Every finding on record at Princeton Rehab & HCC

F600Based on interview and record review, the facility failed to follow its policy to affirm the right of residents (R4 and R5) to be free from abuse. On May 16, 2026, R4 hit/struck R5 on the face and head, resulting in R4 sustaining a fracture of the right hand fifth metacarpal. A total of six residents were reviewed for abuse. The findings include: R4's face sheet shows an admission date of 5/22/24, with diagnoses including-but not limited to-Bipolar disorder, schizoaffective disorder, and Anxiety disorder. The Minimum Data Set (MDS) dated [DATE] indicates R4 is cognitively intact. R5's face sheet shows admit date on 8/14/24 with diagnoses not limited to Bipolar disorder, Schizophrenia, Legal blindness, Unspecified lack of expected normal physiological development in Childhood, Developmental disorder of scholastic skills, Restlessness and agitation, Psychotic disorder with hallucinations, Essential (primary) hypertension. The MDS dated [DATE] indicates R5's cognition is moderately impaired. On 7/12/26 at 10:48AM Observed R4 up and about, ambulatory, alert, and verbally responsive. He appeared well groomed, comfortable, and guarded. R4 stated he remembers the incident involving R5. He reported feeling aggravated by R5 but declined to provide full details. R4 stated he does not feel comfortable speaking with the surveyor and does not wish to discuss the incident from 5/16/26 further. On 7/12/26 At 11:17AM Observed R5 up and about, ambulatory with a steady gait, appearing comfortable and well groomed. R5 was wearing a safety helmet/head protector. He was able to recall the incident on 5/16/26 involving R4. R5 stated he attempted to give R4 a fist bump when R4 suddenly attacked him. He reported that R4 struck / hit him on the head and face and demonstrated the action to the surveyor by mimicking air punches to his head and face. R5 stated he did not attack, hit, or fight back and that staff immediately separated them. He reported the incident that occurred near the nurse's station. R5 stated he was not hurt and was wearing safety helmet/head protector at the time of the incident. On 7/12/26 AT 11:04AM V5 (LPN / Licensed Practical Nurse) stated she was the nurse on duty during the incident between R4 and R5 on 5/16/26 around 12 PM. She reported that she was providing resident care when she was notified of the incident by V7 (LPN); she did not personally witness the event. V5 stated that V7 informed her R5 attempted to give R4 a fist bump, and R4 then struck R5 with his fist, hitting R5's head and face. V5 stated the incident occurred near the nurse's station. She stated R4 and R5 were immediately separated. V5 reported the incident was an example of physical abuse because R4 struck / hit R5. V5 reported she notified V19 (R4's physician), who ordered R4's transfer to the hospital for a psychiatric evaluation due to aggressive behavior. She stated R4 was the aggressor. V5 reported that when R4 returned from the hospital, he had a right hand fracture and was wearing a brace. She stated the fracture was caused by the physical altercation, specifically the force used when hitting another resident. She reported that R4 has paranoia and at times refuses to talk or accept care. On 7/12/26 AT 11:24AM V14 (Activity Aide) stated she heard the incident between R4 and R5. She reported that R4 walked up to R5 and punched him with his fist on the face/head. V14 stated that hitting, punching, or striking a resident is an example of physical abuse. On 7/12/26 At 11:31AM V7 (LPN / Licensed Practical Nurse) stated she was able to recall the incident on 5/16/26 involving R4 and R5. She reported that she was near the nurse's station when she heard a commotion and observed R4 punching R5 with a closed fist, striking or hitting R5's head and face. She stated the incident occurred very quickly, and she immediately separated R4 and R5. V7 stated that R5 had been attempting to give R4 a fist bump, but R4 misinterpreted the gesture and suddenly punched / hit R5. She reported that the incident occurred around lunchtime/mid day. V7 identified punching or hitting as an example of physical abuse. On 7/13/26 At 9:22AM V38 (CNA / Certified Nursing Assistant) stated he did not witness the incident between R4 and R5. He reported that he was informed by a nurse that a physical altercation between R4 and R5 resulted in R4 being hospitalized . He stated he was told that R4 punched or hit R5 but did not know which part of the body was struck. V38 stated that punching or hitting is an example of physical abuse. On 7/13/26 At 9:33AM V19 (R4's Physician) stated he was made aware of the incident between R4 and another resident on 5/16/26. He reported that R4 was sent to the emergency department for a psychiatric evaluation due to the physical altercation. V19 stated R4 had a fight with another resident and was considered a danger to himself and to others, which warranted hospital transfer. V19 stated he was aware that R4 sustained a fracture to one of the fingers on his right hand, although he could not recall which specific finger. He reported that R4 was using a brace due to the fracture. V19 stated the fracture was most likely caused by trauma from the physical altercation, specifically from punching or hitting. According to V19, R4 could have broken one of his fingers while punching the other resident. On 7/13/26 At 9:42AM V6 (PMNP / Psychiatric Mental Health Nurse Practitioner) stated she was made aware that R4 had been physically aggressive and made physical contact with R5. She reported that R4 required hospitalization due to physical aggression. V6 stated she observed R4 wearing a brace-she believed in the right hand-after he returned from the hospital. The surveyor reviewed V6's notes, which documented that R4 was hitting or swinging at R5. V6 stated the fracture could possibly have resulted from physical aggression, such as hitting or swinging, but she was not fully certain of the exact cause. She noted that the fracture would depend on the severity or force R4 used during the swinging or hitting. V6 stated that hitting or swinging is an example of physical abuse. On 7/13/26 At 10:31AM V4 (Director of Behavioral Health) stated she was informed that there had been a physical incident between R4 and R5. She stated she was unable to speak with R4 because he was hospitalized at the time. V4 stated she was able to speak with R5 after the incident. R5 told her he attempted to greet R4 with a fist bump, and R4 became upset and hit him on the head or face. On 7/13/26 At 10:59AM V2 (DON / Director of Nursing) stated she was informed of the alleged physical aggression between R4 and R5. After reviewing R4's electronic health record (EHR) with V2, it was confirmed that R4 hit another resident. She stated she did not witness the incident. When R4 returned from the hospital, she observed he was wearing a brace on his right hand; however, she stated there was no documentation from the hospital and described it as an alleged fracture. V2 stated that, in general, hitting is considered physical abuse, but she did not witness the incident. She stated the goal is to ensure residents remain safe and free from abuse. On 7/13/26 At 11:34AM V1 (Administrator) stated he began working in the facility on Friday, 7/10/26, and serves as the Abuse Coordinator. V1 stated he was made aware of the 5/16/26 incident between R4 and R5. He reported he was briefed that R5 attempted a fist bump, which R4 misinterpreted, leading R4 to lash out or possibly swing defensively. He reported swinging or attempting to swing could constitute hitting, though he was unsure whether physical contact occurred. V1 stated hitting is an example of physical abuse. He stated that depending on the force used during hitting or swinging, such an action could cause a broken finger or hand. R4's progress notes dated 5/16/26 show in part: R4 hit another resident. R4 stated the other resident was trying to give him a fist bump and he started swinging. MD (Medical Doctor) notified and gave order to send R4 to hospital. R5's progress notes dated 5/16/2026 show in part: R5 was standing in the hall talking when another resident walked up and started to hit him in his head and facial area. Nurses Note dated 5/21/2026 shows in part: R4 readmitted to facility from Hospital. R4 wearing brace to right hand. Nurses Note dated 5/22/2026 shows in part: NP / Nurse Practitioner made aware of resident Fracture of the right hand and presently on brace. Nurses Note dated 5/26/2026 shows in part: R4 observed wearing brace to right hand due to right hand fracture. Radiology Note dated 5/28/2026 shows in part: X-ray exam of hand. FINDINGS RIGHT HAND: Examination reveals mild soft tissue swelling with fracture of the proximal shaft of the fifth metacarpal with no significant displacement. Nurse Practitioner notes dated 5/28/2026 show in part: R4 is calm and cooperative sitting up in chair in dining room. R4 has brace to right arm due to fracture of the proximal shaft of the fifth metacarpal with no significant displacement. R4 has ortho appointment scheduled. V6's (Psychiatric - Mental Health Nurse Practitioner) notes dated 6/3/2026 show in part: Recent records indicate R4 was transferred to the hospital for psychiatric evaluation after exhibiting behavioral decompensation, including a physically aggressive episode where he hit another resident, starting to swing when the other resident tried to give him a fist bump, which led to their immediate separation and an order to send him to Hospital. R4 subsequently returned to the facility on 5/21/26 following psychiatric stabilization. Care plan dated 2/3/2026 shows in part: R5 is at risk for abuse related to: Diagnosis of serious mental illness, history of self-injurious, history of socially inappropriate behavior, and diagnosis of legal blindness. R5 will remain safe, calm and free from abuse. Facility's final investigation report submitted to State Agency shows in part: On 5/16/26, It was reported that R5 was walking in the hallway and was moving close to his peer. He stuck out his hand to greet his peer trying to give him a fist bump; however, R4 stated that he misconceived it to be threatening and hit his co peer in self-defense. Facility's abuse policy dated 03/25 shows in part: this facility affirms the right of our residents to be free from abuse. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment.

Based on interviews and records review, the facility failed to ensure resident right to maintain family authorized oversight by covering an in-room electronic monitoring device for one resident (R5) of five reviewed during patient care in a sample if 15.Findings include:R5 is a closed record and was not residing in the facility during this investigation. Current face sheet documents R5's medical diagnosis includes but not limited to: Chronic Obstructive Pulmonary disease with (acute) exacerbation, Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, Osteochondropathy, unspecified, Right ankle and foot. MDS (Minimum Data Set) section C-Cognitive abilities [DATE], documents R5's Brief Interview for Mental Status (BIMS) as 00/00 indicating R5 has severe cognitive impairment.On 06/12/2026 at 11:15AM, V33(Certified Nursing Assistant-CNA) was reached by phone and stated she usually and staff (no names provided) covered R5's camera when in R5's room. V33 stated on 4/19/2026, she went to change R5 and covered the recording camera. She did this to provide privacy for R5's perineal area to prevent exposing R5's private area to anyone watching the camera. V33 stated residents have a right to have a recording device in their rooms.V33 stated there was no signage on R5's door stating R5's room was under video surveillance. V33 stated the facility did not notify her there was a recording camera in R5's room and no one asked her if she (V33) wanted to be recorded. V33 the facility did not provide her education on video surveillance in residents room and what to do.V33 stated she was suspended during facility investigations following the incident with covering the camera and R5 being noted with a bruise on the forehead on the day V33 took care of R5. V33 stated she was reinstated after investigations and was not disciplined but did not work with R5 anymore.R5's Facility Reported Incident Report (FRI) dated 4/20/2026, documents V33 stated she worked with R5 on 4/19/2026 and covered the camera placed in R5's room by family while providing care.On 06/11/2026 at 4:32PM, V1 (Administrator) stated V33 knew it was wrong to cover the camera but felt uncomfortable providing perineal care with the camera recording. V1 stated the monitoring camera contract was signed by V35(R 5's Family member) on 03/21/2026. The date on some of the pages for the consent document is 4/21/2026, but that was the wrong date. V1 stated the recording camera consent start date was 3/21/2026.Policy titled Guidelines for electronic monitoring, no date documents:-Facility staff may not touch the electronic surveillance device.R5's Electronic Monitoring Notification and Consent agreement dated 3/21/2026 documents:-I understand I may place conditions or restrictions on the use of the electronic monitoring device. The conditions or restrictions I want to place on the electronic monitoring are (check one or more boxes).-V35 did not check the box to turn camera off during patient care.-Policy titled Resident Rights, dated 05/1999, documents:Staff shall demonstrate knowledge of the residents rights by respecting them at all times.

Based on observation, interview, and record review the facility failed to ensure staff followed proper food safety procedures (did not clean the thermometer with alcohol between uses). This failure have the potential to affect all 181 residents receiving an oral diet in the facility. Findings include: On 3/16/26 V10 (Dietary Manager) presented a list of 181 residents who were present in the facility on 3/15/26 receiving an oral diet. On 3/15/26 at 12:07 pm, Surveyor observed V11 (Dietary Aide) during the third floor dining perform temperature checks of the lunch meal at the steam table. Surveyor observed V11 with the following: Surveyor observed V11 place a thermometer inside of a Western Style Burger and register a temperature of 108 degrees Fahrenheit (F), remove the thermometer, grab a white napkin from a table next to the steam table area, wipe the thermometer that was used for the Western Style Burger, then proceed to shake the excess food from inside of the thermometer into a sink, and rinse the thermometer under water before placing the thermometer into a pan with broccoli. Surveyor then observed V11 place a thermometer into a pan of broccoli that registered at 150 degrees F, remove thermometer from the broccoli, wipe it with a white napkin from the steam table area, rinse the thermometer under water in a sink then proceed to stick the thermometer into a pan with French fries. Next, Surveyor observed V11 place a thermometer into a pan of puree meat that registered at 114 degrees F, remove thermometer from the pureed meat wipe it with a white napkin from the steam table area, rinse the thermometer under water in a sink then proceed to stick the thermometer into a pan of puree broccoli. On 3/15/26 at 12:18 pm, Surveyor interviewed V11 regarding cleaning of the food temperature thermometer and V11 stated that he did not need to use alcohol to sanitize the food thermometer in between food items. V11 stated, I sanitize the thermometer by making sure I wiped the thermometer then rinse with water. On 3/15/26 at 12:41 pm, V10 (Dietary Manager) stated that the food thermometer should be wiped with alcohol to sanitize the thermometer in between taking food temperatures. V10 explained that if the food thermometer is not properly sanitized it can cause cross contamination of the food. The facility document dated 1/2015 and titled Dietary Aide documents in part: Job summary: To provide assistance in all dietary functions as directed, in accordance with current Federal, State, and local standard, guidelines and regulation, and facility policies . IV. Essential Functions: A. Assure that all dietary procedures are followed in accordance with established policies . C. Maintain the care and use of supplies, equipment and appearance of work areas in a clean, sanitary, and orderly fashion. The facility's document dated 7/18 and titled Taking Temperatures of Food documents, in part: Policy: Food temperatures will be monitored. Purpose: To reduce the risk of food borne illness from undercooking or improper holding. Procedure: 4. After taking the temperature of any food, sanitize the probe to reduce the risk of cross contamination. The facility document titled Diet Type Report shows that the facility has 181 residents receiving an oral diet.

Based on observation, interview, and record review the facility failed to failed to ensure a homelike environment for three residents (R34, R77 and R192). Additionaly, the facility failed to ensure the lint trap was in good repair; and failed to empty the lint compartment in an effort to provide a safe environment to residents. These failures have the potential to affect 188 residents in the facility. Findings include: R34's Face sheet documents that R34 has a diagnosis which include but not limited to paranoid schizophrenia, schizoaffective disorder, bipolar and insomnia, R34's Brief Mental Status Interview (BIMS) dated 3/6/26 shows a score of 15 which indicates that R34 is cognitively intact. R192's Face sheet documents that R192 has a diagnosis which include but not limited to paranoid schizophrenia, and bipolar. R192's Brief Mental Status Interview (BIMS) dated 12/9/25 shows a score of 15 which indicates that R192 is cognitively intact. On 3/15/26 at 10:43 am, Surveyor observed R34 and R192's room ceiling tiles with multiple brown stained spots that were loose and building throughout the room ceiling. R34 and R192 stated that their ceiling tile are always stained. On 03/16/26 at 2:49 am, V23 (Maintenance Director) stated that he is responsible for inspecting and replacing the ceiling tiles in the residents rooms when they become stained or damaged. V23 explained that ceiling tiles become damaged or stained when there is a leak in the ceiling. V23 stated that he is aware of the ceiling tiles in R34 and R192's room and that a roofing company repaired the leak in their room last summer. V23 stated that he will contact the roofing company to repair the leak that causes the damage and staining ceiling tiles in R34 and R192's room again. V23 then explained if the ceiling tiles in residents rooms become stained or damaged, the ceiling tiles get weak, can fall down, and injure a resident. The facility's document dated 1/2015 and titled Building Manager documents, in part: Job Summary: Direct, plans, coordinates, and administer the overall operation of the Maintenance Department in accordance with federal, state, and local laws, and regulations which govern a long term facility. Work involves the coordination of safety and maintenance needs to ensure a comfortable and safe environment . IV. Essential Functions: A. Facility Safety- Ensures high standards of safety are developed, met, and maintained in accordance with all facility policy and procedure; and applicable federal, state, and local laws, rules, and regulations. 2. Arranges and coordinates, and schedules internal safety inspections and determines appropriate corrective actions, when necessary. On 03/15/2026 at 11:30 am tour of R77's room, brown stains observed in two white ceiling panels located near R77's window. On 03/15/2025 at 11:35am R77 stated water is leaking down from the third floor in that area and that is why there are brown stains on the tiles. R77's BIMS (Brief Interview for Mental Status) dated 12/22 /2025, documents R77's has a BIMS score of 15, indicating R77's cognition is intact. On 03/17/2026 at 11:37 am surveyor requested V23 (Building Manager/Maintenance) to come into R77's room. V23 arrived in R77's room and observed the brown stains on the ceiling tiles. V23 stated the water leaks down from the third floor and causes brown stains in the ceiling tiles. The maintenance staff is responsible for changing the damaged tiles. I have received new tiles, and I will be changing them out today. V23 stated this does not represent a homelike environment for the residents; but things do happen. Findings include: On 3/16/26 at 2:20 pm, tour of the laundry room with V28 Laundry Aide. There were three washers and three dryers in the laundry room. All three dryer's lint traps were reviewed. The right dryer's lint screen was not attached and was hanging were lint was observed near a vent. Surveyor asked V28 should the lint screen be hanging down and not attached. V28 stated, The lint screen should not be hanging, and it is supposed to be attached to catch the lint. The linen traps are cleaned at the end of every shift and should be documented in the lint trap cleaning book. The lint trap cleaning book was reviewed from January 2026 to March 2026 with V28 and multiple dates were noted blank. V28 stated, I was not working on the days the book was not signed and the reason the lint traps are cleaned is to prevent a fire. Dates noted blank for January 2026 were the 9th, 13th, 25th and the 30th. Dates noted blank for February 2026 were the 14th, 17th, 22nd 25th. Dates noted blank for March were the 13th. On 3/16/26 at 2:30 pm, V28 and V23 Building Manager/ Laundry were in the laundry room. Surveyor asked V23 if the lint screen should be hanging and not catching the lint? V23 stated, The lint trap screen should not be hanging, and the staff should have notified me immediately. The dryer's get hot, and the three dryer's vent goes out then up to one vent on the roof. The lint traps should be cleaned after each shift. A buildup of lint can catch fire. V23 attached the lint screen at that time. V28 stated, I should have notified him (V23) when I saw it, Facility policy titled Laundry Procedures dated 6/18, documents in part, Keep the Machinery Functioning: Report to the Building Manager any equipment breakdown.Dryer lint traps must be cleaned each shift. A clogged lint trap is not only a fire hazard but will lessen the drying efficiency of the dryer. Facility's job description titled Laundry Aide dated 1/2015, documents in part, Essential Functions: B. Preform laundry functions and tasks in accordance with written laundry procedures and verbal instructions from the laundry Superviosor or Administration. F. Immediately report any safety concerns and broken equipment to the Laundry Supervisor or Building Manager.

Based on observation, interview, and record review the facility failed to ensure that residents had a privacy curtain which extended around the bed. This failure affected four residents (R141, R146, R157, and R159) in the total sample of 67 residents. Findings include: R141's Face sheet documents that R141 has a diagnosis which include but not limited to paranoid schizophrenia. R141's Brief Mental Status Interview (BIMS) dated 12/30/26 shows a score of 15 which indicates that R141 is cognitively intact. R146's Face sheet documents that R146 has a diagnosis which include but not limited to bipolar disorder current episode hypomanic, and insomnia. R146's Brief Mental Status Interview (BIMS) dated 12/15/25 with a score of 9 which indicates that R146 has some cognitive impairments. R157's Face sheet documents that 157 has a diagnosis which include but not limited to bipolar, anxiety, and schizoaffective disorder. R157's Brief Mental Status Interview (BIMS) dated 1/26/26 with a score of 14 which indicates that R157 is cognitively intact. R159's Face sheet documents that R159 has a diagnosis which include but not limited to unspecified mood disorder and bipolar. R159's Brief Mental Status Interview (BIMS) dated 1/30/26 with a score of 11 which indicates that R159 has some cognitive impairments On 3/15/26 at 11:08 am, Surveyor observed R146's room without a privacy curtain. R146 stated that he has not had a privacy curtain for six months and would like a privacy curtain in his room. On 3/15/26 at 11:09 am, Surveyor observed R159's room without a privacy curtain. R159 was not able to state how long his privacy curtain was missing, however, he verbalized that he would like a privacy curtain. On 3/15/26 at 11:11 am, Surveyor observed R157's room without a privacy curtain. R157 stated that he has been in his current room for five months without a privacy curtain. R157 stated that since he is without a privacy curtain he does not change clothing in the open space by his bed and that he only changes his clothes in the bathroom. On 3/15/26 at 11:14 am, Surveyor observed R141's room without a privacy curtain. R141 was not able to state how long he has been without a privacy curtain and verbalized that he would like a privacy curtain for his privacy. On 3/16/26 at 9:30 am surveyor observed that R141, R146, R157 and R159 rooms remain without a privacy curtain. On 3/16/26 at 9:56 am, V16 (Housekeeping Supervisor Director ) stated that the housekeeping department is responsible for ensuring the residents have privacy curtains. V16 explained that residents that are in a private room do not have a privacy curtain and any resident with a roommate is required to have a privacy curtain for the residents privacy. V16 stated that if a resident is sharing a room with another resident and does not have a privacy curtain the resident can become uncomfortable if they do not have a privacy curtain for their privacy. The facility's document dated 6/2023 titled Dignity documents, in part: Policy: The facility will promote care for residents in manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Procedure: 1. Residents should be treated with dignity and respect . Residents' private space and property should be respected, unless there is reasonable suspicion to believe there is property that may pose a risk of harm to the residents or others in the facility. 7. Residents' rights to personal privacy will be respected. The facility's job description document dated 1/2015 and titled Housekeeping Supervisor documents, in part: Job Summary: To plan, organize, develop, and direct the overall operation of the Housekeeping Department in accordance with current federal, state and local standards, guidelines and regulations, and facility policies. IV. Essential Functions: B. Assures that all Housekeeping Procedures are followed in accordance with facility policies . N. Makes rounds regularly to assure that Housekeeping personnel are performing required duties, and to assure that appropriate Housekeeping Procedures are being followed.

Based on Observation, interview, and record review, the facility failed to implement a comprehensive care plan for activities for one resident for the individualized activity care plan. This failure affected one resident (R140) reviewed for activities care plans in a sample of 67 residents. Findings include:R140's Face sheet dated May 17, 2026, documents that R140 was admitted to facility January 15,2025 with diagnosis including Alzheimer's disease, dementia, disorders of the lung, rhabdomyolysis, hyperlipidemia, essential hypertension, history of falls, edema.R140's MDS (Minimum Data Set) dated February 25,2026 section C, shows R140 has a score of 01 which means R140 is severely cognitively impaired.R140's care plan dated March 3,2026 does not show that R140 has a care plan specific to her individualized activity care needs or interventions/task for staff to implement and meet R140's psychosocial/clinical care needs. Focus: resident chooses not to wear the identification wrist band at times;[Intervention: staff will allow resident to make personal choices whenever possible and safe to do so; staff will avoid power struggles with the resident].On 3/15/2026 at 12:10 PM,R140 was observed sitting up in her wheelchair with family at bedside.R140 presented alert and responsive to her name but unable to respond to open or closed ended questions as it relates to activity participation.R140 denied pain by nodding her head and stopped responding to any further questions that were asked.On 3/15/2026 at 12:12 PM, V6 ( family member) at bedside stated that R140 only responds to closed ended questions on most days because of her cognitive impairment.V6 stated she visits R140 frequently if not her it is other family members and the concern is that there is no activities centered around R140's current care needs to keep her stimulated and engaged.V6 stated she feels that if their family does not come then R140 is not engaged much by staff.On 03/17/26 at 12:32 PM, V31(Activity aide) stated that she completes care plans for the second floor residents, and that the second floor consist of majority of dementia residents.V31stated R140 would benefit from 1:1 activities because it would keep R140 from becoming over stimulated with a crowded room of other residents and would provide R140 with (10-20 minutes) of 1:1 activities with staff based on things of R140's preferences.V31 stated she is not the staff member that schedules residents for 1:1 activites.V31showed the care plan of R140 that was created by herself which displays : Focus: resident chooses not to wear the identification wrist band at times;[Intervention: staff will allow resident to make personal choices whenever possible and safe to do so; staff will avoid power struggles with the resident].On 03/17/26 at 12:56 PM, V32 ( Activity director) stated that 1:1 activity is for residents who do not come out of their rooms much and have dementia. The 1:1 activity consist of painting nails, playing music, and having a staff sit with the resident who requires more individualized care. This is a time that the resident is given to talk about their past lives, children their old careers and future on a 1:1 basis with the activity aide. The activity aides also play bingo with the residents.V32 stated that R140 would benefit from1:1 activities because R140 drifts off to sleep at times in larger group settings, and that the family comes a lot and spend time with R140.V32 stated that V31 is aware of how to complete care plans for the residents and could not explain why the care plan for R140 was not implemented to reflect R140 individualized activity care needs.R140 stated she is responsible to review the care plans of the residents and it was an oversite on her part that R140's care plan was not implemented and that she will complete the care plan at this time. On 03/17/26 at 2:27 PM, V1(Administrator) stated the expectations that she has for the activity staff is to ensure that they engage with the residents and have high energy of the facility because the activity department is the facilities face of energy and happiness.V1 stated even the residents who have certain limitations the activity department should be engaging with the residents and keeping them involved on a daily basis.V1 stated the purpose of the individualized care plans is so the residents personalities and preferences are made aware to all staff to ensure the residents receive the care they desire and need. Facility Job description dated 1/2015 titled: Activity aide documents in part; Essential functions: B).Lead a therapeutic, person -centered activity program, which constantly strives to enhance the quality of life of each resident and meets the Activity Mission and Philosophy).become knowledgeable of each individual residents background, cultural life history, disease and medical care needs in detail to ensure and appropriate person- centered activity plan; E).Activities shall be daily and shall reflect the schedules, choices,and rights of the residents. Facility Job description dated 1/2015 titled: Activity Director documents in part; Job Summary: Directly responsible for the activity department. Achieves and maintains the highest quality of life for each resident, with understanding of all psychosocial, medical, and activity needs/ preferences').Develop and maintain a therapeutic person centered activity program to enhance the quality of each resident and meet the activity mission).conduct, oversee, and complete initial and all on going assessments and care planning initiatives).Become knowledgeable of each individual residents background to ensure an appropriate person centered activity plan; K).1:1 program implementation as needed with ongoing assessment and placement in the program.Facility policy dated 1/2012 titled One-to-One programming policy documents in part; A. Purpose: To provide necessary 1:1 intervention for residents who do not benefit from group interventions. These residents can remain part of the group structure if appropriate; however their needs are generally met through structured 1:1contacts.Residents appropriate for 1:1 include those who do not benefit from group involvement or prefer 1:1involvement only or in conjunction with their group participation, due to any (but are not limited to) of the following:1.Cognitive impairment from decreasing meaningful responses to group involvement;3).behavioral issues that impact outcomes on participating in group activities.Facility policy dated May 1999 titled Care planning documents in part; Policy: a goal will be formulated for residents who have an activity problem, need or concerns within twenty- one days of admission and quarterly as needed, corresponding with the care plan conference date. Activities shall be an active approach on other care plans throughout the comprehensive care plan for each resident.

