Every finding on record at Ryze at the Ridge

Based on interview and record review, the facility failed to administer medication as ordered by the physician. This failure affected one (R1) of four residents reviewed for improper nursing care. The findings include:R1's admission record/face sheet shows an admit date of 8/31/2022, with diagnoses including, but not limited to, paraplegia, bipolar disorder, unspecified psychosis, low back pain, and anemia. The MDS (Minimum Data Set) dated 8/12/26 indicates R1 is cognitively intact.On 8/16/26 at 10:18AM, R1 was observed resting in bed, alert and oriented x3, and verbally responsive. R1 stated that from May 5-8, 2026, Topiramate-prescribed for headache/migraine-was not available and she did not receive the medication during this period. R1 stated that when she misses a dose of Topiramate, she experiences severe migraine pain.Review of R1's EMAR (Electronic Medication Administration Record) indicates Topiramate was not administered on 5/6/26, 5/7/26, 5/8/26, 5/29/26, and 5/31/26.R1's POS (Physician Order Sheet) shows an order including but not limited to: Topiramate Oral Tablet 25 mg - Give 2 tablets by mouth two times a day for migraine headaches.On 8/16/26 At 12:39PM V13 (RN / Registered Nurse) stated there was an incident in which R1's Topiramate was not available and was not given. She stated that once medications are administered, they should be signed off in the EMAR. If medication is not given for any reason, it must be documented, and MD (Medical Doctor) or NP (Nurse Practitioner) must be notified to obtain a possible order or further guidance. She stated that standard nursing practice is: If it is not documented, it was not done. On 8/16/26 at 1:58 PM, the surveyor reviewed R1's EMAR and progress notes dated 5/6/26 with V9 (LPN). R1's EMAR dated 5/6/26 indicates Topiramate was not given, as it was not checked off. V9 documented a 9 in the EMAR on 5/6/26. V9 stated she was not sure what 9 represents because the entry did not indicate that the medication was not administered. She stated a check mark means the medication was given, and 9 could mean the medication was not given or something else. V9 stated her progress notes dated 5/6/26 do not indicate that the MD/NP was notified. She stated that the nursing standard practice: If it was not documented, it was not done. On 8/17/26 at 9:43 AM, the surveyor reviewed R1's EMAR and progress notes dated 5/8/26 with V11 (RN). V11 confirmed that Topiramate Oral Tablet 25 mg was not available and therefore was not given to R1. She stated her progress note dated 5/8/26 reflects that the medication was not administered because it was not available. V11 stated the documentation does not indicate that the MD/NP was notified. She stated that when medication is not available, the MD/NP should be notified to obtain a possible order or guidance. V11 stated that per nursing standard practice, If it was not documented, then it was not done. She further stated that once a medication is administered, it should be checked or signed off in the EMAR to indicate it was given. R1's EMAR dated 5/8/26 shows the medication was not given.On 8/17/26 At 10:33AM V2 (DON / Director of Nursing) stated nurses should check the EMAR, administer medications as ordered by the physician, and document in the EMAR to certify that the medication was given. She stated the medication should be checked off once administered. V2 stated that there should be documentation explaining why the medication was not administered to clarify the reason. V2 stated Topiramate is an anticonvulsant medication but is used by R1 for migraine management. She stated that missing this medication could potentially lead to severe pain, headache, distress, discomfort, or behavioral changes such as agitation. She noted that pain is subjective and can vary greatly. V2 stated the MD/NP should be notified when medication is not available and was not given so that an alternative medication or guidance can be provided. She stated it is at the discretion of the MD/NP whether the medication can be missed or whether an alternative medication should be ordered. V2 stated the MD or NP determines the resident's clinical need for the medication. V2 reiterated that nursing standard practice is: If it was not documented, it did not occur or was not done. Review of R1's progress notes from 5/6/26 to 5/8/26, 5/29/26, and 5/31/26, it does not reflect that the MD/NP was notified that R1 did not receive Topiramate as ordered.Facility's Medication administration policy dated 1/2026 shows in part: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. If medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required. If the physician's order cannot be followed for any reason, the physician should be notified in a timely manner (depending on the situation), and a note should reflect the situation in the resident's medical record.

Based on observation, interview, and record review the facility failed to ensure residents knew staff names and titles due to staff not wearing identification badges. This failure has the potential to affect all residents residing in the facility. Findings include:On 3/17/2026 at 11:03 AM, R1 stated that when he wants to make a complaint about a staff member, he is unable to identify the individual because staff do not wear identification badges. R1 stated he had spoken with the (V10) (Assistant Director of Nursing), the nurse, and the nurse on staff; however, many staff use nicknames and do not wear name badges, so he is unable to identify which staff members he reported concerns to. On 3/17/2026 at 11:22 AM, V8 (Certified Nurse Assistant-(CNA) stated I (V8) don't have an identification badge because I (V8) am a new employee. Observed V8 in the hallway on unit 2 with towels in his hand. On 3/17/2026 at 11:23 AM, V3 (Certified Nurse Assistant-(CNA) was stopped in the hallway and verified with surveyor she (V3) was not wearing her identification badge. Observed V3 in the hallway on unit 2 entering in resident rooms without her identification on. On 3/17/2026 at 11:24 AM, V3 (Certified Nurse Assistant-(CNA) stated she should be wearing her identification badge, and it should not be in her pocket; the purpose of wearing an identification badge is for residents to identify who is taking care of them; staff do not speak different languages in front of residents. On 3/17/2026 at 11:29 AM, V9 (Licensed Practical Nurse) observed not wearing an identification badge on the second floor. V9 (Licensed Practical Nurse) stated it is the facility's policy that all staff are required to wear Identification (ID) Badges; the purpose of wearing ID badges is so that residents can identify who is providing care to the resident; it is the resident's right to know who is caring for them.On 3/17/2026 at 11:35 AM, V13 (Registered Nurse) stated staff are required to wear an identification badge while at work on duty; the purpose of wearing an identification badge is to recognize who is taking care of them.On 3/17/2026 at 2:31 PM, V6 (Social Services Director) was observed not wearing an identification badge during an interview in the conference room. On 3/17/2026 at 11:38 AM, V14 verified she (V14) was not wearing an identification badge on the first-floor unit. V14 (Licensed Practical Nurse) stated she (V14) should be wearing an identification badge during her shift to let residents know who is taking care of them. V14 stated the expectation is for all staff to wear identification badges while on duty. On 3/18/2026 at 2:02 PM, surveyor observed V15 (Licensed Practical Nurse) not wearing an identification badge on the first-floor unit and V15 verified she was not wearing an identification badge. V15 stated I (V15) am not wearing an identification badge; required to wear an identification badge; staff should wear an id badge for resident identification of a nurse, visitors to identify who they are in contact with; and it is a safety issue if a resident cannot identify a staff member or someone in the building not wearing and identification badge. Facility's employee handbook dated 1/2025 documents name badges are supplied by the facility and must be worn by all employees when on duty. Each employee is responsible for his/her name badge and must bear the cost of replacement if it is lost or misplaced.

Based on interview and document review the facility failed to ensure the residents right to be free from physical abuse for 2 of 4 residents (R1, R2) reviewed for abuse. This resulted in R1 being grabbed by the throat by R2.Findings include:R1 is a [AGE] year old with a diagnosis including Fibromyalgia , Bipolar disorder , COPD , Alcohol Abuse , Anxiety Disorder and Borderline personality Disorder. R1 was first admitted to the facility on [DATE]. R1 has a BIMS ( Brief Interview Of Mental Status ) score of 15/15 indicating R1 is cognitively intact.R2 is a [AGE] year old with a diagnosis including COPD , Post Traumatic Stress Disorder , Bi Polar Disorder , Fibromyalgia and Venous Insufficiency. R2 was first admitted to facility on 4/30/25. R2 has a BIMS ( Brief Interview Of Mental Status ) score of 14/15, indicating R2 is cognitively intact. On 7/23/25 at 10:20AM R1 stated R2 grabbed my throat a couple days ago outside the room at the door during smoking time. R2 was my roommate at the time. I reported this to V4, Registered Nurse (RN). The facility didn't do anything about it, except they did move R2 to a different room.On 7/23/25 at 10:28 AM R2 stated R1 was not nice to be roommates with. R1 was always complaining about R2 to the nurses. I was really aggravated by R1. About 2 days ago I was out in the hallway and R1 came up to me complaining. I had enough so I grabbed her throat. I didn't squeeze or anything. R1 then started hitting my face with a closed fist. V5,Certified Nursing Assistant (CNA) came up and separated us. I was later moved to another room.On 7/23/25 at 10:36AM V4 (RN) stated a few days ago (7/21/25) V5, (CNA) and I heard a commotion at the end of the corridor across RM [ROOM NUMBER]. R1 and R2 were in an altercation. I didn't see them hitting each other. V5 and I went down there and separated them. R1 reported to me that R2 grabbed her by the throat. I assessed for injury and there were no marks or any other signs of injury. R2 was later moved to another room.On 7/23/25 at 10:40AM V5 (CNA) stated I heard an altercation at the end of the corridor during smoking time. I went down there and R1 and R2 were face to face. I had to separate them. V4 (RN) was with me. R1 stated that R2 choked R1's throat. V4 (RN) reported this incident to V1 (Administrator/Abuse Prevention Coordinator) . I am aware that this was abuse.On 7/23/25 at 1:30PM R7 stated I saw R2 choke R1 about two days ago at the end of the hallway. We were waiting to go out and smoke. I didn't see R1 hit R2 back. The nurse came and separated R1 and R2.On 7/23/25 at 1:40PM R8 stated R1 was standing waiting to smoke. R2 came up and started pushing residents with R2's wheelchair. R1 started arguing with R2. R2 then grabbed R1 by the throat.On 7/23/25 at 1:45PM R9 stated R9 saw R2 grab R1 by the throat.On 7/23/24 at 1:50PM R10 stated R1 and R2 were arguing because R2 was crowding the doorway to go smoke. R2 grabbed R1 by the neck. The staff came and stopped the two from fighting. The camera was right there and it should be on camera.Facility policy titled Abuse Policy And Prevention Program shows:This facility affirms the right of our residents to be free from abuse, neglect , exploitation , misappropriation of property ,deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation , misappropriation of property, and mistreatment of residents.

Based on interview , observation and document review the facility failed to ensure the facility maintains an effective pest control program on 1 of 3 resident floors.Findings include.On 7/29/25 the facility was toured and observed for evidence of rodents and insect infestation. V5, Maintenance Director was present during tour.R11s room observed with numerous mouse droppings between wall and bedside cabinet.R12s room mouse droppings observed all along top of floor heat register.R13 and R14s room mouse droppings under floor heat register.R15s room observed with mouse droppings under the floor heat register.On 7/29/25 at 1:05PM R11 stated I see mice here a lot at night.On 7/29/25 at 1:10PM R12 stated I see mice they come from under the floor heat register mostly at night.On 7/29/25 at 1:15PM R13 stated yes mice are all over on this floor. I see them at night.On 7/29/25 at 1:16PM R14 stated there are mice here in my room at night. They come from the walls.On 7/29/25 at 1:20PM R15 stated I see mice here in my room on the floor at night.Facility policy titled Integrated Pest Management (IPM) Policy states the facility has adopted this Integrated Pest Management Plan for the buildings and grounds it manages. The plan outlines procedures to be followed to protect the health and safety of staff, residents and visitors from pest and pesticide hazards. The plan is designed to voluntarily comply with policies and regulations promulgated by the Illinois Department of Public Health and the Department of Agriculture for public buildings and health care facilities.Objectives of the IPM plan include:Elimination of significant threats caused by pests to the health and safety of residents, staff and the public.Prevention of loss or damage to structures or property by pests.Protection of environmental quality inside and outside buildings.

Based upon observation, interview, and record review, the facility failed to immediately assess a resident (post fall), failed to follow physician's orders, and failed to provide timely hospital transfer for one of three residents (R3) reviewed for falls. These failures resulted in R3's (5/2/25) delayed care of a fall with right impacted intertrochanteric fracture - with varus deformity [an excessive inward angulation of a joint or bone's distal segment] which required surgical intervention and likely experienced excruciating pain [for roughly 33 hours - prior to transfer] which was rated 3/10 - by facility staff. Findings include: R3's diagnoses include metabolic encephalopathy and fracture of unspecified part of neck of right femur. R3's (5/14/25) BIMS (Brief Interview Mental Status) determined a score of 6 (severe cognitive impairment). R3's (5/14/25) functional assessment affirms resident is dependent on staff for chair/bed to chair transfer and walking was not attempted due to medical condition or safety concerns. R3'S (10/2/24) fall risk evaluation determined a score of 25 (high risk). R3's progress notes states (5/2/25) at approximately 10:00 am, resident observed with an unwitnessed fall in his room. Noted to be lying in supine position on the floor by his bed with rolling walker next to him. Unable to narrate events leading to the fall. Observed with facial grimacing during passive range of motion to right leg. Medical Doctor notified with orders for x-ray of bilateral hip and knee to rule out injury. Order noted and carried out. Acetaminophen administered for pain. Urgent care called for x-rays; all papers faxed. 3:25 pm, urgent care here to carry out x-ray [roughly 5.5 hours after fall] to bilateral hips [knee x-ray was excluded] awaiting results. (5/3/25) 1:12pm, Resident observed hopping on right leg. X-ray carried out per doctor order; results show right hip fracture [roughly 22 hours after x-rays were obtained]. Doctor gave order to transfer resident to nearest ER (Emergency Room). 7:18 pm, Order to transfer resident to ER carried out [roughly 6 hours after transfer orders were received and 33 hours after R3 fell]. R3's (5/2/25) Physician Order Sheets include x-rays of bilateral hip - entered at 10:33am [x-ray of knee is excluded]. R3's (5/2/25) right hip x-ray affirms impacted intertrochanteric fracture with varus deformity - reported 5/2/25 at 10:04pm [roughly 12 hours after x-ray orders were received]. R3's (5/3/25) Medication Administration Record states that pain was rated 3/10 on evening shift. On 5/28/25 at 10:21 am, V2 (Director of Nursing) stated He (R3) had a fall on 5/2 around 10:00 in the morning. At the time of the fall there were no signs of injury or apparent injuries noted. R3 exhibited facial grimacing during range of motion per 5/2 progress note]. He started showing injury the following day, so the doctor sent him out for evaluation. On 6/2/25 at 11:53 am, V7 (Licensed Practical Nurse) stated On 5/2/25, I saw him (R3) on the floor because it was unwitnessed fall. The resident (R3) can't talk much, he don't (sic) remember exactly what happened. After the assessment was done, he can't verbalize pain but he was grimacing when we were doing the range of motion on the right leg. I notified the doctor and he ordered for x-ray that we should do bilateral x-ray to the legs it was carried out, done. I called the state guardian and give (sic) a pain pill. R3's (5/2/25) X-ray order wasn't put in stat because when I called the doctor, he didn't say to put stat, so I didn't get a stat order from the doctor. I don't remember if the physician ordered x-ray of bilateral hip and knee to rule out injury per progress note (entered by V7), but I know its bilateral leg. I know when I was documenting I wanted to put knee and leg. R3's (5/4/25) history & physical includes Musculoskeletal: Deformity present, right lower extremity externally rotated. R3's (5/6/25) history and physical affirms status-post right hip intramedullary nailing. On 5/29/25 at 1:55pm, V11 (Medical Director) stated When a resident falls, they (staff) usually assess the patient, call me (V11) right away, and let me know what's going on. The resident should be assessed as soon as the patient fell, they have to assess right away. Surveyor inquired if a resident sustains an unwitnessed fall and exhibits facial grimacing during passive range of motion (to the right lower extremity) what should be ordered V11 replied We order the x-rays if there's swelling of the knee or hip we order the x-rays right away. If the patient is confused, we send the patient out [R3's cognitive status is severely impaired]. V11 stated that x-rays (post fall) should be ordered stat and once the xray is done staff should be following up with the provider or the provider should be calling the facility with results and that the provider usually calls within 1 or 2 hours for the results. V11 also stated that resident should be transferred to the hospital if they see any deformity. V11 further explained that a lower extremity varus deformity presents usually the leg is rotated to the left if it was the right leg and that the potential harm to a resident that sustained an unwitnessed fall is that If there's fracture, there is pain and sometimes surgery is required. Considering reasonable person concept, right lower extremity deformity, and fracture (which required surgery) R3's pain was likely excruciating therefore higher than 3/10. On 5/27/25 at 2:12pm, R3 was observed lying on the floor (adjacent the bed) and the curtain was pulled. V6 (Certified Nursing Assistant) affirmed that she was assigned to R3 at the time of R3's fall incindent. V6 stated I was here (room) watching him and went to bring water for him, and the Nurse saw he was sliding down. R3 was unable to provide a description of what happened due to cognitive status. Several staff subsequently entered the room and transferred R3 back to bed [prior to assessment]. On 5/27/25 at 2:22 pm, V7 (Licensed Practical Nurse) entered R3's room and affirmed that she was assigned to R3 at the time of R3's fall. V7 stated He (R3) went for therapy, he just came in. I'm the one that set him down. I saw him from the Nurse's station trying to slide down. Surveyor inquired if R3's vital signs were obtained post fall V7 responded I want to do it now, I'm doing it. I'm gonna assess the patient and call the doctor [roughly 10 minutes after falling]. V7 also stated If a resident falls, the nurse should assess the resident before we (staff) pick them up. I did not assess R3 prior to placing back in bed because I went downstairs to get the (mechanical lift). No, that getting the mechanical lift is not the priority. On 5/28/25 at 10:36 am, V2 (Director of Nursing) stated When a resident falls, we (Nurses) assess the patient before transferring. We do vital signs, range of motion and assess for injuries before we move this patient. The change in resident condition policy (reviewed 01/2025) states Nursing will notify the resident's physician or nurse practitioner when: there is a significant change in the resident's physical, mental or emotional status. It is deemed necessary or appropriate in the best interest of the resident.

Based upon observation, interview, and record review the facility failed to implement fall prevention interventions. These failures resulted in R3's (5/2/25) fall with sustained right hip impacted intertrochanteric fracture with varus deformity which required surgery. Findings include: R3's diagnoses include metabolic encephalopathy, lack of coordination, abnormalities of gait/mobility, and fracture of unspecified part of neck of right femur. R3'S (10/2/24) fall risk evaluation determined a score of 25 (high risk). R3's (5/14/25) functional assessment affirms resident is dependent on staff for chair/bed to chair transfer and walking was not attempted due to medical condition or safety concerns. R3's (7/23/24) care plan states resident is at high risk for falls related to unsteady gait and incontinence. Interventions: (10/2/24) encourage appropriate use of assistive devices. (5/7/25) staff to monitor resident and assist as needed, (5/20/25) keep bed in lowest position, (5/27/25) promote placement of call light within reach, (5/27/25) bed wedges in place on side of bed for additional support, (5/27/25) floor mats in place. R3's (5/2/25) fall incident report states resident observed with an (unwitnessed) fall in his room. Noted lying in supine position on the floor by his bed, with rolling walker next to him. Resident unable to give description. Full body assessment completed, with no apparent injury observed, no opened skin noted. Observed with facial grimacing during passive range of motion to right leg. Medical doctor notified with orders for x-ray of bilateral hip and knee to rule out injury. Order noted and carried out. On 6/2/25 at 11:53am, V7 (Licensed Practical Nurse) stated R3's fall prevention interventions include call light within the reach, bed in the lower position, we monitor the resident every 2 hours, and the resident is close to the nurse's station [bed wedges and floor mats were excluded]. Regarding R3's (5/2/25) fall, I (V7) was doing my morning medication. The patient (R3) is in bed, he is okay, and he is very close to the nurse's station. So, when I went across the hallway, he (R3) was still in his room lying in bed, but he is confused, and we need to remind him to use his walker. I saw him on the floor because it was unwitnessed fall. The resident (R3) can't talk much he doesn't remember exactly what happened. After the assessment was done, he can't verbalize pain but he was grimacing when we were doing the range of motion on the right leg. I notified the doctor and he ordered for x-ray that we should do bilateral x-ray to the legs it was carried out, done. I called the state guardian and give a pain pill. Surveyor inquired if a floor mat was in place at time of fall V7 stated No, he wasn't using floor mat at the time of the fall and he (R3) did not require bed wedges, but he is using it now. On 5/29/25 at 1:55pm, surveyor inquired about potential harm to a resident that sustained an unwitnessed fall V11 (Medical Director) responded If there's a fracture there is pain and sometimes surgery is required. R3's (5/2/25) right hip x-ray affirms impacted intertrochanteric fracture with varus deformity. R3's (5/6/25) history and physical states status-post right hip intramedullary nailing. _ R3's (5/14/25) BIMS (Brief Interview Mental Status) determined a score of 6 (severe impairment). On 5/27/25 at 2:12pm, R3 was observed lying on the floor (adjacent the bed) and the curtain was pulled. R3's bed was noted to be in low position (without sheets/linen) and the call light was on the floor. R3 was unable to provide a description of what happened due to cognitive status. V6 (Certified Nursing Assistant) affirmed that she was assigned to R3 at the time of R3's fall on 5/27/25. V6 stated I (V6) was here (room) watching him (R3) and went to bring water for him, and the Nurse saw he was sliding down. Surveyor inquired about R3's fall prevention interventions V6 responded There is a form that they (facility) keep here for him then searched the room to no avail and failed to answer the question. V6 affirmed that there was no clip on R3's call light to secure it within reach there was not. On 5/27/25 at 2:22pm, V7 (Licensed Practical Nurse) affirmed that she was assigned to R3 at the time of R3's fall (5/27/25). V7 stated He (R3) went for therapy, he just came in. I'm (V7) the one that set him (R3) down. I (V7) saw him from the Nurse's station trying to slide down. All the people (referring to R3 and 2 other residents) in this room are fall risk so we monitor them. R3's call light, It's not within reach, it's on the floor. There's no clip to secure it within reach, we put it on the side. The fall prevention and management policy (reviewed 2/2025) states this facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the residents existing plan of care shall be evaluated and modified as needed. Residents at risk for falls will have fall risk identified on the interim plan of care with interventions implemented to minimize fall risk. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence.

Based on observation, interview and record review, the facility failed to notify the physician and obtain a treatment order, failed to monitor and document the status of a wound, and failed to develop an individualized care plan to address the wound of 1 resident (R1) out of 2 residents reviewed for wound care. Findings Include: On 5/6/25 at 10:56 AM, observed R1 in her room alert and able to verbalize needs. R1 stated when she was admitted in the facility, she had a healing surgical wound on her abdominal area. R1 stated she had a hernia repair six months ago and it takes a while for the wound to heal because she is Diabetic. R1 stated that the surgical site re-opened sometime last month, and she notified a nurse (could not remember nurse's name). R1 stated that staff are not doing anything to treat her re-opened surgical wound. On 5/6/25 at 11:15 AM, V7 (Registered Nurse) was asked to check R1's surgical site on her abdominal area with this surveyor and noted a small, opened wound measuring approximately 0.5 centimeter in width around R1's naval area with no signs and symptoms of infection noted. The wound was open to air with no wound dressing. R1 stated that the opened wound rubs off on her clothes and get irritated. V7 stated the last time she saw R1's surgical site was last week, and it was scabbing with no open area. On 5/6/25 at 12:23 PM, V10 (Assistant Director of Nursing/Licensed Practical Nurse) stated that there is no wound care nurse in the facility. V10 stated she oversees and tracks pressure ulcers and surgical wounds in the facility and make rounds with the wound doctor weekly. V10 stated that there is no resident in the facility that currently has surgical wound. V10 stated she was not notified and has no information regarding R1's surgical wound. V10 stated that if a surgical wound is re-opened, the nurse should assess and call the doctor to get treatment order. Nurses will enter the physician's orders in the resident's chart and carry out the orders. V10 stated when treatment is done, the nurse should sign and document in the treatment administration record (TAR) and the progress notes. V10 stated that if it's not documented or signed off, it means it's not done. If treatment is not done for any type of wound, there is a risk for infections. V10 stated opened wounds should be monitored and documented in the resident's chart if it's healing or getting worse. On 5/6/25 at 12:41 PM, V2 (Director of Nursing) stated that if resident is admitted with a surgical wound, nurses should monitor the site even if it's healed especially if the resident is new to the facility. The nurse should assess and call the doctor to get treatment order if the wound re-opened. The orders are entered in [electronic health record] and TAR and document in progress notes the assessment and what was the intervention. V2 stated nurses are supposed to check and monitor the wound at least daily until healed. They would document in progress notes the condition of the wound, if it's healing, or if it is getting worse. Treatments done are signed off in the TAR. On 5/6/25 at 2:00 PM, V7 (Registered Nurse) stated that R1's healing skin on her surgical wound peeled off (does not remember the exact date). V7 stated she cleansed the area with normal saline and applied bandage, so R1 won't scratch it. V7 stated she did not notify R1's doctor. V7 stated she notified V10 (Assistant Director Of Nursing/Licensed Practical Nurse) . V7 stated, I put it on the communication board in the computer to notify all the staff. I did not call the doctor. The wound did not look infected. It was not red. No drainage. No pus. She was not complaining of pain. On 5/7/25 at 10:28 AM, V20 (MDS Coordinator) stated that if a resident is at risk for skin breakdown and if there is current wound, it should be addressed in the care plan. If they have acquired wound the care plan should be updated when it has been identified. Residents who were identified with new skin breakdown should be communicated in the electronic health records for all the staff to see and the care plan will be updated as soon as possible. V20 stated that the care plan shows what the staff will do for the resident, what problems they are exhibiting and the interventions on how to address the problems. The care plan goal is to help the staff complete the process. V20 stated that she was notified just last night about R1's surgical wound. V20 stated, I check the communication board every day for any updates with the residents. I was not notified of her [R1] healing surgical wound until last night. 5/6/25 at 1:09 PM, surveyor requested a list of residents with current skin breakdown. The facility provided a list with one resident currently have vascular wound and R1 was not included on the list. R1's clinical records show an admission date of 4/7/25 with included diagnoses but not limited to type 2 diabetes mellitus and cirrhosis of liver. R1's Minimum Data Set, dated [DATE] shows R1 is cognitively intact. R1's progress notes dated 4/7/25 at 6:31 PM documents R1 was admitted in the facility and was noted with a surgical scar on the abdomen. R1's progress notes on 4/17/25 at 9:31 PM, V7 documented in part: [R1] called NOD [Nurse on Duty] to come to her room. On getting to the resident room, resident asked the NOD to take a look at the incision site at the upper middle of the navel. The site was assessed with a little round dry scar that peeled off. Site was cleanse with normal saline and kept dry. Resident request bandage for the site, resident was remind that the site doesn't need bandage for now, that it needs a bit of air to make the surface dry, resident became agitated. Resident was reminded that the wound nurse will assess the site. Wound nurse was notified to see the resident. R1's physician orders and TARs from 4/17/25 to 5/5/25 revealed no treatment order for R1's surgical wound. R1's comprehensive care plan does not have an individualized care plan addressing R1's surgical wound with measurable goals and interventions. The facility's CHANGE IN RESIDENT CONDITION policy dated 1/25 documents in part: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician and resident's responsible party of a change in condition. Nursing will notify the resident's physician or nurse practitioner when: It is deemed necessary or appropriate in the best interest of the resident. The resident's care plan will be updated as appropriate. The facility's SKIN MANAGEMENT: Monitoring of Wounds and Documentation policy dated 1/25 documents in part: It is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. The facility's COMPREHENSIVE CAREPLAN policy dated 3/17/25 documents in part: The facility must develop a comprehensive person-centered care plan for each resident. The care plan will include a focus, measurable goal, and interventions specific to the resident's medical, nursing, mantal, and psychosocial needs.

