar language and R23 saying he does not want to stay here. On 12/15/16 at 2:05 PM, E3 (director of nursing) stated that R23 was difficult to please and he expressed that he did not want to be in a nursing home. E3 stated that R23 had some legal problems in the community he needed to take care of and wanted to come and go. E3 stated that R23 left the faciity on [DATE] to go to court. The pass was for 4 hours only. E3 stated she does not know how long R23 was out but he returned at 3:15 PM and signed in at the receptionist's desk. E3 stated that Z3 called earlier in the day around 2 PM and stated she was busy and not to send R23 down to her office. E3 stated she believes that R23 never saw Z3. E3 stated that Z2 (nurse practitioner) was here to exam R23's foot and he was not here. E3 stated that Z2 stated R23 is out against medical advise in regards to his foot and is out of facility for over 4 hours. E3 stated Z2 was still in the facility when R23 came back. E3 stated that Z2 wrote an order for [REDACTED]. E3 stated that when R23 returned to the facility, it was R23, E1, E6 and possibly E19 (receptionist) who were all in the lobby. E3 stated she saw this from a distance and the discussion started to escalate louder with a lot of swearing and yelling. E3 stated she left the area and went to do her job. E3 stated that R23 was in the lobby making phone calls on a cell phone prior to leaving AMA. E3 stated she believes someone picked him up at facility. On 12/16/16 at 9:47 AM, E19 (receptionist) stated she recalls R23 leaving the facility on 12/5/16 at 9:30 AM or 10 AM. E19 stated not to be sure when R23 returned because she did not see him return. E19 stated she recalls E6 and E20 (staffing coordinator) asking R23 if he needed transportation and to wait because of the cold weather prior to R23 leaving the facility. E19 stated she works 8 AM to 4:30 PM Monday through Friday. The facility's sign in/out sheet was at the front desk. On it, was R23's signature dated 12/5/16 signed out at 10:15 AM and signed in at 3 PM upon return to facility which was confirmed by R19. When E19 was questioned about returned time of 3 PM for R23, E19 stated that she tries to check the sheet for time accuracies but she does not always catch it. E19 stated she did sign the AMA sheet for R23 and says she signed it before she left that day. On 12/16/16 at 10:48 AM via phone conversation, Z2 (nurse practitioner) stated that she was informed by E2 that R23 was not in the facility. Z2 stated she wrote the order for AMA because R23 was not in the facility and was told by E3 that there is no order for R23 to be out of the facility. Z2 stated R23 was okay with her. Z2 stated that when she would want to see his foot, he would request later. Z2 would came back later and R23 would allow Z2 to see his foot. Z2 stated that R23 exhibited a calm demeanor. Z2 stated she could not remember if she ever saw R23 on 12/5/16 when she wrote the AMA order. On 12/20/16 at 7:45 AM via phone conversation, R23 stated he asked permission from E6 if he could go to see Z3 (an outside advocate). R23 stated E6 asked E1 if it was okay and it was okay. R23 stated he took the bus ride to Z3's office, waited and met with Z3, then returned back to the facility and was 30 to 35 minutes late (past the 4 hours) on getting back to the facility. R23 stated he was in the lobby with E1, E3, E6 and E19 when he was confronted with being late from his 4 hour pass. R23 states the conversation gets louder with everyone yelling in the lobby when E3 states that the conversation needs to be moved down to the conference room. All 4 of them (R23, E1, E3, E6) go to a conference room where the discussion goes on for 30 minutes. R23 stated that he believes E1 had made up her mind about R23 being thrown out of the facility. R23 states that E1 tells a staff person to pack up all R23's belongings and tells R23 to wait in the lobby. R23's belongings consists of 3 boxes which are put in the lobby. R23 stated he used another resident's phone to call Z3 but E1 would not speak to Z3 on the cell phone. R23 stated he got money from another resident to take the bus to the hospital. R23 stated he has yet to pick up his belongings from this facility. R23 added that he believes this all stems from the fact he received a severe burn to his thigh when a CNA gave him hot water per R23's request. R23 stated it was so upsetting to return to the facility and be confronted about his whereabouts when he informed them prior to his leaving. Everyone is yelling and people stated to gather near the lobby before they moved to a conference room. R23 added that he did not want to be in the nursing home but was trying to make the best of it. Z2's progress note dated 11/23/16 documents R23 is being treated for [REDACTED]. R23 was complaining to increase pain to his right foot. The nursing progress note dated 12/5/16 at 3:45 PM documents Z2 (nurse practitioner) was still in the facility when R23 left the facility and Z2 was aware of the AMA status. There was no documentation to support that R23's foot was examined. There is another nursing progress note dated 12/5/16 that documents R23 reporting to E15 (wound nurse) that he had a skin injury. E15 documents that upon inspection there is a 2nd degree burn to his left front thigh, base 10% of pinkish tissue and 80% of hard yellowish slough, moderate amount of serous exudates, odorless, margins flat equal intact, affected area measuring 7.2 by 6.2 centimeters. Spoke with physician with orders to cleanse the wound with normal saline, apply silverdene cream sparingly and cover with dry dressing and secure with tape daily per the 12/5/16 physician's orders [REDACTED].>R23's clinical record lacks documentation of R23 ever violating any other rules in the facility, being late on return from pass, being physically out of control or threaten to do physical harm to anyone and not being able to re-direct. The 12/5/16 incident is the only documented time that R23 was late from being out on pass. There is no documentation to support the rationale for R23 being turned out of the facility by E1 on 12/5/16. The facility's policy labeled Policy and Procedures for Against Medical Advise documents that 2 staff members are to witness the AMA form when the resident refuses to sign the AMA form. R23's AMA form was signed by E6 and E19. E19 stated in her interview that she did not see R23 return back to the facility but signed the AMA form upon completion of work schedule. E19 did not witness R23 refuse to sign the form. The facility's policy labeled Outside Pass Policy documents that a resident returning to the facility in a timely manner and as agreed upon with the facility staff. Failure to return by the agreed upon time will be grounds for revocation of privilege unless the resident has contacted the the facility and made appropriate arrangements with administrative representative. The facility failed to follow this policy and discharged R23 due to his verbal agitation and irritability when questioned about his whereabouts upon return from an agreed upon outing.

