Every finding on record at Ryze West

Based on observation, interview and record review, the facility failed to prevent one resident at high risk for pressure ulcer development (R3) from acquiring a new facility acquired pressure ulcer and failed to order and perform a wound treatment to promote healing of R3's right buttock wound initially identified as a partial thickness wound/moisture associated skin damage (MASD). These failures affected one resident (R3) out of three residents reviewed for pressure ulcers. As a result of these failures, R3's right buttock wound progressed to a stage 3 pressure ulcer.Findings include:R3's medical diagnoses include but are not limited to pressure ulcer stage 3, muscle weakness, cognitive communication, and essential hypertension.R3's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status score of 13, indicating R3's cognition is intact.R3's MDS dated [DATE] section M for skin conditions documents in part, Number of stage 2 pressure ulcers 0. Number of stage 3 pressure ulcers 1.R3's progress note 06/23/26 titled Skin/Wound Note documents in part, Resident seen by wound care physician and wound care nurse for weekly wound assessment. Resident noted with an active Stage 4 pressure injury to sacrum. Resident also noted with a new non-pressure wound to the right lower buttock related to moisture associated skin damage. Wound measures 6.5cm (centimeters) by 4.2cm by 0.3cm.R3's document titled Wound Summary documents in part, Site: Right Buttock. Type: Pressure. Source: Facility Acquired. Identified by: V11Licensed Practical Nurse. Date: 06/25/26. Status: Active. Clinical Stage: Stage 2. Tissue Types: Blanchable Erythema 100% (percent). Date: 06/17/26. Status: Active. Clinical Stage: Stage 2. Tissue Types: Blanchable Erythema 100% (percent).On 06/25/26 at 9:58am surveyor observed R3's wound care dressing change. Observed R3 with wound to sacrum and wound to right buttock area. Right buttock wound observed to be a full thickness stage 3 wound with 10% white tissue adherent to wound bed and 90% granulation tissue and defined wound edges.On 06/25/26 at 10:13am V11 (Licensed Practical Nurse/LPN) stated that R3 is a high risk for skin breakdown due to R3's immobility, incontinence and prior history of pressure ulcers. V11 stated that she finds R3 soiled a lot. V11 stated that she is responsible for entering R3's physician's orders for wound care.On 06/25/26 at 12:18pm V11 (LPN) stated that initially R3's right buttock wound looked like a stage 2 pressure ulcer. V11 stated that a full thickness wound is considered a stage 3 wound. V11 stated that R3's right buttock wound is a full thickness wound and should have been documented as stage 3 and not stage 2. V11 stated that R3's right buttock wound is worse this week than when she first seen the wound a week ago. V11 stated that R3 is a high risk for pressure ulcers and due to R3's mobility, prior history of wounds and incontinence. V11 stated that R3's right buttock wound had not been documented before V11 documented R3's wound assessment on 06/17/26. V11 stated that she dropped the ball and did not enter R3's physician order for R3's right buttock wound. V11 stated that the documentation of R3's right buttock wound is incorrect. V11 stated that R3's wound bed tissue type is described as blanchable erythema, but R3's wound bed is open and is a full thickness wound. V11 stated that it is important for R3 to have wound care orders so that R3's wound won't be neglected and gets worse. On 06/25/26 at 12:41pm V2 (Director of Nursing/DON) stated that when a resident has an active wound there should be a physician's order for treatment of the wound. V2 stated that if the wound does not have an order and is not treated, the wound could get worse or infected. V2 stated that R3 should have had orders placed when R3's wound was identified. V2 stated that R3 should have had his care plan updated with new interventions when R3's new wound was discovered. V2 stated that the care plan would need new interventions because if R3 developed a new wound, that would mean the current interventions were not working.R3's care plan dated 05/13/26 documents in part, R3 has potential/at risk for alteration in skin integrity due to risk factors associated with . immobility, incontinence of bowel and bladder. R3 will have no complication thru next review date.Review of R3's care plan shows no new updates since new wound documented. Review of R3's physician's orders show no active wound care order for R3's right buttock wound that was identified on 06/17/26.Facility's policy titled Skin Care Prevention reviewed 09/2025 documents in part, General: All residents will receive appropriate care to decrease the risk of skin breakdown. Guidelines: 9. Clean skin at time of soiling and at routine intervals. 10. If incontinent, use a topical agent as a moisture barrier.Facility's resident's right pamphlet dated 11/18 documents in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. You must not be abused, neglected, or exploited by anyone. The facility must provide services to keep your physical and mental health, at their highest practical levels.

Based on interview and record reviews, the facility failed to ensure rehabilitation orders were followed for 1 (R1) out of three residents reviewed rehabilitation services, in a total sample of 3.Findings include: R1's Facesheet documents in part: R1 has a diagnosis of displaced intertrochanteric fracture of right femur. On 11/29/2025, surveyor did not observe any restorative aides assisting residents to walk on second and third floor.On 11/29/2025, at 11:07 AM, V2 (Director of Nursing) stated that she is familiar with R1. V2 stated that she was sent out because she had a high creatinine level. R1 was a hospital contract resident. V2 stated that because R1 was a hospital contract resident, they don't have any insurance. R1 does not have any insurance and physical therapy will not pick her up because she cannot pay for it. V2 stated that instead of physical therapy, restorative picked her up for therapy. V2 stated that while R1 was at the facility she would get 15 minutes a day of restorative therapy. That was all that was covered in her contract from the hospital. V2 stated that R1 was in a lot of pain so whatever she could tolerate that was what was done for her.V2 presented the restorative order for R1. V2 stated that she cannot find any documentation from restorative aides or CNAs carrying out the order. V2 stated that if it is not documented then it is not done.On 11/29/2025, at 12:15 PM, V4 (Restorative Nurse) stated that R1 was picked up for restorative. V4 stated that any restorative therapy that is done should be documented. If it is not documented, then it is not done. V4 stated that she has not worked on R1 expect for the initial evaluation. V4 stated that the certified nursing assistants should have worked with R1 during their daily activities of daily living care in order to prevent the decrease of range of motion.On 11/29/2025, at 12:36 AM, V1 (Administrator) stated that she vaguely remembers R1. V1 stated that R1 was only at the facility for a few days. She was supposed to get picked by restorative. V1 stated that R1 had a fall at home and sustained a femoral fracture. V1 stated that the restorative aides or certified nursing assistants are supposed to work with the residents according to the order that has been placed. V1 stated that if there is no documentation then technically the task was not done.Per R1's Face sheet, R1 was admitted on [DATE] and discharged on 9/26/2025.R1's physician order sheet documents in part: NURSING REHAB: Active ROM (Range of Motion) to upper and lower extremities on the left and right side, twenty times, for 15 minutes, five times weekly as tolerated.Reviewed R1's daily task audit report. No documentation of therapy from 09/20 to 09/24.

Based on interview and record review, the facility failed to report allegations of physical abuse for one (R1) resident out of three residents reviewed for physical abuse. Findings include: R1 (alleged victim) is no longer in the facility. R1's Facesheet documents that R1 was admitted to the facility on [DATE] and discharged on 08/10/2025. R1 has diagnoses not limited to: acute on chronic systolic (congestive) heart failure, type 2 diabetes mellitus with hyperglycemia, opioid abuse with intoxication delirium, alcohol-induced persisting dementia, and other schizoaffective disorders. On 08/10/2025 at 10:36AM, V3 (Hospital Social Worker) states R1 was admitted to the hospital on [DATE] and R1 reported allegations of physical abuse against the facility. V3 states she reported the allegations of physical abuse to the state agency on 08/09/2025. V3 states R1 did not give any names or descriptions of the alleged abusers. On 08/10/2025 at 11:32AM, V4 (Licensed Practical Nurse/LPN) states she was the nurse assigned to care for R1 on 08/09/2025 during the 7:00AM to 3:00PM shift. V4 states R1 made allegations that someone kicked him. V4 states R1 did not specify who kicked him but R1 kept saying they kicked me. V4 states immediately after making the allegation, R1 retracted the allegation and said that no one kicked him or did anything to him. V4 states she was standing close to R1's room and could visually see inside of his room. V4 states she did not witness anyone kick or harm R1. V4 states she informed the DON of R1's behavior and that she had called 911 to have R1 sent to the hospital. V4 states she is a mandated reporter and was trained on abuse. V4 states she is aware to report abuse to (V1/Administrator) and to protect residents from abuse. V4 states she has never seen any of the staff abuse the residents in the facility. V4 states if she witnesses abuse, then she will report it immediately. On 11:52AM, V5 (Certified Nursing Assistant/CNA) states she was the CNA assigned to care for R1 on 08/09/2025 during the 7:00AM to 3:00PM shift. V5 states R1 told her that someone had kicked him in the groin but then R1 immediately retracted that allegation. V5 states she saw 911 arrive and R1 told them that someone kicked him in the groin and then R1 immediately retracted the statement again. V5 states R1 never stated who kicked him or gave any description about the allegation. V5 states she was trained on abuse and knows to report abuse to (V1/Administrator), not to ignore abuse, the different types of abuse, the importance of always reporting abuse, and protecting the residents from abuse. V5 states the last abuse in-service was held approximately last month in July 2025. On 08/10/2025 at 2:01PM, V1 (Administrator) states she is the abuse coordinator, and she was made aware by the staff nurses about R1's behavior. V1 states on 08/08/2025, she was made aware by the staff nurses that R1 had escalating behaviors and was blocking the elevators, being irate, and screaming. V1 states R1 then calmed down and was redirectable. V1 states the next day, she was made aware by the nurses that R1 had become aggressive again and made allegations of someone kicking him. V1 states she came into the facility at approximately 3:00PM on 08/09/2025 and R1 made the allegations at approximately 7:00AM on 08/09/2025. V1 states she started a soft file and began an investigation and interviewed residents and staff regarding the allegations. V1 states she usually would report the allegations to the state agency but then R1 retracted his allegations. V1 states since she has been the abuse coordinator, she has never had a resident retract abuse allegations. V1 states since R1 retracted his allegations, she did not report the allegations of abuse to the state agency. Facility Reported Incidents dated 06/21/2025 to 08/10/2025 reviewed and does not document that the facility reported an allegation of abuse for R1. Facility policy dated 10/2022 titled Abuse Policy and Prevention Program documents in part, VIII. External Reporting- 1. Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator, or designee, shall notify Department of Public Health's regional office immediately by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported to the administrator and is being investigated.

Based on interview and record review the facility failed to ensure a system was in place for documentation of medication disposition. This failure resulted in R4s medication being unaccounted for. Findings Include: R4 was readmitted to the facility on [DATE] with diagnosis not limited to Personal History of Pulmonary Embolism, Cellulitis of Left Lower Limb, Respiratory Failure, Muscle Weakness, Abnormalities of Gait and Mobility, Lack of Coordination, Abnormal Posture, Cognitive Communication Deficit, Morbid (Severe) Obesity due to Excess Calories, Depression, Anxiety Disorder, Obstructive Sleep Apnea, Lymphedema, Hypothyroidism, Binge Eating Disorder, Extreme, Adjustment Disorder with Depressed Mood, Lump in Unspecified Breast, Dependence on Wheelchair, Personal History of Other Diseases of the Musculoskeletal System and Connective Tissue, Abnormal Electrocardiogram, Essential (Primary) Hypertension, Personal History of other Diseases of the Respiratory System, Major Depressive Disorder and Tracheostomy Status. R4's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R4's care plan document in part: Dietary: R4 is at nutritional risk as disease progresses, dx (diagnosis): morbid obesity, depression, lymphedema and hypothyroidism. R4 is taking schedule weekly medication Injections for weight loss management. R4 was receiving weight management medication since 04/25/25. R4's Order Summary Report document in part: Patient having tracheostomy placement at Medical Center 06/04/25 in preparation for bariatric surgery. Zepbound Subcutaneous Solution 2.5 MG (milligrams)/0.5ML (milliliter) (Tirzepatide (Weight Management)) Inject 1 pen needle subcutaneously in the afternoon every Wednesday for Weight Loss unsupervised self-administration. Progress note dated 06/04/25 07:32 document in part: Nursing Note: Patient out to an appointment (ENT) Ear, Nose, Throat VIA Ambulance. Progress note dated 06/04/25 15:07 document in part: Nursing Note: Writer spoke with Charge Nurse at Hospital who stated that the patient will be admitted overnight for Observation due to trach placement. Progress note dated 06/09/25 16:55 document in part: Nursing Note: Resident arrived on stretcher via ambulance from Hospital. Resident is in bed with trach 02 (oxygen) mask on. On 06/25/25 at 02:36 PM R4 stated the doctor from the outside prescribed weight loss medications that would be delivered to the pharmacy, my family would pick it up and bring it to the facility. I went to the hospital 06/04/25 - 06/09/25 to have surgery to put in this trach and when I came back the weight loss medication was nowhere to be found. I had received it previously and had 2 more shots left. The pharmacy sends four in the pack, and I got the shot on Fridays. I received a total of 6 shots and the last 2 were never found, I told V21 (PM Supervisor/Licensed Practical Nurse) and V17 (Licensed Practical Nurse). They said they couldn't find them, so I missed 2 doses. They knew I was coming back to the facility. They did not replace the medication they just put in a new order. The medication needs to be in the refrigerator. On 06/25/25 at 02:51 PM V16 (Licensed Practical Nurse) stated I have not given R4 her shot for weight loss; it is kept in the refrigerator. If a resident is gone for a while we send the medication back to the pharmacy or discard it. I don't know what happened to R4's last 2 doses. On 06/25/25 at 02:57 PM V17 (Licensed Practical Nurse) stated R4 receives shots for weight loss and should have received the shot today. Normally when the resident goes to the hospital, they take the medications off the cart and discard them. I am not aware of what happen to R4's shots. We have the shots in my office in the refrigerator since this incident happened. R4 gets the shots once a week. I don't think R4 missed a dose. When R4 came back they ordered the shots, and she was getting them. R4's family was bringing the shots in prior to that. On 06/26/25 at 12:09 PM Per telephone interview V21 (PM Supervisor/Licensed Practical Nurse) stated I remember a conversation and R4 said she did not know where her injections are. I looked on the cart. Usually when a resident goes to the hospital, we send their medication back to the pharmacy. R4 did not tell me that the medication had to be refrigerated, and I was not aware the medication was brought in by the family. We will send the medication back to whatever pharmacy it came from. I told R4 the medication was sent back to the pharmacy and when R4 was readmitted we get orders from the doctor. The protocol is that all orders are discontinued if a resident spend a number of days in the hospital. I did not see any injections and I was not aware that R4 was in the hospital. It should be documented when the medication was sent back to the pharmacy in the electronic medical records. There should not be any documentation if the medication is discarded. Since there was a concern, about the missing medication we would do an investigation. On 06/26/25 at 11:27 AM V3 (Director of Nursing) stated V1 (Administrator) just told me 5 minutes ago that R4's Zepbound medication was missing. I spoke to R4 yesterday and she did not mention the missing medication. If family brought medication to the facility the staff should put the medication in zip lock bags and the manager can keep the injectable's or put them in the lock box. We knew R4 was coming back to the facility, but we did not know the eta (expected time of arrival) and R4's medication should have been put in the lock box. When the resident returns, we are supposed to put all new orders in. If the resident is gone more than 24 hours the orders will be discontinued. R4's procedure was planned. I did not know the medication was coming to the facility from the family. The medication should be on the cart and getting checked out each time it is being used. If the resident is discharged the medication should go back to the family or let the family know that we have the medication in our possession. I will start the investigation. On 06/26/25 at 12:20 PM Per telephone interview V22 (Licensed Practical Nurse) stated R4 injections were kept in the refrigerator in the medication room, and I never gave it to her. On 06/26/25 at 02:05 PM V16 (Licensed Practical Nurse) stated R4 was going to an appointment, they took R4 to the hospital from the appointment and R4 was admitted to the hospital. I did not send anything with R4, and I did not take R4's medication out of the medication cart. R4 was being admitted and they were going to observe her, so I did not remove any medication. I know the Zepbound was here, and it was in the refrigerator because we have to go in the refrigerator for insulin. It was not that particular day that I saw it, but I know it was in there because it was in a box. When I came back, R4 asked me was the medication on the cart. I checked the cart, and it was not on the cart or in the refrigerator. I asked some of the nurses on the floor and V21 (PM Supervisor/Licensed Practical Nurse). V21 said she did not see it. V29 (Licensed Practical Nurse) said it was in the refrigerator. On 06/26/25 at 02:23 PM V29 (Licensed Practical Nurse) stated I saw R4's Zepbound in the refrigerator maybe a few days after R4's discharge to the hospital. I discarded it along with other insulin and medication for residents that were discharged in a sharp's container. After 72 hours we discard the medication. If there are pills, we send them back to the pharmacy. We cannot send back injectables and things like that. There is no sheet because it is not a controlled substance and there is no charting in the electronic medical records for the discarded medications. I administered the Zepbound to R4 on 06/18/25 and 06/25/25. Originally R4 was getting it on Fridays. I documented when I gave the Zepbound on the 06/18/25 but I did not document it on the MAR. R4 should have gotten the Zepbound on the 06/13/25 but I assume it was not here so R4 missed a dose on 06/13/25 and when it came in on the 06/18/25 on the 3-11 shift that is when I administered it to R4. No one asked where the medication was. R4 told me on 06/18/25 that she missed her dose. I told R4 that it just came in and I would administer it to her shortly. I was not aware that this was medication that R4's family had brought in. There is no process if a family member brings the medication in, we have all their medication here that they take. It was only one syringe of Zepbound in the refrigerator. On 06/26/25 at 02:46 PM V1 (Administrator) stated I have no policy on medication deposition. There is no policy for medication brought in by the family and I am not sure the nurses knew that R4's medication was brought in by the family. Resident census was obtained from the Midnight Census Report dated 06/24/25. Policy: Titled Medication Administration reviewed 01/24 document in part: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis.