Based on interview and record, the facility failed to ensure residents are free from resident-to-resident physical altercation. This failure affected 2 residents (R1,R2) reviewed for abuse in the total sample of 6 residents. Finding include: On 01/27/2025, at 11:43am, R2 stated we (R1 and R2) had a fight. I don't want to talk about it anymore. On 01/27/2025, at 12:21pm, R5 stated the fight happened in the 1st floor dining room. They were to each other's face, talking loudly. Then they start hitting and pushing each other, (R1) hit (R2)'s head and (R2) fell down. On 01/28/2025, at 10:44am, speaking with V11 (Housekeeping Director) and V9 (Housekeeping) stated if there are two residents arguing, the first thing I need to do is to separate them so it will not escalate to physical altercation. On 01/28/2025, at 10:51am, V9 stated I was cleaning room *** or *** when I heard a lot of screaming and I saw (R1) and (R2) were fighting. (R2) pushed (R1). I saw one nurse. This nurse told (R2) to go back to his room on the 2nd floor. I did not see (R2) going back to the second floor because I continued cleaning the room. In about one minute, I was by the door of a room when I heard a loud grunting. Louder than the screaming. I looked and I saw (R1) head locked (R2) with his (R1) left arm. V9 was demonstrating to both surveyor and V11 how (R1) head locked (R2). V9's left upper extremity angled on his left side and V9's right hand holding his left wrist. On 01/28/2025, at 11:09am, V9 stated I did not think the situation would escalate. I did not intervene the first time, I got scared because (R1) is tall and I stand 5'6. On 01/28/2025, at 11:14am, V11 stated I expected him (V9) to intervene and to protect both residents. On 01/28/2025, at 11:30am, V12 (Registered Nurse) stated I was in med room to get insulin for one of my residents. It would not have escalated if only staff intervened while they (R1 and R2) were still arguing. I would still intervene on a safe distance and tell (R1) to calm down and I would have called for other staff to assist. If I cannot manage the situation by myself, I would ask for help. On 01/30/2025, at 10:02am, V18 (Certified Nursing Assistant) stated I did not witness the incident between (R1) and (R2) because I was passing tray in the dining room basement. On 01/28/2025, at 3:25pm, V3 (Social Services Director) stated if residents are arguing, staff are expected to deescalate the situation. Staff meaning anyone can get involve. If (V9) observed (R1) pushed (R2) it is expected of him to help separate the residents or get other staff to help separate the residents. The purpose of deescalating the situation is to avoid anybody to get injured. On 01/28/2025, at 3:49pm, V3 stated in the aspect of height, the staff should have called for assistance and not going back to what he was doing. On 01/29/2025, at 1:28pm, this time speaking with V4 (Admissions Director) translating for V9, V9 stated while cleaning room ***or *** I heard screaming, (R1) and (R2) were arguing, talking loudly and strongly. I went out of the room, and I saw (R2) push (R1). I saw and heard the nurse tell (R2) to go to the second floor. I did not see (R2) go to the second floor because I continued what I was doing. Approximately one minute later, I heard a loud grunting noise. I went out of the room, and I saw (R1) and (R2) fighting on the floor. My initial reaction was to drop my cleaning material and ask myself what am I going to do? I got scared because I have never been in that situation before, I slowly approached them, and I told R1 'Relax'. On both situations, I never asked for help. On 01/29/2025, at 1:35pm, V4 stated I think in this situation, it is appropriate to call for code gray. Gray is for violent behavior. I think if only he asked for assistance it will not escalate to a physical altercation. On 01/29/2025, at 2:47pm, speaking with V4, V9, and V14 (Regional Director of Operations) V9 as translated by V4 stated (R1) and (R2) were fighting on the floor. On 01/29/2025, at 2:48pm, V14 stated fighting on the floor is resident to resident physical altercation. On 01/29/2025, at 2:50pm, V14 stated it is not expected of our resident to be physical abused by another resident. Two residents fighting on the floor is a physical altercation and considered as abuse. R1's (Active Order as Of: 12/15/24) Order Summary Report documented, in part Diagnoses: (include but not limited to) bipolar disorder and schizoaffective disorder, bipolar type. R1's (11/18/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 13. Indicating R1's mental status as cognitively intact. R1's (12/15/2024) progress note documented, in part hospital confirmed resident is admitted with DX (diagnosis) aggression. R1's (initiated: 5/14/24) care plan documented, in part presents with aggression towards staff (06/25/24); exhibit verbal aggression (7/13/24); presents with threatening behavior towards staff (7/22/24). R2's (undated) Admission Record documented that R2's diagnoses (include but not limited to) auditory hallucination, suicidal ideations, and schizoaffective disorder. R2's (01/09/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 10. Indicating R2's mental status as moderately impaired. R2's (12/15/2024) progress note documented, in part returned from the hospital. Diagnosis Contusion of scalp. R2's (12/15/2024) After visit summary documented, in part Diagnosis: contusion of scalp, initial encounter. HPI (history of present illness): brought in after altercation at group home. Says he was pushed over and fell and hit his head. What you need to know: A contusion is a bruise that appears on your skin after an injury. A bruise happens when small blood vessels tear but skin does not. Blood leaks into nearby tissue, such as soft tissue or muscle. R5's (01/07/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating R5's mental status as cognitively intact. The (12/15/2024) First floor daily assignment sheet documented that V7 (Registered Nurse), V8 (Certified Nursing Assistant), V12 (Registered Nurse), and V18 (Certified Nursing Assistant) were working 1st shift. R1 and R2's (12/15/2024) final reportable documented, in part Observed resident (R2) laying (lying) on the ground and he stated (R1) pushed him. R1's (12/15/2024) Witness Statement documented, in part I (R1) pushed him (R2) aside and he fell . He grabbed my leg and I pushed him. R5's (12/15/2024) Witness Statement documented, in part (R2) pushed (R1) and (R1) pushed (R2) and they fell down. V7 (12/15/2024) Witness statement documented, in part I saw (R1) trying to push (R2) to the side. V8 (12/15/2024) witness Statement documented, in part (R2) was talking to (R1). They started to become verbally aggressive. (R1) pushed (R2) to the side. That is when I (V8) jumped in to separate them. V9 (12/15/2024) Witness Statement documented, in part I (V9) saw (R1) and (R2) talking. Then they become verbally aggressive with each other. (R1) pushed (R2). Staff came in and separated them. V12 (12/15/2024) Witness Statement documented, in part the resident pushed co-peer. 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. You must not be abused, physically. Your facility must provide services to keep your physical and mental health at their highest practicable levels. The (10/2022) Abuse Policy and prevention program documented, in part This facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse. This will be done by orienting and training employees on how to deal with stress and difficult situations. This facility is committed to protecting our residents from abuse by anyone including other residents. Abuse means any physical or mental injury inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury with resulting physical harm to a resident.

Based on interview and record review, the facility failed to ensure Abuse final Reportable was sent to the Survey Agency within the mandated time frame. This failure affected 2 (R1 and R2) residents reviewed for timely submission of reportable in the total sample of 6 residents. Findings include. R1 and R2 (12/15/2024) initial reportable documented, in part Date/Time Reported to State: 12/15/2024 at 3:38pm. Time Stamp on the printed Confirmation 12/15/2024 3:38PM. The (printed on: 01/30/2025) Department of Public Health Incident portal documented that abuse report template was uploaded on 12/23/2024. On 01/30/2025 1:16pm, V1 (Administrator) stated the abuse coordinator is myself or the assistant administrator if I am not here. For abuse, the timeframe for reporting the initial reportable is immediately or within 2 hours. Abuse final reportable is expected to be submitted within 5 working days. This surveyor informed V1 there was an uploaded document dated 12/23/2024 and inquired if that was the final reportable for R1 and R2 abuse incident. V1 stated that is correct. This surveyor inquired if the initial reportable was submitted on 12/15/2024 and the final reportable was uploaded on 12/23/2024, did the facility submitted the final reportable within the mandated timeframe. V1 stated I need to check the calendar. V1 then stated the final reportable for (R1) and (R2) was submitted in 6 working days. R1's (Active Order as Of: 12/15/24) Order Summary Report documented, in part Diagnoses: (include but not limited to) bipolar disorder and schizoaffective disorder, bipolar type. R1's (11/18/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 13. Indicating R1's mental status as cognitively intact. R1's (12/15/2024) progress note documented, in part hospital confirmed resident is admitted with DX (diagnosis) aggression. R1's (initiated: 5/14/24) care plan documented, in part presents with aggression towards staff (06/25/24); exhibit verbal aggression (7/13/24); presents with threatening behavior towards staff (7/22/24). R2's (undated) Admission Record documented that R2's diagnoses (include but not limited to) auditory hallucination, suicidal ideations, and schizoaffective disorder. R2's (01/09/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 10. Indicating R2's mental status as moderately impaired. R2's (12/15/2024) progress note documented, in part returned from the hospital. Diagnosis (Contusion of scalp. R2's (12/15/2024) After visit summary documented, in part Diagnosis: contusion of scalp, initial encounter. HPI (history of present illness): brought in after altercation at group home. Says he was pushed over and fell and hit his head. What you need to know: A contusion is a bruise that appears on your skin after an injury. A bruise happens when small blood vessels tear but skin does not. Blood leaks into nearby tissue, such as soft tissue or muscle. The (10/2022) Abuse Policy and prevention program documented, in part This facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse. VIII. External Reporting. 2. Five-day Final Investigation Report. Within five working days, after the report of the occurrence, a complete written report of the conclusion of the investigation will be sent to the Department of Public Health.

Based on observation, interview and record review, the facility failed to ensure the cook has appropriate competencies and skills resulting in recipes during food preparation not being followed. This failure has the potential to affect all 128 residents receiving food prepared in the facility's kitchen. Findings include: On 08/21/24 at 10:30 AM, V21 (Cook) stated V21 is the cook that will be preparing the pureed foods for lunch. V21 stated there are four residents on a pureed diet and V21 follows the recipe for five serving portions. V21 said, I follow that pointing to the recipe binder which was opened to recipe for pureed pork fritter. On 08/21/24 at 10:38 AM, observed V21 review the recipe for pureed pork fritter and then grab a regular soup spoon, not a standard measuring Tablespoon. The recipe for pureed pork fritter on bun listed 1 Tablespoon of chicken base to be added for 5 servings. Observe V21 then opened a large bin container of powdered chicken base and reached in using the regular soup spoon to scoop out two heaping scoops of the chicken base. V21 placed the chicken base in a Styrofoam cup which was approximately 1/3rd full of the chicken base. On 08/21/24 at 10:41 AM, observed V21 add 5 pork breaded fritters and 5 hamburger buns into the blender. Then, observed V21 sprinkle the unmeasured amount of chicken base on top of the hamburger buns and added 1/2 of the water before turning on the blender to pureed the pork fritter. V21 continued to stop and start the blender while added more of the water until 2 1/2 cups were used and the desired pureed consistency was obtained. On 08/21/24 at 10:53 AM, observed V21 add 5-4-ounce portions of tater tots to 2nd blender container with blade. V21 stated the 1st blender lid used to prepare the pureed pork needed to be washed because the kitchen does not have a 2nd blender lid. On 08/21/24 at 10:54 AM, observed V21 take the blender lid to the 3-compartment sink and put the blender lid in the sink containing soap, then rinsed the blender lid in the 2nd sink and then quickly dipped the blender lid into the 3rd sink containing sanitizing liquid while still holding the blender lid the entire time and then placed the blender lid to the side of the 3rd compartment sink to dry. The blender lid was dipped into the sanitizing liquid for 1-2 seconds, not 60 seconds. V19 (Dietary Manager) observed this process and told V22 (Dietary Aide) to clean the blender lid. On 8/21/24 at 10:58 AM, V19 read from the manufacturer's poster on the wall above the 3-compartment sink which stated in part items need to be submerged for a full minute. V19 stated the item needs to be left in the sanitizing solution for a full minute in order to kill bacteria and to disinfect. V19 stated this potential cross contamination could lead to a foodborne illness outbreak. On 08/21/24 at 10:59 AM, observed V21 using a regular soup spoon add 2 large scoops of chicken base into a Styrofoam cup and measure out 1 1/2 cup of water. V21 then sprinkled the unmeasured amount of chicken base on top of the tater tots and add water in 1/2 cup increments until desired consistency was obtained. On 08/21/24 at 11:08 AM, surveyor tasted the pureed tater tots. The taste was so salty it was not edible or palatable. On 08/21/24 at 11:11 AM, V19 tasted the pureed tater tots and V19 stated it tasted too salty. V21 reviewed with V19 how V21 prepared the pureed tater tots including using a soup spoon to scoop out the chicken base. V19 stated that is a soup spoon, not a measured Tablespoon and using the soup spoon would give more product that is needed because it is not a standard measurement. V19 stated the recipe called for 1/2 Tablespoon and V21 should have used standard measuring spoons to measure out the chicken base. V19 stated because V21 did not use the correct measurement of chicken base the product came out too salty. On 08/21/24 at 11:20 AM, V21 stated V21 remade the pureed tater tots to serve to the residents for lunch and asked surveyor to taste them. Surveyor tasted the remade pureed tater tots which was palatable, and not salty. On 08/21/24 at 3:51 PM, V19 stated the cooks should follow the recipe. V19 stated it is important for the cooks to follow the recipes to make sure they are preparing the food in the right way. V19 stated the recipes provide consistency so the food should taste the same no matter who is preparing it. V19 stated V22 did not follow the recipe so the food was too salty, which made the food not good to eat. V19 stated if the food is not good to eat and it is served like that the resident may not want to eat it which could potentially affect their meal intake and nutrition. V19 stated this could also be a problem for any of the residents on a low salt diet which potentially might not be good for their health. Recipe titled, Pureed Pork Fritter on Bun dated 2024 lists ingredients for 5 servings as follows: 5 each pork fritter on bun, 2 1/2 cups water, 1 Tablespoon chicken base and documents in part, combine chicken base and water to make chicken broth. Recipe titled Pureed Tater Tots dated 2024 lists ingredients for 5 servings as follows: 2 1/2 cups tater tots, 1 1/2 cups water, 1/2 Tablespoon chicken base and documents in part, dissolve chicken broth in water to make broth. Facility provided policy titled, Standardization Recipes undated which documents in part, standardized recipes should be followed to produce high quality, flavorful, and consistent products, the Dietary Manager should provide and implement the use of standardized recipes to provide a consistency quality product while maintaining food cost. Facility provide job description for the cook titled Position Description [NAME] undated which documents in part, the cook prepares quality meals for residents in accordance with all laws, regulations, and standards, must have the ability to implement and interpret the programs, goals, objectives, policies and procedures of the dietary department and must be able to read, write, speak and understand the English language. Facility provide policy titled Three and Two Compartment Sinks documents in part, three and two compartment sinks should be maintained, washed, and sanitized properly, purpose to ensure food safety, submerge pots and pans for a minimum of 60 seconds or per the manufacturer's guidelines. Facility provided copy of manufacturer's signage posted above the three compartments sink titled Procedure For 3 Compartment Sinks which documents in part, immerse utensils in SANITIZER SINK for a full minute. On 08/21/24, facility provided list of diet orders for all residents in the facility as of 08/20/24 from the facility electronic health system. The diet order list indicates there are no residents receiving nothing by mouth (NPO).

Based on observation, interview, and record review, the facility failed to ensure food items were labeled and dated with an opened and use by date, failed to discard expired food based on use by guidelines and labeled use by date. The facility also failed to sanitize cooking equipment based on manufacturers' guidelines. These failures have the potential to affect all 128 residents receiving food prepared in the facility's kitchen. Findings include: On [DATE] at 9:22 AM, V19 (Dietary Manager) stated all items in the refrigerators should be labeled with an open and use by date. V19 stated if the item was first delivered as a dry storage item, then there should also be a delivery date on that item in addition to the open and use by date. V19 stated items should be used within six days unless manufacturer label says otherwise. V19 stated it is everyone's responsibility to label and date items. It is important for all items to be labeled and dated to make sure the kitchen does not use expired products because this could potentially lead to food borne illness. On [DATE] at 9:30 AM, observed the following items in the reach in cooler: 1.) Opened 5-pound bag of shredded mozzarella cheese filled 50% labeled with delivery date [DATE]. There was no opened or use by date documented on the opened product. 2.) Opened 46-ounce carton labeled Thickened Honey Orange Juice From Concentrate approximately 60% full labeled with opened date [DATE], and use by date [DATE]. Manufacturer's label printed on container documented in part, After opening may keep up to 7 days under refrigeration. 3.) 2nd Opened 46-ounce carton labeled Thickened Honey Orange Juice From Concentrate approximately 25% labeled with opened date [DATE], and use by date [DATE]. Manufacturer's label printed on container documented in part, After opening may keep up to 7 days under refrigeration. V19 stated the honey thickened juice is used because the facility has two residents requiring honey thickened liquids. V19 stated V19 thought since the use by date printed on the carton was [DATE] that was what the use by date was. V19 stated V19 did not realize that once the product was opened it should be discarded after 7 days and stored in the refrigerator. V19 stated these will be thrown out right away. 4.) Opened one gallon container labeled Red Cooking Wine labeled with opened date [DATE] and use by date [DATE]. Manufacturer's label printed on container documented best if used by [DATE]. On [DATE] at 9:41 AM, observed 16-ounce opened container of cornstarch in the spice storage area with no opened or use by date. V19 stated the cornstarch should be labeled with an open date and use by date. On [DATE] at 9:46 AM, observed in walk-in cooler large plastic bag containing individual slices of garlic bread labeled with preparation date [DATE] and use by [DATE]. V19 stated since the use by date is [DATE] the garlic bread should have been discarded by [DATE]. On [DATE] at 10:54 AM, during pureed food preparation observations observed V21 (Cook) take blender lid to the 3-compartment sink and put the blender lid in the sink containing soap, then rinsed the blender lid in the 2nd sink and then quickly dipped the blender lid into the 3rd sink containing sanitizing liquid and then placed the blender lid to the side of the 3rd compartment sink to dry. V21 did not leave the blender lid in the sanitizing liquid for more than ,d+[DATE] seconds. V19 (Dietary Manager) observed this and told V22 (Dietary Aide) to clean the blender lid. On [DATE] at 10:55 AM, observed (Dietary Aide) take the blender lid and re-dipped it into the 3rd sink containing sanitizing solution and pulled it out of the sanitizing solution after ,d+[DATE] seconds. V19 observed this and told V22 to put it back in the solution. Surveyor asked V22 how long items need to stay in the 3rd sink to sanitize and V22 stated, four seconds. V19 quickly said, no, it needs to be in the solution for 60 seconds. V22 quickly put the blender lid back into the sanitizing solution and V19 told V22 when to remove it after 60 seconds had lapsed. V19 read from the manufacturer's poster on the wall above the 3-compartment sink which stated in part items need to be submerged for a full minute. V19 stated the item needs to be left in the sanitizing solution for a full minute in order to kill bacteria and to disinfect the item. V19 stated if the cooking equipment is not kept in the sanitizing solution for the full minute this could lead to cross contamination and potentially lead to a foodborne illness outbreak. On [DATE], facility provided list of diet orders for all residents in the facility as of [DATE] from the facility electronic health system. The diet order list indicates there are no residents receiving nothing by mouth (NPO). Facility provided policy titled OnTray Dietary Policies and Procedures undated documents in part foods with a use-by guidelines for opened thickened liquids 7 days. Facility provided policy titled Food Safety undated which documents in part, food should be labeled and dated to monitor food safety, food or beverage items that have exceeded the manufacturer's expiration date should be discarded, food items that do not have a manufacturer's expiration date should be labeled with contents and dated with a received and use-by date, and all food items should be consumed or discarded after standard expiration date of food category. Facility provided policy titled, Infection Control undated which documents in part, the Dietary Department should have established effective infection control guidelines in place, purpose to prevent cross-contamination and the spread of infection and open foods are labeled and dated with content, opened on date, and use by date according to guidelines. Facility provide policy titled Three and Two Compartment Sinks documents in part, three and two compartment sinks should be maintained, washed, and sanitized properly, purpose to ensure food safety, submerge pots and pans for a minimum of 60 seconds or per the manufacturer's guidelines. Facility provided copy of manufacturer's signage posted above the three compartment sink titled Procedure For 3 Compartment Sinks which documents in part, immerse utensils in SANITIZER SINK for a full minute.

Based on observation, interview, and record review, the facility failed to ensure that residents who smoke are re-evaluated on a quarterly basis for their ability to smoke safely and smoking care plan was followed. These failures affect 4 (R1, R18, R41, R62) of 7 residents reviewed for smoking in the sample of 26. Findings include: Facility provided policy titled Smoking Policy dated January 2024 which documents in part, to establish guidelines to prohibit smoking by residents and visitors in the building except in designated areas. To establish guidelines for the specific circumstances in which residents may smoke in the designated areas and when increased supervision is required. Facility provided a document titled Smokers undated. R1, R18, R41, R62 are listed on this document. 1. R41's diagnosis included but not limited to Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Personal History Of Nicotine Dependence, Generalized Idiopathic Epilepsy And Epileptic Syndromes, Intractable, With Status Epilepticus, Suicidal Ideations, Schizoaffective Disorder, Bipolar Disorder, Paranoid Schizophrenia, Major Depressive Disorder, Extrapyramidal and Movement Disorder, Trigeminal Neuralgia, Fibromyalgia, Muscle Spasm Of Backpain Disorder Exclusively Related To Psychological Factors, Other Chronic Pain, Restlessness And Agitation, Generalized Anxiety Disorder. R41's MDS (Minimum Data Set) dated 08/01/24 indicates intact cognition with BIMS (Brief Interview for Mental Status) score 15/15 and R41 is a smoker. R41's document titled, Safe Smoking Evaluation last completed 04/16/24 documented in part, smoking determination (0-1) safe smoker: capable and safe, requires no assistance to smoke, develop care plan. R41's smoking care plan documents in part on R41 has a history of violating the facility smoke program, and a room search was conducted on 08/08/24 resident was caught in possession of contraband and was in violation of his smoking contract. R41's interventions in part include the resident requires a smoking apron while smoking and resident will participate in smoking assessments as needed. On 08/21/24 at 1:10 PM, observed V20 (Activity Aide) passing out cigarettes and lighting cigarettes for residents outside on the back patio. On 08/21/24 at 1:24 PM, observed R41 in wheelchair on front patio smoking. R41 was not wearing a smoking apron. On 08/21/24 at 1:28 PM, V16 (Certified Nursing Assistant) stated R41 does not use a smoking apron when smoking. On 08/21/24 at 4:08 PM, observed R41 smoking outside on back patio sitting in wheelchair. R41 was not wearing a smoking apron. R41 said, I used to have a winter coat with a lot of burn marks on it. I don't know how they got there. I don't know where that coat is. R41 stated R41 has never used an apron or covering of any type while smoking since R41 has been at the facility. On 08/21/24 at 9:30 AM, V2 (Social Service Director) stated the social service department is responsible for managing the smoking program which includes assessing the resident for safety, providing education, and smoking contracts signed. V2 stated smoking assessments are completed quarterly by the social service staff. V2 stated the purpose of the smoking assessment is to determine if it is still safe for the resident to smoke. Factors that go in to determining if residents are safe to smoke include if there has been a recent history of non-compliance with smoking in non-authorized areas, the resident's ability to hold their cigarette. V2 stated the other purpose of the smoking assessment is to provide ongoing education to the resident on the smoking rules which are part of the smoking contract. V2 stated any resident who smokes should have a smoking care plan and that the smoking care plan should list appropriate interventions specific to that resident. V2 stated smoking care plans are updated quarterly by the social service department. V2 reviewed R41's electronic health record (EHR) and stated R41's last smoking assessment was completed on 04/16/24 and another one should have been completed toward the end of July because the smoking assessment should be reassessed quarterly. V2 stated R41's Safe Smoking Evaluation form dated 04/16/24 determined R41 is a safe smoker and does not have a history of non-compliance with facility smoking policy or smoking in unauthorized areas. V2 was not aware of R41's recent non-compliance with the smoking contract and stated R41's Safe Smoking Evaluation needs to be reassessed. On 08/21/24 at 4:14 PM, V2 stated V2 has never seen any burn marks on R41's clothing or observed R41 falling asleep when smoking. V2 stated V2 was not aware of the intervention on R41's smoking care plan which says R41 should smoke wearing a smoking apron. V2 stated R41's care plan should reflect R41's current needs. V2 stated, I don't think she needs a smoking apron but based on R41's smoking care plan R41 should be wearing one. V2 stated R41 needs to be re-evaluated by social service using the Safe Smoking Evaluation which will reassess the need for a smoking apron and R41's care plan will need to be revised pending the outcome of the Safe Smoking Evaluation. On 08/21/24 at 2:07 PM, V4 (Regional Director) stated a smoking assessment should be done upon admission, readmission, quarterly and/or with a change in condition. V4 stated the purpose of the smoking assessment is to ensure that the resident can smoke safety. V4 stated if a resident's smoking assessment was completed 04/16/24 then a reassessment of the smoking assessment should have been completed in mid-July 2024. 2. R1's face sheet showed admitted on 4/8/2024 with diagnoses not limited to schizoaffective disorder bipolar type, Other asthma, Restlessness and agitation, Auditory hallucinations, Other schizophrenia, Essential (primary) hypertension, Syndrome of inappropriate secretion of antidiuretic hormone, Other iron deficiency anemias, Benign prostatic hyperplasia, Unspecified convulsions, Insomnia, Hyperlipidemia. MDS (minimum data set) dated 4/15/24 showed R1's cognition was intact and with current tobacco use. R1's care plan dated 8/12/24 documented in part: SMOKING - R1 has a physical and psychological addiction to nicotine and smoking, has poor tolerance to disruptions that may occur to her daily smoking routine, and may act out by displaying physical, psychosocial, and/or behavioral disturbances when unable to smoke. R1's Social Service notes dated 8/18/2024 documented in part: R1 has been restricted from smoking for 7 days for breaking the solicitation contract. Resident was educated by social services on multiple different occasions on selling and buying products from other residents. R1's last smoking assessment was completed on 4/16/24 documented in part: Safe Smoker: Capable and safe, requires no assistance to smoke. On 08/21/24 at 9:30 AM, V2 (Social Service Director) stated the social service department is responsible for managing the smoking program which includes assessing the resident for safety, providing education, and smoking contracts signed. V2 stated smoking assessments are completed quarterly by the social service staff. V2 stated the purpose of the smoking assessment is to determine if it is still safe for the resident to smoke. Factors that go in to determining if residents are safe to smoke include if there has been a recent history of non-compliance with smoking in non-authorized areas, the resident's ability to hold their cigarette. V2 stated the other purpose of the smoking assessment is to provide ongoing education to the resident on the smoking rules which are part of the smoking contract. V2 stated any resident who smokes should have a smoking care plan and that the smoking care plan should list appropriate interventions specific to that resident. V2 stated smoking care plans are updated quarterly by the social service department. At 12:12 PM R1 Observed up and about, ambulatory with steady gait, alert, and oriented x 3, verbally responsive. Stated he is smoking. On 8/21/24 at 1:13 PM, V20 stated R1 is not outside smoking because R1 violated R1's smoking contract. On 08/21/24 at 2:07 PM, V4 (Regional Director) stated a smoking assessment should be done upon admission, readmission, quarterly and/or with a change in condition. V4 stated the purpose of the smoking assessment is to ensure that the resident can smoke safety. V4 stated if a resident's smoking assessment was completed 04/16/24 then a reassessment of the smoking assessment should have been completed in mid-July 2024. 3. R62's face sheet showed admitted on 1/17/2022 with diagnoses not limited to Chronic obstructive pulmonary disease, Ulcerative colitis, Anxiety disorder, Insomnia, Hyperlipidemia, Major depressive disorder, Other obesity due to excess calories, Essential (primary) hypertension, Bipolar disorder. MDS dated [DATE] showed R62's cognition was intact and with current tobacco use. R62's care plan dated 4/8/24 documented in part: SMOKING - has a physical and psychological addiction to nicotine and smoking, has poor tolerance to disruptions that may occur to his daily smoking routine, and may act out by displaying physical, psychosocial, and/or behavioral disturbances when unable to smoke. On 8/20/24 at 11:44 AM R62 observed sitting on the side of the bed, alert, oriented x 3 and verbally responsive. Stated he is smoking. On 08/21/24 at 9:30 AM, V2 (Social Service Director) stated the social service department is responsible for managing the smoking program which includes assessing the resident for safety, providing education, and smoking contracts signed. V2 stated smoking assessments are completed quarterly by the social service staff. V2 stated the purpose of the smoking assessment is to determine if it is still safe for the resident to smoke. Factors that go in to determining if residents are safe to smoke include if there has been a recent history of non-compliance with smoking in non-authorized areas, the resident's ability to hold their cigarette. V2 stated the other purpose of the smoking assessment is to provide ongoing education to the resident on the smoking rules which are part of the smoking contract. V2 stated any resident who smokes should have a smoking care plan and that the smoking care plan should list appropriate interventions specific to that resident. V2 stated smoking care plans are updated quarterly by the social service department. On 08/21/24 at 1:10 PM, observed V20 (Activity Aide) passing out cigarettes and lighting cigarettes for residents outside on the back patio. On 08/21/24 at 1:12 PM, observed R62 smoking outside on back patio. R62's Smoking assessment was last completed on 4/16/2024. On 08/21/24 at 2:07 PM, V4 (Regional Director) stated a smoking assessment should be done upon admission, readmission, quarterly and/or with a change in condition. V4 stated the purpose of the smoking assessment is to ensure that the resident can smoke safety. V4 stated if a resident's smoking assessment was completed 04/16/24 then a reassessment of the smoking assessment should have been completed in mid-July 2024. 4. R18's face sheet showed initial admitted on 9/24/2019 with diagnoses not limited to Chronic obstructive pulmonary disease, Hyperlipidemia, Other asthma, Insomnia, Low back pain, Schizoaffective disorder bipolar type, Major depressive disorder, Restlessness and agitation, Schizophreniform disorder, Other folate deficiency anemias, Bipolar disorder. R18's care plan dated 4/9/2024 documented in part: SMOKING PROGRAM - has a physical and psychological addiction to nicotine/smoking and smoking routine and significant extended disruptions in my smoking routine may result in physical and psychosocial/ behavioral disturbance. I have been provided education on the importance of engaging in safe smoking practices, on smoking cessation, and the negative health consequences of continuing to smoke. R18's Smoking assessment was last completed on 4/16/24. On 08/21/24 at 9:30 AM, V2 (Social Service Director) stated the social service department is responsible for managing the smoking program which includes assessing the resident for safety, providing education, and smoking contracts signed. V2 stated smoking assessments are completed quarterly by the social service staff. V2 stated the purpose of the smoking assessment is to determine if it is still safe for the resident to smoke. Factors that go in to determining if residents are safe to smoke include if there has been a recent history of non-compliance with smoking in non-authorized areas, the resident's ability to hold their cigarette. V2 stated the other purpose of the smoking assessment is to provide ongoing education to the resident on the smoking rules which are part of the smoking contract. V2 stated any resident who smokes should have a smoking care plan and that the smoking care plan should list appropriate interventions specific to that resident. V2 stated smoking care plans are updated quarterly by the social service department. MDS dated [DATE] showed R18's cognition was intact and with current tobacco use. At 3:38 PM Observed R18 alert and verbally responsive, ambulatory with steady gait, stated he is a smoker. On 08/21/24 at 1:10 PM, observed V20 (Activity Aide) passing out cigarettes and lighting cigarettes for residents outside on the back patio. On 08/21/24 at 1:12 PM, observed R18 smoking outside on back patio. On 08/21/24 at 2:07 PM, V4 (Regional Director) stated a smoking assessment should be done upon admission, readmission, quarterly and/or with a change in condition. V4 stated the purpose of the smoking assessment is to ensure that the resident can smoke safety. V4 stated if a resident's smoking assessment was completed 04/16/24 then a reassessment of the smoking assessment should have been completed in mid-July 2024. 47304

Based on observation, interview, and record review, the facility failed to: (a) properly date opened multi-dose medication solution, eye drops and inhalers; (b) properly store unopened multi-dose insulin vial and (c) properly discard expired house stock medication from 3 of 5 medication carts and 2 of 3 medication storage rooms inspected for medication storage and labeling. These failures affect 7 residents (R4, R16, R29, R34, R70, R75, R127) reviewed during medication storage observation. Findings include: On [DATE] at 10:23am Medication cart on 3rd floor inspected with V7 (Licensed Practical Nurse / LPN), stated has been working in the facility for [AGE] years. Observed the following inside the medication cart: 1. R16's Risperidone solution opened with no open date labelled. R16's POS (Physician Order Sheet) with order not limited to: risperidone Oral Solution 1 MG/ML (Risperidone) Give 2 ml by mouth two times a day. 2. R127's multi-dose Brimodine 0.2% solution with no open date. R127's POS showed order not limited to: Brimonidine Tartrate Ophthalmic Solution 0.2% Instill 1 drop in both eyes every 12 hours for Glaucoma. 3. R75's multi-dose Albuterol Sulfate inhaler was open, pharmacy sticker indicated date opened and there was no open date found. R75's POS showed order not limited to: Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT 1 puff inhale orally every 4 hours as needed for sob. 4. R4's multi-dose Albuterol inhaler opened with no open date. R4's POS showed order not limited to: Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT 1 puff inhale orally every 4 hours as needed for sob. At 10:36am 2nd floor medication cart 2 inspected with V8 (Registered Nurse/RN), stated has been working in the facility for 5 years. Observed the following inside the medication cart: 1. R70's multi-dose Trelegy ellipta (Bronchodilator) inhaler opened with no open date. Pharmacy label indicated: Discard 6 weeks after opening. R70's POS showed order not limited to: Trelegy Ellipta Inhalation Aerosol Powder Breath Activated ,d+[DATE]XXX,d+[DATE] MCG/ACT (Fluticasone-Umeclidinium-Vilanterol) 1 puff inhale orally in the morning. 2. R34's multi-dose Albuterol inhaler with no open date. R34's POS showed order not limited to: Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate)2 puff inhale orally every 4 hours as needed for SOB/Wheezing. 3. R29's unopened Insulin Lispro vial was kept inside the medication cart. Pharmacy label: Refrigerate. V8 said insulin is refrigerated if not opened. R29's POS showed order not limited to: Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 61 - 174 = 0 units; 175 - 200 = 1 unit; 201 - 250 = 3 units; 251 - 300 = 5 units; 301 - 350 = 7 units; 351 - 400 = 9 units, subcutaneously two times a day. At 10:56am 2nd floor medication room inspected with V9 (LPN) and found 1 bottle of house stock medication - Vitamin B6 tablets with expiration date ,d+[DATE] was kept inside the medication cabinet in the medication storage room. V9 said expired medication should be disposed or discarded. On [DATE] at 9:24am V3 (Director of Nursing / DON) said nurses need to label the date when the medication was opened to know when to discard the medication. Inhalers need to be discarded in 6 weeks after opening. If there is no open date, we will not know when the next 6 weeks is, not able to know when to discard the medication. She said the medication will not have a full effect if given after the discard date, it's like the resident is not getting medication. Stated eye drops could store at least 30days once opened, then should be discarded. V3 said insulin vial if not open should be refrigerated for temperature control and maintain potency of the medication. V3 said nurses should check expiration date of every medication including house stock and if expired should be discarded right away. If not discarded, could potentially give expired medication to the resident, and potentially cause some reactions to resident. Facility's policy for medication labels dated ,d+[DATE] documented in part: Medications are labeled in accordance with facility requirements and state and federal laws. Each prescription medication label includes: Beyond use or expiration date of medication. Facility's policy for medication storage dated ,d+[DATE] documented in part: Medications requiring refrigeration are kept in the refrigerator. Outdated drugs will be immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures.