Based on observation, interview, and record review the facility failed to ensure that two residents (R6, and R192) who depend on staff's assistance for their ADL (Activities of Daily Living) care received shaving. This failure affected two out of 67 residents reviewed for ADL care.Findings include: R192's Face sheet documents that R192 has a diagnosis which include but not limited to paranoid schizophrenia, and bipolar. R192's Brief Mental Status Interview (BIMS) dated 12/9/25 shows a score of 15 which indicates that R192 is cognitively intact. On 03/15/26 at 10:34 am, R192 was observed at the nurses station, sitting in a wheelchair, awake, and alert ungroomed with facial hair beard and mustache visible. When surveyor asked R192 regarding being shaved he stated that he has not been shaved for three weeks. R192 explained that he would like to be shaved, and the Certified Nursing Assistants (CNA's) shave him when they say they have time. On 03/15/26 at 11:34 am, V2 (Director of Nursing, DON) stated that Certified Nursing Assistant (CNA) is responsible for shaving the residents daily during ADL (Activities of Daily Living) and PRN (as needed). V2 explained that shaving is performed with the residents to ensure the residents are neat, clean and groomed. V10 also explained if the resident is not shaved the residents dignity can be affected. R192's MDS (Minimum Data Set) dated 12/9/25 shows that R192 requires ADL (Activities of Daily Living) supervision or touching assistance with personal hygiene (shaving). R192's care plan dated 10/09/24 documents in part: Focus: R192 has ADL Functional Performance deficit due to paranoid schizophrenia . Interventions: Assist with ADL task as needed . Provide needed level of assistance and support to complete Activities of Daily Living. The facility's policy dated 9/2020 and titled Shaving The Resident documents, in part: Purpose: To remove facial hair and improve the resident's appearance and morale. The facility's policy dated 3/10/2022 and titled Dressing/Grooming documents, in part: Definition: Dressing/grooming refers to activities provided to improve or maintain the resident's self-performance in dressing and undressing, bathing and washing, and performing other personal hygiene tasks. These activities are individualized to the resident's needs, planned, monitored, evaluated and documented in the residents medical record . c. Grooming: vii. Shaving General Dressing/Grooming Procedures: . 5. Maintain the resident's self-esteem, privacy and confidentiality. The facility's document dated 6/2023 titled Dignity documents, in part: Policy: The facility will promote care for residents in manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Procedure: 1. Residents should be treated with dignity and respect . 5. When assisting with care, residents are supported in exercising their rights. The facility's job description dated 03/2023 and titled Certified Nursing Assistant (CNA) documents, in part: Job Summary: Provide residents with daily nursing care in accordance with current federal, state and local standards, guidelines and regulations, facility policies and as may be directed by the Charge Nurse, Supervisor, Assistant Director of Nursing, Director of Nursing or Administrator to ensure that the highest degree of quality care is maintained at all times. Essential Functions: B. Provides assistance with activities of daily living to a specific number of residents and/or as directed by the staff nurse. Findings Include: R6's diagnoses include but are not limited to chronic diastolic heart failure, dementia, bipolar, chronic kidney disease, hypertension, peripheral vascular disease, and pulmonary hypertension. R6's Minimum Data Set (MDS) dated [DATE], documents in part, Section C. Brief Interview for Mental Status (BIMS) score is a 14. R6 is cognitively intact. Section GG. Self-Care: I. personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands), is coded a 1 which indicates dependent. (Helper does all the effort). On 3/16/26 at 1:10 pm, R6 is in room lying in bed with hair noted on R6's chin. R6 stated that she does not want hair on her face and wants the hair removed from her face. R6's care plan dated 8/13/25 documents in part, Focus: R6 has an Activity of Daily Living (ADL) self-care performance deficit related to generalized weakness, pain to knees and impaired cognition due to arthritis, dementia, asthma, depression/bipolar disorder. Interventions: Assist with personal hygiene as needed. On 3/16/26 at 11:48 am, V3 Assistant Director of Nursing (ADON) stated that staff does not document when doing ADL care if shaving was done or declined by the resident.

Based on Observation, interview, and record review, the facility failed to provide individualized activities for one resident with cognitive impairment . This failure affected one resident (R140) reviewed for activities and programming in a sample of 67 residents Findings include:R140's Face sheet dated May 17, 2026, documents that R140 was admitted to facility January 15,2025 with diagnosis including Alzheimer's disease, dementia, disorders of the lung, rhabdomyolysis, hyperlipidemia, essential hypertension, history of falls, edema.R140's MDS (Minimum Data Set) dated February 25,2026 section C, shows R140 has a score of 01 which means R140 is severely cognitively impaired.R140's care plan dated March 3,2026 does not show that R140 has a care plan specific to her individualized activity care needs or interventions/task for staff to implement and meet R140's psychosocial/clinical care needs. Focus: resident chooses not to wear the identification wrist band at times;[Intervention: staff will allow resident to make personal choices whenever possible and safe to do so; staff will avoid power struggles with the resident].On 03/15/2026 at 12:10 PM,R140 was observed sitting up in her wheelchair with family at bedside.R140 presented alert and responsive to her name but unable to respond to open or closed ended questions as it relates to activity participation.R140 denied pain by nodding her head and stopped responding to any further questions that were asked.On 03/17/2026 at 12:28 PM,R140 observed sitting in wheelchair near table in dining room , no 1:1 activities observed for resident at this time.On 03/17/26 at 12:32 PM, V31(Activity aide) stated that she completes care plans for the second floor residents, and that the second floor consist of majority of dementia residents.V31stated R140 would benefit from 1:1 activities because it would keep R140 from becoming over stimulated with a crowded room of other residents and would provide R140 with (10-20 minutes) of 1:1 activities with staff based on things of R140's preferences.V31 stated she is not the staff member that schedules residents for 1:1 activites.V31showed the care plan of R140 that was created by herself which displays : Focus: resident chooses not to wear the identification wrist band at times;[Intervention: staff will allow resident to make personal choices whenever possible and safe to do so; staff will avoid power struggles with the resident].On 03/17/26 at 12:56 PM, V32 ( Activity director) stated that 1:1 activity is for residents who do not come out of their rooms much and have dementia. The 1:1 activity consist of painting nails, playing music, and having a staff sit with the resident who requires more individualized care. This is a time that the resident is given to talk about their past lives, children their old careers and future on a 1:1 basis with the activity aide. The activity aides also play bingo with the residents.V32 stated that R140 would benefit from1:1 activities because R140 drifts off to sleep at times in larger group settings, and that the family comes a lot and spend time with R140.V32 stated that V31 is aware of how to complete care plans for the residents and could not explain why the care plan for R140 was not implemented to reflect R140 individualized activity care needs.R140 stated she is responsible to review the care plans of the residents and it was an oversite on her part that R140's care plan was not implemented and that she will complete the care plan at this time. On 03/17/26 at 2:27 PM, V1(Administrator) stated the expectations that she has for the activity staff is to ensure that they engage with the residents and have high energy of the facility because the activity department is the facilities face of energy and happiness.V1 stated even the residents who have certain limitations the activity department should be engaging with the residents and keeping them involved on a daily basis.V1 stated the purpose of the individualized care plans is so the residents personalities and preferences are made aware to all staff to ensure the residents receive the care they desire and need. Facility Job description dated 1/2015 titled: Activity aide documents in part; Essential functions: B).Lead a therapeutic, person -centered activity program, which constantly strives to enhance the quality of life of each resident and meets the Activity Mission and Philosophy).become knowledgeable of each individual residents background, cultural life history, disease and medical care needs in detail to ensure and appropriate person- centered activity plan; E).Activities shall be daily and shall reflect the schedules, choices, and rights of the residents.Facility Job description dated 1/2015 titled: Activity Director documents in part; Job Summary: Directly responsible for the activity department. Achieves and maintains the highest quality of life for each resident, with understanding of all psychosocial, medical, and activity needs/ preferences').Develop and maintain a therapeutic person centered activity program to enhance the quality of each resident and meet the activity mission).conduct, oversee, and complete initial and all on going assessments and care planning initiatives).Become knowledgeable of each individual residents background to ensure an appropriate person centered activity plan; K).1:1 program implementation as needed with ongoing assessment and placement in the program.Facility policy dated 1/2012 titled One-to-One programming policy documents in part; A. Purpose: To provide necessary 1:1 intervention for residents who do not benefit from group interventions. These residents can remain part of the group structure if appropriate; however their needs are generally met through structured 1:1contacts.Residents appropriate for 1:1 include those who do not benefit from group involvement or prefer 1:1involvement only or in conjunction with their group participation, due to any (but are not limited to) of the following:1.Cognitive impairment from decreasing meaningful responses to group involvement;3).behavioral issues that impact outcomes on participating in group activities.

Based on review of records and interviews, the facility failed to ensure interventions were in place to prevent weight loss for 1 out of 3 residents (R3) reviewed for nutritional care. These failures are not in accordance with facility's nutrition policy and affected 1 resident (R3) who sustained multiple significant weight loss.Findings include: R3 [AGE] year-old resident initially admitted on [DATE]. R3's medical diagnosis includes intracerebral hemorrhage, encephalopathy and dysphagia among others. R3 was on enteral feeding upon admission and does not take any food and fluids by mouth. All nutrition will be administered via tube feeding. Weight history records show that R3 sustained multiple significant weight loss from 07/25/2025 initial date of admission to 01/04/2026 three (3) days prior to resident (R3) transfer to hospital on [DATE]. Per R3's weight history, R3's weight upon admission dated 07/25/2025 was 165.0 LBS. On 10/27/2025 R3's weight was 161.8 LBS. On 11/24/2025 R3's weight was 150.0 LBS, a decrease of 11.8 LBS or 7.3% for a period of 28 days. On 12/07/2025 R3's weight was 150.8 LBS. On 12/14/2025 R3's weight was 143.5 LBS, a 7.3 LBS or 4.84% for a period of 7 days or 1 week. On 01/04/2026 R3's weight was 142.5 LBS, a loss of 22.5 LBS or 13.64% for a period of 163 days or 5 months (30 days per month) and 13 days. Per facility's policy on Nutrition Care Significant Weight Loss dated 01/2028: A significant weight loss is 5% in one month, 7 1/2 % in 3 months and 10% in 6 months. Full care plan of R3 was reviewed, significant weight loss was not included or addressed. On 02/19/2026 at 12:55 PM, V3 (State Guardian of R3) stated R3 was transferred to another facility due to hospital doctor recommendation that R3 was not being fed properly in the facility. According to V3, hospital doctor informed him that R3 has poor laboratory results during evaluation that shows R3 was not properly fed. R3 currently is on another facility. Per R3's laboratory results dated [DATE] done in the facility, R3 results on BUN (Blood Urea Nitrogen) 181 mg/dL normal range between 7 to 23 mg/dL. Sodium level 178 mg/dL normal range between 133 to 148 mmol/L. Chloride level 133 mmol/L normal range between 95 to 112 mmol/L. BUN (Blood Urea Nitrogen), Sodium level and Chloride level results are at critical results. Nursing notes of V12 (Registered Nurse) dated 01/07/2026 documents that R3 transferred to hospital due to oral bleeding. V12 received critical laboratory results after R3 was transferred to hospital. V2 (Director of Nursing) on 02/18/2026 stated that R3 has several hospitalizations that may contribute to R3's weight loss. Residents that have weight loss need collaboration from nursing, the dietitian, doctor and family. V2 after reviewing R3's full care plan stated, I mean weight loss should be addressed in the plan of care, but resident has a lot going on. V8 (MDS Coordinator) on 02/18/2026 at 11:34 AM stated that care plan needs to be updated according to the schedule and as needed. Newly identified problems or concerns including pressure sores or significant weight loss need to be care planned. V8 reviewed R3's full care plan stated: No, I don't see a weight loss care plan in there. V7 (Registered Dietitian) on 02/18/2026 at 12:21 PM stated that R3 was NPO or does not take food with mouth since admission in July 2025. All nutrition is given via enteral feeding or tube feeding. V7 stated that R3 did have significant weight loss from October to November and January based on R3's weight history. Per V7 weight loss can be caused by R3's hospitalization. V7's enteral feeding formula does not need to be changed. There needs to be documentation that R3's significant weight loss was being addressed. V7 stated that she does not do care plan. Did not comment about significant weight loss not addressed in R3's plan of care. R3 have three (3) Enteral Nutrition Assessments dated 10/24/2025, 11/28/2025 and 12/22/2025. assessment dated [DATE] documents significant weight loss from 161.8 LBS to 150.0 LBS loss of 11.8%. Per assessment notes current weight of 150.0 LBS. Assessment documents weight stable, although 11.8% loss of weight for a period of one (1) month considered significant weight loss. Recommendation was to continue POC (Plan of Care). Assessment does not offer any other recommendation. R3's does not have plan of care for significant weight loss. assessment dated [DATE] documents significant weight loss from 159.9 LBS to 143.5 LBS loss of 10.26% for a period of three (3) months. R3's weight trending loss of 16.4 LBS or 10.3% period of three (3) months and loss of 21.5 LBS or 13.0% period of five (5) months all are significant weight loss. Recommendation was to start Expedite enteral feeding formula via tube feeding for six (6) weeks. V7 (Registered Dietitian) on 02/18/2026 at 12:21 PM stated that it was not given due to lack of availability. Nutrition Care Significant Weight Loss policy dated 01/2028: Residents with a significant weight loss will be assessed by the Licensed Dietitian. To reduce the risk of resident malnutrition the following procedures are as follows:Residents with significant weight loss will be discussed with members(s) of the interdisciplinary team (IDT).A significant weight loss is 5% in one month, 7 1/2 % in 3 months and 10% in 6 months.The Licensed Dietitian (LD) will evaluate the cause of weight loss and recommend nutrition interventions to prevent further weight loss.Interventions may include supplements, snacks, favorite foods, referral to other members of the health care team for evaluation, diet liberalization, etc.The Licensed Dietitian will document findings and recommendations in the medical record. Recommendations will be discussed with the residents, members of the IDT, and forwarded to the physician via nursing services.Upon change in diet order (physician order) or other interventions the care plan will be updated.

Based on interview and record review the facility failed to ensure that residents in the facility were free from abuse. This failure affected one of three (R4) residents reviewed for abuse and resulting in R4 acquiring a laceration to the head requiring sutures.Findings include:R4's medical diagnoses include but are not limited to schizophrenia, bipolar disorder, essential hypertension and major depressive disorder.R4's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 15, indicating R4's cognition is intact.R4's progress note dated 08/07/25 documents in part, Resident became agitated, pacing and engaged in a verbal altercation with peer that turned physical. Residents were separated and placed on 1:1. Hospitalization required.R4's progress note dated 08/08/25 documents in part, Resident has had an increase in anxiety and aggressive behavior.R4's progress note dated 08/16/25 documents in part, Writer made aware resident had and altercation as evidenced by pushing his co-peer.R4's care plan dated 09/18/25 documents in part, resident has the potential for/history of physical aggression towards others. History of physical aggression, poor impulse control.R5's medical diagnoses include but are not limited to schizoaffective disorder, violent behavior, bipolar disorder, chronic obstructive pulmonary disease.R5's MDS dated [DATE] has a BIMS score of 3, indicating R5's cognition is severely impaired.R5's progress note dated 08/16/25 documents in part, CNA (Certified Nursing Assistant) informed writer that resident had an altercation, and he was pushed to the floor, hitting the right side of his head. Some bleeding note by the right eyebrow and some swelling noted to the right side of his head.R5's care plan dated 07/01/25 documents in part, R5 is at risk for abuse related to: Has a dx (diagnosis) of severe mental illness and hx (history) of aggression.R5 will remain safe, calm and free from abuse.The Facility's Final Incident Investigation Report sent to the state agency on 08/21/25 documents in part, A follow up interview was conducted with R5 and he stated that while walking down the hallway R4 pushed him causing him to fall to the floor. R5 stated that he believes the incident was an accident. He doesn't feel it was intentional.The Facility's Final Incident Investigation Report sent to the state agency on 08/12/25 documents in part, CNA was interviewed and stated R4 was on his phone singing to himself and walking around the dining room. R7 returned to the dining room and approached R4. Both residents exchanged words. CNA called for help. When she returned to the dining room both residents were on the floor wrestling.On 09/27/25, surveyor attempted to interview R5 regarding the incident between R4 and R5. Surveyor was unsuccessful with interview due to R5's mumbled and distorted speech.On 09/27/25 at 1:00pm V18 (Licensed Practical Nurse/LPN) stated that she witnessed the altercation between R4 and R5 on 08/16/25. V18 stated that R4 and R5 were both walking in the hallway, going in opposite directions. V18 stated that when R4 and R5 were about to pass each other in the hallway, R4 pushed R5 to the floor. V18 stated that when R4 pushed R5 to the floor, R5 slid hit his head on the floor. V18 stated that she then ran to R5 because R5's head was bleeding. V18 stated that R5 was sent to the hospital for evaluation of R5's head wound and R5 received sutures to the head.On 09/27/25 at 1:52pm V16 (Certified Nursing Assistant/CNA) stated that R4 tries to intimidate other residents. V16 stated that R4 pushed R5 to the ground and R5 was sent to the hospital because R5's head was bleeding after being pushed to the ground. Facilities policy title abuse policy dated 07/2025 documents in part policy, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by:. 2. Orientating and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of mistreatment, neglect and abuse;. 3. Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment;.4. Identifying occurrences and patterns of potential mistreatment; 5. Immediately protecting residents involved in identifying reports of possible abuse;. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. This facility will not knowingly employ individuals who have been convicted of abusing, neglecting or mistreating individuals.Definitions: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment.

Based on observation, interviews, and record reviews the facility failed to maintain a safe, comfortable home like environment [A] failed to maintain adequate running water for one [R1] resident on the third floor and [B] failed to maintain a dry home like environment due to leaking roof. This failure has the potential affect all sixty residents residing on the third floor.Findings Include:Maintenance Log indicates the following in part:1/23/25 R1's room ceiling. [third floor].3/31/25 R1's room no running water in bathroom. [third floor]5/27/25 Next door to R1's room ceil tile wet and falling [third floor]5/30/25 R1's room no running water in bathroom. [third floor]6/4/25 third floor dining room ceiling leaking water.6/11/25- third floor room, flooding in room.7/26/25- roof leaking in resident room on third floor.7/29/25- roof leaking in resident room on third floor.8/18/25- roof leaking in resident room on third.8/18/25- roof leaking in R1's room [third floor]8/18/25- third floor, floor tiles are soaking wet9/8/25- R1's room third floor, bathroom sink water not working.R1 is a sixty-eight-year-old admitted with the following medical diagnosis in part: polyarthritis, peripheral vascular disease, type II diabetes, dementia, essential hypertension, asthma, schizoaffective disorder, osteoarthritis, pulmonary embolism acute pulmonale, and muscle spasm. R1's, minimum data set [MDS] Brief Interview Mental Status score= 15. Indicates R1 is cognitively intact.R1's Census Report indicates:1/23/23 admitted to second floor.8/2/25 R1 was moved to third floor.9/9/25 R1 was moved back to the second floor.On 9/16/25 at 11:58 AM, R1 stated, I requested a room change and was moved to the third floor. During my stay the roof started leaking and I saw water in the light fixture. The bathroom sink was not working. There was no water coming out of the sink. I reported my concerns to the nurse. Nursing told me the roofer fixed the leak, but the bathroom sink was never fixed. I requested to be moved back to the second floor, and I was moved. No one should live with the roof leaking every time it rained. The nurse aides would have to leave out my room to get water to wash me with, that was terrible.During facility tour with V5 [Maintenance Director] on 9/16/25 at 11:45 AM, noted with brownish spots on the ceiling tiles on throughout the building. V5 stated The discolored ceiling tiles on the third floor is from the ceiling leaking. The facility has a metal roof and when it rains hard the water will leak through the roof and travel around. The second and first floor ceiling tiles are stained due to water leaks, air conditioners leaking sometimes, and toilet overflows. On 8/13/25 R1's room on the third floor was leaking water from the ceiling, not in the light fixture. I notified corporate for repairs and repairs were made on 8/18/25. R1's bathroom sink was not running water; I had to replace the whole unit. The unit was replaced on 9/8/25, I am not sure how long it was broken.On 9/18/25 at 2:00 PM V1 [Administrator] stated, The facility roof has some leaks during heavy rain falls and storms. The roofing company came out to make repairs.V4 [Certified Nurse Assistant], V11 [Registered Nurse] and V15 [Housekeeper Supervisor] all said the roof leaks especially when it rains hard at times throughout the summer, but repairs were made recently. Policy:Building Manager Responsibilities dated 3/2014.The building manager will assure that maintenance services are provided to all arears of the building, grounds, and equipment in a prompt and professional manner.For the safety and comfort of residents, staff and visitors.Maintain the building in good repairBuilding Manager Job Description:Ensure high standards of safety are met and maintained in accordance with facility policy, federal, state, and local regulations.

Based on interview and record review the facility failed to follow their policy to obtain informed consent and develop plan of care for psychotropic medication use. These failures affected five (R1, R6, R7, R10 and R11) out of six residents reviewed for improper nursing care. Findings include: 1. R1's admission record showed admit date on 1/26/2022 with diagnoses not limited to Other paralytic syndrome following cerebral infarction bilateral, Paraplegia, Spinal stenosis cervical region, Essential (primary) hypertension, Schizoaffective disorder, Urinary tract infection, Vascular dementia. MDS (Minimum Data Set) dated 5/29/2025 showed R1 was cognitively intact. R1's June and July MAR (Medication Administration Record) showed order not limited to Olanzapine Oral Tablet 10 MG Give 1 tablet by mouth at bedtime for Schizoaffective with order date on 6/16/25. MAR showed medication was given on 6/17/25 to 6/30/25 and 7/1/25 to 7/4/25. Reviewed R1's EHR (Electronic Health Record), no care plan and consent found for psychotropic medication use. Facility was not able to provide consent for Olanzapine. 2. R6's admission record showed admit date on 9/13/2024, with diagnoses not limited to Adult failure to thrive, Chronic obstructive pulmonary disease, Adjustment disorder with depressed mood, Essential (primary) hypertension, Hypertensive chronic kidney disease. MDS (Minimum Data Set) dated 5/22/2025 showed R6 was cognitively intact. MDS showed R6 took antidepressant medication. R6's July POS (Physician Order Sheet) and MAR showed order not limited to Mirtazapine Tablet 15 MG Give 1 tablet by mouth at bedtime for Depression and appetite with order date on 10/8/24 and it showed medication was given. R6's EHR reviewed with no consent found for Mirtazapine. Facility was not able to provide consent for Mirtazapine. Care plan dated 2/21/2025 showed in part: R6 is receiving antidepressant medication, Mirtazapine, as an appetite stimulant and depressed mood. Care plan interventions included but not limited to Obtain informed consent prior to initiation of medication or increase in dosages. 3. R7's admission record showed admit date on 11/29/23 with diagnoses not limited to Epilepsy, Schizophrenia, Unspecified dementia, Unspecified psychosis, Bipolar disorder, History of falling. MDS dated [DATE] showed R7 was cognitively intact. MDS showed R7 took antipsychotic medication. R7's July POS and MAR showed order not limited to: Quetiapine Fumarate Oral Tablet 50 MG Give 1 tablet by mouth in the evening for Schizophrenia with Order date on 2/19/24. Risperidone Tablet 1 MG Give 1 tablet by mouth every 12 hours related to psychotic disorder with order date on 12/5/23. Lithium Carbonate ER Oral Tablet Extended Release 450 MG Give 1 tablet by mouth one time a day related to schizophrenia with order date on 12/5/23. MAR showed Quetiapine, Risperidone and Lithium Carbonate were given. R7's EHR reviewed and found consent for Risperidone and Lithium Carbonate. No consent for Quetiapine was found. Facility was not able to provide consent for Quetiapine. Care plan dated 2/21/2025, showed in part: R7 is receiving antipsychotic medications Quetiapine and Risperidone, and mood stabilizing medication, Lithium and Lamotrigine, to manage behaviors related to a diagnosis of schizophrenia. Care plan interventions included but not limited to: Obtain informed consent prior to initiation of medication or increase in dosages. 4. R10's admission record showed admit date on 2/05/2025 with diagnoses not limited to Type 2 diabetes mellitus, Epilepsy, Major depressive disorder, Encounter for attention to gastrostomy, Essential (primary) hypertension, Primary insomnia, Alcohol dependence with unspecified alcohol-induced disorder, Altered mental status. MDS dated [DATE] showed R10's cognition was moderately impaired. MDS showed R10 took antidepressant medication. R10's July POS and MAR showed order not limited to: Sertraline HCl Oral Tablet 25 MG Give 1 tablet via G-Tube in the morning for Depression with order date on 2/13/25 and it showed medication was given. R10's EHR reviewed, no consent for Sertraline found. Facility was not able to provide consent for Sertraline. Care Plan dated 2/21/25 showed in part: R10 is receiving antidepressant medication, Sertraline, to manage depressive symptoms (low mood) related to diagnosis of Major Depressive Disorder. Care plan interventions included but not limited to: Obtain informed consent prior to initiation of medication or increase in dosages. 5. R11'S admission record showed admit date on 8/20/2021, with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Epilepsy, Essential (primary) hypertension, Type 2 diabetes mellitus, Schizophrenia, Undifferentiated schizophrenia, Altered mental status. MDS dated [DATE], showed R11's cognition was moderately impaired. MDS showed R11 took antipsychotic medication. R11's JULY POS and MAR showed order not limited to: Olanzapine Oral Tablet 7.5 MG Give 1 tablet by mouth at bedtime related to undifferentiated schizophrenia with order date on 5/2/25 and it showed medication was given. R11's EHR reviewed, no consent for Olanzapine found. Facility was not able to provide consent for Olanzapine. Care plan dated 9/19/2024, showed in part: R11 Receiving Olanzapine psychotropic medication. Noted to have diagnosis of undifferentiated schizophrenia. Noted with behavior or mood issues of noncompliance, hallucinations and verbal aggression. Care plan interventions included but not limited to: Obtain informed consent prior to initiation of medication or increase in dosages. On 7/8/25, at 11:35AM, observed R1 resting in bed, on moderate high back rest. Alert and oriented x 3, and verbally responsive. R1 stated she has been residing in the facility for over 3 years. R1 said she is on antibiotic treatment for UTI (Urinary Tract Infection). She said she was sent out to hospital on 7/6/25. The other day she was hearing voices or crazy stuff. R1 said the psychiatrist came on to see her and prescribed medication for her. R1 said she and her family did not give the consent for the medication. R1 stated she took the medication without their consent, and she started hearing voices in her head like crazy sounds. R1 said the medication is given at night; it was a small white round pill. She said after coming back from the hospital, the other day, nurse gave her the same white round pill at nighttime, and she did not take it. On 7/8/25, at 11:53 AM, V5 (RN / REGISTERED NURSE) stated he has been working in the facility for 9 years. He stated psychotropic medication need consent before administering the medication, it should not be given if there is no consent from the resident or representative. V5 said he is working with R1 and Olanzapine medication is on hold due to no consent. Surveyor checked R1's Olanzapine order with V5 in the medication cart, medicine is small white round pill. On 7/8/25, at 1:22 PM, V2 (DIRECTOR OF NURSING / DON) stated has been working in the facility for over 5 years. She stated she oversees psychotropic medication use. V2 said psychotropic medications are antidepressant, antianxiety, sedatives / hypnotics and antipsychotic medicines. V2 stated If there is an order for psychotropic medication, staff is expected to educate the resident and family / representative regarding the use and side effects of the medication. V2 said staff is expected to obtain consent of psychotropic medication and should not be given with no consent. V2 said staff will complete the consent form and upload it in the resident's health record. V2 stated the care plan is needed for use of psychotropic medication use. Surveyor reviewed R1's EHR with V2. V2 stated R1 is on psychotropic medication - Olanzapine. V2 was unable to find care plan and consent for psychotropic medication use in R1's EHR. V2 stated it is important to obtain consent for psychotropic medication use before giving the medication to educate or inform the resident / family / representative regarding the side effects, and purpose of the medication. V2 stated the care plan should be individualized and personalized according to resident's needs. She said psychotropic medication use should have a care plan so staff would know the plan of care of the resident. On 7/8/25, at 1:38 PM, V8 (RN Care plan coordinator) stated she has been working in the facility for 15 years. The nurse should get consent before starting psychotropic medication and it should not be given if there is no consent obtained from resident if cognitively intact, family or representative. V8 said psychotropic medication use should be care planned. SS / Social Service should be doing care plan for psychotropic medication use. On 7/8/25, at 2:46 PM, V21 (SOCIAL SERVICE DIRECTOR / SSD) stated he has been working over 6 years in the facility. He is doing resident's care plan for psychosocial wellbeing, behavior, cognition and psychotropic medications. He said the care plan is to inform the staff regarding the plan of care of the resident that would include goals and interventions and would direct staff on how to care for the resident. Facility was not able to provide psychotropic medication consent for R1, R6, R7, R10 AND R11 despite several requests. Facility's use of psychotropic medications policy dated 9/2020, showed in part: To establish a standardized system to inform residents and / or their responsible parties and about psychotropic medications and their side effects. Plan of care including treatment goals, evaluation of any precipitating factors in the resident's environment, and any non-drug approaches to providing care. For each psychotropic medication ordered either a verbal or a written consent from the resident or the resident's responsible party will be obtained prior to initiation of the medication. Information regarding possible side effects will be discussed with the resident's responsible party. Facility's comprehensive care plan policy dated 11/2017, documented in part: an individualized, person-centered comprehensive care plan, including measurable objectives with timetables to meet resident's physical, psychosocial and functional needs, is developed and implemented for each resident.