Based on interview and record review, the facility failed to ensure one resident was free from mistreatment when resident returned late from being out on pass for 1 (R23) of 2 closed records reviewed for leaving the facility against medical advice (AMA) in the sample of 24 residents. This failure resulted in R23 becoming very irate along with verbal agitation when confronted by staff after returning late from an outside appointment and still requiring medical attention to 2nd degree leg burn and severe foot infection. The findings include: R23, a [AGE] year old, non-ambulatory male was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. R23's brief interview mental status (BIMS) is a 15 which indicates he orient times three (person, place and time.) The MDS documents R23 exhibits verbal behavior one to three times a week and rejects care 4 to 6 times a week. R23's care plan dated 11/24/16 documents his problematic areas to be exhibiting attention-seeking behaviors, exhibiting manipulative behavior at times, such as, giving contradictory information on his history and therapy and hoarding of food. R23 exhibits intermittent episodes of verbal outburst and has surgical wound to his right 5th toe which was amputated as a result from [DIAGNOSES REDACTED] of the right foot. The care plan addresses R23 receiving anti-psychotic medications for his [DIAGNOSES REDACTED]. On 12/15/16 at 10:35 AM via phone conversation with Z3 (outside advocate), Z3 stated R23 was 45 minutes late in returning to the facility on [DATE]. R23 had a 4 hour pass to come see Z3. Z3 stated she received a phone call from E3 (director of nursing) and E6 (Social Service Director) around 2 PM on 12/5/16 requesting to schedule a meeting with R23 and ombudsman to discuss a behavioral contract. Later that same day, Z3 states she receives a phone call from R23 all upset saying the facility is throwing him out of the facility for being late from out on pass. Z3 request to talk to E1 (administrator) but E1 would not take call from R23's phone. Z3 stated she called the facility's phone line and eventually spoke to E1. Z3 stated that E1 stated R23 was leaving AMA per his choice. Z3 stated that she understood that R23 is being discharged due to returning late to the facility and was the facility sending him to another facility. Z3 stated that E1 stated that R23 was leaving on his own accord and it was not considered a discharge but an AMA. Z3 stated when she had concluded her conversation with E1, she was told that R23 had left the facility. Z3 stated R23 is homeless and has no identification cards or medical card. Z3 stated that R23 left 2 to 3 voice messages about being very distraught, scared, not knowing what was going to happened to him or where to go and it being very cold outside. Z3 stated that R23 was not happy at this nursing home but was trying to adjust. Z3 stated R23 went to the facility due to an infection in his foot after amputation of his 5th toe. Z3 stated R23 was still receiving antibiotic treatment and dressing changes to his foot. On 12/15/16 at 12:45 PM, E6 (Social Service Director) stated R23 was admitted for a foot infection. E6 stated that R23 would exhibit verbal aggression in regards to his medical treatment and would voice veiled threats toward staff but no actual physical harm or threats. E6 stated he had a good relationship with R23. E6 stated that R23 just wanted to be heard and to vent. E6 stated R23 is alert and orient times 3 (person, place and time). E6 stated R23 left the facility for a personal matter and was gone over 4 hours. E6 does not recall the exact time R23 returned. E6 stated R23 did speak to E6, E1(administrator) and the E19 (receptionist) about permission to leave facility prior to leaving the facility. E6 stated that the facility was planning on meeting with R23 and the ombudsman to develop a behavior contract regards to the 4 hour pass privilege and his foot infection. E6 stated R23 returned to the facility and became verbally aggressive toward E1, E3 and E6 when R23 was questioned about his whereabouts. E6 stated that R23 was exhibiting his base-line behavior of using vulgar language and was not re-directable as E1 and E3 explained the pass privilege. E6 stated he left the room [ROOM NUMBER] to 6 minutes into the conversation and left R23, E1 and E3 in the room. On 12/15/16 at 1:07 PM, E1 (administrator) stated that E6 informed E1 and E3 that R23 was back in the facility and to come to E6's office. E1 stated that as E6 was explaining the 4 hour pass privilege R23 starts screaming, he is an adult, this is not a jail, I am only here for rehab and awaiting to get his car back. E1 stated that R23 was allowed to vent and then E1 decided that the conversation was going nowhere because R23 saying he does not want to be here, the place is terrible, and he is on his way. E1 stated herself and E3 left conference room for something and R23 ends up in the lobby at the front desk. E1 states that R23 is making calls on a cell phone in the lobby and tries to hand the cell phone to E1 who says she does not take calls from resident's cell phone for whoever it is to call the facility's phone number. E1 stated that a call from Z3 comes to the facility and she takes it. E1 stated that Z3 asks why she did not take the call from R23, E1 stated that she only takes calls on the facility line. E1 stated she informed Z3 that she can not discuss R23 because he has made the decision to leave and is no longer a resident here at the facility. E1 stated R23 is alert and orient times three and left the faciity on [DATE] at 10 AM and returned sometime after 4 PM, not sure of the exact time. E1 stated she could not recall if R23 ever violated the PASS privilege before this time but believes there was one time when he returned 15 minutes late pass the curfew time. E1 stated that Z2, the nurse practitioner was here waiting to see his foot infection but R23 was not here. E1 stated she was aware of R23's visit into the community to see Z3. On 12/16/16 at 10:48 AM via phone conversation, Z2 (nurse practitioner) stated that she was informed by E3 that R23 was not in the facility. Z2 stated she wrote the order for AMA because R23 was not in the facility and was told by E3 that there is no order for R23 to be out of the facility. Z2 stated R23 was okay with her and exhibited a calm demeanor. Z2 stated that when she would want to see his foot, he would request later and Z2 would came back later and R23 would allow his foot to be examined. Z2 stated she could not remember if she ever saw R23 on 12/5/16 when she wrote the AMA order. On 12/20/16 at 7:45 AM via phone conversation, R23 stated he asked permission from E6 if he could go to see Z3 (an outside advocate). R23 stated E6 asked E1 if it was okay and it was okay. R23 stated he took the bus ride to Z3's office, waited and met with Z3, then returned back to the facility and was 30 to 35 minutes late (past the 4 hours) on getting back to the facility. R23 stated he was in the lobby with E1, E3, E6 and E19 when he was confronted with being late from his 4 hour pass. R23 states the conversation gets louder with everyone yelling in the lobby when E3 states that the conversation needs to be moved down to the conference room. All 4 of them (R23, E1, E3, E6) go to a conference room where the discussion goes on for 30 minutes. R23 stated that he believes E1 had made up her mind about R23 being thrown out of the facility. R23 states that E1 tells a staff person to pack up all R23's belongings and tells R23 to wait in the lobby. R23's belongings consists of 3 boxes which are put in the lobby. R23 stated he used another resident's phone to call Z3 but E1 would not speak to Z3 on the cell phone. R23 stated he got money from another resident to take the bus to the hospital. R23 stated he has yet to pick up his belongings from this facility. R23 added that he believes this all stems from the fact he received a severe burn to his thigh when a CNA gave him hot water per R23's request. R23 added that he did not want to be in the nursing home but was trying to make the best of it. Z2's progress note dated 11/23/16 documents R23 is being treated for [REDACTED]. R23 was complaining to increase pain to his right foot. The nursing progress note dated 12/5/16 at 3:45 PM documents Z2 (nurse practitioner) was still in the facility when R23 was discharged from the facility and was aware of the AMA status. There was no documentation to support that R23's foot was examined. There is another nursing progress note dated 12/5/16 that documents R23 reporting to E15 (wound nurse) that he had a skin injury. E15 documents that upon inspection there is a 2nd degree burn to his left front thigh, base 10% of pinkish tissue and 80% of hard yellowish slough, moderate amount of serous exudates, odorless, margins flat equal intact, affected area measuring 7.2 by 6.2 centimeters. Spoke with physician with orders to cleanse the wound with normal saline, apply silverdene cream sparingly and cover with dry dressing and secure with tape daily per the 12/5/16 physician's orders [REDACTED].