Based on interview and record review, the facility failed to assess eligibility and offer pneumococcal vaccinations, and failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations to 4 (R1, R11, R128, R102) out of 6 residents reviewed for pneumococcal vaccinations in the sample of 26. Findings Include: On 8/20/24 at 10:54 AM, interviewed V14 (Infection Control Nurse) and stated that the facility sets up vaccination clinics for residents who need to receive the vaccines. V14 stated that the residents are educated about the vaccines. V14 stated that after the education is provided, consents are obtained from the resident or their representative. V14 stated that consents are uploaded right away in the resident's electronic health records (EHR) under the miscellaneous tab. V14 stated that V14 has no educational material that V14 provides to the residents about the vaccines. V14 stated V14 does it verbally. V14 stated that all education is documented electronically in the residents' chart, and it should show under the immunizations tab. V14 stated that V14 does not keep an immunization tracker because everything should be recorded in the resident's electronic records. V14 stated that the residents' immunization report is pulled from the EHR. On 8/20/24 at 11:37 AM, the following residents' EHR were reviewed for their information regarding pneumococcal vaccinations. R128's EHR shows R128 is [AGE] years of age and was admitted on [DATE] with diagnoses that included, but were not limited to type 2 diabetes mellitus, essential hypertension, alcoholic liver disease, and congestive heart failure. R128's Minimum Data Set (MDS) dated [DATE] shows R128's Brief Interview for Mental Status (BIMS) is 6 which means R128 is cognitively impaired. R128's EHR revealed no information of R128's pneumococcal vaccination status. R128's EHR revealed no documentation indicating the facility assessed R128's eligibility to receive the pneumococcal vaccination and/or that R128 or R128's representative was provided education related to the pneumococcal vaccination. R102's EHR shows R102 is [AGE] years of age and was admitted on [DATE] with diagnoses that included, but were not limited to anemia, essential hypertension, acute kidney failure, and bipolar disorder. R102's MDS dated [DATE] shows R102's BIMS is 14 which means R102 is cognitively intact. R102's EHR revealed no information of R102's pneumococcal vaccination status. R102's EHR revealed no documentation indicating the facility assessed R102's eligibility to receive the pneumococcal vaccination and/or that R102 was provided education related to the pneumococcal vaccination. R11's EHR shows R11 is [AGE] years of age, a smoker, and was admitted on [DATE] with diagnoses that included, but were not limited to alcohol use, essential hypertension, and schizophrenia. R11's Minimum Data Set (MDS) dated [DATE] shows R11's Brief Interview for Mental Status (BIMS) is 15 which means R11 is cognitively intact. R11's EHR revealed no information of R11's pneumococcal vaccination status. R11's EHR revealed no documentation indicating the facility assessed R11's eligibility to receive the pneumococcal vaccination and/or that R11 was provided education related to the pneumococcal vaccination. R1's EHR shows R1 is [AGE] years of age, a smoker, and was admitted on [DATE] with diagnoses that included, but were not limited to asthma, essential hypertension, hyperlipidemia, and convulsions. R1's MDS dated [DATE] shows R1's BIMS is 15 which means R1 is cognitively intact. R1's EHR revealed no information of R1's pneumococcal vaccination status. R1's EHR revealed no documentation indicating the facility assessed R1's eligibility to receive the pneumococcal vaccination and/or that R1 was provided education related to the pneumococcal vaccination. R1, R11, R128, and R102 are not listed in the facility's pneumococcal immunization report provided on 8/20/24 at approximately 2:00 PM. On 8/20/24 at 12:14 PM, interviewed R128 and was unable to recall if R128 received the pneumococcal vaccine. R128 stated that R128 has not received any education about the pneumococcal vaccination. On 8/21/24 at 10:43 AM, interviewed R11 and stated that R11 has been in the facility for four months. R11 stated that R11 did not receive the pneumococcal vaccine. R11 stated that R11 does not think the facility provided education on any immunizations. On 8/21/24 at 10:46 AM, interviewed R102 and stated that R102 does not need to receive any vaccines. R102 stated that R102 was vaccinated years ago but was unable to recall which type of vaccines. R102 stated that the facility did not provide education on the immunizations. R102 stated, That would be good to get some education on those vaccines. They have not done it yet. I would like to know about those unnecessary vaccines. On 8/21/24 at 9:20 AM, interviewed V3 (Director of Nursing) and stated that documentation should be completed after an education to the resident is provided. V3 stated, They have to document under the resident's chart. Everything is electronic. They have to document to show that the resident is educated. If it's not documented that means, it's not done. The facility's policy titled; Pneumococcal Vaccinations reads 1/24 reads in part: All current residents or the resident's responsible party will be screened and offered the pneumonia vaccine within the 1st week of admission and annually if eligible per Centers for Disease Control (CDC) guidelines. A consent will be obtained and serves as the education tool for the vaccine. If the Resident has previously received any of the pneumonia vaccines, the date and location will be entered into the Immunization Tab of EHR.

Based on interview and record review, the facility failed to assess eligibility and offer COVID-19 vaccination for 4 residents (R11, R110, R231, R128), failed to ensure the residents medical records includes documentation if COVID-19 vaccinations were received or did not receive for 5 residents (R1, R11, R110, R231, R128), and failed to ensure the residents medical records includes documentation that education was provided to residents and/or resident representatives regarding the benefits and potential side effects of COVID-19 vaccination for 6 residents (R1, R11, R110, R231, R128, R102) out of 6 residents reviewed for COVID-19 vaccination in the sample of 26. Findings Include: On 8/20/24 at 10:54 AM, interviewed V14 (Infection Control Nurse) and stated that the facility sets up vaccination clinics for residents who need to receive the vaccines. V14 stated that the residents are educated about the vaccines. V14 stated that after the education is provided, consents are obtained from the resident or their representative. V14 stated that consents are uploaded right away in the resident's electronic health records (EHR) under the miscellaneous tab. V14 stated that V14 has no educational material that V14 provides to the residents about the vaccines. V14 stated V14 does it verbally. V14 stated that all education is documented electronically in the residents' chart, and it should show under the immunizations tab. V14 stated that V14 does not keep an immunization tracker because everything should be recorded in the resident's electronic records. V14 stated that the residents' immunization report is pulled from the EHR. On 8/20/24 at 11:37 AM, the following residents' EHR were reviewed for their information regarding COVID-19 vaccinations. R11's EHR shows R11 was admitted on [DATE] with diagnoses that included, but were not limited to essential hypertension and schizophrenia. R11's Minimum Data Set (MDS) dated [DATE] shows R11's Brief Interview for Mental Status (BIMS) is 15 which means R11 is cognitively intact. R11's EHR revealed no information of R11's COVID-19 vaccination status. R11's EHR revealed no documentation indicating the facility assessed R11's eligibility to receive the COVID-19 vaccination and/or that R11 was provided education related to the COVID-19 vaccination. R110's EHR shows R110 was admitted on [DATE] with diagnoses that included, but were not limited to type 2 diabetes mellitus, essential hypertension, and schizophrenia. R110's MDS dated [DATE] shows R110's BIMS is 15 which means R110 is cognitively intact. R110's EHR revealed no information of R110's COVID-19 vaccination status. R110's EHR revealed no documentation indicating the facility assessed R110's eligibility to receive the COVID-19 vaccination and/or that R110 was provided education related to the COVID-19 vaccination. R231's EHR shows R231 was admitted on [DATE] with diagnoses that included, but were not limited to schizoaffective disorder and bipolar disorder. R231's MDS dated [DATE] shows R231's BIMS is 15 which means R231 is cognitively intact. R231's EHR revealed no information of R231's COVID-19 vaccination status. R231's EHR revealed no documentation indicating the facility assessed R231's eligibility to receive the COVID-19 vaccination and/or that R231 was provided education related to the COVID-19 vaccination. R128's EHR shows R128 was admitted on [DATE] with diagnoses that included, but were not limited to type 2 diabetes mellitus, essential hypertension, alcoholic liver disease, and congestive heart failure. R128's MDS dated [DATE] shows R128's BIMS is 6 which means R128 is cognitively impaired. R128's EHR revealed no information of R128's COVID-19 vaccination status. R128's EHR revealed no documentation indicating the facility assessed R128's eligibility to receive the COVID-19 vaccination and/or that R128 or R128's representative was provided education related to the COVID-19 vaccination. R102's EHR shows R102 was admitted on [DATE] with diagnoses that included, but were not limited to anemia, essential hypertension, acute kidney failure, and bipolar disorder. R102's MDS dated [DATE] shows R102's BIMS is 14 which means R102 is cognitively intact. R102's EHR revealed R102 refused the COVID-19 vaccination. R102's EHR revealed no documentation indicating that R102 was provided education related to the COVID-19 vaccination. R1's EHR shows R1 was admitted on [DATE] with diagnoses that included, but were not limited to asthma, essential hypertension, hyperlipidemia, and convulsions. R1's MDS dated [DATE] shows R1's BIMS is 15 which means R1 is cognitively intact. R1's care plan shows R1 is a smoker. R1's EHR revealed no information of R1's COVID-19 vaccination status. R1's EHR revealed no documentation indicating the facility assessed R1's eligibility to receive the COVID-19 vaccination and/or that R1 was provided education related to the COVID-19 vaccination. R1, R11, R128, R231, R110, and R102 are not listed in the facility's COVID-19 immunization report provided on 8/20/24 at approximately 2:00 PM. On 8/20/24 at 12:11 PM, interviewed R231 and stated that R231 did not receive the COVID-19 vaccine. R231 stated R231 has been in the facility for a month and has not received any education about the COVID-19 vaccination. On 8/20/24 at 12:14 PM, interviewed R128 and was unable to recall if R128 received the COVID-19 vaccine. R128 stated that R128 has not received any education about the COVID-19 vaccination. On 8/21/24 at 10:41 AM, interviewed R110 and stated that R110 has been in the facility for a year. R110 stated that R110 is vaccinated with COVID-19. R110 does not remember if facility provided education on COVID-19 vaccination. On 8/21/24 at 10:43 AM, interviewed R11 and stated that R11 has been in the facility for four months. R11 stated that R11 did not receive the COVID-19 vaccine. R11 stated that R11 does not think the facility provided education on any immunizations. On 8/21/24 at 10:46 AM, interviewed R102 and stated that R102 does not need to receive any vaccines. R102 stated that R102 was vaccinated years ago but was unable to recall which type of vaccines. R102 stated that the facility did not provide education on any vaccinations. R102 stated, That would be good to get some education on those vaccines. They have not done it yet. I would like to know about those unnecessary vaccines. On 8/21/24 at 9:20 AM, interviewed V3 (Director of Nursing) and stated that documentation should be completed after an education to the resident is provided. V3 stated, They have to document under the resident's chart. Everything is electronic. They have to document to show that the resident is educated. If it's not documented that means, it's not done. The facility's policy titled; COVID-19 VACCINATION - Resident dated 5/31/23 reads in part: All residents will be offered the COVID-19 vaccine. Vaccine clinics will be held within the facility on a regular basis. Unvaccinated residents will be offered the COVID-19 vaccine prior to each clinic date. Facilities will report vaccination data as required into the NHSN database weekly.

Based on interview and record reviews, the facility failed to complete a significant change in status Minimum Data Set (MDS) assessments using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for one (R30) of seven residents reviewed for resident assessment in a sample of 26. Findings include: On 8/20/24, per review of R30's electronic health record (EHR) R30 was admitted to hospice on 06/26/24. Review of R30's Minimum Data Set (MDS) schedule indicates R30's last MDS assessment was completed 06/14/24 as a quarterly assessment and R30's next quarterly assessment is scheduled for 09/16/24. On 08/21/24 at 1:44 PM, V23 (MDS Coordinator) stated residents are reassessed every 90 days and/or if there is a significant change. V23 stated significant change assessments must be done if there is a change in one or two areas relate to functional ability or Activities of Daily Living, if the resident is admitted to hospice, and/or if the resident has had a fall with injuries, and/or readmitted from the hospital with a new diagnosis. V23 stated a significant change assessment should be started within 14 days and completed by day 21. V23 stated V23 follows the Resident Assessment Instrument (RAI) Manual for MDS guidelines on completion and time frames. V23 stated R30 is on hospice. Looking at R30's electronic health record (EHR) V23 stated R30 was admitted to hospice 06/26/24 and R30's last MDS was completed on 06/14/24. V23 stated a significant change in status MDS should have been done according to the RAI Manual once R30 was admitted to hospice. V23 stated a significant change MDS should have been started no later than the 14th day which was 07/09/24 and completed by day 21. On 08/21/24 at 2:11 PM, V4 (Regional Director) stated when a resident gets put on hospice that is a significant change no matter what the reason they are put on hospice for. V4 stated this would mean a new MDS assessment should be completed. V4 stated R30 should have had a significant change in status MDS completed when R30 was admitted to hospice. Chapter 2 of the RAI manual pages 22-23 titled RAI OBRA-required Assessment Summary documents in part, that a Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program, the ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than), a SCSA must be performed regardless of whether an assessment was recently conducted on the resident to ensure a coordinated plan of care between the hospice and nursing home is in place and for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and service to assist the resident in achieving hi/her highest practicable well-being at whatever stage of the disease process the resident is experiencing.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for a resident receiving hospice services for end-of-life support. This failure affects one resident (R30) out of one reviewed for hospice and comprehensive care plan in a sample of 26. Findings include: R30 has a diagnosis including but not limited to Chronic Respiratory Failure, Weakness, Unsteadiness On Feet, Dysphagia Following Cerebral Infarction, Lack of Coordination, Abnormal Posture, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Type 2 Diabetes Mellitus without Complications, Sequelae of Cerebral Infarction, Hydronephrosis, Shortness Of Breath, Long Term (Current) Use of Insulin, Cognitive Communication Deficit, Personal History of Traumatic Brain Injury, Hypertension, Personal History of Suicidal Behavior, Anemia, Gastro-Esophageal Reflux Disease without Esophagitis, Major Depressive Disorder, Schizophrenia, Hyperlipidemia, Bipolar Disorder, Current Episode Mixed, Severe, with Psychotic Features, Unspecified Dementia, Unspecified Severity, With Other Behavioral Disturbance, Hypothyroidism. On 08/20/24, per review of R30's electronic health record (EHR) R30 was admitted to hospice on 06/26/24 and does not have a care plan for hospice. On 08/21/24 at 1:40 PM, V23 (MDS Coordinator) stated a care plan should be generated if a resident is on hospice care. V23 stated the purpose of the hospice care plan is let everyone know that person is on hospice and receiving specialized care. V23 reviewed R30's EHR and stated R30 is on hospice. V23 stated R30 was admitted to hospice on 06/26/24. V23 stated a hospice care plan was added just today, 08/21/24 by V4 (Regional Director) for R30 being on hospice due to having a terminal condition. On 08/21/24 at 2:07 PM, V4 stated if a resident is on hospice this should also be care planned. V4 said, (R30) did not have a hospice care plan so I added one today. V2 stated it is important for a resident on hospice to have a hospice care plan to ensure the facility is meeting all of the resident's psychosocial needs. Facility policy titled; Comprehensive Care Plan dated 01/2023 documents in part: 1.) The facility must develop a comprehensive person-centered care plan for each resident. 2.) The care plan will include a focus, measurable goal, and interventions specific to the resident's medical, nursing, mental and psychosocial needs. 3.) The comprehensive care plan should drive the care and services provided for the resident and allow for the highest level of physical, mental, and psychosocial function based on the comprehensive MDS assessment. 4.) The comprehensive care plan is reviewed quarterly, annually and with any significant change.

Based on observation, interview, and record review, the facility failed to follow their policies and procedures to appropriately store oxygen tubing when not in use for 1 (R70) resident in a sample of 26. Findings Include: R70's Minimum Data Set (MDS) dated [DATE] shows R70 is cognitively intact. R70's Physician Order Sheet (POS) shows active order as of 8/20/24, Oxygen at 2Liters per nasal cannula continuous every shift related to acute and chronic respiratory failure with hypoxia. On 08/20/24 at 11:14 AM, surveyor with V10 (Certified Nursing Assistant/CNA) observed R70's oxygen nasal cannula tubing on the floor when not in use. V10 picked R70's oxygen nasal cannula tubing from the floor and placed the nasal cannula tubing on the oxygen tank. On 08/20/24 at 11:20 AM, surveyor and V8 (Registered Nurse/RN)) both entered R70's room. Surveyor asked V8 where should R70's oxygen nasal cannula tubing be stored when not in use? V8 stated R70's oxygen tubing should have been stored inside a plastic bag when not in use to prevent infection. On 8/21/24 at 9:40 AM, V5 (Regional Nurse Consultant) stated, according to the policy of the facility, the oxygen tubing should be stored appropriately when not in use. V5 stated appropriately means, inside a plastic zip bag when not in use to prevent contamination. On 8/21/24 at 9:58 AM, V3 (Director of Nursing/DON) stated it is V3's expectation that nurses would keep oxygen nasal cannula tubing inside a plastic zip bag when not in use to prevent infection. V3 stated R70's oxygen nasal cannula tubing should not be on the floor. V3 stated R70's oxygen tubing should be replaced. On 08/21/24 at 12:55 PM, surveyor observed R70 with the same oxygen tubing. Surveyor asked V8 (RN) if R70 has the same oxygen tubing from 8/20/24? V8 stated yes, V8 did not change R70's oxygen nasal cannula tubing, because the tubing will be changed on Thursday (8/22/24). Facility Policy titled, Oxygen Safety/Use dated 01/2024 documents in part: Oxygen tubing will be changed weekly and appropriately stored to prevent contamination when not in use.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% for 2 (R27, R103) of 11 residents in the sample reviewed for medication administration. There were 31 opportunities and 4 errors resulting to 12.9% medication error rate. Findings include: R27's face sheet documented admitted on 8/25/2021 with diagnoses not limited to Type 2 diabetes mellitus, Chronic obstructive pulmonary disease, Personal history of covid-19, Schizoaffective disorder, Bipolar disorder, Major depressive disorder, Anxiety disorder, Gastro-esophageal reflux disease without esophagitis, Fibromyalgia. R103's face sheet documented admitted on 4/12/2023 with diagnoses not limited to Schizophrenia, Major depressive disorder. On 8/20/24 at 9:33AM Medication administration observation conducted with V6 (Registered Nurse / RN), checked R27's BP (blood pressure) =125/78 and PR (Pulse Rate) =101/min. V6 prepared and administered the following medications to R27: Saccharomyces Boulardi Probiotic 1 capsule, Omeprazole (Anti-reflux) 20mg (milligrams) 1 capsule, Aspirin (non-steroidal antiinflammatory) 81mg 1 tablet, Lisinopril (Antihypertensive) 2.5mg 1 tablet, Divalproex (Anit-seizure) 500mg 1 tablet, Metformin (antidiabetic) 1000mg 1 tablet. R27 took medications by mouth. V6 instilled 1 drop Cromolyn sodium 4% ophthalmic solution to each eye. V6 administered 2 sprays of Fluticasone (steroid) nasal spray to each nostril for about 3-5 seconds between sprays. She administered 2 puffs Albuterol (corticosteroid) inhaler for about 3-5 seconds between puffs. V6 said saline nasal spray was not available. R27 stated has only been getting 1 kind of nasal spray, did not receive saline nasal spray for a long time. R27's POS (Physician Order Sheet) and MAR (Medication Administration Record) reviewed with orders not limited to: Aspirin EC Tablet Delayed Release 81 MG, Lisinopril Tablet 2.5 MG, Probiotic Oral Capsule 250 MG (Saccharomyces boulardii) Give 1 capsule, Cromolyn Sodium Ophthalmic Solution 4 % Instill 1 drop in both eyes, Divalproex Sodium Tablet Delayed Release 500 MG, metformin HCl Tablet 1000 MG, Fluticasone Furoate Nasal Suspension 2 puff in each nostril, Omeprazole Capsule Delayed Release 20 MG Give 1 capsule, Ventolin HFA Aerosol Solution 2 inhalation inhale orally every 6 hours as needed, Saline Nasal Spray Solution 1 spray in each nostril four times a day (ordered time at 8am, 12noon, 4pm and 8pm). R27's MAR showed saline nasal spray was not given at 8am and 12noon dose on 8/20/24. R27's record did not show that V6 informed the doctor that Saline nasal spray was not available and R27 missed doses of medication. At 9:47 AM V6 prepared and administered Sertraline 100mg 1 tablet to R103 and taken by mouth. V6 administered earwax softener drops to R103's left ear, she instilled 4 drops for about 1-2 seconds between drops. V6 was not observed cleansing the external auditory canal with a cotton applicator and did not straighten auditory canal by pulling up and back. V6 did not insert a small cotton ball in external auditory canal. R103's POS AND MAR reviewed with order not limited to: Sertraline HCl Tablet 100 MG Give 1 tablet by mouth one time a day, Debrox Otic Solution (Carbamide Peroxide (Otic)) Instill 4 drop in left ear two times a day. On 8/21/24 at 9:24am V3 (Director of Nursing / DON) stated nurses are expected to follow the 5R's (right resident, right medication, right route, right time, right dose) in giving medications. She said if medication is not available, nurses are expected to call the doctor or follow up with pharmacy. If resident missed nasal spray as scheduled could possibly cause respiratory issues. V3 said nurses are expected to wait at least 2 minutes between puffs of nasal spray, so it doesn't force medication to go down, don't want to rush to administer another puff. She said same thing with Inhaler, wait for at least 1-2 minutes between puff to give the lungs time to expand and absorb the puff and have full effect of the medication. She said for ear drop administration, nurse is expected pull up the earlobe and wait for at least 1-2 minutes in between drops for full medication absorption. Facility's policy for medication administration dated 1/2024 documented in part: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Check medication administration record prior to administering medication for the right medication, dose, route, patient / resident and time. If medication is not given as ordered, document the reason on the MAR and notify the health care provider if required. If the physician's order cannot be followed for any reason, the physician should be notified in a timely manner. Facility's oral inhalation administration policy dated 8/2020 documented in part: If another puff of the same or different medication is required, wait at least 1-2 minutes between. Facility's ear drops policy dated 1/2024 documented in part: Ear drops are placed in the auditory canal for purposes of softening cerumen, removing debris and reducing inflammation. Cleanse the external auditory canal with a cotton applicator and wipe away discharge. Straighten auditory canal by pulling up and back. Insert a small cotton ball in external auditory canal.

Based on interviews and record reviews, the facility failed to protect a resident's (R1) right to manage their financial affair and inform R1 of the charges the facility imposed against R1's personal funds. This affected one out of four residents reviewed for personal funds. This failure resulted in the facility, misusing R1's $10,000 check R1 received from family member without R1's consent. Findings include: R1 oriented to person, place, time, and situation. R1 answered questions appropriately. R1's 4/16/2024 Quarterly Minimum Data Set assessment documents in part that R1 is cognitively intact with no signs and symptoms of delirium. R1's 6/20/2024 Behavioral Health Progress Note documents in part that R1 is alert and oriented to person, place, time, and situation. During multiple interviews with R1 on 7/09/2024 at 11:53 AM and 1:51 PM and again on 7/10/2024 10:50 AM, R1 was alert stated receiving a $10,000 check from V33's (R1's family member) estate at the beginning of the year. R1 did not know what to do with the money and approached V4 (Psychiatric Rehabilitation Services Director). V4 suggested to get a lawyer. The next day, V34 (former Business Office Manager) 'sternly' instructed R1 to sign the back of the check and hand it over to the facility. Facility told R1 that R1 could not keep the money and Medicaid will refuse to pay for care. R1 felt uneasy because facility did not provide any other option besides handing the check over to V34. R1 stated she (R1) did not sign a written authorization to deposit the check into the Resident Fund Management Service (RFMS) account. R1 stated facility did not inform [R1] of the billing process that occurred afterward. R1 did not agree to switch to private pay in February and never signed paperwork to decline Medicaid assistance. Facility did not inform R1 about the charges that ensued for room, board, and care costs. R1 stated repeatedly asking the facility for an itemized bill of all the charges but facility did not provide it until July. On 7/09/2024 at 1:21 PM, V4 stated filling out R1's Concern/Compliment Form dated 5/9/2024. V4 stated another company owned the facility in February. When R1 asked about the money, V4 contacted the pervious company's corporate office. Corporate office informed V4 of what's written under 'Resolution of Concern' on the form. It documents in part: Medicaid will not pay with that amount of money in [R1's] account. $6960 paid for room and board. $3040 was put into [R1's] account. $2980.19 was paid for [R1's] care. [R1] has $160 left from $10,000. Facility attached R1's Resident Statement Landscape from R1's RFMS account (printed 5/29/2024) to the concern form. V4 did not know what the credits and debits meant. V4 did not know what the $2980.19 paid for or if the facility provided an itemized bill explaining it to R1. During a telephone interview with V17 (R1's Family Member/Power of Attorney) on 7/09/2024 at 3:35 PM, V17 stated at one point earlier in the year when R1 requested funds, facility informed R1 that R1 didn't have any more money. When R1 inquired about where the money went, facility provided different answers. V17 came to facility around 5/9/2024 and asked V4 where R1's money went. V17 stated facility provided different answers from the money going towards private care, to social security taking it, and Medicaid taking it. V17 stated facility did not explain the charges or how much was taken. On 7/10/2024 at 9:36 AM, V1 (Administrator) stated another company owned the facility in February. V1 was Administrator at the time of the incident. V1 knew R1 received the check. R1 asked V1 what to do with the check for tax purposes. V1 told R1 that [V1] could not provide legal tax advice. V1 let V34 handle R1's funds from then on. V1 does not know whether facility obtained written authorization for R1 to deposit the check into the RFMS account. V1 doesn't know if facility explained R1's rights with personal funds when R1 received the check. V1 stated there had to be some paperwork. Facility provided survey team a copy of R1's Resident Trust Fund Policy Notification and Authorization form. There is no date on the form. V2 (Director of Nursing) stated R1 signed it on admission giving facility authorization to hold personal funds. However, the form contains Medicaid's previous asset limit of $2000. Provider Notice issued 5/19/2023 to All Medical Assistance Program Providers documents in part: The new resource limit amount is changing from $2000 for an individual and $3000 for a couple to $17,500 for both individuals and couples for medical cases eligible under the Aid to the Aged, Blind, and Disabled (AABD) medical program. (Notice taken from the Illinois Department of Healthcare and Family Services website). Facility failed to have R1 sign an updated form for personal funds. Reviewed R1' progress notes. None pertaining to R1's check, billing status, or personal fund concerns. Survey team requested to see any documentation that R1 declined Medicaid benefits in February or agreed to be a Private Pay Resident at that time and agreed to the charges against R1's personal funds. Facility did not provide any such documentation at the conclusion of the survey. Attempted telephone interview with V34 on 7/10/2024 at 10:43 AM. No answer and no return call. Facility's Resident Personal Trust Funds Policy and Procedure dated 5/2023 documents in part: Residents will be provided with receipts of any deposits to their trust accounts and will sign the facility's copy of the receipt indicating their authorization for the any withdrawals. No charges will be imposed against the personal funds account for any item or service for which payment is made under Medicaid or Medicare. Facility provided surveyor a copy of Illinois Long-Term Care Ombudsman Program's Residents' Rights for People in Long-Term Care Facilities booklet (Rev. 11/18). It documents it part: You have the right to manage your own money. The facility must not require you to let them manage your money or be your Social Security representative payee. If you ask the facility to manage your money it may only spend your money with your permission.