Based on interviews and record review, the facility failed to follow physician orders for a resident (R2) who required a physical and occupational therapy evaluation. This failure affected 1 resident out of 3 residents reviewed for therapy services. Findings include: R2 has a history of diverticulosis, syncope, congestive heart failure, chronic kidney disease, and alcohol abuse. R2's Brief Interview of Mental Status (BIMS) dated 4/15/25 score is 8, which indicates R2 has moderate cognitive impairment. R2's mobility function requires mobility devices walker and wheelchair. Functional status for toileting hygiene, shower/bath, lower body dressing, putting on /taking off footwear requires partial/moderate assistance. R2's Physician orders dated 4/9/25 documents in part, may evaluate and treat PT/OT (Physical Therapy/Occupation Therapy). On 6/4/25 at 10:18 am, V3 DON (Director of Nursing) stated that Doctors orders should be followed. Therapy department is notified by the floor nurse for an evaluation order. The therapy supervisor is in the morning meetings and made aware of the therapy orders. The stand down meetings in the evening we follow up to make sure that therapy is done. On 6/4/25 at 10:40 am V14 Occupational Therapist stated We (Therapy Department) get the information from the nurses or facility staff who needs to be seen or evaluated for therapy. The communication is verbal or in the morning meeting. I would not know to evaluate him (R2) if I am not told. V14 looked at R2's orders and stated, He (R2) should have been seen by the therapy department. V14 looked at her computer and then stated, I do not see where therapy evaluated him. He was not seen for therapy. On 6/4/25 at 2:40 pm, V17 Physical Therapy Assistant stated, If there were an ancillary order for an evaluation for therapy, the nurses would notify the department. The nurses did not notify the therapy department for the order to evaluate. I (V17) would have done an evaluation with insurance approval if I was aware of the order. He (R2) was not evaluated from the order of 4/9/25. On 6/4/25 requested from V3 DON facility policy for following doctor's orders. Received a policy titled Physician Orders for Medication . On 6/5/25 at 10:30 am, V3 sent an email stating the policy for medications in the one the facility have for following doctor's orders. R2's Care plan revision date 4/24/25 documents in part, Focus: R2 has an ADL (Activity of Daily Living) functional performance deficit secondary to unsteady gait and general weakness. Status post GI surgery. Uses a cane to ambulate. Facility's policy titled Direct therapy Services and dated 3/10/22, documents in part, Policy: The qualified therapist, in conjunction with the physician and nursing administration, is responsible for determining the necessity for and the frequency and duration of the therapy services provided to residents. Residents are provided direct therapy services upon the written order of their physician. Facility's job description titled Staff Nurse (Registered Nurse/License Practical Nurse) documents in part, Essential Functions: BB. Arrange for diagnostic and therapeutic services, as ordered by the physician. Facility's job description titled Staff Physical Therapist documents in part, Adhere to the policies and procedures necessary for day-to-day operations of the rehab department: Maintain communication between therapy department and interdisciplinary team. Facility's job description titled Occupational Therapist documents in part, Adhere to the policies and procedures necessary for day-to-day operations of the rehab department: Maintain communication between therapy department and interdisciplinary team.

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to implement care plan interventions, and failed to provide ADL (Activities of Daily Living) care to one of three dependent residents (R3) reviewed for quality of life. Findings include: R3's diagnoses include osteoarthritis of right knee, muscle wasting/atrophy of bilateral thighs, and dementia. R3's (4/14/25) BIMS determined a score of 9 (moderate impairment). R3's (4/14/25) functional assessment affirms supervision or touching assistance is required for eating and substantial/maximal assistance is required for dressing. R3's (4/26/23) care plan states resident has an ADL self-care performance deficit due to impaired cognition and limited mobility, intervention: assist with ADL tasks as needed. On 5/12/25 at 1:27pm, R3 was seated at a table in the dining room and the table was completely cleared however dried red sauce was observed on the front of R3's shirt & pants. A large ravioli was also noted on R3's thighs. Surveyor inquired what time lunch was served today R3 stated 12 or 12:30. On 5/12/25 at 1:30pm, V5 (CNA/Certified Nursing Assistant) affirmed that she was currently assigned to monitor the dining room and stated, It's one CNA assigned at a time. Surveyor inquired about R3's appearance, V5 responded I'm not her CNA, her CNA is (V6's name). Surveyor inquired why R3 remained seated at the table and not attended to, V5 replied The residents, they sit in the dining room and failed to provide R3 any assistance. Surveyor inquired when lunch was served today V5 stated Like 12:00 (1.5 hours ago). On 5/12/25 at 1:34pm, V7 (CNA) stated All of the CNAs have a set time in the dining room, every 30 minutes so we (staff) have time to complete whatever we are assigned to. We got fall risk in there (dining room), we gotta watch em (residents). Surveyor inquired what staff should do if residents (in the dining room) need attended to, V7 responded Usually a CNA not doing anything or anybody for that matter can help with that. If I'm assigned to the resident, there's someone in the dining room that can relay to me that the resident needs something so we can get the patient taken care of. Surveyor inquired if R3 requires assistance, V7 replied She's a feeder, she needs maximal assistance. Restorative (staff) usually sets her up, and someone tries to assist her. Surveyor inquired who's assigned to R3 today, V7 stated (V6's name). At 1:37pm (10 minutes after surveyors' initial observation), surveyor inquired about concerns with R3's appearance, V7 subsequently entered the dining room and stated She (R3) needs to be repositioned; she's sliding down the chair. She also needs to be changed; her clothes need to be changed. Surveyor inquired what was on R3's clothing, V7 responded Food, its stains from the ravioli, some of it is wet some of it is dry. Surveyor inquired what was on R3's lap, V7 replied Ravioli. On 5/12/25 at 1:41pm, V8 (Minimum Data Set Coordinator) presented the (5/12/25) assignment sheet and affirmed that V6/CNA (assigned to R3) was also assigned to the dining room from 12:30 to 1:00. The (09/2020) facility feeding policy states place a napkin under the resident's chin or put on clothing protection if desired by the resident. The (3/10/22) dressing/grooming policy states dressing/grooming refers to activities provided to improve or maintain the resident's self-performance in dressing and undressing and performing other personal hygiene tasks. These activities are individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record. Determine if the resident has specific tasks and areas requiring dressing/grooming assistance.

Based on observations, interviews and record reviews, the facility failed to provide, (A) incontinence care, (B) assistance with oral hygiene for five [R1, R3, R4, R5, R6] out of five residents who requires assistance with activities of daily living in a total sample of seven residents Findings Include, R1's clinical record indicates in part: R1'a medical diagnosis includes but not limited to dysplasia of anus, syphilis, gastrostomy, asthma, dysphagia, oropharyngeal phase, chronic obstructive pulmonary disease, acute chronic congestive heart failure, seizure disorder, human immunodeficiency virus HIV disease, pulmonary embolism, tachycardia, cerebral infarction stroke, constipation, vitamin D deficiency, anemia, depressive mood disorder, sepsis, hypotension, and essential hypertension. R1 has an ADL Functional Performance Deficit due to incontinence of bowel and bladder, aphasia, recent stoke limited mobility, and dysphagia: Assist with ADL tasks, assist with locomotion, and assist with personal hygiene. R1 requires assistance from staff in the area of personal grooming. a nursing rehab: dressing a grooming goal: R1 will participate in grooming daily, washing her face, combing her hair and brushing her teeth while listening to verbal cueing from staff daily as tolerated. R1's minimum data set section GG document in part: 1/24/25, R1 need maximal assistance with ADL care, and oral care. R1's care plan document in part: R1 has an ADL functional performance deficit due to recent stroke and limited mobility; staff to assist with personal hygiene. On 4/22/25 at 12:39 PM, observed R1 resting in bed alert and oriented x3. R1 was none verbal but was able to point to answer yes or no questions appropriately. Gastric tube feeding per bed side. Noted R1's lips with dried white and red substance. Inside R1's mouth noted thick layers of white, yellow, brown substances covering teeth, gums, and tongue area. R1 was asked the following questions using the yes or no paper: Are you lying in bed right now? R1 pointed yes. Is your last name R1's last name asked by surveyor R1 pointed to yes. Do you receive oral care, such as teeth brushing? R1 pointed No. Do you receive showers and bed baths? R1 pointed No. Are kept clean and dry? R1 pointed yes. R1's Care plan: R1 has an ADL Functional Performance Deficit due to incontinence of bowel and bladder, aphasia, recent stoke limited mobility, and dysphagia: Assist with ADL tasks, assist with locomotion, and assist with personal hygiene. R1 requires assistance from staff in the area of personal grooming. a nursing rehab: dressing a grooming goal: R1 will participate in grooming daily, washing her face, combing her hair and brushing her teeth while listening to verbal cueing from staff daily as tolerated. R1's minimum data set section GG document in part: 1/24/25, R1 need maximal assistance with ADL care, and oral care. R1's care plan document in part: R1 has an ADL functional performance deficit due to recent stroke and limited mobility; staff to assist with personal hygiene. Interviews: On 4/22/25 at 11:15AM V4 [R1's Friend/ Power of Health Care] stated, R1 has been drinking water and eating ice for the last six months. The facility nursing staff tells me and R1 that she cannot eat, nor drink anything, if so R1 would choke or aspirate. R1's mouth has a lot of white build up and now R1's teeth are discolored from all the oral neglect. I have complained to the nursing staff about oral care, but I was never done. R1 has a stroke and is unable to use her right hand to brush her teeth. R1 usually communicate with yes, unable to express her needs. However, R1 is alert and oriented. R1 is not able to write her thoughts down due to the stroke affecting her right hand. On 4/22/25 at 1:25 PM, R3 stated, I have an urostomy pouch that has been leaking for two days. This morning, I told V12 [Certified Nurse Assistant] , but no one came to change the pouch. On 4/22/25 at 1:30 PM, V12 [Certified Nurse Assistant] stated, When I made rounds this morning and R3 told me she was okay. R3's urostomy has been leaking off and on about a month. When her urostomy was leaking this morning but the nurses already know. I am not allowed to change the pouch; I just placed a bath towel under the pouch to catch the urine. I cannot remember if I told the nurse R3's urine pouch was leaking this morning. On 4/22/25 at 1:35 PM, V19 [Licensed Practical Nurse] and surveyor observed R3 resting in bed with R3 holding a wash towel on her side. Noted yellow brownish large circle stain on the bed linen. On 4/22/25 at 1:50PM, V19 {Licensed Practical Nurse] stated, I was made aware this morning that R3's urostomy was leaking, but I just got the supplies to change the urostomy. On this floor we did not have the wafers needed for me to change the urostomy. I received the supplies a couple of hours ago. I been busy today, I will replace R3's urostomy pouch now. R3' clinical record indicates in part: R3 was admitted with cerebral infarction, hemiplegia and hemiparesis, artificial opening of urinary tract, aphasia, dysphagia, gastrostomy, chronic heart failure, chronic pulmonary disease, gout, and malignant neoplasm of cervix. R3's minimum data set indicates R3 is alert and oriented x3, able to make her needs known. R3's Minimum Data Set, dated dated dated [DATE]; R3 is dependent with toileting hygiene and managing ostomy care. R3's care plan: R3 requires an urostomy. Staff to perform ostomy care. R3's physician order: 6/6/24; Urostomy care every shift and as needed. 6/6/24: Monitor urostomy tube bag every shift and record urine output every shirt. On 4/22/25 at 1:00 PM, surveyor and V9 [Registered Nurse] observed R4 resting in bed with gastric feeding infusing. V9 asked R4 to open his mouth and noted R4's tongue completed covered in thick white milking substance, with yellowish dark substance covering R4's teeth. On 4/22/25 at 1:05 PM, V9 [Registered Nurse] stated R4 receives gastric tube feeding and oral pleasure feedings. I am not sure what is on his tongue. R4 was admitted here from the hospital with oral thrush, maybe the white substance is oatmeal, I am not sure. R4's clinical record indicates; R4 admitted with gastrostomy, atrial fibrillation, dehydration, and gastro-esophageal reflux disease. Alert to self, no able to make his needs known. R4's minimum data set section GG indicates R4 is dependent with ADL oral care. On 4/22/25 at 12:55 PM, observed R5 resting in bed with a foul odor. R5 was alert x1, not able to make her needs known. V8 [Licensed Practical Nurse] with the surveyor present observed R5's bottom bed sheet with a dark brownish colored circle coming from underneath R5. Inside R5's under brief noted the brief was soaked with bowel movement from the back of the brief up to the top of the pubic area. R5's teeth were covered with a thick yellow brownish substance around the teeth and gums. V8 [Licensed Practical Nurse] stated, The odor is strong, the urine is soaked all the way through the under brief on to the bed linen. R5's needs her teeth brushed. I will have her clean up and oral hygiene. On 4/22/25 at 1:20PM, V17 [Certified Nurse Assistant] stated, I start my shift at 7AM. I checked on R5 at 10:30 AM and she was okay. I will clean R5 now. This is my first-time providing ADL care to R5 during my shift. R5's clinical record indicates R5 was admitted with cerebral infarction, hemiplegia and hemiparesis, gastrostomy, schizoaffective disorder, chronic embolism, heart failure, and type II diabetes. R5's minimum data set [MDS] indicates R5 is alert to self and is not cognitively intact. R5's MDs section GG indicates R5 is dependent for ADL and incontinent care. R5's Care Plan: R5 has limited ability to perform person hygiene task. Due to stroke with left sided hemiplegia and impaired cognition; Staff to assist with oral care, personal hygiene and toileting needs as necessary. R6 was resting in bed alert and oriented x3. Observed yellow, white, and brown debris on R6's teeth. On 4/22/25 at 3:00 PM R6 stated, I get my teeth brushes two to three times per week, just depends on who is working. The certified nurse assistant does not even provide me with the tooth bush, toothpaste or basin so I could try and brush my teeth. I need help from the staff while trying to brush my teeth. R6's clinical record indicates the following: R6 was admitted with human immunodeficiency virus [HIV] disease, chronic kidney disease stage 5, iron deficiency anemia, major depressive disorder, chronic obstructive pulmonary disease, cerebral infarction, weakness, gout, restlessness and agitation, arthritis, acute kidney disease, and hypertensive chronic kidney disease. R6 minimum data set indicates R6 is alert and oriented X3 able to make her needs known. R6's minimum data set section [GG]; R6 requires moderate assistance with oral hygiene. On 4/24/25 at 10:31 AM, V3 [Director of Nursing [ stated All nursing staff should make rounds at least every two hours and as needed while answering the call lights and provide ADL care. If a resident is wet and need changing from incontinence or urostomy need changing the care should be provided right away. If incontinent care is not provided timely it could potentially cause skin alterations and or urinary infections. Oral care is part of the daily ADL care. All residents need their teeth brushed daily. If not, it could potentially cause tooth decay or oral infections. Nursing staff were in-serviced on ADL, oral, urostomy care. On 4/25/25 at 9:31 AM, V1 [Administrator] stated The facility does not have any ADL, incontinent care policy. The facility follows the standard of care. The nursing staff will provide showers at least twice per week and daily bed bath. The nursing staff will change residents timely and as needed. Policy: Resident Rights Ombudsman Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. 483.24 (All)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview and record review the facility failed to a.) follow a physician's order and b.) failed to relay the need for a physician order and implement a system to ensure that specific treatments or procedures, which requires a physician's order, were being carried out for 1 (R1) of 3 (R5, R7) residents reviewed for therapy services. This failure has the potential to affect the effectiveness of patient care and lead to improper/delayed treatment. Findings Include: R1 was admitted to the facility on [DATE] with diagnosis not limited to Essential (Primary) Hypertension, Syphilis, Gastrostomy, Asthma with (Acute) Exacerbation, Dysphagia, Oropharyngeal Phase, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Acute on Chronic Systolic (Congestive) Heart Failure, Long Term (Current) use of Anticoagulants, Epilepsy, Human Immunodeficiency Virus [HIV] Disease, Single Subsegmental Thrombotic Pulmonary Embolism, Ventricular Tachycardia, Polyneuropathy, Dysphagia Following Cerebral Infarction, Adjustment Disorder with Depressed Mood, Vascular Dementia, Sepsis, Hypoxemia and Hypotension. R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 00 indicating R1 was not able to answer the questions in Section C Cognitive Pattern. Order Summary Report dated 01/13/25 document in part: May evaluate and treat: PT/OT (Physical Therapy/Occupational Therapy). R1's Physical Therapy evaluation is dated 05/08/24 with a discharge date of [DATE]. R1's Occupational Therapy evaluation is dated 05/06/24 with a discharge date of [DATE]. There are no additional documented Physical/Occupational Therapy notes/evaluations for the physician order dated 01/13/25. On 04/22/25 at 12:37 PM R1 was observed lying in bed in a low [NAME] position. R1 responded yes to each question that was asked by the surveyor even while pointing to no on the paper that was held by the surveyor with written yes/no responses. On 04/22/24 at 11:16 AM V4 (R1's Family Member) stated the requested rehabilitation facility did an assessment, and it took 2 1/2 weeks before the facility sent the paperwork. On 04/22/25 at 11:23 AM V7 (R1's Family Friend/Care Giver) stated The facility faxed the medical records over to the requested rehabilitation facility. On 04/22/25 at 12:08 PM V6 (R1's Power of Attorney) stated V5 (Requested Rehabilitation Facility Nurse) said she (V5) need the Occupational Therapy and Physical Therapy evaluation. On 04/22/25 at 11:41 AM V5 (Requested Rehabilitation Facility Nurse) stated the family wanted R1 to come to the requested rehabilitation facility. I can't get the therapy evaluations. R1 is not getting therapy so there is not anything to send so that I would have the physical therapy and occupational therapy evaluation to submit to the insurance. I got medical records from the facility, but it took a long time. I can't do anything until I get the therapy evaluation. It has been a couple of weeks since I received documentation from the facility. I received the documentation on 04/11/25. I am idling and asked the family to help. Sometimes the facility responds and a lot of times I would be sent to a phone that rings and rings. The case has been opened for a while, 6-8 weeks. I spoke to the family last week and told them I needed their help so I can submit it to the insurance. On 04/22/25 at 01:19 PM V8 (Licensed Practical Nurse) stated I think they are trying to get R1 in the requested rehabilitation facility. I know the paperwork has been sent to V5 (Requested Rehabilitation Facility Nurse) on 04/11/25. R1 is not receiving any current physical or occupational therapy. On 04/22/25 at 01:27 PM V11 (Certified Nurse Assistant) stated I contacted V5 (Requested Rehabilitation Facility Nurse) if she (V5) has what she (V5) needs for insurance purposes for R1 to get evaluated by one of their doctors. V4 (R1's Family Member) has been requesting for R1 to go to the requested rehabilitation facility. I sent over what I have to the requested rehabilitation facility, and it depends on if the insurance will approve it. I did a follow-up last Thursday 04/17/25 and V5 (Requested Rehabilitation Facility Nurse) was not in the office. On 04/23/25 at 10:47 AM V15 (PTA/Physical Therapy Assistant/ Director of Rehab) stated R1 received physical therapy and occupational therapy in May of 2024. The physical therapy initial evaluation was on 05/08/24. The physical therapy discharge date was 05/28/24. The occupational initial evaluation was on 05/06/24. The occupational therapy discharge date was 05/23/24. Reevaluation for physical and occupational therapy after a hospital discharge depends on what warrants it. We don't necessarily pick a resident back up for therapy. We screen quarterly and talk to the staff on the floor if they notice any improvements or decline or if the doctor gives a referral. We can only do evaluations if we get a doctor's order. On 04/23/25 at 12:34 PM V14 (Social Service Director) stated I am learning about R1's family request for a transfer. I was on vacation when all of this came about and the requested rehabilitation facility reached out to the facility. I did not know that V11 (Certified Nurse Assistant) sent a packet to the requested rehabilitation facility. On 04/23/25 at 12:58 PM V14 (Social Service Director) presented the surveyor with R1's face sheet, labs and progress notes that was sent to the requested rehabilitation facility. V14 stated I am going to speak with the administrator. On 04/23/25 at 01:05 PM V14 (Social Service Director) stated the plan is we are going to obtain orders from the physician for the physical and occupational therapy evaluation and once we obtain the order, we will do the evaluation and send the results to the requested rehabilitation facility. I can't give you and answer why the evaluation was not done. On 04/23/25 at 01:44 PM V14 (Social Service Director) presented the surveyor with an order for R1's occupational and physical therapy evaluation. V14 said here is the order. On 04/23/25 at 02:29 PM V1 (Administrator) stated one day V4 (R1's Family Member) came up here. R1 use to be at the requested rehabilitation facility and V4 wanted R1 to go back to the facility. V4 said V5 (Requested Rehabilitation Facility Nurse) was trying to contact V14 (Social Service Director). I told V4 that V14 was on vacation and to have V5 call me. V11 (Certified Nurse Assistant) our scheduler for appointments called V5 about a follow up for another resident and got into what V5 needed, a doctor order for therapy services. V5 never called me directly for R1. V11 just told me yesterday that R1 needed an order to be evaluated by physical and occupational therapy. On 04/23/25 at 02:34 PM V3 (Director of Nursing) said we followed up with the nurse practitioner today and got an order for R1's physical and occupational therapy evaluation. The order was just written today. I let V15 (PTA/Physical Therapy Assistant/Director of Rehab) know and V15 said that she (V15) will do the evaluation first thing in the morning. On 04/23/25 at 02:41 PM V11 (Certified Nurse Assistant) stated I sent V5 (Requested Rehabilitation Facility Nurse) R1's documentation on 04/11/25. V5 told me R1 needed an evaluation for physical and occupational therapy. V14 (Social Service Director) was on vacation, and I talked to V20 (Resident Care Coordinator) MDS (Minimum Data Set) and she (V20) said that she (V20) was going to look into R1's chart. Progress note dated 03/07/25 08:07 document in part: MD (Medical Doctor) Progress Note Text: R1 would benefit from the requested rehab center. Resident was a total care before, but now only needs 1 person assist, a lot of improvement is needed. They (R1) will benefit from the requested rehabilitation facility outpatient therapy. Progress note dated 04/22/25 12:54 document I part: Social Services Note Text: Resident's family is requesting for a discharge to the requested rehabilitation facility for therapy. This is pending acceptance, therefore discharge plans will be initiated, if accepted. Order Summary dated 04/23/25 document in part: PT/OT evaluation only. On 04/23/25 V1 (Administrator) emailed an Employee Counseling Form for V11 (Certified Nurse Assistant) dated 04/23/25 documenting in part: Problem: Staff member failed to notify management team timely of orders needed for evaluation to send over to the requested rehabilitation facility for further review. Resolution of Problem or Action Taken: Staff member educated on the importance of effective communication. On 04/24/25 surveyor requested a Policy on Effective communication & Timely notification for a physician order. V1 (Administrator) sent an email at 07:48 PM documenting: We do not have a Policy on Effective communication & Timely notification for a physician order. On 04/25/25 at 02:13 PM V1 (Administrator) stated V3 (Director of Nursing) would be responsible for making sure the physician order for the PT/OT was carried out. I talked to V20 (Resident Care Coordinator) and V20 said that V11 (Certified Nurse Assistant) never disclosed that R1 needed a PT/OT evaluation. V20 set up a care plan meeting with V6 (R1's Power of Attorney) but V6 did not show up. Policy: Titled Physician's Orders for Medications or Treatments dated 01/13 document in part: Verbal orders will be received only by licensed nurses and subsequently confirmed in writing by the prescribing physician.

Based upon observation, interview, and record review the facility failed to ensure that 2 (R116 and R159) residents' call lights main plates were attached, failed to ensure 5 residents' (R112, R133, R136, R179 and R434) bathroom sinks were functioning properly and failed to ensure 1 resident's (R133) room was well-maintained/in good repair. These failures have the potential to affect 7 residents (R112, R116, R133, R136, R159, R179 and R434) reviewed for safe and clean homelike environment, in a total sample of 66 residents. Findings include: 1. On 2/23/25 at 9:38am, while in R179's and R434's bathroom, surveyor observed the bathroom sink clogged with light brownish colored water and numerous hairs floating in the water. On 2/23/25 at 9:41am, with V24 (Registered Nurse/RN), while in R179's and R434's bathroom, V24 said, It looks like someone shaved and clogged it. Housekeeping is up here. I'll see if they have a plunger. R179's Face sheet documents diagnoses that include but are not limited to benign neoplasm of the brain, unspecified psychosis, and schizophrenia. R179's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 9 which indicates that R179's cognition is moderately impaired. R434's Face sheet documents diagnoses that include but are not limited to chronic kidney disease, unspecified psychosis, Type II Diabetes Mellitus, and dementia. R434's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 5 which indicates that R434's cognition is severely impaired. 2. On 2/23/25 at 10:27am, while in R112's and R136's bathroom, surveyor observed the bathroom faucet with continuously running water. Surveyor attempted to shut the water off but was unsuccessful. On 2/23/25 at 10:38am, with V24 (Registered Nurse/RN), while in R112's and R136's bathroom, V24 attempted to shut the water off for the bathroom sink but was unsuccessful. V24 said, I'll call for repair. R112's Face sheet documents diagnoses that include but are not limited to schizoaffective disorder, dementia, and chronic obstructive pulmonary disease. R112's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 00 which indicates that R112's cognition is severely impaired. R136's Face sheet documents diagnoses that include but are not limited to Parkinson's disease, unspecified psychosis, anxiety disorder and major depressive disorder. R136's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 9 which indicates that R136's cognition is moderately impaired. On 2/25/25 at 12:10pm, V7 (Housekeeping Supervisor) said, Maintenance is responsible for sinks. We're (housekeeping) responsible for cleaning up the floor. On 2/25/25 at 12:32pm, V16 (Building Manager) said, There's a log binder on each unit for employees to write repairs in. I check it twice a day. Once in the morning and once towards the end of my shift. I was notified yesterday of the sink issues on the third floor. They are taken care of. Clogged sinks can be a fall issue and the build up of water can cause more damages to the building. Facility policy titled, Housekeeping Department, revised date 1/23, documents, in part, The Facility will follow an effective plan to maintain a clean, safe, and orderly environment . 2. Floors will be maintained as clean and free of slipping and tripping hazards. 3. Reported or discovered environmental hazards will be removed or mitigated promptly. Facility presented pamphlet titled, Residents' Rights for People in Long-term Care Facilities, revised date 3/17, documents, in part, . safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction. Facility job description titled, BUILDING MANAGER RESPONSIBILITIES, revised date 3/14, documents, in part, . Building Manager will assure that maintenance services are provided to all areas of the building, grounds, and equipment in a prompt and professional manner . The Building Manager is responsible for assuring that the following functions are performed as necessary for the safety and comfort of residents, staff, and visitors: i. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. ii. Maintaining the building in good repair and free from hazards. v. Maintaining the HVAC system, plumbing fixtures, wiring, all equipment, etc., in good working order . ix. Maintaining communication systems (nurse call, paging, telephone) in good working order . xii. Maintaining all areas in a safe condition. Performing Safety Inspections as required. Facility job description titled, Housekeeping Aide, dated 1/2015, documents, in part, . C. Follow and complete cleaning schedules daily as assigned . L. Check all windows, furniture, fixtures, etc. for correct operation and complete maintenance repair slip, turn into supervisor. Facility job description titled, Housekeeping Supervisor, dated 1/2015, documents, in part, . F. Develops and maintains a cleaning schedule to meet the demands of the facility to ensure a clean, sanitary, odor free environment . N. Makes rounds regularly to assure that Housekeeping personnel are performing required duties, and to assure that appropriate Housekeeping Procedures are being followed . R. Ensures that facility equipment is maintained in accordance with manufacturer's guidelines and (Facility) policies. 45196 3. R116'S Face sheet shows that R116 has a diagnosis which include but not limited to malignant neoplasm of unspecified part of unspecified bronchus or lung, dizziness and giddiness, cerebral atherosclerosis, other sequelae of cerebral infarction, unspecified severe protein calorie malnutrition, muscle spasm, mixed hyperlipidemia, nicotine dependence cigarettes, and essential primary hypertension. R116's has a Brief Interview for Mental Status (BIMS) dated 12/10/25 with a score of 15 which indicates that R116 is cognitively intact. R159'S Face sheet shows that R159 has a diagnosis which include but not limited to Cauda Equina syndrome, Crohn's disease without complications, anemia, partial loss of teeth due to trauma, undifferentiated schizophrenia, obesity, paraplegia, chronic vascular disorders of intestine and acute pancreatitis without necrosis of infection. R159's has a Brief Interview for Mental Status (BIMS) dated 01/20/25 with a score of 15 which indicates that R116 is cognitively intact. On 02/23/25 at 11:12 am, Surveyors observed R116 and R159's call device plate missing a cover with interior fixtures externally exposed. R116 stated, That has been like that for a long time. They never fixed it. I think that's why I (R116) have to press hard for my call light to work. Surveyor observed R116 and R159's call device functioning without concerns. On 02/25/25 at 11:18 am, Surveyor questioned V16 (Maintenance Director) regarding R116 and R159's call device cover and V16 stated that V16 is aware of R116 and R159 missing call device cover. V16 then explained that V16 has to get approval to purchase more call device covers and has only been allowed to purchase five call device covers at a time. V16 further explained that V16 has approval to order five more call device covers for the facility and that the call device covers are on back order. When V16 was asked regarding the internal fixtures exposed externally from R116 and R159's missing call device cover V16 explained that the exposed fixtures were not wires and cannot harm anyone if touched. V16 stated that the call device cover is for a homelike cosmetic appearance for R116 and R159's room. 41611 4. R133 has a diagnosis of but not limited to Type 2 Diabetes Mellitus, Vascular Dementia, History of Falling, Acute Osteomyelitis, and Malignant Neoplasm of Prostate. R133 has a Brief Interview of Mental Status score of 15. On 2/23/2025 at 10:57am surveyor attempted to turn off R133's sink in the bathroom with no success. Surveyor turned both handles on the sink to turn the water off and the water continued to run from the faucet. Surveyor also observed a missing floor tile from in front of R133's bed. On 2/23/2025 at 10:59am R133 stated he has reported the faucet issue to nursing and maintenance staff and they come and look at it but that never come back to fix it. R133 stated that he gets out of his bed on the other side, by the window, because he does not want to step down on the floor where the floor tile is missing. On 2/25/2025 at 10:31am V30 (Maintenance Coordinator) said, No, faucets should not be running continuously. V30 said that there are guys here today, to assist in replacing floor tiles. On 2/25/2025 at 12:32pm V16 (Building Manager) stated he was just made aware of the sink in R133's bathroom that would not shut off and the missing floor tile and said the water should not be continuously running.