>R23's clinical record lacks documentation of R23 ever violating any other rules in the facility, being late on return from pass, being physically out of control or threats to do physical harm to anyone and not being able to re-direct. The 12/5/16 incident is the only documented time that R23 was late from being out on pass. There is no documentation to support the rationale for R23 being turned out of the facility by E1 on 12/5/16. The facility's policy labeled Outside Pass Policy documents that a resident returning to the facility in a timely manner and as agreed upon with the facility staff. Failure to return by the agreed upon time will be grounds for revocation of privilege unless the resident has contacted the facility and made appropriate arrangements with administrative representative. The facility failed to follow this policy and discharged R23 due to his verbal agitation and irritability when questioned about his whereabouts upon return from an agreed upon outing. The facility's policy labeled Abuse Prevention Program Facility Policy documents the facility affirms the right of our residents to be free from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. The facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. This policy was not followed.

Based on observation, record review and interviews the facility failed to 1) provide adequate supervision and initiate interventions to address exit seeking behavior for 1 of 3 residents (R1) identified as not appropriate for unsupervised outside pass privileges, who subsequently eloped from the facility without staff knowledge in the late night and was located later at hospital emergency room . 2) accurately reassess R1 for elopement risk after history of elopement from facility on 3/28/2012. 3) follow facility missing resident protocol checklist by not completing incident investigation, notify police within 30 minutes after being discovered missing from facility and notify Public Health within 24 hours of incident. These failures resulted in R1, who has a [DIAGNOSES REDACTED]. E1 (Administrator) was notified of the Immediate Jeopardy on 5/14/12 at 12:00 PM. The Immediate Jeopardy began when R1 displayed exit seeking behavior on 5/1/12 and no further interventions were put in place. On 5/9/12, E1 stated that there were 26 residents identified as being at risk for elopement; R1 was not one of those residents identified as at risk by the facility. Although the Immediate Jeopardy was removed on 5/7/2012, the facility remains out of compliance at a severity level 2 due to the need to implement and evaluate their removal plan. Findings include: R1, a 63 y/o male, was readmitted to facility from acute care hospital on 11/23/11 with [DIAGNOSES REDACTED]. R1's quarterly Minimum (MDS) data set [DATE] under Temporal Orientation and Recall, assessed R1's temporal orientation as unable to correctly report or answer questions regarding year, month and day, and had no recall of previous asked questions. Prior to his elopement on 3/28/2012, R1 resided on the second floor unit where residents are able to leave unit on an unalarmed elevator. R1's community skills assessment dated [DATE] assessed R1 as not capable of unsupervised outside pass privileges at this time. R1's elopement risk assessment decision form dated 1/10/12 denoted R1 is not at risk to elope at this time. R1's care plan dated 2/6/12 denotes under Problem: Resident wanders around the facility without direction which put resident at danger because he can get confused. Goals included : Resident will respond to redirection 100% of the time when displaying wandering behavior per CNA report. R1's psychiatry report dated 2/26/12 assessed R1 as alert, cooperative, disorientated x 2, thought process slowed, thought content confused, and judgement and insight impaired. Subsequent reports by Z1(psychiatrist), dated 3/31/12 and 4/28/12, show continued disorientation, impaired insight and judgement and continuing confusion. Nurse notes by E12 dated 3/29/2012 at 5:28AM states "on 3/28/12 upon rounds @ 11:30PM writer notified by CNA that resident was not in room. Writer called each floor to do a full check of each room, B/R"s shower room, closets and dining rooms. The basement was also checked. Patio and courtyard along with parking lot. Called the 3-11 nurse and CNA's. Administrator and DON (Director of Nursing) called. Administrator called hospitals. Writer called local police department. Administrator started to question all staff and residents that he is friends with." On 5/15/12 at 2:15 pm E12 stated in phone interview that she was informed by CNA that R1 was not found in room on 3/28/12. E12 stated she initiated a search for R1 throughout the unit (2 main north) and outside the facility. E12 stated she did not notify police or notify E1 within 30 minutes after R1 was missing because she was outside looking for R1. E12 stated she called the police and administrator about 2AM. E12 stated she did not see R1 during initial rounds when she started the shift on 3/28/12. E12 stated R1 would have periods of confusion. E12 stated she called the previous 3-11 nurse of 3/28/12 to see if she had seen R1. E12 stated E15 (LPN) told her R1 was seated at the nurse station. The last charting done on R1 prior to eloping from the facility on 3/28/12 was on 3/15/12. Review of EMS (emergency management run sheet) dated 3/29/12 at 11:02 AM denotes EMS was called for incident type "person down from unknown cause." Patient (pt.) was found sitting on crate in rear lot. Bystanders state pt has been milling around all AM. Pt. answers to all questions appropriately and follow commands. Pt is lethargic. Transported to nearby hospital." The location R1 was found at on 3/29/12 almost 12 hours after eloping from facility was 4.7 miles from facility. R1's emergency record denotes R1 was admitted to ER per ambulance on 3/29/12 at 11:31 AM. Documentation of history and physical states "61 y/o male here for confusion. Acute onset, location generalized, duration unknown, associated with odd behavior. Bystanders called EMS stating he was walking around parking lot for extended period of time, not answering questions. No Seizure activity witnessed by bystanders or EMS. Patient with slow speech, denies history of seizure. Physical exam normal. Patient remains unchanged-not seizing, no clearing. Eyes open, speech slow/clear, repeating question, unable to give info beyond his name. Unsure where he lives, where he stays, or any other info. Pt. is not dischargeable in current condition, although no explanation for his condition "transient [DIAGNOSES REDACTED] but long-term recall seems equally affected. Unable to obtain any family member. Staff from nursing home here to ED. They called 911 and got information. R1 is long-term resident at their facility who wandered off. This is baseline per staff/Social Worker who knows him well. They will take back under their care." Documentation in nurse notes 3/29/12 denotes R1 returned to facility from hospital #1 by private ambulance at 8:15PM. R1 was readmitted to the 2nd floor unit which is not a secured unit. E1(administrator) initiated facility initial 24 hour incident investigation report dated 3/28/12-3/2912 states the following : Event started at 11:30PM-11:45 PM per staff started to check all rooms because of resident history of sleeping in the wrong bed. Full review of facility done. Complete by nurse E12. Spoke with residents, spoke with staff-see interviews, started to call hospital. R1 was at hospital since 3/29/12 (12PM), but because at 5:00AM facility gave R1's wrong birthday, the call at 5:00AM showed R1 not there. E1 stated in phone interview on 5/16/12 at 2:30PM, concerning the 3/28/2012 elopement, "she was not notified of R1's elopement until 4:00AM, started calling hospitals at 5:00AM, recalling hospitals every couple of hours." Local police records dated 3/29/12 denote police were not notified of R1 missing from the facility until 5:00AM on 