Based on interviews and record reviews, the facility failed to keep R4 free from abuse for one out of five residents reviewed for abuse. This failure resulted in R4 sustaining abrasions to the face and right wrist. A reasonable person would feel terrified and scared to be attacked by being punched and kicked while on the floor. Findings include: On 04/03/2024 at 12:06 PM, R4 was alert and oriented to person, place, and date. R4 had a red mark near the right eye, abrasions underneath the left eye, and a red mark to right wrist. R4 stated getting into an altercation on Monday with another resident (R5). R4 was scared because the other resident was slamming bedroom door loudly. The resident was running and cursing in the hall. R4 went to the nurses' station to ask what was going on. R4 headed back towards the bedroom. R4 stated [resident] was using [resident's] freedom of speech. I was scared with what was going on. So, I started using my freedom of speech. R4 stated the resident went into the bedroom and then all of a sudden came back out and started attacking R4 with punches. [Resident] just came out and started hitting me. I got a few scratches on my head and face. R4 stated It was a vicious attack. On 04/04/2024 at 10:58 AM, R10 stated The [resident] from across the hall was slamming the door real hard and annoying people. That [R5] was on something. [R5] was mad at everybody. R10 stated R4 asked R5 what was wrong and R5 got mad. R10 was waiting for the elevator to go downstairs when [R10] overheard R4 and R5 arguing. On 04/03/2024 at 12:22 PM, V8 (Activity Aide) stated the other resident involved in the altercation was R5. V8 stated [R5] was already agitated and running around here. V8 stated [R4] came up here near the nurses' station asking what's going on and why was [R5] agitated. I think [R4] got involved and started saying stuff like 'I'm not scare of you.' V8 stated R5 went back to bedroom while R4 stayed standing in the hallway. V8 stated Then [R5] came running out [R5's] room. I saw [R5] punching and kicking [R4]. [R5] had history of aggressive behaviors and when [R5] gets worked up [R5] gets ready to fight. You got to put [R5] on one-to-one when [R5's] agitated. On 04/03/2024 at 2:52 PM, V12 (Housekeeping Director) stated R4 was standing by the elevators near [R4's] room with arms crossed. R5 was standing close to R4. As V12 headed to the main entrance of the building, V12 head screaming. I turned around and [R5] was attacking [R4]. [R4] was lying down on the floor on [R4's] back. [R5] was standing over [R4] and punching. [R5] was also kicking [R4]. On 04/04/2024 at 10:11 AM, V15 (Certified Nurse Aide) stated R4 was on the floor and R5 was hitting and punching R4. V15 stated [R5] was agitated. One thing about [R5] is if [R5] get angry, [R5] will keep going back and forth. V15 stated R5 started getting agitated around 10:00 AM. R5 went to bedroom and slammed the door. V15 stated I think it was like 30 minutes of [R5] going back and forth. R5 came to the nurses' station and then a few minutes later, staff heard screaming. V15 stated when R5 gets agitated, they involve social service and behavioral aides. They'll try to calm R5 down. V15 stated Monday that didn't happen. On 04/04/2024 at around 11:15 AM, V16 (Psychiatric Rehabilitation Services Director stated) stated when residents are experiencing behaviors, staff usually call social services to talk to the residents. During the morning of the altercation, V16 stated there were no social workers in the building. V16 did not arrive until after the altercation between R4 and R5. V16 stated since there was no social worker in the building, the staff should have attempted to talk and redirect R5. The staff should have had R5 on one-to-one monitoring. On 04/03/2024 at 12:39 PM, V10 (Restorative Aide) stated R5 has history of verbal aggression. When [R5's] like that, we have to tell the nurse and have the male CNAs (Certified Nurse Aides) watch [R5]. Get social service to deal with it and calm [R5] down. Sometimes might need one-to-one. On 04/03/2024 at 12:18 PM, V7 (R5's assigned Nurse time of altercation) stated was not aware of R5's behaviors until after the altercation. On 04/04/2024 at 12:58 PM, V20 (Assistant Director of Nursing) stated if R5 is agitated, R5 needs one-to-one monitoring. V20 stated if R5 was pacing or running down the hall, that was abnormal behavior for [R5]. V20 stated staff should have intervened and assessed the situation to see why [R5] was pacing and running down the hall. R5's comprehensive care plan contains a focus that documents in part that R5 has the potential to be physically and verbally aggressive (initiated 02/28/2024). One intervention documents in part: Monitor/document/report [as needed] any [sign and symptoms] of resident posing danger to self and others (initiated 02/28/2024). V7's progress note about R4, dated 04/01/2024 10:00 AM, documents in part: Resident was in an alleged physical altercation by co-peer without provocation in the hallway. Noted with some abrasions to the facial area. V7's progress note about R5, dated 04/01/2024 10:00 AM, documents in part: Resident physically attacked co-resident without provocation in the hallway. Staff intervened immediately and separated residents. Resident shouted that is what you get for talking. R4's After Visit Summary papers from the hospital, dated 04/01/2024 1:23 PM, documents in part diagnosis of Abrasion. Facility presented a plan of correction education titled Behavioral Health: Behavioral Assessment, Management, Documentation & Interventions at the end of January to the nurses, CNAs, activity staff, and social service staff. Training went over early signs of agitation which included fidgeting, restlessness, and pacing. Proactive approach included immediate interventions such as removing the resident from the situation to a quiet location; providing one-to-one calming, reassurance, and allowance to vent frustration; and increasing monitoring such as one-to-one or 15-minute safety checks. Slide six of the presentation documents in part: However, based on the presence of resident-to-resident altercations, if the facility did not evaluate the effectiveness of the interventions and staff did not provide immediate interventions to assure the safety of residents, then the facility did not provide sufficient protection to prevent resident-to-resident abuse. Redirection alone is not a sufficiently protective response to a resident who will not be deterred from targeting other residents for abuse once he/she has been redirected. Facility's Abuse Policy and Prevention Program, dated 10/2022, documents in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.

Based on interviews and record review the facility failed to supervise (R3). A resident with criminal background history, with aggressive behaviors and non-compliant with smoking, from intentionally starting a fire to R3's roommate's bed (R4). This failure has the potential to cause serious harm or death to all 123 residents in the facility at the time of incident. The facility failed to have a system to ensure that contraband and/or hazardous devices are secured and not brought into the facility. The facility lacks a system to ensure that all residents are closely monitored. The facility lacks a system to ensure that the residents' environment is free of hazards. The facility failed to report incident to IDPH. The immediate Jeopardy began on 1/21/24 at 11:30PM when R3 set R4's bed on fire. V1 (Administrator), V2 (Director of Nursing) and V11 (Corporate Nurse Consultant) were notified of the Immediate Jeopardy on 2/27/24 at 3:29PM. On 2/28/24 at 11:09AM abatement plan submitted and not approved. On 2/28/24 at 12:38PM revised abatement plan submitted and not approved. On 2/28/24 at 2:35PM revised abatement plan submitted. On 2/28/24 at 2:50PM revised abatement plan was approved. The non-compliance remains at a level two until the facility evaluates the effectiveness of the removal plan. Findings include: R3 is a [AGE] year-old male resident with a diagnosis including COPD, Bipolar Disorder, Epileptic Seizures and Schizoaffective Disorder. R3 was first admitted to the facility on [DATE]. R3 has a BIMS (Brief Interview for Mental Status) score of 15/15, cognitively intact. R3 is fully ambulatory and goes into the community unsupervised. R3 has a criminal background and has served time in Department of Corrections Correctional Center. R4 is a [AGE] year-old male with a diagnosis including Major Depressive Disorder, Bipolar Disorder and Schizophrenia. R4 has a BIMS (Brief Interview for Mental Status) score of 15/15. R4's 1/15/24 Minimum Data Set (MDS) section GG (functional abilities) shows total dependence, helper does all the effort. This resident is bed bound. R4 uses a wheelchair for mobility. Review of R3's progress behavior note dated 1/22/24 states resident (R3) came out of his room yelling that his roommate was talking, and he wanted him to be quiet and to move him out of the room. Certified Nursing Assistant (CNA) redirected resident and advised him to talk to social services in the morning for a room change. At approximately 11:30 pm the smoke detector in the room went off and the aide went to check, and the bed of his roommate (R4) was on fire. All staff responded to the fire and this writer (V20) grabbed the fire extinguisher to put out the fire. All residents were moved out of the room. 911 was contacted and responded. PPHP (Provider Partners Health Plan) was notified and order given to send this resident out to the emergency room (ER) for evaluation. Police transported resident to hospital with petition. Administrator notified of incident. On 2/20/24 at 10:39 AM V1 (Administrator) stated we were considering discharge of R3 after the fire but after speaking with the Guardian we did not. I did not file an incident with the mattress fire because nobody was hurt, and no one was touched. R3 started the fire with a lighter. R3 stated he brought the lighter in from the community. He has behaviors when we restrict him from going into the community. We let him go into the community by himself, so he does not have aggressive behaviors. Initially we wanted to involuntarily discharge him. We informed the guardian. I spoke with guardian, and we accepted R3 back. Since R3 came back social service does more frequent room checks. The social service room checks are not documented that I know of. We did a medication review. The doctor was involved in the medication review. I am not sure what doctor. We have a new Director of Nursing (DON) that just started yesterday so she will not have anything to do with this incident. On 2/20/24 at 11:17AM V5 (Social Service Director) stated I am responsible for R3. I was not here during the incident with the fire, it was about 11PM. From what was told to me R3 was in room with roommate (R4). R3 walked over and lit R4s mattress on fire. R3 ran out of the room and staff came to room. Staff put out fire and called 911. R4 was evaluated by paramedics with no injury. R4 refused to go to hospital. R3 was sent to hospital. R3 came back to facility. We had R3 restricted from going to community. We searched all belongings when R3 was in hospital. We have behavior aides on the floor doing behavior checks. There was a behavior aide on the floor during the fire incident. I am not aware of R3's non-compliant smoking incidents during his stay. I am unsure on how R3 started the fire. At the time of incident R3 was not on smoking restriction. To my knowledge R3 never threatened anyone before. R3 had verbal altercations with staff because he was restricted from community pass. The 72-hour pass restriction was in effect when he had those behaviors. He is on unrestricted pass now in the community. I believe he is out of the facility now. On 3/6/24 at 11AM V1 (Administrator) stated that R3 was put on pass restriction due to being readmitted to the facility. All residents who are newly readmitted are put on 72-hour pass restriction. This is the reason R3 was on 72-hour pass restriction. R3 was on the 72-hour pass restriction from 2/8 to 2/11/24. On 2/21/24 at 10:22AM V7 (RN) stated I was there when R3 started the fire. It was the end of the shift about 11:30PM. I saw R3 come to another nurse to have discussion. R3 walked away. Later the fire alarm went off. We dialed 911. The 2 CNAs (V21 and V22) and the night nurse (V20) ran to the room and I followed. The nurse (V20) went to get the fire extinguisher. The CAN's were covering the fire on the bed with a blanket on the corner of the mattress. The nurse came in and used the extinguisher. All residents were moved out of the room. R4's was the bed on fire. He was not injured. All residents were moved out of the room. R4, R5 and R10 were moved off the room. We (the nurses and CNAs) assessed all of them. There were no injuries. R3 was not in the room when we went in. He started the fire and left room. The fire department arrived but the fire was already out. The police then arrived. R4 said he was ok to the fire department captain and he did not want to go to hospital. We searched for a lighter, but nothing was found. He did leave the unit during the incident. He must have hidden the lighter. The police questioned him, but he stated he didn't do anything. The police took R3 from the building. R3 was taken to hospital and is now back. R3 is supposed to be monitored by the behavior aides. On 2/22/24 at 2:05PM V8 (CNA) stated I was working when the fire happened. R3 came out of his room and was yelling that R4 was making noise and he couldn't sleep. I went in the room and saw no issue. R3 went back in the room. A little while later R3 and R4's roommate pulled the nurse call. The fire alarm went off. I went in room and R4's bed was on fire at the foot of the bed. Other staff rushed in and put out the fire. The residents in the room were taken out. The fire department and police came. On 2/21/23 at 3:05PM per phone R4 stated yes R3 started my bed on fire. I didn't get hurt though. We argued before he did it. I was making some noise and he got mad. I fell asleep and was awoken by all the commotion and my bed was burning. They came in and put it out. I am in another place now and I'm fine. On 2/26/24 at 11AM per phone R4 stated I am doing ok here at the new facility. I am safe. I never had any fights with R3 before the fire incident. That night R3 yelled at me to be quiet when I was praying out loud. I fell back asleep and woke up by commotion. My bed was on fire. The smoke alarm was on, and the staff all came in and put the fire out. I was not burned, and I was ok. They wanted to send me to the hospital, but I didn't need to go. I was transferred to another facility because my family made them after the fire. On 2/20/24 at 1:55PM R3 stated I started a fire with paper, and it caught R4s sheet on fire. There was a lot of smoke. I had the lighter in my bed drawer. That is where I got it. The nurses came in the room and put out the fire. The police came and took me away to hospital. I came back here, and I am good now. I smoke with the group here once a day. I go out into the community. I work for people with houses. I clean yards and do gardening I make some money. On 2/20/24 at 1:11 PM R5 (R3's and R4's roommate at time of incident) stated I woke up and seen R3 got mad at R4. R3 took out a lighter and held it to R4's sheet and it caught fire. The sheet was hanging off the edge of the bed. About a minute and a half after, about three staff came in and put out the fire. R4 was in his bed, he is paralyzed on the left side, and he couldn't move. The staff were using their hands to put out the fire and another staff came in with a fire extinguisher. The police came and took R3 away. R3 was gone for about 20 to 25 days before he came back. R3 was smoking in our rooms unauthorized often before this happened. It happened at least three times. On 3/4/24 at 9:30AM V14 (Nurse Practitioner) stated I cannot say R3 would have started another fire in the facility, but he was capable of it. R3 had psychosis and was psychotic because of diagnosis of schizophrenia, but I cannot predict whether he would have done it again. The following review of documents show that R3 was a noncompliant smoker in the facility and the facility was aware. 8/25/23 behavior note: The resident has a history of smoking in a non-designated area in which counseling was conducted on three occasions, 05/18/23, 07/15/23, 07/29/23. The resident care plan was updated for each occurrence. and smoking assessment periodically when needed. Monitoring for non-compliant smoking behavior will continue to determine if the behavior increase or decrease. 1/5/23 Smoking Safety Risk Assessment: A. 9. Does the resident have a history of or currently presents with unsafe/hazardous behavior causing injury to self or others? 1. Yes The following review of documents show R3 has a history of aggressive behavior, and the facility was aware. 11/27/23 behavior note: Received resident from Hospital via ambulance and two staff who transferred resident to bed around 7:20 p.m. Resident present with aggressive behavior. Alert and Oriented X 3 able to make his needs known to staff and staff respond to res needs in a timely manner. Head to toe assessment performed and all skin integrity intact. Abdomen soft, non-tender and non-distended. Lung sound clear bilaterally with an audible heart tone. Vital Signs (V/S) Blood Pressure (bp)-111/68, Temperature (t)-97.6, Pulse (p)-78, Respirations (r)-18, Oxygen (02) saturation-97%. Medical Doctor (MD) notified of resident's arrival with an order to carry out all discharge orders. Guardian by name (V13) notified at this number xxx xxx xxxx. Call light kept in place and res in bed resting. 11/20/23 nurse note: At 4:30 pm, resident returned from Hospital ER Visit for behavioral issues. Immediately on his arrival, resident left for social services office, and became verbally, and physically aggressive to staff. He began to disorganize, and destroy office properties, and becoming non redirectable. Resident refused medication compliance, scheduled, or PRN for stabilization. Code yellow was called for staff reinforcement. He was placed on 1:1 close monitoring for his safety, and others. MD (V10) gave order to transfer him to Hospital. Provider Partner Patient (PPP) was called, and report given to (Nurse). Resident State Guardian (V13) made aware via message received by staff at the state Guardian office. Bed remains on hold per facility protocols. Endorsed for follow up. 11/20/23 social service note: R3 had a verbal altercation with staff. Behavior aids came to intervene, but redirection was not successful. With time, the resident went upstairs and was calm. 11/19/23 social service note: Resident came by the nurses' station stated he wanted to leave he was asked by the staff why he wanted to leave with no reply. Then a few minutes later he tried to push open the front door to leave, stated he will kick the door open, gave resident an Against Medical Advice (AMA) paper to sign he refused to sign, then he physically threatened the nurse that he would stab him with the pen. Nurse Practitioner (Np) for V10 (physician) was informed. Call placed to 911 to transfer the resident to the hospital for psyche evaluation. Emergency ambulance along with police escort transferred the resident to the ER for psychiatric evaluation. 8/24/23 behavior note: Resident has been noted displaying delusional thought, throwing objects, and making threats towards staff and co-peers, with the intent of becoming physical. Resident was unresponsive to counseling and redirection. Nurse on duty was made aware and further behavior monitoring will continue. 8/1/23 behavior note: Resident is refusing medication and meals. Observed displaying delusional thoughts stating that the world is out to get him and barricading his room door because the ghost and the gays are out to get him. Urinating in the garbage cans. Action: health teaching encouragement and redirection Counsel by social services on duty. Doctor (V10) notified and received an order to petition resident to hospital for Psych Evaluation. 7/30/23 behavior note: The resident has history of behavior that consist of throwing beverages, screaming, and yelling. The resident had three occasions 07/10/23, 07/19/23, 07/24/23 whereas counseling was conducted. The resident behavior will continue to be monitored for increase or decrease to determine need for evaluation. Facility policy titled Security, Supervision, & Safety Policy states: Purpose: To ensure the ongoing security and close supervision of all residents Due to the nature of the resident population served, the facility employs a number of measures to ensure the ongoing security and close supervision of all residents. Furthermore, the facility does not maintain an open environment. At a minimum, the following are components of the ongoing close supervision evidenced in the facility's daily operations: 1. The facility maintains a Behavior Management / Level Program to provide for the necessary structure and supervision; promotion of positive behavior and administration of natural consequences to an individual's behavior. 2. As a component of the Level Program, community integration e.g., passes, is progressive and only granted dependent upon an individual's positive behavior. 3. The facility specifically & comprehensively assesses behaviors, monitors, and promptly addresses and/or intervenes upon the same to minimize physical aggression and altercations. 4. Acute, or sustained visual monitoring or 1:1 observation on a time limited basis is provided as necessary for residents demonstrating an increase in psychiatric symptoms or aggressive behaviors 5. If increasing psychiatric symptoms or escalating aggressive behaviors have been determined, the physician will be notified. 6. Clinical staff are specifically trained in the methods promulgated by the Crisis Prevention Institute 7. The facility has incorporated the methods of the Crisis Prevention Institute as a standard of practice. 8. The facility maintains Psychiatric Rehabilitation staff on duty twenty-four hours a day, seven days a week. 9. The facility has incorporated the practice of making regular rounds at regularly identified intervals throughout each day. 10. The facility routinely identifies hazards and risks; evaluates and analyzes hazards and risks; implements interventions to reduce hazards and/or risks; and monitors for effectiveness modifying interventions when necessary related to the physical plant, equipment devices and operations as facilitated by a Safety Committee. 11. Maintains and implements prohibition of specified contraband per a Contraband listing 12. Maintains an audible alarm on all exit doorways with continuous and ongoing visual monitoring as necessary. 13. Maintains a stringent smoking program which prohibits indoor smoking, limits smoking times, access to materials and allows for ongoing supervision of resident smoking. 14. Visitors are requested to sign in and out and show identification, if needed. As such, the facility maintains a moderate to high level of supervision on an ongoing basis to provide for the early detection of and response to any demonstrated behavior changes. On 03/04/24, the surveyor made observations, conducted interviews and reviewed documentation to confirm that the facility took the following actions to remove the immediacy: Fire was put out immediately by staff who responded to code red when fire alarm activated. Fire was contained and clear before the fire department arrived at the scene. Completed 1/21/24. R3 was immediately removed from the scene, placed on 1:1 monitoring/supervision until transported to the hospital. Completed 1/21/24. R3 was issued an IVD (Involuntary Discharge). Completed 1/22/24 R3 was readmitted after communication with V13 (Guardian). R4 was removed from the bed and transferred to a different room. Respiratory assessment and monitoring completed. No respiratory or emotional distress noted on R4 and R4's roommates. Completed 1/21/24. R4 was transferred to another facility. Completed 2/7/24. Psychosocial assessments were performed and completed for R4 and R4's roommates. No one sustained any mental or emotional trauma. Completed 1/22/24. Social Services staff and Behavior aides were re-educated on monitoring, to prevent illegal smoking and removal of contrabands by the PRSD (V5). Completed 1/23/24. All staff were in serviced by the director of behavioral health performed behavior crisis intervention training and abuse prevention and reporting and identifying and reporting of hazardous and contraband materials. Staff that were on leave and on vacation were called and were in-serviced by CNA supervisor V16. Completed 2/26/24. Mental health Technicians continued to monitor all residents every 2 hours on all floors, on all shifts to ensure no illegal smoking going on in the building. Ongoing R3 signed a new behavior contract stating to be compliant with smoking, medication compliance and agreed not to possess any contraband. He agreed for the increased room searches and to be searched when he returns to the facility from out on a community pass. Completed 2/9/24. Upon R3's return to facility on 2/8/24, he was placed on 30 minutes checks and 72-hour monitoring by Mental health Technicians. His pass was restricted for 72 hours per policy. Completed 2/11/24. R3 was placed on 1:1 counseling with PRSD/PRSC for symptoms management, coping skills, and anger management. Completed 2/22/24. R3's room searches were increased at a minimum of 2x/week. Completed 2/22/24. When R3 goes out on a pass, two staff are responsible for checking his belongings for any contraband. Completed 2/22/24. The abuse coordinator (V1) was in serviced on proper abuse reporting to the state regulatory department. Completed 2/27/24. Investigation Reportable was submitted to IDPH by the Administrator (V1). Completed 2/27/24. Audit was completed by Social Service Consultant (V17) to identify residents at risk for having hazardous contraband. Completed 2/27/24. All resident identified as at risk for having hazardous contraband had their care plans reviewed and updated appropriately to address the unsafe smoking behavior by Social Service Consultant (V17) and the director of behavioral health (V18). Completed 02/28/27. Housekeeping and Maintenance staff were in-serviced by Housekeeping Director (V19) on identifying and immediately reporting hazardous items. Completed 2/28/24. Receptionist was in serviced by the director of behavioral health (V18) on proper searching protocols for residents and guests entering the facility. Completed 2/28/24. Department Heads were in-serviced by Administer (V1) on safety rounding x3 times weekly to identify and report hazardous materials and contraband to PRSD (V5). Initiated 2/28/24. Social Service Department was in-serviced by the director of behavioral health (V18) to increase monitoring and room searches for residents identified at risk to have hazardous contraband. Completed 2/28/24. List of residents identified to be at risk for having hazardous contraband was placed by the nurse's stations and reception desk and will be updated weekly or as needed by the PRSD (V5). Initiated 02/28/24. Social Services, Activities, Receptionist and Department heads were in-serviced on facility smoking policy by the director of behavioral health (V18). Completed 2/28/24.

Based on interview and review of document the facility failed to ensure the right to be free from abuse for one of three residents reviewed (R2) for allegations of abuse. This failure resulted in R2 being sent to the emergency room and returning to facility with a 1cm laceration to the right cheek. Findings include: R2 is a [AGE] year-old male with a diagnosis including Schizophrenia, Psychosis, Bipolar Disorder, Chronic Obstructive Pulmonary Disease , and Anxiety Disorder. R2 was admitted to the facility on [DATE] and was discharged from facility on 2/9/24. R2 BIMS (Brief Interview for Mental Status) is 15/15, cognitively intact. Resident is at moderate risk for abuse due to possible misinterpretations of events and the intentions of others. Denial and/or evasiveness: when discussing mental health issues, signs and symptoms of depression/mood distress, Low self-esteem, isolation and withdrawn behavior. R8 is a [AGE] year-old male with a diagnosis including schizoaffective Disorder, Bipolar Type. R8 has a BIMS (Brief Interview for Mental Status) score of 15/15. R8 was admitted to the facility on [DATE] and was discharged to hospital on 2/16/24. R8 displays delusional thoughts, verbal aggression towards staff and co peers with intent of becoming physically aggressive. R8 is care planned for physical aggression. Resident is assessed for aggressive behavior. Resident has been noted to display verbal and physical aggression toward staff and co-peers r/t diagnosis of severe mental illness and has history of self-destructive statements/behavior/threats and episodes of aggressive/agitated behavior. R8 is at high risk for abuse r/t poor insight/poor judgement, delusional thinking, hallucinations, persistent anger, fear and / or anxiety and dysfunctional behavior including provoking and aggressive behavior. During investigation R2 and R8 could not be contacted for interview. 2/2/24 nurse note states: 6:40 pm writer heard residents shouting code yellow, code yellow, and for help by the day room watching TV. Writer and other staff immediately ran towards the day room saw resident with his broken glasses in his hand and slight bleeding dripping at the right side of the cheek saying, he hit me, punching me on my head and on my face and broke my glasses. Resident assessed, did not lose consciousness, area to the right eye clean with normal saline noted 0.5 cm (centimeter) superficial cut to the lower side of the right side covered with steri strips. V/S as follows: bp-134/90, p-92, r-20, t-99, 02 sat 97%. Doctor made aware with an order to send resident to the nearest ER. Facility Abuse Investigation Form dated 2/2/24 (Summary on investigative findings) states including after thoroughly reviewing all the available evidence, we have concluded that resident R9 was seeing multiple men. When R8 saw another man talking to her (R2), he struck R2. Staff immediately separated the 2 residents. R2 was treated for a slight laceration and was sent to the ER for an evaluation. Ct scan was negative, and no sutures were required. The laceration has since healed. R2's hospital record dated 2/2/24 states including diagnosis of injury: 1cm laceration to the right cheek with a steri-strip over site. CT scan negative. R2 was discharged from hospital back to facility on 2/3/24. On 2/28/24 at 1:10 PM V7 (RN) stated I was the nurse on duty when R2 and R8 had the altercation. R2 was talking to R8's girlfriend R9. R8 approached R2 and struck him with fist. R2's glasses flew off. The glasses caused a laceration to the cheek. They were separated immediately. R2's doctor was notified. R2's family was notified. R2 was sent to the hospital. The police were notified. R8 was sent to the hospital for evaluation. Our abuse prevention policy was followed. On 2/28/24 at 4:05PM V12 (Physician) stated yes, I was aware of the physical altercation with R2. R2 was sent to the hospital with a small laceration. The emergency room contacted me and R2 received no serious injury and was returned to the facility. R2 is now at another facility and is doing well. That is all I can give you since the injury was minimal. Facility policy titled Abuse Prevention and Reporting - Illinois Revisions: 10-24-22 states including: The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Definitions: Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines). Resident to Resident Abuse (any type) resident to resident altercations that include any willful action that results in physical injury, mental anguish or pain must be reported in accordance with regulations.