Based on observation, interview and record review the facility failed to ensure the low air loss mattress was on the correct setting for the wound care prevention protocol. This failure has the potential to affect 1 (R6) of 3 (R2, R5, R6) residents reviewed for wound care. Findings Include: R6 was readmitted to the facility on [DATE] with diagnosis not limited to Essential (Primary) Hypertension, Type 2 Diabetes Mellitus, Nontraumatic Subdural Hemorrhage, Intervertebral Disc Degeneration, Thoracic Region, Epilepsy, Iron Deficiency Anemia, Disorder of Thyroid, Gastrostomy, Hyperosmolality And Hypernatremia, Vitamin D Deficiency, Muscle Weakness (Generalized), Lack of Coordination, Abnormal Posture, Cognitive Communication Deficit, Protein-Calorie Malnutrition, and Hepatic Encephalopathy. R6's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 10 indicating moderate cognitive impairment. R6's weights are documented on 06/23/25 141.4 Lbs. (pounds) 05/06/25 152.2 Lbs., 04/14/25 150.2 Lbs. and 03/31/25 150.0 Lbs. Progress note date 06/20/25 23:42 document in part: Nursing Note: Patient received from hospital. Progress note dated 06/23/25 14:21 document in part: Skin/Wound Note Text: Resident admitted to facility with warm, dry skin presenting with open area to sacrum noted with no drainage nor s/s (signs and symptoms of infection and gastric tube in place to abdomen. Treatment orders and pressure relief interventions in place and carried out. Resident is chairfast and incontinent of bowel and bladder. Wound care to follow until resolved. R6 has Potential/At Risk for alteration in skin integrity due to risk factors associated with Cardio-vascular disease, Cognitive impairment, Diabetes, Immunocompromised, Incontinence (bowel/bladder). Care Plan document in part: R6 has Potential/At Risk for alteration in skin integrity due to risk factors associated with Cardio-vascular disease, Cognitive impairment, Diabetes, Immunocompromised, Incontinence (bowel/bladder). Pressure redistribution mattress Date Initiated: 06/26/25 Created on: 06/26/25, Alteration in skin integrity - R6 has Moisture Associated Skin Damage (MASD. Site: (sacrum) Factor that may inhibit healing: Moisture Date Initiated: 06/24/25. Pressure redistribution mattress Date Initiated: 06/26/25. Braden Scale for Predicting Pressure Sore Risk dated 06/26/25 document in part: Braden Scale of 14. (Moderate Risk). Wound Summary dated 06/20/25 document in part: MASD present on admission. Clinical stage: Erythema. Tissue Type: Bright pink or red =100%. Length 6.00 cm (centimeters) Width 3.00 cm and Depth 0.00 cm. On 06/26/25 at 09:14 AM R6 was observed lying in bed on a low air loss mattress with a setting of 320. Gastric tube feeding Glucerna infusing at 70 ml/hr. On 06/26/25 at 09:16 AM V16 (Licensed Practical Nurse) entered R6 room. Surveyor asked V16 the setting of R6 low air loss mattress. V16 responded, a little after 320. Surveyor asked V16 the weight of R6 and how is the low air loss mattress setting determined. V16 responded, I am not sure what R6 weighs. I think the low air loss mattress is set based on the resident's weight. Surveyor asked V16 does R6 weigh 320 pounds. V16 responded. Not at all. On 06/26/25 at 09:17 AM V19 (Wound Care Tech) entered R6's room and said I am making my rounds now and I am about to update R6's weight. On 06/26/25 at 09:18 AM V19 (Wound Care Tech) stated I have a list downstairs, and I am going to have to print out a new weight label to put on the low air loss mattress machine. The label is put on the low air loss mattress machine so if the staff is done with patient care they can set it back to the correct setting. I know that is not set on R6's weight, that is why I am going to try and fix the issue now. The purpose of the low air loss mattress is to prevent wound break down on their body. If the weight is set to high, the bed will be a little too hard for their body. The low air loss mattress setting is set based on the resident's weight. On 06/26/25 at 09:32 AM V10 (Wound Care Nurse) stated R6 has a MASD (Moisture Associate Skin Damage) to the sacrum and the treatment is zinc daily. The area is open but not staged, just moisture with no drainage. R6 is on a low air loss mattress. R6 had a decline since readmission and does not move as much as he used to. The purpose of the low air loss mattress is for pressure relief and is set based on the resident's weight. It sounds like they just set up the low air loss mattress and it was put in place yesterday 06/25/25. The low air loss mattress should be set based on R6's weight. I would say the setting of 320 would be too firm and there is a potential of skin integrity and not getting the benefit of the low air loss mattress if it is too firm. I did not get the confirmation that R6 was on the low air loss mattress yet. V19 (Wound Care Tech) is the wound care technician, and her responsibility is to make sure the low air loss mattress was in place and on the correct setting. R6 is a readmission. I print the resident's weight on the label and put it on the machine. If the weight change, I will reprint a label. Housekeeping is putting the mattress in place and if they turn the setting up all the way it will fill up faster. Part of V19 role is to make sure the low air loss mattress is functioning properly, but everyone's responsibility is to make sure the low air loss mattress settings are correct. 06/26/25 at 10:29 AM V10 (Wound Care Nurse) stated R6's low air loss mattress was ordered on Monday 06/23/25 and I updated the care plan to include R6's mattress now that it is in place. The low air loss mattress is used if the person is immobile and have sacral wounds. Some residents come with orders or wound care determines if they need a low air pressure relief intervention. R6's low air loss mattress was not in place. We have the pressure relief mattress in house. I had to ask again yesterday where was R6's mattress. Document titled Proactive Medical Products undated document in part: Introduction: Indications; Mattress system, is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. Control Unit: Determine the patient's weight and set the control knob to that weight setting on the control unit. Operating Instructions: Step 6 Determine the patient's weight and set the knob to that weight setting on the control unit. Policy: Titled Skin Care Prevention reviewed 01/25 document in part: All residents will receive appropriate care to decrease the risk of skin breakdown. 1. The Nursing Department will review all new admissions/readmissions to put a plan in place for prevention based on the resident's activity level, comorbidities, mental status, risk assessment and other pertinent information. 15. For residents who are bed or chair bound, a chair and pressure reducing mattress is needed.

Based on interview and record review, the facility failed to administer ordered topical medication used for lice and scabies exposure; failed to document notification of physician and or nurse practitioner of residents' exposure to lice and scabies; failed to obtain an order for Contact precautions for lice and scabies isolation; failed to perform isolation assessments and infection criteria evaluations for residents exposed to lice and scabies; failed to perform a proper room deep cleaning for residents exposed to lice and scabies; and failed to follow their facility policies for residents with confirmed cases of and exposure to lice and scabies. These failures resulted in R2 experiencing one occurrence of scabies and two occurrences of lice; R4 experiencing one occurrence of head lice; and R1 experiencing psychosocial harm from exposure to scabies and lice in the sample of 4 residents (R1, R2, R4 and R7) reviewed for infection control. Findings include: 1) On 5/19/25 at 10:30 am, R1 observed in R1's room, well dressed and groomed and walking independently. Contact Precautions sign posted on R1, R2 and R4's door with a PPE (personal protective equipment) bin located outside their door. R1 stated that R1 moved into this current room on 3/19/25 after another resident (R7) moved to a different room on the floor. R1 said that the staff informed R1 that the room was cleaned before R1 moved in. R1 stated that R1 recently saw R2 scratching R2's self and reported it to the nursing staff. R1 stated that an unknown nursing staff informed R1 that the staff saw nits and scabies on R2's body, and R2 moves around the facility and goes out to the smoking patio. R1 stated that R1 follows R2 in the bathroom and see's spots of blood on the toilet seat where R2 has scratched R2's skin scabies bites, and R1 tries to clean it prior to R1's use of the toilet. R1 stated, I have to protect myself because my immune system is low. R1 stated that when the CNA (Certified Nursing Assistant, V3) was bagging up their clothes in the room for washing, V3 bagged all of their clothes (R1, R2 and R4) together in a special bag. R1 stated that R1 told V3 that R1 was putting R1's clothes in a separate bag because R1 didn't want the bugs contaminating R1's clothes, saying That's just not right. R1 stated that V3 responded back saying that V3 didn't want to stay in our room too long. R1 stated that this is not a life and death situation for staff to come into R1's room, but questions if staff know how R1 feels. R1 stated that being exposed and treated for lice and scabies in the facility makes R1 feel horrible and it's all I can think about. How would you feel? They aren't doing enough to stop this contamination. On 5/21/25 at 11:39 AM, R1 stated that V22 (Assistant Administrator) spoke to R1 about the deep cleaning that was done for R1's room after the recent lice and scabies exposure. R1 stated, It's the same curtains that are hanging up with the same stains on them and that they were not changed during R1's deep room cleaning. When asked about R1 being offered a commode for a different toileting option, R1 stated no. R1's Admission Record documents, in part, diagnoses of systemic lupus erythematosus, primary osteoarthritis, anemia, anxiety disorder, depression, insomnia, pain in right arm, pain in right shoulder, and shortness of breath. R1's Census List indicates that R1 resided in the same facility room with R2 and R4 since 3/19/25. R1's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R1 is cognitively intact. In R1's Progress Notes, on 5/13/25 at 9:03 AM, V18 (Infectious Disease Nurse Practitioner) documents, in part, that R1 was being treated for exposure to an infectious rash from roommate a plan as follows: Treatment and deep clean of room need to be concurrent (or else pt {patient} risks reinoculation); Recommend room be deep cleaned; Recommend all launderable items in the room are washed in hot water and dried on high heat. Items that cannot be laundered should be placed in a sealed, air-tight back for a minimum of 72 hours with treatment of Permethrin Cream 5% at bedtime and oral Ivermectin. Facility Contact Precautions sign (undated) documents, Stop. Contact Precautions. Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gowns before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. 2) On 5/19/25 at 10:42 am, R2 observed laying in bed with a rollator walker next to R2. R2 observed R2 scratching legs under R2's pants and asked about R2 scratching. R2 stated that R2 was rubbing the leg and showed this surveyor R2's legs with dry skin. R2 showed this surveyor R2's bilateral arms and shoulders by pulling up shirt sleeve, and surveyor noted small, pinpoint, dried scabs and lotion residue noted. R2 stated that R2 could not recall specific dates but does remember have bites from bugs on R2's body. R2 stated that R2 did receive a cream last week for treatment of the bugs, but R2 does not know the medication or when R2 received it. On 5/20/25 at 9:57 am, R2 stated that R2 has been using the toilet in their bathroom. When asked about R2's shorter haircut, R2 stated that the staff recently cut R2's hair. R2's Admission Record documents, in part, diagnoses of dementia, epilepsy, seizures, asthma respiratory failure, chronic obstructive pulmonary disease, personal history of pneumonia, hereditary and idiopathic neuropathy, encephalopathy, hypokalemia, altered mental status, reduced mobility, anemia, chronic systolic (congestive) heart failure, hypertension, hyperlipidemia and cognitive communication deficit. R2's MDS, dated [DATE], documents, in part, a BIMS score 9 which indicates that R2 has moderate cognitive impairment. R2's Census List indicates that R2 resides in the same facility room since 7/18/24 which is the same room with R1 and R4 since 3/19/25 and with R2 and R7 from February 2025 to 3/19/25. In R2's Progress Notes, dated 2/14/25 at 10:35 AM, V11 (Nurse Practitioner, NP) documents, in part, that R2 is being seen for scabies exposure due to roommate (R7) just got diagnosed with scabies by an outside provider and that V11 is ordering Permethrin for prophylaxis. In R2's Progress Notes, dated 3/10/25 at 5:00 PM, V12 (Licensed Practical Nurse, LPN/Unit Manager) documents, in part, that R2 complained of itchiness to right arm. Writer assessed patient (R2) noted redness and irritation to right arm inner fold; that V11 (NP) was notified with orders received to apply Permethrin Cream 5% to entire body topically x 1 at bedtime. On 5/21/25 at 10:38 AM, V12 (LPN/Unit Manager) stated that on 3/10/25, R2 complained of itchiness and that V12 performed a skin assessment of R2 showing skin abnormalities. V12 stated that the purpose of Permetherin is to kill the infection. V12 stated that an unknown CNA seen some bugs in R2's room on 3/10/25, but I didn't see anything. When asked where did V12 document this account of seeing bugs near R2 and R2 scratching self, V12 stated, I didn't see any bugs. I didn't see bugs. I saw itching. CNA saw the bugs. V12 stated that V12 notified V18 (NP) who ordered R2's Permetherin cream 5% on 3/10/25, and this medication comes from pharmacy. V12 stated that V12 did not administer R2's Permetherin 5 % cream as ordered on 3/10/25. V12 stated that V12 would document administration of Permetherin cream for R2 on the eMAR by clicking administer to obtain a check mar or in an eMAR progress note. In R2's Progress Notes, dated 3/11/25 at 9:15 AM, V11 (NP) documents, in part, that R2 is being seen due to skin irritation and with insects found in the room on Monday (3/10/25). Resident with bites to arms and back, redness and scabs noted since Monday. Endorses itchiness. V11 ordered Permethrin Cream, Benadryl and room deep cleaning. In R2's Progress Notes, dated 5/12/25 at 9:50 AM, V11 (NP) documents, in part, that R2 is being seen for body lice infestation. This writer was called to the shower room by NOD (nurse on duty). When this writer entered the shower room, and walked up to the shower chair, there was a t-shirt and a pair of sweatpants with a significant amount of tiny, light tan bugs crawling around on the clothes, mostly around the neck/upper back portion of the t-shirt. The clothes were identified as (R2's). V11 further documents, in part, that R2 was assessed by V11 with raw areas from scratching with redness to the neck and upper back, and V11 ordered Permethrin cream and Contact isolation per infection department protocol. In R2's Progress Notes, dated 5/13/25 at 9:26 PM, V18 (Infectious Disease NP) documents, in part, that R2 is being evaluated for a pruritic rash with noting R2's skin with maculopapular rash on BLE (bilateral lower extremities), abdomen; burrows visualized with a diagnosis of scabies. V18's plan for R2 is as follows: Treatment and deep clean of room need to be concurrent (or else pt risks reinoculation); Recommend room be deep cleaned; Recommend all launderable items in the room are washed in hot water and dried on high heat. Items that cannot be laundered should be placed in a sealed, air-tight back for a minimum of 72 hours with treatment of Permethrin Cream 5% at bedtime, oral Ivermectin, and contact precautions. R2's Order Summary Report (POS) which includes active, discontinued and completed orders from 2/1/25 to 5/21/25 documents, in part, the following: a) Order date of 2/13/25: Permethrin Cream 5 % Apply to entire body topically at bedtime for treatment for 1 Day Apply from the neck all the way down to the toes. Overnight. Shower the patient in the morning hours. b) Order date of 3/10/25: Permethrin Cream 5 % Apply to entire body topically at bedtime for treatment for 1 Day Apply from the neck all the way down to the toes. Overnight. Shower the patient in the morning hours. c) No Contact Isolation order is ordered for R2 for 3/10/25. R2's February 2025 Electronic Treatment Administration Record (eTAR) documents, in part, the order of Permethrin Cream 5 %: Apply to entire body topically at bedtime for treatment for 1 Day Apply from the neck all the way down to the toes. Overnight. Shower the patient in the morning hours scheduled on 2/13/25 at 9:00 pm. No nurse's documentation for administration of this ordered medication on 2/13/25 (date is blank with no check mark or no pharmacy code) is present on R2's February 2025 eTAR, and no additional documentation for administration for Permetherin Cream 5% on R2's eTAR February 2025 is noted. R2's March 2025 eTAR documents, in part, the order of Permethrin Cream 5 % Apply to entire body topically at bedtime for treatment for 1 Day. Apply from the neck all the way down to the toes. Overnight. Shower the patient in the morning hours scheduled on 3/10/25 at 9:00 pm. No nurse's documentation for administration of this ordered medication on 2/13/25 (date is blank with no check mark or no pharmacy code) is present on R2's February 2025 eTAR, and no additional documentation for administration for Permetherin Cream 5% on R2's eTAR February 2025 is noted. Review of R2's February 2025 and March 2025 eMARs show no orders for Permetherin Cream 5% and no administration of Permetherin. Review of R2's Progress Notes from 2/10/25 to 2/17/25 and from 3/10/25 to 3/15/25 show no nurses' documentation of administration of Permethrin Cream 5% on 2/13/25 or 3/10/25. R2's Isolation Assessment, dated 5/12/25 at 7:23 am, V16 (IP) documents, in part, that R2 requires transmission-based precautions related to diagnosis of Body lice with Contact precautions. R2's Infection Criteria Evaluation, dated 5/12/25 at 7:23 am, V16 (IP) documents, in part, that R2 has 2a maculopapular and/or itching rash and 2b Physician diagnosis. Review of R2's electronic health record (EHR) for Isolation Assessments and Infection Criteria Evaluations from 2/1/25 to 5/11/25 show none were performed. On 5/21/25 at 12:15 pm, this surveyor requested from V1 (Administrator) for R2's Isolation Assessments and Infection Criteria Evaluations prior to 5/12/25, and none were provided. 3) On 5/19/25 at 10:46 AM, R4 observed laying in bed with gown on and groomed. R1 has pulled the cloth privacy curtain hanging in between R1 and R4's bed during R4's interview. This surveyor noted small tan discolorations on the cream-colored privacy curtain. R4 stated that R4 did receive a special cream over R4's body last week, but R4 could not remember specific dates of when R4 may have been exposed or treated for lice or scabies or previous treatments. R4 stated that R4 needs one staff member to help turn in bed, change incontinence brief and to be transferred from the bed to R4's wheelchair. On 5/20/25 at 9:57 am, R4 stated that the nursing staff cut R4's hair because they had to clean R4's head because R4 kept itching my head. R4's Admission Record documents, in part, diagnoses of type 2 diabetes mellitus, moderate protein-calorie malnutrition, chronic obstructive pulmonary disease, immunodeficiency due to conditions classified elsewhere, muscle weakness, peripheral vascular disease, major depressive disorder, lack of coordination, abnormalities of gait and mobility, heart failure, constipation, obesity, partial loss of teeth, chronic kidney disease stage 1, polyosteoarthritis, malignant neoplasm of left breast, acute embolism and thrombosis of right femoral vein, personal history of peptic ulcer disease, bradycardia, hypertension, and localized edema. R4's MDS, dated [DATE], documents, in part, a BIMS score 10 which indicates that R4 has moderate cognitive impairment. R4's Census List indicates that R4 resides in the same facility room since 7/16/24 which is the same room with R1 and R2 since 3/19/25 and with R2 and R7 from February 2025 to 3/19/25. In R4's Progress Notes, dated 2/14/25 at 10:35 AM, V11 (NP) documents, in part, that R4 was being seen for scabies exposure due to roommate (R7) just got diagnosed with scabies by an outside provider and that V11 is ordering Permethrin for prophylaxis. In R4's Progress Notes, dated 3/10/25 at 3:40 PM, V9 (Registered Nurse, RN/Assistant Director of Nursing, ADON) documents, in part, Per NP request all patients in room are medicated due too (to) one roommate (roommate) having possible rash. On 5/21/25 at 10:10 am, V9 (RN, ADON) stated that all residents (R2, R4, and R7) were being treated due to R2's possible rash. V9 stated that V9 did assess R2 on 3/10/25 and saw some bite marks but didn't know what it was. V9 stated that residents placed on contact isolation need a physician's order placed in the EHR. When asked if R4 had a physician's order for contact isolation on 3/10/25, V9 stated, Not to my knowledge. In R4's Progress Notes, dated 5/13/25 at 4:49 PM, V18 (Infectious Disease NP) documents, in part, that R4 is being seen due to exposure to an infectious rash with R4 complaining of significant head pruritus, and that V18 discussed with primary and reported seeing nits two days ago. V18 documents a diagnosis of lice with exposure to scabies with recommended Permethrin shampoo, combing hair with lice comb; Room should be deep cleaned at the same time as pt receives treatment (or else (R4) risks reinoculation); All launderable items should be washed in hot water and dried on high heat. Items that cannot be laundered should be placed in a sealed, air-tight bag for at least 72 hrs (hours); and Contact precautions. R4's Order Summary Report (POS) which includes active, discontinued and completed orders from 2/1/25 to 5/21/25 documents, in part, the following: a) Order date of 2/13/25: Permethrin Cream 5 % Apply to entire body topically at bedtime for treatment for 1 Day Apply to entire body (From neck all the way down to the toes). b) Order date of 3/10/25: Permethrin Cream 5 % Apply to entire body topically at bedtime for treatment for 1 Day Apply to entire body (From neck all the way down to the toes). c) No Contact Isolation order is ordered for R4 for 2/13/25 or 3/10/25. R4's February 2025 Electronic Medication Administration Record (eMAR) documents, in part, the order of Permethrin Cream 5 % Apply to entire body topically at bedtime for treatment for 1 Day Apply to entire body (From neck all the way down to the toes) scheduled on 2/13/25 at 9:00 pm with a chart code: of 9 documented by V4 (LPN). R4's February 2025 eMAR Chart Codes display indicate 9=Other / See Nurse Notes. In R4's eMAR Progress Note, dated 2/13/2025 at 9:16 pm, V4 (LPN) documents, Note Text: Permethrin External Cream 5 %. Apply to Apply to entire body topically at bedtime for treatment for 1 Day Apply to entire body (From neck all the way down to the toes). On order. On 5/22/25 at 8:46 am, V4 (LPN) stated that V4 could not remember the details of R4's treatment order of Permethrin scheduled on 2/13/25, and V4 stated, I do know somebody had something in there (R2, R4, R7's room) but V4 cannot remember the exact organism. V4 stated that V4 remembers not having the Permethrin cream yet from pharmacy, meaning that it was still on order as V4 documented in the eMAR note on 2/13/25 at 9:16 pm, and this note was created by V4 with a 9 chart code that V4 documented. V4 stated that V4 if the medication comes later in the shift, V4 would have had to document administration of the Permethrin in a progress note at a later time, due to the eMAR already being documented with the 9 chart code. V4 stated if V4 did not document administration of R4's Permethrin on 2/13/25, V4 would have told the oncoming nurse of the pending administration and would have notified nurse practitioner or physician that the medication was being administered late. When informed that review of R4's progress notes from 2/10/25 to 2/17/25 show no progress note for notifying V4's NP or physician of this, V4 stated, I should have. Review of R4's Progress Notes from 2/10/25 to 2/17/25 show no nurses' documentation of administration of Permethrin Cream 5% on 2/13/25. R4's Isolation Assessment, dated 5/12/25 at 7:35 am, V16 documents, in part, that R4 requires transmission-based precautions related to Body lice with Contact precautions. R4's Infection Criteria Evaluation, dated 5/12/25 at 7:33 am, V16 documents, in part, that R2 has 2a maculopapular and/or itching rash. Review of R4's electronic health record (EHR) for Isolation Assessments and Infection Criteria Evaluations from 2/1/25 to 5/11/25 show none were performed. On 5/21/25 at 12:15 pm, this surveyor requested from V1 (Administrator) for R4's Isolation Assessments and Infection Criteria Evaluations prior to 5/12/25, and none were provided. 4) On 5/21/25 at 9:43 AM, R7 observed propelling self in wheelchair in room, dressed and groomed, wearing a head scarf. R7 stated that R7 remembers living in former room with R2 and R4 and does not remember seeing bugs in their room. R7 stated that R7 goes to see a dermatologist for R7's chronic skin condition of eczema and has received far too many body creams that R7 can't remember each one. When asked about being treated for scabies from an outside dermatologist on 2/13/25 with an order for Permetherin, R7 stated that R7 does not remember that specific dermatology visit. R7 stated that R2 and R7 still talk and visit on the smoking patio during smoke breaks. R7's MDS, dated [DATE], documents, in part, a BIMS score 15 which indicates that R7 is cognitively intact. R7's Census List indicates that R7 resided in the same facility room with R2 and R4 from 2/1/25 to 3/19/25 (with a hospital stay from 3/2/25 to 3/3/25). R7's Order Summary Report (POS) which includes active, discontinued and completed orders from 2/1/25 to 5/21/25 documents, in part, the following: a) Order date of 2/13/25: Permethrin Aerosol 0.5% Apply to Body (Neck to Toes) topically at bedtime for Scabies for 1 Day Apply from the neck all the way down to the toes. Over night. Repeat in one week. 2/20/25. b) Order date of 3/10/25: Permethrin Aerosol 0.5% Apply to Body (Neck to Toes) topically at bedtime for Scabies for 1 Day Apply from the neck all the way down to the toes. Over night. Repeat in one week. 2/20/25. c) No Contact Isolation order is ordered for R7 for 2/13/25 or 3/10/25. In R7's Progress Notes, dated 2/13/25 at 2:19 pm, V7 (LPN) documents, in part, Patient (R7) has returned back to the facility from (R7's) (Dermatology) appointment . New orders in place. R7's Dermatology prescriptions, dated 2/13/25, documents, in part, Apply Permetherin 5% cream from the neck to the toes overnight. Repeat in 1 week. R7's February 2025 eMAR documents, in part, the order of Permethrin Aerosol 0.5% Apply to Body (Neck to Toes) topically at bedtime for Scabies for 1 Day Apply from the neck all the way down to the toes. Over night. Repeat in one week. 2/20/25 scheduled on 2/14/25 at 9:00 pm with a chart code of 9 documented by V17 (LPN). R7's February 2025 eMAR Chart Codes display indicate 9=Other / See Nurse Notes. In R7's eMAR Progress Note, dated 2/14/2025 at 9:08 pm, V17 (LPN) documents, in part, Note Text: Permethrin Aerosol 0.5 %. Apply to Body (Neck to Toes) topically at bedtime for Scabies for 1 Day Apply from the neck all the way down to the toes Over night. Repeat in one week. 2/20/25. Not available. Will administer upon arrival. On 5/22/25 at 9:35 AM, V17 (LPN) stated that V17 documented this Not available. Will administer upon arrival to indicate that at the time when V17 documented this note, the facility did not have the Permetherin cream from the pharmacy. V17 stated that V17 did not administer R7 the Permetherin cream on 2/14/25 indicated by the 9 on the eMAR to document that the medication is not available to administer. V17 stated that V17 then endorses to the following shift's nurse to administer the pending medication and that nurse will then document it as administered. V17 stated that V17 will also notify the nurse practitioner that the ordered medication is not available to administer at the scheduled time and will document this notification in the resident's EHR. V17 stated that for R7's Permetherin cream scheduled to be administered on 2/14/25, V17 stated that V17 could not remember if V17 notified V19 (Nurse Practitioner); would have to look through previous phone calls or texts; and if V19 was notified, V17 would have documented it in R7's progress notes. V17 stated that V17 could not remember exactly about R7's condition on 2/14/25, but Permetherin cream is used to treat lice or scabies. Review of R7's Progress Notes from 2/10/25 to 2/17/25 show no nurses' documentation of administration of Permethrin Cream 5% on 2/14/25, and there is no nurses' documentation present for notification of R7's nurse practitioner or physician for this new scabicide topical medication. Review of R7's EHR for Isolation Assessments and Infection Criteria Evaluations from 2/1/25 to 5/11/25 show none were performed during this time frame. On 5/21/25 at 4:54 pm, this surveyor requested from V1 (Administrator) for R7's two most recent Isolation Assessments and Infection Criteria Evaluations, and none were provided. On 5/20/25 at 10:07 AM, V5 (CNA) stated that V5 is the regular day shift CNA on R1, R2, R4 and R7's floor and normally assigned to R1, R2 and R4's current room. V5 stated that on two different days (unknown dates), V5 observed nits on R2's bed sheets and on R2's bag of clothes. V5 stated that R1 had notified V5 that R1 used the bathroom after R2 who left bugs on the toilet seat. V5 stated that V5 observed R2 frequently scratching R2's body, and V5 told several nurses about these situations, including V7 and V12. V5 stated that another resident, R7, moved to another room from R1, R2 and R4's current room. V5 stated, There was an infestation before in that room [ROOM NUMBER] to 3 months ago and it was not properly handled. V5 stated that only now that R1 is complaining about R2's scratching that something is happening. On 5/20/25 at 1:22 PM, V7 (LPN) stated that V7 works on R1, R2, R4 and R7's floor and is normally assigned to R1, R2, R4 and R7's rooms. V7 stated that R2 moves throughout the building, goes out to smoke but mostly stays in R2's room. When asked why was R1, R2, and R4 on Contact precautions as of 5/19/25, V7 stated, Lice is what I have been told. V7 stated that R2 had lice, and that R1, R2, and R4 needed to be treated. V7 stated, Bugs travel. When asked about reports (from R1 and V5) of R2's frequent body scratching, V7 stated, If (R2) was scratching, I did not paid attention to it. V7 stated, I did not see (R2) scratching. No one told me. On 5/20/25 at 2:58 PM, V8 (Housekeeping Director) stated that deep cleans are performed by housekeeping staff when nurse manager or Infection Preventionist nurse lets V8 know to do a deep clean when a resident(s) may have lice or scabies. V8 stated that the CNAs will bag up all clothes of those residents in the room in special melt away bags than disintegrate when laundered at 130 to 140 degrees Fahrenheit. V8 stated that each resident's clothes are bagged in a different melt away bag and washed and dried separately. V8 stated, The heat kills the bugs. V8 stated that every surface is cleaned with bleach in the room, and the residents are out of the room while this is being done. V8 added that deep cleans of rooms are also done on a normal basis about 1 time a month, and housekeeping staff document all deep cleans of rooms. V8 stated that for R1, R2, and R4's current room, a deep clean was just done last week, and it was not scabies, only lice. V8 stated that V8 has worked as the facility's housekeeping director since September 2024 and that a deep clean due to lice or scabies was not done prior to May 2025. On 5/20/25 at 3:40 pm, after V8's interview was completed and V8 left the conference room with surveyor, V8 returns to this surveyor asking if this surveyor had asked V8 about prior deep cleans for bugs for R1, R2 and R4's current room prior to May 2025, V8 stated that V8 had forgot that there was one more time a few months ago due to bugs. On 5/21/25 at 12:20 PM, V10 (Housekeeping Aide) stated that V10 is the regular housekeeper on R1, R2, R4 and R7's floor. V10 stated that V10 performed the deep cleaning of R1, R2 and R4's room on 5/13/25 for report of bugs. V10 stated that for the deep clean, all residents have to be out of the room and all of their clothing items removed from the room. V10 stated that all of the furniture is moved to the center of the room; and V10 starts from top to bottom to wipe all surfaces with bleach wipes including bed mattresses, bed frames, furniture (inside drawers too), walls, and floors. V10 stated that floor techs take down the privacy curtains prior to the deep clean to be laundered. V10 stated that V10 performed R1, R2 and R4's room deep clean on 5/13/25 by V10's self. When asked about R1, R2 and R4's privacy curtains being removed prior to V10 performing the deep clean on 5/13/25, V10 stated, Well, I (V10) can't tell you that because I don't do the privacy curtains. V10 stated that the floor techs are the only ones who can get up on the ladder to remove the residents' privacy curtains hanging from the ceiling. V10 stated that V10 does not know if R1, R2 and R4's privacy room curtains were removed on 5/13/25 for the deep clean, by saying, I had everything on. The gown and stuff on my face. I really didn't pay it no attention. I can't remember. Facility documents, each titled Deep Clean Checkoff List, were provided by V8 (Housekeeping Director) on 5/21/25. Upon review of the Deep Clean Checkoff Lists for the month of February 2025, the February 2025 Deep Clean Checkoff Lists were performed on 2/6/25 and 2/28/25 for R2, R4 and R7's room with V10's signature. No deep clean was performed on 2/13/25 or 2/14/25 when R2, R4 and R7's resided in the same room. On 5/21/25 at 11:10 AM, V11 (NP) stated that V11 is the NP assigned to R2 and is familiar with R2. V11 stated that on 5/12/25, V11 went into the shower room on R1, R2 and R4's floor with nurse on duty, V7 (LPN), and observed body lice crawling on R2's T-shirt around the neck region. V11 stated that the lice were small, light tan and some were a little bit darker. V11 stated that V11 knows that scabies differ from body lice in that scabies show signs of burrowing in the skin, plus they leave little clusters of bites. V11 stated that V11 assessed R2's skin on 5/12/25 and observed bite marks on neck and upper back that matched the areas of the lice noted on R2's T-shirt along with some redness and some raw areas from R2 scratching. V11 stated that V11 ordered for Permethrin cream 5% and Benadryl, ordered Contact precautions, ordered for deep room cleaning and ordered for infectious disease consult. V11 stated that V11 did view V18's progress note after V18 examined R2 on 5/13/25 for R2 having scabies. V11 stated that the medication treatment for lice and scabies must be done congruently with the deep room cleaning for effectiveness. V11 stated that Contact precautions are ordered for prevention of spreading the lice or scabies and must continue for 24 hours post treatment and room cleaning. V11 stated that on 3/10/25, V11 was notified about R2's itchiness and redness to arm by the nurse. V11 stated that V11 assessed R2 on 3/11/25 seeing bite marks to R2's arms and back with redness and scabs. V11 stated that V11 ordered the Permethrin cream again and Benadryl. V11 stated that V11 should have been placed on Contact precautions and that V11 would have given the order for R2's contact precautions. V11 stated that V11 does not manage, evaluate or provide orders for R4 and R7 (R2's roommates on 3/10/25) and that any orders for R4 or R7 for Permetherin cream and Contact precautions would have come from the other providers at that time (3/10/25). V11 stated that V11 expects that the ordered Permetherin cream is administered timely as V11 as ordered. V11 stated that in March 2025, the facility did not have an infection preventionist. On 5/20/25 at 2:08 pm, this surveyor requested to speak with the facility's Infection Preventionist. On 5/20/25 at 3:00 pm, V1 (Administrator) stated that facility does not have an IP nurse and that V2 (DON) was handling it. On 5/21/25 at 3:04 PM, V16 (Infection Preventionist, RN) stated that V16 has been working in the facility as the Infection Preventionist for approximately 4 weeks and is responsible for managing the antibiotic stewardship program, do a deep dive into why residents are placed on isolation precautions, and manage the overall infection control needs for the residents and staff in the facility. V16 stated that there must be a physician's order for isolation precautions which is entered into the resident's EHR. V16 stated for Contact precautions for residents suspected to have lice or scabies, staff are to wear gowns, gloves, hair covers and shoe covers. V16 stated that on 5/12/25, V16 assessed R1, R2 and R4, and Contact precautions was started; V16 stated that V16 observed bugs on R2's skin. V16 stated that V16 performed R1, R2 and R4's isolation assessments and infection criteria evaluations on 5/12/25. This surveyor showed V16 the facility policy for lice, titled IC-Lice/Pediculosis dated January 2023 (review date January 2024). V16 stated for lice, staff members are to discard combs, brushes or communal personal items of residents that could be contaminated. V16 stated that Contact precautions will remain in effect for 24 hours after treatment is completed. V16 stated that nurses will document on the eMAR that Permetherin been administered. V16 stated that if the pharmacy takes time to deliver the Permethrin to the facility, the resident will remain on Contact isolation and all care should o [TRUNCATED]