Based on observation, interview and record review, the facility failed to provide ADL (Activities of Daily living) care for 5 dependent residents (R30, R34, R70, R91, R95). This failure affected 5 residents out of a sample size of 66 residing in the facility. Findings include: 1. R70 has a diagnosis of but not limited to Schizoaffective Disorder, Depressive Type, Superficial Frostbite of Right Hand, Superficial Frostbite of Left Foot, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side. R70 has a Brief Interview of Mental Status score of 14. R70's care plan focus (Activities of Daily Living) dated 1/15/2025 documents, in part, has an ADL Functional Performance Deficit due to unsteady gait, CVA with left hemiplegia with interventions of Assist with personal hygiene as needed and provide needed level of assistance and support to complete Activities of Daily Living. On 2/23/2025 at 11:48am, surveyor observed R70's fingernails to be extremely long on both hands and R70 stated that he would like his nails to be cut. On 2/24/2025 at 11:24am, V6 (Licensed Practical Nurse) stated nail care is provided twice a week, on shower days, and as needed. 2. R95 has a diagnosis of but not limited to Dysphagia Following Nontraumatic Subarachnoid Hemorrhage, Sequelae Following Nontraumatic Subarachnoid Hemorrhage, Hydrocephalus, Cerebrospinal Fluid Drainage Device, Dementia, Moderate, with Other Behavioral Disturbance and Blindness Left Eye Category 5, Normal Vision Right Eye. R95 has a Brief Interview of Mental Status score of 02. R95's care plan focus (Activities of Daily Living) dated 5/31/2021 documents, in part, R95 has an ADL self-care performance deficit secondary to impaired mobility, deficit in cognition with an intervention of Check nail length and trim and clean on bath days and as necessary and assist with ADL tasks as needed. On 2/23/2025 at 10:27am, surveyor observed R95's fingernails on both hands to be long. On 2/23/2025 at 10:31am, V23 (Certified Nursing Assistant-CNA) stated nail care is provided on shower days (twice a week) and as needed. On 2/25/2025 at 8:56am, V2 (Director of Nursing) stated nail care is provided on shower days and as needed. Policy dated 09/2020 titled Nails (Care of) documents, in part, all residents will have clean, well-trimmed nails. CNA Job Description dated 3/2023 documents, in part, provides assistance with activities of daily living to a specific number of residents. 52136 3. On 2/23/25 at 12:05 PM, R30's fingernails appeared long and jagged. A dark substance was visible under R30's fingernails. R30 stated he needs his nails clipped. R30's face sheet dated February 25, 2025, shows R30 was admitted to the facility on [DATE] with multiple diagnoses including Schizophrenia, human immunodeficiency virus, hypertension, hyperlipidemia, chronic viral hepatitis C, rhabdomyolysis and anxiety. R30's MDS (Minimum Data Set) dated February 4, 2025, shows R30 has a score of 11 which means R30 has moderate cognitive impairment, requires supervision or touching assistance with most ADLs and is incontinent of bowel and bladder. R30's care plan dated November 15,2024 shows R30 requires assistance with personal hygiene and ADLs including brushing teeth, washing/drying face and hands, combing hair, cutting nails, shaving etc. due to decreased motivation, incontinence and impaired cognition. Intervention/Tasks: staff will assist [R30] with needed level of assistance and support to complete ADLs through next review. 4. On 2/23/25 at 12:11 PM, R34 was sitting in chair in R34's room. R34's fingernails were long, and a dark brown substance was visible under R34's nails. R34 stated he wants his nails cut. R34's face sheet dated February 25, 2025, shows R34 was admitted to the facility on [DATE] with multiple diagnoses including Dementia, hypertension, hyperlipidemia, schizoaffective disorder bipolar type, impulse disorders, and depression. R34's MDS (Minimum Data Set) dated December 6, 2024, shows R34 has a score of six which means severe cognitive impairment, requires supervision or touching assistance with most ADLs and is incontinent of bowel and bladder. R34's care plan dated May 15,2024 shows R34 requires assistance with personal hygiene and ADLs including brushing teeth, washing/drying face and hands, combing hair, cutting nails, shaving etc. due to Dementia and Alzheimer's disease. Intervention/Task: staff will assist [R34] with personal hygiene and ADLs through next review. 5. On 2/23/25 at 11:44 AM, R91's fingernails appeared long and jagged. A dark substance was observed under R91's fingernails. R91 stated he needs his nails clipped. R91's face sheet dated February 24, 2025, shows R91was admitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, major depressive disorder, psychosis, chronic obstructive pulmonary disease, benign prostatic hyperplasia, and anxiety. R91's MDS (Minimum Data Set) dated February 12, 2025, shows R91 has a score of 11 which means R91 has moderate cognitive impairment, requires supervision or touching assistance with most ADLs. R91's care plan dated December 6,2024 shows R91 requires assistance with personal hygiene and ADLs including brushing teeth, washing/drying face and hands, combing hair, cutting nails, shaving etc. due to bipolar disorder. Intervention/Task: staff will assist [R91] with personal hygiene and ADLs through next review.

Based on observation, interview, and record review the facility failed to assure that emergency medical equipment stored to be used in emergency basic life support was checked daily. This deficient practice has the potential to affect all sixty one residents that reside on the 3rd floor of the facility. Findings include: Facility census, dated [DATE], documents 61 residents residing on the third floor. On [DATE] surveyor observed document titled, Emergency Cart Daily Review, month February 2025, with missing a daily crash cart check for [DATE]. On [DATE] at 11:58am, V25 (Licensed Practical Nurse/LPN) said, Yes, the emergency cart should be checked daily. We (staff) want to make sure everything is working in case of an emergency. If the crash cart is not checked, and something is missing or not working, something bad can happen to the resident that could have been prevented. On [DATE] at 12:47pm, V2 (Director of Nursing/DON), said Crash carts are checked daily and signed off that they were checked to ensure its locked, there's O2 (oxygen), backboard, and the suction machine is working and ready to go. Facility policy titled, Emergency Carts, dated ,d+[DATE], documents, in part, . Emergency carts will be accessible for facility staff to readily provide supplies for emergency situations . 3. Emergency carts will be checked daily to assure that the lock tab is not broken. If the lock tab is broken, supplies must be checked against the supply checklist, missing or expired supplies replaced. Check that oxygen tank is filled, suction machine is set-up ready and CPR board is present. Facility presented pamphlet titled, Residents' Rights for People in Long-term Care Facilities, revised date ,d+[DATE], documents, in part, . safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction. Facility job description titled, Staff Nurse (Registered Nurse/License Practical Nurse), dated ,d+[DATE], documents, in part, . Responsible to provide direct nursing care to the customer, and to supervise the day-to day nursing activities performed by the nursing assistants. Such supervision must be in accordance with current Federal, State, and local standards, guidelines and regulations, facility policies. The objective is to ensure the highest degree of quality care is maintained at all times . C. Assume all Nursing procedures and protocols are followed in accordance with established policies.

Based on observation, interview, and record review, the facility failed to ensure the janitor closet was locked at all times where residents with a diagnosis of dementia reside. This failure has the potential to affect all the 25 residents on the 2nd floor [NAME] Wing of the facility. Findings include: On 02/25/2025 at 3:12pm, V1 (Administrator) stated the resident's rooms on the second floor [NAME] wing are from rooms 201 to 212. The (02/22/2025) Midnight Census Report documented that there were 25 residents on the second floor's [NAME] Wing. On 02/23/2025 at 11:00 AM, the janitor closet on the second floor's [NAME] Wing was not locked. This observation was pointed out to V7 (Housekeeping Supervisor). V7 checked the closet, removed a piece of paper from the strike plate hole where the latch bolt lies when closing the door, and stated somebody put a piece of paper or something to stop the door from locking. This surveyor requested V7 to keep the door open and to tell this surveyor what's inside the Janitor's closet. V7 stated we have the electric circuit breaker and chemical solution dispenser inside the janitor closet. This door should not be left unlocked. The janitor closet should be locked at all times because we have a circuit breaker, and chemicals are stored inside. On 02/23/2025 at 12:50pm, facing the 2nd floor elevator, V6 (Licensed Practice Nurse) stated you cannot use the elevator without an elevator key. V6 used the elevator key to access the elevator. On 02/24/25 at 11:07 AM, V16 (Building Manager) stated the janitor closet should be locked at all times to prevent anybody from shutting off the power. The chemicals inside the janitor closet, I am pretty sure, are harmful. On 02/24/2025 at 11:15am, with V16 (Building Manager). This surveyor instructed to open the second floor [NAME] Wing janitor closet and inquired what potentially could happen if the janitor closet was left unlocked. V16 opened the janitor closet and stated well we have the breaker panel on the right side of the Janitor closet and chemicals on the left side. Resident may potentially shut off the breaker and there will be no electric power on the nurse's station and on the rooms on this wing. On 02/24/2025 at 11:20am, V16 used the elevator key to access the 2nd floor elevator. On 02/26/2025 at 9:42am, V2 (Director of Nursing) stated the 2nd floor is a skilled floor. This surveyor inquired why a key is needed to use the elevator on the second floor. V2 stated because some of the skilled residents on the second floor have a dementia diagnosis. The (02/25/2025) Inservice/meeting Attendance record documented, in part The HSKP (housekeeping) staff will make sure that the janitor's closet(s) are closed and properly locked on a daily basis. The (3/14) Secured Hazardous Area Door Check documented, in part A. Policy. All doors to hazardous areas will be kept locked to ensure the safety of residents and staff. B. Procedure. 5. Housekeeping are responsible for locked areas under their control. The (undated) Residents' Rights for People in Long-Term Care Facilities documented, in part As a long-term care resident in the State, you are guaranteed certain rights, protections and privileges according to State and Federal laws. Your rights to safety. Your facility must be safe.

Based on interview and record review, the facility failed to ensure a second staff member was present to assist in a mechanical lift transfer for three resident (R1, R2 and R3) reviewed for accidents and incidents in the sample. This failure resulted in R1 sustaining a laceration to the right foot requiring five sutures and a fracture to the right great toe. Findings include: On 6/17/24 at 11:55am, V1 (Administrator) presented the facility's report of injury dated 4/11/24 and 6/3/24 that were sent to the State Agency. The report dated 4/11/24 states in part: On 4/11/24 during transfer with a mechanical lift, resident's foot was inadvertently bumped on the lift. Upon assessment by the assigned nurse, open area was observed to right great toe, bleeding observed, first aid rendered immediately. Primary physician and family made aware. Orders received to transfer resident to the (hospital). Resident returned to the facility with 5 sutures to the right great toe. On 6/17/24 at 11:25am, together with V4 (LPN/Licensed Practical Nurse), the surveyor interviewed R1 about how he (R1) got injured on the right foot. R1 stated that the CNA (Certified Nursing Assistant) was transferring him in the mechanical lift by herself and did not get any help, and she (CNA) bumped his foot on the machine. The surveyor asked R1 how the injury to his foot could have been prevented; R1 stated that there should have been a second staff to help during the transfer. On 6/17/24 at 11:10am, together with V3 (LPN), the surveyor interviewed R3 about how staff transfers R3 with the mechanical lift. R3 stated that only one CNA usually transfers her in the mechanical lift, and there is no second staff to help. R3 stated that she (R3) has bumped her right foot slightly a couple of times, but not painful enough to report to staff. On 6/17/24 at 11:15am, together with V4(LPN), the surveyor interviewed R2 about how staff transfers R2 with the mechanical lift. R2 stated that most times, only one CNA moves her in the mechanical lift by themselves and she (R2) is sometimes scared. On 6/17/24 at 1:33pm, V9 (CNA) was interviewed about how R1's foot was injured on 4/11/24. V9 stated I waited on another staff to help me with the (mechanical) lift but when they did not come, I did it by myself. His (R1's) foot got caught in the seat belt, and I saw the foot bleeding when he (R1) was in the air. The nurse was outside the room in the hallway close to the door and quickly came to help. Inquired from V9 if V9 attended any training about the use of the mechanical lift; V9 stated that she has been a CNA for 9 years and that she knows that two staff are required to use the mechanical lift. R1's Face sheet documents an admission diagnoses include but are not limited to Flaccid Hemiplegia Affecting Left Non-Dominant Side, Convulsions, Diabetes, Depressive Disorders, and Muscle Spasms. R1's MDS (Minimum Data Set) section C dated 5/13/24 shows BIMS (Basic Interview for Mental Status) score of 15 indicating R1 is cognitively intact. R1's Care plan dated 1/10/2014 with revision date 5/25/2023 states in part: R1 requires the use of a mechanical lift for transfers due to impaired mobility. Intervention states to provide 2 staff assistance for transferring. R1's Progress notes date 4/11/24 at 8:30pm written by V8 (LPN/Licensed Practical Nurse) states in part: Writer was called to room [ROOM NUMBER] by CNA. Upon arrival, writer noted resident bleeding profusely from under the toes of right foot. Bandages and pressure applied to the site. 911 called. R1's Hospital Records dated 4/11/24 written by V14(Hospital Physician) states in part: [AGE] year-old with past medical history as noted above, presenting with right foot bleeding noted to be from laceration sustained from web between first and second toes on the right foot. No active bleeding noted at bedside on examination. Injury concerning for deep laceration potentially involving tendon injury. Will get imaging and talk to orthopedic surgery regarding evaluation and management. Right Foot X-Ray Report 3 Views states under Impression: 1. Intra-articular fracture of the lateral base of the first proximal phalanx. 2. Soft tissue laceration between the first and second digits without evidence of radiopaque foreign bodies. 3. Other chronic findings are described. R1's Acute Episodic Visit Note dated 4/12/24 written by V13 (Nurse Practitioner/NP) states that R1 had laceration to the right great toe and Avulsion fracture of the metatarsal bone of right foot. R2's MDS section C dated 5/13/24 documents a BIMS score of 15 indicating R2 is cognitively intact. R2's Care plan dated 4/13/23 states R2 requires the use of a mechanical lift for transfers with 2 staff's assistance. R3's MDS section C dated 5/17/24 documents a BIMS score of 15 indicating R3 is cognitively intact. R3's Care plan dated 4/9/2017 states R3 requires the use of a mechanical lift for transfers with 2 staff's assistance. On 6/17/24 between 10:40am and 10:55am, nursing staff members including V5 (CNA), V6 (CNA), V3 (LPN), and V4 (LPN) were interviewed about the use of mechanical lifts for transfer of residents with mobility issues. All 4 staff stated that mechanical lifts require 2 staff members to operate. On 6/17/24 at 12:35pm, V7 (Restorative Nurse) stated that CNAs and nurses have been trained on the use of mechanical lift and they know to have assistance from another staff before operating the lift. At this time, V7 presented the list of staff that were trained on 4/12/24 and 4/22/24. On 6/17/24 at 2:20pm, V2 (Director of Nursing) stated CNAs and Nurses know to call for a second staff to operate the (mechanical) lift. They know that even I will come up to help them, and they should not do it with only one staff. At this time, V2 presented a facility-wide list of 39 residents who use mechanical lift transfer. This list included R1, R2, and R3. On 6/17/24 at 3:10pm, V13(Nurse Practitioner/NP) was interviewed regarding R1's foot injury 2 times in a row. V13 stated They told me that the resident was injured during transfer. It was a laceration that required 5 stitches and he was on antibiotics. The injury was completely healed in the same area. The second injury happened on a weekend and the resident was not sent to the hospital. But on Monday when we assessed the injury, the wound care team decided to send him to the hospital. The resident was observed and later returned from the emergency room . Inquired from V13 if staff should have followed the resident's care plan and instructions for using the mechanical lift to prevent the injury on 4/11/24. V13 stated that staff should comply with the care plan to reduce injuries, and the interventions in the care plan should be followed. Facility's policy on Total Mechanical Lift dated 1/14/2021 states the purpose is to lift, transfer, and move a resident from one surface to another. #4 states: 2 caregivers are required to operate the mechanical lift. Facility's Competency titled Total Mechanical Lift states in #5a: Safe techniques are demonstrated by placing the equipment in position with the assistance of a second caregiver. Facility's policy titled Incident/Accident Reports dated 09/2020 states in #15: 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.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for a cognitively impaired resident (R1); failed to visually check every two hours for the presence of one of four residents (R1) reviewed who were at risk for elopement and wandering; and failed to ensure the facility entrance/exit was secure. As a result, R1 eloped from the facility on the night of 8/07/23, without the facility staff being aware the resident (R1) was missing until the morning of 8/08/23. This failure resulted in Immediate Jeopardy which began on 8/07/2023, when R1 eloped from the facility unnoticed and was unaccounted for. V1 (Administrator) was informed of the Immediate Jeopardy on 8/28/2023. On 8/31/23, an acceptable removal plan was received after revision from the original plan submitted 8/28/23. On 9/05/23, the surveyor confirmed by observation, interview, and record review, that the removal plan was initiated, and Immediate Jeopardy was removed on 9/01/23. However, the non-compliance remains at a level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: According to roster and surveyor's observation of R1's assigned room, R1 was located on the facility's first floor. R1's admission record showed R1 was admitted to the facility on [DATE], with diagnoses including, but not limited to: non-ST elevation (NSTEMI) Myocardial Infarction, History of falling, Unspecified Dementia moderate with other behavioral disturbances, Restlessness and agitation, other Schizophrenia, Cough Variant Asthma, and Essential (Primary) Hypertension. R1's MDS (Minimum Data Set) assessment, dated 07/04/2023, indicated R1 is cognitively impaired. R1's medical record fall assessment, dated 5/4/23 and 7/4/23, showed R1 is at risk for falls, with a score of 8.0 as of 05/4/2023, and a score of 7.0 as of 7/4/23. R1's plan of care, with initiated date 3/15/2023, documented under focus, (R1) is found exploring/elopement/exit seeking familiar setting as evidenced by looking persistently for a way to get out or get home, attempts to get on elevator, attempt to use alarmed fire exit doors. Goals includes, to safely remain on unit or under supervision. Intervention /task-initiated, date 3/15/2023, listed to initiate frequent checks and supervision. R1's care plan for mental illness, initiated 2/28/23 and revised 5/08/2023, under focus, documented R1 has a diagnosis and history of severe mental illness, with symptoms manifestation that includes display of unknown risk for factors that includes wandering, elopement risk, and poor safety awareness. Goals set includes R1 taking medication as prescribed. According to the Emergency Medical Services (EMS) report, on 8/07/23, R1 was taken to a local hospital at 9:55pm (21:55). The report documented R1 was found in care of the local fire company. The bystanders on the scene stated R1 was walking in the middle of the road, confused about her location. R1's ER (Emergency Record), 8/07/23, documented R1 was confused and appears to have Dementia. According to the facility investigation report the following staff statements were presented: -V22, LPN (Licensed Practical Nurse), stated she worked 7pm to 11:27pm on 8/07/23, and was the nurse for R1. V22 made rounds and R1 was refusing care and medications, walking around the floor throughout the night. V22 documented R1 was encouraged to go to bed. -V28, CNA (Certified Nursing Assistant), documented she worked on 8/07/23 on the 1st floor where R1 was at the time of elopement, but did not hear any alarm, and was not aware of any resident leaving the building (referring to elopement). -V29 (Housekeeping) stated on Monday (referring to 8/07/23), V29 did not hear any alarm sound. -V6, CNA (Certified Nursing Assistant) statement, dated 8/08/23, documented, I started work around 9:00pm and started my rounds around 10:30pm. I opened the door to (R1's) room and investigated her room. (R1) 's bed looked like someone was in it. The covers were on it, and the pillow was there. (R1) has been pretty loud lately, so I was letting (R1) stay quiet, so I did not go over to (R1's) bed. V6 statement included some previous behaviors of throwing garbage can, claiming to see someone behind the curtain that was not there, and claiming to see rats that were not there. I did not see (R1) physically, but saw the blanket and the pillow, which looked like (R1) was in bed. V6 stated she made her rounds at 2:00am or 2:30am, and it was the same thing she saw (referring to 10:30pm). V6 statement documented at 5:45am on doing the last rounds she went back to R1's room. I must be honest, I thought that (R1) was just quiet and peaceful, so I didn't go into the room to get a look at (R1). (R10 only needs a little supervision and goes to the bathroom independently. V6 indicated she did not hear any alarm besides the one she heard at 7:15am, which was V30 (Painter) for the facility. -V23 (LPN) undated statement, stated, On Monday I worked with (R1) from 11pm to 7am. I am going to be honest, did not see (R1) all night. She gets one pill at 6am, but I did not give it to her. I saw her at the elevator around 8 to 8:30, and I asked her to go to her room. (R1) moved away from the elevator area then went back to it. V23 stated that was the last time she saw R1. V23 stated when she was about to give her medicine, she (V23) found that R1 was missing. I did not notify anyone that she was missing. The protocol for missing resident is search, page code green and inform the administrator. According to the facility investigation V22, LPN (Licensed Practical Nurse), was contacted via telephone and stated she worked on 8/07/23 from 7am to 7pm, and the last time she saw R1 was around 8:30pm, and was re-directed back to the room. V22 statement indicated V22 did not see R1 after that time. R1's medication record progress note, dated 8/08/23 timed 2:33pm (14:33), V26, SSD (Social Services Director), documented R1 eloped on 8/08/23. This conflicts with the EMS report that R1 was taken to hospital 8/07/23 at 9:55pm. Review of facility schedule sheet for January to April 2023 showed Security staff scheduled for 10pm to 6am, but no security staff were scheduled for the 10pm to 6am shift for May to August 2023. On 8/21/23 at 9:03am, V1 stated R1 eloped on 8/08/23, and V1 was notified at around 8:30am. According to the facility's documented investigation, the facility was unaware R1 was missing until 8/08/23 at 8:30am. On 8/21/23 at 9:45am, V20 (Security staff) stated, The Security staff are supposed to check residents and visitors in and out of the facility and make sure the residents going out are the ones allowed to go out without supervision. The smoking list is by Security, and the resident pictures are in a binder by Security, along with the pictures and list of those who wander and can elope. V20 stated there was usually one Security staff scheduled for the night shift, but lately there has been no security staff at night. On 8/21/23 at 10:04am, V19 (Security staff) who was scheduled for 2pm to 10pm on 8/07/23, stated he works from 2pm to 10pm, and there is no other Security staff scheduled for 10pm to 6am. V19 was not sure how R1 eloped. On 8/21/23 at 11:40am, V19 stated he did not leave the Security post all night. However, the facility's video showed between 9:04pm and 9:10pm, V19 was not at the door monitoring. When this was made known to V19, he stated, I only left one time to use the bathroom. V19 stated when he is on toilet break or any break, there should be a staff monitoring the door, but there was no staff to relieve him. The Security guard desk and the door leading to the 1st floor residents' area was left wide open. On 8/21/23 at 12:36pm, V1, Administrator, stated, The doors (referring to the entrance door to the 1st floor residential area) should not be left unattended, without staff supervising (monitoring) the doors. There is usually one Security staff on schedule from 10pm to 6am, but that staff is no longer working at the facility. The facility was trying to get another Security staff to replace the one that was gone. V1 stated the doors should not be left unattended without staff supervising /monitoring those doors. On 8/22/23 at 9:37am, V7 (Clinical Director) stated, I oversee the Security staff and their schedule. Regarding security staff staffing, because we (referring to the facility) have residents with behavioral health problems, the facility is required, and must have 24 hour security guards trained in CPI (Crisis Prevention Intervention). Recently, we (Facility) don't have any staff to replace the person who was here on night shift in the past two months, but we are trying to fill that position, trying find some-one. When asked about the purpose of having Security staff 24 hours a day, V7 stated it is to assist with any behavior challenges, and anything the facility may need, and that includes residents who are physically aggressive, at risk for elopement and who wander, and with some residents who need re-direction. Surveyor asked V7 if, in the case of R1's elopement, not having door alarms to alert staff is effective. V7 stated in part, Yes, I do think it is effective, but I do think there should be a Security staff on duty at night. The surveyor asked V7 about the expectation of staff in monitoring and supervising the residents who are at risk for elopement and who wander. V7 stated, Staff are to keep eye on them, be aware of where they are. Then the surveyor asked, In your professional opinion, was this followed in the case of (R1)? V7 stated, I digress in answering that question; I'm keeping my answer to myself (with smiling gesture and shrugging of the shoulder). V7 presented the facility schedule sheet for Security staff presented from January to April 2023, that showed Security staff was scheduled for 10pm to 6am, and from July to August 2023, there was none scheduled. On 8/22/23 at 12:43pm, V24 (CNA) stated, On 8/08/23 when I came, (R1) had already gone missing (eloped). When I came into work, I did my rounds; she usually sits up on the side of the bed, but I noticed she was not in her room, so I thought she was in the dining room for breakfast. But she was not there; then I got busy doing the breakfast cards for the trays. After a while I asked (V17, Restorative Aide/CNA) to help whether (R1) was in the room and then we (staff) started calling Code Green (For missing resident). V24 stated, Rounds means I physically see the resident, asking them about their needs, if they are wet (incontinent), change them, but (R1) is continent. Rounds was to be done every 2 hours; about three times during the shift I make my rounds. At 8:30am was the time we knew (R1) was not on the floor, so we called code green and other staff started looking for (R1). On 8/22/23 at 2pm, V17 (Restorative Aide/CNA) stated On that morning on 8/08/23, I was the one that discovered R1 was gone (eloped). When I was doing my rounds at about 8:30am or 9am to get (R1) a breakfast tray, (R1) was not in her room. I checked the dining room, shower room, and I talked to the nurse, (V16), thinking (R1) might have gone for appointment or went out. (V17) stated that the dinner tray was left on the side table, then we did the room search, after then called Code Green because we could not find (R1) in the facility. The surveyor then asked V17 about how often rounds are made. V17 stated, Every two hours, but I am a Restorative Aide; at times we work on the floor. I know she wanders, but I did not know she could elope. (R1) needs supervision in the community; she cannot function on her own. V17 stated, It's not safe for her out there. On 8/28/23 at 9:04am, V1 (Administrator) stated when there is no Security staff in the facility after 10pm, all the staff in the facility from that time are responsible for monitoring the residents, which includes the nursing staff. On 8/28/23 at 9:06am, V2, DON (Director of Nursing) stated residents are monitored through making routine checks. V2 stated, Rounds are to be made every two (2) hours by nursing staff by visually seeing the residents. On 9/05/23 at 9:54am, V23 (LPN) stated on 8/07/23, she was the nurse for R1 from 11pm to 7am. V23 stated she was the only nurse in charge on the 1st floor after 11pm until 7am. V23 stated she did not make any rounds at 11pm, and I did not see (R1) throughout the night. I saw her at about 8:30pm; she was by the elevator. Rounds are supposed to be made every 2hours and as needed. V23 stated, I did not see (R1) during the night shift, because throughout the night I did not notice that (R1) was gone, and none of the CNAs told me (R1) was not in here (Facility). The surveyor then asked when you did become aware R1 was not on the floor and in the room, what is the facility protocol to be followed. V23 stated she is to search for (R1) and call code green, search all the facility inside and outside, call the Administrator, the doctor, and the family. But that was my mistake. I did not follow the policy and procedure on elopement. V23 confirmed, (R1) is at risk of danger out there; I did not give the 6am medicine because (R1) was gone. V23 stated the Security guard leaves at 10pm, and after the nursing staff are to monitor the residents. I did not hear any alarm that night and I did not see (R1) go out of the building. V23 stated, (R1) is known to wander. There was a time (R1) was found in the elevator on the 2nd floor, and in the basement confused. I know I should have followed the elopement policy and procedure. On 9/05/23 at 9:58am, V23 stated R1 is cognitively impaired to function well out in the community, and has a BIMS (Brief Interveiw for Mental Status) score of 07. V23 stated, (R1) is at risk of danger out there (Community). The facility policy on Routine Resident checks, dated 9/2020, documented the routine checks policy interpretation and implementation includes ensuring the safety and well-being of our (referring to the facility) residents, a resident check will be made at least every two (2) hours throughout each 24-hour shift by nursing services personnel, and it involves entering the resident's room to determine if the resident's needs are being met, if there has been a change in the resident's condition, if the resident has any complaints, and if the resident is sleeping or needs toileting assistance etc. On 9/05/23, the surveyor made observations, conducted interviews, and received documentation to confirm the following removal plan was initiated: 1. R1 was reassessed by Social Service for elopement risk on 08/08/23, after the elopement occurred and deemed an elopement risk. 2. Upon R1's return to the facility, R1 was moved to a secured unit on the 2nd floor of the facility. 3. The DON (Director of Nursing), ADON (Assistant Director of Nursing), and Social Services are responsible for assessment and updating care plans, monitoring, and reeducating staff on safety. All staff responsible for monitoring all residents. 4. Identified other residents at risk for elopement as having the potential to be affected by the same deficient practice. 5. All residents were reassessed by Social Services for elopement risk. 6. All new residents will have an elopement risk assessment by Social Services to be completed within 24 hours upon admission, and an interim care plan will be initiated based off the assessment, and will be reassessed every three months, and as needed. 7. All residents determined to be at risk for elopement and with active exit-seeking behaviors will be evaluated by Social Services for possible room change to the secure unit on the second floor. 8. Special Resident council meetings were held to educate residents on seriousness of safety; informed of the requirements to leave facility unsupervised. 9. All staff managers were reeducated by V1 (Administrator) and V2, DON (Director of Nursing) on routine checks, exit seeking, abuse prevention, incident and accidents, elopement policy and procedure and where to locate the risk of elopement binders. 10. All staff and managers were re-educated by V1 and V2 on elopement risk and reporting behaviors or changes in factors related to elopement risk appropriate discipline. 11. All staff and managers were re-educated by V1 and V2 regarding door alarms, checking to ensure doors are opening and closing properly, and responding to door alarms to ensure it was not triggered by a resident. 12. Building manager was assigned to monitor alarms on all units and lower levels on all shifts. 13. Building manager or designee will monitor the exit door in the daytime when nursing staff are on break. 14. The only time when alarms will be unalarmed will be during deliveries in the daytime in the back of the building. 15. The front door alarm was fitted on 08/08/23. 16. Exterior door alarms will be checked by the building manager to ensure they are in working order on each shift. 17. Review of compliance using Quality Assurance Audit tool for elopement and door alarm working condition. 18. Elopement audit started 08/08/23. Audits will be done weekly for four weeks, then monthly x 3months, and then randomly by V1 or designee.