Based on observation, interview, and record review, the facility failed to properly assess and supervise a newly admitted resident (R2) for risk of elopement for one (R2) out of 7 residents reviewed for hazards and accidents on the sample list of 11. This failure resulted in R2 eloping from the facility through a window. R2 was subsequently found at the lake and transported to the hospital where R2 was pronounced dead by neurological criteria by ICU (Intensive Care Unit) and Neurology attending physician. This failure resulted in an Immediate Jeopardy which began on 08/30/2023 when R2 went out of a window on the second floor of the facility, eloped and was later found in a lake. R2 was transported to the hospital and pronounced dead. On 09/29/2023 at 09:38 AM V1 (Administrator) was notified of immediate jeopardy via phone call. V11 (MDS Coordinator) and V2 (Director of Nursing) were present and signed immediate jeopardy template form. V1 was not present in the facility and thus, was notified via telephone conversation. The facility presented a final removal plan on 09/29/2023 at 11:22 AM that was rejected at 12:26 PM. Modified removal plan was submitted on 02:06 PM and was rejected 04:16 PM. Modified removal plan was submitted at 4:38 PM. The facility's removal plan was accepted at 04:40 PM on 09/29/2023. The surveyor conducted additional observations, interviews, and record reviews on 10/03/2023 and 10/04/2023 to verify the plan was implemented. The immediate jeopardy was removed on 10/04/2023 based on actions from the removal plan. Although the immediacy was removed, the deficiency remains at the level of no actual harm with the potential for more than minimal harm until the facility determines the effectiveness of the implementation of the removal plan. Findings include: R2, a [AGE] year-old resident, initially admitted on [DATE]. R2's Face Sheet documents R2's medical diagnoses including bipolar disorder and psychosis. R2's Progress Notes dated 08/30/2023 by V6 (Assistant Director of Nursing / Licensed Practical Nurse) documents that approximately 10:50 AM (08/30/2023) R2 was not observed in his room, resulting in a code pink (CODE PINK- is the facility term for ELOPEMENT , which signals staff to search for the missing resident). Multiple parties were informed including police department. Progress notes dated 08/30/2023 by V16 (Licensed Practical Nurse) documents that at 7:00 PM two police officers arrived at the facility and informed the facility (R2) was found and was transferred to the hospital. The Initial and final facility reported incident dated 08/30/2023 for R2 submitted by facility under description of occurrence has the same documentation that reads received a report that resident (R2) with an unauthorized exit is admitted at the hospital. No other documentation describing the incident was given. On 09/26/2023 at 11:52 AM, V1 (Administrator) discussed R2's incident of leaving the facility on 8/30/23 with V2 (Director of Nursing) present. V1 stated R2 went out of the facility through the window using a metal instrument but no one saw what happened. V1 stated R4, the roommate of R2, saw that the lock mechanism was broken and R4 alerted V6 (Assistant Director of Nursing / Licensed Practical Nurse) that R2 climbed out of the window. V1 stated that a video was captured showing R2 was moving towards south of the street in front of facility. V1 stated a bystander saw R2 get out of the window, but the facility failed to get information about the identity of the bystander. V1 stated the equipment automatically erased the video after specific number of days and is not available anymore. V1 showed the window that R2 exited the facility from. This window was on the 2nd floor near the corner right side of the building when facing the building from outside. Inside the room the window opens and closes which has a small mechanism on the side. V1 said that the mechanism was to stop the window from moving upwards/limit the window to fully open. V1 presented three copies of photo of a window that per V1 was the same window that R2 was able to get out. One of the copies show a window detached on the top part with the bottom part still attach to the base of the window leaving the window wide open. V1 stated (referring to the picture), That is the window R2 went out. On 09/26/2023 at 12:10 PM V1 pointed to the window on the exterior of the facility building that R2 exited the facility from and got a measuring tool that points a red light to the window to get measurement. V1 stated that from the window the elevated portion (attach to the wall of the building) measures 16 feet and the ground will be 19 to 20 feet. R2's Facility Initial Elopement Risk and Community Survival Skills assessment dated [DATE] upon initial admission by V4 documents that R2 has no severe mental illness. This assessment recommends that R2 is not at-risk of elopement that time and placement of Elopement Risk Protocol is not indicated. On 09/26/2023 at 01:51 PM V4 (Registered Nurse) stated that she was the nurse who admitted and assessed R2 during initial admission on 08/28/2023. V4 stated that R2 was able to express his thoughts during conversation and that R2 stated that he (R2) was homeless. V4 stated that R2 liked to smoke and was able to walk without help. V4 stated R2's medical diagnoses during admission including He has medical diagnosis of schizophrenia bipolar, suicidal ideation, homelessness, and diabetes. V4 stated that being homeless and first time in the nursing home he would be an elopement risk. V4 was given a copy of initial Elopement / Community Survival Assessment of R2. Upon reading V4 said, I did the assessment it was signed by me. I don't know why I answered NO for risk of elopement and the diagnosis of severe mental illness. It should have been YES. R2 has psychosis and bipolar and is at risk for elopement. I don't see any care plan for elopement or behaviors. With this diagnosis there is a need for behavior care plan. R2 is at risk for elopement. On 09/26/2023 at 03:01 PM with V6 (Assistant Director of Nursing / Licensed Practical Nurse) stated that she was the nurse that was taking care of R2 during elopement. R2 was regarded as independent because he can perform activities of daily living by himself. V6 stated it is not only physical capabilities that need to be considered and that given his medical diagnosis of bipolar disorder and psychosis, V6 stated, We need to take behaviors into consideration not only physical functions. V6 stated R2 needs supervision and monitoring. R2's Hospital Admission referral documents given to facility during admission document, history of present illness in part reads: On 08/19/2023 R2 was brought to the hospital. These document R2 has diagnosis of bipolar disorder and that R2 was expressing having command type auditory hallucinations and visual hallucinations telling him to kill himself. R2 has been agitated responding to internal stimuli and was posturing to hit staff. These documents also document R2, at present time is not psychiatrically stable and poses a risk of harm to self or others. On 09/27/2023 at 09:58 AM, R5 was observed inside his room. R5 was alert and able to express his thoughts well during conversation. R5 stated that he used to work in law enforcement and was in the hospital when R2 eloped. And before he went to the hospital, he met with R2. R5 stated that R2 looks crazy, R2 never spoke, and he walks (like a marching motion moving both right and left arms alternation up and down on a stiff position) schizophrenic. R5 said, He (R2) did not blink and stone as crazy as hell. On 09/27/2023 at 9:35 AM, V7, Maintenance Staff, inspected random windows at the facility. V7 stated that all windows that have screws that stop the window from opening has been replaced by brackets. V7 stated windows should not open more than 4 inches. At room [ROOM NUMBER] two windows that were seen can open wide about 12 inches. And only has small screw to stop the window to slip and fully open. V7 stated that he is not sure if a resident may be able to fit through the window but will fix it right away to make sure it will not go as far as 4 inches. On 09/29/2023 at 10:54 AM, V13 (Psychiatric Rehabilitation Service Coordinator) verified that the signatures on all documents titled Witnesses Statement dated 08/30/2023 by V14 (Certified Nursing Assistant), V4 (Registered Nurse), R4, and V6 (Assistant Director of Nursing / Licensed Practical Nurse) were his signatures. And that he (V13) spoke to V14, V4, R4, and V6 directly. V13 stated that R4 probably saw R2 went out of the facility through the window. Witness Statement of R4 dated 08/30/2023 in part reads: The resident came in my room walked to the other side then jumped out of the window. On 09/29/2023 at 11:12 AM with V13, surveyor met R4 in his room. R4 was alert and able to express thoughts during conversation. R4 stated that he saw R2 trying to open the window and that he told R2 to use the main door. R2 was walking going back and forth to the hallway and back to the window when he went to toilet. About 5 minutes after when he (R4) went out, the window was opened and when he (R4) looked outside he cannot find R2. R4 said that there was a guy that was working on the light bulb who stated a person went out of the window. On 09/29/2023 at 11:39 AM, V14 (Certified Nursing Assistant) confirmed that the Witness Document signed by V13 (Psychiatric Rehabilitation Services Coordinator) to be accurate. V14 stated that he was assigned to R2 during the time R2 eloped. V14 stated that R4 was the first person to start calling that R2 jumped out of the window. On 09/29/2023 at 11:56 AM V7 (Maintenance Staff) stated that the window had no bracket when the incident happened. V7 stated R2 was able to open the window. V7 observed the pictures the facility presented the State Survey Agency with on 09/26/2023. V7 stated, Yes, the brackets on those two pictures were placed after R2 went out of the window. There are clips that hold the window so that it will not be opened, but somehow R2 was able to pull the window open. The window can be opened by pulling to detach/remove the top part open with the bottom part still attached to the base of the window. V7 confirmed that the picture with open window provided by V1 on 09/26/2023, is identical to his description when he first saw the window after R2 eloped. On 09/29/2023 at 12:22 PM, V2 (Director of Nursing) stated that when R2 was admitted , R2's medical diagnosis includes psychosis and that to understand better what R2 needs, referral documents from the hospital were received which included behavioral notes. V2 provided hospital referral notes that were used during R2's admission. R2's referral documents R2's history of present illness including bipolar disorder, expressing command auditory and visual hallucination to hurt himself and others were pointed out and confirmed by V2. On 10/03/2023 at 11:01 AM, V15 (Nurse Practitioner / Psychiatrist) stated that it depends on the facility if they will place interventions. In the hospital if a patient has active symptoms, they put the patient on one-on-one monitoring. If it happens in the nursing home setting, the patient needs to transfer to the hospital. V15 stated psychosis means psychiatric crisis, active psychosis like auditory or visual hallucination, delusion, and loss of external reality. R2's Hospital records document R2 was brought to the hospital after being found at a lake on 08/30/2023 and sustained anoxic brain injury due to drowning. After few days of medical intervention R2 was pronounced dead by neurological criteria by ICU (Intensive Care Unit) and Neurology attending at 9:12 am on 09/03/2023. On 10/04/2023 at 10:03 AM, V1 presented a list of residents that are at risk of elopement with 10 residents included in the list. At the first floor V8 (Registered Nurse) enumerated current residents that are at risk for elopement including R11. V1 stated that social services department with social worker does the elopement assessments after initially completed by the nurses on the floor. V13 (Psychiatric Rehabilitation Service Coordinator) brought his laptop and showed elopement assessment process in electronic health records performing elopement assessment to R11. During the assessment V13 stated that R11 has a medical diagnosis of dementia but does not have behavior to place R11 under risk of elopement. V13 said that it is upon discretion of the staff doing elopement to recommend whether to place resident on elopement risk or not. Even if resident is obviously an elopement risk, the staff assessing has discretion not to place resident deemed as an elopement risk. Upon review of V27's (Licensed Practical Nurse) notes dated 08/15/2023, R11 has increased agitation and delusional thinking. R11 stated to call the police that her son is outside killing himself. R11 attempted to pull fire alarm and was hard to redirect. Elopement assessment of R11 dated 09/12/2023 by V28 (Social Worker) recommends that R11 as not at risk for elopement and placement of Elopement Risk Protocol not indicated. At 01:52 PM, R11 was sitting on the chair in her room. R11 alert, verbally responsive, and confused. R11 does not know her present placement. R11 at first stated her current placement was in the hospital, then apartment, and then said that she is currently at home. R11 thinks that she can still drive and wants to go home. The facility's undated Full Administrative Identification of Elopement Risk policy reads: Policy statement is to identify residents that are at risk for elopement. Policy interpretation and implementation are as follows: Residents will be evaluated for elopement risk on admission and quarterly. The resident's service plan will be modified to indicate the resident is at risk for elopement episodes, if applicable. Interventions to prevent elopement will be entered into the resident's service plan. The surveyor confirmed on 10/04/2023 through observation, interview, record review, that the facility took the following actions to remove the Immediate Jeopardy: The facility implemented all measures on the removal plan. To wit: 1 - Per progress notes of R2 dated 08/30/2023 code pink initiated with parties as stated made aware. Completed 08/30/2023. 2 - Investigation was completed by V1 (Administrator) *Reviewed Investigation report submitted to the surveying agency. Date of final report was changed from 09/04/2023 to 09/05/2023 to be consistent to final report document. Completed 09/05/2023. 3 - All windows were inspected dated 09/29/2023 with opening not wide enough for residents to go through. Facility windows were seen to have brackets. V1 (Administrator) said that there are nine rooms that has windows that go up and down instead of sliding side to side. Observation affirms that the three rooms in each floor were seen to have brackets to prevent from opening when pulled. Completed 09/29/2023. 4 - Weekly Assessment of windows is being done by maintenance director, V7, for maintenance and preventative measure. A weekly checklist audit tool is being utilized. Weekly assessment of windows completed by V7 (Maintenance Staff). Inclusive dates are 09/02/2023, 09/04/2023, 09/11/2023, 09/15/2023, 09/18/2023, 09/22/2023, 09/25/2023, 09/29/2023, 10/02/2023, and 10/03/2023. Initiated 09/01/2023 and will be completed indefinitely. 5 - All elopement risk assessments were reviewed, and elopement precautions were implemented and updated as appropriate, care plans were updated as appropriate. This is being conducted by Social Service Consultant, V29. *All Elopement Risk Assessments were reviewed by the facility, and elopement precautions included in the review by facility. Elopement Precautions were included in plan of care of residents. On 10/04/2023 R11 was identified by facility and was included as an elopement risk, previously assessed as not an elopement risk. Initiated 09/28/2023 completed 10/04/2023. 6 - All admissions from last 30 days had elopement risk re-assessed, completed by the Social Service Consultant, V29. *Residents that are admitted in the last 30 days are R6, R7, R8, R9, and R10 that are in the facility. Facility presented a copy of Elopement Risk and Community Survival Skill Assessments of R6, R7, R8, R9, and R10. These assessments were initiated on 09/29/2023 completed on 10/03/2023. 7 - Licensed Nurses and Social Service Staff were reeducated on proper elopement risk assessment documentation. Licensed nurses and social service staff who are on vacation or FMLA (Family Medical Leave Act) will be in-serviced before returning to work by DON- V2 and ADON-V6. The facility does not have agency staffing. Re-education of staff related to proper elopement risk assessment documentation were reviewed. V1 stated that staff were given instruction in the correct way to complete an Elopement Assessment Form. An Elopement Risk Assessment Inservice Sign in Sheet dated 10/02/2023 was presented with facility staff as signatories. This was initiated on 09/29/2023 and completed on 10/02/2023. 8 - All staff were in-serviced on elopement, elopement behaviors and response. Elopement education will be ongoing. Staff on vacation or FMLA will be in-serviced before returning to work by DON- V2, ADON-V6 and Administrator, V1. V1 will monitor for compliance. On 10/04/2023 V24 (Certified Nursing Assistant) was identified as staff that was not a signatory in Elopement In-service. Facility presented document with V24's signature on the same day. In-service on elopement, elopement behaviors, and response were conducted as planned. V1 presented Elopement Risk documents that were used to educate staff in the facility. V1 also presented Elopement protocols, process, policy, signs, and symptoms, and reporting in-service that was signed by all staff currently working in the facility. Five facility staff that are on vacation or FMLA were reached out by V17 (Human Resources Director) and was given in-service by phone according to both V1 and V17. Initiated 09/29/2023 completed 10/04/2023.

Based on observation, interview, and record review, the facility failed to protect a resident from physical abuse. This failure resulted in one resident having a change in condition and requiring emergency medical services. The resident was diagnosed with a concussion syndrome. This failure affects one of three residents (R4) reviewed for physical abuse in a total sample of six residents. Findings include: R4 is a [AGE] year-old male. R4's diagnoses are but not limited to depression, diabetes, anxiety disorder, and suicidal ideations. R4's BIMS (Brief Interview for Mental Status) dated 05/09/2023, notes R4 is alert. R4's MDS (Minimum Data Set) dated 05/09/2023, notes R4 requires supervision only. R4's care plan notes R4 has the potential to be physical aggressive due to poor impulse control. On 05/17/2023, R4 had a physical altercation with staff that left R4 with a bruise to the right eyebrow. Progress note dated 05/17/2023, notes R4 had a physical altercation with a staff member (behavioral aide). Noted with swollen right eyebrow, no bleeding noted. R4 was noted to be threatening towards writer demanding for a cigarette. R4 started recording, following, and blocking writer's ability to leave the basement area. As writer attempted to leave the area to another exit, R4 attacked writer. Writer then called for a code yellow to assist with the situation. NOD (Nurse on duty) was made aware of the incident. R4 refused emergency medical services but complained about being dizzy. R4 noted with extreme agitation. Nurse on duty made aware; monitoring will continue. R4 refused to go to the emergency department. R4 educated and advised on the importance to seek further medical attention. R4 verbalized understanding but still refused. R4 responsible for self. Progress note dated 05/18/2023, R4 sent out to local hospital today due to altercation the previous day. R4 left in stable condition. R4 walked out of the facility. At 9:00PM, R4 returned from local emergency room visit. R4 returned with a diagnosis of post-concussion syndrome. R4 was advised to follow up appointment with R4's primary physician. On 05/18/2023, at 12:24PM, V1 (Administrator) stated, the staff member was suspended pending investigation. Originally, I was told by V3 (Psychiatric Services Coordinator) that V3 was attacked by a resident. V3 called the police, and a code yellow was called. V3 tried to call later. The nurse called me and told me R4 has an injury, and R4 stated R4 was attacked. Once the police left, I made a preliminary. No one saw anything. This is unwitnessed. Staff did come down afterwards. I did see the video this morning. There are cameras in the hallway. This is currently being investigated. On 05/18/2023, at 1:51PM, R4 stated, Last night they did not call for a smoke break. I made a complaint, and the staff member started acting hostile. The staff member works with social services. My right eye is swollen. This staff member hit me. I don't know the staff member's name. The staff member straight-up assaulted me. I informed the police and the administrator. On 05/18/2023, at 1:54PM, R5 stated, I saw them both shove each other, I saw a blood clot on R4's right eye and R4 puked many times last night. It was V3. I am new to the facility. During this interview, R4 does have a swollen right eye. R4 also stated R4's head is swollen. On 05/18/2023, at 2:25PM, V3 (Psychiatric Services Coordinator) stated, I was attempting to leave work. R4 would not let me leave because R4 wanted a cigarette. I said R4 missed the smoke break. R4 stated R4 was going to record me with R4's phone. R4 would not let me leave and was blocking the door. I tried to go another way. I said leave me alone. R4 told me R4 was filming, and I said alright R4 can film me. R4 was coming after me and I was trying to leave. R4 followed me into the stairwell where R4 can't go. R4 pushed me into the stairwell. R4 had me in a choke hold and gauged my eyes. At that point R4 was trying to kill me. I just used CPI (Crisis Prevention Intervention) to get R4 under control and call for help. People came and R4 started yelling and stated how I beat R4 up. I could have gotten killed. I would never strike a patient. I held R4 by R4's upper body where R4 could not grab at my face and control R4's arms. I was able to get my hips on top of R4's hips so R4 could not keep fighting me. I was able to control R4 there. R4 got a finger in my eye. I had to control R4's arms. I have a bite mark, and we were in a tight space place. This was a matter of trying not to get R4 to kill me. R4 might have fallen against the stairs and hurt himself. I do not know. On 05/23/2023, at 10:30AM, V1 stated, post-concussion syndrome was listed as the diagnosis after R4 was sent out to the hospital on 05/18/2023. The facility does not share camera footage. V3 was CPI (Crisis Prevention Intervention) trained. V4 (CPI trainer) trains and provides education to the staff. Staff had several trainings in January. Staff was in serviced last week and one coming today. I spoke to the Ombudsman today and did a presentation for staff. There have been several abuse trainings, and some people do not act as trained. V3 acted inappropriately on many levels and V3 is being terminated. I expect the staff to give the resident what they want within reason. V3 failed to deescalate the situation. It could have been deescalated before things happened. Or V3 could have been nice to R4. Focus on customer service. V3 could have gotten help much sooner than V3 did if V3 acted appropriately. If a resident misses a smoke break, V3 could have taken R4 out. R4 did send me the video. If staff is being attacked by resident, there is appropriate use of CPI to be used. V4 could not be contacted during this investigation. On 05/23/2023, at 12:29PM, V5 stated, I responded to the code yellow that was called. When I got there, I saw R4 being restrained by V3. Another aide joined me, and we asked what transpired. V3 said R4 would not let V3 go home. R4 stopped V3 from going. V3 tried to explain to R4 that V3 was not in charge in cigarette breaks. That is what caused the trouble. I was able to calm R4 down. I saw that R4's right eye was swollen and administered aide. I did not see the altercation. CPI is crisis intervention. This is used to try to make the residents calm. There are strategies to do that. Staff should never hit a resident. There are other ways to deescalate a situation. On 05/23/2023, at 12:39PM, V6 (Certified Nursing Assistant/CNA) stated, I was not involved in the situation. I heard someone screaming. I thought it was in a room, but it was in the stairway. I went to the stairway. A nurse from the 1st floor was already there with V3 and R4. The nurse told us to take R4 back to the second floor. There was swelling by R4's eye and it was blood from V3, I believe. R4 showed the surveyor R4's video. R4's phone video shows R4 and V3 men having an argument. V3 tries to walk away and states R4 is trying to assault V3. V3 tries to go in the stairwell and then the video goes dark. This is where R4 states V3 hit R4. CPI document titled, CPI Nonviolent Crisis Intervention Training, undated, notes CPI training is safe, nonharmful behavior management system designed to help professionals in any setting provide the best possible care, welfare, safety, and security, of individuals presenting a range of crisis behaviors. V3 was CPI trained on 1/24/2023. R4's medical records dated 05/18/2023, notes police report notes R4 was attacked by social worker physically. R4's medical records document R4 had soft tissue swelling and bruising on the right eye. R4 at the hospital for evaluation after assault/ trauma last night at the nursing home. Possible loss of consciousness. R4 has been nauseous and vomiting since then. R4 complains of pain on the back of R4's scalp with bruising over the right eye. R4 has vision changes and difficulty coordinating R4's movements. R4 was diagnosed with post-concussion syndrome. Facility final investigation dated 05/23/2023, notes it was determined that V3 failed to de-escalate the situation numerous times, acting in an unprofessional manner, using language that was inconsistent with the facilities values. V3 failed to call a code yellow properly and used CPI inappropriately. Facility policy titled, Abuse Prevention and Reporting, dated 12/17/2021, notes this facility affirms the right of our residents to be free from abuse. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and requires medical attention. Physical abuse includes slapping, hitting, pinching, and kicking.

Based on observations, interviews and record review, the facility failed to protect the residents' (R1) right to be free from physical abuse from R2 for 3 out of 4 residents (R1, R5 and R6) reviewed for abuse. Failures includes R2, a resident with history of multiple physical aggression towards other residents (R1, R5 and R6) hitting R1 unprovoked resulting to R1 sustaining a deep abrasion requiring stitches to the forehead. Findings include: Per facility reported incident dated 10/9/2022, R4 came to the Nurse's Station and reported to V2 (Licensed Practical Nurse/LPN) that R1 was sitting on his bed with blood on his face inside the room. R4 was seen on 10/27/2022 at 11:50 AM entering the front door of the facility and agreed to talk inside his room. R4 was alert and able to express his thoughts well. R4 stated that he was the person who reported what happened to R1. R4 stated that he saw what happened between R1 and R2. R4 said, He (R2) punched him in the eyes. R1 was bleeding from his nose and eye, and blood covered his face. R4's BIMS score dated 9/7/2022 was 14, which means R4's cognition was intact. R2 is [AGE] years old, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was seen on the bed inside R2's room. R2 was alert and kept turning R2's head when being asked a question. R2 did not respond to conversation after multiple question. R1 is [AGE] years old, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was in the dining room at the basement, eating lunch. R1 was observed with a dressing on his forehead about 3 to 4 inches in length. R1 said another resident hit him on the head. R1 did not respond when asked if R1 felt safe. R1 kept on repeating the word alright. then did not respond to my question after R2's name was mentioned. A review of R2's progress notes documented that R2, not including current incident, had 2 prior incidents involving other residents being physically aggressive. The following are incidents related to R2 being physically aggressive to other residents: The first incident happened on 7/2/2022 between R2 and R6. Per Facility Reported Incident dated 7/2/2022 documents that R2 hit R6 on the head while inside the elevator. R6 sustained scratch to the left side of his head. Second incident happened on 7/12/2022 between R2 and R5. Per Facility Reported Incident dated 7/12/2022 documents that on day, V9 (PRSC) stated that he heard a noise outside of the social service office. When he looked outside into the hall R5 was noted crying, stating that R2 hit her in the back. On the same report, documents that R7 was interviewed. R7 stated that he noticed R2 and R5 talking to each other, and shortly after that, R7 noticed R2 ran and hit R5 on the back. R7's BIMS (Brief Interview for Mental Status) score dated 4/5/2022 was 15, which means his cognitive status was intact. The third incident happened on 10/9/2022 between R2 and R1. Per Facility Reported Incident dated 10/9/2022 documents that R2 punched R1 resulting to R1 sustaining a wound to upper right eye. Per V2 (LPN) notes dated 10/9/2022, R1 was sent to the hospital. And per V10 (Licensed Practical Nurse/LPN) notes dated 10/9/2022, R1 returned to facility with abrasion and stitches on his right forehead. On 10/27/2022 at 1:32 PM, V5 (PRSD) said, Care plan must be done on the same day to address an identified problem. Yes, a behavioral care plan should have been done on 7/2/2022 after the first incident. After showing V5 the history of R2's intervention documenting the same intervention after second and third incident, V5 said, I see what you mean. I think these interventions do not address R2's behavioral problem. Care plan intervention needs to be modified if it does not work. I agree if there was intervention in place during the first incident on 7/2/2022. And other interventions were put into place. Yes, I agree subsequent incidents may have been prevented. On 10/27/2022 at 1:52 PM, V7 (Wound Coordinator / Registered Nurse) stated that R1 sustained a deep abrasion with 4 stitches because of the incident that happened between him (R2) and R1. R1's initial wound assessment dated [DATE], documents right forehead traumatic laceration facility acquired measuring 3 by 0.25 by 0.10 centimeters. R2's behavioral symptoms care plan for physically aggressive related to anger was initiated on 7/13/2022. The same care plan was not initiated after first incident, dated 7/2/2022. Review of intervention addressing R2's interventions related to physical aggression documents that identical interventions were placed after repeated physical aggression by R2. On 10/27/2022 at 2:57 PM, V1 (Assistant Administrator) was asked related to R2's notes by V11 (Licensed Practical Nurse/LPN) and V12 (Licensed Practical Nurse/LPN) dated 10/11/2022 which document R2 was only transferred to the hospital after another behavioral aggression. Although the incident between R1 and R2 occurred on midnight of 10/9/2022, given R2's history of physical aggression, V1 said, I understand what you mean. Although R2 was transferred to another floor, other residents are still at risk of his aggression. I think you are right, it would be safer for other residents if R2 was transferred to the hospital instead of waiting for another possible incident to happen. I agree that it preventive measures should have been placed to avoid similar incidents to happen. Given R2's history, preventive measures should have been in place. Facility policy on Abuse Prevention dated as revised 4/29/2022 in part reads: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting to physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Under abuse prevention, this facility desires to prevent abuse by establishing a resident sensitive and resident secure environment. Under protection of resident, resident who allegedly abused another resident will be removed from contact with other residents during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility.

Based on interview and record review the facility failed to 1. Document medication in Medication Administration Record (MAR) per policy; and 2. Follow medication refusal policy for resident with physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Failures affected R1 who was medically diagnosed for [CONDITION(S)] for not receiving complete dose of antibiotics and caused R3 to be sent to the hospital for [CONDITION(S)]. Findings include: R1 was [AGE] years old, initially admitted on [DATE] and was transferred to hospital on 8/22/2022, 10 days after admission. R1's medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was ordered multiple antibiotics ([MEDICATION(S)] 250 MG, [MEDICATION(S)] Solution Reconstituted 50 MG ([MEDICATION(S)]) and [MEDICATION(S)] Tablet Give 500 mg) and insulins (Insulin [MEDICATION(S)] insulin to inject 25, [MEDICATION(S)] insulin inject 25 unit and [MEDICATION(S)] Solution 100 UNIT/ML (Insulin [MEDICATION(S)]) Inject 5 unit). The following medications were not signed as given on 8/18/2022: Antibiotics ([MEDICATION(S)] Solution Reconstituted 50 MG ([MEDICATION(S)]) and [MEDICATION(S)] Tablet Give 500 mg) and Insulins ([MEDICATION(S)] insulin 25 unit). R3 was [AGE] years old, initially admitted on [DATE] with medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R3's Medication Administration Record (MAR) for August 2022 documents that R3 was receiving [MEDICATION(S)] Insulin 100 unit per ML via sliding scale to determine amount to receive. From 8/22/2022 to 8/26/2022 11:00 AM schedule inclusive dates were not signed as given. And on 8/26/2022 at 7:30 AM, R3's blood sugar result was 523 which is considered as high level of blood sugar. Per R3's progress notes dated 8/26/2022 documented as follows: At 11:00 AM, R3 was observed on the floor in the washroom adjoining to her bedroom responds to verbal cues. R3's blood sugar was 523mg after checking. R3 was sent to the hospital. On 9/8/2022 at 10:35 AM, V3 (Director of Nursing/DON) said, As to medication administration, nurses should document it. Recording on the MAR (Medication Administration Record) must be done during giving of medications. Yes, R1 was taking antibiotic and insulin medications. I see what you are saying. Nurses need to document it, and because it is not documented. We do not know if it is done or given. I understand that doctors should be informed when resident diagnosed with diabetes and [CONDITION(S)] does not received insulin for 2 to 3 days. And should have been addressed in the care plan. Let me look into the care plan. I know there should be a care plan in place when resident refusing medication. Much more it is insulin, I know resident (R3) blood sugar went up to 523 and she was sent to the hospital. V3 was asked what was or is the plan. Since, R3 was refusing her medications including insulin. V3 said, Yes, I understand that there should have been a plan to address this problem. I need to talk to the doctor. After review of R3's full care plan it was documented that R3 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Included in the intervention is diabetes medication as order and to document and record side effects and effectiveness. But refusal of diabetic or any medication was not addressed as an identified problem. Facility's Medication Administration Policy dared 1/1/2015 in part reads: Documentation of medication administration is recorded on the Medication Administration Record (MAR) includes the date, time and initials of the licensed nurse who administered the medication. Medication and Treatment Refusal Policy not dated in part reads: Under procedure: Should a resident refuse his or her medication, documentation must be recorded concerning the situation. Documentation pertaining to a resident's refusal will include as a minimum (in part): The resident's response or reason(s) for refusal. The date and time that the physician was notified as well as the physician's response. Note: Cardiac, [CONDITION(S)], oral glycemic, insulin refusal must be reported to physician each time refused.