3/29/12, 5 1/2 hours after R1 eloped from the facility. E1 stated she did not know why it took so long for the police to be notified by staff nurse E12 of R1's elopement, but facility policy requires E1 to be notified immediately. E1 stated all doors were checked and were functioning at time of R1 leaving the facility. E1 stated she could not determine how R1 left the faciity on [DATE] without staff knowing it. On 5/16/12, E1 stated interventions after R1's initial elopement of 3/28/12 included: R1 was placed on close monitoring, a receptionist for the front lobby was hired for the 8:00 PM shift till 8:00AM shift though the receptionist only lasted a couple of weeks (April 25, 2012). Staff were inserviced on missing residents and notification of administration, door alarms, and updated elopement book at front desk. E1 also stated R1 was always on elopement review which required R1 not being able to leave 2nd floor, and must be in eyesight of staff, or staff must know that R1 is in bed asleep. There was no final investigation or report of the incident of 3/28/12 and the incident was not faxed to IDPH as required on the back of the facility incident report form which states "A final investigation report will be sent to the Department of Public Health within 5 working days. R1's care plan was updated on 4/2/12 to reflect the above information. R1's updated care plan after the first elopement dated 4/2/12 includes under problem "The resident demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming and may go towards exit. Care plan of 4/5/12 denotes "if independent in the community, resident may also become lost or become disorientate in an environment outside of the facility. Approaches included 'post a picture of the resident at near the front desk of nursing station in a discreet place identifying possible elopement risk. Monitor resident whereabouts, reorient/direct as able, record episodes of wandering, establish routine, divert attention as able and walk along with resident. Care plan also addresses staff response to alarms and to follow facility protocol which includes "If a resident appears to have eloped, then keep one person at main desk to man floor. Send designated staff to the grounds to search the premises, send designated staff through the facility again checking all rooms, even those that are locked. Check closets, bathrooms, etc. Ensure the management are notified, contact resident physicians/family, and police department if the resident not found within 30 minutes. Notify public health within 24 hours of incident. Redirect resident if able and notify nursing staff/administration if episodes of wandering noted. R1 was moved to secure unit and monitor whereabouts at all times. R1 was not placed in secure unit on 2nd floor until after the elopement of 5/6/12. Documentation of nursing notes reflected R1 was on elopement watch from 3/30/12 through 4/11/12. From 4/11/12 through 4/29/12 there was no documentation if R1 had any exit-seeking behavior or if R1 was still on elopement risk. On 4/30/12 at 4:00PM documentation included R1 asleep majority of shift, no elopement risk during shift. On 5/1/12 nurse notes of E12 (LPN) reflect the following: "At 6:00AM pt is awake alert, verbally responsive, came to nurse station and told to writer that 'I am sure leaving this place and going to my home.' Writer listened carefully. Say nothing and direct to his room, sit with him for while. Writer started making morning rounds, call made to first floor nurse (E14) LPN that pt is trying to leave the facility. Close observation maintained. 2nd time writer saw resident running so fast to leave the unit. Writer follow-up and directed resident to room, asking resident what is address of place you want to go resident states 'I am not letting you know'. Resident remains on close observation, day staff and night staff aware. To monitor closely per staff." There was no documentation regarding R1's exit seeking behavior from 5/1/12 until R1 was discovered missing from facility on 5/7/12 at 11:15 PM. E12 (LPN) stated during phone interview on 5/14/12 that on 5/1/12 she observed R1 running onto unalarmed elevator on 2nd floor to get to the 1st floor. E12 stated she did report incident to nurse (E14) but did not notify social service regarding R1's exit seeking, because they come in later. E14 (LPN) stated on phone interview on 5/14/12 she was not notified by E12 regarding R1's behavior of 5/1/12 and was only aware of R1's previous elopement of 3/28/12, because she heard about it. On 5/9/12 during investigation of elopement of 3/28/12, upon review of R1's nurse notes, it was discovered R1 had eloped again on 5/6/12 without staff awareness. Nursing notes entered by E14 and dated 5/7/12 at 2:23 AM denote "During shift change rounds at 11:15 PM, noted patient not in his bed, room or unit facility searched all floors rooms and stairwells. Patient not located in building, administrator and police notified of missing person and report initiated at 11:30PM. Called around to neighboring hospital, resident was located at hospital at 12:30 AM, was brought into ER by a police officer. Social services director went to hospital to verify patient and patient was being admitted . Hospital #2 record review denotes R1 arrived in theER on [DATE] at 11:22PM per ambulance with complaints of abdominal pain and shortness of breath. R1's history and physical dated 5/7/12 denotes: Reason for Admission: Acute Renal Failure, Dehydration History of Present Illness: The patient is a 62 y/o male with significant past medical history of [REDACTED]. Pt found confused and disorientated stating the he "left a hospital on the north side of Chicago." Pt is a resident at long term care facility. Pt was unable to provide any past medical history or events that led to this hospitalization . All past medical history obtained from NH (nursing home) via telephone and via fax. Currently pt is alert and orientated to self only. R1 was discharged back to facility on 5/7/12. E1 stated on 5/10/12 that R1 was placed on a secured unit upon readmission due to elopement of 5/6/12. A request was made to review facility elopement risk book at front desk from receptionist E16 on 5/9/12. Surveyor requested to review R1's elopement risk assessment, E16 responded, "R1 is not an elopement risk." Review of R1's assessment revealed R1's last elopement risk assessment was done on 1/10/12. A community skills assessment was completed on 3/20/12 and 4/4/12 assessing R1 as not appropriate for access to community pass privileges due to R1 not being alert and orientated. E17 (social service director) stated in interview on 5/10/12 he does not consider R1 as an elopement risk due to the fact when R1 leaves the facility he does have a "purposeful action." E17 stated R1 leaves because he has family/ money problems. E17 stated R1's confusion can vary from time to time. E1 stated on 5/10/12 R1 has poor insight in decision making and R1's assessment of community skills and not being suitable for unsupervised pass is due in part to R1's Dementia. Review of R1's updated elopement risk assessment of 5/7/12 revealed the following computerized documentation: ("1. Does resident have a history of elopement/elopement attempts?Yes, but he know were he is going, has community skills but not appropriate to be in community independently due to AOx1 or x2 (ao changes at times due to dementia). 2. Does resident spend time near and around exit doors/front doors in an attempt to elope? No. 3. Does resident have a [DIAGNOSES REDACTED]. 4. Does resident have severely impaired skills or decision making. Yes, but has impaired memory which may affect decisions at times. 