Based on interviews and record review, the facility failed to regularly re-evaluate, refer, and document any referrals to the local contact agencies for discharge planning and assessment for one (R3) of three residents reviewed. Findings include: R3 is an individual whose current face sheet documents was admitted to the facility on [DATE]. Medical diagnosis include but not limited to: chronic obstructive pulmonary disease, unspecified, major depressive disorder, recurrent, unspecified, rheumatoid arthritis, unspecified, unilateral primary osteoarthritis, left knee. R3's MDS (Minimum Data Set) section C dated [DATE], documents R3 's Brief Interview for Mental Status (BIMS) as 15/15 indicating R1's cognition is intact. MDS Section GG - Functional Abilities document's R3 requires supervision or touching assistance with eating, oral hygiene, Toileting hygiene, Shower/bathe self, Upper body dressing, Lower body dressing, putting on/taking off footwear. On 04/23/2025, at 10:57 AM, R3 was observed in his room laying on his bed. R3 was well groomed, alert, and oriented to person, place, time, and situation. R3 stated he was waiting for the facility to transfer him to an assisted living facility. R3 stated he met with a social worker who left the facility (no name provided) in November 2024, who told him he refereed R3 to the [NAME] program. R3 stated since then, no one has told him when he will be discharged . V8 (Social Services Assistant) has told him he will be handling his discharge arrangements, but he has not been given any update. R3 stated if the facility does not help him find a place, he has nowhere else to discharge to. R3 stated he does not do much at the facility and just stays in his room. R3 would like to be discharged to assisted living because he is independent with his activities of daily living and uses a cane to ambulate. R3 further stated he takes his medications as scheduled. On 04/23/2025, at 1:05 PM, V7 (Nurse Practitioner) stated R3 could be discharged to the community but he is homeless. V7 does not know the discharge planning process because social services is responsible. V7 stated after social services plans the discharge and informs her there is placement for the resident, she would come evaluate the resident for discharge. On 04/23/2025, at 1:25 PM, V8 (Social Services Assistant) and V3 (Social Services Director) stated residents who have been in the facility for more than 60 days qualify to be referred to the [NAME]-[NAME] program for assistance with housing and discharging into the community. V8 further stated R3 is a resident who would benefit from being referred to the [NAME]-[NAME] program because he is stable. V8 stated R3's care plan was last updated on 10/10/2024. Residents' care plans should be updated every three months to ensure transparency regarding plan of care and potential for discharge to the community. V3 stated R3's initial comprehensive assessment dated [DATE], documents R3 scored Good, and the assessment is supposed to be completed every three months because it indicates a resident's discharge potential. V3 stated residents who score good or excellent are able to be discharged to the community safely.V3 further stated care plan updates are updated every quarter to make sure the residents are being assessed for readiness to discharge in a timely manner. V3 stated she looked in Assessment Pro (referral tool for [NAME] program) and there is no record he(R3) was referred for discharge assessment. V3 stated she just started working at the facility less than week ago and does not know much about which residents are ready for discharge. V3 stated most of the social workers left the facility and she has a new team who started recently. R3's Social Services assessment titled -Social Services Comprehensive Assessment Initial Comprehensive Assessment V2, dated 10/10/2025 documents: -R3's discharge potential is good, R3 is sufficiently alert, oriented, coherent and knowledgeable allowing him to be considered for independent outside pass privileges, R3 is able to move/navigate/negotiate safely on community streets, is able to refrain from self-harm and/or socially inappropriate behavior while in the community. -R3 knows how to ask for help in an emergency or problematic situation while out in the community and has knowledge of potentially dangerous situations while in the community, has no severe debilitating physical impairment, is able to behave with respect in the community, and is medication compliant. -R3 has no aggressive behavior, has potential to be able to integrate into the peer community, minimal risk for aggression. R3's care plan dated 10/10/2024, documents: -Discharge preparations will continue to occur and implemented when local agency is able to provide services. Policy titled Discharges, dated 1/2025 documents: -To establish a plan of how to discharge a resident from the facility to home, another facility or the hospital. -Discharge potential is assessed by Social Services on admission

Based on interview and record reviews the facility failed to follow their policy and coordinate with the appropriate, state-designated authority to refer one resident with a severe mental disorder for a new PASRR level I screen prior to the resident's PASRR level II short-term approval ended. This failure affected one resident (R7) out of four residents reviewed for resident rights, in a total sample of 20 residents. This failure places residents with related conditions at risk to not receive care and services in the most integrated setting appropriate to their needs. Findings include: On [DATE], 10:45 AM, V20 (Social Services) states that social services are responsible to follow up with PASRR (Pre-Admission Screening and Resident Review) process. V20 reports that if a PASRR level II, requires them to update the care plan, rubrics, we just did a level II audit. V20 continues to state when it has an expiration date, it means that they need a new level I assessment. Social services are responsible to check on the expiration date. V20 states that he was not aware that R7's PASRR level II was expired. V20 states that if the PASRR level II is expired, we cannot confirm that he is appropriate for this setting. On [DATE], 11:32 AM, V20 states that R7 has not had any behaviors in the past weeks. R7's current face sheet documents that R7 is a [AGE] year-old individual with diagnoses not limited to: cognitive communication deficit, schizophrenia, schizoaffective disorder, bipolar type. R7's document dated [DATE], titled notice of PASRR level II outcome documents in part short-term approval without specialized services. Date short term approval ends: February 27, 2025. This determination allows you a limited number of days in a Medicaid-certified nursing facility. The short-term approval will end on the Date Short Term Approval Ends listed on the Notice of PASRR Level II Outcome that came with this letter. If you or your care provider thinks you need to stay after that date, a nursing facility staff member must submit a new Level I screen to Maximus. The new Level I screen must be submitted no later than 10 days before the Date Short Term Approval Ends. There is no documentation to show that R7 was screened for a new Level I screen since the PASRR level II expired. Facility document dated ,d+[DATE] documents in part the facility has established this policy and is addressing issues related to problems within the PAS (Pre-Admission Screening) system. It is the policy of this facility to comply with Illinois standards addressing the PAS assessment/screening process. Review the PAS documents to help assess/ascertain what type of problems, needs, and issues need to be addressed to help the resident function at his/her maximum level of well-being. As indicated, the screening material should be reviewed as a component of the assessment process and treatment suggestions/recommendations should be identified and appropriately addressed.

Based on observation, interview and record review, the facility failed to follow a resident's food preference by serving oatmeal instead of grits. This failure affected 1 resident (R10) out of 7 residents reviewed for dietary services, in a total sample of 20 residents. Finding Include: R10's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Malignant neoplasm of supraglottis, moderate protein-calorie malnutrition, cerebral infarction, unspecified asthma, vitamin D deficiency. Minimum Data Set Section (MDS) section C (dated 02/13/2025) documents that R10 has a Brief Interview for Mental Status (BIMS) score of 15, indicating that R10's cognition is intact. Care plan (dated 05/28/2024) documents that R10 is at nutritional risk as disease progresses. Diagnoses are supraglottis cancer, moderate protein calorie malnutrition, lymphedema, schizo-affective disorder, nicotine dependence, dysphagia. The care plan documents that R10 has been identified to have some degree of risk to develop malnutrition with a body mass index (BMI) of 20.9. On 03/18/2025, surveyor was conducting a complaint investigation survey in regard to dietary services. At 9:20 AM, surveyor interviewed R10. R10 stated, They keep sending me oatmeal for breakfast. I have oatmeal and I breakout when I eat it. I keep on telling them not to send me oatmeal, but they keep sending it anyway. I told the nurses and the certified nursing assistants (C.N.A.s) that I don't want oatmeal. Yesterday, I spoke to a dietary aide that works in the kitchen and I told her that I hate oatmeal and that I breakout when I eat it. I told the aide not to send me oatmeal, and they still continue to send it. Surveyor assured R10 that surveyor would come and inspect R10's breakfast tray the following day in order to determine if the facility is following R10's dietary preference. The following morning, on March 19, surveyor went to R10's room to inspect R10's breakfast tray. At 9:13 AM, R10's breakfast tray arrived. Surveyor inspected R10's breakfast tray and noted that R10 received oatmeal, which is a type of hot cereal that R10 strongly dislikes. Surveyor inspected R10's meal ticket which was located on R10's tray. The meal ticket read, Dislikes: Oatmeal. R10 was upset when she saw that she was served oatmeal again. R10 stated, See they keep sending me oatmeal, I hate oatmeal. I am allergic to oatmeal and I breakout from it. On 03/19/2025, at 9:40 AM, V7 (registered dietitian) stated,R10 is on a general diet with thin liquids. As far as preferences, oatmeal is listed as a dislike. This is one of the meals that the resident does not like and does not wish to have oatmeal for breakfast. R10 had a 6-month weight loss, and interventions were put into place to prevent R10 from losing weight. R10 has nutritional drink called 2 Kal 3 times per day as a weight loss intervention. On 03/19/2025, at 10:19 AM, V16 (dietary aide) stated, R10 did express to me that she does not like the oatmeal. R10's ticket does state that R10 does not like oatmeal. The oatmeal was placed on her try by accident because myself and my colleague overlooked it. We corrected the problem immediately and sent R10 a bowl of grits. On 03/19/2025, at 10:25 AM, V17 (dietary aide) stated, I know R10 because I have spoken to R10 several times. I do know per R10's meal ticket that R10 dislikes oatmeal for breakfast. R10 received the oatmeal today by accident by grabbing the wrong hot cereal. Residents can receive either oatmeal or grits as hot cereal and the wrong type of hot cereal was grabbed during tray line. As soon as I was informed that R10 received the wrong type of cereal, the grits were immediately sent up for R10. The problem was corrected immediately. R10's Dietary Preference Sheet (dated 02/21/2024) documents that oatmeal is listed as food dislikes. R10's Physician Order (02/21/2024) states: General diet. Regular texture, thin consistency. Diet History, Preferences, Fortified Foods and Meal Add Ons Policy (undated) documents in part: All resident should be interviewed for a diet history with food and beverage preferences documented upon admission, per facility protocol. Their nutritional needs should be assessed regularly by the clinical team, communicated with dietary, and kitchen staff to updated menus to include preferences or fortified foods, as deemed necessary. Purpose: To individualize meal services for each resident's needs and preferences.