Based on observation, interview and record review, the facility failed to ensure that a resident (R23) remained free from physical abuse. This failure resulted in R23 being slapped in the face and sustaining bruising to R23's eyes. Findings include: R23's Face sheet documents that R23 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's Brief Mental Status Interview (BIMS) dated 03/16/22 documents that R23 has a BIMS score of 15 which indicates that R23 is cognitively intact however when R23 was interviewed by Surveyor R23 was reluctant to respond to most of the Surveyors questions during R23's interview. On 06/07/22 at 1:51 pm, V3 (Assistant Director of Nursing/ADON) was interviewed regarding R23 on day of incident. V3 stated that on 06/03/22 around 3:30 pm, V17 (Licensed Practical Nurse/LPN) asked V3 to come to room R23's room to see R23's eyes. V3 stated that V3 and V17 observed R23's right eyelid was discolored red. V3 stated that R23 stated, A staff member slapped me (R23) in the face and bruised my eyes. V3 stated that R23 described a staff member V12 (Certified Nursing Assistant/CNA) as the person who slapped R23. V3 also stated that V3 reported to V1 (Administrator) R23's allegations that V12 slapped R23, called the local police department, R23's physician and R23's family immediately upon R23's statement. V3 stated that V3 had already left the facility for the day. During surveyors review of R23's EHR (Electronic Health Record) progress note, there was no documentation that V3 informed V1(Administrator) of R23's allegations regarding V12. On 06/07/22 at 3:06 pm, Surveyor observed R23 in bed with reddish purple bruising to right and left upper eyelid areas. When R23 was asked what happened to R23's right and left upper eyelid areas R23 stated that R23 and a Certified Nursing Assistant (CNA) who was identified as V12 (CNA) got into a physical fight at the nurses' station a week ago after R23 threw a cup at V12 and grabbed V12 arms. R23 stated that V12 followed R23 into R23's room and slapped R23 in R23's face with an open hand causing R23's eyes to turn red. On 06/08/22 at 11:40 am, Surveyor and V1 (Administrator) viewed the video recording from the second-floor unit nursing station area and elevator area from 06/03/22 at 7:27am. Surveyor and V1 observed at 7:26 am, R23 pacing down the second-floor hallway with an empty water pitcher in R23's hand. At 7:27 am, R23 was then observed at the nursing station throwing the empty water pitcher at nursing staff member identified as V12 (CNA) and hitting V12 on V12's left side. R23 then walked away from V12 after R23 threw the empty water pitcher and proceeded to pace down the Y hallway. R23 returned to V12 at the nursing station and hit V12 on V12's arms. V12 was then observed directing R23 to go near the elevator area. As R23 walked towards the elevator area V12 was observed following R23 towards the elevator and R23 began to grab and hit V12 again in V12's head and body. Another staff member identified as V19 (Certified Nursing Assistant/ CNA) was then observed holding R23's left arm. While V19 was observed holding R23's left arm, R23 grabbed V12's hair and V12 then swung at R23 striking R23's right eye and cheek bone area with V12's open right hand. At 7:28 am, V19 and V12 are observed directing R23 down the hallway towards R23's room. V12 and V19 followed R23 inside of R23's room and was observed staying inside of R23's room for approximately 15 seconds before leaving R23's room and returning to the second-floor hallway nurses' station area. On 06/08/22 at 11:57 am, V12 (CNA) was interviewed regarding the incident with R23 on 06/03/22. V12 stated that on 06/03/22 around 7:30 am, V12 was passing breakfast trays at room XXX across from the nurses' station and R23 threw a pitcher at V12. V12 stated that no nurse was on the second-floor unit and that V12 informed V19 (CNA) that R23 threw a pitcher at V12. V12 stated that 2 minutes after R23 threw a pitcher at V12, V12 then started hitting V12 and V19 rescued V12 from R23 hitting V12. V12 stated that while R23 was hitting V12 and pulling V12's hair, V12 reached V12's arm out to stop R23. V12 stated that V12 and V19 then asked R23 to go back to R23's room. V12 denied escorting R23 inside of R23's room. V12 stated the nurse was still not on the second floor and that V12 reported the incident to V3 (Assistant Director of Nursing/ADON) on 06/03/22 around 8:00 am. V12 stated that V12 saw R23 again at lunch time on 06/03/22 and did not observe any bruising to R23's eyes. V12 stated that V12 saw R23 again around 2:00 pm on 06/03/22 coming from room YYY with no bruising from R23's eyes. V12 stated that V12 last saw R23 on 06/03/22 at 3:05 pm in bed sleeping and denies seeing bruising to R23's eyes. V12 stated that V12 is aware of the types of abuse and that all allegations of abuse are to be immediately reported to V1 (abuse coordinator). V12 stated that I (V12) was called at home on 06/04/22 and that I (V12) would be taken off the schedule while an abuse investigation with R23 is being conducted. On 06/08/22 at 12:38 pm V19 (CNA) was interviewed regarding the incident that occurred on 6/3/2022 with V12 and R23. V19 stated, R23 on 06/03/22 at around 7:30am, I (V19) heard V12 (CNA) yelling out from the nursing station that R23 threw a cup at V12 while V12 was serving breakfast trays in the hallway near room XXX. V19 stated that after R23 threw the cup at V12, R23 asked for a mask and then started hitting V12 while V12 was standing at the food cart at the nurses' station. V19 stated (V19) told R23 to stop and for R23 to go to R23's room. V19 denied seeing V12 hit R23 during the altercation. V19 stated that V19 and V12 escorted R23 to R23's room but denied entering R23's room. V19 stated that V19 and V12 called V3 to the second floor and reported the altercation with R23 around 8:30 am. V19 denied ever seeing R23's eyes discolored on 06/03/22. V19 stated that V19 is aware of the types of abuse and that all allegations of abuse are to be immediately reported to V1, the abuse coordinator. On 06/08/22 at 3:27 pm, V17 (Licensed Practical Nurse/LPN) was interviewed regarding R23's reddish purple discolored right and left upper eyelids and V17 stated that on 06/03/22 V17 arrived on the second-floor unit around 3:30 pm and began rounding in residents' rooms. V17 stated that when V17 entered R23's room R23 was observed with red discoloration to both of R23's upper eyelids. V17 stated that V17 tried to wake R23 to ask R23 what happened to R23's eyes but R23 was not responding. V17 stated that V17 then asked the 7:00 am- 3:00 pm nurse, V10 (Licensed Practical Nurse/LPN) what happened to R23's eyes and V10 stated that V10 was not aware. V17 stated that V17 called V3 (ADON) to the second-floor unit to inform V3 of the discoloration to R23's eyes. On 06/09/22 at 1:49 pm, Surveyors and V1 reviewed the video recording from the second-floor unit nursing station and elevator area dated recorded on 06/03/22 at 7:27 am. During the video review, V1 was asked where did R12's right open hand land on R23 from the observation in the video. V1 stated, It landed on R23's face. When V1 was asked if V12 and V19 followed the facility's abuse policy V1 stated, No they (V12 and V19) did not. I am still investigating this allegation. V1 was asked if V12 and V19 had abuse training at the facility. V1 stated, Yes. On 06/09/22 at 2:27 pm, V27 (R23's Physician) was interviewed regarding R23's right and left upper eyelid areas. V27 stated that I (V27) was notified on 06/03/22 that R23 was having behaviors and threw a cup of water at staff and had a cut over R23's left eye area. V27 stated that I (V27) gave orders for R23 to be placed on 1:1 monitoring and for the psychiatrist to be notified of R23's behavior. V27 denied that I (V27) was made aware that R23 was in an altercation with staff and was hit by staff on R23's right side of R23's face. V27 was asked what could happen to R23 if R23 is hit in the face by staff with an open hand striking R23's right eye and right cheek area. V27 stated, It (referring to being struck with an open hand in the right eye and right cheek area) is dangerous and can cause a scratch, an abrasion, a break in the skin, or bleeding in the eyes. R23's Treatment Administration Record (TAR) with orders dated June 7, 2022, documents monitor skin discoloration to the left eyelid every shift for 7 days. R23's Progress notes dated 06/03/22 at 17:03 authored by V3 documents, in part: During rounds resident (R23) observed with left eye lip (referring to R23's right eyelid) discoloration . MD call ice pack applied, [MEDICATION(S)] apply for 7 days. V12's timecard report reviewed for 05/29/22 through 06/11/22 documents, V12's last In punch on 06/03/22 at 7:05 am, and Out punch on 06/03/22 at 3:13 pm. Facility's document dated May 2, 3, 4, 2022 and titled Abuse documents, in part that V12 was in-serviced regarding the facility's abuse policy. On 06/09/22 at 2:00 pm, Surveyor requested for V19's abuse in-servicing, V1 was unable to provide. Facility's document dated 11/28/16 and titled Abuse Prohibition Policy and Procedures documented, in part: Guidelines: The resident has the right to be from abuse, neglect, misappropriation of resident property, and exploitation . Definition: Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish . Internal Investigation: All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation . Orientation and Training of Employees: Staff obligations to prevent and report abuse, neglect, exploitation, mistreatment and misappropriation of residents property . An employee's obligation under the law for reporting a suspected crime to the facility, the state survey agency and local law enforcement; the time frames for reporting; and state survey agency and local law enforcement; the timeframes for reporting and management's obligation to prohibit retaliation against anyone who makes a report. On an annual basis, staff will receive a review of the above topics. On an annual basis, supervisory personnel will receive training on their obligations under law when receiving an allegation of abuse, neglect or misappropriation of resident property, and how to monitor and correct inappropriate or insensitive staff action, words or body language. Internal Reporting Requirements and Identification of Allegations: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator . Reports should be documented and a record kept of the documentation . External Reporting: All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or results in serious bodily injuries . Five-day Final Investigation Report: Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.

Based on observation, interview and record review, the facility staff failed to ensure timely intervention was done resulting to a cognitively impaired, dependent, elderly resident waiting in pain for 6 hours who was found to have a closed displaced right tibia and fibula fractures of the right leg along with 4 toe fractures of the right foot for 1 (R1) of 3 residents reviewed for accidents. These failures resulted in R1 sustaining a closed displaced fractures of the right tibia, the proximal Fibula and 4 toes on the right foot from an unknown source and waiting for 6 hours before procedure was done to confirm the injury. The finding include: On 3/31/22 at 10:10 AM, R1 is sleeping in her bed and not able to be aroused. R1 is laying on her right side with ace bandage, a compression wrap on her right lower leg from ankle to the thigh. The bed is in its lowest position which is 20 inches from the floor to top of the mattress. There is no floor mats or alarms. On 3/31/22 at 11 AM, V1 (administrator) stated V1 has done some interviews but has not interviewed the staff on duty that discovered the fractures. V1 stated she is still acquiring interviews and investigating it. R1 is an [AGE] year old, dependent female who was admitted to the facility on [DATE] per the face sheet. R1's quarterly Minimum Data Set (MDS) dated [DATE] documents her brief interview mental score (BIMS) of 3 which means R1 is not able to be interviewed due to cognition. The MDS documents R1 to require extensive to total care for her needs, is frequently incontinent of bowel and bladder and is non-ambulatory. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/31/22 at 1:10 PM, V3 (Licensed Practical Nurse/LPN) stated R1 is very restless when up in wheelchair so R1 will be laid down in bed to ease restlessness and falls asleep. V3 stated that R1 is usually seen sitting up in bed. On 3/31/22 at 1:17 PM, V2 (Licensed Practical Nurse/LPN) stated V2 works days 7 AM to 3 PM. V2 stated when V2 did rounds in the morning, R1 was seen up and dressed in a wheelchair. V2 stated that it was near the end of the shift when V4 came to tell me about R1's leg that is swollen and red and R1 is in a lot of pain. V2 goes to assess R1 and sees her right leg is red and swollen. V2 stated R1 was in the bed when she assessed her. V2 stated R1 denies pain until her leg was touched then she would scream out in pain. V2 stated she calls V8, the attending physician who orders x-rays. V2 stated she contacts portable x-ray company to find out it is an estimated time of arrival is 6 hours. V2 stated she did not call back physician to inform him of the 6-hour wait and she endorsed it over to oncoming shift. V2 stated that the facility's fall interventions are call light within reach, frequent rounding every 2 hours, lower the bed, put in supervised area and use of floor mats. V2 stated she thought maybe R1 had a floor mat when informed that there is no floor mat on floor or in R1's room. V2 stated the restorative nurse has been here 3 days and the Director of Nursing (D.O.N.) has been here one week. On 3/31/22 at 1:30 PM, V4 (Certified Nurse Aide/CNA) states R1 was dressed and up in the wheelchair at the start of the 7 AM to 3 PM shift on 3/29/2022. V4 stated it was after lunch near end of the shift when V7 asked for help with transferring R1 from the wheelchair to the bed. V4 stated R1 voiced take it easy and was guarding her right side as R1 is put into the Hoyer lift. V4 asked what is the matter?, R1 did not say. V4 said R1 is on the bed when they start to remove her clothes. V4 stated as she pulled down R1's pants, R1 cried out, ouch and R1's right leg is red and swollen. V4 stated that R1 is in a lot of pain when the right leg is touched and she will cry out. On 3/31/22 at 4:30 PM, V5 (11 PM to 7 AM CNA) stated that R1 is never gotten out of the bed on the night shift. V5 stated he provides care to R1 during the night and is careful because R1's legs are so severely contracted. V5 stated that a lot of caution is needed when caring for R1. V5 stated R1 is not combative during care. On 3/31/22 at 5:09 PM, V7 (assigned CNA) to R1, stated that R1 was in the bed at 7 AM when shift was started on 3/29/22. V7 stated that it was after the breakfast meal around 9:30 AM when she asked V4 to help her with incontinent care for R1. V7 stated when they both entered the room, R1 was in the bed and when they started to perform incontinent care, R1 screamed out in pain. R1's right leg is red and swollen. V7 states that V4 went to inform the nurse, V2. Informed V7 that her account does not line up with the other staffs' interviews, V7 response is just telling you what I know. On 4/1/22 at 7:47 AM, V6 (Licensed Practical Nurse/LPN) stated that residents on the night shift are not gotten up. It is the day shift's responsibility to get residents up for the day. V6 stated V5 has worked for the facility for [AGE] years and is a caring CNA. V6 stated that R1 is very contracted in the legs and extreme care is needed when caring for R1. V6 stated R1 can get combative when up in wheelchair so R1 is laid down to ease her restlessness and R1 falls asleep. On 4/1/22 at 8:53 AM, V8 (Attending Physician) stated R1 is very demented and disoriented and cannot say what happened to her. V8 stated R1 is severely contracted in the legs and has been since admission to the facility 2 and half years ago. R1's legs are not able to be straighten. V8 stated he was aware of the fractured right tibia and fibula but was not aware of the fractured toes (2nd to 5th toes). V8 stated R1 was sent to the hospital again last night due to the amount of pain R1 was experiencing. V8 stated not to know why an orthopedic surgeon did not examine R1 while in emergency room but does understand that there is not much to do with these type of fractures and R1 is non-ambulatory. V8 stated that the Orthopedic Physician will examine R1 today and decide if surgery is warranted. V8 stated he cannot say how the fractures occurred because R1 is not ambulatory and requires staff's assistance. The hospital x-rays dated 3/29/22 at 00:36 show acute fracture of the distal third of the tibia with prominent displacement, a fracture of the proximal fibula with soft tissue swelling and postop hardware in the 1st proximal phalanx fracture of distal 2nd to 5th metatarsals. On 4/1/22 at 12:45 PM, V1 (Administrator) stated V1 was told that the injury was noted in the morning of the 3/29/22. Explained that 2 staff members, V4 (CNA) and V2 (LPN), both said it was found in the afternoon before the end of the day shift. V1 agreed that someone is not being forthright. V1 confirmed that restorative nurse and D.O.N. are new to the facility and have been here less than one week.

Based on observations, interviews and record reviews, the facility failed to monitor and supervise 2 of 2 residents (R8 and R11) reviewed for illicit substance use out of 7 residents (R8, R12, R13, R14, R15, R16, R17) reviewed for substance abuse history. This failure resulted in R8 being found unresponsive, [MEDICATION(S)] given and R8 being transferred to the hospital for drug overdose, R8 leaving the facility without authorization and R11 going into [CONDITION(S)], transferred to the hospital, and intubated related to drug overdose. This was identified as an immediate jeopardy situation which began on 03/09/2022. On 03/16/2022 the administrator was notified of the immediate jeopardy. The immediate jeopardy was removed on 03/18/2022. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. Findings include: 1. According to a face sheet, R8 is a 60-year resident admitted to the facility on [DATE]. R8's Minimum Date Set assignment dated 01/05/2022 indicated R11 has a Brief Interview for Mental Status (BIMS) score of 14, which indicates resident has intact cognitive response. R8's care plan dated 01/06/2022 indicated resident has a history of alcohol and cocaine abuse and resident last relapse occurrence was on 8/3/21 and 11/30/21. R8's Nursing Progress Note (dated 01/27/2022 11:54pm) documents: 11.15pm resident came to report to the nurse that R8 was not breathing. Nurse entered the room resident noted in bed lethargic, non-responsive to verbal or tactile stimulation. Call placed to 911. 11.30pm Emergency crew arrived resident transferred to the closest hospital. R8's Nursing Progress Note (dated 01/28/2022 12:42pm) documents: Resident admitted to hospital with dx of drug overdose. R8's Hospital Records (dated 01/28/2022) documents: Patient brought from nursing home with complaint of drug overdose, found unresponsive and [MEDICATION(S)] was administered. Patient states he had a bag of drugs that was supposed to be cocaine, but thinks dealer gave him heroin instead. R8's Social service note (dated 01/31/2022) documents R8 was involved with an illegal transaction regarding drugs, with peers witnessing R8 conducted the transaction in which co peers was involved with as well. The facility failed to put R8 on 1 to 1 supervision immediately after the surveyor notified the administrator R8 admitted to leaving the facility without authorization using the back door, R8 was not placed on 1 to 1 supervision unit 6:11pm. R8 progress note (dated 3/9/2022 18:11) documents: R8 continues to leave the facility unauthorized, counseling implemented but the resident refuses teaching by staff. On 03/09/2022 at 1:50pm, R8 stated I was given crack cocaine. On 01/27/22 I used crack cocaine. On 01/27/2022, I didn't leave the facility and another resident from this facility brought me the drugs to my room. There are a lot of residents here that use drugs, so another resident gave me the phone number for a drug dealer, and I contacted the drug dealer recommended by the resident. I won't tell you who told me the name and phone number of the drug dealer. There are a lot of residents here who are using drugs. I know for a fact that there are a lot of residents who do drugs here because we smoked crack-cocaine together here in this facility on many occasions, that's how I know that these residents here take drugs. We get together with some of the residents here and we use drugs together. If I cannot go out into the community because they take my community pass away from me, and I am not able to meet up with the drug dealer to buy the crack-cocaine, then another resident will meet with the dealer and bring me the drugs to my room. I cannot go out right now because they took my pass away, so yesterday (03/08/2022), I used the basement back door to sneak out of the facility and I went to the gas station and drank a 6 pack of beer, and I came back through the front door, and nobody noticed that I was out. There is a back door that I use to leave the facility whenever I want, especially when they refuse to give me the pass to go out into the facility. R11 is my roommate, and R11 saw me do drugs many times. R11 knows that I do drugs and R11 saw me do it many times. I did not give R11 drugs, so R11 must have gotten the drugs from another resident. On 03/09/2022 at 9:30am, V3 (Assistant Director of Nursing) stated, On 01/17/2022, we found R8 unresponsive, we did not know what was happening to R8, so we sent R8 to the hospital. The hospital confirmed R8 overdosed. R8 has been a resident of our facility for a while and has had a problem with substance abuse in the past. R8 is here back from the hospital. R8 has community pass privileges currently revoked. We did not do an investigation on this incident because it was a medical emergency so there was nothing to investigate. On 03/09/2022 at 10:48am V2 (Director of Nursing/DON) stated, When I looked at R8's hospital records, the records stated R8 only has a history of drug overdose. It did not state R8 overdosed on 01/27/2022. On 03/09/2022 at 11:36am, V1 stated, All I know is on 01/27/2022, R8's nurse went into R8's room and found R8 on the bed unresponsive. R8's nurse called 911 and the paramedics arrived and decided to administer [MEDICATION(S)] to R8. After the paramedics administered the [MEDICATION(S)], they transported R8 to the hospital. I asked R8's nurse if there were any injuries and R8's nurse said that R8 did not have any injuries. We sent R8 to the hospital for a medical emergency, and I did not do an incident report or an investigation of the overdose because R8 had a medical emergency because there was nothing to investigate. 2. According to a face sheet, R11 is a 54-year resident admitted to the facility on [DATE]. According to physician note dated 02/11/2022, R11 has a history of Diabetes Mellitus type II, GERD, [CONDITION(S)] Arthritis, [CONDITION(S)], [CONDITION(S)], cigarette smoking addiction, Obesity. Class II. R11's Minimum Date Set assignment dated 01/25/2022 indicated R11 has a Brief Interview for Mental Status (BIMS) score of 13, which indicates resident has intact cognitive response. R11's care plan dated 01/04/2022 indicated resident has a history of depression and scores a 14 out of 27 on the PHQ9 (Patient Health Questionnaire) which is indicative of the presence of mood symptoms and alteration in mood state which is evident in the areas of psychosocial well-being, adjustment and coping challenges, increased dependency, energy, and emotional distress R11's Nursing Progress Note (dated 02/18/2022 4:56am) documents: At 1.40 AM, NOD (Nurse On Duty) noted this resident sitting on the chair on the Hallway sleeping, having difficulty in breathing, Non responsive to Calls and other Stimuli. Breathing very shallow with Oxygen Saturation at 57% HR 103. At 1.44 am, Code Blue announced and 911 team called. Oxygen at 5L administered via Nasal Cannula. At 1.53 am,911 arrived and continued with resuscitation. Administered [MEDICATION(S)] injection to this resident and R11 answered his name but remain very weak and Lethargic. At 2.02 am, resident was picked up by 911 ambulance to the hospital. ADON made aware of this situation. R11's Nursing Progress Note (dated 02/18/2022 at 7:44am) documents: At 7.28 am, NOD placed call to the hospital and confirmed this Resident admitted into the ICU with DX of Drug overdose. R11's Hospital Discharge Summary (dated 02/22/2022) documents that R11 presented to the emergency room with possible drug overdose from nursing home after R11 took unknown pill. R11 was found to have pinpoint pupil and was given [MEDICATION(S)] and became more alert afterwards. R11 was intubated. R11's admitting diagnosis is accidental drug overdose. On 03/09/2022 at 1:39pm, V6 (Certified Nursing Assistant/CNA) stated, R11 does not go out to the facility independently. R11 goes outside to smoke and returns back into the facility. R11 only visitor comes to visit R11 is R11s mom. I don't know how R11 got access to drugs. I don't know how R11 got drugs because on 02/17, R11 did not go out on pass. I know we have new residents in the building, but I don't know how R11 got access to illegal drugs. On 03/11/2022 at 12:17pm, V11 (Licensed Practical Nurse/LPN) stated, On 02/18/2022, R11 had a doctor's appointment during the day and was back in the facility. When I came in in the evening shift, R11 was in a chair, and I heard R11 snoring loud. I called R11 name and attempted to wake R11 up, but R11 was not responding to any stimuli. I called a code and checked R11's vitals. R11's oxygen was in the 60's. R11 was slumped over and drooling. We called 911 and they asked me what time I saw R11 last, which I explained that I start my shift at 11:30pm and I just basically started my shift, so I saw the resident close to 11:30pm. R11 was found slummed over and unresponsive at 1:40am. The paramedics administered [MEDICATION(S)] and R11 responded to the [MEDICATION(S)] right away, and then the paramedics took R11 to the hospital because R11 became unresponsive again. On 03/11/2022 at 12:40pm, V12 (Registered Nurse) stated, On 01/27/2022, I sent R8 to the hospital because R8 was lethargic and non-responsive. The last time I saw R8 was at 9 pm when R8 came to me to get R8's bedtime medication, so that was the last time I saw R8. Around 11pm, R8's friend came and notified me that something is wrong with R8. I went to R8's room and saw R8 on R8's bed and R8 was unresponsive, so I called a code, and we applied oxygen to R8 and we called 911. The paramedics came and I am not sure if [MEDICATION(S)] was given because other staff was there but shortly after the paramedics took R8 to the hospital. On 03/11/2022 at 2:21pm, V15 (R11's Nurse Practitioner) stated, R11 does not have a drug use history. [MEDICATION(S)] is given in an emergency during a narcotic episode. It is used in an emergency during a drug overdose situation. It is given during a drug overdose. 3. Staff interviews were conducted related to R8 and R11 and revealed the following: On 03/09/2022 at 9:20am, surveyor requested facility drug overdose incident report and investigation for R8 and R11. V3 (Assistant Director of Nursing/ADON) and V1(Administrator) informed the surveyor that no indecent report and investigation was done because this was a medical emergency and did not require an investigation and reporting. On 03/09/2022 at 9:30am, V3 stated, R11 was sent to the hospital on 02/18/2022 because of a medical emergency so we did not do an investigation. On 03/09/2022 at 10:48am V2 (Director of Nursing/DON) stated, When I looked at R8's hospital records, the records stated R8 only has a history of drug overdose. It did not stated R8 overdosed on 01/27/2022. On 03/09/2022 at 11:36am, V1 stated, There was no incident report or investigation done for R8 and R11 because these two residents were sent to the hospital due to change of status. The only documentation we have for both R8 and R11 is the nursing progress note, that's all. R8 and R11 was sent out because of a medical change of condition. On 03/09/2022 at 11:36am, V1 stated, On 02/17/2022, R11 did not overdose on drugs. On 02/17/2022, we sent R11 to the hospital for a medical emergency. R11's admitting diagnosis was respiratory failure. R11 did not overdose on drugs. I did not know that R11 was administered [MEDICATION(S)] at our facility. There was progress note made on R11's condition and that we sent R11 to the hospital. I did not do an incident report nor an investigation because R11 had a medical emergency, so there was nothing to investigate. 4. On 03/09/2022 at 2:20pm, the surveyor made V1 (administrator) aware R8 informed the surveyor, R8 sneaks out of the facility using the back ramp ambulance entrance to go to the gas station and buy beer. The surveyor accompanied V1 to observe the back door used by R8 to leave the facility unauthorized. V1 stated, the facility will change the security code on all doors. V1 informed that R8 stated that other residents bring drugs into the building on regular basis. On 03/10/2022 at 11:13am V8 (Maintenance Director) stated, If the facility administrator tells me the facility security access codes need to be changed because it is compromised so what I do is I call the company and they come out and change the codes. What happened is we have two security systems on the back ambulance ramp door. One alarm alerts the front desk which that alarm is always active. If anyone leaves out that door without putting in the security code, it will alert the front desk. The second alarm is a magnetic lock with a siren. That magnetic lock w2as disabled and the company Hollow point was called couple of weeks ago to come and do maintenance on it and fix it. They have not come out to fix it. Yesterday, on 03/10/2022, I called the security company again and followed up with them to come out and fix the other security system. So the reason why the resident, R8, was able to go out the back door was because the second security system was not working at all. I called the company, and I am waiting for them to come and fix it, they are supposed to come and fix it today. So basically, we only change the security codes when there is a need such as the codes have been compromised. I was aware that the magnetic lock was not working, and I have called the company a couple of weeks ago. Because the magnetic lock has not been working for weeks, the residents are able to leave through the back door, but they cannot come back through the back door, but they are able to leave through the back door. The alarm will sound, and it will alert the front receptionist that someone without the code opened the door and they are supposed to come to the back door immediately when they hear the back door alarm. Door Alarm Inspection Record (dated 02/18/2022) documents that the northwest ramp exit door used by R8 to leave the facility on multiple occasions without authorization was identified as failing inspection and not sealing the door properly on 02/16/2022. Email Communication to the security company (dated 02/16/2022) documents, V8 (maintenance director) notifying the security company that the Northwest Ramp Exit Door used by R8 to leave the facility on multiple occasions without authorization failed the inspection and the security feature was not sealing the door properly. 5. On 03/10/2022 at 12:25pm, V9 (Social Service Director) stated, Currently, we have 7 residents (R8, R12, R13, R14, R15, R16, R17) with history of substance abuse. Some of the residents with the substance abuse history are placed on the 3rd floor, that's how we monitor them. On 03/09/2022, when the back door alarm went off, which is after the state surveyor made facility aware of R8's unauthorized leave, the staff saw R8 leaving on camera and the staff ran out after R8 and followed R8 for a while, and finally R8 returned back. Currently, R8 has a restriction on community pass privileges. R8 had community pass privileges revoked before, due to alcohol, because R8 returned into the facility intoxicated, so we revoked R8's pass and we moved R8 to the 3rd floor in the past. We had a big problem before with a lot of residents using drugs inside the facility. R8 escaped 3 times through the back door on 03/09/2022, after the surveyor made the administrator aware that the back door is breached and residents can escape, R8 escaped a total of 3 times, and after R8's 3rd elopement attempt, R8 was placed on 1 to 1 supervision. V10 (Behavioral Aide) was placed on 1 to 1 to monitor R8, but R8 was able to escape away from V10 (behavior aide) because V10 walked away from R8, did not have R8 in visual field to go get a chair, and R8 took advantage of the fact that V10 (behavior aide) walked away to escape again, and we had to run outside after R8. I attempted to place R8 to the 3rd floor, but R8 refused for us to place R8 to the 3rd floor. We cannot force R8 to go to the 3rd floor. I talked to R8 on several occasions, I did not talk to R8's physician and inform R8 that R8 is using drugs and attempting to elope to get drunk. I don't know what R8 is on parole for. I did not ask what R8 is on parole for, because I did not want to be in R8's business. On 03/08/2022, R8 told me that R8 told the parole office and R8 did drugs and will continue to do drugs. After R8 told me that R8 admitted to the parole office that R8 does drugs, I was trying to change rooms for R8, to put R8 from the first floor to the 3rd floor, but R8 refused, and I can't force R8. I did not petition R8 and send R8 out. R11 does have community pass privileges and only goes to get some fast food and comes right back. I don't believe that R11 overdosed. I know that the progress notes and the hospital record say that, but I don't believe that R11 uses drugs, R11 did not have any drug use history prior to this incident. On 03/10/2022 at 2:49pm V1 (administrator) stated, When we have a resident in the building on parole, we are required to know what the resident is on parole for. I do not know what R8 is on parole for. I am not sure; I would have to go and check. If they are on parole, we do the background check and we have a process in place for monitoring R8. The social service director and the social service team is responsible for knowing what the resident, R8, is on parole for, so that we don't put vulnerable residents in place. It is the responsibility of the social service director and social service staff to know what R8 and other residents on parole are on parole. Not knowing what residents are on parole for, poses a significant threat to vulnerable residents and other residents in the facility, especially because the resident on parole can cause harm to other residents. Not knowing the reason why residents are on parole, can have a big significant harm to the residents in the facility. I don't know what if there are other residents in the building that are on parole. After I was notified by you (state surveyor) that R8 elopes from the facility using the back door, I got in touch with maintenance director, and notified the maintenance that R8 has access to the codes or that there is a possibility that R8 knows the codes, and asked maintenance to change the codes. About 10 minutes after I was notified that R8 escapes I would say about 2:40pm, I asked V2 (ADON) to have the resident placed on 1 to 1 observation due to the elopement. Approximately around 3:30pm, V2 (ADON) told me R8 was placed on 1 to 1 and the 1 to 1 was assigned to V10 (behavior aide). On 03/11/2022 at 2:40pm, V10 (Behavioral Aide) stated, They asked me to provide 1 to 1 supervision for R8 around 8pm on 03/09/2022. They asked me to watch R8 because R8 was attempting to leave the facility unauthorized after several attempts. So around 8pm I started to watch R8 for 1 to 1 supervision. R8 ran out the back door and went out of the facility unauthorized, and I followed R8 out of the facility and brought R8 back. I heard the alarm and saw R8 leaving through the camera, I followed R8 and brought R8 back into the facility. I was providing 1 to 1 until the ambulance arrived which was around 9pm. The ambulance arrived around 9pm and took R8 to the hospital. The facility's Security, Supervision & Safety Policy (undated) states: Acute or sustained visual monitoring or 1:1 observation on a time limited basis is provided as necessary for residents demonstrating an increase in psychiatric symptoms or aggressive behaviors. The facility routinely identifies hazards and risks; evaluates and analyzes hazards and risks; implements interventions to reduce hazards/risks. On 03/11/2022 at 1:13pm, V14 (Nurse Practitioner) stated, I am familiar with R8 using drugs and alcohol. I was notified R8 was transferred to the hospital due to drug overdose. I believe the social worker was helping R8 with R8's substance abuse problem. [MEDICATION(S)] is for people who overdose on drugs and is used to resuscitate a person and bring back. The facility's Behavior Management Contract (undated) lists using non-prescribed drugs and alcohol as inappropriate and unacceptable behaviors. On 3/18/2022 the surveyor confirmed via observation, record review and interview facility did the following to remove the immediacy: 1. R8 has returned to the facility. Resident is in stable condition. Resident is currently attending substance abuse program, and symptoms management. Initiated and completed 3/15/22. R8 was reassessed for community access and substance use. R8 placed on community pass restriction and re-educated on facility behavior management. R8 care plan was reviewed and updated accordingly. Initiated and completed 3/16/22. 2. R11 has returned to the facility. Resident is in stable condition. He participates in activities. No further incidents noted. Initiated and completed 2/22/22. R11 was reassessed for community access and substance use. R11 placed on community pass restriction and re-educated on facility behavior management. R11 care plan was reviewed and up-dated accordingly. Initiated and completed 3/16/22. 3. All residents were in-serviced on the community pass policy with emphasis on Contraband to prevent drug and alcohol trafficking and ensure resident safety. Retention of training will be verified and ongoing to account for new admissions and readmissions by Activity Consultant. Initiated 3/16/2022. 4. Efforts to prevent the sale and use of illegal drugs within the facility: Behavior aides, nurses, C.N.A, and receptionist will be checking residents' personal items upon entry to the facility including but not limited bags, shoes, pockets, opened packages such as food, cups, delivered items from restaurants, delivery services etc. New procedure is adding behavior aides to the supervision and monitoring process Pass restriction will be instituted for all violators of the Community pass policy, Behavior Contract for Substance abuse, and Behavior management contract. Initiated 3/16/22 and ongoing to account for staff on leave of absence, vacation and new hires. 5. Efforts to ensure an effective monitoring system: Initiated 3/16/22 andOngoing. Signage/posting indicating the facility will search all personal belongings including but not limited to bags, shoes, pockets, opened packages such as food, cups, delivered items from restaurants, and delivery services upon entry into the facility. IDT conducts assigned regular rounds during shift to ensure visual monitoring and staff supervision; Rounds are conducted every shift checking stairwells, basement, halls and doorways. Currently the facility have elopement binders placed on each unit updated as needed by social services to identify residents at risk for unauthorized leave/elopement. In addition, for added monitoring staff including Behavior Aides, CNAs, RAs, are assigned to monitor the doorway and stairwell for any unusual activity or exit seeking behaviors and report the activity to the nurse on duty and social services. Daily and random room searches of anyone suspected of use or distribution of illegal substances. Initiated 3/17/22 and ongoing to account for new admissions and re-admissions. Social Service has identified all residents with history of substance use have been assigned to attend one or more internal groups. Social Service has identified all residents with history of substance use have been recommended for available external substance abuse recovery program. Six residents have been identified as substance abusers. Staff were made aware of the 6 identified substance abusers. All staff are expected to report any suspicious substance use and/or behavior immediately to Administrator, DON, ADON and Social Service Director. 6. Effort to supervise residents to prevent residents from leaving facility unauthorized: The alarm company (xyz technology solutions) is currently inspecting ramp door alarms to ensure proper functionality. Maintenance staff are checking the doors daily for proper alarm functionality. Initiated 3/16/22 and ongoing: Initiated and completed 3/16/22. 7. All residents with identified substance abuse issues have been reassessed and care plans updated accordingly. Initiated 3/16/22 and ongoing to account for new admissions and re-admissions. 8. An emergency resident council meeting was called to explain the behavior management contract, substance abuse contract and community access behavior contract. Residents were notified at emergency resident council meeting. Initiated and completed 3/16/22. 9. Family members, POA and responsible parties notified via electronic messaging system. Initiated and completed 3/17/22. 10. All staff were in-serviced on the community contraband list to prevent drug and alcohol trafficking, substance abuse disorder, community access, signs and symptoms of substance abuse, staff supervision, and conducting person and belonging searches to ensure resident safety. In-service will include a post test. Retention of training will be verified by Director of Behavioral Health and Assurance. Initiated 3/17/22 and ongoing to account for staff on leave of absence, vacation and new hires.