5. Does resident express wanting to leave the facility without authorization? No, because if resident expresses that he "events or occurrences that he needs to be addressed" to staff but is redirected when staff says he is unable to do so. 6. Is resident unrespectable when wandering or spending time at exit doors? No 7. Is resident able to ambulate with /without assistive devices? Yes. 8. Are there any special environmental/safety considerations for this outside of the facility's standard protocols that need to be made? No. 9. Is resident at risk to elope (If 1. or 2. answer yes, resident will be at risk. If 3. or 4. AND 5. or 6. answer, then resident is at risk. Care plan if need if resident is at risk dn resident will be placed on Elopement risk protocol) No. Resident is not at risk for elopement due to addressing staff when he wants to be leave. When he does want to leave the facility, he is doing so of his belief of a purposeful task and alerting staff beforehand. Staff will redirect resident as appropriate to remain the facility. If resident does require to leave the facility, staff will escort resident due to resident not being appropriately for resident to be in the community independently due to dementia. Resident was placed on the memory care floor that will allow for a failure free environment and constant redirection or reassurance.") On 5/14/12 during review of R1's risk elopement assessment dated 5/7/12 surveyor asked why the assessment does not assess R1 as an Elopement Risk. On 5/14/12 E 1 redid the assessment which now identifies R1 as having exit seeking behavior, as being at risk to elope, and assessing R1 as wanting to leave the facility without authorization. E 1 stated R1 was placed on Elopement Risk Protocol). On 5/10/12 surveyor observed R1 sitting in the dining room on the secure unit of the 2nd floor. R1 was alert but confused to time, date and place. R1 was asked if he ever left the building and R1 nodded his head up and down. R1 was asked how he would leave the building, R1 responded, "by the front door." R1 was asked if he ever heard alarms or bells when he left, R1 shook his head no. On 5/10/12 E1 stated immediately after R1's elopement of 5/6/12 she was notified by staff immediately, facility and area were searched, police were notified and surrounding hospitals called. E1 stated door alarms were checked and working. E1 stated during the initial investigation staff were asked if they had heard any alarms in the evening of 5/6/12, staff reported hearing an alarm at 8:30PM, but was reported to be a family member leaving the facility after visiting hours. On 5/14/12 at 3:12 pm, E13 (CNA) who filled in as a receptionist on Sunday 5/6/12 stated "I worked 4:30 PM-8PM. I announced to visitors that visiting time is over. I know everybody left because I know who comes in and who comes out. I have them sign. E13 stated she then locked outside front door with key and then turned alarm on on the inside lobby door and waited for green light to go on indicating the door is alarmed. (Demonstrated to surveyor by E13 on 5/10/12.) E13 stated she then went upstairs to 2nd floor prior to leaving facility. E13 stated she saw R1 sitting in dining room on 2nd floor (not secured unit.) E1 stated in interview on 5/14/12 she had not completed an investigation of how R1 got of the facility on 5/6/12, because "you guys came in right after. When asked how she thinks R1 got out E1 stated "Don't know." The facility elopement book located at receptionist front desk identifying residents at risk for elopement included a protocol checklist that included the following : "Facility current Missing Resident Protocol Checklist states once it has been determined that there is a possible elopement/missing resident, this checklist may be used to assist in following procedure. A system will be established which will be utilized during drills and in the event of elopement." -If alarm has sounded, check area of alarm to see if any resident is in the surrounding area. -If no one is the area, send one person out the door that alarmed to check the premises, -Designate a room by room check, sending one person to each hallway to initiate a head count. -Have each designated person report the count back to the charge nurse on duty. -If a resident appears to have eloped, then keep one person at main desk to man floor. -Send designated staff to the grounds to search the premises. -Send designated staff throughout facility again checking all rooms, even those that are locked. Check closets, bathrooms, etc. -Ensure that management is notified (Administrator/Director of Nursing) -Contact resident physician -Contact resident family -Contact the police department if the resident is not found within 30 minutes -Try to identify what the resident was wearing and any other identifying items that may be helpful in the search -Chart incident clearly and concisely -Complete incident investigation -Notify Public Health within 24 hours of incident. Facility Elopement Policy Statement states nursing personnel must report and investigate all reports of missing residents. Policy Interpretation and Implementation states under section 4. Should an employee discover that a resident is missing from the facility, he/she should: a. Determine if the resident is out on an authorized leave or pass. IF NOT; b. Make a thorough search of the building(s) and premises. IF NOT LOCATED; c. Notify the Administrator and the Director of Nursing Services; d. Notify the resident's legal representative e. Notify the attending physician f. Notify law enforcement officials g. If necessary, notify volunteer agencies h. Provide search teams with resident identification information; and i. Make an extensive search of the surrounding area. 5. Upon return of the resident to the facility, the Director of Nursing Services or charge nurse should a. Examine the resident for injuries. b. contact the Attending physician and report findings and conditions of the resident C. notify the resident's legal representative d. notify search teams resident has been located. e. Completa and file and incident report f. Make appropriate entries into the resident's medical record: g. Complete investigation report and h. Amend resident's care plan as appropriate. The facility took the following actions to remove the immediacy: Abatement Plan is as follows: -Immediately following the event of 5/6/12, the resident was comprehensively reassessed including but not limited to potential for elopement, and risk for falls. The resident was transferred to the facility's secured unit. R1's care plan was reviewed to ensure that interventions are commensurate with the resident's current condition, care and supervision needs. -Immediately following the event of 5/6/12, resident on the facility's non-secured units were reassessed regarding their respective elopement risk potential and if they are a potential fall risk. Care plans were reviewed to ensure that interventions are commensurate with resident's current condition, care and supervision needs. The following actions were taken immediately following the event of 05/06/12. The facility immediately initiated an investigation of the event circumstances: -All elopement prevention mechanical systems, i.e. alarms, were tested and found to be completely functional 5/7/12 and remain functional. -Staff promptly and appropriately initiated search procedure, internal and external notifications, as required by the facility's Elopement Prevention and Missing Resident policies /procedures 5/6/12. -The facility reviewed the care plans of all residents affected by elopement and those residents who have the potential for elopement to ensure that interventions are in place in accordance with their current condition and supervision needs. (05/07/12). The facility reviewed its Elopement Prevention policies and procedures. -The facility will continue to assess all residents regarding elopement risk potential upon admission/readmission, quarterly and upon change of condition. 05/07/12. -The facility will continue to maintain a folder with pictures/description of residents at high risk for elopement at the reception desk and elsewhere within the facility as applicable. 