Based on observation, interview, and record review, the facility failed to provide ordered oral nutritional supplements, and failed to follow Registered Dietitian's recommendations for one resident's (R78) reviewed for nutrition and significant weight loss in the sample of 50 residents. This failure resulted in R78 having continued weight loss including significant weight loss (13.44% change over 3 months and 18.50% change in 6 months). Finding include: R78's Admission Record documents, in part, R78's diagnoses include cirrhosis of liver, diabetes, and vitamin D deficiency. R78's (1/5/23) Brief Interview of Mental Status (BIMS) score is 13. R78 is cognitively intact. R78's Monthly Weight Report documents September 13, 2022 - 251.4 lbs., October 11, 2022 - 252.0 lbs., November 21, 2022 - 248.2 lbs., December 07/2022 - 217.6 lbs., January (no specific date documented) - 202.2 lbs., February (no specific date documented) - 204.9 lbs. R78's Care plan, dated (1/5/23), documents, in part, Focus requires nutritional support secondary to need for Therapeutic diet. Goal: Will adhere to therapeutic diet and maintain weight. On 3/05/23 at 11:32 am, R78 stated, I do not eat the food in the facility; the facility does not give me food that I can eat. I have lost a significant amount of weight. Surveyor asked R78 if he was receiving nutritional supplements. R78 stated, No. On 3/6/23 at 12:50 pm, surveyor observed R78's lunch tray which consisted of ham, broccoli, maccaroni and cheese, fruit cup, and a cup of yellow fluid. No ordered nutritional supplements were observed on R78's food tray. On 3/7/23 at 12:40 pm, surveyor observed R78's lunch tray which consisted of chicken, rice, mixed vegetables, biscuit, ice cream and a cup of yellow fluid. No ordered nutritional supplements observed on R78's food tray. R78's Order Summary Report, dated 3/7/23, with active orders, documents, in part, Diet: No Concentrated Sweets (NCS) diet Regular texture, M**** C** two times a day at lunch and dinner. M***** S**** no sugar added two times a day with lunch and dinner. On 3/7/23 at 12:45 pm, R78's Meal ticket, documents, name, room number, diet, NCS (No Concentrated Sugar) NAS (No Added Salt). Breakfast, Lunch, and Dinner section (blank). No Fish across ticket. Dislikes section (Blank). Coffee, Tea, Milk, Decaf, Water, Juice (Blank). On 3/7/23 at 3:45 pm, V1 presented an updated meal ticket for R78. On 3/8/23 at 1:13 pm, surveyor received a copy of R78's updated meal ticket with m**** c** and m***** s**** for lunch and dinner added to the ticket. R78's Nutrition Quarterly/Reassessment/ Assessment (1/4/23) documents, in part, 1. (d) Supplements: M***** S**** no sugar added, M**** C** or G*******. 3. (a) Most Recent Weight: 217.6 (date: 12/07/2022 at 19:03 (7:03pm) 3. (c) Weight History: current weight is pending 12/7/22 217lbs (pounds) triggering weight loss 30.6 lbs. Comparison Weight 11/21/2022, 248.2 lbs., RD (Registered Dietician) recommended re-weigh 10/11/22 252 lbs. 9/13/22 251.4 lbs . 4. (a) significant weight change in past 1 month? No. (b) Significant weight change in past 3 months? No, Significant weight change in past 6 months? No. On 3/7/23 at 1:50 pm, V10 (Dietary Supervisor) stated R78 is expected to get his m**** c** and m***** s**** for lunch and dinner daily. V10 stated, I do not know why the supplement was not on (R78's) tray, we are not out of it in the facility. Surveyor inquired how staff know to give R78 a supplement with lunch and dinner, because it is not on the meal ticket. V10 stated, The staff knows who gets a supplement. On 3/7/23 at 2:15 pm, V35 (Dietitian) stated the dietary supplement order for R78 should be given as ordered two times a day for lunch and dinner. Surveyor inquired if R78 was order dietary supplement, should it be on R78's tray whether he east or drinks it or not. V35 stated, That's correct. (R78) should still get it on his tray whether he eat or drink it or not, absolutely. On 3/8/23 at 12:45 pm, V39 (Nurse Practitioner) stated the supplements were ordered for R78's weight loss and decline in appetite. V39 stated the supplements should be on R78's tray for lunch and dinner. V39 stated the potential harm in not receiving the supplement is there could be continued weight loss. The supplement is provided to help assist in R78's weight loss. Facility Dietary Supplement Policy (1/18), documents, in part, Purpose: Dietary supplements may be required to enhance the resident's nutritional status. Facility Weights Policy (9/20) documents, in part, Policy: Residents will be weighed to established upon admission. The resident will be weighed weekly for 4 weeks after admission and monthly thereafter. Report to nursing supervisor, physician/NP, dietary supervisor, RD consultant and family/responsible party of any weight loss or gain greater than 5% within one (1) month, 7.5% within three (3) months or 10% within six (6) months. Facility Dietary Aide job description, documents, in part, Essential Functions: Prepare food for therapeutic diets in accordance with planned menu extensions. (As appropriate). Q. Prepare food in accordance with standardized recipes and special diet orders. Facility Food and Nutrition Services Manager job description, documents, in part, Essential Functions: C. Assess nutritional status of each resident per standards of care. M. Process diet changes and new diets as received from nursing department. P. Maintain an up-to-date list of all diets, blue cards, nourishment list, resident preferences, and resident diet census.

Based on record review and interview, the facility failed to follow their abuse policy for two residents (R1,R2) out of four residents reviewed abuse. This failure resulted in a staff members not immediately intervening before R1 became physically aggressive towards R2. This failure resulted in R1 hitting R2 on the head, causing R2 a laceration requiring five staples. The Findings Include: R1's care plan, dated 11/2/19, denotes R1 is at risk for abuse related to: Not easily redirected with challenging behaviors. He has a history of being easily upset and quick tempered being verbally aggressive toward staff and peer. On 1/24/2023 at 11:32, R2's Psychiatrist/Psychologist Note Text: Psychiatry Progress Note reads : Present History: 75yr old male, was seen for follow-up, and is alert and oriented to self. Staff reported occasional aggressive behavior but can be redirected, no agitation or aggressive behavior was noted. Patient functioning at baseline. R1's 2/11/2023 at 20:29 nurses note text reads : Nurse was notified that resident hit another resident on the head with his walking stick. Resident voiced 'He was in my room so I told him to leave and he will not leave so I walked up to him and hit him on the head with my stick' . On getting to resident room nurse observed resident sitting in his bed complete body assessment done with no injury noted vitals taken at this time are as follow BP 132/68, P 78, T 98, R 18 spO2 98% RA (room air) resident remained in his room under security watched. Facility Administrator informed. NP (nurse practitioner) made aware order to petition resident out to (hospital) given. Order noted and carried out. Resident POA (Power of Attorney) made aware of resident situation and transferred. R2's 2/11/2023 at 23:33 nurses note text reads: Nurse was called to room (residents room number) by a staff that resident was bleeding from the head . rResident voiced 'I got hit on the head'. On getting to room (residents room), nurse observed resident lying in bed. Complete body assessment and neuro check done with an open area to the top of the head observed and no confusion noted. The site was cleaned with NS (normal saline) and bandage applied vitals taken at this time are as follow (BP) 155/85, P 88, R 20 T 98 spO2 99% RA (room air) . Resident was taken to the nursing station for close monitoring . Facility Administrator made aware per facility protocol. NP (Nurse Practitioner) made aware order to send resident to (hospital) given order noted and carried out . Resident POA (Power of Attorney) was informed of resident condition and transferred Facility's abuse report, dated 2/11/23, denotes Administrator was made aware both residents (R1,R2) were in a physical altercation. Both residents were immediately separated. Full body assessment done. R2 sustained an injury and was sent to the hospital per physician order. An investigation was immediately initiated. R2's hospital record, dated 2/11/22, denotes R2 was brought to emergency room for head injury, laceration. R2's hospital Computed Tomography Scan negative for any acute process . Laceration Wound closed with five staples. R2's 2/12/2023 at 05:23 Nurses Note Text reads : Writer spoke to RN (Registered Nurse) who verbalized Resident being admitted to the Acute Care Area (room and bed number) for 1) Dizziness, Head injury with Scalp Laceration ,closed.2) Uncontrolled HTN (hypertension) On 2/24/23 at 10:00 am, V20 (Doctor) stated R2 did sustain a cut to his head, which was superficial laceration. V20 stated, Fortunately (R2) was not seriously harmed because his CT (Computed Tomography) showed that no subdural/epidural or acute bleed which could be considered potentially serious injuries. V20 stated R2 was treated the same day at the hospital and sent back to the facility in stable condition. On 2/22/23 at 10:00 am, V1 (Social Worker) statedshe has worked on the third floor for nine years, and R1 been a resident on the third floor for a few years. V1 stated R2 has been a resident on the third floor for a couple of years. V1 stated R1 is confused at times and gets agitated sometimes when asked to do something he does not like to do. V1 stated R2 is very confused and sometimes can be verbally aggressive with staff or his peers. On 2/22/23 at 10:30 am,V6 (Certified Nursing Assistant) stated she was in another room serving dinner when she heard a loud commotion, then came out into the hallway, and saw R2 with blood with on his face. V6 stated she yelled for the nurse (V8) who came running towards R2. V6 stated sV6 aw the nurses assess R2, then took him to his room. V6 stated R2 has psych (psychiatric) issues, and his behavior changes from day to day. V6 stated whenever she has seen R2 getting into arguments with another resident, they have been able to redirect him. V6 stated R1 has a history of being aggressive when he has these mood swings. V6 stated she has never seen R1 hit another resident with his cane. V6 stated they have to redirect all the residents because it is a behavior unit with psych residents. On 2/22/23 at 11:00am, V8 (Licensed Practical Nurse) stated he has worked at the facility for several years and took care of both R1 and R2. V8 stated R1 was alert and oriented times 2-3 with some confusion. V8 stated most of the time, R1 would stay in his room, but would walk out of his room using his cane if he needed something. V8 stated R1 has a history of aggression and needed to be redirected when he got upset. V8 stated R2 was alert times 1-2, and would roll around on the unit in his wheelchair. V8 stated R2 sometimes gets confused and wanders into the wrong room, but they usually see him and redirect him to his room. V8 stated on Saturday (2/11/23) around dinner time, V8 was at the nurses station when another staff member told him R2 was bleeding. V8 stated V8 noticed R2 had cut on the top of his head. V8 stated cleaned the wound with normal saline and applied a clean band aide. V8 stated asked R2 who hit him, and pointed to R1's room. V8 stated he went to R1's room to interview him to ask what happened. V8 stated during the interview, R1 told him R2 would not leave his room, so he hit him with his cane. V8 stated he called the doctor, Administrator and family members. V8 stated R1 and R2 were both sent to the hospital for evaluation. V8 stated this has never happened before while he was taking care of R1. On 2/22/23 at 9:30 am, V2 (Administrator) stated all abuse reports should be sent to IDPH (Illinois Department of Public Health) within 24 hours according to the facility abuse protocol. V2 stated any allegation of abuse is filled out on the incident form, but the preliminary 24-hour abuse form then faxed to IDPH within 24 hours. V2 stated she got a call on Saturday R1 hit R2 on the head with his walking cane. V2 stated staff had separated both residents, doctor and family notified. V2 stated staff told her R2 sustained a cut to his head. V2 stated at this time ,she is not sure if R1 is coming back to the facility. Facility's abuse policy denotes, This facility prohibits mistreatment, neglect, or abuse of its residents and attempted to establish a resident sensitive and resident secure environment. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers and staff from other agencies providing services. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility.

Based on observation, interview, and record review, the facility failed to ensure each resident's room window was secured to prevent a resident from eloping via the window, and failed to have an effective maintenance program that ensures all resident room windows are secured throughout building. 1 of 162 residents (R7), who resided on the facility third floor monitored psychiatric unit, was able open a room window and jump from a window in his room. As a result of the failure, R7 sustained left leg, right leg, and foot fractures on 11/29/22. This was identified as an Immediate Jeopardy which began on 11/29/22. V1, Administrator, was notified of the Immediate Jeopardy on 1/12/2023. The facility presented a removal plan on 1/13/2023 at 4:24pm that was accepted. However, on 1/18/2023 during the onsite verification, observations indicated the Immediate Jeopardy was not removed. V1 submitted a second removal plan with additional interventions on 1/18/2023 at 4:25pm that was accepted. On 1/20/2023, the surveyor confirmed by observation, record view, and interview, the Immediate Jeopardy was removed. The deficiency remains at actual harm until the facility can evaluate the effectiveness of the implementation of their removal plan and maintain substantial compliance with this regulation. The Immediate Jeopardy was removed on 1/18/2023. Findings include: Current face sheet documents R7 is a [AGE] year-old resident admitted to the facility at 5/26/2022. R7's medical diagnosis includes, but not limited to: Restlessness and Agitation, Unspecified fracture of the left lower leg, Initial encounter for closed fracture, Pathological Fracture, Right ankle, Initial Encounter for fracture unspecified fracture of left lower leg, initial encounter for closed fracture, Nondisplaced [NAME] fracture of the right Tibia, Initial Encounter for Closed Fracture. R7's MDS (Minimum Data Set) Section C -Cognitive Patterns, dated [DATE], documents: BIMS (Brief Interview for Mental Status) score of 8/15= moderately cognitive impairment. MDS Section GG - Functional Abilities and Goals, dated November 22, 2022, documents: Eating ability as needed, setup or clean-up assistance, oral hygiene, requires supervision or touching assistance, for toileting, shower/bathe self, upper body dressing, requires supervision or touching assistance. Facility reported incident report, dated 12/05/2022, documents: On 11/29/2022 at approximately 8:00am, R7 exited the facility via window resulting in a fall. R7 was observed outside of the facility. R7 was alert to person and place with periods of confusion. R7 was observed with swelling to lower extremities. Physician notified; Guardian notified. R7 transferred to nearby community hospital emergency room for further evaluation. R7 was admitted with bilateral broken ankles, fractured lumbar and thoracic spine. Social services notes documents the following: On 11/29/2022 14:31 Behavior/Interventions Describe Behavior: Upon doing rounds it was discovered that R7 had eloped from his room. Interventions Implemented: Immediate search of the room and unit did not reveal resident (R7). Code green initiated. Under Did Intervention(s) work? Resident (R7) was located in the nearby area by police: Area police called to the facility. Police report dated 11/29/2022 remarks: Resident found. Care Plan Updated: Y - N - N/A: yes R7's Nursing notes, dated 11/29/2022 08:00, documents: At the start of my (V4-Licensed Practical Nurse/LPN) shift approximately 7:30 AM, it was identified that (R7) was not in his room. A CODE GREEN was called, a search of the floor and outside ground was conducted. (R7) was noticed on the ground outside of the facility. (R7) complained of pain to bilateral legs. Police on scene and ambulance. (R7) transported to (community hospital). PPHP NP (Nurse Practitioner) notified of occurrence and transfer to Hospital NP aware. Facility window maintenance log, dated 11/29/22, documents R7's window on the 3rd floor was not properly secured. R7's hospital medical records, dated 11/29/2022, contained the following information: R7's diagnosis as: 1. QT Prolongation (Heart dysrhythmia) 2. Closed fracture of the left ankle, initial encounter 3. Closed fracture of the left ankle, initial encounter 4. Fall, initial encounter 5. Acute non-intractable headache, unspecified headache type 6. Closed displaced [NAME] fracture of tibia, unspecified laterality, initial encounter 7. Physical fracture of distal end of tibia, unspecified laterality, unspecified physical fracture, configuration, initial encounter. 8. Closed nondisplaced [NAME] fracture of the right tibia, initial encounter. R7's X-ray results, dated 11/29/2022, documents: Findings: Left tib/fib: Redemonstrated acute comminuted fracture of the distal left tibia and fibula, better evaluated on dedicated left ankle radiographs, Acute comminuted, minimally displaced fracture of the proximal fibula with mild apex posterior angulation. There is soft tissue swelling about the proximal leg. Left foot: Right tib/fib: Redemonstrated acute comminuted fracture of the distal left tibia and fibula, better evaluated on dedicated left ankle radiographs. On 1/10/2023 at 11:33am, R7 was observed lying in bed awake, with R7's right leg in a plaster cast from the toe to mid upper thigh. R7 was alert and oriented to name and place. R7 stated he fell from 3rd floor roof to the ground. R7 said, I used to live on the 3rd floor, they would not give me speech (sic). I was not feeling good, and I wanted to go home so I jumped from the roof. He (unknown person) denied me speech to go outside (sic), so I wanted to go home, so I jumped out window and tried to go home, which is my right because I am not incarcerated. It was a paranoid thing. On 1/10/2023 at 11:54am, V4 (Licensed Practical Nurse/LPN) said on the day of the incident (11/29/22), (R7) was in the room. (R7's) bed was near the window. V4 stated she checked R7's room and did not see R7 in his room during morning rounds after she started the morning shift. V4 said he notified V9 (Clinical Director-social worker) and code green (Missing resident) was called. V4 said staff started looking for R7, but R7 was not found. V4 said R7's window was open. V4 stated after R7 was not found, staff (names not provided) went outside and found R7 laying down on the ground below R7's window. V4 said V4 was not sure how R7 got out of the unit. On 1/10/2023 at 12:09pm, V9 (Clinical Director-social worker) said on 12/29/2022 at about 7:30am, V9 went to R7's room and did not see R7. V9 stated she saw the lower half of the window against the wall. V9 stated she observed a gap/hole where the bottom window was supposed to be. V9 said, I saw bed sheets hanging from the gaping window to the outside. I left to notify (V1, Administrator). (V1) was on the 3rd floor by the nursing station. V9 stated she called Code Green (Missing resident) and all the staff started to look for R7. V9 commented she got in her car and started driving around the facility looking for R7. V9 said, I got a text from (V12, Assistant Administrator) notifying me that (R7) was found by the parking lot and police were already there with (R7). V9 further commented when she got to the parking lot, R7 was on a stretcher, ready to be transported to the hospital for evaluation. On 01/10/2023 at 12:24pm, V10 (Maintenance Director) said, On 11/29/2022 in the morning around 7:30am, I was notified that (R7) was missing. I went to (R7's) room on the 3rd floor and saw the whole bottom part of the window missing. V10 stated the window is supposed to open only 4 inches upwards so residents can get fresh air but it's (window) supposed to have two metal stops on each side of the window to prevent it from opening up higher, but the metal safety stops on (R7's) windows were not operational at the time. V10 stated R7 opened the window and took the whole bottom window off. V10 said the windows are designed to open and remove easily for cleaning; it takes about five minutes to remove the whole bottom window from the track. V10 demonstrated how the window is removed by pressing the two metal stops inwards, pulling the window inwards (room side), and lifting the window up and out from the track. V10 said, There are other windows in the building with the broken/nonfunctional safety metal stops, the bottom windows could have been easily removed. V10 said the windows are easily removable for easy window cleaning by housekeeping. They (Housekeepers) are supposed to place windows back on track and secure them. V10 said after R7's incident of jumping from the window, staff from corporate office come to assist in temporarily fixing the windows by screwing in one bolt at the bottom of the window to prevent it from being opened. V10 measured the bottom window that R7 opened and took off the track. Measurements were observed to be: height-29.5 inches by width=45 inches wide. On 1/10/2023 at 3:14pm, V1(Administrator) stated on 11/29/2022 at about 7:30am, V1 was on the 3rd floor doing rounds, when V1 heard V9 saying, Oh My God, oh my God! V1 stated (V9) was saying this because she saw (R7's) bed sheets (about 4 sheets) were tied together to (R7's) bed frame to window, hanging from window to outside. The sheets were hanging from (R7's) bed frame all the way outside the window. V1 said the lower part of R7's window was missing, there was an open gap/hole open to the outside. V1 stated the whole lower part of the glass window was behind R7's bed. V1 said V9 left the room to continue looking for R7. V1 stated she remained in R7's room, looked through the open window, but did not see R7. V1 said, All I could see was the bed sheets hanging down from the window. I had never seen anything like this before. V1 commented Code Green was called, and all staff started looking for R7. V1 stated she received a text from (V12, Assistant Administrator) letting V1 know R7 was found in the facility parking lot by police. V1 stated she did not know how R7 got to the 1st floor, but stated R7 did not go through facility doors. V1 said, I think (R7) got to the ground floor using the bed sheets (R7) had tied to (R7's) bed frame. (R7) is a veteran, and was in the Air Force and used to jump from airplanes/heights. V1 said the window was put back in and screwed shut at the bottom to prevent it from opening. V1 said, this is a temporary fix. On 01/11/2023 at 11:31am, V12 (Assistant Administrator) stated there was a code green called on 11/29/2022, in the morning. V12 went to the 3rd floor to R7's room, and R7 was not in the room. The window was missing. V12 stated he went downstairs to the east side of the building down from residents' room, but R7 was not there. V12 stated at the time, he walked around the building and saw the police in the facility. R7 was with the police, but V12 stated he did not remember if R7 was sitting down or laying down. V12 said he went back into the building to let other staff members who were looking for R7 know R7 was found outside. V12 said he does not remember how he notified staff, but after notifying staff, V12 went back out and the ambulance was at the scene. V12 said he does not recall anything else about the incident or what happened after that. On 1/11/2023 at 12:51pm, on day two of the survey, with V10 (Maintenance Director), the surveyors were able to unscrew the safety bolt previously placed by maintenance to secure the window in the resident rooms on the 3rd floor. According to V10, the bolts were placed on all resident's windows to prevent the windows from opening. At this time, V10 stated the bolts will be replaced next week with bolts that can only be opened with a special screwdriver. V10 presented a work order, dated 1/11/23, from (Construction company). V10 stated all resident windows will be secured next week. (Construction company) recommendations documents in part: Going forward it is recommended that any high-risk patients have an audible monitor put on the window to alert staff of any potential tampering, similar to what is currently on the stairwell doors. On 1/18/2023 at 12:41pm, V30 (Facility general superintendent) stated all windows have been secured with Hex locks at the top of the windows in resident rooms. During walking tour with V30 for observation of resident windows, surveyor, using facility butter knife, demonstrated removal of [NAME] screw, at the bottom of window in resident 3rd floor room. Surveyor was able to remove bottom half of window from the window tract. On 1/20/2023 the surveyor verified the facility's second removal plan was implemented via observation, interview, and record view, as follows: 1. On 11/29/2022, the Administrator immediately implemented an audit of all residents to assess for cognitive impairment. The Brief Interview for Mental Status (BIMs) was conducted and completed by key department heads, (Resident Care Coordinator, ADON, Assistant Administrator, Social Services, and Behavioral Health Director) on 12/2/2022 to identify residents with moderate to severe cognitive impairments. The residents identified are those residents who BIMs score are 12 or lower. As of 1/18/2023, all residents' rooms windows had three safety features to prevent window from being removed. a. First safety feature: Secure all windows with 1 Hex screw in the center of the bottom flange. The screw will prevent the tip out feature to function, not allowing residents to open window. This is in response to secure the window and ensure the safety of the residents. b. Second Safety Feature: Tip out stop in place on windows which prevent the windows from being tipped out. c. Permanent solution to prevent window from being opened installed 1/18/2022: Installed 1 hex screws in the bottom flange. The hex screw cannot be removed without the appropriate hex tool. d. As of 1/12/2023 & 1/18/2023, room sweeps were conducted removing all devices that could potential be used to open the window. e. Window inspections are done daily by above listed key department heads, maintenance and on off hours security guards do window check. (Initiated 11/30/2022, 1/12/2023 & 1/13/2023) f. On 1/18/2023, 1 Hex Screw will be applied to all windows on the 1st, 2nd and 3rd floor. All windows were inspected by outside contractor on 1/18/2023. 2. The facility Quality Assurance Team (including Medical Director, Administrator, Assistant Administrator, social services, DON, ADON and facility consultant) revised the process of residents having access to outdoor socialization group. Staff will offer each resident the opportunity to participate in an outdoor socialization group minimally three time per week. Window inspections are done daily by above listed key department heads, and maintenance. (Initiated 11/30/2022, 1/12/2023 & 1/18/2023) 3. An in-service was initiated on 12/1/2022, 1/12/2023, and 1/18/2023 (by Key Department Heads) to all staff about residents' leaving the building, and pass procedures. On 12/1/2022, 1/12/2023, 1/18/2023, an in-service was initiated with staff regarding safety feature to prevent window from being open, checking windows for disrepair and reporting any occurrence of resident tampering with windows. 4. Based on the assessment of the windows at the facility and the following steps will be done: Secure all windows with 1 Hex screw in the center of the bottom flange. The screw will prevent the tip out feature to function, not allowing residents to remove the lower sash. This is the long-term solution to prevent windows from being opened and removed. 5. On 1/18/2023, room sweep conducted by (Resident Care Coordinator, ADON, Assistant Administrator, Social Services, and Behavioral Health Director) on all residents' rooms. All items which could potential be used to unscrew on window was removed. As of 1/18/2023, a Hex Screw being applied to the window to prevent it from being open. No resident was identified with having a Hex Tool to remove the Hex Screw. 6. On 1/18/2023, Hex screw will be applied to all windows on the1st, 2nd ,and 3rd floor. All windows were inspected by outside contractor. The facility will continue to use QA tool to check all windows daily to ensure they are good repair.