Based on records review and interviews, the facility failed to provide person-centered care planning for a resident ' s behavioral concern who refused psychotropic medication for 1 (R1) of 3 residents reviewed for inadequate nursing care. This failure impacted 1 resident (R1) who expressed behavioral concerns and continues to refuse medications that may help with behavioral concerns. Without adequate care planning addressing medication refusal, resident (R1) has the potential to continue to express behavioral concerns. Findings include: R1 is [AGE] years old, initially admitted on [DATE] with medical diagnosis of mood affective disorder, anxiety disorder, cocaine abuse, bipolar disorder, manic severe disorder. Per MDS (Minimum Data Set) assessment, R1 cognition is intact with a BIMS (Brief Interview for Mental Status) of 15. On 02/27/2025 at 11:17 AM, during initial review, facility staff V4 (Registered Nurse) noted that R1 was out on pass. R3 roommate of R1 was present during this time. R3 said, I think he is a guy that always something ain't right. R3 was asked to elaborate what he means with his statement. R3 stated, Something always wrong with him. I mean he always complaining. At 12:01 PM, V3 (Case Manager of R1 / Emergency Contact of R1) stated that R1 was complaining about mistreatment, and not getting respect he deserves. V3 stated that R1 told him that R1 had a verbal altercation with a staff member. And that R1 has repeatedly spoken his unhappiness in the facility. R1 did not say that staff hit him. V3 said, No, staff not physical aggressive but verbally negligence. V3 made as an example that R1 was asking for Robitussin 4 or 5 times. And after that, staff told R1 that there is no more Robitussin. V3 stated that he was informed by R1 that he refused medication because he does not trust staff in the facility that gives his medication. V3 was asked in his determination, R1 is a victim of abuse. V3 replied, No, I haven't witness it. I could not say that staff are abusive, I only have what he was saying. All I can say is what I witness. I cannot say staff was abusive with him. I can only say what I witness. Review of R1's notes documents multiple behavioral concerns between R1 to staff or other residents. R1 went to the hospital on 01/23/2025 due to aggressive behavior towards staff and peers. Per V7 (Social Worker) notes dated 01/24/2025, it documents that V3 (Case Manager of R1) was given an update about R1's aggression towards staff and peers. R1 returned in facility on 01/29/2025. Per R1's physician orders psychotropic medication were ordered related to R1's behavior. Hydroxyzine HCl 25 MG (antianxiety) to be given twice a day for anxiety and agitation order date 01/22/2025. And Seroquel 50 MG (antipsychotic) to be given every 12 hours for bipolar and manic severe disorder with order date of 01/29/2025. R1's Medication Administration Record (MAR) for January and February 2025 documents that almost every day Hydroxyzine and Seroquel was not given due to refusal. On 02/28/2025 at 10:47 AM, V2 (Director of Nursing) stated that R1 was verbally aggressive to staff and other residents with frequent room changes. R1 was involuntary discharge on 01/23/2025 because of his behavior. V2 stated that R1 aggression was more on verbal. V2 stated that R1 has psychotropic medication Hydroxyzine and Seroquel for his behavior. And that R1 did not take his psychotropic medication. Because R1 did not take his psychotropic medication, it did not help him. V2 stated that if only R1 takes his psychotropic medication it would help with his behavior. V2 said, That is how he (R1) became this behavior. Verbally vocal and disrespectful from the time he wakes up to the time he sleeps. V2 was requested to review full care plan of R1 to address identified problem of refusing psychotropic medication. V2 after reviewing full care plan of R1 and said, I do not see it, about his (R1) refusal of psychotropic medication. I understand it needs to be addressed in the care plan. Care plan policy dated 01/2023 reads: The facility must develop a comprehensive care plan person-centered care plan for each resident. This comprehensive care plan should drive the care and services provided for the resident and allows for the highest level of physical, mental, and psychosocial function based of comprehensive assessment.

Based on observations interview and record review the facility failed to keep three residents (R8, R10, R11) safe from a fire incident that occurred on 1/6/25. The facility failed to a.) properly assess and b.) maintain monitoring of R8's motorized wheelchair per the facility preventative maintenance policy in accordance with the manufactures guidelines. This failure resulted in three residents (R8, R10, R11) being involved in a fire and exposed to smoke. This failure has the potential to affect all 221 who reside in the facility. This was identified as an immediate jeopardy situation which began on 01/06/25. On 01/24/25 the administrator was notified of the immediate jeopardy. The abatement plan was sent via e-mail on 1/28/25 and not accepted. The abatement plan was resubmitted on 1/29/25 and 1/30/25 and accepted on 1/31/25. The immediate jeopardy was removed on 02/04/25. However, the deficiency remains at the second level of harm until the facility determined the effectiveness of the implementation of the removal plan. Findings include: R8's admission record showed admitted on 12/7/20 with diagnoses not limited to Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, Dysphagia oral phase, Anemia, Peripheral vascular disease, Absence epileptic syndrome, Other hereditary and idiopathic neuropathies, Encounter for attention to gastrostomy, Hyperlipidemia, Unspecified dementia, Chronic embolism and thrombosis, Gastro-esophageal reflux disease, Crohn's disease, Obstructive and reflux uropathy, Other sequelae of cerebral infarction, Type 2 diabetes mellitus with diabetic neuropathy, Aphasia, Essential (primary) hypertension, Heart failure, Major depressive disorder. MDS (Minimum Data Set) dated 11/14/25 reflects: R8's cognition was severely impaired. R8 needs partial/ moderate assistance with oral hygiene, dependent with toileting hygiene, Substantial / maximal assistance with shower / bathe self, upper and lower body dressing, personal hygiene, chair / bed, and toilet transfer. On 1/21/25 At 12:05pm R8 was sitting up on a motorized wheelchair, alert, and responsive. R8 is non- verbal but able to make needs known by hand and head gestures. During interview R8 was able to recall the fire incident on 1/6/25, R8 nodded her head up and down, indicating yes when asked if she was involved and if she almost got burned. R8 then pointed to where the fire was and pointed and motioned to her left towards the arm and pointed at the back of the wheelchair. R8 then pointed the left side of her shoulder. R8 appeared scared and anxious. Surveyor then asked R8 were you scared? and R8 nodded her head up and down, indicating yes. Surveyor further asked are you still scared and R8 nodded her head again up and down, indicating yes and also appeared to become teary-eyed. Surveyor asked R8 if this was the wheelchair and R8 gestured to the chair and nodded her head up and down, indicating yes that she is still using the same motorized wheelchair. R8 also pointed to her bed. Surveyor observed that R8 was in the same room where the fire incident happened and noted dark brownish and black spots and markings on the side of the railing on R8's bed closest to the door. Surveyor also observed the footboard of R8s bed. The footboard appeared to have small charred circle like markings to the black strip at the top of the footboard, as well as melted portions to the black stripping at the top of the footboard. On 1/21/25 at 3:25 PM, R10 stated she was lying in her bed next to R8's bed and smelled smoke so R10 yelled fire. R10 stated she was concerned about R8 because the fire was on R8's bed and she was worried R8 could get burned. R10 stated she called out to get help, but no one came so R10 stood up and got into her wheelchair to go for help. R10 stated the staff pulled me from the room into the hallway. On 1/22/24 Surveyor Conducted Observations to all 3 floors to review fire extinguishers. It was observed that all fire extinguishers had been recently inspected and one of the fire extinguishers where the fire occurred had been filled on 1/8/25. When conducting observations on 01/22/25 R10 spoke to the surveyor again and stated to the curtain (that separates their beds/personal space) was opened and that was how she could see fire on R8's bed. R10 stated I saw the flames and it was big, big and a lot and it was scary. When asked if R10 had been smoking or had her lighter in the room R10 stated, no. R10 is a [AGE] year-old female admitted to the facility 06/08/2023 with diagnosis included but not limited to Chronic Kidney Disease, Emphysema, Hypertension, Major Depressive Disorder, Opioid Abuse With Withdrawal, Insomnia, Solitary Pulmonary Nodule, Alcohol Abuse, Fall From Bed, Generalized Muscle Weakness, Alcohol Use, Nicotine Dependence Cigarettes, Repeated Falls, Reduced Mobility, Abnormalities Of Gait and Mobility, Need For Assistance At Home and No Other Household Member Able To Render Care, Vascular Dementia. R10's MDS dated [DATE] documents in part, R10 requires supervision/touching assistance with chair/bed to chair transfers and with walking 10 feet, walking 50 feet with two turns, and walking 150 feet. R10 uses a manual wheelchair and smokes. R10's BIMS (Brief Interview for Mental Status) indicates R10 is moderately cognitively impaired. On 1/21/25 at 3:30 PM, R11 stated R11 is blind and cannot see. R11 stated there was a fire in R11's room and R11 could smell the smoke. R11 stated, I was scared. R11 is a [AGE] year-old female admitted to the facility 11/17/16 with diagnosis included but not limited to End Stage Renal Disease, Dependence On Renal Dialysis, Chronic Obstructive Pulmonary Disease, Legal Blindness As Defined In USA, Type 2 Diabetes Mellitus, Cerebral Infarction, Protein Calorie Malnutrition, Hemiplegia and Hemiparesis Following Other Cerebral Vascular Disease Affecting Left Non-Dominant Side, Hypertension, Malignant Neoplasm Of Unspecified Kidney, Heart Failure, Primary Thrombophilia, Open Angle Glaucoma, Chronic Embolism And Thrombosis Of Unspecified Vein, Contracture Of Muscle Left Upper Arm, Dementia, Anemia In Chronic Kidney Disease. R11's MDS dated [DATE] documents in part, R11 is dependent for transfers and R11 does not use a wheelchair and/or scooter. R11's BIMS indicates R11 is cognitively intact. On 01/21/25 at 11:05 AM, V5 (Director of Maintenance) stated fire drills are conducted monthly on alternating shifts and all the facility fire pull stations are connected to a main fire panel located in the basement and this main fire panel is connected directly to the city emergency system. V5 stated anytime a fire alarm pull box is activated in the building the fire department should be notified automatically within seconds. V5 stated this is important because the fire department needs to be notified that there is a fire onsite, so they know to come to fight the fire for the safety of the residents and staff in the building. V5 stated we had a fire in a resident's room on 1/6/25 and staff was in the room when it happened. V5 stated the fire department said the fire was caused by a short in the electrical outlet on the wall which created a spark which then landed on the bedsheet and caught on fire. V5 stated the fire pull alarm on the unit was triggered by a staff but no alarm sounded, no lights were flashing, and the doors did not close. V5 stated someone called 911 to notify the fire department manually about the fire. V5 stated an outside vendor was called and came to the facility on [DATE] and found there was a short in the system and that is why the fire panel system did not trigger the fire department or sound the fire alarm in the building. V5 stated this outside vendor reset the system. On 01/21/25 at 12:12 PM, V9 (Licensed Practical Nursing) stated V9 was assigned to R8's room on 01/06/25 and that after dinner around 6:30 PM V9 heard a Certified Nursing Assistant yell, fire! V9 stated V9 entered the room and saw R8 sitting in R8's motorized wheelchair next to the bed and saw flames coming from R8's bed. V9 stated it looked like R8's mattress was on fire. V9 stated R10 was in R10's wheelchair exiting the room as V9 was entering the room and R11 was lying in bed near the window. V9 stated R8's wheelchair was not moveable and did not work. V9 stated it might have been that the wheelchair sparked the fire and V9 does not know if the wheelchair was plugged in or not. V9 stated V9 and V37 (Licensed Practical Nurse) transferred R8 into a geriatric chair as quickly as they could and R8 was brought down to the unit dining room. V9 stated the flames were close to R8 and if we had not removed R8 there is a potential that R8 could have been burned. V9 stated none of R8's clothing was burned. V9 stated V9 did a full body assessment and took vitals of R8 and R11. V9 stated V9 did not see any injuries on R8 but V9 noted R8 was scared. V9 stated R8 and R11's nurse practitioner (V49), family and V1 (Administrator) was notified and that they were not sent to the hospital. V9 stated everything happened all at once, and there was a lot of commotion. V9 stated V9 never heard any type of fire alarm sound or lights going on. 0n 01/21/25 at 1:10 PM, surveyor went with V5 to R8's room and viewed the location of the outlet. V5 stated the outlet was too far away from the bed to have caused the fire. On 1/21/25 at 1:30 PM, V5 (Director of Maintenance) stated he had made a mistake earlier and that the fire was caused by the R8's motorized wheelchair, not from a faulty electric outlet. V5 stated V5 does not know if the facility has a policy on wheelchair maintenance. V5 stated, I don't do any routine checks or monitoring on the electric wheelchairs because they are owned by the residents, not by the facility and if we do something to the electric wheelchair then we are liable, so it is not part of our responsibility. V5 stated V5 took R8's motorized wheelchair out of the room the night of the fire and V41 (R8's Son) came that same night and replaced a part. V5 stated V5 does not know what part V41 replaced or what R8's son did to the wheelchair. V5 provided document dated Fire Drill Evaluations dated 01/06/25 completed by V5 (Maintenance Director) documents in part, did the fire alarm strobe devices function properly? yes On 01/21/25 at 2:22pm V41 (R8's son) stated that he received a call from V9 (LPN) on 1/6/25 sometime in the evening but can't remember the specific time. He stated V9 told him that there was a fire in R8's room. V41 said as soon as he got the call he drove to the facility and was onsite within 5-10 minutes of receiving the phone call. V41 stated when he arrived, he saw a fire vehicle and a police car in front of the building. When he got up to the 3rd floor R8 was by the nursing station in a Geri chair. V41 said R8 was hysterical, and he could tell she was really scared and nervous. V41 said R8 was shaking her head back and forth and her eyes were big. V41 said he had to sit down to talk to V8 and try to calm her down. V41 stated R8's pillow, sheets and mattress were burned. V41 stated there were no burn marks on the wall but there were holes in the wall caused by R8 backing R8's motorized wheelchair into the wall. V41 stated there is a narrow space between the bed and the nightstand that R8's motorized wheelchair must fit into and so it is important that R8 has a little space on both sides of the wheelchair so that the electrical components of the motorized wheelchair do not scrape up against R8's bed frame. V41 stated R8's motorized wheelchair was still in the room after the fire and V41 could see that the fire department had pulled R8's wheelchair out from between the bed and the nightstand. V41 stated the fire department told V41 that the fire was started by the wheelchair. V41 stated V41 could see that the cord on the motorized wheelchair that connects to the controller on the left arm side of R8's wheelchair had exposed wires. V41 stated V41 could see a red and black wire which are normally contained and covered up by the plastic sheathing. V41 stated V41 thinks the cord that got caught up between the chair and the bed because the staff put the wheelchair too close to the bed and that the wheelchair rubbed up against the metal bed causing the cord to be shredded, thereby exposing the red and black wire, which must have created a spark. V41 stated V41 thinks it is that spark which caused the fire. V41 stated normally, the chair does not touch the bed and if it's touching the bed that means R8 is too close. V41 stated other damage to R8's wheelchair included a turn knob located on the back left side of the wheelchair which was melted to the point wherein all the knobs were no longer there. V41 stated that night V41 replaced the cord and secured it with zip ties. V41 stated on 1/5/25 prior to the fire V41 had replace the electronic charger for R8's motorized wheelchair. V41 stated V41 bought the motorized wheelchair for R8 in May 2024 and that V41 is the one who maintains R8's motorized wheelchair. V41 stated, I do all the repairs and maintenance checks on my mom's wheelchair. V41 stated V41 has experience fixing motorcycles so that is how V41 knows how to do the repairs on R8's motorized wheelchair. On 01/21/25 at 2:50 PM, surveyor met with R8 and V41 (R8's Son) in R8's room. V41 showed the surveyor the melted knob on the back of R8's motorized wheelchair and stated there used to be 4 nubs on the knob but the fire burned them off and now there are none. V41 showed the area on the metal bed frame and stated, See? you can see the spots on the bed frame where the black plastic from the knob melted into clumps onto the bed frame. He said there were 3 black lumps which V41 proceeded to flick off 2 of the 3 spots. V41 also said you can see where the fibers of the plastic sheathing shredded and melted onto the bed frame. V41 then showed the surveyor photos on his cell phone that he took the night of the fire. The pictures showed that the mattress was burned on the side closest to the door/entrance of the room, and bed sheets/linens were charred black in the same area and that there were black charred areas on the bed frame in the same area of the melted plastic. V41 stated on 01/06/25 he could see that the cord on the motorized wheelchair that connects to the controller on the left arm side of R8's wheelchair had exposed wires. V41 stated he thinks the cord got caught up between the chair and the bed because the staff put the wheelchair too close to the bed and that the wheelchair rubbed up against the metal bed causing the cord to be shredded, thereby exposing the red and black wire, which must have created a spark. V41 stated that night V41 replaced the cord and secured it with zip ties. Surveyor requested for V41 to send copies of the photos to the email provided. State agency did not receive the photos via email provided on 1/21/24. On 1/22/25 at 11:45am V1 (Administrator) stated she arrived at the facility around 8:00pm on 1/6/25 and saw R8 who appeared scared surrounding the fire incident. V1 stated she spoke to the fire department staff and V1 stated she spoke with the Fire Investigator/Marshall directly and the Fire Marshall/Investigator stated there was nothing in the room which could have set the fire. V1 stated R8's doctor was notified and V1 asked R8 if R8 wanted to go to the hospital and R8 said no. V1 stated she did not do an investigation or report the incident to the state. V1 stated this fire incident was not reported to IDPH (Illinois Department of Health) because there was no injury and based on the facility's policy this incident was not considered to be an unusual occurrence and it did not need to be reported to IDPH. V1 stated none of the residents were sent to the hospital for evaluation. On 1/22/25 at 12:30pm, V38 (Housekeeper) stated V38 started working at the facility in 11/2024. V38 stated V38 was working on 01/06/25 downstairs in the basement cleaning the dialysis room when around 6:00-6:30 PM V38 stated heard a CODE RED announced overhead but V38 is not familiar with the code so V38 continued cleaning and mopping the dialysis room and did not go up to the unit. V38 stated after cleaning the dialysis room, V38 went up to unit about 15-20 minutes after the code red was announced. V38 stated that is when V38 saw ambulance people, fire people, policemen and residents in the dayroom. On 01/22/25 at 2:50 PM, V32 (Certification Nursing Assistant) stated V32 was walking by R8, R10 and R11's room on 01/06/25 and heard someone saying fire, fire. V32 stated V32 could see flames from the hallway, and it looked like the fire was coming from R8's bed. V32 stated the curtain and the side of R8's mattress was in flames. V32 stated R8 was sitting in R8's motorized wheelchair next to R8's bed which was on fire. V32 stated V32 pushed the mattress away and pulled the privacy curtain away from R8 to try to get R8 away from the flames but could not move R8's motorized wheelchair. V32 assisted R10 out of the room and then went to the nursing station to alert the nurses about the fire. V32 stated V32 went back into the room to retrieve R11, unlocked R11's bed and as V32 was leaving the room with R11, V32 observed two EMT (Emergency Medical Technicians) entering the room. V32 saw the two EMTs grab R8 from R8's motorized wheelchair using sheets and transferred R8 into the geriatric chair. On 01/22/25 at 2:01 PM, via phone interview V46 (Registered Nurse) stated V46 was working on 01/06/25 and sitting at the nursing station when V32 (CNA) walked to the nursing station and said, there is a fire. V46 stated V46 could already see smoke in the hallway and when V46 entered the room, V46 saw R8's bed on fire and R8 was sitting in R8's motorized wheelchair which was right next to the fire. V46 stated V46 could smell burning rubber and saw a white extension cord on the floor which was melted. V46 stated that morning R8's wheelchair was not working correctly and that evening the staff was charging the wheelchair using a white extension cord. V46 stated the smoke and fire alarm did not go off in the room or hallway or the rest of the building so, initially none of the staff knew that there was a fire in the building. V46 stated R8's motorized wheelchair would not move so; we were trying to figure out the best way to move R8. V46 stated there were two EMTs (Emergency Medical Technicians) on the floor because they had just delivered a resident to the floor from the hospital and the EMTs are the ones who [NAME] into action. V46 stated one EMT and the CNA (V32) wrapped R8 in a blanket and transferred R8 into a geriatric chair. V46 stated V46 told someone to make an overhead page to alert the other staff that there was a fire in the building because we needed help removing the residents away from the fire. V46 stated one of the other nurses was directing the other EMT on where to get the fire extinguisher and that is when V46 called 911 right there from the room from V46's personal cell phone because V46 stated the fire didn't stop, it was growing and getting bigger. V46 stated V46 was getting scared. V46 stated then V46 saw the other EMT use the fire extinguisher to put out the fire. V46 stated after the fire was put out it was very smokey in the hallways and in R8's room. V46 stated the fire department who came told the staff that it was an electrical fire cause by the extension cord or motorized wheelchair. On 01/22/25, V11 (Evening Nursing Supervisor, Licensed Practical Nurse) stated after the fire V11 could see cords hanging on the back of the wheelchair and you could tell that someone had tried to fix it because there was black electric tape on the cord, and it was hanging from the wire. V11 stated there was no alarm going off on the floor or anywhere else in the building and there should have been because the fire alarm sound is needed to alert everyone that there is an active fire going on. On 01/22/25 at 2:50 PM, V32 (Certification Nursing Assistant) stated V32 was walking by R8, R10 and R11's room on 01/06/25 and heard someone saying fire, fire. V32 stated V32 could see flames from the hallway, and it looked like the fire was coming from R8's bed. V32 stated the curtain and the side of R8's mattress was in flames. V32 stated R8 was sitting in R8's motorized wheelchair next to R8's bed which was on fire. V32 stated V32 pushed the mattress away and pulled the privacy curtain away from R8 to try to get R8 away from the flames but could not move R8's motorized wheelchair. V32 assisted R10 out of the room and then went to the nursing station to alert the nurses about the fire. V32 stated V32 went back into the room to retrieve R11, unlocked R11's bed and as V32 was leaving the room with R11, V32 observed two EMT (Emergency Medical Technicians) entering the room. V32 saw the two EMTs grab R8 from R8's motorized wheelchair using sheets and transferred R8 into the geriatric chair. On 1/22/25 at 3:32 PM, V37 (Licensed Practical Nurse) stated V37 was working on 01/06/25 and sitting at the nursing station around 6:30-6:50 PM when V37 heard someone yell out fire, fire. V37 stated as V37 was entering the room R10 was in R10's wheelchair by the entrance of the room and V37 quickly moved R10's wheelchair into the hallway. V37 stated V37 entered the room at the same time as V9 (LPN) and that's when V37 saw flames of fire and smoke coming from R8's bed. V37 stated V37 could see that R8 was sitting on that side of the bed near the flames in R8's motorized chair. V37 stated it looked like the flames were coming from behind R8's motorized wheelchair and the wheelchair was so close to the bed that R8 was close to the fire. V37 stated V9 and V37 picked up R8 and one of the CNA brought in a geriatric chair and removed R8 from the room to make sure R8 was safe. V37 stated V37 does not recall hearing any alarms. V37 stated one of the CNAs ran to get the fire extinguisher and when V37 came back into the room the fire had been put out. V37 stated V37 does not remember any EMTs helping. V37 stated V9 is the nurse who conducted the assessment on R8 and R11 and there was no talk about transferring them to the hospital. On 01/22/25 at 4:30 PM, V31 (Certified Nursing Assistant) stated V31 been working at the facility since October 2024 and works at the facility full time. V31 stated V31 usually covers the 11-7 shift but sometimes picks up overtime by working the 3-11 shift. V31 stated V31 was working on 01/06/25 and was at the nursing station doing charting when around 6:45-7:00 PM when V31 heard V9 (LPN) yell fire, fire! V31 stated V31 walked down to the room and in the doorway V31 could see flames coming from the 1st bed and the flames were one to two feet high. V31 stated V31 has never experienced something like that before and it was alarming. V31 stated there were two EMTs in the room helping. V31 stated V31 did not hear any fire alarms or sounds or see any lights but the doors shut. V31 stated since V31 has been working at the facility, we haven't had any fire drills for night shift. V31 stated when the fire box is triggered the fire alarms should go off and make a loud sound. V31 stated the alarms are what alerts the staff so the staff can get the residents to safety. On 01/22/25, V11 (Evening Nursing Supervisor, Licensed Practical Nurse) stated on 01/06/25 at 6:50 PM, V11 was taking a break in V11's office on the 1st floor when V11 received a cell phone call from V9 (LPN) notifying V11 that there was a fire on the floor. V11 stated, I asked her, a real fire? And V9 replied, yeah! V11 stated V11 did not hear any type of fire alarm sounding in the building. V11 stated V11 left V11's office immediately and went passed the receptionist and told the receptionist to announce CODE RED overhead. V11 stated by the time V11 arrived on the unit there was no active fire, only a lot of smoke. V11 stated there were no residents in the room. V11 stated R8's motorized wheelchair was in the hallway and V11 could see cords hanging on the back of the wheelchair. V11 stated you could tell that someone had tried to fix it because there was black electric tape on the cord, and it was hanging from the wire. V11 stated there was no alarm going off on the floor or anywhere else in the building and there should have been because the fire alarm sound is needed to alert everyone that there is an active fire going on. On 01/24/25 at 9:48 AM, V2 (Director of Nursing) stated she was not onsite at the time of the fire. V2 stated all three residents should have been assessed by a nurse that night since they were all in the room at the time of the fire and exposed to the smoke. V2 stated a fire is an unusual event and since it was an unusual event the nurses would need to monitor the residents regularly to make sure they are okay. V2 stated this monitoring should be done every shift for the following 72 hours after the fire by the nurse on duty and documented under the assessments tab listed under skin assessments. With surveyor V2 reviewed R8's EHR (Electronic Health Record) and stated R8 does not have any 72-hour nursing assessments completed after the fire on 01/06/25 but should. V2 reviewed R10 and R11's EHR and verbalized that there are some 72-hour nursing assessments missing and not all the shifts were done. On 01/24/25 at 10:30 AM, observed R8 lying in bed and R8's motorized wheelchair next to R8's bed. V48 (Day Nurse Manager/Licensed Practical Nurse) stated R8's motorized wheelchair was not working. V48 stated, we are trying to figure it out. It won't move. It was on the charger, but it won't turn on. When we press the button to turn it on, it turns right off and I'm going to call the son so he knows it's not working and can fix it. Surveyor observed white sticker on R8's motorized wheelchair for Pride Mobility and listed a web site. On 01/24/25 at 11:40, V5 (Director of Maintenance) stated the nurses told V5 that R8's wheelchair was not working. V5 stated V5 took off the cover on the wheelchair and moved some of the wires around and replaced the cover and it turned back on. On 1/24/25 at 11:54 AM, was interviewed further about the fire incident and her chair not working. R8 indicated by nodding R8's head up and down in a yes motion that there was a fire in R8's room when R8 was sitting in R8's motorized wheelchair. R8 nodded and gestured that the fire was coming from the back left side of R8's wheelchair. R8 gestured to the left side of R8 wheelchair when asked if R8 felt hotness from flames and motioned up and down R8's left arm. R8 indicated that R8 was still using the same motorized wheelchair that was involved in the fire and that it wasn't working again today. R8 indicated by nodding R8's head up and down in a yes motion when R8 was asked if she scared during the fire and if R8 is still scared. R8 appeared to display wide open eyes, raised and furrowed eyebrows, while communicating about the fires R8 gestured and responded no, when R8 was asked if R8 needed to go to the hospital on 1/6/25. R8 indicated that if someone had asked R8 if R8 wanted to go to the hospital the night of 1/6/25, R8 would have said yes, because R8 wanted to be checked after the fire incident. On 01/24/25 at 11:04 AM, V49 (R8 and R11's Nurse Practitioner) stated V49 was called by V9 on the evening of 01/06/25 and was made aware of the fire that occurred. V49 stated V49 was told there was a localized fire in the room and all the residents had been removed from the room. V49 stated V49 takes care of R8 and R11, not R10. V49 stated V49 was aware that R8 and R11 was exposed to fire and smoke. V49 stated V49 was told the fire was caused by R8's motorized wheelchair and that R8 was sitting in the wheelchair when the fire broke out and R11 was also in the room. V49 stated based on what was communicated to V49 there was a fire, and R8 was evacuated, and R8 had no clinical symptoms of smoke inhalation and no burns. V49 stated R8 was the focus of the phone conversation, not R11. V49 stated V49 she was not made aware of the fire alarm system not working. V49 stated if V49 had known that V49's clinical judgment could have been potentially different, but V49 still does not know if V49 would have sent R8 or R11 to the hospital. V49 stated if the fire alarm did not sound this could potential have caused a delay in staff response and longer resident exposure to the fire and smoke. V49 stated it is possible to have smoke inhalation without having overt clinical symptoms. On 01/24/25 at 1:05 PM, V53 (Vice President of Operations for [NAME] Health Care) stated R8's motorized wheelchair is what caused the fire. V53 stated the son helps R8 with the wheelchair and the wheelchair was removed and repaired by the son. V53 stated the facility does not do any repairs because the wheelchair is not owned by the facility. V53 provided the survey team with a printed documents from the facility's internal [NAME] Management portal. It was labeled in part, #1742 other, the date and time was not visible on the top portion of the document. V8's name was also on the top of the 5 pages provided. R10 and R11 were not listed. V53 also provided survey team a printed copy of the Manufacturers Guide for Pride Mobility Motorized Wheelchair for R8. Document titled Pride Mobility Owner's Manual which documents in part, under no circumstances should you modify, add, remove, or disable any feature, part or function of your power chair and do not modify your power chair in any way not authorized by Pride and if you discover a problem, contact your authorized Pride Provider for assistance. General Guidelines include but not limited to avoid knocking or bumping the controller and avoid prolonged exposure of your power chair to extreme conditions, such as heat. Daily, weekly, monthly, and yearly checks listed. On 01/27/25 at 2:13 PM, via phone interview V52 (Service Telephone Support Pride Mobility for R8's Motorized Wheelchair) stated if a Pride motorized wheelchair was involved in a fire and/or within close proximity to a fire, exposed to high temperatures it should be evaluated by an authorized licensed Pride Technician before putting it back in use. V52 stated this is a safety precaution in case anything externally and/or internally got burned or damaged. V52 stated you may not be able to see the defect and it might not be safe for use and should be evaluated by a licensed authorized Pride Technician. V52 stated all replacement parts must be ordered from Pride, be certified Pride parts and repairs should be scheduled through a dealer. V52 stated any parts ordered off internet could be defective and should not be used. V52 stated if non-Pride replacement parts are used this would null and void the warranty on the wheelchair as the dealer cannot ensure the safety of the wheelchair. On 01/29/25 at 9:31 AM, V56 (Director of Rehab/Occupational Therapist I've been working here for 2 years. I screen new admissions to see what they are here for, what they can/cannot do. If they cannot stand and/or transfer, then make a recommendation for them to use a wheelchair. V56 stated all residents who use motorized wheelchairs should be assessed by therapy to see if the resident can safety and independent maneuver the motorized wheelchair. V56 stated it would be important for them to be assessed for their safety and the safety of the other residents living in the facility. If they are on therapy the assessment would be in your documentation. If they are not on therapy, I use a screening sheet which I give to the Administrator. Unless there are concerns or something is brought to our attention by nursing, we don't reassess. The assumption is that the resident will maintain their level of function regarding using the motorized wheelchair safely and independently. We don't do any maintenance on the motorized wheelchair. If I notice any wires hanging, I'd notify the Maintenance Director. I never noticed any hanging wires from R8's motorized wheelchair before or after the fire. R8 is not on my case load but I am familiar with her. R8 uses a motorized wheelchair and I have seen her using it well - safely and independently. I did not evaluate her for the use of the motorized wheelchair. Recently, V1 or nursing had asked me to observe R8 usin [TRUNCATED]