05/07/12. -Visitor instructional signed regarding resident safety will remain posted at the lobby exit. -All elopement prevention mechanical systems will continue to be checked daily to ensure functionally. -Staff will continue to be inserviced regarding the facility's elopement prevention and missing resident policies/procedures during orientation, at random intervals, and a minimum of annually. -Facility will report all elopement that causes serious harm or injury to IDPH. -The facility staff was trained on policy/procedure regarding constant activation/immediate reactivation of the lobby door locking mechanism following visitor entrance/exit. -New security guard started on May 7, 2012. The guard will work from 8pm-8:30am 7 days a week. Who is stationed on the first floor lobby and ---will be making rounds and door alarm checks on 5/14/12. -The maintenance dept started daily alarm checks on 5/07/12 -All facility staff were inserviced regarding the facility's Elopement Prevention policies/procedures, their respective roles in its implementation, and monitoring resident whereabouts and safety. This started on 5/07/12 and continued through this week each shift and then done weekly. All new hires will be inserviced in all the areas that have been cited. -The Administration/designees will continue to ensure compliance with the facility's Elopement Prevention policies/procedures through ongoing routine daily observation of receptionist performance and adherence to lobby door exiting procedures. -The facility will continue to conduct Elopement Drills to evaluate the longterm effectiveness of the Elopement Prevention program, security system mechanicals, and staff response. Results of Elopement Drills and routine daily observations will continue to be incorporated into the facility Quality Assurance process. Trends/patterns will be evaluated with corrective actions implemented as indicated. The aforementioned actions were taken/implemented immediately following the events of 05/06/12.

Based on interview and record review the facility failed to ensure the supervision and safety of 1 resident (R1). R1 is identified with advanced dementia, aggressive disorder, history of verbal outburst, wandering, and impaired cognition. The facility also failed to develop a plan of care to ensure supervision and monitoring of 1 of 3 residents (R2). R2 is identified with dementia, and a noted history of aggressive behavior. These failures resulted in a physical altercation between R1 and R2 on [DATE]. R1 required emergency hospitalization , and admitted to the hospital with [REDACTED]. Subsequently R1 expired on [DATE] from these injuries. These failures resulted in an Immediate Jeopardy. E1 (Administrator), was notified of the Immediate Jeopardy on February 23, 2012 at 1:20pm via telephone. The Immediate Jeopardy was determined to have begun on February 12, 2012 at 9:00pm when R1 was found lying on the floor by facility staff with bleeding from the right side of his head. Findings include: The facility's initial resident abuse report form dated [DATE] 9:00pm indicates that R1 and R2 were walking in the hallway when the nurse heard yelling in the hallway. The report indicates that the nurse responded to the yelling, and found R1 on the floor with R2 standing next to him. R1 was noted with injuries to the right eye, and right forearm. The facility's final investigation report indicates that on [DATE] at approximately 9:30pm the nurse heard a yell and a sound coming from the hallway. The report indicates that R1 was observed on the floor in the hallway, and that R2 was standing next to R1 in the hallway. The report indicates that R1 was assessed with [REDACTED]. The report indicates that there were no eyewitnesses to the incident. The report also indicates that neither R1 nor R2 has any prior issues with physical aggression/violence toward each other. On [DATE] at 1:00pm E1 (administrator/Abuse coordinator), said that she was notified by phone on Sunday [DATE] around 9:10pm that R1 and R2 were involved in an incident. E1 said that she was told that there were no eyewitnesses to the incident, and that R1 was found on the floor with a laceration. E1 said that she was familiar with both residents and that she was unaware of either R1/R2 having a history of aggressive behavior. E1 said that she was told that R2 was observed just standing near R1, with no weapon or nothing in his hands. E1 said that both R1/R2 were oriented to name only. E1 said that R1 was found on the floor facility staff. E1 said there was no indication that R1 was struck by R2. According to the clinical record R2 was admitted to the facility with a [DIAGNOSES REDACTED]. (R8). According to the social service notes dated [DATE] 6:03pm R2 was noted being pushed by R8 in the dining room, and that R2 in turn pushed R8 onto the floor. The note also indicates that R2's plan of care will be updated. According to R2's current comprehensive plan of care there are no interventions/approaches noted addressing R2's altercation and act of physical aggression toward R8. According to the clinical record there was no aggression risk assessment done or presented to survey team on [DATE] when the incident was brought the facility's attention. On [DATE] E2 (Director of Nursing), said that she is familiar with both R1/R2. E2 said that R1 has displayed behaviors of constant wandering, verbal outburst, and signs of forgetfulness. E2 said that she doesn't know if R1 was able to protect himself from others knowing his history of verbal outburst, and aggressive disorder. Staffing for [DATE] at the time of the incident was discussed with E2, and E2 said normal staffing for the 3rd floor pavilion was (1) nurse, and (2) certified nurse aide. E2 said that one of the two cna's should have been in the dining room monitoring residents in that location, and the other cna should have been monitoring residents that are known to wander throughout the nursing unit. E2 identified both R1/R2 with behaviors of wandering the nursing unit. E2 said that the cna not in the dining room usually sits in a chair near the door way of the dining room to monitor and supervise residents wandering the unit. E2 was told that E4 (nurse) sitting at the nurse station, and that E5 (certified nurse aide), was inside the dining room monitoring residents. E2 said that E6 (certified nurse aide), should have been seated near the dining room supervising/monitoring residents wandering the hallways. E2 said that she was aware of R1's behavior of verbal outburst, and wandering, E2 said "that is why we have cna seated in the hallway to monitor". On [DATE] at 9:45am E4 (nurse), said that she was working the 3rd floor pavilion on the 3:00pm to 11:30pm shift on [DATE]. E4 said prior to the incident between R1/R2, there were no unusual occurrences. E4 said around 8:40pm R1 was up wandering the nursing unit, and that R2 was standing between rooms 354 and 355. E4 indicated that she was seated at the nurse station, and that she heard R2 raise his voice. E4 said that she couldn't tell what R2 said, however E4 said that she got up to go and investigate R2's yelling, and said that she heard a loud noise. E4 said that as she rounded the corner R1 was lying on the floor on his right side and blood on the floor. E4 said that she immediately called 911, and for all nurses to come to the third floor stat. E4 said she was quickly assisted by the other nurses and assessed R1 with a laceration over the right eye with moderate amount of bleeding, E4 said that R1's right eye was swollen. E4 said she and the other nurses applied first aide. E4 said that R2 was standing there but wandered off into another room. E4 said that E11 (social service), also came to the 3rd floor pavilion and took R2 to his own room and provide 1:1 supervision. E4 said that R1 initially was un-responsive. E4 said that when she asked R2 what happened R2 said that he didn't know. E4 said that R1 was noted for having behaviors of wandering around the nursing unit, E4 also said that R1 would have verbal outburst of cursing at other residents/staff when walking by. E4 said that she was unaware of R1 or R2 ever being involved in any other physical altercations. E4 said there were three staff members