Based on observation, interview, and record review, the facility failed to ensure resident safety for one resident (R7) of three residents reviewed for elopement on a secured psychiatric unit. This failure resulted in R7 jumping from his room window. R7 sustained right left leg and ankle foot fracture. R7 was hospitalized and received a plaster cast to his right leg. Findings include: Social Services Assessment under Exit Seeking/wandering/Elopement risk assessment, dated 06/3/2022, documents: R7 has the physical ability to leave the building on his own. R7 has a current diagnosis of severe mental health illness, and information was provided by R7 and staff interview/observation. Also documents R7 has experienced two or more psychiatric hospitalization s. R7's care plan, dated 06/07/2022, documents: Resident(R7) is content with current placement and discharge to the community is not feasible due to mental health and lack of support as determined by interdisciplinary team, physician, resident, or regal representative. R7's care plan, dated 06/07/2022, documents: Resident(R7) has been evaluated to be placed on a Level One Behavioral Health Pass Program. This level allows the resident (R7) dependent time with a responsible party. R7's care plan, dated 06/09/2022, documents: R7 displays delusional behavior problem, R/t (related to) Yelling out, and confused, and negative thinking. Difficult to reason with. Social Services note, dated 06/1/2022, documents: R7 met with staff 1:1 concerning R7 temper and how he responded towards staff. Social services note, dated 7/31/2022, documents R7 washing his clothes in his room sink instead of sending clothes to laundry. Social services note, dated 08/17/2022, documents R7 was not changing his clothes and staff met with R7 to discuss importance of changing his clothes. Social services note, dated 10/12/2022, documents R7 was spilling water on floors. R7's social services progress notes, dated 11/01/2022, document: R1 engaged in an incident of peer-to-peer incident in which R1 threw beverages. Interdisciplinary note, dated 11/2/2022, documents R7 has not recollection of incident of 11/1/2022, R7 communicates some cognitive deficits and laughs in place of responses at times Facility reported incident report, dated 12/05/2022, documents: On 11/29/2022 at approximately 8:00am. (R7) exited the facility via window resulting in a fall. (R7) was observed outside of the facility. (R7) was alert to person and place with periods of confusion. (R7) was observed with swelling to lower extremities. Physician notified; Guardian notified. (R7) transferred to nearby community hospital emergency room for further evaluation. (R7) was admitted with bilateral broken ankles, fractured lumbar and thoracic spine. The facility's incident report further documents R7's diagnoses, not limited to: unspecified psychosis, Unspecified symptoms, and signs involving cognitive functions and awareness, TBI (traumatic brain injury), restlessness and agitation. R7's X-ray results, dated 11/29/2022, documents: Findings: Left tib/fib: Redemonstrated acute comminuted fracture of the distal left tibia and fibula, better evaluated on dedicated left ankle radiographs, Acute comminuted, minimally displaced fracture of the proximal fibula with mild apex posterior angulation. There is soft tissue swelling about the proximal leg. Left foot: Right tib/fib: Redemonstrated acute comminuted fracture of the distal left tibia and fibula, better evaluated on dedicated left ankle radiographs. On 1/10/2023 at 11:33am, R7 was observed lying in bed awake, with R7's right leg in a plaster cast from the toe to mid upper thigh. R7 was alert and oriented to name and place. R7 stated he fell from 3rd floor roof to the ground. R7 said, I used to live on the 3rd floor, they would not give me speech (sic). I was not feeling good, and I wanted to go home so I jumped from the roof. He (unknown person) denied me speech (sic) to go outside, so I wanted to go home, so I jumped out window and tried to go home, which is my right because I am not incarcerated. It was a paranoid thing. On 1/10/2023 at 12:09pm, V9 (Clinical Director-social worker) said on 12/29/2022 at about 7:30am, V9 went to R7's room and did not see R7. V9 stated she saw the lower half of the window against the wall. V9 stated she observed a gap/hole where the bottom window was supposed to be. V9 said, I saw bed sheets hanging from the gaping window to the outside. I left to notify (V1, Administrator). (V1) was on the 3rd floor by the nursing station. V9 stated she called Code Green (Missing resident) and all the staff started to look for R7. V9 commented she got in her car and started driving around the facility looking for R7. V9 said, I got a text from (V12, Assistant Administrator) notifying me that (R7) was found by the parking lot and police were already there with (R7). V9 further commented when she got to the parking lot, R7 was on a stretcher, ready to be transported to the hospital for evaluation. On 1/12/2023 at 4:10pm, V25 (R7's State Guardian) stated she was notified by facility when R7 jumped out of the window, attempting to elope. V25 commentated R7 is head strong and strong physically, and R7 is very smart. V25 said R7 went to college and was R7's major was in engineering. V25 said R7 was living alone independently in the community, but about seven months ago, R7 got into a fight in his neighborhood, and R7 was beat up and sustained a traumatic brain injury (TBI). V25 said that is when R7 went into state guardianship, and V25 started working with R7 as his state appointed guardian. V25 said before R7 come to this facility, R7 was in another facility. V25 further stated R7 used to live in New York with his sister (V26), who used to take care of R7, but R7 became too much for V26 to handle. V26 also takes care of R7's mother. V25 said R7 tried to jump from another facility in New York. V25 commented R7 has been calling his mother and upsets her during the calls, so V26 has restricted R7's phone calls to R7's mother, who is elderly. R25 said R7 is delusional and thinks people are watching him from space, and that is why R7 was not compliant with medications at the last facility. On 1/13/2023 at 2:04pm, V27 (R7's physician) said because R7 has a diagnosis of psychosis, agitation, and restlessness, and R7 was exhibiting signs and symptoms of agitation, R7 should have been on treatment to manage R7's behavior. V27 stated during R7's mood and behavior assessments, the facility should have looked at risks and benefits of R7 receiving psychotropic medication. V27 further said that given R7's previous actions and diagnosis of mental health condition, R7 have been on a scheduled mood/ behavior medication. On 1/13/2023 at 10:49am, V26 (R7's family member said R7 has never been in the military, and she stated R7 was diagnosed with schizophrenia around 1998 in New York, where R7 and family were living. V26 said she was helping R7 and took R7 in to help him, and would make sure every time R7 had a mental breakdown, R7 was admitted to the hospital for treatment stabilization. V26 said at that time, R7 did not like living with V26, because V26 would call 911 to take R7 to the hospital any time R7 stopped taking his behavioral health medication and R7 started showing signs of paranoia and laughing uncontrollably. V26 said R7 tried to elope from the hospital when R7 was first diagnosed with mental health illness. V26 said R7 does not believe R7 has mental health challenges and is in denial. She commented R7 cannot stay at one place because of R7 living with schizophrenia. V26 said she was monitoring R7, but when she left New York for work, R7 left his apartment and started wandering, and at one point, R7 was incarcerated. V26 further commented R7 eventually left New York and ended up in Chicago where R7 does not have any family. V26 said because of R7's mental health issues, R7 can be paranoid, and these behaviors might have led to R7 being involved in a fight in Chicago where R7 was terribly hurt. V26 said R7 calls his mother screaming and saying he wants to visit her, and this upsets R7's mother, who is [AGE] years old. V26 said she has now restricted R7's calls to his mother. V26 commented she takes care of her and R7's parents, who are both [AGE] years old, and V26 cannot take on R7 because V26 is already overwhelmed with taking care of both parents. V26 said when R7's mental health issues are under control, and R7 is properly medicated, R27 is the sweetest person you will ever met. V26 said R7 wants to visit his parents, especially his mother, but V26 said this is not possible at this time because V27 cannot take care of R7. On 1/13/2023 at 12:18pm, V9 said there were no discharge plans when R7 was first admitted , and he never said he wanted to leave. V9 said V9 did not think R7 was not a risk for elopement prior to R7 jumping out the window, and R7 had an accompanied pass to go out with guardian/staff. On 1/17/2023 at 3:28pm, V29 (R7's Psychiatrist) said R7 was visited two times by the psychiatry Nurse Practitioner in November and December 2022 for further assessments, but both times R7 was not in the building. V29 stated the facility never notified V29 about any behavioral issues/hallucinations R7 was experiencing before R7 jumped out of the window on the 3rd floor. V29 said even after R7 jumped out of the window, the facility never notified V29 of the incident, and V29 just recently learned (after Christmas) R7 had jumped out of the window. V29 said it is documented on several occasions R7 was preoccupied with going out of the facility see his mother, and R7 should have been moved to the 1st floor for supervision and monitoring in case R7 tried to leave the facility. V29 said, If the facility staff had called me to let me know R7 wanted to leave the facility to visit his mother, I would have instructed them to move him (R7) to the first floor since he (R7) has cognitive deficits. V29 commented having R7 on the first floor could have prevented R7 from sustaining serious injuries from falling out of the 3rd floor window. V29 further commented R7 is on psychotropic medications, which were started while at the hospital for treatments for injuries sustained during the fall on 11/29/2022. Fall Policy, dated 08/2020, titled: Fall Management Program, documents: The facility is committed to minimizing resident falls and/or injury so as to maximize each resident's physical, metal and psychosocial wellbeing. While preventing all residents' falls is not possible, it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment. Facility window maintenance log, dated 11/29/22, documents R7's window on the 3rd floor was not properly secured.

Based on obervation, interview, and record review, the facility failed to provide appropriate treatment and services for assesed delusional thoughts and aggressive behaviour for one resident (R7) out of three residents reviewed for psychological treatment. This failure resulted in R7 jumping out of his 3rd floor bedroom window to the ground on 11/29/2022. The fall resulted in R7 being hospitalized with left and right fractured legs, fractured ankles, and fractured lumbar and throracic spine. Findings includes: Nurses Note, dated 5/30/2022 at 16:59, documents, Resident is alert & confused. No complain of pain. Barricade self in his room, compliance with all is medication vital check. Very talkative, complaint with isolation protocols. Will continue to monitor. Admission Note, dated 5/31/2022 at 06:15, documents, N/A 3/3 Alert/confused. Comes to doorway at times. Verbalized wanting to go home. Resident is reluctant at times to cooperate with care needs. Able to get Resident to comply with taking all Q 4 hr VS this noc shift and the taking of Med Therapy. Continue current plan of care and continue to monitor behavior. No C/O pain. Let in no distress. Social services note, dated 06/1/22, documents: R7 met with staff 1:1 concerning R7 temper and how he responded towards staff. Nurses Note, dated 6/2/2022 at 08:50, documents, Resident started going off on one of the housekeepers while Writer on the phone with DON (Director of Nursing) about another matter. Security call to assist in calming Resident down as not easily re-directable. Resident does not fully understand the PUI (Patient Under Investigation) protocol and started shouting, 'I am not an animal! F u and this place, I want to go home, I want get out of here and if necessary I want you to release me to the streets/sign me out.' Endorsing f/u care needs to the relieving Nurse. Able to get Resident to calm down w/o having to medicate at this time. Resident is not easy to reason with/he is confused and laughing at times after his negative outburst. Continue to monitor. Left in No distress and w/o any physical violence at present. Social Services Assessment under Exit Seeking/wandering/Elopement risk assessment, dated 06/3/2022, documents: R7 has the physical ability to leave the building on his own. R7 has a current diagnosis of severe mental health illness, and information was provided by R7 and staff interview/observation. Also documents R7 has experienced two or more psychiatric hospitalization s R7's care plan, dated 06/09/2022, documents: R7 displays delusional behavior problem, R/t (related to) Yelling out, and confused, and negative thinking. Difficult to reason with. Social services noted, dated 7/31/2022, documents R7 washing his clothes in his room sink instead of sending clothes to laundry. Social services note, dated 08/17/2022, documents R7 was not changing his clothes and staff met with R7 to discuss importance of changing his clothes. Nurses Note, dated 8/24/2022 at 18:12, documents, Resident is alert and able to make needs known. Assisted with meal set up and performed ADL tasks with staff supervision. Avoids lying flat due to diagnosis of Heart Failure. Resident is anxious, verbally aggressive as exhibited in talking and laughing loudly, internally preoccupied and noted with frequent auditory hallucination. Resident is easy to redirect and medication compliant. Nurses Note, dated 8/25/2022 at 14:25, Late Entry: Resident is alert and able to make needs known. Assisted with meal set up and performed ADL tasks with staff supervision. Avoids lying flat due to diagnosis of Heart Failure. Resident is anxious, verbally aggressive as exhibited in talking and laughing loudly, internally preoccupied and noted with frequent auditory hallucination. Resident is easy to redirect and medication compliant. Nurses Note, dated 8/26/2022 at 17:25, documents, Resident is alert and able to make needs known. Assisted with meal set up and performed ADL tasks with staff supervision. Avoids lying flat due to diagnosis of Heart Failure. Resident is anxious, verbally aggressive as exhibited in talking and laughing loudly, internally preoccupied and noted with frequent auditory hallucination. Resident is easy to redirect and medication compliant. Social services note, dated 10/12/2022, documents R7 was spilling water on floors R7's social services progress note, dated 11/01/2022, documents: R1 engaged in an incident of peer-to-peer incident in which R1 threw beverages. Interdisciplinary note, dated 11/2/2022, documents R7 has not recollection of incident of 11/1/2022, R7 communicates some cognitive deficits and laughs in place of responses at times. Admission Note, dated, 11/7/2022 at 17:25, documents, Re-admit [AGE] years old resident from St. [NAME] Hospital. Alert and oriented x2. Resident appear anxious, labile with disorganized thoughts and flight of ideas during admission processes. Breathing non-labored with no shortness of breath noted. Denies any pain at this moment. Lung sound clear upon auscultation. Abdomen soft and non-distended with bowel sound present in all 4 quadrants. Skin warm and dry to touch with no breakdown or wound noted. Resident denies any auditory or visual hallucination. Denies any suicidal or homicidal ideation. Resident educated about management of his blood pressure, the importance of complying with medications and prescribed diet. Resident verbalized understanding of the teaching and readiness to comply with medications and diet. Resident medications verified with NP and orders carried out as given. Staff will continue to monitor resident for safety and comfort. Admission Note, dated 11/9/2022 at 18:33, documents, Resident received in room alert and able to make needs known. Resident endorses auditory hallucination with disorganized thoughts and flight of ideas. Breathing non-labored with no shortness of breath noted. Denies any pain at this moment. Lung sound clear upon auscultation. Abdomen soft and non-distended with bowel sound present in all 4 quadrants. Skin warm and dry to touch with no breakdown or wound noted. Assisted with meal set-up and performed ADL tasks with staff supervision. Resident educated about management of his blood pressure, the importance of complying with medications and prescribed diet. Resident verbalized understanding of the teaching and readiness to comply with medications and diet. Resident blood pressure managed with prescribed medications during the shift. Staff will continue to monitor resident for safety and comfort. Nurses Note, dated 11/16/2022 at 18:32, documents, Resident is alert and able to make needs known. Assisted with meal set up and performed ADL tasks with staff supervision. Avoids lying flat due to diagnosis of Heart Failure. Resident is anxious, verbally aggressive as exhibited in talking and laughing loudly, internally preoccupied and noted with frequent auditory hallucination. Resident has order for Haloperidol lactate solution 1 mL every 4 hours as needed for symptoms of agitation. Resident is easy to redirect and medication compliant. Nurses Note, dated 11/19/2022 at 17:22, documents, Resident is alert and able to make needs known. Assisted with meal set up and performed ADL tasks with staff supervision. Avoids lying flat due to diagnosis of Heart Failure. Resident is anxious, verbally aggressive as exhibited in talking and laughing loudly, internally preoccupied and noted with frequent auditory hallucination. Resident has order for Haloperidol lactate solution 1 mL every 4 hours as needed for symptoms of agitation. Resident is easy to redirect and medication compliant. Nurses Note, dated 11/20/22 at 18:00, documents, Resident is alert and able to make needs known. Assisted with meal set up and performed ADL tasks with staff supervision. Avoids lying flat due to diagnosis of Heart Failure. Resident is anxious, verbally aggressive as exhibited in talking and laughing loudly, internally preoccupied and noted with frequent auditory hallucination. Resident has order for Haloperidol lactate solution 1 mL every 4 hours as needed for symptoms of agitation. Resident is easy to redirect and medication compliant. Nurses Note, dated 11/22/22 at 18:55 documents, Resident is alert and able to make needs known. Assisted with meal set up and performed ADL (Activities of Daily Living) tasks with staff supervision. Avoids lying flat due to diagnosis of Heart Failure. Resident is anxious, verbally aggressive as exhibited in talking and laughing loudly, internally preoccupied and noted with frequent auditory hallucination. Resident has order for Haloperidol lactate solution 1 mL every 4 hours as needed for symptoms of agitation. Resident is easy to redirect and medication compliant. Nursing notes, dated 11/29/2022 at 08:00, documents, At the start of my (V4-(Licensed Practical Nurse/LPN) shift approximately 7:30 AM, it was identified that (R7) was not in his room. A CODE GREEN was called, a search of the floor and outside ground was conducted. R4 was noticed on the ground outside of the facility. R4 complained of pain to bilateral legs. Police on scene and ambulance. R4 transported to community hospital). PPHP NP (Nurse Practitioner) notified of occurrence and transfer to Hospital NP aware. Facility reported incident report, dated 12/05/2022, documents: On 11/29/2022 at approximately 8:00am. (R7) exited the facility via window resulting in a fall. (R7) was observed outside of the facility. (R7) was alert to person and place with periods of confusion. (R7) was observed with swelling to lower extremities. Physician notified; Guardian notified. (R7) transferred to nearby community hospital emergency room for further evaluation. (R7) was admitted with bilateral broken ankles, fractured lumbar and thoracic spine. The facility's incident report further documents R7's diagnoses, not limited to: unspecified psychosis, Unspecified symptoms, and signs involving cognitive functions and awareness, TBI (traumatic brain injury), restlessness and agitation. Physician Order Summary: QUEtiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) Active date 1/17/2023 12:15 Give 1 tablet by mouth every 6 hours as needed for Psychosis/agitation for 14 Days Physician Order Summary: QUEtiapine Fumarate Tablet 25 MG Active date: 12/15/2022 21:00 Give 1 tablet by mouth at bedtime related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION (F29) Physician Order Summary: QUEtiapine Fumarate Tablet 50 MG Active date 12/15/2022 09:00 Give 1 tablet by mouth every 12 hours related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION (F29) On 1/10/2023 at 11:33am, R7 was observed lying in bed awake, with R7's right leg in a plaster cast from the toe to mid upper thigh. R7 was alert and oriented to name and place. R7 stated he fell from 3rd floor roof to the ground. R7 said, I used to live on the 3rd floor, they would not give me speech (sic). I was not feeling good, and I wanted to go home so I jumped from the roof. He (unknown person) denied me speech (sic) to go outside, so I wanted to go home, so I jumped out window and tried to go home, which is my right because I am not incarcerated. It was a paranoid thing. On 1/13/2023 at 10:49am, V26 (R7's family member) said R7 has never been in the military, and she stated R7 was diagnosed with schizophrenia around 1998 in New York, where R7 and family were living. V26 said she was helping R7, and took R7 in to help him, and would make sure every time R7 had a mental breakdown, R7 was admitted to the hospital for treatment stabilization. V26 said at that time, R7 did not like living with V26, because V26 would call 911 to take R7 to the hospital any time R7 stopped taking his behavioral health medication and R7 started showing signs of paranoia and laughing uncontrollably. V26 said R7 tried to elope from the hospital when R7 was first diagnosed with mental health illness. V26 said R7 does not believe R7 has mental health challenges and is in denial. She commented R7 cannot stay at one place because of R7 living with schizophrenia. V26 said she was monitoring R7, but when she left New York for work, R7 left his apartment and started wandering, and at one point, R7 was incarcerated. V26 further commented R7 eventually left New York, and ended up in Chicago where R7 does not have any family. V26 said because of R7's mental health issues, R7 can be paranoid, and these behaviors might have led to R7 being involved in a fight in Chicago, where R7 was terribly hurt. V26 said R7 calls his mother screaming and saying he wants to visit her, and this upsets R7's mother, who is [AGE] years old. V26 said she has now restricted R7's calls to his mother. V26 commented she takes care of her and R7's parents, who are both [AGE] years old, and V26 cannot be able to take on R7, because V26 is already overwhelmed with taking care of both parents. V26 said when R7's mental health issues are under control, and R7 is properly medicated, R27 is the sweetest person you will ever met. V26 said R7 wants to visit his parents, especially his mother, but V26 said this is not possible at this time because V27 cannot be able to take care of R7. On 1/12/2023 at 4:10pm, V25( R7's State Guardian) stated she was notified by facility when R7 jumped out of the window, attempting to elope. V25 commentated R7 is head strong and strong physically, and R7 is very smart. V25 said R7 went to college and was R7's major was in engineering. V25 said R7 was living alone independently in the community, but about seven months ago, R7 got into a fight in his neighborhood, and R7 was beat up and sustained a traumatic brain injury (TBI). V25 said that is when R7 went into state guardianship, and V25 started working with R7 as his state appointed guardian. V25 said before R7 come to this facility, R7 was in another facility after the TBI. V25 further stated R7 used to live in New York with his sister(V26), who used to take care of R7, but R7 became too much for V26 to handle. V26 also takes care of R7's mother. V25 said R7 tried to jump from another facility in New York. V25 commented R7 has been calling his mother and upsets her during the calls, so V26 has restricted R7's phone calls to R7's mother, who is elderly. R25 said R7 is delusional and thinks people are watching him from space, and that is why R7 was not compliant with medications at the last facility. On 1/13/2023 at 2:04pm, V27 (R7's physician) said because R7 has a diagnosis of psychosis, agitation, and restlessness, and R7 was exhibiting signs and symptoms of agitation, R7 should have been on treatment to manage R7's behavior. V27 stated during R7's mood and behavior assessments, the facility should have looked at risks and benefits of R7 receiving psychotropic medication. V27 further said given R7's previous actions and diagnosis of mental health condition, R7 have been on a scheduled mood/ behavior medication. On 1/17/2023 at 3:28pm V29 (R7's Psychiatrist) said R7 was visited two times by the psychiatry Nurse Practitioner in November and December 2022 for further assessments, but both times R7 was not in the building. V29 stated the facility never notified V29 about any behavioral issues/hallucinations R7 was experiencing before R7 jumped out of the window on the 3rd floor. V29 said even after R7 jumped out of the window, the facility never notified V29 of the incident, and V29 just recently learned (after Christmas) R7 had jumped out of the window. V29 said it is documented on several occasions R7 was preoccupied with going out of the facility see his(R7) mother, and R7 should have been moved to the 1st floor for supervision and monitoring incase R7 tried to leave the facility. V29 said, If the facility staff had called me to let me know (R7) wanted to leave the facility to visit his mother, I would have instructed them to move him to the first floor since he has cognitive deficits. V29 commented having R7 on the first floor could have prevented R7 sustaining serious injuries from falling out of the 3rd floor window. V29 further commented R7 is on psychotropic medications, which were started while R7 was admitted to hospital for treatments for injuries sustained during the fall on 11/29/2022. On 1/18/2023 at 1:15pm, R7 was observed to be on 1:1 with a sitter due to R7 exhibiting elopement behavior. Facility policy titled Psycho-social Programming Protocol (corresponds with Policy), no date, documents: Psycho-social programming should be offered to anyone who expresses during our assessment process or is observed with maladaptive behaviors, mental health issues, and any cognitive issues resulting in behavioral issues. Facility policy titled: Psychotropic Medications-Use Of, dated 09/2020, documents: A psychotropic medication will be defined as any medication that is prescribed for the purpose modifying mood and/or behavior.