Based on observation, interview, and record review, the facility failed to properly assess and implement interventions related to the psychosocial needs of one resident (R8) who was involved in and exposed to fire and smoke surrounding a fire related incident that occurred on 1/6/25 in R8's room. These failures resulted in R8 expressing emotional distress and fear after the incident. The findings include: R8's admission record showed admitted on 12/7/20 with diagnoses not limited to Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, Dysphagia oral phase, Anemia, Peripheral vascular disease, Absence epileptic syndrome, Other hereditary and idiopathic neuropathies, Encounter for attention to gastrostomy, Hyperlipidemia, Unspecified dementia, Chronic embolism and thrombosis, Gastro-esophageal reflux disease, Crohn's disease, Obstructive and reflux uropathy, Other sequelae of cerebral infarction, Type 2 diabetes mellitus with diabetic neuropathy, Aphasia, Essential (primary) hypertension, Heart failure, Major depressive disorder. MDS (Minimum Data Set) dated 11/14/25 reflects: R8's cognition was severely impaired. R8 needs partial/ moderate assistance with oral hygiene, dependent with toileting hygiene, Substantial / maximal assistance with shower / bathe self, upper and lower body dressing, personal hygiene, chair / bed, and toilet transfer. On 1/21/25 At 12:05pm R8 was sitting up on a motorized wheelchair, alert, and responsive. R8 is non- verbal but able to make needs known by hand and head gestures. During interview R8 was able to recall the fire incident on 1/6/25, R8 nodded her head up and down, indicating yes when asked if she was involved and if she almost got burned. R8 then pointed to where the fire was and pointed and motioned to her left towards the arm and pointed at the back of the wheelchair. R8 then pointed the left side of her shoulder. R8 appeared scared and anxious. Surveyor then asked R8 were you scared? and R8 nodded her head up and down, indicating yes. Surveyor further asked are you still scared and R8 nodded her head again up and down, indicating yes and also appeared to become teary-eyed. Surveyor asked R8 if this was the wheelchair and R8 gestured to the chair and nodded her head up and down, indicating yes that she is still using the same motorized wheelchair. R8 also pointed to her bed. Surveyor observed that R8 was in the same room where the fire incident happened and noted dark brownish and black spots and markings on the side of the railing on R8's bed closest to the door. Surveyor also observed the footboard of R8s bed. The footboard appeared to have small charred circle like markings to the black strip at the top of the footboard, as well as melted portions to the black stripping at the top of the footboard. On 01/21/25 at 12:12pm V9 (Licensed Practical Nursing / LPN), stated she was assigned to R8's room on 1/6/25 and that after dinner around 6:30pm she heard a Certified Nursing Assistant / CNA yell, fire! V9 stated she entered the room and saw R8 sitting in her motorized wheelchair next to the bed and saw flames coming from R8's bed. V9 stated it looked like R8's mattress was on fire. She stated R8's wheelchair was not moveable and did not work. V9 stated it might have been that the wheelchair sparked the fire. V9 stated the flames were close to R8 and if R8 was not removed there was a potential that R8 could have been burned. V9 stated none of R8's clothing was burned. V9 stated she did a full body assessment and did not see any injuries but R8 was scared. V9 stated the nurse practitioner was notified and R8 was not sent out to the hospital. V9 stated R8 is non-verbal but alert, orientated and can understand what you are saying and will respond to yes/no questions. On 01/21/25 at 2:22pm V41 (R8's son) stated via phone interview that he received a call from V9 (LPN) on 1/6/25 sometime in the evening but can't remember the specific time. He stated V9 told him that there was a fire in R8's room. V41 said as soon as he got the call he drove to the facility and was onsite within 5-10 minutes of receiving the phone call. V41 stated when he arrived, he saw a fire vehicle and a police car in front of the building. When he got up to the 3rd floor R8 was by the nursing station in a Geri chair. V41 said R8 was hysterical and he could tell she was really scared and nervous. V41 said R8 was shaking her head back and forth and her eyes were big. V41 said he had to sit down to talk to V8 and try to calm her down. On 1/21/25 at 2:50pm V41 (R8's son) was in R8's room and showed the surveyor the melted knob on the back of R8's motorized wheelchair and stated there used to be 4 nubs on the knob but the fire burned them off and now there are none. V41 showed the area on the metal bed frame and stated, See?, you can see the spots on the bed frame where the black plastic from the knob melted into clumps onto the bed frame. He said there were 3 black lumps which V41 proceeded to flick off 2 of the 3 spots. V41 also said you can see where the fibers of the plastic sheathing shredded and melted onto the bed frame. V41 then showed the surveyor photos on his cell phone that he took the night of the fire. The pictures showed that the mattress was burned on the side closest to the door, and bed sheets/linens were charred black in the same area and that there were black charred areas on the bed frame in the same area of the melted plastic. Surveyor requested for V41 to send copies of the photos to the email provided. State agency did not receive the photos via email provided on 1/21/24. On 1/22/25 at 11:45am V1 (Administrator) stated she arrived at the facility around 8:00pm on 1/6/25 and saw R8 who appeared scared surrounding the fire incident. On 1/22/25 at 12:36pm V34 (Certified Nursing Assistant / CNA) stated she was working during the fire incident on 1/6/25. V34 said R8 was involved in the fire incident and looked distraught and scared out of her mind. V34 stated R8 is non-verbal but she can communicate with hand and head gestures. V34 said she knows R8 well and could tell R8 was shaken up by the whole experience. V34 said she asked R8 if she was scared, and she nodded her head up and down to indicate yes repeatedly. V34 said it gave her flashbacks herself (from a personal fire experience she was involved in) so she could understand how R8 was feeling. V34 stated R8 kept shaking her head from side to side as if R8 could not understand what had just happened, like R8 was in disbelief or shock. On 1/22/25 at 3:32pm V37 (LPN) stated she was working during the fire incident on 1/6/25 and R8 was shaken up and looked scared. V37 stated she asked R8, are you okay?, R8 shook her head no. V37 asked R8, Are you scared?, R8 shook her head yes. On 1/24/25 at 9:32am V8 ( Social Service Director/SSD ) stated their role includes mainly advocating for residents, checking, and monitoring psychosocial wellbeing and ensure documentation is done in a timely manner. He said SS (social service) department develop an individualized plan of care regarding resident's psychosocial wellbeing. V8 stated care plans would include goals and appropriate interventions in place to guide staff on how to care for the residents. V8 said care plans should be reviewed / revised at least quarterly and as needed to reflect the status and needs of the residents. V8 said psychosocial wellbeing includes emotions / feeling of the resident and Psychotherapy services are being offered in the facility. V8 stated he saw R8 the following day after the fire incident and R8 appeared scared and R8 was holding his hand very tightly. V8 said R8 being involved or experiencing the fire incident on 1/6/25 could be traumatizing to her because it is an unusual event. V8 said R8 should be checked /evaluated and monitored, provide with revisits, support/ reassurance and they ensure any psychosocial concern/issues are being addressed. R8's records were reviewed with V8. There was no documentation that interventions were provided to R8. V8 stated R8's psychosocial wellbeing and care plan should be reviewed / revised to reflect R8's status, any concerns and to evaluate appropriate interventions. V8 stated R8 could benefit with psychotherapy to discuss the fire incident that occurred on 1/6/25 to process her emotions. R8's progress notes from 1/6/25 to 1/14/25 were reviewed and no Social Service documentation was found. R8's care plan did not reflect that it was reviewed / revised to reflect R8's status after the fire incident on 1/6/25. On 01/24/25 at 9:48am V2 (Director of Nursing) stated she was not onsite at the time of the fire. V2 stated a fire is an unusual event and since it was an unusual event, the nurses would need to monitor the residents regularly to make sure they are okay. V2 stated this monitoring should be done every shift for the following 72 hours after the fire incident on 1/6/25 and document would be in resident's EHR (electronic health record). Surveyor reviewed R8's EHR with V2 and there was no documentation found that R8 was monitored 72 hours post fire incident. On 1/24/25 at 10:20AM V60 ( Licensed Clinical Social Worker / LCSW) stated she has been a contracted staff for the facility since March 2024. V60 stated she has been seeing R8 weekly due to diagnosis of MDD (Major Depressive Disorder) with symptoms of self-isolation in her room. V60 said she started seeing R8 in April 2024. She said R8 is alert and oriented x 4, nonverbal, and able to make needs known to staff using hand and head gestures. V60 said she was informed by facility staff that R8 was scared due to being exposed in a Fire incident on 1/6/25. She said she did see R8 on 1/14/25 and the fire incident was not directly discussed. V60 said V8's room change was the main topic of discussion. She said R8's involvement or exposure to fire and smoke incident is a traumatizing event. V60 said R8 could be helped on how to process her emotions by letting her express the traumatizing event. She said staff could provide reassurance that she is safe (presently) to help deal with anxiety that came with traumatic experience. V60 said she would not not recommend or be in favor for R8 to still used the same piece of equipment like the bed or chair with burn markings on it as it would possibly keep the trigger lasting. She said any little things could possibly trigger the traumatizing event. R8's progress notes dated on 1/14/25 created by V60 (LCSW), documentation did not reflect psychotherapy session regarding fire incident on 1/6/25. On 1/24/25 at 11:15am V49 ( Nurse Practitioner/ NP) stated the fire incident on 1/6/25 could be a traumatizing event for R8 and she should have received psychotherapy to process her emotions and provide her with reassurance. V49 said the chair and bed could be a provocative cue and that using the same bed is not ideal. V49 said the facility should switch her bed as that could be triggering for R8. On 1/24/25 at 11:54 AM, was interviewed further about the fire incident and her chair not working. R8 indicated by nodding R8's head up and down in a yes motion that there was a fire in R8's room when R8 was sitting in R8's motorized wheelchair. R8 nodded and gestured that the fire was coming from the back left side of R8's wheelchair. R8 gestured to the left side of R8 wheelchair when asked if R8 felt hotness from flames and motioned up and down R8's left arm. R8 indicated that R8 was still using the same motorized wheelchair that was involved in the fire and that it wasn't working again today. R8 indicated by nodding R8's head up and down in a yes motion when R8 was asked if she scared during the fire and if R8 is still scared. R8 appeared to display wide open eyes, raised and furrowed eyebrows, while communicating about the fires R8 gestured and responded no, when R8 was asked if R8 needed to go to the hospital on 1/6/25. R8 indicated that if someone had asked R8 if R8 wanted to go to the hospital the night of 1/6/25, R8 would have said yes, because R8 wanted to be checked after the fire incident. On 1/30/25 At 10:26am V1 (Administrator) said the fire incident on 1/6/24 could be a traumatizing event for R8. V1 stated Social Services interventions could be utilized such as checking her mood, providing support, and should be documented. V1 said that during R8's Psychotherapy session, the fire incident could have been discussed to process her emotions. Surveyor requested facility's policy related to resident's psychosocial wellbeing, V1 stated facility does not have it. Facility's residents' rights policy dated 11/18 documented in part: Your rights to safety. The facility must provide services to keep your physical and mental health, at their highest practical levels. Facility's comprehensive care plan policy dated 1/2023 documented 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, mental, and psychosocial needs. 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. The comprehensive care plan should be reviewed with the resident and/or resident representative and changes made as appropriate.