working the nursing unit on [DATE] (E4, E5 and E6). E4 said around the time of the incident there should have been 1 certified nurses aide in the dining room monitoring residents as they watched television, and another certified nurse aide sitting near the door way of the dining room to monitor and supervise residents wandering the hallways. E4 said the certified nurse aides are responsible for monitoring all residents regardless of there assignments. E4 said that E5 was stationed inside of the dining room, and E6 was assigned to sit in the hallway to monitor residents wandering around the nursing units. E4 said she didn't recall seeing E6 sitting in the hallway the evening of [DATE]. E4 said that E6 should have been sitting in a position to see the entire hallway and able to see the section of hallway where R1/R2 were involved in the altercation on 2//,[DATE]. On [DATE] at 4:00pm via telephone E4 said that she was unaware of R2 being involved in other altercation, however E4 said that she has heard things regarding R2. E4 said that she was unaware of any unusual behaviors displayed by R2. E4 said that behaviors and interventions are located and reviewed on residents plan care. E4 said that if a behavior is not noted on the plan of care she wouldn't be aware of it. E4 said that there was no supervision or monitoring in place for R1/R2. E4 said that after finding R1 on the floor she yelled for help and paged all nurses to the third floor pavilion stat. E4 said that the (3) nurses from the 1st and 2nd floor arrived to the 3rd floor at the same time E5 and E6 arrived, both which were working on the 3rd floor pavilion. On [DATE] at 3:30pm E5 (certified nurse aide), said that on [DATE] between 8:00pm and 9:00pm, she was assigned to the dining room to monitor residents that were in there. E5 said there were about 3 residents in the dining room. E5 said that she heard E4 call for help and she went into the hallway and observed R1 lying on the floor not moving unconscious with blood coming from his head. E5 said that R2 was in the hallway pacing back and forth next to R1. E5 said that there was nothing noted in R2's hand, and no blood noted on R2's hand. E5 said that both R1/R2 has a history of wandering the nursing unit. E5 said that she has witnessed R2 getting agitated but not aggressive. E5 said that E6 was sitting in a chair in the doorway of the dining room facing inside the dining room. E5 said that E6 should be facing the hallway to monitor residents known for wandering the nursing unit. E5 said that R1 has a history of wandering the nursing unit, verbal outburst (cursing at staff/residents). E5 said that she couldn't recall R1/R2 being involved in any other physical altercations. E5 said she wasn't aware of any supervision or monitoring in place for R1/R2. E5 said that she was told by E4 that R2 hit R1 in the face. On [DATE] at 2:30pm E6 said that she was working on the 3rd floor pavilion. E6 said around 7:00pm to 8:00pm said she was seated near the dining room and was monitoring residents inside the dining room and, monitoring the hallways. E6 said that she was facing the dining room at the time of the incident between R1/R2. E6 also said that she was not assigned to R1/R2, and said that she was monitoring her assigned residents. E6 said that she heard E4 hollering her name, E6 said that she got up, and saw R1 lying on the floor face down. E6 said that she observed blood on the floor "lots of Blood" coming from R1's head. E6 said that she didn't hear or see anything prior to E4 calling her name. E6 showed the surveyor exactly where she was seated at the time of the incident. The seat was in direct line and direct view of the incident. However E6 denied seeing R1/R2, or hearing a verbal or physical altercation between R1/ R2 prior to E4 calling her name. On [DATE] at 3:25pm E7(Nurse) said that she has never witnessed R2 display any behavior of aggression, however E7 said that she has heard that R2 could be aggressive. E7 said that R1 has a history of wandering the nursing unit, and could be touchy feeling. E7 said that R1's touching could at times be inappropriate. E7 said that E4 said that she heard R2 hit R1 and then got up and found R1 lying on the floor bleeding. E7 said that normal staffing for the 3rd floor pavilion is (1) nurse and (2) cna's. E7 said that (1) cna is assigned to be in the dining room and the other cna is assigned to sit and monitor wandering residents in the hallway. E7 said that R2 was escorted off the nursing unit by E11 after the incident. E7 said that she asked R2 what happened and said that R2 was very emotional and looked as if he wanted to cry. E7 said that R2 was displaying a remorseful disposition. E7 said this was side of R2 that she never witnessed before. On [DATE] at 2:30pm E11 (Social Service), said that he heard a page from E4 to come to the 3rd floor pavilion stat. E11 said that when he arrived to the 3rd floor, R1 was on the floor being attended to by nursing staff. E11 said that R2 was standing in the hallway gesturing his shoulders upward motion. E11 said that he redirected R2 to a room and asked R2 what happened, and said that R2 said that we (R1/R2) had some issues over some water bottles. E11 said that he was told by the local police department that R1 was punched in the face by R2. E11 said that he petitioned R2 out for a psychiatric evaluation. E11 said that he completed the petition to discharge R2 involuntarily due to his aggression on R1. According to the social service progress note dated [DATE] 10:10pm E11 indicated that R2 was assessed to be alert and oriented to name only, and couldn't recall any reason for him being upset. The note indicates that R2 said "we had a skirmish" the note indicates that R2 was disoriented. The note also indicates that due to the physical nature of the incident R2 will be sent to the hospital for evaluation. According to the petition for involuntary admission completed by E11 and signed by (E4, E6, and E11). The petition indicates that both R1/R2 were walking down the hall, and R2 punched R1 in the face. The petition denotes that this aggression was unprovoked and due to R2's [DIAGNOSES REDACTED]. On [DATE] via telephone at 10:45am E18 (nurse), said that it is normal staffing on the 3rd floor pavilion (1) nurse and (2) certified nurse aides, and at times an activity aide. However E18 said that (1) cna should monitor the dining room, while the other cna sits in a chair near the dining room and monitors the hallway for wandering residents along with the nurse which should also be monitoring the hallway for wandering residents. E18 said the cna seated near the dining room should be able to view the length of hallway. E18 also said that R1 has a history of wandering and verbal outburst toward co-peers/staff. On [DATE] at 3:00pm E8 (Social Service Director), said that R2 had no known history of abnormal behaviors, and that R1 had a history of [REDACTED]. E8 said that he wasn't aware of any physical altercations involving R2. However E8 said that he recalls R1 brushing up against someone a few weeks ago. E8 said that brushing up against some one is not a physical altercation. However E8 said that when residents are involved in a physical altercation the resident plan of care is reviewed and new interventions/approaches are implemented. Both current plans and progress notes for R1/R2 were reviewed with E8. R2's social service progress notes were reviewed with E8 dated [DATE] denotes that R2 is observed displaying inappropriate behavior toward another resident, R2 is noted as following another residents around, and laying down next to resident. R2 is also noted as trying to enter another resident room. The note indicates that R2's care plan will updated. Social service note dated [DATE] indicates that R2 was pushed by R8, and in turn R2 pushed R8 onto the floor, again the note indicates that R2's plan of care will be updated. According to R2's current plan of care R2 has no plan to monitor/supervise R2's behavior of wandering into other residents room, no