Based on interview, and record review, the facility failure to monitor the [MEDICATION(S)] level of one resident (R6) out of 3 residents (R6, R11 and R12) receiving [MEDICATION(S)]. This failure has caused R6 to be hospitalized with [MEDICATION(S)] overdose. Findings included: Face sheet documents R6 was admitted to facility on 10/14/2020. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . January Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Records shows no order for [MEDICATION(S)] level since R6's admission on 10/14/2020. Progress note dated 1/29/22 11:30 am reads; Narrative: During this shift writer observed resident (R6) being lethargic. Mumbling with words and could not follow command. V/S taken, was not registering, noted with shallow breathing and desaturating. Writer informed Assistant Director Of Nursing (ADON), 911 called and arrive at 12:45 PM and took over resident care. First responder departed the facility around 12:57 PM to xx xx Hospital. Progress note dated 1/6/22 reads: Resident with c/o blurred and fading vision, no eye pain or drainage. Progress note documents R6 was admitted into Intensive Care Unit with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The complaint intake documents R6's [MEDICATION(S)] level upon hospitalization was 3.2 and that the [MEDICATION(S)] range should be 0.8 to 1.2. Medication Regimen Review (MRR) dated 12/31/21 reads: R6 is receiving medications which may require routine laboratory monitoring. Please consider ordering the following laboratory test, if appropriate. [MEDICATION(S)] level. This document is signed by pharmacist Consultant (V9). The Nurse Practitioner (V10) signed it on 2/8/22. R6 was hospitalized on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Electronic record shows progress notes from psychiatrist on 12/15/20, 1/21/2021 and 8/6/21. None of this notes documents that the [MEDICATION(S)] level was addressed. Facility provided a non - electronic documentation (form typed and hand written) dated 10/26/21; 11/18/21 and 12/19/21 as a psychiatrist progress noted signed by V10. On those forms there is a box for labs orders included [MEDICATION(S)] level. The box is unchecked in all 3 psychiatrist review. There is no order to check [MEDICATION(S)] level. On 02/09/22 at 04:05 PM V1 stated None noted as a response to surveyor request of R6's [MEDICATION(S)] level lab result. Care plan documents: I use [CONDITION(S)] medications [MEDICATION(S)] [MEDICATION(S)], [MEDICATION(S)] medications r/t Behavior management and goals is I will be/remain free of [CONDITION(S)] drug related complications, including movement disorder, discomfort, [CONDITION(S)], gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. And the interventions to achieve it included: Monitor/document/report PRN any adverse reactions of Psycotropic medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/10/22 at 11:38 AM primary care physician (V8) denies ordering [MEDICATION(S)] and stated it is the psychiatrist responsibility. Stated I limited my activity to diabetes and other issues. I never ordered a [MEDICATION(S)] in my life. On 02/10/2022 at 01:26 pm V 10 (nurse practitioner) states I am a family nurse practitioner. I am about to finish my training on psychiatric. There should be a standard order to check the [MEDICATION(S)] level every 3 months. I believe I saw R6 last year. I gave order to the nurses to check the [MEDICATION(S)] level. I have not seen R6 this year. Last time probably was in November or December. Once the results comes back the nurses notify the provider and we will check the level. We don't know when the lab will be there to drawn blood. Checking the [MEDICATION(S)] level is important, of course, because we have to monitor for toxicity. If the patient is having nausea, vomiting, changing mental status, changing in vitals, blurred vision that is a red flag. We don't check the level of the [MEDICATION(S)] only if we see side effects. It is part of the protocol, and it should be checked every 3 months at least. If the facility don't give the GDR, I wouldn't have it, because I don't have access to it. The pharmacy sends the GDR to facility (Director of Nursing -DON or psych nurse) and they will send it to us (provider). We agree or not with pharmacy recommendation. When I give a verbal order for a lab, I absolutely expect to see the result. I didn't ask for the result. I didn't make an adjustment on the [MEDICATION(S)] because I was not notified that the [MEDICATION(S)] level was elevated. We adjust the dosage of the medication ([MEDICATION(S)] and any other meds) for 2 different reasons. If the medication is not effective, the resident is exhibiting symptoms, for instance the mood is not stabilized, than you adjust the medication. And also we adjust the medication (in this case [MEDICATION(S)]) if the level of the medication is elevated. I signed the MRR on 02/08/22 because the facility gave it to me that day. On 02/10/2020 at 03:15 PM V10 stated the Graduation Drug Reduction, per our practice is to be done twice a year to make recommendation to the provider for the [CONDITION(S)] medication. All the other meds active on the resident's profile we review it monthly. I did recommend a [MEDICATION(S)] level lab on December because I didn't see any [MEDICATION(S)] level lab in the chart. I also recommend it on August 2021. The December 31 was a follow up for the August recommendation. V10 said that the records she (V10) had on R6 were from April 2021, and from April to August 2021 there was no [MEDICATION(S)] level documented. On August 2021 she recommended a [MEDICATION(S)] level lab. On December she review it again and because there was no [MEDICATION(S)] level lab V10 recommended it again. On 02/10/22 at 05:57 PM V1 states We are supposed to get the pharmacy review monthly. Even with the [CONDITION(S)]. The pharmacy is supposed to send it to V2 (Assistant Director of Nursing -ADON). On 02/10/22 at 06:00 PM V2 States V9 (Pharmacy consultant) never sent the pharmacy recommendation to me until the day you (surveyor) requested. I go all the time to the pharmacy website and I didn't see any recommendation. They normally will send to me by email. I checked my email from August and it was not there. I never received anything from pharmacy. The pharmacy is supposed to do the medication review each month and send the recommendation to me. If I don't receive it I am assuming there is no problem. If the pharmacy send's to me I need to call the doctor and ask if they agree or disagree with pharmacy recommendation. My responsibility is to ask the pharmacy. When I receive the pharmacy recommendation I email it to doctor or wait until the doctor/NP next visit. I never had anything to give to the nurse practitioner. I never received any order for [MEDICATION(S)] level lab. When you (surveyor) asked for R6's GDR we called the pharmacy and the pharmacy sent it to us. I called the NP and she signed it agreeing with the recommendation. It was on 02/08/22. The NP and doctors could have ordered the [MEDICATION(S)] level when they were here to see the patient. On 02/10/22 at 07:06 PM V1 states Unable to obtain additional information requested from pharmacy in response to request of documentation showing when the pharmacy had sent the MRR with the recommendation for the [MEDICATION(S)] level laboratory test for R6. Facility Policy and procedure on pharmacist Medication Regimen Review revised on 04/01/21 reads: Procedure: Federally mandate standards of care as well as other applicable standards serve the basis for review to ensure that residents' medications are promoting or maintaining the residents' highest level of function in congruence with the residents' therapeutic goals and to identify clinically significant risk and /or adverse medication reaction. It is the responsibility of the facility to assure that each of the recommendations results in a response by either a physician or nurse, as appropriate. And that the documentation of completed medication regimen review should be kept as part of the resident's records to reflect at least twelve months of review.

Based upon interview, and record review, the facility failed to monitor resident and failed to account for shaving material (razor) for one resident (R2) of seven residents in the sample who had a moderate risk assessment for self-harm/suicide. This facility's failure resulted in (R2) cutting (R2's) wrist with a razor that was given to (R2) by an unknown nursing staff member. Findings include: On 11/15/2021 at 11:25am, surveyor inquired about the incident on the morning of 10/21/2021. (R2) stated, I cut my wrist because I remembered my family, my mother doesn't care about me; and the state took my son. It's the hardest part of my life. R2's wrist was healed at the time of surveyor's observation, no cut mark observed. On 11/15/2021 at 2:21pm. Surveyor inquired about the razor in the resident's room. (V2) (Assistant Director of Nursing) ADON stated, No sharp object for any resident regardless of suicidal ideation. The high functioning residents who can perform personal shaving, the CNA will hand them the razor with the shaving cream, the CNA will accompany the resident to the bathroom and make sure when the resident is done shaving, the resident would hand back the razor to the CNA. The CNA will dispose of the razor to the sharp container box attached to the medication cart. This process will make sure there is no sharp object in the resident's room. Surveyor asked (V2) for list of residents on suicidal risk. (V2) stated, there are no residents on suicidal risk. On 11/16/2021 at 10:08am, surveyor inquired how R2 got the razor. (R2) stated, From the staff at the nurse's station. From the nurse or could have been from a CNA. (R2) got it in the morning, the day before (R2) cut my wrist, around 9am or 10am to shave my chin. The usual thing is to give it back to the staff and they dispose of it in one of those things (R2 pointing to the sharp container). But not on that day. (R2) did not return it. (R2) kept it in my drawer. R2 was pointing at the bottom drawer of R2's night stand, and added, Nobody came back and asked me where the razor was. On 11/16/2021 at 10:19am, surveyor inquired about the process of providing razors for the residents. (V14) (Registered Nurse) stated, The CNA will give or provide the razor to the resident. They watch the resident shave, the CNA will dispose of the razor in the sharp container attached to the medication cart. On 11/16/2021 at 11:28am. (10/20/2021) Daily staffing sheet documented V9 (Certified Nursing Assistant) CNA, and (V9) confirmed (V9) worked on that day in the morning shift and was assigned as CNA for (R2). (V9) stated, Actually (V9) can't remember what happened on that day. Most of the time, the residents who will ask for a razor are male residents. Any female that comes to me (V9), I (V9) make sure to go with them and ask them what they need the razor for. They would tell me (V9) they want to shave their arm pit. I (V9) make sure after they are done with it, collect the blade, I (V9) don't leave the blade with the resident. Each time a resident request for a razor, monitor them. On 11/16/2021 at 3:17pm, surveyor showed the (10/20/2021) daily assignment sheet to (V17) (Licensed Practice Nurse) LPN, and confirmed (V17) worked on that day during the 3pm - 11pm shift and was assigned as nurse for (R2). (V17) stated, It is usually the CNA who gives the razor to the resident. There is only one key for the storage, (V17) has a master key. Yes, (V17) hand's razors to some residents and tell them to return it to me. If the resident don't return the razor to me (V17), (V17) would get it in 10-15 minutes. It is very rare they (residents) don't return it. They (residents) always return it to me (V17). (V17) don't remember handing a razor to (R2). We can never tell what they are going to use it for, if roommate is suicidal, they can use it to hurt themselves or other residents or staff. All sharp objects should be in the sharp container. (V17) received an In-Service about proper handling of sharp about a month ago. (V17) don't know how (R2) got the razor. On 11/16/2021 at 3:32pm, surveyor inquired about (R2). (V16) stated, We saw (R2) at the hospital 2 weeks ago, maybe. (R2) was very agitated, difficult to redirect, was verbally aggressive, and made verbal threats to harm self (R2). On 11/16/2021 at 3:35pm, surveyor inquired about initial suicide risk assessment. (V16) stated, Nursing and social service do that. We ask the history of in-patient psychiatric hospitalization , history of taking psychiatric medications before, history of suicide attempts. Then we go from the history and take it from there. Majority of these patients are not new to the facility. When (V16) see them, they have established history and established list of medications. It is very problem focused. When (V16) saw (R2) on November 2, because (V16) knew (R2) was admitted for aggression and suicidal ideation, of course I asked (R2). On 11/16/2021 at 3:37pm, surveyor inquired about (R2's) response for suicidal ideation during the initial encounter with (R2) on first admission in the facility. (V16) stated, I don't know. I don't remember. On 11/16/2021 at 3:38pm, surveyor inquired during observation if there was a change of behavior. (V16) stated, I observed (R2) from an aggressive psychotic stand point. We have done multiple medication changes because of that. On 11/16/22 at 3:39pm, surveyor inquired if (R2) manifested suicidal ideation during the time multiple medication changes were made. V16 stated, (R2) did not. At least, not what I remember. On 11/16/2021 at 3:40pm, surveyor inquired if facility should monitor residents when giving them razors. (V16) stated, I don't know the answer to that. It is usually reserved to facility protocol. Some facilities, when residents are highly suicidal, they are being closely monitored. Some facilities, they even have locked units for residents that are highly suicidal. On 11/16/2021 at 3:42pm, surveyor asked (V16) if (R2) had any triggers that would cause (R2) to become suicidal. V16 stated, I don't know the answer to that. On 11/17/2021 at 11:12am, surveyor reviewed the 10/20/2021 Daily Assignment Sheet with (V18) (Certified Nursing Assistant). V18 confirmed with the surveyor that V18 worked on the night of 10/20/2021 and was assigned as CNA for (R2). On 11/17/2021 at 11:13am, V18 stated, (R2) came out from the room and said, I should see (R2)'s hand (R2) was using a shaving blade to cut (R2's) self. (V18) checked R2's hand (referring to wrist cut). (V8) said to (R2) why are you doing this? R2 said nobody cares about me (R2) and my family don't check on me (R2). On 11/17/2021 at 11:14am, surveyor inquired if V18 saw the razor. V18 stated, Yes, (R2) brought everything out. When (R2) came out from (R2's) room, (R2) showed me everything. The razor was with (R2). The razor was blue, what we normally give to them. On 11/17/2021 at 11:15am, surveyor inquired if V18 asked R2 where R2 got the razor. V18 stated, I asked (R2) where (R2) got the razor and (R2) said (R2) wanted the razor to shave. (R2) did not tell me who gave it to (R2).(V18) did not ask what shift (R2) got the razor. On 11/17/2021 at 11:26am, surveyor asked about the process of providing razors to the residents. V18 stated, If a resident wants to be shaved, I have to ask the nurse if the resident is diabetic. If not, (V18) ask the nurse if I can shave the resident, if the nurse said Go ahead. I have to shave the resident. After I (V18) shave the resident, I dispose of the razor in the sharp container attached to the medication cart. On 11/18/2021 at 10:10am, surveyor inquired about R2. V19 (Primary Care Physician) stated, (V19) just saw (R2) in the hospital yesterday. On 11/18/2021 at 10:11am, surveyor inquired about R2's diagnosis of [CONDITION(S)] and current Schizo affective Disorder Depressive Type. V19 stated, Both of them are okay. Schizo Affective [CONDITION(S)] Type. On 11/18/2021 at 10:12am, surveyor inquired if (R2) can independently be trusted to use a razor. V19 stated, Yes, if the resident is stable. If suicidal, I will not give. We have to monitor (R2), that's all, make sure (R2)'s okay. Don't give the razor for a long time. (R2) can use a razor but needs to be closely monitored and once done shaving take razor right away. On 11/23/2021 at 9:20am, surveyor inquired if resident with diagnosis of Schizo affective [CONDITION(S)] depressive type can independently use a razor without supervision. (V20) (Psychiatrist) stated, If (R2) really needs that (referring to razor), (R2) can handle it. (R2) just needs the staff to do whatever they are supposed to do so (R2) cannot have any injury on (R2's) wrist. I talked to (R2) in the hospital. (R2) said (R2) did not mean to cut her (R2) wrist. (R2) just wanted to leave the facility. (R2) got this attention seeking behavior. The staff have to watch (R2). (V20) talked to the staff already. (V20) talked to the DON there and told them that anybody who gets a razor they need to be supervised. On 11/23/2021 at 9:23am, surveyor asked reasons the resident (R2) should be monitored. (V20) stated, Most of the patients are psych patients, and we don't know what they're going to use the razor for. (R2) was depressed. (R2) wanted to get out sometimes. A lot of patients, if they get cold infection, they are restricted from going out. They (referring to residents) are getting upset very easily. These are all attention seeking behaviors. (R2) did not mean to cut self. (R2's) Admission Record was reviewed; (R2's) diagnoses include: [CONDITION(S)] Disorder, [CONDITION(S)] Type. R2's (10/07/2021) Resident Assessment Instrument documented, in part Section C. Brief Interview for Mental Status (BIMS) score: 11 for moderately impaired. Section G. J. Personal hygiene- how resident maintains personal hygiene including . shaving . 2/2 for limited assistance / One person physical assist. (R2's) (Revision on: 05/07/2021) care plan documented, in part Focus: I have a potential for ADL self-care, performance deficit r/t [CONDITION(S)], ASTHMA, [CONDITION(S)] DISORDER. Intervention: personal hygiene: Limited assistance. One person physical assist. (R2's) (revision on 10/15/2021) Care plan documented, in part Focus: Behavior Symptom. I am at risk for depression AEB (as evidenced by): [CONDITION(S)] Disorder. Interventions/Tasks: Observe for s/s of depression: (persistent sad, anxious, or empty feelings, thoughts of suicide, suicide attempts.) (R2's) (10/18/21) Behavior Occurrence Form documented, in part where did behavior occur: Nurses station. Problem Behavior: screaming and swearing. Interventions attempted: redirection and conversation. Resident's response to intervention: accepted and calmed down. Behavior duration: 2 min. (minutes). (R2's) (10/21/2021) Physician Order Sheet documented, in part Send Resident to Thorek Hospital ER with Petition for Psych evaluation. (R2's) (10/21/2021) Progress Note documented, in part . Resident came out of her room and showed the CNA her wrist with minimal bleeding and a razor she is using in cutting her Lt (left Wrist) . Site of injury cleansed with saline and bleeding stopped. (R2's) (10/21/2021) EMS (Emergency Medical Service) Report Form documented, in part Comments: Staff informed crew that pt (patient) cut wrist at approx (approximately) 6am. Upon exam of left wrist, a scratch was seen. Bleeding was controlled. Necessity for ambulance. Marked - Was transported in an EMERGENCY SITUATION. (R2's) (07/01/2020) Screening assessment for Eval (evaluation) Self Harm/Suicide was reviewed; R2 scored 5 = Minimal or Low Risk. (R2's) (09/28/2021) Screening Assessment for Eval (evaluation) Self harm/suicide was reviewed; R2's scored 6 = Moderate Risk. (R2's) (08/13/2020) Interagency Certification of Screening Results documented, in part screening indicated nursing facility services are appropriate. Screening certified by: Department of Human Services: Office of Mental Health. (R2's) (08/13/2020) Illinois Department of Human Services Nursing Facility Placement Assessment Summary Information documented, in part Previous/Current MH (Mental Health Provider: Thorek Memorial Hospital. Provider Type: Inpatient psychiatric hospital. (R2's) (08/13/2020) Illinois Department of Human Services Nursing Facility Placement PAS (pre Admission Screening) MH (Mental Health) Level II Notice of Determination documented, in part Determination: Eligible for Nursing Facility. Special services: Professional Observation (MD/RN-Medical Doctor/Registered Nurse) for medication monitoring, adjustment and/or stabilization. Instrumental Activities of Daily Living training/reinforcement. Mental Health Rehabilitation activities. The (undated) Suicide Observation and Prevention documented, in part Purpose: To protect resident from self-injury or death. Procedure. 1. Pre admission assessments should be sufficiently thorough to identify care needs or need for active treatment which the facility may or may not be able to provide. 2. Continuous monitoring includes mental and psychosocial as well as physical. 6. Conduct a search of resident room, clothing etc. for any harmful objects, and remove. To provide protection. 1. Remove sharp objects such as sharp scissors, razor blades, or knives. The (undated) Activities of Daily Living (ADLS) documented, in part Grooming: Maintaining personal hygiene, including planning the task and gathering supplies, comb . shaving or . The (11/18/2021) email correspondence with V2 documented, in part No skin assessment on 10/20-10/21 for (R2). The (11/18/2021) email correspondence with V1 documented, in part The facility does not have a shaving policy. The (05/02/2017) Licensed Practical Nurse Job Description documented, in part Essential Duties and Responsibilities: Monitor your assigned personnel to ensure that they are following established safety regulation in the use of equipment and supplies. The (05/02/2017) Registered Nurse Job Description documented, in part Essential Duties and Responsibilities: Monitor your assigned personnel to ensure that they are following established safety regulation in the use of equipment and supplies. The (05/02/2017) Certified Nursing Assistant Job Description documented, in part Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Essential Duties and Responsibilities: Provide assistance in personal hygiene by giving bedpans, urinals, baths, backrubs, shampoos, and shaves. The (revised 11/20/2020) Security, Supervision, and Safety Policy documented, in part The facility routinely identifies hazards and risk; evaluates and analyzes hazards and risks; implements interventions to reduce hazard and/or risk; monitors for effectiveness modifying interventions when necessary related to the physical plant, equipment devices and operation as facilitated by a safety committee.

Based on interviews, observations, and record review, the facility failed to provide interventions and supervision to reduce the risk of one resident (R2) leaving the facility. This failure resulted in R2 leaving the facility unsupervised multiple times without developing new interventions to prevent further elopements. In addition, the facility failed to prevent R2 from being punched in the face, and suffering a facial laceration and acute comminuted nasal bone fracture. This failure affected 1 (R2) of 3 residents reviewed. Findings include: R2 is a 73 - year old military veteran residing in the facility. R2 said he served 3 tours in Vietnam. R2's [DIAGNOSES REDACTED]. R2 was transferred to the hospital for evaluation on 1/20/21 and had not returned on 1/22/21. During an interview on 1/19/21 at 10:45AM V9, Social Service Director, said an elopement assessment is completed when a resident is admitted , quarterly, and following an incident. A resident at risk is monitored more closely, but this is not documented anywhere. During an interview on 1/19/21 at 1:25PM V15, Activity Director, said the patio door is always unlocked. V15 said residents at risk for elopement are watched while smoking. R2 is a smoker and he is supervised while smoking. V15 said R2 is at risk for elopement. R2 has jumped the fence at least once, might have been twice. During an interview on 1/19/21 at 1:46PM V21, Registered Nurse (RN), said she did not see R2 had left the facility. Once she was alerted, she began a search, all staff was searching all over the facility for R2. V21 said during the search R2 was suddenly in front of me. He denied going anywhere, but I saw him pouring vodka in a cup. Following this incident, we were not given new instructions to provide care to R2. V21 said she tries to watch R2 to prevent from leaving, but she does not stop her tasks. V21 said she tries to watch R2 from the windows when he is on the patio. V21 said after the activity monitor leaves in the evening all the residents go to the patio, if we call them to come in they won't. V21 said there is a potential that R2 is outside on the patio unsupervised. On 1/19/21 at 2:00PM V13, Licensed Practical Nurse (LPN), was at the 2nd floor nurses station, watching the phone with earbuds on. Surveyor was unable to get V13's attention to request assistance. R2 was not in his room. During an interview on 1/19/21 at 2:20PM R2 said in December I climbed the fence to get tobacco and vodka. Staff just told me to go to my room when I returned. No one is in the patio that evening. I go behind the fence grab the rail, pull myself up, and put my foot on the other rail and push myself up and over. During an interview on 1/19/21 at 2:34PM V9 said R2 should have had an elopement risk assessment completed after he eloped in July 2020. V9 said at the time she spoke with the former administrator and R2 was not able to be moved to the secured 3rd floor, because no rooms were available. V9 said R2 does not necessarily need to be on a locked floor, he needs to be supervised. V9 said on 12/4/20 R2 said he didn't climb the fence to get out. There were no cameras in the area at the time. V9 said the Certified Nursing Assistants (CNA) are supposed to monitor the smoking patio after activity and behaviors monitors leave. V9 said the door to the patio remains unlocked at all times. During an interview on 1/19/21 at 2:54PM V14, Director of Nursing (DON), said I was first made aware of R2's risk for elopement in December of 2020. V14 said R2 goes outside unsupervised. V14 said since R2's elopement in December increased cameras were placed in the area. V14 was unable to provide a date when the cameras were placed. During a phone interview on 1/20/21 at 9:28AM V31, R2's family, (listed as Power of Attorney) said they should have it so he (R2) can't get out to buy alcohol. They never give me an answer when I ask what changes are in place. V31 said R2 has an escape route he uses. During an interview on 1/20/21 at 9:55AM V6, Certified Nursing Assistant, the surveyor asked V6 what is a Code Pink. V6 said I have to ask. V6 told the surveyor the rooms she is assigned to for care. V6 said R2's room is assigned to the CNAs on the other side of the unit. V6 did not follow up with surveyor regarding a code pink. During an interview on 1/20/20 at 10:00AM R2 said I went to the liquor store at 8PM last night. I didn't ask anyone. The stores is about 4-5 blocks away. I took a bus, it was dark out. No one saw me leave. I climbed the fence. Surveyor spoke with V17, CNA, on 1/20/20 at 10:04AM. V17 said R2 is not her assigned resident. V18, CNA, said R2 is not my assigned resident. V18 said there are 2 CNAs, myself and V17, on this side and V18 said we have a trainee but he is not assigned any rooms. During an interview at the nurses' station on 1/20/21 at 10:07AM V11, Registered Nurse (RN), was asked by surveyor what a Code Pink is. V11 said hang on I have to check. V11 left the nurses' station and went into a locked room behind the station. V11 observed searching in a bag she grabbed. At 10:09 V11 said Pink is elopement. During an interview on 1/20/21 at 10:30AM V14, Director of Nursing, looked at her schedule and reported 3 CNAs are working on R2's floor. V14 spoke with V6 over the phone who said she is not assigned to R2. V14 then spoke with V18 who said she is not assigned to R2. V14 then spoke with V17 and said you are assigned to R2. V14 said to V17 you are to know where R2 is at all times. During an interview on 1/20/21 at 10:38AM V16, Dietary Manager, said I don't know what a code pink is. V16 left the office and returned with his name tag. The tag has a list of codes on it. V16 said pink is not on the list. V17 witnessed this observation. During a phone interview on 1/20/21 at 11:05AM V28, outside facility Social Worker, said R2 is a high risk for elopement and the facility is not taking precautions. V28 said R2 has a history of elopement. During an interview with V9, Social Services Director, on 1/20/21 at 11:26 AM, she said we need the gate fixed. V9 said nothing else is in place to prevent R2 from climbing the fence. V9 said currently groups are on hold and R2 has not been able to attend his behavior group. During a phone interview with V13, on 1/20/21 at 12:38PM, V13 said she was notified on 1/19/21 that R2 had gone over the gate. This was my first notification he was out of the facility. V13 said she had seen R2 between 5:15PM and 6:00PM. R2 was assigned to V30, CNA. V13 said rounding should be done every 30 minutes to 1 hour. V13 said residents at high risk for elopement should have rounds every 15-30 minutes. V13 said when R2 returned 2 bottles of brandy were confiscated. V13 said one bottle was open and he maybe drank 6-7 ounces of the brandy. During a phone interview with V30, CNA, on 1:13PM V30 said he was notified R2 was outside on 1/19/20 around 9:00PM. I was instructed to go get him. V30 said this is not the first time R2 has gotten out. V30 said he last saw R2 around 4:30PM or 5:00PM. V30 said we don't know when he was last seen before leaving. V30 said R2 may have gone out for a smoke around 7:00PM. V30 said he went at least 3 hours without seeing R2. V30 said I don't do rounds on R2 every 15 or 30 minutes. During an interview on 1/20/21 at 2:00PM V25, Doctor, said they call me about R2 eloping the facility. They called me on 1/19/21 and said R2 was drunk. V25 said they could put him on a locked floor, report to his psyche, or put some kind of device on him to alert the staff when he leaves. V25 said over the last 2-3 weeks he has gotten worse. He is not safe to be climbing fences and going out unsupervised. V25 said R2 ambulates with a cane and has tremors. V25 said they need to monitor, if nobody checks on him .(did not complete sentence or statement).V25 said when the nurse is busy R2 leaves. I know they check on him daily. On 1/20/21 V1, Administrator, said she is not able to find a history of the date the surveillance cameras were worked on. On 1/20/21 at 3:00PM V14, DON, brought surveyor 2 clear, glass, bottles of Brandy that were confiscated from R2 on 1/19/21. Both bottles were 375ml and one bottle was open with approximately 1/3 liquid gone. During an interview on 1/21/21 at 11:56AM V14 said elopement is when someone is missing from the facility and is unable to be located. V14 said R2 is not an elopement because he has a mission. We would prefer he not leave to get alcohol. V14 said a resident needs an order from the physician to leave the facility. V14 said a resident is an elopement if he does not return. Even if the police return the resident it is not an elopement because he has returned. I expect staff to follow procedures and nurses to follow physician orders. During an interview on 1/22/21 at 9:52AM outside at the fence V8, Housekeeping Supervisor - serving as temporary maintenance director, said the smoke tent could be moved to block the access to the gate. V8 said he was told by a previous administrator to remove the grill on the patio because the residents used it to jump gate. V8 said this week he has not been informed of any residents climbing the fence. During an interview on 1/22/21 at 10:24 AM V3, Minimum Data Set Nurse, said risk assessments are done quarterly by each department. During a phone interview on 1/22/21 at 10:31AM V32, Registered Nurse, said she told them how R2 gets out of the fence. V32 did not clarify who she told. V32 said she worked on 12/5/20 when R2 reported another resident hit him in the face. V32 said no staff was in the basement when R2 was hit. V32 said rounds on R2 are done hourly. R2 has continuous movement and goes to the basement at night. V32 said R2 goes by himself anywhere. V32 said a code yellow is elopement or fighting, she was unable to report what a code pink is. During an interview on 1/22/21 at 11:00AM R9 said she was drinking coffee with R2 in the basement when R2 was hit. R9 said she saw when R2's was punched, but she did not know who the other guy was. R9 said R2 and another resident were fighting over the vending machine. R9 said there was no staff in the basement when this happened. R9 said the staff was made aware when they returned to the unit. During an interview on 1/22/21 at 11:23AM V14 said R2 had increased behaviors in December. V14 said I don't know if a medication review was conducted on R2. During an interview on 1/22/21 at 11:26AM V34, Psyche Nurse Practitioner, said when he is notified of a psyche emergency (such as behaviors) he would either order an as needed medication be given or to send the resident for evaluation. During an interview on 1/22/21 at 12:13PM V2, Assistant Director of Nursing, said if R2 had been seen by V34 there would have been a note. On 1/19/21 an Elopement Risk List updated 10/1/20 was provided to the surveyor. R2's name is not on the list. Note R2 has been outside the smoking patio 4 times since this list was updated. Review of R2's Order Summary Report active as of 1/20/21 notes may have community access with supervision only. The 12/28/20 Elopement Risk Review was completed by V14 and the following questions are documented Yes: Is there a history (prior to admission) of wandering/elopement and/or does the resident verbalize a strong desire to leave? Is there a [DIAGNOSES REDACTED].? Reported episodes of elopement and or attempts to elope? Signs of compromised decisional capacity and impaired judgement and/or physical status limitation that would place the resident at risk in the community? Has the resident's representative requested that the resident be monitored on the Elopement Protocol? Verbalizes a serious/strong intent to leave the facility in the absence of an appropriate discharge plan? Has the physical ability to leave the building? Elopement Risk Decision: the resident presently appears to be at risk to elope and should be placed on the Elopement Risk Protocol. Review of R2's Progress Notes state on 12/4/20 around 8:15PM R2 left the building without permission. Review of R2's Progress Notes from 12/5/20 state at 1:30AM resident reported to the nurse that a co-resident hit him on the face in the basement. R2 noted with bleeding from his face. At 6:22AM emergency room notified the facility R2 will be returning to the facility. Review of R2's Progress Notes on 12/17/20 state R2 on the street across from the facility. According to the note R2 said he jumped over the fence at the patio to get out to buy cigarettes. Review of R2's Progress Notes on 12/24/20 state staff was conducting a search and saw police drop off R2. Police reported to nurse R2 slid through the space between the iron fence and the wall. Review of R2's Progress Notes on 1/19/21 state R2 was observed climbing the gate returning to the facility. R2 noted with 2 bottles of prohibited items. Review of R2's Progress Note dated 11/6/20 is the most recent Psychiatrist Note. R2 had 3 episodes in December of getting out of the facility. R2's care plan initiated on 12/31/20 notes he is an elopement risk/wanderer. History of attempts to leave facility unattended. Intervention dated 12/31/20 states distract resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, book. Resident prefers: (no further text). No other interventions are listed. R2 has a care plan stating he has impaired cognition. R2's history of active alcohol use is identified on his care plan. R2's care plan identifies smoking as a focus. Interventions do not include supervision while smoking. Review of R2's emergency room History and Physical from 12/5/20 note R2 presents after being punched in the face by another resident. Admits to alcohol use tonight, stating he drank half a pint of vodka. [DIAGNOSES REDACTED]. Review of R2's hospital records dated 12/5/20 note R2 with facial trauma after being punched in the face. Has obvious nasal deformity with facial bone tenderness over the right maxilla. Review of R2's hospital records dated 12/5/20 note R2 underwent a laceration repair to the right infraorbital. R2 received 4 sutures to the laceration. Review of R2's CT report from 12/5/20 note acute comminuted nasal bone fracture with associated soft tissue swelling. On 1/22/21 surveyor requested a smoking assessment for R2. The facility provided a SS Lookback Summary dated 4/3/20. The lookback summary does not address safety, supervision, or resident's ability to hold smoking devices. This summary states the resident is a smoker. On 1/22/21 surveyor was provided a list of Resident Smokers R2's name is not listed. Shortly after a second list was provided to the surveyor of Current Smokers 1/22/21. Current list notes Bed hold residents that smoke, includes R2. Surveyor requested reports of investigation R2's elopements on 1/20/21. V14 said she was unable to give surveyors copies and surveyor requested she review the investigations with surveyor. V14 did not provide review. Per the facility Smoking Safety policy dated 11/28/12 A Smoking Safety Assessment will be completed upon admission, quarterly, and with significant change. Per the facility Code Pink - Missing Resident Elopement policy review date 11/15/20 notes: Upon return of the resident to the facility, the DON or charge nurse should: Complete a new Elopement Risk Assessment and update plan of care as appropriate.