Based on observation, interview and record review, the facility failed to provide monthly surveillance and maintain patient care equipment, to ensure that it is in safe operating condition. This failure affected one (R8) out of five residents (R4, R8, R12, R13, R14) reviewed for preventative maintenance. Findings include: On 01/21/25 at 1:30 PM, V5 (Director of Maintenance) stated the fire was caused by the R8's motorized wheelchair. V5 stated he does not know if the facility has a policy on wheelchair maintenance. V5 stated, I don't do any routine checks or monitoring on the electric wheelchairs because they are owned by the residents, not by the facility and if we do something to the electric wheelchair then we are liable, so it is not part of our responsibility. V5 stated he took R8's motorized wheelchair out of the room the night of the fire and V41 (R8's Son) came that same night and replaced a part. V5 stated V5 does not know what part V41 replaced or what R8's son did to the wheelchair. On 1/21/25 at 2:22 PM, V41 (R8's Son) stated V41 he was called on 01/6/25 and drove to the facility that same night. V1 stated the fire department told him that the fire was started by the wheelchair, and he could see that the cord on the motorized wheelchair that connects to the controller on the left arm side of R8's wheelchair had exposed wires. V41 stated on 01/05/25, the day prior to the fire V41 had replace the electronic charger for R8's motorized wheelchair. V41 stated he is the one who maintains R8's motorized wheelchair. V41 stated, I do all the repairs and maintenance checks on my mom's wheelchair. V41 stated he has experience fixing motorcycles so that is how he knows how to do the repairs on R8's motorized wheelchair. V41 stated that night V41 replaced the cord and secured it with zip ties. On 01/22/25 at 2:01 PM, via phone interview V46 (Registered Nurse) stated V46 was working on 01/06/25 and sitting at the nursing station when V32 (CNA) walked to the nursing station and said, there is a fire. V46 stated V46 could already see smoke in the hallway and when V46 entered the room, V46 saw R8's bed on fire and R8 was sitting in R8's motorized wheelchair which was right next to the fire. V46 stated V46 could smell burning rubber and saw a white extension cord on the floor which was melted. V46 stated that morning R8's wheelchair was not working correctly and that evening the staff was charging the wheelchair using a white extension cord. V46 stated the smoke and fire alarm did not go off in the room or hallway or the rest of the building so, initially none of the staff knew that there was a fire in the building. V46 stated R8's motorized wheelchair would not move so; we were trying to figure out the best way to move R8. V46 stated there were two EMTs (Emergency Medical Technicians) on the floor because they had just delivered a resident to the floor from the hospital and the EMTs are the ones who [NAME] into action. V46 stated one EMT and the CNA (V32) wrapped R8 in a blanket and transferred R8 into a geriatric chair. V46 stated V46 told someone to make an overhead page to alert the other staff that there was a fire in the building because we needed help removing the residents away from the fire. V46 stated one of the other nurses was directing the other EMT on where to get the fire extinguisher and that is when V46 called 911 right there from the room from V46's personal cell phone because V46 stated the fire didn't stop, it was growing and getting bigger. V46 stated V46 was getting scared. V46 stated then V46 saw the other EMT use the fire extinguisher to put out the fire. V46 stated after the fire was put out it was very smokey in the hallways and in R8's room. V46 stated the fire department who came told the staff that it was an electrical fire cause by the extension cord or the motorized wheelchair. On 01/22/25, V11 (Evening Nursing Supervisor, Licensed Practical Nurse) stated by the time V11 arrived on the unit there was no active fire, only a lot of smoke. V11 stated R8's motorized wheelchair was in the hallway and V11 could see cords hanging on the back of the wheelchair. V11 stated you could tell that someone had tried to fix it because there was black electric tape on the cord, and it was hanging from the wire. On 01/24/25 at 10:30 AM, observed R8 lying in bed with R8's motorized wheelchair next to her bed. V48 (Day Nurse Manager/Licensed Practical Nurse) stated R8's motorized wheelchair was not working. V48 stated, We are trying to figure it out. It won't move. It was on the charger, but it won't turn on. When we press the button to turn it on, it turns right off and I'm going to call the son so he knows it's not working and can fix it. Surveyor observed a white sticker on R8's motorized wheelchair for Pride Mobility and listed a web site. On 01/24/25 at 11:40 AM, V5 (Director of Maintenance) stated the nurses told him that R8's wheelchair was not working. V5 stated he took off the cover on the wheelchair and moved some of the wires around and replaced the cover and it turned back on. Chicago Fire Department Office of Fire Investigation Fire Marshall Report requested and obtained by the surveyor dated, 01/06/25 documents in part, there was no visible fire to the exterior of building; fire alarm system activated - no ; smoke detectors alerting - no ; after a thorough fire scene examination and evaluation it is the considered opinion that this fire incident was caused by the ignition of plastic wiring insulation from electrical energy, then spreading to immediately adjacent cloth/fabric combustibles in the form of bedding. On 1/24/25 at 12:24 PM, via phone interview V51 (Commanding Fire Marshall Deputy District Chief, Chicago Fire Department) stated V51 was not part of the team that responded to the fire on 01/06/25 but he spoke with the Fire Marshall who did respond, who said the fire appeared to be caused by an electrical issue. V51 stated V51 is looking at the Fire Marshall's Report of the incident on 01/6/25 and at pictures taken at the scene. V51 stated the pictures show that the cord in the back of the wheelchair is exposed and severed. V51 stated at one point the cord was one piece and the wires were contained inside the cord, but in the picture, there are two dangling pieces with exposed wires. V51 stated in V51's experience what happens is the cord containing the wires is subjected over time to physical damage either from getting banged, pinched, rubbed against, or perforated in some way. V51 stated the electricity heats up, melts the plastic and escapes from the plastic sheathing and now the electricity can jump and ignite any combustible material nearby. V51 stated in this case it appears the combustible material was the sheets and bed linens which acted as fuel for the fire. V51 stated this could be one of the causes of the fire based on what V51 is seeing in the pictures. V51 stated it is clear from looking at these pictures that the motorized wheelchair was involved in the fire but V51 cannot say definitively what caused the fire, but it appears it was from some type of electrical fire. V51 stated in V51's opinion this motorized wheelchair should be inspected by an electrical engineer before the resident is allowed to use it again. V51 stated It should not just be taped up and put back in service because we don't really know what happened and if there was an electrical event it may not be safe for the resident to continue using it. V51 stated the motorized wheelchair may be malfunctioning inside the wheelchair, but we cannot see it. V51 stated an electrical engineer should do an inspection to make sure the issue that potentially caused the first fire could not create another potential fire. On 01/27/25 at 2:13 PM, via phone interview V52 (Service Telephone Support Pride Mobility) stated if a Pride motorized wheelchair was involved in a fire and/or within proximity to a fire, exposed to high temperatures it should be evaluated by an authorized licensed Pride Technician before putting it back in use. V52 stated this is a safety precaution in case anything externally and/or internally got burned or damaged. V52 stated you may not be able to see the defect and it might not be safe for use and should be evaluated by a licensed authorized Pride Technician. V52 stated all replacement parts must be ordered from Pride, be certified Pride parts and repairs should be scheduled through a dealer. V52 stated any parts ordered off Amazon could be defective and should not be used. V52 stated if non-Pride replacement parts are used this would null and void the warranty on the wheelchair as the dealer cannot ensure the safety of the wheelchair. Document titled Pride Mobility Owner's Manual which documents in part, under no circumstances should you modify, add, remove, or disable any feature, part or function of your power chair and do not modify your power chair in any way not authorized by Pride and if you discover a problem, contact your authorized Pride Provider for assistance. General Guidelines include but not limited to avoid knocking or bumping the controller and avoid prolonged exposure of your power chair to extreme conditions, such as heat. Daily, weekly, monthly, and yearly checks listed. Facility provided policy titled, Preventative Maintenance Plan dated 1/2025 which documents in part, monthly surveillance of all resident rooms for any repairs needed and proper operation of all equipment. If a resident has personal equipment, it should be maintained according to manufacturer's guidelines.

The facility failed to ensure the resident's call light device was within reach for two residents (R1, R3) out of three residents reviewed for quality of care. This failed practice placed the resident at risk for not being able to call for help, if needed. Findings include: On 10/22/2024, 10:41 AM R1's call light was on top of 3 pillows without pillowcases that are on top of R1's nightstand. R1 was sleeping, easily arousable, and in no apparent distress. R1 states that she is not sure when she first came to the facility. R1 states I have memory loss, maybe about 6 months ago, I don't like it here. R1 cannot remember the names of the staff that take away her call light. R1 states that when they do come to check on her, R1 states that she forgets what she even yelled out for. R1 cannot remember when she yelled out for help. R1 states that currently, she cannot reach her call button. R1 states look and see they took it away from me, I can't reach it. On 10/22/2024, 10:55 AM V3 (Certified Nursing Assistant) states that call lights must be in reach of the residents. V3 states that she has not heard any resident yell out for help. V3 reports that residents who are more vulnerable and must have their call light within reach is contracted, if a resident has some confusion, or residents that are non-verbal or non-ambulatory. V3 states that residents should not be ignored if they are yelling for help because they might need or want something, or they can be slipping. V3 and surveyor entered R1's room and V3 states that R1's call light is not within reach. V3 grabbed R1's call button that is on top of the pillows on the nightstand and placed it within R1's reach. R1 states thank you. V3 states that she has not taken away call lights form any resident because that is neglect. R1's Face sheet documents that R1 is a [AGE] year-old female admitted to the facility on [DATE], who has diagnoses not limited to: paraplegia, major depressive disorder, insomnia due to other mental disorder, bipolar disorder. R1's Minimum Data Set (MDS) Section C, dated 10/02/2024, documents R1 has a Brief Interview for Mental Status (BIMS) of 12 out of 15, R1 is moderately cognitive impaired. R1's Minimum Data Set (MDS) section GG dated 10/02/2024, documents in part R1 needs substantial/maximal assistance for ability to roll from lying on back to left and right side and return to lying on back on the bed. On 10/22/2024, 11:05 AM R3 was lying in bed, covered in a white sheet, in no apparent distress. R3's call button attached to the lowest part of the right bed side rail. R3 states I need a diaper change; I don't have the call light as R3 looked around for his call button. On 10/23/2024, 10:09 AM R3's call light button noted on the floor. R3 states that his nurse gave him some medicine earlier. On 10/23/2024, 10:12 AM surveyor and V9 (Licensed Practical Nurse) entered R3's room and V9 states that the call button should not be on the floor. V9 states it probably slipped off of him. It was on his chest. I did initially go to him because he pulled the call light. V9 states that she did not move R3's call light away from him. V9 denies any resident complaining of this to her. V9 states that it is important for residents to have their call light within reach just in case an emergency happens or if they ask for something simple as some water. R3's Face sheet documents that R3 is a [AGE] year-old male admitted to the facility on [DATE], who has diagnoses not limited to: adult failure to thrive, history of falling, syncope and collapse, generalized anxiety disorder, major depressive disorder, recurrent, unspecified, legal blindness. R3's Minimum Data Set (MDS), dated [DATE], documents R3 has a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating R3 is cognitively intact. R3's care plan dated 5/14/2024 documents in part R3 has a potential for falls. R3 had an actual fall. Interventions include encourage to utilize call light for staff assistance, have commonly used items within reach. Facility policy dated 01/10/2024, titled Call Light Response documents in part, to provide the staff with guidance on responding to residents' requests and needs. Ensure the call light is always within the resident's reach. When the patient or resident is in bed or confined to a bed or chair, provide the call light within easy reach of the patient or resident.

Based on observation, interviews, and review of records the facility failed to follow policy in giving/providing a shower/bath to 1 (R1) out of 4 residents reviewed for resident shower or bathing schedule. This failure has the potential to affect 1 resident (R1) in maintaining hygiene through bathing at least once a week. Findings include: R1 is [AGE] years old, initially admitted on [DATE] with medical diagnosis that includes paraplegia and bilateral (right and left) foot drop. On 9/17/2024 at 12:50 PM, R1 was seen in her room laying on her bed. R1 was alert and able to maintain conversation within topic very well. In front of R1 was a moving table with her cell phone and TV remote control. During conversation the cell phone rings that was answered by R1. After R1's phone conversation, R1 stated that it was her daughter on the phone (V7). R1 confirmed that the phone and TV remote control was her own. R1 stated that she had a scheduled surgery but was not able to go. R1 stated that she did not have any formal appointment as to who her power of attorney will be. But V8 (Family of R1/Sister) or V7 (Family of R1/Daughter) can represent her. R1 was asked if V7 is allowed to visit her in the facility. R1 said that V7 brings her food but is not allowed to visit her in the facility. R1 said that it was due to a fight between her (R1) and V7, that V7 hits her (R1) around four (4) years ago. R1 stated that Department of Elderly does not allow V7 to visit her in the facility. R1 stated that V8 was able to visit her in the facility. R1 was asked if she has any concern. R1 replied that staff does not take her to shower for a long time. And that she did not have any shower since May. R1 stated that even before she has shingles, she was not showered for at least more than a month. R1 comb her hair using her fingers and her hair was sticking and hard to detached. R1 said, This feels so sticky and uncomfortable. On 9/17/24 at 1:30 PM at the nurse station, V5 (Restorative Nurse/Licensed Practical Nurse) presented a shower schedule sheet. V5 was asked for the binder of shower that was done by staff. V2 (Regional Nursing Consultant/Former Director of Nursing) took the binder and gave it to writer. There was no record of R1 in the binder containing shower sheets. V2 stated that shower forms are not complete because it is being collected by V6 (Wound Nurse/Licensed Practical Nurse) and bring it to her office on a daily basis. V6 who was at the nurse station went to her office check on all shower sheet that was filed. Upon checking, R1 does not have any record of taking a shower on 9/10/2024 (Tuesday) and 9/13/2024 (Friday) per shower schedule sheet provided by V5. V6 stated, That is the only record I have, I think R1 came from the 3rd Floor. Per R1's census R1 was transferred from 3rd floor to second floor on 9/9/2024. V6 stated, that staff may be doing a bed bath because R1 has shingles. But staff needs to fill out shower form when performing a bed bath. And since R1 was transferred to 2nd Floor from 3rd Floor without record for being showered by staff. 9/9/2024 to present (9/17/2024) is more than a week without shower sheet to support. V6 also reviewed all shower sheets from the previous floor (3rd Floor) of R1 but there was none on the file. On 9/17/2024 at 2:25 PM, V3 (Licensed Practical Nurse) stated that R1 is bedbound due to paraplegia and need to be assisted of her ADLs (Activity of Daily Living). R1 MDS (Minimum Data Set) assessment dated [DATE] documents that bilateral (both) lower extremities of R1 are impaired. And R1 is dependent to staff for shower/bathing. On 9/18/2024 at 1:52 PM, V1 (Administrator) stated that shower of the residents are done by CNA (Certified Nursing Assistant). And the CNAs should fill up the shower form. All the shower forms are being collected by the Wound Nurse (V6) because it serves as a weekly skin assessment. V1 stated that all residents needs to be bath or shower at least once a month. V1 was informed that R1 stated that the last shower she had was on the month of May. And R1's hair does not flow and sticking when she uses her fingers to comb her hair. V1 stated that staff were instructed to include cleaning R1's hair during bed bath because R1 gets a bed bath due to shingles. Bathing policy dated 1/10/2024, reads: All residents are offered a bath or shower at least one time per week. More frequent bathing or showering is given as needed. Under guidelines, if a resident requires a bed bath, a complete bed bath is given one time per week, and a partial bed bath the other days.

Based on observation, interview, and record review the facility failed to provide proper positioning for 1 (R1) resident during dining. This failure has the potential for R1 to be at risk for choking and aspiration during dining experience. Findings Include: R1 has diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Aphasia Following Cerebral Infarction, Essential (Primary) Hypertension, Atrial Fibrillation, Type 2 Diabetes Mellitus, Anxiety Disorder due to Known Physiological Condition and Post-Traumatic Stress Disorder. R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 04 indicating severe cognitive impairment. R1's Care Plan document in part: Focus: Bed Mobility: R1 has a self-care deficit in bed mobility r/t (related/to) (Decreased ability to position or reposition self in bed/ Turn from side to side/ Move from lying to sitting or sitting to lying position). Intervention: Position and reposition resident in bed for comfort, joint support, and skin integrity. During the initial tour of the facility on 09/10/24 at 01:05 PM, the surveyor observed R1 in bed in a low fowlers position with the meal tray in front of him while trying to eat lunch from an overbed table. R1's reclined body was level with the overbed table and R1 was drinking thin red liquid from a cup. On 09/10/24 at 01:11 PM Surveyor went to the nurse station and asked V7 (Licensed Practical Nurse) to go to R1's room. Surveyor asked V7 R1's position in bed. V7 responded, R1 is in a low [NAME] position. R1 should be up right in bed. The position that R1 is in is not appropriate for eating. There is a potential for choking or R1 may aspirate. On 09/10/24 at 01:14 PM while waiting for staff to reposition R1, R1 was observed coughing. V7 (Licensed Practical Nurse) was standing near the foot of R1's bed then stated, let me get some gloves, I got someone on the way to help pull you (R1) up. On 09/10/24 at 01:22 PM the nurse and certified nurse assistant repositioned R1 in bed. On 09/11/24 at 12:14 PM surveyor asked V9 (Certified Nurse Assistant) what the correct positioning of a resident in bed while eating. V9 responded, the position of the residents while eating in bed is 90 degree. On 09/11/24 at 03:03 PM V11 (3rd floor unit manager) was asked the correct positioning of a resident while eating in bed. V11 responded, the resident should be in an upright position when eating or being fed. On 09/12/24 10:26 AM V17 (Licensed Practical Nurse/Restorative Nurse) stated R1 is a substantial assist with toileting and sitting up in the bed. R1 was supervision with eating up until this week. R1 need assistance with eating because he is not eating well. The position that a resident should be in when eating or being fed in bed should be a semi-Fowler position, sitting up to prevent aspiration. Document undated document in part: R1 requires assistance with dining. In-Service, Education and Staff Development undated documents in part: Topic: It is the expectation that restorative aides' complete rounds on residents requiring assistance dining to ensure that they are positioned appropriately prior to the arrival of floor trays. In-Service, Education and Staff Development undated documents in part: Topic: Resident should be positioned in semi to high [NAME]'s position during mealtimes to prevent aspiration and/or choking and to promote optimal intake. Policy: Titled Feeding Assistance revised 01/24 document in part: General: To attempt to provide adequate nutrition to a resident. Guideline: 3. Position resident in proper body alignment for eating. Titled Activities of Daily Living reviewed 05/24 document in part: General: A program of activities of daily living is to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis. D. Feeding a. Proper positioning for eating is maintained.