Based upon observation, interview, and record review, the facility failed to follow the fall management program/policy, and failed to implement fall prevention interventions (R1, R12), failed to conduct a thorough investigation to determine root cause (R1), and failed to conduct a timely investigation (R12) for 2 of 3 residents reviewed for falls. These failures resulted in R1's (10/4/22) fall with right foot soft tissue swelling. Findings include: 1. R1's diagnoses include bilateral paralytic syndrome following cerebral infarction, paraplegia, right/left foot drop. R1's (9/21/22) BIMS determined a score of 15 (cognitively intact). R1's (9/21/22) functional assessment affirms 2 person physical assist is required for transfers and 1 person physical assist is required for locomotion. R1's (9/27/22) fall risk assessment determined a score of 4 (at risk). R1's care plan includes (2/12/22) resident is at risk for falls secondary to paraplegia, wheelchair bound, functional deficits, and muscle weakness. Intervention: encourage appropriate use of wheelchair. (4/20/22) Resident is noted to have limitation in range of motion secondary to foot drop. Intervention: assist as needed. R1's (10/4/22) initial report states resident left facility with an escort for scheduled appointment at the hospital, resident was noted slightly slid off her wheelchair while taking her off the vehicle lift at the destination. According to her assigned escort, resident legs touched the floor, and she was immediately readjusted back on the wheelchair. R1's final report excludes a root cause analysis. R1's (10/4/22) history & physical includes chief complaint: fall. Stated complaint: foot pain status post fall. Patient accidentally slipped partially out of the wheelchair prior to arrival when she hit a bump and complains of some right foot discomfort. Patient states that after she had a stroke 6 months ago, she's been lying contracted in a crooked position on her right hip. R1's (10/4/22) x-rays include posterior dislocation of the right hip and soft tissue swelling along the dorsum of the (right) foot. On 11/28/22 at 11:02am, V3 (RN/Registered Nurse) was observed exiting R1's room. Surveyor inquired about R1 functional status V3 stated, She's not able to walk. On 11/28/22 at 11:05am, R1 was lying in bed on her left side. R1's right leg was severely contracted and right foot drop was noted. Surveyor inquired about R1's contractures, R1 replied, I had a stroke my whole body is contracted. I have a contracted hip. R1's bed was in high position and side rails and/or floor mats were not in use. Surveyor inquired about the (10/4/22) incident. R1 stated, I fell out the wheelchair. I had to go to another facility to see the pain doctor. The gentleman was pushing me into the facility as we got to the doors, he hit a little crinch in the sidewalk and I slid out the wheelchair onto my bad leg because I was in a regular wheelchair not with a seatbelt. R1 affirmed her specialty wheelchair (which has a seatbelt) is too small, therefore, a regular wheelchair was in use at the time of the incident. Surveyor inquired about R1's (10/4/22) injuries. R1 responded, My butt hit the ground and the back of my knee was bruised. My hip was already dislocated. On 11/28/22 at 11:12am, V3 (RN) entered R1's room. Surveyor inquired about the height of R1's bed, V3 stated, Right now, it's a bit high. It's supposed to be low. Surveyor inquired why side rails were not in use, V3 responded, We need the rails. On 11/28/22 at 3:37pm, surveyor inquired about R1's (10/4/22) incident, V15 (Bus Driver) stated, I was unloading the passenger (R1) and she kinda slipped down. She ended up, I think, barely touching the floor. Surveyor inquired if V15 was pushing R1's wheelchair when the incident occurred. V15 responded, I was assisting to bring it out to the ramp to go inside the hospital. If you don't push her out, she just stays there, so you gotta assist her to come out, and affirmed he (V15) was pushing R1's wheelchair towards the ramp. Surveyor inquired what R1's facility escort was doing. V15 replied, Waiting for me (V15) to take her (R1) on the ramp so she (Escort) could take her (R1) inside. Surveyor inquired if V15 received training for transferring residents to and from the bus. V15 stated, Yes, to work the lifter up and down. Surveyor inquired if V15 is a CNA (Certified Nursing Assistant), V15 responded No. On 11/29/22 at 9:23am, surveyor inquired about the root cause of R1's (10/4/22) incident. V2 (Director of Nursing) stated, She (R1) was out on an appointment at the hospital, as they were letting the lift down, the wheel went on some uneven pavement and she slid out of the chair. To prevent it from happening again, we reassessed her (R1) for wheelchair, and spoke with her (R1) in regards to safety and sitting up in the chair, and spoke to staff regarding safety during transport. Surveyor inquired about the facility failures which likely caused R1's (10/4/22) incident. V2 responded, I believe we didn't fail at all. Surveyor inquired why R1 was transported in a regular wheelchair (without a seat belt). V2 replied, Because at that time she was using a regular wheelchair and was sitting comfortably in the wheelchair. Surveyor inquired if V15 received any training for transporting and/or assisting residents prior 10/4/22. V2 stated, That's information that I would have to find out, however, no additional information and/or documentation was provided. On 11/30/22 at 10:44am, surveyor inquired about R1's functional status, V31 (Restorative Nurse) responded, Her functioning is bad she's pretty much total care. She can't do anything really, the way her body is crooked. I did a geri assessment on her when she's in the bed she can come up just a little bit, not a whole lot. She couldn't really lift up. Surveyor inquired if a regular wheelchair is appropriate for R1, V31 responded, No, never. Surveyor inquired about an appropriate mode of transportation for R1's appointments, V31 stated, If she has to go somewhere she has to go via stretcher. 2. R12's diagnoses include dementia and acquired absence of right leg (above knee). R12's (10/14/22) BIMS (Brief Interview Mental Status) determined a score of 1 (severely impaired). R12's (10/14/22) functional assessment affirms (1 person) physical assist is required for transfers. R12's (10/14/22) fall risk assessment determined a score of 7 (at risk). R12's (7/15/22) care plan states resident is at risk for falls secondary to history of falls, right AKA (Above Knee Amputation), dementia, and seizure disorder. Intervention: promote placement of call light within reach. R12's (11/15/22) incident report states the nurse went to resident's room and observed resident on the floor with linen wrapped around his body having a seizure. R12's (11/16/22) head CT (Computed Tomography) includes deformity of the nasal bones with associated soft tissue swelling and could reflect fractures of indeterminate age. On 11/28/22 at 10:50am, R12 was sitting in a wheelchair (adjacent the bed) however a call light was not within reach. Surveyor inquired about the (11/15/22) incident, R12 stated, I just fell out standing up or something. On 11/28/22 at 10:56am, V3 (Registered Nurse) entered R12's room surveyor inquired if R12 requires transfer assistance, V3 stated, He needs help. We always tell him to wait for the CNA (Certified Nursing Assistant) to help him. Surveyor inquired about R12's fall prevention interventions. V3 responded, We have a CNA to meet up with his needs if he goes back to the bed. He uses the call light to get the attention of the CNA or the Nurses. The call light is functioning. Surveyor inquired about the location of R12's call light. V3 moved R12's bed, lifted R12's mattress and stated Where is the call light? It fell on the floor. It's supposed to be on the bed all the time. On 11/29/22 surveyor requested R12's (11/15/22) fall investigation, however, the investigation was not received. On 11/29/22 at 2:42pm, surveyor inquired about R12's (11/15/22) incident/injury, V2 (Director of Nursing) responded, He was sent out to the ER (emergency room ) to be evaluated. I know there was no injuries. Surveyor inquired if an investigation was conducted for R12's (11/15/22) incident. V2 responded Yes. Surveyor inquired why the investigation was not received. V2 affirmed she provided surveyor staff statements. On 11/30/22 at 9:36am, surveyor requested R12's (11/15/22) alleged investigation. V2 stated, I did report that deformity yesterday (14 days after the incident). V2 subsequently presented R12's preliminary incident investigation report which includes date of alleged incident: 11/16/22 (the incident occurred on 11/15/22). Any obvious injuries: no (R12 sustained nasal injuries). The facility will continue to conduct a complete and thorough investigation until a conclusion is reached. R12's 11/15/22 final investigation was not received during this survey. On 11/30/22 at 1:36pm, surveyor inquired about potential harm to a resident that sustains a fall. V29 (Medical Director) stated, Usually with a fall that's unwitnessed let's say that the patient hits the head, there could be injury to the scalp or bleed to the brain that could lead to death. Another one would be fractures. The (8/2020) fall management program states it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment. Educate staff members to check during room rounds the 4 P's (pain, positioning placement of personal items, personal needs). The nurse call device will be placed within the resident's reach. The bed will be maintained in a position appropriate for resident transfers. Use standard fall/safety precautions for all residents. The (8/2020) management of falls policy states provide assistive devices for mobility, hearing and vision as appropriate for the resident. Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards.

Based on observation, interview, and record review the facility failed to implement a protocol to secure razors and ensure the safety involving four of nine sampled residents (R10, R21, R23 and R26) and nine supplemental residents (R31, R33, R34, R35, R36, R37, R38, R39 and R40) reviewed for behavior symptoms, in a sample of 26. This failure resulted in R26 cutting his right inner arm with a razor found in the shower room and being sent to the hospital for treatment. This failure was identified as an immediate jeopardy for 11 of 13 residents who had a history of [REDACTED]. The Immediate Jeopardy began on 4/9/14 at 3:18pm when R26 gained access to a razor used to self-mutilate and cut his right inner arm. E1 (Administrator) was notified of Immediate Jeopardy on 5/22/14 at 4:48pm. The Immediate Jeopardy was removed on 5/22/14 at 5:32pm. The deficiency remains at a level two severity until the facility revise and implement a plan for distribution and retrieval of disposal razors, and in-service all staff members. In addition, the facility failed to implement the use of bilateral floor mats to prevent injury from a fall for one of nine residents (R15) reviewed for falls in the sample of 26 residents. Findings include: 1.) The Face Sheet documents that R26 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Progress Notes dated 4/5/14 at 6:11pm documents that R26 was hearing voices telling him to cause self-harm. R26 was redirected, given an anti-anxiety medication, and monitored throughout the night. The Progress Notes and Incident Report both dated 4/9/14 at 3:18pm documents that R26 approached E8 (Nurse) at the nurse's station with bleeding to the right inner arm. R26 informed E8 that voices told him to do it and the razor was found in a garbage can in the shower room three weeks prior. At 6:22pm, R26 was sent to the hospital with a [DIAGNOSES REDACTED]. On 5/21/14 at 2:10pm, E8 stated "the resident had a history of [REDACTED]. The interventions in place were 1:1 observations and the resident was not allowed to shave himself. The aides shaved him. The housekeepers clean the shower daily and I have no idea how he got the razor." On 5/22/14 at 11:25am E11 (Behavioral Unit Director) during interview stated "We keep a razor log on the unit and the residents tell staff when they need a razor. The staff signs out the razors and they are responsible for signing the log when the razor is returned. Any residents that are mentally impaired or have suicidal ideations are not allowed to have razors." On 5/22/14 at 11:38am, E11 was unable to find the log used to track the residents' used razors. On 5/22/14 at 11:40 am, E11 stated "We give out razors daily and we have a log that staff signs to track the razors, but I can't find it." On 5/22/14 at 11:45am, E8 stated "One resident asked for a razor today so that he can shave. I didn't log it, but when he returned it I just put it in the sharps container." On 5/22/14 at 11:50am, R31 stated "I ask the nurse for a razor when I need it and I keep them until I'm done, then I put them in the box in the shower room." On 5/22/14 at 11:55am, R10 stated "When I need a razor I get if from the nurse and I keep it in my drawer until I want to use it." On 5/22/14 at 12:00pm three razors were observed in R31's bathroom. The social service department provided the survey team with a list of residents from the behavioral unit with a history of aggressive, homicidal and suicdal behavior. R21, R23, R31, R34, R35, R36, R37, R38, R39 and R40 were listed among the 55 residents on the unit with these types of behavior during the time of the survey. The facility's policy on Regulated Medical Waste documents that sharps will be placed directly into impervious, rigid, leak proof and puncture-resistant containers to eliminate the hazard of physical injury. On 5/22/14 at 5:32pm the facility took the following steps to remove the Immediacy: 1. Immediate sweep of the entire facility was conducted and completed on 5/22/14 (By Key Department Heads) for sharps in all resident rooms, all resident care areas, and all common areas. 2. The nurse assigned to 3rd floor was immediately counseled and placed on administrative leave on 5/22/14 (By the Director of Nursing) pending outcome of investigation. 3. An in-service was promptly initiated on 5/22/14 (By Key Department Heads) on monitoring for residents who exhibit suicidality. On an ongoing basis, in-servicing was continued (By Key Department Heads) and included residents who exhibit aggression, homicidality/suicidality, and depression tendencies. 4. An in-service was initiated with all staff on duty (By Key Department Heads) on the following: Potential for resident self-injurious behavior for aggression, homicidality/suicidality, and depression. (started 5/22/14 and continue until all staff members have received the in service ) Proper supervision of sharps (started 5/22/14 and continue until all staff members have received the in service ) Proper disposal of sharps (started 5/22/14 and continue until all staff members have received the in service ) Importance of timely communication of residents who express aggression, homicidality/suicidality, and depression tendencies. (started 5/22/14 and continue until all staff members have received the in service ) 5. Social services began interviewing residents on the behavior unit on 5/21/14 regarding any feelings of suicidality. Interviews were initiated and completed on 5/22/14 for Residents with conditions of aggression, homicidality/suicidality, and depression tendencies to verify no expression of aggression, homicidality/suicidality, and depression. 6. Residents who actively express any indicators of aggression, homicidality/suicidality, and depression will be reassessed. doctorMD notification and have a care plan review. (By Social Services) 8. The facility protocol for distribution of razors was reviewed by the Administrator on 5/22/14. 9. No razors will be distributed without one to one supervision during use. 10. Razors will be secured by staff after use and properly disposed of in sharps container. 11. Quality Assurance Tools were implemented for the following: Proper disposal of sharps (Initiated on 5/22/14 and ongoing) Conducting random spot-checks for residents displaying aggression, homicidality/suicidality, and depression tendencies (Initiated 5/22/14 and ongoing) 2.) On 5/20/14 at 3:20 PM, R15 was laying in the low bed without the bilateral floor mats. On 5/21/14 at 10:33 AM, R15 was laying in his low bed without bilateral floor mats. On 5/22/14 at 9:35 AM to 9:45 AM, R15 was laying in his low bed without bilateral floor mats and his call cord was on the floor behind the head of the bed. R15 has had 4 falls per the facility's incident log. The falls were on 9/8/13 at 2:01 PM, 2/9/14 at 12:40 PM, 3/8/14 at 5:45 PM and 3/22/14 at 11:09 AM. The facility's Fall Detail Report dated 9/8/13 documents the interventions to be applied are: initiate the falling star protocol, keep bed in lowest position and promote placement of the call light within reach when in room. The facility's Fall Detail Report dated 3/8/14 documents R15 will be provided with floor mats on the both sides of his bed. The facility's Fall Detail Report dated 3/22/14 documents R15 did not have his bilateral floor mats on the floor. The current care plan dated 4/28/14 document the approaches for the falls include low bed, bilateral floor mats and call light within reach. The quarterly minimum (MDS) data set [DATE] documents R15 to be severely impaired in cognition.

Based on observation, interview and record review, the facility failed to provide necessary care and services to identify, assess, monitor and treated one of three residents (R5) with a diabetic ulcer reviewed for wound care. This failure resulted in R5 bring admitted into hospital with osteo[DIAGNOSES REDACTED] infection and amputation of right great toes. Failed to obtain physicians/pharmacy orders, transcribe and process these orders in a timely manner for one of eight residents (R6) reviewed for physician orders [REDACTED]. Failed to assess and document vital signs, blood glucose results, and gastrostomy feeding tube residual for R6. Failed to notify a physician of the death of R6, prior to releasing his body to a funeral home. Findings include: 1. R5's was observed with surgical wound on [DATE] at 12:30pm. The dressing contained scant, serous drainage, and there was no odor present. The area of R5's right foot at the base of where the toe had been was covered in white tissue that appeared to be slough tissue. R5 was confused during this visit, stating his toe had just gotten this way "all of a sudden". R5 further could not state why his toe was amputated, or what his [DIAGNOSES REDACTED]. A facility face sheet document, R5 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. R5's current POS (physician's orders [REDACTED]. R5's MDS (Minimum Data Set) dated [DATE] notes R5 was unable to complete the BIMS (Brief Interview for Mental Status), and was assessed by staff as having a memory problem. E8's (Nurse) nursing note dated [DATE] at 7:25am documents "noted right great toe opening on outer area 0.3cm (centimeters) X 0.3cm with drainage. Also, open area on upper interior side. Paged MD (Medical Doctor)." There is no follow up note regarding the physician calling back, or giving orders. E8's nursing note dated [DATE] at 7:52am documents "After making rounds this morning noted that resident was picking skin off his toe, causing it to bleed. Noted drainage and appears to be slightly swollen. MD (Medical Doctor) called. New orders to start [MEDICATION NAME] 300mg (milligrams) twice a day noted and carried out". There is a physicians order for this medication noted on that date. Nursing note dated [DATE] documents "Resident seen by Wound Care Nurse Practitioner. Nurse Practitioner assessed right great toe and gave orders for resident to be transferred to hospital for signs of infection. Primary nurse made aware. ADON (Assistant Director of Nursing) made aware". R5's care plan dated [DATE] documents the focus "R5 has a [DIAGNOSES REDACTED]. R5's care plan dated [DATE] that documents the nursing intervention "inspect skin daily" and "monitor for signs and symptoms of infection". Hospital records document R5 underwent an amputation of his right great toe [DATE], for a [DIAGNOSES REDACTED]. E8 stated [DATE] at 12:00pm; she first noticed R5's toe was infected on [DATE]. E8's [DATE] nursing note entered at 7:25am, first documents her discovery of R5's wound, as stated above. E8 further stated R5 had been lying in bed [DATE], without shoes and socks, and picking on his right great toe. E8 then described R5's right great toe to be red, and have pus coming from it. E8 stated she then asked R5 if it the toe was painful, and he answered "yes". E8 then stated she notified R5's physician, as well as E10 (Treatment Nurse). E8 further stated that after several days, R5 was not improving, and that's when he was sent to the hospital. R5's physician ordered treatment dated [DATE] states soak his right great toe and foot in Providine Iodine solution with warm water for 10 minutes daily, and apply [MEDICATION NAME] ointment twice daily. Z3 ( Nurse Practioner) stated [DATE] at 12:30pm states upon her visit to examine R5 on [DATE], she found his right great toe to have an odor, and necrotic tissue. Z3 further stated this toe looked infected, and was warm and painful to touch. Z3 then stated she ordered R5 to be sent to the hospital for evaluation. Z3 also stated he ordered [MEDICATION NAME] 1 gm (gram) IVPB (Intravenous Piggy Back) every 12 hours to be infused. Z3 further stated she had never seen R5 as a patient before. Z3 also stated she gave R5 the [DIAGNOSES REDACTED]. Z3 also ordered lab work and a Bone Scan of R5 ' s right foot to rule out [DIAGNOSES REDACTED], in case he refused to go to the hospital, due to his mental illness. Z3 stated [DATE] at 12:30pm, she's not sure how long R5's toe had been infected when she first saw him [DATE], but it was obviously not an acute injury. Z3 then stated nursing staff should be performing daily skin checks for residents. Z3 further stated it is especially important to monitor a diabetic resident's skin, and particularly his feet, as a small wound can quickly progress into necrotic tissue or become infected. E9 (CNA-Certified Nursing Assistant) stated [DATE] at 1:51pm, R5 is confused at times, and sometimes has hallucinations and delusions; for example, R5 thinks the other residents are his family members or his children. E9 further stated R9 showers and dresses himself. E9 further stated staff does not have the opportunity to view R5's feet, as he showers and dresses himself. E9 then stated if R5 is asked if he needs help, he becomes defensive, saying "What, are you trying to look at me? " E2 (Director of Nursing) stated [DATE] at 9:40am, residents receive a shower twice weekly. E2 further stated CNA's are to fill out "shower sheets" after every resident shower. Surveyor requested a copy of all R5's shower sheets from [DATE] through [DATE]. Shower sheets dated [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] do not indicate the condition of the right great toe Facility policy titled "Shower Day Worksheet" states, in part "Once a week on resident bath/shower day obtain a Shower Day Worksheet. During bath/shower if the CNA notes any skin abnormality place an "X" where you notice abnormality or change in color on the shower day worksheet. The nurse will assess all areas where the CNA has indicated a change on the Shower Day Worksheet, and determine if there is a treatment, whether the current treatment if effective. If not, a change treatment as ordered by MD". Facility policy titled "Change of Condition" states, in part "Attending physician or physician on call/ Nurse Practitioner and responsible party will be notified of all changes in condition Facility policy titled "Diabetes Management" states, in part "General guidelines for assessment may include, but are not limited to skin: color, temperature, irritation, abrasions, open areas, turgor, pruritus, and condition of feet". 2. R6 was admitted to the facility [DATE] from a sub-acute hospital, arriving at 2:00pm, according to nursing notes. R6 had [DIAGNOSES REDACTED]. There was no documentation of R6's vital signs recorded from [DATE] at 11:00pm through [DATE] 3:00pm. There was no documentation of R6 receiving a blood glucose test from [DATE] 11:00pm through [DATE] at 7:00am. There is no documentation of R6's gastrostomy tube feeding residual for the entire time he was at the facility. Nursing note dated [DATE] at 1:36am, documented as a late entry: [DATE] at 9:25pm states "Family member alerted the writer to resident condition. The writer immediately rushed into the room with team 1 nurse. Resident found unresponsive. CPR (Cardio [MEDICAL CONDITION] Resuscitation) initiated 911 and code blue called for assistance. Paramedics arrived and confirmed resident dead at 9:35pm with family member present". Nursing note dated [DATE] at 8:24pm documents: "MD was paged in regards to resident had expired on [DATE]. Medical Director (Z2) was notified about resident at 5:20pm. Z4 returned call at 8:30pm and was informed about resident". E4 stated [DATE] at 4:20pm that when she tried to call Z4 approximately 3:00pm on [DATE] and again before 5:00pm, and got no response. E4 then called Z2 at 5:20pm, stating nurses need to inform the Medical Director after two attempts are made to reach a resident's attending physician. E13 (Nurse) stated [DATE] at 4:20pm she received resident upon admission [DATE] at 2:00pm, in stable condition, with stable vital signs. E13 also stated R6 was non-verbal, had [MEDICAL CONDITION] and a gastrostomy tube. There is no documentation of R6's blood glucose level upon admission. E13 further stated she worked until 3:00pm that day, so only did resident's initial assessment, and endorsed R6's admission to E4 (Nurse). Nursing Initial assessment dated [DATE] at 5:29pm document R6's bowel sounds as "absent". E4 stated [DATE] at 4:20pm she cared for R6 [DATE] from 3: pm to 11:00pm; however, E14 (Nurse) completed his admission, as there was multiple admissions that day on her shift. E4 also stated E14 would have called R6's physician for admitting orders, as well as faxing those orders to pharmacy. E4 further stated she did not recall receiving a blood glucose result when she received report from E13. E4 also stated she doesn't recall taking blood glucose, vital signs, or R6's gastrostomy tube feeding residual on her shift. There are no nursing notes for [DATE] for the 3:00pm through 11:00pm shift. There is no documentation of R6's gastrostomy tube residual amount. E14, during interview stated [DATE] at 5:08pm, that he admitted R6 [DATE], receiving report from E13 at 3:00pm. E14 did not recall receiving a blood glucose result given to him in report. E14 stated it took him "awhile" to review R6's chart from the subacute hospital he was transferred from. E14 also stated he called Z4 (Attending Physician) three times between 7:00pm and 9:00pm, then finally reached him approximately 9:00pm to get admission orders [REDACTED]. E14 further he did not check R6's blood glucose test. POS dated [DATE] contains the order for blood glucose monitoring every six hours, with sliding scale coverage using Regular Insulin. E14 further stated he did not check R6's gastrostomy feeding tube residual. E12 stated [DATE] at 1:12pm, he cared for R6 on [DATE] from 3:00pm until his death at 9:35pm. E12 stated R6's medications had been delivered on his shift from pharmacy. E12 also stated at 9:15pm, R6's family member came rushing out of his room, and came to find him. E12 then stated that upon entering R6's room, he found R6 to be unresponsive, with brown liquid that appeared to be gastrostomy tube feeding coming out of his mouth. E12 then stated a Code Blue and 911 was called, and he and E5 (Nurse) performed CPR (Cardio [MEDICAL CONDITION] Resuscitation). R12 also stated that after R6 was pronounced dead by CFD (Chicago Fire Department) paramedics at 9:35pm, he paged Z4 (R6's attending Physician) at 9:45pm, but got no response. E12 also stated he stayed until "sometime after 1:00am" [DATE] to complete his charting, and endorsed to E26 (Nurse) that Z4 still hadn't called back. E12 stated he did not call the coroner's office to notify them of R6's death. E12 stated R6's family called a funeral home, which picked up R6's body. No medical doctor was aware of R6's death, or gave authorization for his body to be released to a funeral home. E12 stated he endorsed to E26 to follow up with physician notification regarding R6's death, when he left after 1:00am of [DATE]. E26 made no documentation on R6's chart for the entire shift she worked (11:00pm [DATE] through 7:00am [DATE]). E13 stated [DATE] at 4:20pm she worked [DATE] from 7:00am to 3:00pm. E13 further stated R6's body had already been removed when she came on duty. E13 stated she attempted to call Z4 at 8:37am, 10:27am, 11:39am, and 2:41pm, but was unable to reach him. Nursing notes dated [DATE] document these attempts. E13 further stated she endorsed to E4 (Nurse) at 3:00pm that Z4 had not yet called back, and was still unaware of R6's death. Z4 stated [DATE] at 12:50pm the facility has his cell phone number, as well as his answering service number. Z4 further stated sometimes his cell phone is not working, due to loss of service. Z4 further stated that as soon as he got the message from his answering service [DATE] to call the facility, he did so within the hour. Z4 then stated when he called E4 [DATE] at 8:30pm, she informed him of R6's death. Z4 further stated nursing should monitor the vital signs on a newly admitted resident every shift for 72 hours, and should check a resident's gastrostomy tube feeding residual every shift. Z4 further stated that if a resident expires and the nurse is unable to contact him within 4 to 5 hours, she/he should notify the Medical Director (Z2). Z4 further stated a physician needs to make the decision of whether to release a resident's body to a funeral home, or if the medical examiner's (coroner's) office should be called. Z4 further stated nurses should call the attending physician for orders one to two hours after the resident is admitted , and those orders should be faxed to pharmacy within two to three hours after they have been received. Z2 (Medical Director) stated [DATE] at 1:28pm a resident's nurse should notify him of a resident's death after two hours of attempting to notify the resident's attending physician. Z2 further stated a physician must be notified of a resident's death, and is the one to decide whether the body can be released to the funeral home, or if the coroner's office should be called. Z7 (former Administrator), who was administrator at the time; stated [DATE] at 1:05pm there is no facility policy as to when to call the medical examiner/coroner. Z7 further stated a physician needs to make the decision of whether to release a resident's body to a funeral home, or to call the medical examiner/coroner. E2 (Director of Nursing) stated [DATE] at 4:02pm stated the attending physician should be notified for orders on a newly admitted resident as soon as the nurse is through assessing the resident and obtaining vital signs. E2 stated [DATE] at 10:45am newly admitted residents are to have their vital signs taken and documented every shift for 72 hours. E2 further stated all residents having a gastrostomy tube should be checked for gastrostomy residual every shift. E2 also stated all residents having a [MEDICAL CONDITION] with oxygen should have their oxygen saturation monitored every shift. Pharmacy records note R6's admitting orders were faxed to them [DATE] at 12:36am. R6 arrived at the facility [DATE] at 2:00pm. Z5 (Pharmacy Representative) stated [DATE] at 3:38pm R6's medications left the pharmacy at 11:30am [DATE], and arrived at the facility at 3:14pm [DATE]. Pharmacy Delivery Manifest dated [DATE] confirms this. Z8 (Pharmacy Technician) stated [DATE] at 11:00am deliveries for the facility leave daily at 11:30am and 11:30pm, seven days/week. Z8 also stated that orders faxed to the pharmacy at 12:36am would leave the pharmacy on the 11:30am delivery. Z8 further stated the cut off time to send faxes to pharmacy for the 11:30pm delivery is by 8:30pm. Facility policy titled "Death of a Resident' states, in part "Notify primary MD of death. Follow Medical Examiner policy, if applicable." Facility policy titled "Code Blue/Medical Emergencies" states, in part "Code Blue will be announced for medical emergencies if additional staff is needed to respond. 911 will be notified, if indicated. First aid will be administered. The attending physician on call/nurse practitioner and responsible party will be notified".