Based on observation, interview, and record review, the facility staff failed to ensure that a resident was free of physical abuse when R3, who requires supervision due to exhibiting verbal aggression with threats of physical harm toward staff earlier in the day, got into physical altercation with fell ow resident and staff. Facility failed to ensure that residents in the vicinity were safe when R3 picked up a chair and hit R2 in the forehead sustaining a laceration that required 7 stitches and 2 staples for one (R2) of three residents reviewed for physical abuse in the sample of 3 residents. The findings include: R2 is a [AGE] year-old, non-ambulatory male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2 has been assessed to be oriented with a brief interview mental score (BIMS) of 15 with periods of confusion and requires extensive assistance with his Activities of Daily Living (ADL) per the annual minimum data set (MDS) 12/27/19. R2 has been care planned for verbal and physical aggression due to his [MEDICAL CONDITION] and poor coping skills. R3 is a [AGE] year-old, ambulatory male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3 was assessed to require limited assistance to supervision for his ADLs and has a brief interview mental score (BIMS) of 15 per the admission MDS 12/30/19. R3 has been care planned for adjustment to the facility and behavior management and assessed to be moderate risk per the admission (12/26/19) Screening Assessment for Indicator for Aggressive and/or Harmful Behavior. On 1/28/20 at 2 PM, R2 stated he was talking with R4 in the 2nd floor alcove area adjacent to the dining area, the elevator and the nurses' station when this white guy (R3) came up to him and used the n-word which made R2 mad. R2 stated the next thing he knows is R3 hits him with leg of a chair. R2 stated that the staff were quick to the scene but did not stop R3 from hitting R2 with the chair. R2 stated he said nothing to R3 to provoke him but understands that the staff are saying he provoked R3. R2 then states he remembers saying sit down and be quiet after R3 used the n-word. R2 stated he went to the emergency room and required 7 stitches and 2 staples to his forehead. R2 showed his scar on the forehead leading into the hair line. R2 stated that he does not know what the white guy looks like but knows he is new to the facility. R2 stated it is the first time he has been hurt in the facility. R2 stated that R3 was taken to jail and allowed to return to the facility which he thinks is not right. On 1/28/20 at 1:08 PM, R3 stated he was coming off the elevator to go to his room. R3 stated R2 and himself exchanged expletive words when R2 started to come toward R3 in his wheelchair. R3 stated he thought that R2 was going to stand up out of the wheelchair and hit him. So, he grabbed a chair and hit R2 with the chair leg. R3 stated he thinks R2 needed stitches to the forehead. R3 stated that at a previous nursing home, a resident hit him with a chair. R3 stated that the staff were asking R3 if he knew that R2 had a bum arm but R3 stated he did not know this. R3 stated he was counseled and told not to start a fight or be in a fight and to report to his social worker. R3 asked if he is in trouble. On 1/29/20 at 1:50 PM, R4 stated she was in the dining room talking with R2 when out of the blue R3 hits R2 with the chair leg. R4 stated not to know where R3 came from and stated she did not see R3 until he hit R2 with the chair. R4 stated that the staff say R2 provoked R3 but claims R2 said nothing to R3. R4 stated that R4 was taken to jail but allowed to come back. R4 is an [AGE] year-old female and assessed to have a BIMS of 9 and has the [DIAGNOSES REDACTED]. On 1/28/20 at 12:10 PM, V5 (Certified Nurse Aide/C.N.A.) stated she was present and talking with R2 and R4 when R3 came off the elevator and interrupted the conversation they were having to ask V5 a question. R2 was not happy and both R2 and R3 exchanged words but only was able to make out the word coward. V5 stated before she knew it, R3 grabbed a chair and hit R2 in the forehead which required stitches. V5 stated that R2 is wheelchair bound and R3 is ambulatory and new to the facility. V5 stated that R2 likes to provoke and R3 is easily set off. V5 stated that both residents reside on the same floor but at opposite ends of the floor. V5 stated neither have had any altercations since and have exhibited acceptable behaviors since the incident. V5 stated that the rest of the staff were busy but came running to the scene when they heard the commotion. On 1/30/20 at 4:30 PM, V9 (C.N.A.) stated she was in resident room [ROOM NUMBER] when she heard the commotion outside the room, V9 stated she came out of room and saw R3 holding the chair over R2's head. V9 stated that R3 was agitated earlier in the day and was sent down to the social service office due to being agitated and threatening physical harm toward staff. When R3 came off the elevator, he was still very agitated. V9 stated she saw R3 holding the chair over R2's head and came behind R3 and removed the chair form him. At this time, the rest of the staff came to the scene. V9 stated that V5 was present but that everything happened so quickly, and no one expected R3 to be physical. V9 stated that R2 had blood gushing from his forehead and staff applied pressure then a gauze bandage was wrapped around his head. On 2/6/20 at 10:50 AM, V1 (administrator) stated he was doing morning rounds on 1/7/20 when he heard R3 being verbally aggressive toward the nurse and the nurse was telling R3 that she needed to call the physician for an order. R3 continued to be verbally aggressive saying he needed cough medicine now. V1 stated R3 can be very impulsive. V1 stated he was able to calm R3 down. V1 stated that the hospital informed this facility that R3 was sent to hospital due his behavior and that initially R3 wanted to return to his previous nursing home. V4 (Social Service Director) reached out to the previous nursing home but they said no. This was confirmed per social service note. V1 stated that they never received the previous nursing home documentation only the hospital documentation on R3's aggressive behavior. On 2/6/20 at 11:25 AM, V4, Social Service Director/Psychiatric Rehabilitation Service Director (SSD/PRSD) stated she was on the phone 1/7/20 when R3 came to her office. V4 asked R3 to come back later to talk. V4 stated R3 was very anxious, moving his hands about, voicing repetitive concerns about his possible need for [MEDICAL TREATMENT] due to his recent kidney diagnoses, and talking real fast making his mouth dry. V4 stated R3 left her office being anxious. V4 stated she heard All staff to 2nd floor and possibly code Green (behavior/emergency) when R3 hit R2 with the chair. V4 stated she took R3 to his room for 1:1 where R3 continued to pace the room, excessive repetitive talking and asking if he was going to jail and requesting water to drink for his dry mouth. V4 stated the facility staff are not trained in CPI (Crisis Prevention Institute). CPI is a non-violent crisis intervention training designed to teach best practice for managing difficult situations and disruptive behaviors. V4 stated the staff are instructed to ask resident what is bothering them as they talk in a calm voice and try to de-escalate and re-direct the resident. V4's description of anxiousness sounds more like symptoms of agitation per the definition of agitation. The facility's incident report documents the rest of the staff V7 and V8 (both Licensed Practical Nurses) and V9 and V10 (both CNA) were not present but came running to the scene when hearing the noise and saw R3 with the chair in his hands. The report documents that R2 told R3 to shut up which resulted in R3 picking up a chair and hitting R2 in the head and causing a laceration requiring emergency services. The incident report lacked information on the staples and stitches. Later, R2 recanted and stated he said nothing to cause the incident. Per nurses' notes, both were separated and R2 was sent to the emergency room for 2 staples and several stitches and R3 was monitored 1:1 until he was sent to the psychiatric hospital where he stayed for 7 days. On 1/29/20 at 11:40 AM in the 2nd floor dining room, R3 was exhibiting verbal aggression about the meal he received and saying he was given the wrong food, did not want it, F . can't eat it, wants PBJ sandwich, and it is not his fault as his voice escalated. V5 and V11 (C.N.A.) were able to re-direct R3 and he calmed down. Other residents present did not respond to R3's verbal aggression. Nurses' note 12/30/19 documents R3 being restless and agitated during breakfast. R3 attempts to fight co-residents. Staff intervene and redirect R3 back to his room. R3 is given [MEDICATION NAME] injection which was effective. Nurses' note 1/4/19 at 10:34 PM, R3 is repetitive with his questions and staff are constantly re-directing R3. R3 exhibits restlessness, pacing and talking to himself. R3 was asked if he had a problem and R3 responded he is fine. R3 did calm down and went to bed. Nurses' note 1/7/20 at 8:50 AM, R3 is cursing and threatening to hit staff. Staff intervene and re-direct R3. R3 is counseled about acceptable behaviors and is educated that if he hits anyone there will be consequences. At 10:30 AM on the 2nd floor, R3 hits R2 with a chair leg saying, he verbally abused me. R3 was placed on 1:1 (one on one) with V4 in his room until R3 was sent to the psychiatric hospital and admitted with [DIAGNOSES REDACTED]. R3's care plan (12/23/19) addresses his behavior of physical aggression due to his [DIAGNOSES REDACTED]. The interventions are to provide 1:1, re-direct, support groups and to remind resident he/she is in safe and secure environment. The facility's policy labeled ABUSE PREVENTION POLICY documents residents have the right to be free from physical abuse. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than accidental means. Abuse is also the willful infliction of injury. Facility's policy labeled MANAGING RESIDENTS WITH AGGRESSIVE BEHAVIORS IN LONG TERM CARE documents potential injury to resident and staff must be minimized. By understanding extrinsic and [MEDICATION NAME] factors and triggers which may contribute to the resident's escalation in behaviors, caregivers can implement strategies that will address the resident's predisposition to certain triggers which in turn can potentially minimize the risk of injury.

Based on interview and record review, the facility failed to supervise two residents, which resulted in one resident (R2) falling from a third floor window, and one resident (R1) eloping from the facility. The facility also failed to follow their elopement policy by not reporting the resident elopement to the Police, the Administrator or the Director of Nursing for over four hours. Four residents (R1, R2, R3 and R5) were reviewed for falls and supervision in a total sample of 12. This failure resulted in one resident (R2) sustaining multiple bone fractures. Findings Include: 1. The medical record documents R2 as a [AGE] year old admitted to the facility on [DATE]. R2 has [DIAGNOSES REDACTED]. Interview on 11/14/17 at 1:45 PM E3 ADON ( Assistant Director of Nursing) stated I was leaving the office at the end of the day, I forgot something so I parked the (car) in front of the building. I saw someone lying on the ground. I noticed it was a new resident. I called for help. The receptionist and the first floor nurse came out to help. We kept R2 immobile. We assessed R2 and called 911. I didn't see any injuries. R2 was able to speak, he/she didn't say what happened, she/he just kept repeating I'm trying to get to my daughter. The EMT (Emergency Medical Team ) and the police came, and took R2 to the hospital. I then went inside and called the DON (Director of Nursing) and the Administrator. The Final Incident Investigation Report written by E2 DON documents, date and time of incident 9/28/17 at 5:15 PM. The admitting hospital reported upon inquiry that resident (R2) was admitted for extensive injuries due to fractures of some bony prominences. Investigations and reports did not give us any clue of how resident might have sustained such injuries. Resident was last seen in her/his room and within the next two hour rounds resident was noted on the spot in front of the building, where he/she was transferred for evaluation. Interview on 11/14/15 at 2:30 PM E9 LPN (Licensed Practical Nurse) stated that I pass med's (medications) between 4:00 and 6:00 PM. It is a very busy time. I saw R2 around 4:30 in her/his room. Before that R2 was very agitated, going in other residents rooms, the nurse on the previous shift said R2 was trying to get off the floor. R2 was very confused all the time. Her/his roommates are also confused. On 11/9/17 at 12:45 PM E1 Administrator and E2 DON stated in reference to R2, no alarms went off, we checked the videos, R2 did not go out the doors. The window frame in R2's room was picked at. The window and screen was intact. I had the window boarded up. The ADON was going home and saw R2 outside at about 5:30 PM on 9/28/17. R2 was able to speak, but did not say what happened. R2 was found below her/his room window. We are assuming he/she jumped out the window. On 11/9/17 at 12:00 PM E5 Maintenance Director stated they called me in to check the window in R2's room. The window frame was tampered with, the frame was pried apart and the screw inside the frame, that holds the glass was gone. The window on the bottom has two panes of glass sandwiched together. One pane of glass was missing. The other pane was still in the window, but only in place by the epoxy seal on the top of the frame, it was loose. The tamper guard that keeps the window from being raised to high was tampered with, but still intact in the window frame. The Housekeeper, E8 told me when he got to R2's room, the one pane of glass was still in the window, the other pane was resting against the wall below the window. On 11/9/17 at 1:20 PM E8 stated in Spanish, interpreted by E5, stated that when he got to R2's room, the window had one pane of glass still in the window frame and the other pane of glass was leaning against the wall under the window. The window screen was pushed up. I took the glass pane downstairs to the maintenance room. On 11/9/17 at 3:00 PM E1 stated I did not know about the extra pane of glass, when I saw the window it had glass in it. They (E5 and E8) did not tell me it was a double paned window, and I did not know the screen was pushed up. Progress Notes by E2 dated 9/27/17 for R2 document Resident demonstrates poor impulse control by opening doors, triggering alarms, not sitting still, intruding on other residents by getting in to their personal space and belongings, not easily re-directed. The MDS (Minimum Data Set) dated 9/28/17 documents R2 as severely impaired cognition. The Elopement Risk Tool for R2 dated 9/28/17 documents the resident is confused at time and place and has the ability to leave the building. Types of Interventions: staff aware of resident on wander/elopement risk, exit and stairwell alarms, frequent monitoring. Comment: Resident is very confused and attempts to leave the floor. Resident resides on the third floor and is supervised at all times. Cat Scan of the lower left extremities results from the local hospital dated 9/28/17 document R2 has a badly comminuted intra articular open fracture of the calcaneus, Minimally displaced fracture of the lateral malleolus, chip fracture off the dorsal anterior aspect of the talus. X-ray of the pelvis dated 9/28/17 for R2 document an acute comminuted fracture of the intertrochanteric area of the left femur with a coxa vera deformity. Cat Scan of the pelvis dated 9/28/17 for R2 document acute compression fractures of L1 and L2 (lumbar spine), fractures of L5 transverse processes extending into the vertral body and involving the spinous process, multiple bilateral fractures of the sacrum with spinal canal stenosis, multiple fractures of the pelvis, hematoma and hemorrhage. 2. The medical record documents R1 as a [AGE] year old admitted to the facility on [DATE]. R1 has [DIAGNOSES REDACTED]. The Missing Person Incident Report of 9/29/17 written by E2 DON for R1 documents date of incident 9/29/17 at 4:00 AM. Staff immediately search the surrounding area, staff searched the facility, lower level. MD (Medical Doctor) notified at 9:00 AM, Family notified at 9:00 AM, Police 9:30 AM, Administrator Notified at 9:00 AM. On 11/9/17 at 9:00 AM via telephone E6 LPN (Licensed Practical Nurse) stated, I did rounds at about 3:00 AM (R1) came to the Nurse's station and asked for paper, then went back to his/her room. At 4:00 AM the CNA (Certified Nursing Assistant) noticed (R1) was not on the floor, we searched the floor, around the building. The first floor Nurse heard an alarm, they called me. No one saw (R1) go out. (R1) went out the first floor back door. We searched the perimeter. The door alarm never went off. I didn't call the police, or the Administrator, time just got away from me. I know the protocol is to call the Police and the Administrator. This has never happened to me before. On 11/8/17 at 1:30 AM E2 DON (Director of Nursing) stated the alarm went off on the first floor. R1 was on the third floor. The first floor back door alarm went off. The Nurse and CNA went to the alarm door. The third floor alarm did not go off. The video shows R1 was picking at the alarm on the third floor door and disarmed it. They did a head count and found out R1 missing. E6 texted me at around 4:30 AM, she did not call. Around 7:00 AM E6 called and told me what happened, I told her to call the Police and the family. I called E1, but she did not receive the call. The Police arrived around 9:00 AM. R1 was gone 5 days. The Kane County Police called and stated they found R1 and R1 was in custody for warrants under his/her name. R1 has been here for over a year, I don't know of any problems. R1 cannot go out alone, he/she has to have supervision. On 11/8/17 at 4:15 PM E1 stated that I did not find out about R1 leaving until I got to work at 9:00 AM. The nurse should have called me, the Police and the DON, that is the protocol. On 1114/17 at 12:00 PM by telephone E7 CNA stated that E6 and myself worked the third floor the night R1 left. We looked on all the floors and outside. The third floor alarm did not go off. Someone on the second floor told me the outside door alarm went off so I went outside. I drove around the neighborhood with another CNA but we didn't see R1. E6 stayed on the floor. On 11/8/17 at 2:00 PM with E5 observed third floor alarm above the door. There were two exposed wires connected to two screws, and a wire connected to a box above the screws. Writer asked E5 if you pull the wires off the screws would that disarm the alarm and E5 stated yes. Writer was able to reach the wires and screws. E5 stated he checks the alarms monthly. The alarm for the outside doors only sounds at the first floor Nurse's Station, not any of the other floors. I changed the codes after R1 got out. The facility policy titled Facility Policy Regarding Missing Residents and Elopement ,undated, documents : Should a thorough search for the resident prove unsuccessful, the Administrator or designee shall make a report of the incident to the local law enforcement emergency response system within 2 hours.

Based on observation, interview and record review, the facility failed to follow physician' s order for gastrostomy feeding for one of one resident (R18) reviewed for Tube feeding by administering the supplement in a time that was not ordered by the physician in a sample of 24. The facility failed to follow their gastrostomy tube feeding policy and procedure. This failure resulted in R18 having abdominal discomfort, grimacing and vomiting. Findings include: As documented on R18's October 14, 2012 hospital records, R18 is a resident who was admitted in a local hospital after vomiting coffee-ground emesis in the facility. R18 was readmitted to the facility on [DATE] and is diagnosed with [REDACTED]. During the medication pass observation on October 23, 2012 at 9:00 a.m. in R18's room, E4 (Licensed Practical Nurse) administered two packs of [MEDICATION NAME] 1.0 with fiber through R18's gastrostomy tube by gravity after administering R18's medications. Five seconds after administering the supplements, R18 vomited cream-colored fluid. Two cups of liquid came out from R18's nose and mouth. R18 was asked how he felt, and replied, "Not well." R18 had one hand on abdomen and was grimacing. R18 also refused to take the nasal spray which was scheduled to be given at this time. On October 23, 2012 at 10:30 a.m., R18 had a hand on abdomen and when asked if having abdominal pain, R18 noded his head. R18's October 2012 Physician order [REDACTED]. "Dietary: Thin Liquids, [MEDICATION NAME] 1.0 with fiber 7 cans '[MEDICATION NAME]' via [DEVICE] daily, 2 cans at 7 a.m., 12 pm, 5 p.m. and 1 can at 9 p.m.. Schedule: Every day at 7:00am, 12:00 pm, 5:00 pm, 9:00 pm." On October 23, 2012 at 1:30 p.m., R18's Medication Administration Record (MAR) was reviewed. Gastrostomy feeding was given at 7:00 am as documented on MAR. On October 23, 2012 at 1:35 p.m., E4 stated, "I made a mistake. The nurse signed the MAR which means that the feeding was given at 7:00 am." The "Employee Report" which was presented on October 24, 2012 at 11:00 a.m. by E2 (Director of Nursing) documents that "Charge nurse administered tube feeding ([MEDICATION NAME] 1.0) at 9am ...Resident vomited after 9 am tube feeding. Tube feeding given at 7am was documented on the MAR. Charge nurse failed to follow MD order, failed to check MAR. " The Facility's 2010 "Tube Feeding" Policy documents that "A naso-[MEDICAL CONDITION] or gastrostomy tube feeding will be provided as ordered by the physician, who due to clinical condition, are unable to eat enough to meet nutritional needs. " The facility failed to follow their policy on tube feeding and failed to provide appropriate services to prevent R18 from vomiting and placing R18 at risk for aspiration by administering the supplement at 9:00 a.m. when the scheduled order was for 7:00 am and 12:00 p.m.

Based on observation, record review, interview, the facility failed to monitor, supervise, assess and care plan 3 residents (R18, R22 and R14) who attempted suicide of 21 residents reviewed with behavior problems in the sample of 24. Findings include: 1. R18 was observed on 08/21/11 at 9:30am to 11:30pm, sitting in a electrical wheelchair in room. R18 on 08/21/11 at 11:30am in the room stated," I just got out the hospital. I tried to kill myself." R18 on 08/22/11 at 12:40pm in room stated, "I tried to kill myself twice, three times before. I was going to kill myself. They are causing my suicidal attempts. I tried to kill myself three times because the doctor told me." R18 was observed on 08/22/11 9:30am sitting in room yelling and screaming. R18 was observed 08/22/11 at 10:30am sitting in the basement talking to self. The nurses notes state the resident on 5/25/11 at 2:30am attempted to propel her wheelchair down the stairs and stated, "I want to kill myself, leave me alone". On 07/25/11 at 7:00pm the resident wheeled herself to the nurse station and showed nurse her bleeding left hand. Stated, "I cut myself with a razor". The resident was very agitated and yelling that she wants to get out of here and will kill herself if not sent out. 07/26/11 at 2:30pm the resident was admitted to the hospital with [REDACTED]. E2 (Director of Nurses) on 08/23/11 at 1:00pm stated, "I have to keep eye on her. If she said she wanted to do that then we 1:1 monitor, remove everything from her that she could hurt herself with. Whenever necessary, medication is given to calm her down. She would lie to go to the hospital and ask for medication that is not ordered. If she don't get her way she will tell you she will kill herself. She is a attention seeker; I don't know if she is in groups". E19 (Social Service Director) on 08/22/11 at 12:15pm stated, " She uses that every day when her needs are not immediately met. The resident tried to wheel herself down the stairs. She was already having behavior symptoms. I was watching the behavior when I was able to catch her. She was in a house program for entering back into community. She is not in any in house program for the suicidal ideation." Z2 (Physician) on 08/22/11 at 1:30pm per telephone stated,"I was doing rounds early morning and I saw her . She has a long history of drug abuse. She wants narcotics. She was not in pain. She was asking for narcotics. I said she did not need narcotics. She became agitated and crying. I left the facility. I was on call that evening that she attempted suicide where she cut her wrist with a razor. I sent her to the hospital. She is a very attention seeking and demanding." Z2 was asked if the nurse or social service notified him that R18 tried to wheel herself down the stairs. Z2 stated," I did not know she tried to wheel self down the stairs. I was not aware of the incident." There was no documentation to show that R18 was on a monitoring program because of her suicide attempts or that there was any type program that R18 attended to address this issue. 2. The initial Psychiatric Evaluation for R22 shows R22 had become upset because his brother failed to visit him and started hearing voices telling him to harm himself. The nurse notes dated 01/28/11 at 7:15pm - resident made threats that he would leave nursing home and never come back. Left facility then came back into facility. Started complaining he must leave facility. Went into a room and made superficial cuts to both wrists. States " I am going to kill myself," also said he will cut deeper, drink cologne or any substance in order to kill himself. Resident is unstable. The social services initial admission progress notes date 12/20/10 for R22 document that the resident's recent hospitalization was for responding to the voice telling him to hurt himself causing him to cut his wrist with his keys. "Resident is alert but had difficulty comprehending the questions in the psychosocial history causing him to contradict himself. 01/31/11 - resident sent to hospital on [DATE] for [MEDICAL CONDITION] and cutting self on both wrists. E19 on 08/22/11 at 12:35pm stated," He has history of suicidal attempts. He was like a child. His personality is child like and his history reports that as a child he was eating lead paint. He had suicidal ideation and his mental status lacks development. He did not understand the suicide attempts." E2 (Director of Nurse) on 08/23/11 at 1:00pm stated," He wants to go hospital 90% of the time. The attempted suicide was attention seeking ." No documentation was found that this resident is being monitored for this suicidal behavior, or that any programming is in place to address this behavior. 3. The Facility's Incident Report for R14 dated 5/2/11 documents that R14 told the nurse that that he scratched his own arm while in the basement of the facility. The Facility's Incident Report for R14 dated 6/19/11 documents that R14 notified the NOD (nurse on duty) of scratches on R14's left arm and stated that he was hearing voices. The Nurse's Notes for 6/19/11 at 11:10pm also state this incident. The Facility's Incident Report for R14 dated 8/6/11 documents: R14 was noted with a self inflicted cut to the left forearm and verbalized the use of a hanger in the incident. The Nurse's Notes for R14 dated 8/6/11 at 10:00am documents that R14 stated "I cut myself with a hanger." On 8/6/11 the physician's orders [REDACTED]. Even though R14 had cut himself with a hanger and was sent to the hospital for suicidal ideation, on 8/23/11 at 11:35 am there were 6 metal hangers hanging in R14's closet. E19 (Social Worker) stated on 8/22/11 at 12:30 pm that the metal hangers should not have been in R14's closet. No documentation was found that the resident was in programming for this behavior or that this behavior is being monitored.