Based on observation, interviews and record review, the facility failed to schedule a dental appointment as ordered by a Nurse Practitioner for a dependent resident noted with severe dental decay. This failure has affected one (R5) of nine residents reviewed for nursing care. This failure resulted in R1 experiencing pain and a continuation of dental decay. Findings include: Resident is [AGE] year old with diagnosis including but not limited to: Need for assistance with personal care, essential hypertension, weakness, respiratory failure and abnormal posture. On 8/26/2024 at 10:46 AM, R5 was observed sitting in dining room on the second floor. At that time, R5 said, I have to have my tooth pulled. It hurts me sometimes, but thankfully it is not hurting right now. I had Txxx (painkiller) and it helps. I just need this tooth pulled because it is rotten. Surveyor inquired about the process of scheduling resident's appointment. On 8/28/2024 AT 10:19 AM, V12 (Restorative Nurse) said, If a resident needs an appointment scheduled, it would show up on the communication board and in the residents orders. For R5, I noticed the order for dental was in the patient's chart, but was not scheduled. I knew that the order for R5 wasn't carried out because I did not see it on the home screen. I added the order to the home (communication) screen so that the appointment can be scheduled. On 8/28/2024 at 10:30 AM, V13 said, I am responsible for scheduling the resident's appointments. If an appointment is to be scheduled, it should be communicated on the home/ communication page. The Nurses relay all orders from the Medical Doctor or Nurse Practitioner on the communication board pertaining to appointments or appointment requests. This is the only way that I know to schedule an appointment, unless it was verbally told to me. On 8/29/2024 at 3:23 PM V1 said, Doctor's appointments shown on the order to schedule should be scheduled as soon as possible. A delay in dental treatment could results in pain and infection. R5's care plan dated 7/17/2024 documents, R5 presently requires the care and support/services that this facility setting provides in order to provide highest practical functioning. R5's care plan dated 7/24/2024 documents, R5 has impaired oral/dental hygiene. Antibiotics prescribed for left molar. R5's Minimum Data Set- Oral/ Dental Status dated 7/24/2024 documents, likely cavity or broken natural teeth. Nurse Practitioner note written on 7/24/2024 by V21 (Nurse Practitioner/NP) documents, Severe dental decay left molar with surrounding swelling and lymphadenopathy; In house or outpatient dental consult asap (as soon as possible) for extraction. Nurse Practitioner note written on 8/5/2024 by V22 (NP) documents, R5 has a bad left molar that needs extraction in which a dentist appointment has yet to be made. I (V22) believe this may be the cause of her headaches. Discussed with nursing to get dental appointment ASAP. R5's Physician Order Sheet documents an order entered on 7/24/2024 documents an order to schedule dental exam for evaluation for tooth extraction left molar which is cracked, extensive decay and pain. R5's Physician Order Sheet excludes any scheduled dental appointments for R5 as of 8/28/2024. Facility policy titled Dental Services documents, to provide for needed dental services to our residents.

Based on interview and record review the facility failed to a.) follow their policy and monitor vital signs during a medical emergency and b.) perform needed interventions for a resident who experienced a change in condition for one (R2) resident out of three residents reviewed improper nursing care. Findings include: On 6/9/24 at 11:22 AM V8 (Licensed Practical Nurse/LPN) states that she was doing rounds with the unit manager, and they noticed R2 was shaking, in his bed. V8 states that she performed vital signs on him, and they were high, V8 states that R2 normally has low blood pressure. V8 states that the doctor was called and V8 states that the doctor gave orders to send R2 to the hospital. V8 states that the paramedics informed her that they were transferring R2 to a closer hospital because R2 ' s blood pressure kept spiking and R2 was seizing. V8 states that R2 was not having any seizure when the private ambulance picked him up. V8 states that R2 was antsy and trying to remove his belt and picking at his shirt. V8 states that when she initially saw R2 having a seizure, V8 states that she saw his eyes rolling, and his hands were clinched downward. V8 states that R2 only had one seizure that morning. V8 states that the seizure lasted maybe two minutes, maybe like a minute with his eyes rolling, and two minutes with the jerking. V8 states that she stayed with him the whole time. V8 states R2 ' s seizure occurred maybe around 9:00AM. V8 states that the doctor did not order for R2 to be sent out via 911 because V8 states that the seizure stopped. V8 states that the private ambulance informed her that if R2 had another seizure then to call 911. On 06/09/24 at 1:01 PM V8 states that a set of vital signs are blood pressure, respiration, pulse, temperature, and O2 sat (oxygen saturation). V8 states that a full set of vital signs should be taken after a seizure. V8 states the normal range for O2 sat is between 90%-100%. V8 states that R2 ' s O2 sat reading of 90% could have been caused from him having a seizure that day. V8 states that she does know that when the ambulance arrived, V8 states that R2 was saturating at 88%, and V8 states that the paramedics placed R2 on oxygen. V8 states that R2 was not on oxygen prior to the paramedics arriving to the resident. V8 states that low oxygen saturation can affect the oxygen that is going to R2 ' s brain. On 06/09/24 at 1:33pm V7 (doctor) states that he remembers they called him about R2, and he was sent out. V7 states that he thinks it was ok for resident to be sent to the hospital via private ambulance instead of 911 because the nurse informed him that he was stable. V7 states that he does not remember if he was notified of R2 ' s O2 sat reading of 90%. V7 states that the preferred normal oxygen saturation range is to be in the high 90s unless the resident has COPD (chronic obstructive pulmonary disease), V7 states it is preferred above 90%. V7 states that if 90% is not the resident ' s baseline then V7 states he can start him on oxygen therapy with this number. Surveyor informed V7 of R2 ' s usual O2 sat readings and V7 states that is lower than his normal and V7 states that is a drop. V7 states that the pulse oxygen saturation number gives them a guide, and V7 states that if the resident is short of breath, pale, and even with a normal pulse oxygen number, V7 states that he would still place resident on oxygen therapy. V7 states that if the resident is asymptomatic then they would look at the number. R2's Face sheet documents that R2 is a [AGE] year-old male admitted to the facility on [DATE] who has diagnoses not limited to: dementia, epilepsy, personal history of traumatic brain injury. R2's nursing progress note dated 06/06/2024 09:46 AM documents in part: The writer observed a resident in bed displaying seizure activity. The writer remained with the resident until seizure was complete. Resident assessed and v/s as followed. B/P 118/65, RR18, P88, T97.8. No documentation of R2 ' s oxygen saturation post seizure activity. R2's electronic health record dated 06/06/2024 11:45 AM indicates R2's O2 saturation is 90 % (Room Air). R2's electronic health record dated 06/06/2024 11:45 AM indicates R2's blood pressure is 109/42 mmHg (millimeter of mercury). R2's electronic health record dated 06/06/2024 11:45 AM indicates R2's pulse is 61 bpm (beats per minute). R2's electronic health record dated 06/06/2024 11:45 AM indicates R2's temperature is 96.8 F (Fahrenheit). R2's electronic health record dated 06/06/2024 11:45 AM indicates R2's respiration is 14 Breaths/min. R'2 nursing progress note dated 06/06/2024 11:54 AM documents in part: Resident transported to the hospital via private ambulance. Facility document, dated 1/2024, titled Medical Emergency Management documents in part, General: Emergency guidelines refer to actions given to residents with urgent and critical needs .take vital signs and provide reassurance to the resident. Vital signs should be taken every 10-15 minutes based on resident need until the resident is stable or transferred . A convulsive seizure is involuntary contractions of muscles resulting from abnormal cerebral stimulation . After the seizure reorient the resident. e. Take vital signs and record. Facility document, dated 1/10/2024, titled Change in Resident Condition documents in part, Policy: 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.

Based on observation, interviews, and record reviews the facility failed to provide the appropriate treatment to attain the highest practical mental and psychosocial wells-being of one [R125] resident reviewed in a sample of 35. This failure resulted in R125 feeling sad, depressed, tired, and refusing care. Findings include: R125's clinical indicates in part, he is a twenty-eight-year-old admitted on [DATE], with the medical diagnosis of attention-deficit hyperactivity disorder, depression, paraplegia, neuromuscular dysfunction of bladder, essential (primary) hypertension. R125's physician order dated 5/15/24- Dextroamphetamine Sulfate Oral Tablet 5 MG (Adderall) [Controlled Drug], give 1 tablet by mouth in the morning and afternoon for ADHD. R125's Progress Notes: Documented in part. Dated 4/28/24- Nursing Note-R125 refused care and weights, he became verbally aggressive, nurse practitioner gave order for psych consult. 4/28/24-Nurse note: refused ADL care and increase in anxiety. 4/29/24-Nurse note: refused ADL care. 5/2/24-nurse practitioner note requested to go back on ADHD meds, and psychiatry consult ordered. 5/2/24- social service note: R125 presents with moderate severe depression. 5/3/24-nurse note refused ADL care. 5/4/24- nurse note: refused ADL care, shower, and lab work. 5/5/24- nurse note: picking wounds. 5/6/24- nurse note: attempted to throw away personal belongings. 5/7/24 -nurse note: picking wounds. 5/12/24, 5/13/24 nurse note: refused ADL care. 5/14/24- nurse note: R125 request to psychiatrist. 5/15/24- nurse note: [V2 Director of Nursing] Psychiatrist assessed R125 and prescribed new order Dextroamphetamine Sulfate Oral Tablet 5 MG (Adderall) [Controlled Drug], give 1 tablet by mouth in the morning and afternoon for ADHD. Carried out orders. Next visit with psychiatrist in one week. 5/15/24 thru 5/23/24- No note from psychiatrist [V47]. 5/20/24 nurse note: refused skin treatment. 5/22/24 nurse note: refused ADL care. 5/23/24 nurse note at 13:51 (1:51PM) phoned V47 regarding prescription for Dextroamphetamine Sulfate Oral Tablet 5 MG (Adderall). R125's Medication Administration Sheet: 5/15/24- Dextroamphetamine Sulfate Oral Tablet 5 MG (Adderall) [Controlled Drug], give 1 tablet by mouth in the morning and afternoon for ADHD. [Medication was not administered 5/15/24 thru 5/23/24. On 5/21/24 at 11:37 AM, R125 stated, I was admitted here on 4/27/24. I requested to see a psychiatrist, but I was not seen until 5/15/24. The psychiatrist [V47] on 5/15/23, reorders my medication, Dextroamphetamine Sulfate that I been taking since I was sixteen years old. On 5/16/24, I did not receive my mediation. I been asking different nurses, why I have not received the Dextroamphetamine Sulfate. Some nurses told me they will call pharmacy, other nurses said they was going to call V47. I don't think the nurses called V47. Not having my medication has made me feel terrible, feeling sad, depressed, tired, disorganized, and not wanting to move around to allow ADL care. I just been staying in my room, not wanting to be bothered. On 5/22/24 at 1:35 PM, (Face to Face Interview) V47 [Psychiatrist] stated, I assessed R125 for the first time on 5/15/24. R125 expressed he needed the medication Dextroamphetamine Sulfate Oral Tablet 5 MG, that he has taken since a teenager. After my assessment it was determined that R125 did in fact need the medication to treat attention-deficit hyperactivity disorder [ADHD]. I completed a form with V2 [Director of Nursing] and she was to fax the form to pharmacy. The sign form to pharmacy will allow any of my orders for narcotics to be filled and delivered, and my signature will remain of file with the pharmacy. I did not receive any notification from nursing staff that R125 did not receive his medication. I was not made aware the pharmacy did not receive the completed form. I did not give an order to place the medication on hold. Not receiving Dextroamphetamine Sulfate, could cause the resident to feel sad, a down mood, tired, and poor concentration. I will go up to R125's room and assess his mood and behavior. I will complete the required forms and submit them to pharmacy, R125 will have his medication today. I did complete R125's psychological assessment. I did not have time to document my encounter. I will complete our encounter today for 5/15/24. On 5/22/24 at 3:10 PM, V2 [Director of Nursing] stated, I placed in the order for R125's medication Dextroamphetamine Sulfate Oral Tablet 5 MG. I received the order from V47 on 5/15/24. V47 was supposed to complete a prescription and fax it to the pharmacy. I did place in the progress note in R125's clinical record. I thought V47 completed the prescription and faxed the order over to pharmacy. I was not made aware that R125 did not receive his medication from pharmacy. The procedure for any narcotic order, a prescription must be completed and faxed to pharmacy. If the medication was not delivered, the nursing staff should first call pharmacy to find out the reason why the resident's medication was not delivered. Then call the physician for any need prescriptions or forms. If a resident does not receive Dextroamphetamine Sulfate, the behaviors potentially can continue or worsen. V47 should document his assessments and encounter with the resident. On 5/23/24 at 12:35PM, R125 stated, I did not receive my Dextroamphetamine Sulfate Oral Tablet 5 MG, today. I did not see V47 yesterday. The first and last time I saw him was on 5/15/24. My nurse V8 [Licensed Practical Nurse] told me the prescription was faxed yesterday (5/22/24). On 5/23/24 at 12:57 PM V8 (Licence Practical Nurse) stated, V47 told me yesterday that he faxed R125's medication to the pharmacy. On 5/23/24 at 1:00 PM, V17[Wound Care Nurse] stated, I will call the pharmacy to find out if the prescription was faxed. V17 phoned the pharmacy on speaker in the presents of V8 and surveyor. The pharmacist said there was no prescription on file. V17 was transferred to the data entry department, it was verified there was no fax, e-script, sent to the pharmacy for R125. V8 stated, I will call V47 for a script. Policy documented in part: Controlled Substance Orders (No Date) -A controlled substance medication will be dispensed by the pharmacy if all state and federal requirements are met. -A controlled substance prescription will only be accepted and dispensed if the pharmacy receives a valid prescription. -A valid controlled substance prescription can be received by the pharmacy by the following ways. Electronically, fax, or phone call. -Once the valid prescription is received from the physician the medication will be delivered in the next delivery.

Based on observation, interview and record review, facility failed to provide an adequate supply of linens to meet staff and resident needs in the provision of resident care. This failure has the potential to affect all 180 residents of the facility. Findings: On 5/21/2024 at 2:30 PM observed three CNAs (certified nursing assistant) carts on the 2nd floor. No bath towels were observed on any of the three carts. On 5/21/2024 at 2:35 PM, V9 (CNA) was interviewed. V9 stated that the CNAs start the shift with a linen cart that each CNA puts together. Linens are brought up by the laundry room and put in an alcove in the hallway. Each resident uses three towels to shower or bathe so V9 stated that the staff go through towels quickly. Once the towels are gone, V9 stated that staff call the laundry room to get more. Our shift is over at 3, so there are no towels on the floor. The laundry room will bring new linens for the 3-11 shift. Laundry bring the cart each shift. V9 stated that they sometimes have to wait for linens to come up to the floor. On 5/21/2024 at 3:25 PM V30 (Laundry Aide) was interviewed and stated that linen carts go up to the floors at the start of each shift. Staff come down if they run out of linens during a shift. Staff have to wait to get linens if the laundry has accumulated and linens are not yet clean. I have to clean, dry and sort the linens so staff do run out at times. On 5/22/2024 at 12:15 PM V29 (Laundry Aide) was interviewed and stated that the Daily Linen Delivery chart documents the linen that is sent in three carts (one per floor) for each shift. Par levels are listed on the document. V29 stated that she was not sure what the par levels meant. V29 stated that the laundry aide writes down how much linen is sent to the floor each shift. V29 stated For example, if we write twenty-one bath towels on the sheet, that means that we sent seven bath towels to the second floor, seven bath towels to the third floor, and seven bath towels to the fourth floor. On 5/22/2024 at 12:28 PM V32 (Division Manager Laundry Services) was interviewed and stated that that clean laundry is sent to each floor each shift at 7 AM, 3 PM and 11 PM. V32 stated that the laundry room does not send linens up to the floors at 12 PM. V32 stated that laundry aides should be stocking the linen carts to the par levels. V32 reviewed the document Daily Linen Delivery and stated that the par levels on the sheet were outdated. There should be three bath towels for each resident each shift. For example, if there are two hundred residents, there should be three bath towels sent up for each resident which would total six hundred bath towels (two hundred for each floor) plus some overage for accidents. The par level on the Daily Linen Delivery document says sixty bath towels each shift. V32 stated that the laundry room does not always get linens to wash because the staff do not send them down or the staff throw away linen. We see linens come down as garbage. When asked if there is enough linen in the building, V32 stated I don't think so. V32 stated I have text messages and pictures that I have sent to V1 (Administrator). We don't have enough extra linens on hand. V32 stated that she keeps additional linen stock and the laundry aides know to come to her office to get what they need to get to par level. V32 stated However, the facility does not have bath towels. On 5/22/2024 at 12:45 PM, the linen overstock area was observed with V32 (Division Manager Laundry Services) . V32 stated, and surveyor observed, that there are flat sheets, fitted sheets and washcloths available. There were no bath towels available in the overstock area. On 5/22/2024 at 1:00 PM, the Daily Linen Delivery documents for May 15, 2024 at 7 AM through May 22, 2024 at 7 AM were reviewed. These documents provide the par levels (minimum count) for linen items for each shift and then the number of actual items that we sent to the floors each shift and this document states the facility did not meet minimum count of [NAME] for resident care. On 5/22/2024 at 1:15 PM Concerns about substandard quality of care was discussed with V1 (Administrator). Findings of Daily Linen Delivery logs were discussed, and plan of correction was requested. On 5/22/2024 at 1:44 PM V1 (Administrator) stated that she had ordered linens and spoken to a sister facility who was sending linens to the facility today. On 5/22/2025 at 2:51 PM V1 (Administrator) stated that 300 wash clothes and 98 bath towels had arrived from a sister facility. An additional four hundred and fifty-six bath towels were ordered and four hundred and fifty six wash clothes were ordered and are due to arrive at the facility on Saturday, May 25, 2024. On 5/23/2024 at 9:18 AM V37 (CNA) stated that there are no bath towels on the 2nd floor. On 5/23/2024 at 9:27 AM V28 (CNA) stated that there are 20 bath towels and 45 wash clothes on the 3rd floor. V28 stated that residents will use two to three towels to shower or have a bath. Sometimes we are stocked with linens. Sometimes we are not. V28 explained that residents hide towels because when they need one, they can't get it. On 5/23/2024 at 9:32 AM, V38 (CNA) stated that there were 22 bath towels and 45 wash clothes on the fourth floor. V38 stated that he had fifteen residents assigned to him. There are five CNAs on the unit and each have approximately fifteen residents assigned to them. Each resident will use one or two bath towels during the shift and one or two wash clothes. On 5/23/2024 at 9:48 AM, V1 (Administrator) was made aware that the second floor had no bath towels at 9:18 AM, third floor had twenty bath towels and forth floor had twenty-two bath towels. V1 stated We just added towels yesterday. I will call V32 (Director Laundry Services). RESIDENTS ' RIGHTS LONG-TERM CARE OMBUDSMAN PROGRAM booklet documents in part: Your facility must be safe, clean, comfortable and homelike.