Based on observations, record review and interview, the facility neglected to: a. Have identified fall prevention measures in place for 3 of 8 residents (R2, R5, R6,) reviewed for neglect in a sample of 8; b. Timely access emergency treatment for [REDACTED]. c. Stabilize R5 to protect from the potential of further injury after a fall; d. Immediately report R5's fall to the physician and administrative personnel; e. Conduct a thorough, accurate investigation to rule out the root cause of fall for R5; R5 sustained an unwitnessed fall on 3/1/12 from which she complained of leg pain. Portable X-ray results were obtained 5 hours after the fall. R5 was transferred several times from chair to bed during the hours following the fall. R5 was evaluated in the emergency room 7 hours after fall occurrence. Hospital records shows a subcapital comminuted left femoral neck fracture with external rotation and superior displacement. Findings include: 1. R5 is a [AGE] year old resident admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] states R5 has moderately impaired cognition with short and long term memory impairment and uses a wheel chair for mobility on the unit with limited, 1 person assist. Fall Risk assessment dated [DATE], 8/6/11, 12/6/11 shows R5 at high risk for falls. Assessments dated 5/6/11 and 8/6/11 refers to history of fall in past 1-6 months, however, information regarding recent falls was not found in the clinical record. Hospital records dated 3/2/12 states an 'old [MEDICAL CONDITION] inferior pubic ramos and right hip prosthesis was noted. Care Plan dated 5/26/11 shows the following fall prevention interventions: scheduled toileting, encourage to stay in high visibility areas, keep frequently used personal items within reach when in room. R5 has impaired physical mobility, impaired decision making. Physician's monthly progress notes dated 10/30/11 through 1/31/12 describes R5 as confused. On 2/29/12 R5 was described as 'very confused'. There were no new interventions in place to address fall risk concerns with this change in condition. E11's (Nurse) nursing notes dated 3/1/12, 3:25pm, states R5 was observed on the floor laying on her right side. R5 complained of pain to right side/leg area when the area was touched or moved. R5 was moved from the floor to a chair being manually lifted off the floor by staff. There is no documentation regarding the time X-rays were done however the X-ray results were not received and relayed to the physician until 6 hours later (9:40pm) at which time the physician gave orders for R5 to be sent to the hospital. Patient transportation report shows R5 arrived at the hospital via ambulance at 10:51pm. Hospital records shows a subcapital comminuted left femoral neck fracture with external rotation and superior displacement. E9 stated on 4/20/12 at 11:25am that she was alerted to R5 being on the floor by another resident as they were both walking down the hallway. E9 stated she did not see the call light on nor heard an alarm activated. E11 (Nurse) was at the nurses station at the time of the fall and was alerted to the occurrence by E9. E12 (Certified Nurses Aid-CNA) was also on the unit doing rounds and was not aware of the fall until informed by E11. Fall investigation report dated 3/1/12 contains conflicting information. It states R5 fell while being transferred by 2 staff members. The report also states the bed alarm was sounding and R5's call light was on. The assistant director of nursing's (ADON) written statement states R5's fall occurred on 2/28/12, not 3/1/12. E1 (Administrator) stated that this erroneous date was brought to the ADON's attention and the ADON refused to change his statement. E11 stated on 4/20/12 at 12:45pm that she believe R5 was trying to go to the bathroom because she was found incontinent of bowel. E12 stated the following during a telephone interview on 4/20/12 at 12:10pm that this was the first time working with R5 after 7 months and she was not familiar with R5's routine. E10 (CNA) removed R5's wheelchair from the bedside and put it in the bathroom. E12 stated being unfamiliar with R5's routine she did not know whether R5 would have need for the wheelchair. E12 went on to say that once R5 was put back in bed, she was rolled her over to her left and right sides to provide incontinent care. One staff member held the affected limb as the other two conducted the roll. R5 was crying with pain during the rolling. A cushion was placed under R5's thighs when care was completed. R5 remained in bed for dinner where she was fed. She complained of pain when the head of her bed was raised and lowered. During X-ray procedure she was again complaining of pain. She had two more incontinent episodes during the shift and required to be changed with 2 persons assist. E10 (CNA) stated during a telephone interview on 4/20/12 at 1:30pm that she took care of R5 on a regular basis but was not the assigned care giver on the day of fall. R5 usually wants to go to the toilet shortly after her arrival on duty (3-11pm shift). She (R5) was in bed at the beginning of the shift so E10 wheeled the chair into the bathroom and closed the door as she did not want R5 to get to it. R5 has tried more than once to transfer herself to the wheelchair (this behavior is not addressed in the care plan). E10 decided it best to remove her wheelchair from the bedside to the bathroom and has been doing this since October (past 6 months). E10 stated this was not standard practice for R5, but was her decision. E10 does not know what the other CNA's do to prevent her from transferring. E1 assisted with her transfer from the chair to the bed after her fall, stating a gait belt was used to stand R5 up, then lifted onto the bed. After the fall R5 was put back in the wheelchair and taken to the dining room. R5 seemed ok but was still complaining of pain. A written statement from the then assistant director of nursing (no longer employed at the facility) shows R5 was back in her wheelchair at 4:30pm, approximately one hour after the fall. R5 was taken to the dining room. On the following day E8 stated she forgot to report the fall to E2 (Director of Nursing). E2 was made aware of R5's fall and fracture on the day following the fall. E8 was not available for interview. E2 stated on 4/20/12 at approximately 4:50pm that the facility took disciplinary actions against E8 and she was let go. E2 stated that R5's wheelchair was removed from the bedside because staff did not want her to transfer herself. E2 went on to say there was no need to have the wheelchair next to the bed because fall prevention measures were in place. Z1 (Nurse Consultant) stated that there was no need for R5 to be sent out immediately to the hospital for X-Rays. Z1 further stated it is not a common practice to send a resident to the hospital immediately for a fall incident. E1 (Administrator) stated on 4/20/12 at approximately 2:40pm that it is still not known how R5 got onto the floor. E1 went on to say she is not convinced that R5 fell . Residents who are observed on the floor, unwitnessed, this occurrence is not classified as a fall unless the investigation proves that it is a fall. E1 went on to say she does not know what caused R5's fracture because she (E1) is not a doctor. R5 could have rolled out of bed. The facility could not determine why R5 was on the floor. E1 stated she would have to speak with E2 regarding the cause of the fall. 2. R2 has [DIAGNOSES REDACTED]. MDS shows R2 with impaired decision making skills and short and long term memory deficit. R2 is Aphasic with poor communication. R2 has been assessed as at high risk for falls and has a history of falls. Careplan interventions includes use of safety helmet, falling star program, bilateral floor safety mats, positioning cushion for reclining chair, bed and chair alarm. On 4/6/12 at approximately 10"45am, R2 was observed sitting in the hallway in a reclining chair with positioning cushion out of place and no chair alarm on chair. R2 was exhibiting agitated body movement. Fall report dated 1/1/12 to 4/19/12 shows R2 had an unwitnessed fall on 3/28/12, sustaining a swollen, excoriated wound to the nose bridge. R2 received first aid treatment in the facility. 3. R6's [DIAGNOSES REDACTED]. R6 is alert with periods of confusion, has short and long term memory deficit and impaired judgement. Care plan dated 12/23/11 states R6 is at high risk for falls. Fall incident log shows on 3/7/12 R6 had an unwitnessed fall when she rolled out of bed while attempting to reposition herself in bed. R6 sustained a 1 inch laceration to the left forehead. R6 was treated in the hospital. Low bed with mat and body sensor alarm was initiated. On 3/15/12 R6's bed alarm sounded and R6 was found on the floor mat. R6 sustained no injuries. On 4/1/12 R6's alarm sounded and R6 was found on the floor with head against the bathroom door. R6 stated she was trying to reach for her hat and fell . There were no injuries upon assessment. A sensor pad to chair was initiated and order for physical and occupational therapy evaluation. On 4/6/12 at approximately 10:50am, R6 was observed in the activity room in an unlocked wheelchair. R6 was transferred to a standing position with the assist of 2 staff. R6's chair alarm did not activate. Staff adjusted the cord that attaches the alarm to the chair. Again, the alarm did not activate when R6 was assisted to standing position.

Based on observations, interview and record review, the facility failed to adequately supervise and ensure fall prevention measures were in place for 3 of 8 (R2, R5, R6,) cognitively impaired residents identified as high risk for falls. The facility also failed to immobilize R5's injury for him to minimize risk of further injury to the hip. R5 sustained an unwitnessed fall on 3/1/12 from which she complained of leg pain and X-ray results showed a subcapital fracture with posterolateral displacement. R5 was transferred from bed to chair and back to bed during the hours following the fall. Hospital emergency room records dated 3/2/12 shows "a subcapital comminuted left femoral neck fracture with external rotation and superior displacement". Findings include: 1. R5 is a [AGE] year old resident admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] states R5 has moderately impaired cognition with short and long term memory impairment and uses a wheel chair for mobility on the unit with limited, 1 person assist. Activity of Daily Living (ADL) Functional Assessment states R5 is non-weight bearing due to physical limitations in lower extremities. R5 has functional incontinence resulting from poor mobility. Fall Risk assessment dated [DATE], 8/6/11, 12/6/11 shows R5 at high risk for falls. Assessments dated 5/6/11 and 8/6/11 refers to history of fall in past 1-6 months, however, information regarding recent falls not found in the clinical record. Care Plan dated 5/26/11 shows the following fall prevention interventions: scheduled toileting, encourage to stay in high visibility areas, keep frequently used personal items within reach when in room. R5 has impaired physical mobility, impaired decision making. Physician's monthly progress notes dated 10/30/11 through 1/31/12 describes R5 as confused. On 2/29/12 R5 was described as 'very confused'. E11's (Nurse) nursing notes dated 3/1/12, 3:25pm, states R5 was observed laying on her right side. R5 complained of pain to right side/leg area when the area was touched or moved. R5 was moved from the floor to a chair by staff. Approximately one-half hour later the physician was notified of the fall and complaint of pain and stat X-rays of left side and left hip were ordered (per previous notes, R5 was found laying on her right side and complained of pain in the right side). A portable X-ray provider was contacted and assistant director of nursing (no longer works at the facility) was notified. Subsequent nurses notes written by E8 (Nurse- no longer employed at facility) at 4:00pm states R5 was given analgesic for pain in left leg and hip. At 7:30 pm E8 wrote that X-ray results were pending and R5 complained of pain to left hip with movement during X-ray procedure. At 9:05 pm E8 wrote that the physician was 'on page' related to X-ray result. At 9:40pm the physician called the facility and gave orders for R5 to be sent to the hospital. Patient transportation report shows R5 arrived at the hospital via ambulance at 10:51pm. E9 stated the following on 4/20/12 at 11:25am: E9 was walking down the hallway when a resident walking in the opposite direction told her that R5 was on the floor. E9 immediately went to R5's room, observed her on the floor on her right side in front of the bathroom door which was located near the room door. R5 said 'help' and E9, seeing E11 (Nurse) at the nurses' station, called out for help. There were no other staff in the area. R5 did not appear to be in pain because she was not crying nor screaming. The bed alarm was not activated. When E11 came to the room, E9 left the area. A telephone interview was conducted with E11 on 4/20/12 at 12:45pm. E11 stated the following: R5's assigned nurse was not on the unit at the time of the fall. E9 summoned her to go to R5's room where she found R5 laying on the floor on her right side. E11 believed that R5 was trying to go to the bathroom because she was found incontinent of bowel. R5 did not answer when asked if she was in pain. There were no non-verbal expressions of pain. Passive range of motion was performed to all extremities. There was no evidence of pain. There was redness on R5's right arm and right thigh but not on hip. E11 asked E10 (CNA) and E12 (assigned CNA) to transfer R5 from floor to chair. One CNA held R5 under arms and the other held the legs and R5 was manually lifted from floor to chair. E11 asked R5 if she was ok and R5 shook her head affirmatively. E11 then told the CNA's to put R5 to bed and render incontinent care. Later, R5 was sitting in her wheelchair during dinner and again later after X-rays were done. R5 appeared uncomfortable. E12 stated the following during a telephone interview on 4/20/12 at 12:10pm: This was the first time working with R5 after 7 months. E12 was not familiar with R5's routine and during rounds observed R5 in bed sleeping. E10 was present and she (E10) removed R5's wheelchair from the bedside and put it in the bathroom. E10 stated she always put R5's wheel chair in the bathroom. Not being familiar with R5's routine, E12 did not know whether R5 would have need for the wheelchair. E12 was still making rounds when she was notified by E11 that R5 had a fall and was moved from the floor to the chair. E12 did not hear the bed alarm activating nor saw R5's call light on. E11 asked her (E12) to put R5 back to bed. E12 proceeded to R5's room and found her sitting in a chair. When she asked R5 if she was in pain, R5 stated that her left hip was hurting. R5 was not exhibiting any non-verbal signs of pain. 3 persons transferred R5 from the chair to the bed, two lifting either side of upper body and one lifting the legs. R5 complained that her hip was hurting during the transfer. The movement made the pain increase. There were no nurses present during the transfer. Once in the bed, R5 was rolled onto her left and right sides to provide incontinent care. There was more crying during the rolling. There was an area of redness on her left hip. There was no swelling. The alignment of her leg seemed normal. When we were done we put a cushion under her thighs, covered her with a blanket and lowered the bed. E12 stated she thinks that she mentioned the reddened left hip to E11. R5 remained in bed for dinner where she was fed (this conflicts with E11's statements). She complained of pain when the head of her bed was raised and lowered. During X-ray procedure she was again complaining of pain. She had two more incontinent episodes during the shift and required to be cahnged with 2 persons assist. She was later taken to the hospital. E10 (CNA) stated the following during a telephone interview on 4/20/12 at 1:30pm: E10 took care of R5 on a regular basis but was not the assigned care giver on the day of fall. R5 needs help with transfer from the bed to the wheelchair and from wheelchair to the toilet. R5 can stand with 1 person assist. R5 usually wants to go to the toilet shortly after I arrive on duty (3-11pm shift). She (R5) was in bed at the beginning of the shift. I told E12 I would remove the wheelchair because R5 tends to transfer herself from bed to chair. I wheeled the chair into the bathroom and closed the door as I did not want R5 to get to it. I was afraid that if she attempts to transfer herself it would be too late for us to reach her after the bed alarm activates. R5 has tried more than once to transfer herself to the wheelchair. I always remove her wheelchair from the bedside to the bathroom since October (past 6 months). I do not know what the other CNA's do to prevent her from transferring. I assisted with her transfer from the chair to the bed after her fall. there were 3 people assisting with the transfer. We used a gait belt, stood her up, then lifted her to the bed. I assisted with the incontinent care. She was complaining of pain in her hip and leg area. When she was put back in the wheelchair and taken to the dining room she seemed ok but was still complaining of pain. A written statement from the then assistant director of nursing (no longer employed at the facility) shows R5 was back in her wheelchair at 4:30pm, approximately one hour after the fall. R5 was taken to the dining room. E8 was not available for interview. E2 stated on 4/20/12 at approximately 4:50pm that the facility took disciplinary actions against E8 and she was let go. E2 stated that R5's wheelchair was removed from the bedside because did not want her to transfer herself. E2 went on to say there was no need to have the wheelchair next to the bed. E1 (Administrator) stated on 4/20/12 at approximately 2:40pm that it is not known how R5 got onto the floor. E1 went on to say she is not convinced that R5 sustained a fall. Residents who are observed on the floor, unwitnessed, this is not classified as a fall unless the investigation proves that it is a fall. E1 went on to say she does not know what caused R5's fracture. R5 could have rolled out of bed. The facility could not determine why R5 was on the floor. E1 stated she would have to speak with E2 regarding the cause of the fall. 2. R2 has [DIAGNOSES REDACTED]. MDS shows R2 with impaired decision making shills and short and long term memory deficit. R2 is Aphasic with poor communication. R2 has been assessed as at high risk for falls and has a history of falls. Careplan interventions includes use of safety helmet, falling star program, bilateral floor safety mats, positioning cushion for reclining chair, bed and chair alarm. On 4/6/12 at approximately 10"45am, R2 was observed sitting in the hallway in a reclining chair with positioning cushion out of place and no chair alarm on chair. R2 was exhibiting agitated body movement. Fall report dated 1/1/12 to 4/19/12 shows R2 had an unwitnessed fall on 3/28/12, sustaining a swollen, excoriated wound to the nose bridge. R2 received first aid treatment in the facility. 3. R6's [DIAGNOSES REDACTED]. R6 is alert with periods of confusion, has short and long term memory deficit and impaired judgement. Care plan dated 12/23/11 states R6 is at high risk for falls. Fall incident log shows on 3/7/12 R6 had an unwitnessed fall when she rolled out of bed while attempting to reposition herself in bed. R6 sustained a 1 inch laceration to the left forehead. R6 was treated in the hospital. Low bed with mat and body sensor alarm was initiated. On 3/15/12 R6's bed alarm sounded and R6 was found on the floor mat. R6 sustained no injuries. On 4/1/12 R6's alarm sounded and R6 was found on the floor with head against the bathroom door. R6 stated she was trying to reach for her hat and fell . There were no injuries upon assessment. A sensor pad to chair was initiated and order for physical and occupational therapy evaluation. On 4/6/12 at approximately 10:50am, R6 was observed in the activity room in an unlocked wheelchair. R6 was transferred to a standing position with the assist of 2 staff. R6's chair alarm did not activate. Staff adjusted the cord that attaches the alarm to the chair. Again, the alarm did not activate when R6 was assisted to standing position.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to promote healing and prevent pre-existing pressure ulcers from increasing in size for 2 of 4 residents (R3 and R2) with pressure ulcers in the sample of 26. Findings include: R3 is a [AGE] year old with a [DIAGNOSES REDACTED]. On 03/11/12 at 10:40am, during the initial tour accompanied by E21 (nurse), R3 observed in bed laying on back area, the mattress R3 is on is identified as an air mattress by E21. R3 is unable to answer questions appropriately. The resident is incontinent of bowel with an indwelling catheter in place. R3 is identified as having a sacral pressure ulcer. So, accompanied by E21 and E20 a visual inspection of R3's body was done. When the top covers/linen were removed and R3 turned to the right side using the chuck under R3, the bottom sheet covering the mattress observed to have an extra large amount of semi-dry dark brown colored stool with an odor on it. The chuck had a moderate amount of the same stool on the top portion of it. In R3's diaper was a large amount of semi-dry sticky (in appearance) stool in it. The large deep sacral pressure ulcer had no covering at all over it. At 10:55am, E4 (treatment nurse) joined the team in R3's room. E4 ask if R3 should have a covering over the sacral wound? E4 stated, "There should be a dry dressing covering the wound." Then E21 stated, "I (E21) didn't know it was uncovered, but I (E21) do know R3 has a treatment to it (sacral pressure ulcer). I (E21) don't know when the last time R3 was changed." At 11:00am, the assigned aide E14 was questioned related to R3 being left in the stool. E14 stated, "There is enough help today. I (E14) started at 7:00am. Not yet I (E14) haven't did the care. I (E14) washed R3's face and hands, so, R3 could eat at 7:45am. I (E14) didn't do patient care yet, I (E14) want you (surveyor) to know I (E14) didn't do it (referring to putting the chuck over the stool soiled sheet). On 03/12/12 at 3:40pm, accompanied by E4 and E20, R3's sacral pressure sore was measured by E4. The measurement's are as follows: length = 2.3cm, width = 2.3cm, depth = 3.0cm. The most recent weekly assessment of skin alteration form presented to the team by the facility dated 03/06/2012 depicts the sacral wound measurement's as follows: length = 2.2cm, width = 2.0, depth = 2.0. The Nutritional Assessment/Reassessment dated [DATE] indicate the sacral pressure ulcer is as follows: length = 2.2cm, width = 1.8cm, depth = 2.4cm. There is an increase in the length, width, and depth of the wound. Per review of R3's current plan of care, R3 have long and short term memory deficits related to Dementia and requires assistance with grooming. Another problem addressed in the care plan is pressure ulcer-sacral, one of the approaches is "keep linen dry and wrinkle free and keep clean and dry." Based on a review of R3's Comprehensive Pressure Ulcer Assessment's dated 10/28/11 and 01/27/12, the resident's appetite is good at meals, takes supplements without a problem but,unable to evaluate labs because R3 refuses lab draws. The current Braden Scale For Predicting Pressure Sore Risk" dated 03/05/12 is scored at 13, a moderate risk for skin breakdown. Interview with E4 (treatment nurse) on 03/14/12 at 3:38pm about R3's sacral pressure ulcer increased measurements. E4 stated, "From working with R3 the past year. R3 refuse to be turned, sometimes R3 nutrition is up and down. Incontinence can be an issue, R3 is incontinent of bowel, R3 has an indwelling catheter." Per review of R3's current physician orders [REDACTED]. daily for two weeks, [MEDICATION NAME] One Scoop PO/by mouth TID, three times a day. On 03/15/12 at 11:35am, E2 contacted via telephone to request R3's lab results and recent dietary assessment. Received via fax at 12:48pm was a nutritional assessment/reassessment dated [DATE] and a care plan related to behavior dated 10/15/11. There were no lab results received as requested. On 3/13/12 at 2:40pm, in room [ROOM NUMBER]-2, E4 (Treatment Nurse) was observed doing measurements of R2's sacral decubitus. Results of measurements were as follows, length 4.7cm x width 5.0cm x depth 0.5cm. Weekly skin assessment form for R2 for the week of 3/6/12 , performed by E4, results were as follows. Length 4.5cm x width 5.0cm x depth 0.3cm. Results show a .2cm increase in the length and depth of R2's sacral decub within one week. E4 stated on 3/14/12 at 2:45pm that the only reason she can think of that may have caused the increase in size of R2's wound is due to her frequent bowel movements.

1. Based on observations, interviews, and record reviews, the facility failed to ensure that two residents R26 and R27 (2 residents in a sample of 4 residents), who have a history of aggressive behavior toward others, received adequate supervision and monitoring to prevent verbal and physical altercations. This failure resulted in both resident getting into a physical altercation, one resident sustaining a busted lip, the other resident going to the hospital for evaluation and treatment. This has a potential to effect all the resident living on the 3rd floor, who have a history of mental illness with aggressive behavior. Findings include: On 12/17/10, surveyor heard a call for all available staff to report to the 3rd floor. Upon arriving on the 3rd floor, surveyor observed that staff had separated R26 and R27, after they got into a physical altercation/fist fight. Surveyor observed that R27 and R26 live next door to one another. When R26 became calm, surveyor interviewed R27 in the day room. R27 told surveyor: "R27 had been picking on me for the last 2 weeks. Two weeks ago he (R27) ended up coming out of the room and he was ready to attach me. E10 (PRSC), he stopped me. R27 called me... (a racial slur). Staff did not do anything, they let me go back to my room. They did nothing to R27... Today was the worst!... He (R27) was yelling and swearing. He (R27) threw the first punch. He ripe my shirt and bust my lip." Then, surveyor went to R27's room on 12/17/10. R27 was in his room by himself. R27 was not on 1:1 monitoring. The certified nurse aide and nurse on duty were down the hallway. When surveyor asked R27 about the incident, R27 stated: "I got into a fight. He (R26) was punching on the wall and it annoyed me. I told staff and he continued to punch the wall. We argued back. Yeah, we called each other names. I'm calm now. My face got swollen. He was banging on the wall. Sometimes it's me talking loud to myself. They bang on the wall. I went to his room. We just start fighting." R27 told surveyor that R26 was banging on the wall last night. Then, surveyor observed the paramedics come and transported the resident to the hospital. When R27 and R26 got into the physical altercation, E12 was the nurse on duty. Before the fight, she (E12) was not present to intervene. During the interview, E12 was not aware of R26 and R27 for pass verbal altercations and the needed for very close supervision. E12 was interviewed on 12/17/10 at 2:40 PM. E12 said, "I came out and observed they were in a physical altercation, like they were on the streets. I asked them to stop. I called for a code white (an emergency call for staff assistance). The security guard and nursing supervisor came. They got them (R26 and R27) to stop fighting. I yelled for them to stop. They would stop for a few seconds and start back... They were roommates when they first got here. They asked to be separated. They had words, but nothing physical. I asked R27 why they wanted to be separated. R27 just said R26 was crazy. I'm not sure why they were put next door (to one another). R27 choose his room." When surveyor asked if R26 and R27 had any physical altercation, E12 said, "I saw one verbal spat. They (R26 and R27) were separated." E13 was the certified nurses aide/CNA (E13) on duty during the fight between R26 and R27. E13 was interviewed on 12/17/10 at 10:45 AM. E13 was also not available to supervisor/monitor R26 and R27 before the physical altercation. E13 also was not aware that R26 and R27 were at high risk for verbal and physical altercation and required close monitoring. E13 stated, "I came out the room (with another resident). I heard one call the other a name. I'm not aware of any verbal or physical fights... Sometimes R27 would hit on the walls" Surveyor asked E13 how often she made rounds on the unit to monitor and supervise the residents. E13 said she makes rounds "every 20 minutes". However, E13 told surveyor, she also had residents that required her to spend time in their rooms providing care, because they need help with ADL (activities of daily living, such as grooming and dressing). E13 said she was "the only working CNA on the unit." When asked if she needed more staff on the 3rd floor, E13 said, "It could be a little bit more staff to assist me in case something happened." The PRSC (E11) on duty was interviewed in her office on 12/17/10 at 11 AM. E11 stated: "When the incident happened, I was in my office with a resident's mother. The door was opened. I heard and saw some staff going by. I came out. I looked in the direction the staff was going, so I called code white (an emergency call for staff to come to provide assistance)... I saw the residents fighting... I'm unsure they were never in a physical altercation... They're not on my case load. I remember they got separated (R27 and R26 use to be roommates, but could not get along.) R27 pounds on the wall when he (R26) plays Spanish Music. R27 said when he gets on his bed or move around in the bed, R26 would pound on the wall. R27 went to the hospital because he started the fight. I'm not sure why R26 did not go to the hospital, because it was self defense." E11 gave the following response, when asked about a possible cause for R27 and R26 getting into a physical altercation. E11 said, "R27 yells a lot in his room. Yes, it disturbed R26 because they share that wall (to their rooms). I never asked R26 about it (being disturbed by R27)." E10, the assigned PRSC to R26 and R27 was interviewed on 12/17/10 at 3:10 PM. E10 stated, They (R26 and R27) have been in verbal altercations a few times. I have had to separate them. When I see residents start to get agitated. I get between them to make sure they're not in a physical conflict. I separate them. They did have a verbal conflict. They were yelling and threatening each other with violence. I counselor them both. R26 stated R27 had banged on the wall in the past. R26 sleeps a lot. R27 can be more violent then R26. R27 doses not exhibit any physical or verbal violence. He (R27) isolates a lot. He only did that with R26. They were 2 doors apart. I don't know how they came to be next door." However, E10 did not ensure that the treatment team was aware of the need to closely supervise and monitor the resident to prevent possible verbal and physical altercations. None of the staff ensured that two residents with a history of verbal conflict and threats were appropriately separated from one another, as well as supervised. Review of R27's Resident Admission Record Sheet documented that R27 is [AGE] year old male with a [DIAGNOSES REDACTED]. R27 was admitted to the facility on [DATE]. Review of R27's POS (Physician order [REDACTED]. "Depakote EC 500 mg two tablets by mouth every morning Cogentin 1 mg by mouth twice a day Haldol one tablet by mouth three times a day Depakote one tablet by mouth at bedtime 12/02/10 Haldol Decanoate 50 mg Intramuscular Injection every month" Review of R27's care plan documented the following concerns in R27's care: "10/26/10 Resident had difficulties managing his anger as evidenced by: verbal abusive behaviors. Goal: Resident will show improve ability to appropriately manage his anger..." The following interventions were documented for staff to implemented to address the above care issue and achieve the goal: "Assess resident for any changes in baseline mood and behavior and intervene as appropriate. During periods of increased agitation, move resident a quiet location. Allow resident to vent frustrations. Encourage relaxation during periods of stress or anger. Engage resident, and assist in basic problem solving skills during Anger Management Group or 1:1 counseling sessions. Assess whether behavior endangers residents and or others, intervene as necessary." However, none of the above approaches were implemented by the staff, while caring for R27 on 12/17/10. So, R27 did not receive the appropriate supervision to help him manage his behavior. Review of R26's Resident Admission Record Sheet documented that R26 is a [AGE] year old male with [DIAGNOSES REDACTED]. R26 was original admitted to the facility on [DATE]. R27 went to the hospital because he hit another resident at the facility and was readmitted on [DATE] Review of R26's POS (Physician order [REDACTED]. "Depakote 500 mg two tablets by mouth twice a day Seroquel 200 mg one tablet by mouth every night Seroquel 50 mg one tablet everyday" Review of R26's care plan identified the following as issues in his care: "11/22/10 Problem: R26 has a [DIAGNOSES REDACTED]. R26 became aggressive with another peer. Goal: Resident will not have any incidents of aggression... 11/22/10 Problem: R26 has history of physically abusive behavioral toward other as evident by history of violence against family members. Goals: R26 will not harm self or others secondary to physically abusive behavior." The staff identified intervention such place resident on 1;1. However, there is no evidence to support that R26 received consistent 1:1's or monitoring and supervision, when he got into verbal altercations with R27 During the Daily Status Meeting on 12/17/10 and 12/22/10 with the administrator (E1) and director of nursing (E2), the surveyor team expressed concerns that R26 and R27 were not given the supervision and monitoring they required to prevent possible verbal and physical altercations. E1 and E2 present documentation of inservice for psychosocial staff. However, E1 nor E2 provided any evidence to support that R26 and R27 received the supervision they required. 2. Based on observations and interviews, the facility failed to provide adequate monitoring and supervision to 2 resident (R15 and R14 in a sample of 29 residents) while they went out in cold weather condition to smoke. This failure left the resident unsupervised while being blocked on the ramp by another resident and unable to enter the building. This area of noncompliance has the potential to effect the other residents when they go out to smoke. Findings include: As the survey team came up the ramp to enter the facility on 12/15/10, surveyor observed three wheel chair bound residents sitting out in the cold weather on the ramp. As surveyor walk by, the two female residents (Staff later identified one of the female resident as R15) complained to surveyors that they had came out to smoke, but a male resident (Staff reported he was R14) would not move his wheel chair. The two female resident said that they needed help to get the male resident to move, and to to return to the building. The male resident had a protective head covering, was confused, and did not respond when surveyor request he move his wheel chair. Another male resident was in his wheel chair at the entrance of the facility. Surveyor observed that he was trying to open the door. After attempting to open it, he could not get it to opened. So surveyor assisted the resident to open the door. When surveyors entered the lobby, no one was observed sitting at the security desk. Surveyor observed a tall young man (E15) coming toward the lobby from the direction of the elevator. So, surveyors requested he (E15) provide assistance to the residents being block on the ramp. Surveyor also asked him why no one was monitoring the residents outside smoking in the cold weather. E15 identified that it was his responsibility to sit at the desk and monitor the resident. But E15 said he had to leave his post and go to the basement. After prompting, E15 got R14 to move and allow the two female residents to get back into the building out of the cold weather. The director of nursing was immediately interviewed on 12/15/10 and informed of the above observation. Surveyor asked her to identified what staff member was responsible for monitoring residents, who need assistance, while they go out to smoke in the cold weather. E2 informed the survey team that security sitting at the front desk in the lobby was responsible for monitoring the residents. However, the residents were not provided with consistent supervision and monitoring until prompted by the surveyor team on 12/15/10. 3. Based on observations and interviews, the facility failed to ensure that the resident's environment was free of hazards. This has the potential to effect all the residents in the facility, who are dependent upon staff to keep their environment safe. Findings include: During tour of the facility on 12/15/10, surveyor observed oxygen tanks stored on top of the heating units in room 118 and 109. There also was nothing in place to secure them from falling over.