plan to monitor/supervise R2's inappropriate behavior with other residents, and no plan monitor/supervise R2's history of aggression toward other residents until after R2's incident dated [DATE] with R1. According to R1's current plan of care problem dated [DATE] indicated R1 was involved in a physical altercation, indicating R1 slapped another resident in the chest area, according to the plan of care there were no approaches to monitor/supervise R1 for acts of aggression, there were no approaches/interventions for staff to monitor/supervise R1 for behavior of wandering the nursing unit. The current plan of care failed to indicate a plan to monitor/supervise R1 for verbal outburst to include cursing at co-peers. On [DATE] at 8:45am E1 (Administrator), said that the facility did not have a policy or plan to address coping with physically aggressive behavior. On [DATE] via telephone Z3 said that he was notified that R1 was involved in a incident on [DATE] and that R1 sustained a cut over his right eye by a male member from facility staff. Z3 was unable to recall the name. Z3 said 20 minutes later the same male staff member called him back and said that R1 was severely injured and needed to go to the hospital for evaluation. Z1 said that on [DATE] 1:00am he was notified by the hospital of the proposed treatment plan, and then at 3:30am the hospital inform Z3 of R1's condition indicating that R1 was brain dead. Z3 said that R1 subsequently expired [DATE] related to the sustained injuries. Z3 also said that he was told by local police that the incident was between R1/R2 was ruled a homicide due to the nature of the injury was no due to a fall, but was due to a blow to the head. According to the hospital record history of present illness R1 is a [AGE] year old male with [DIAGNOSES REDACTED]. R1 was sent to the hospital for evaluation status [REDACTED]. Indicated right parietal and right frontal parenchymal hematoma with smaller contusions in the left frontal region. Diffuse subarachnoid hemorrhage and large intraventricular hemorrhage also noted. 2). Effacement of sulci, especially on the right, about 12mm midline shift to the let, subfalcine and pending right to left uncal herniation, entrapment of the left temporal horn with enlarged left lateral ventricle, and about 6 mm inferior displacement of cerebellar tonsils through the foramen magnum. 3). Right maxillary sinus anterior and posterior wall comminuted fractures as as the right orbital floor fracture. Protosis on the right with right hemifacial soft tissue swelling/hematoma. 4). External drainage catheter in the right middle cranial fossa. The immediate Jeopardy was removed on February 29, 2012. However the facility still remains out of compliance at a scope and severity level 2 because of the need to allow for the facility to complete staff in-service, and to evaluate the effectiveness of the new policy and procedure for Dementia residents at risk for aggression at the facility. The Facility provided the following plan: REPORT OF CORRECTION PREPARATION AND/OR EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OF THE CONVICTIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES REQUIRED BY THE PROVISIONS OF THE FEDERAL AND STATE LAW. F 323 483.25 (h) ACCIDENTS AND SUPERVISION The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Please accept the following as the facility ' s Abatement for The administration will implement systems that will permit the facility to maintain substantial compliance with all regulatory requirements. 1)All of the residents, 19 of them on the 3rd floor unit were reassessed for potential risk of aggressive behavior. This started on by the LCSW,[DATE]/-[DATE] The facility will also start a NEW assessment tool [DATE] to track and trend behaviors to include but not limited to .. Anxiety &Agitation, Catastrophic reactions,Combativeness ,aggression ,sundowning ,inappropriate sexual responses,repetitious movements, wandering & pacing,sleep disturbance and nocturnal wandering, Demonstrations of hallucinations,aberrations,and delusional, Yelling,calling ,and asking repetitious questions ,demonstration withdrawn,apathy,and inability to imitate activity. 2) All residents triggering at risk for potential aggressive behavior have had their care plan reviewed and modified if needed to reflect new monitoring policy. This started [DATE] by the IDT. Once the facility has completed a NEW assessment tool [DATE] to track and trend behaviors to include but not limited to .. Anxiety &Agitation, Catastrophic reactions,Combativeness ,aggression ,sundowning ,inappropriate sexual responses,repetitious movements, wandering & pacing,sleep disturbance and nocturnal wandering, Demonstrations of hallucinations,aberrations,and delusional,Yelling,calling ,and asking repetitious questions ,demonstration withdrawn,apathy,and inability to imitate activity. The IDT will review the track &trend sheet describe behavior, before ,during behavior. What was the residents reaction after behavior.(what did staff do or say. What did the resident do or say) Possible triggers (what do you think caused the behavior) What seems to increase this behavior,what seems to decrease this behavior. What is the approaches for care based on dementia care best practices as identified by the Alzheimer association. This will be established on [DATE] 3). New Policy and Procedures for Dementia residents identified at risk for aggression. This has been reviewed by the team on [DATE].This policy will in include but not limited Anxiety &Agitation, Catastrophic reactions,Combativeness ,aggression ,sundowning ,inappropriate sexual responses,repetitious movements, wandering & pacing,sleep disturbance and nocturnal wandering, Demonstrations of hallucinations,aberrations,and delusional,Yelling,calling ,and asking repetitious questions ,demonstration withdrawn,apathy,and inability to imitate activity. The IDT will review the track &trend sheet describe behavior, before ,during behavior. What was the residents reaction after behavior.(what did staff do or say. What did the resident do or say) Possible triggers (what do you think caused the behavior) What seems to increase this behavior,what seems to decrease this behavior. What is the approaches for care based on dementia care best practices as identified by the Alzheimer association. 4) All staff have been in-serviced on A )policy & abuse prevention and reporting B)Guidelines for coping with disruptive behaviors, C)Possible meanings of behaviors, D)The NEW 72 hr monitoring sheet , E) Behaviors and how to respond when dementia causes unpredictable,responding to behaviors F)Wandering behavior preparing for it and preventing it. G) Supervision of wandering residents This started [DATE] and repeated on [DATE], [DATE] the next week each shift and will be repeated weekly then after for the next 6 months 5) New Monitoring sheet were established on [DATE] .This 72 hours sheet will detail behaviors of residents who have been reported of any behavior outside there normal behaviors , examples are Anxiety &Agitation, Catastrophic reactions,Combativeness,aggression,sundowning ,inappropriate sexual responses,repetitious movements, wandering & pacing,sleep disturbance and nocturnal wandering, Demonstrations of hallucinations,aberrations,and delusional,Yelling,calling ,and asking repetitious questions ,demonstration withdrawn,apathy,and inability to imitate activity. This will be audit by ADM &DON will monitor along with the IDT to ensure a Care plan is established for said behaviors. What approaches will work based on dementia care best practices as identified by the Alzheimer association. 6) A weekly QA meetings to evaluate the behavioral track and trending,the outcomes of all care plans and the continued review of education, policy&procedure for addition improvement and the preventing of further occurrence the follow will be apart of this QA Medical Director & Our NEW Psychiatric Medical Director,Administrator DON , LCSW. IDT, Charge Nurse. This will be done for the next 6 months .