Based on interviews and record reviews the facility (A) failed to ensure the safety of residents by not monitoring and preventing a resident [R2] with a document history of drug usage from obtaining and using an illegal drug. This failure resulted in [R2] overdosing on heroin, requiring treatment, and transferring to the local hospital for further evaluation and medical interventions. Findings included: R2's clinical record, documents in part: R2 is a [AGE] year old with medical diagnosis of cocaine abuse, opioid abuse acute embolism and thrombosis of right femoral vein, vitamin d deficiency, bladder disorder, hematuria, acute posthemorrhagic anemia, , acute kidney failure, chronic obstructive pulmonary disease, disorder of muscle, contusion of abdominal wall, pneumonia, abdominal hernia, and insomnia. R2's minimum data set [MDS] brief interview score=14, indicates R2 is cognitively intact. R2's care plan document in part: - Resident has a history of substance abuse while in the community, Date Initiated: 09/16/2022. - Resident will refrain from using substances while in the facility thru next review date, Revision on: 09/27/2023. On 9/27/23 at 10:18 AM, R2 stated, I been getting high on heroin for over [AGE] years. It all started when I was selling drugs then I started using them too. I went to prison, once I got out, I started back using heroin. I was admitted here in the special program, where I have to attend group meetings, pass and visitors were restricted. On 7/6/23, around 1AM, I used some heroin and was found unconscious, the nurse gave me Narcan and sent me to the hospital. Later that morning I came back to the facility. I still had some heroin left over, and I used it. I only had a little left over, I took the heroin and was found unconscious again the same day. I really messed up. The nurse had to give me Narcan and sent me back to the hospital. The second time I took the heroin on 7/6/23, it was only a little, I could not believe I went unconscious. Then later in July around the end of the month, I used some heroin and was found unconscious. The nurse saved my life and gave me Narcan. I was sent to the hospital again. It is easy for me to get heroin. I just make a phone call and I went outside to the parking lot to pick up the heroin. I was on restriction, but this is not jail. The receptionist does not pay attention to what is going on. I left out the facility whenever I wanted to, no questions asked. R2's clinical record progress notes documents in part: -7/6/2023 00:33 Health Status/Progress Note V16 [Licensed Practical Nurse] Note Text: At approximately 22:00 resident [R2] observed sitting in day room watching tv with other residents no distress noted. Resident asked for facility given snacks. writer gave facility snack and resident returned to watching tv. At approximately 23:30 facility Security called writer to come downstairs. This writer went immediately downstairs and observed resident [R2] on floor on his L side unresponsive to verbal or painful stimuli. VS taken and are as follows BP:162/76 HR:110, T:98.4, RR:16 Sp02:86 on room air. Supplemental 02 [oxygen] placed at 10L/min and 911 immediately called. Upon interview of CNAs and Security resident [R2] found on floor unresponsive when they immediately called a nurse downstairs. Resident taken to Hospital via emergency services on a stretcher. POA [Family Member], called no answer, voicemail left and awaiting call back. ADON [V3], DON [V2], notified Endorsed to relief nurse to f/u with hospital. [First drug overdose on 7/6/23] -7/6/2023 08:11 Health Status/Progress Note V18 [Licensed Practical Nurse] Note Text: Resident [R2] returned from hospital no s/s of distress noted no new orders family and physician notified of return from hospital, resident up in dining area stable condition noted. -7/6/2023 16:09 Health Status/Progress Note-V17 [Agency Nurse] Note Text: Pt [R2] found on floor in the bathroom of his room, unresponsive. yellowish powder found on Kleenex box surface. given two doses of Narcan via both nares. remained nonresponsive but had a pulse and slow respirations. 911 called and pt [R2] taken to hospital. follow up call done, and RN stated that she will call back with status. [Second drug overdose on 7/6/23] -7/25/2023 21:47 Health Status/Progress Note-V16 [Licensed Practical Nurse] Note Text: Resident [R2] found in day room unresponsive labored breathing and a slow pulse. He was given three doses of Narcan in nares 911 called. Pt [R2] taken to Hospital. DON [V2] and unit manager made aware. [Third overdose in July 2023] -7/11/2023 15:47- V9 [Nurse Practitioner] Note Text: History and physical. CC: Readmission HPI: This is a [AGE] year-old male [R2] with a past medical history of HTN, COPD, polysubstance abuse, RLE DVT on Eliquis, Hx [history] of PE [pulmonary embolism], microcytic anemia and peptic ulcer disease being seen for medical management. Patient was sent out to the hospital after being found unresponsive on the bathroom floor. Patient [R2] was treated for a heroin overdose at hospital. Patient [R2] seen sitting on the side of his bed. Denies chest pain, shortness of breath, headache, abdominal pain, n/v [nausea/vomiting], constipation, diarrhea, fever, chills. -8/7/2023 13:29- V9 [Nurse Practitioner] Note: Note: Note Text: History and physical CC: Readmission Subjective: This is a [AGE] year-old male [R2] with a past medical history of HTN, COPD, polysubstance abuse, RLE DVT on Eliquis, Hx of PE, microcytic anemia and peptic ulcer disease being seen for medical management. Patient was sent out to the hospital after being found unresponsive in the day room. Patient was treated for an overdose at the hospital. Patient [R2] seen sitting in the day room. Patient denies any concerns. Staff reports no concerns. Denies chest pain, shortness of breath, headache, abdominal pain, n/v, constipation, diarrhea, fever, chills. On 9/28/23 at 5:38 PM, V9 [R2's Former Nurse Practitioner] stated, I was made aware R2 had a drug overdose on 7/6/23 in the evening, R2 was found unresponsive in his bathroom. I completed a readmission note after reviewing R2's hospital paperwork for 7/6/23 and 7/25/23 heroin drug overdoses, that documented R2 was treated for a heroin drug overdose. I don't remember that R2 was found unresponsive on 7/6/23 around 12:30 AM and sent to the hospital. I no longer work for the facility and cannot access R2's hospital medical records to verify if R2 was treated twice on 7/6/23, for a drug overdose. I do recall R2 being sent out to the hospital for another drug overdose on 7/25/23. Upon R2 return back to the facility, I would order any follow up lab test, but the facility's substance abuse team took care of the actual drug overdose issue and protocol. 7/11/2023 17:19- V7 [Social Service/] Note: Resident [R2] was explain to about the program and he self-reported of his using of heroin for 18yrs.He [R2] stated his last usage was last Tuesday. R2 express of snorting just a little which wasn't even a half of a half a bag. He was told about the 14 days restriction no passes no visitors. On 9/27/23 at 12:52 PM, V7 stated, Upon R2's admission to the facility, he signed and agreed to the (facility's drug abuse) program. The program is to assist with the resident's history of drug abuse. Upon admission all the residents know there are no community passes, or visitors, the resident can leave the facility the first 14 days. The residents are to go to group meeting and participate. The Residents know they are subject to random drug test and room searches. After the 14 days, if a resident lapse, they go on a 30-day restriction, then 60-to-90-day restriction. R2 has a 18-year heroin drug addiction. On 7/6/23 R2 overdoses on heroin around 1AM, and R2 came back to the facility, but later the same day R2 overdosed on the left-over heroin he had, again was given Narcan two times. Whenever Narcan has to be given more than one time, I'm absolutely sure the drugs have fentanyl in it, because Narcan is not for fentanyl, that's why is does not work well. A couple weeks later in July around 7/25/23, R2 was found again overdosed and Narcan was given three times. Whenever a resident in the Duet program overdose, I counsel them and explain the new restrictions and guidelines. A new behavior contract is given to the resident. On 9/28/23 at 2:50 PM, V1[ Administrator] stated, I started working here at this facility on 7/24/23, this is my first administrator job. On 7/6/23, I was not working here at that time. On 7/25/23 a nurse brought me two small square packages with yellowish colored powdered substance inside the package into my office that she found near R2 when he over dosed. V2 made me aware that the hospital notified her that R2 had a drug overdose. I was shadowing V8, she took lead charge of the investigation. I do not have V8's notes. On 9/28/23 at 2:05 PM, V2 [Director of Nursing] stated, I start working here on 7/10/23. On 7/25/23, I was made aware that R2 was found unresponsive, Narcan given, 911 was called and R2 was sent to the hospital for drug overdose. Due to R2 already being on a 30-day restriction from his overdose on 7/6/23, I do not know how R2 got the drugs. On 9/28/23 at 5:45 PM, V8 [Director of Specialize Services/Former Administrator] stated, I'm still currently with the company. During the month of July 2023, I was the sitting administrator. R2 was found unresponsive on 7/6/23 around 4PM, Narcan was administered, 911 was phoned and R2 transported to hospital and treated for drug overdose. On 7/25/23 R2 was found unresponsive, Narcan given, 911 called and R2 was sent to the hospital and treated for drug overdose. I was not made aware that R2 was found unresponsive on 7/6/23 around 1AM. However, for 7/6/23 and 7/25/23, R2 was interviewed, R2 said he had no visitors and refuse to tell me where he got the drugs from. Staff all said they did not see any visitors or no one in and out of R2's room. The interventions for 7/6/23 and 7/25/23 was increase monitoring, and random room searches. On 9/28/23 at 2:40 PM V4 [Director of Social Services] stated, on 7/6/23 went I came into work, I was notified that R2 had overdosed on heroin around 1 AM. During that time, I was not the social service director. I conducted a random search and went over the rules with R2. I was not aware that R2 had another drug overdose on 7/6/23. I see the documentation in the chart, but I was not made aware. On 7/25/23, around 4pm, it was noted that R2 did have a heroin drug overdose, given Narcan and sent to the hospital. R2 is on restriction and has to comply with going to group meetings. R2 agreed to the rules. [R2, and V7 both said there was two heroin drugs overdoses [ 1AM and 4 PM] on 7/6/23. V4 said there was one drug overdose around 1AM on 7/6/23. V8, V9, said they was only aware R2 has one heroin drug overdose on 7/6/23 around 4PM]. Policy documented in part: Substance Abuse Policy dated 5/23 -The facility reserved the right to protect all residents, staff, and visitors from the negative effects of substance abuse. The facility will take all precautions necessary to prevent residents from using alcohol or illegal substances.

Based on observation, interviews and record reviews the facility (A) failed to ensure the safety of residents by not monitoring and preventing a resident [R125] with a document history of drug usage and drug overdose from obtaining and using an illegal drug. This failure resulted in R125 overdosing on heroin, requiring transfer and treatment to local hospital for treatment. (B) failed to follow smoking safety policy by not ensuring smoking materials are kept by facility or designated staff members for 4 (R82, R113, R118 and R413) residents and ensure that residents who smoke will be evaluated quarterly and annually for 2 (R113, R118) residents. These failures can potentially affect 4 (R82, R113, R118, R413) of 5 residents reviewed for smoking in the sample of 32. Findings include: During review of R125's clinical record on 8/15/23 at 11:05 AM, documents in part: R125 is a [AGE] year-old admitted on [DATE], with medical diagnosis of opioid abuse, opioid dependence, poisoning by heroin encounter, nicotine dependence, paraplegia, acute kidney failure, essential hypertension, anxiety disorder, need for assistance with personal care, morbid severe obesity, localized edema, and muscle weakness. R125's record review indicates ( prior to R125's admission) on 4/11/23- Hospital history and physical- R125's admission diagnosis-Opioid overdose. R125 reported to physician that [R125] bought some heroin from someone in the nursing facility, which R125 took. R125 minimum data set [MDS] brief interview score=15, indicates R125 is cognitively intact. 5/3/23 at 6:31 PM- Social Service Note-Social worker met with R125 and R125's family who brought in food, which had contraband in it for R125. Policies were reviewed for R125 and family member. R125's Care plan indicates: - 5/27/23- R125 has a substance abuse problem within the community. -5/2/23- R125 is unable to leave independently on community pass due to physical limitations. R125' Record Review progress notes- Documents in part indicates: 6/10/23 at 8:07 PM- Nurse Note-During rounds nurse observed R125 smoking in bed while laying down. R125 refused to put the cigarette out. Nurse presented R125 with a behavior contract, R125 refused to sign it. Nurse notified social services department. 7/14/23 at 2:59 PM, Nurse Note-During wound care the nurse observed a small plastic bag with a powder substance and straw. R125 was alert and oriented x3 but appeared to be inebriated at the time. Nurse observed a plastic cup on the nightstand with cigarette ashes in the cup. All items given to unit manager. 7/15/23 at 2:03 PM, Nurse Note- Nurse providing care to R125, observed small clear plastic bad containing a white powdery substance along with a straw beneath him [R125]. R125 denied the bag belonged to him. Nurse reminded R125 of the contract he signed, R125 continue to deny that substance belonged to him. Nurse made social worker and director of nursing aware. 7/24/23 at 12:30 PM, Nurse Note- Staff informed writer that R125 was unable to arouse during wound care. Nurse immediately entered room and observed R125 unresponsive. Rapid response initiated, 911 called. Given previous behavior and past medical history Narcan x2 was given. R125 aroused and became verbally aggressive toward the staff members. 911 arrived and transported R125 to the emergency department. Nurse practitioner and management made aware. 7/24/23 Hospital history of present illness- R125 presents to the emergency department from nursing home after being opioids specifically heroin by family members or friends. Diagnosis: Cellulitis, Decubitus, and Opioid overdose, Patient Instruction-Narcotic Abuse Progress noted dated 7/24/23 at 12:30 PM, indicated staff made V39 aware that R125 was not arousable during wound care. V39 went immediately to R125's room and observed R125 unresponsive. The rapid response initiated, 911 was called. Due to R125's previous behavior and past medical history, Narcan was administered two times. V39 initiated sternum rubs and R125's name, then R125 aroused. R125 became verbally aggressive toward staff members. 911 arrived on the scene and transported R125 to the hospital successfully. Nurse practitioner and administration was notified. On 8/15/23 at 12:19 PM, V14[ Director of Social Service] stated, I been working here at this facility since 2019 left and came back here in 2022. R125 was admitted to this facility from a hospital, due to R125 overdose at another nursing facility on heroin. We accepted R125 under strict guidelines. Upon admission R125 agreed and signed to participate in the DUET program here at this facility. The DUET program is for residents with a drug and or alcohol abuse diagnosis. When R125 was admitted here I completed an interview. R125 told me, that he was not a drug head, and he did not overdose on drugs. R125 said he was depressed and got a hold of something bad and ended up in the hospital. R125 agreed and signed the Duet contract which indicates no visitors and no community pass for 14 days. R125 violated the contract in a week of admission. R125 had a family member come to the facility to sneak in. Next, R125 was seen smoking in his bed. R125 then entered into a behavior contract. R125 then ordered a knife from the internet and was delivered to the facility. The knife was given to R125 family member. R125 was not able to attend group meetings with the Duet program because he was in the bed most of the time, due to him being paralyzed. I set R125 up with one -to -one therapy sessions. When the counselor would come, R125 would refuse to meet with the counselor. On 7/24/23 R125 was found by V13 [Wound Nurse] unresponsive. The staff nurse V38 [Licensed Practical Nurse] administered R125 Narcan three times, before R125 came around and responded. R125 was sent to the emergency room . R125 has serval family members that will come visit without authorization. One family member snuck on the floor and told the nurse that the ADON [assistant director of nursing] gave the family member permission, but the ADON said she did not give permission. On 7/13/23, I met with R125 regarding him smoking in bed, and asked for his smoking materials. R125 refused and told me there is nothing anyone can do about it. R125 further said he would continue to smoke. I explained to R125 he would enter another behavior contract and visitors will be restricted. Also, I explained due to him [R125] not wanted to adhere to the facility policies I would send out referrals to other facilities. R313 which was R125's roommate admitted to me that he [R313] will go to the gas station to purchase cigarettes and lighter for R125. Prior to R125 overdosing on 7/24/23, there have been paraphernalia found in R125's bed, such as small packets with white power substance in it and cut up short straws. I had a strong suspicion that R313 was going out and bringing R125 drugs. R313 also have a history of drug addiction as well. On 7/15/23, R313 admitted to another social worker that R125 gave him money for drugs and he [R313] would go to the gas station and purchase cocaine or heroin whatever he could get his hands on for himself [R313] and R125. At that time R313 entered a behavior contract, R313 agreed not to purchase and bring drugs into the facility. During review of R313's clinical record on 8/15/23 at 1:00 PM, documents in part: R313 is a [AGE] year-old admitted on [DATE], with medical diagnosis of opioid use, nicotine dependence, psychoactive substance abuse, acute respiratory failure, poisoning by antineoplastic and immunosuppressive drugs accidental encounter, and chemotherapy. Face sheets, medical diagnosis, physician order sheets, minimum data set [MDS] Brief Interview Mental Status score of 15 indicates R313 is cognitively intact, care plans, medication administration record, treatment administration record, and progress notes. Progress notes indicate in part: -6/23/23 at 3:25 PM -Social Service Note-R313 self-reported of have a 30-year history of drugs heroin and crack. R313 last usage was 2 weeks ago. -7/15/23 at 4:12 PM- Social Service Noted- R313 agrees not to distribute any illegal substances throughout the facility. -7/28/23 at 12:11 PM-Nurse Note- R313 was brought back from chemotherapy and transportation open the door to bring R313 into the facility. R313 would not come into the facility and kept walking down the street. R313 called the facility and stated he will not be returning and will be to pick up personal belongings. Physician notified. On 8/17/23 at 12:54 PM, V13 [Wound Care Coordinator] stated, On 7/24/23 I was making wound rounds to complete wound care and R125 was not responding. I called his name he still did not response, but he was breathing and had a heart rate. I did a sternum rub, and R125 did not respond. I ran and called out for R125 nurse, called a rapid response on the overhead paging system, and grabbed the crash cart. V39 [Licensed Practical Nurse] assisted R125 and I went to print off R125 paperwork and held the elevator for 911. When I returned to R125's room, R125 was awake a very upset. R125 said to the nursing staff, why you all give me that medication, I was okay. R125 was yelling and curing at the staff. R125 was transported to the emergency room . On 8/17/23 at 12:46 PM, V2 [Director of Nursing] stated, I have been working here at this facility since July 10, 2023, however I been a registered nurse for six years. I was here when R125 over dosed on heroin. I saw 911 pull up in front of the facility. I went up on the unit and R125 was waking up. The nurse told me she administered Narcan to R125 a few times and called 911. At first R125 refused to be transported for emergency room evaluation. R125 became verbally aggressive and yelling. The ambulance drivers were able to convince R125 to go and get evaluated, finally R125 agreed. After R125 left the facility. I found three small plastic bags with a brown powder substance inside the bag in R125's bed. The brown powder substance was underneath R125 buttocks area. The brown powder substance was believed to be heroin. When I phoned the hospital, it was confirmed that R125 has overdosed on heroin. I spoke with the staff and other residents on the third floor. The staff thought R125's family member or roommate gave R125 the heroin. R125's family member brought drugs in the facility before for R125. On 8/17/23 at 12:58 PM, V38 [Social Services] stated, At the time of R125's drug overdose, I was the social worker for the third floor. On 7/15/23 R313 went out on pass and tried to bring in illegal substances. R313 told me that he was brought in cocaine for R125 and other residents in the facility. R313 and I had a rapport, and I asked R313 to be straight up honest with me. R313 told me he got the cocaine from gas station. My intervention was to have R313 sign a behavior contract that he wound not go out and purchase cocaine and bring it back in to the facility for other residents. At that time R313 was not allowed to have visitors or go out on pass for thirty days which will end on August 15, 2023. R125 and R313 was roommates, I did not think changing their room would have resolved or stopped any thing from happening. Also, the third floor is for drug opioid substance abuse floor, which the staff provides frequent monitoring. R125 has been giving multiple behavior contracts, that he did not sign. Which includes R125 multiple offensives for smoking in bed and using drugs. On 8/17/23 at 1:18 PM, V1 [Administrator] stated, I started working here on the same day R125 was found unresponsive on 7/24/23. I heard staff call a rapid response and I went to the location. I saw staff standing outside R125's room and he was awake. 911 was on the way. R125 was fussing because he did not want to go the hospital. The ambulance drivers convinced R125 to go for an evaluation. During my investigation there was some type of drug usage. V2 [Director of Nursing] received confirmation from the hospital that R125 had a drug overdose. I do not know how R125 got a hold of heroin. R125 could have got drugs from another resident, family member, or visitor from another resident. V14 [Director of Social Services] interviewed R125's roommate. The staff on the third floor all said they think it could have been a visitor or another resident, but no one was certain and had no proof. I want to change the population of this facility geared towards long term care and rehab services; this is not a drug rehab facility. On 8/15/23 at 10: 13 AM, V2 [Director of Nursing] stated, V39 [Licensed Practical nurse was on vacation, but will work 8/16/23 day shift. On 8/16/23 at 9:43 AM, V2 stated, V39 was not on the schedule to work today, I made a mistake. On 8/16/23 at 10:12 AM, surveyor phoned V39, no answer, unable to leave voice mail. 1:22 PM, no answer, unable to leave voice mail. 2:49 PM, no answer, unable to leave voice mail. Policy documented in part: Substance Abuse Policy dated 5/23 -The facility reserved the right to protect all residents, staff, and visitors from the negative effects of substance abuse. The facility will take all precautions necessary to prevent residents from using alcohol or illegal substances. 47304 R113's health record documented admitted [DATE] with diagnoses not limited to Paroxysmal atrial fibrillation, Essential hypertension, Type 2 diabetes mellitus, Major depressive disorder, Anxiety disorder, Vitamin D deficiency, Gastro-esophageal reflux disease, Hyperlipidemia, Anemia, Nicotine dependence, Heart failure, Atherosclerotic heart disease. R413's health record documented admitted [DATE] with diagnoses not limited to Chronic obstructive pulmonary disease, Type 2 diabetes mellitus, Anxiety disorder, Opioid abuse, Cocaine abuse, Heart failure, Chronic respiratory failure, Nicotine dependence, Dependence on supplemental oxygen, Major depressive disorder, Essential hypertension, Insomnia, Asthma, Bipolar disorder. On 8/15/23 at 11:30 am Observed R113 lying in bed, alert and oriented x 4, verbally responsive. R113 stated that he (R113) is smoking at the designated smoking area - outside patio. Observed with a pack of cigarette and lighter by the TV stand at bedside. At 1:00 pm Observed R413 up and about in room, alert and verbally responsive, with oxygen at 2L/min via nasal cannula. R413 stated that she (R413) is a smoker. Observed a pack of cigarette at bedside table. On 8/16/23 at 1:44 pm V14 (Social Service Director / SSD) stated she has been working in the facility since 2019. V1 (Administrator) was present during V14's interview. V14 (SSD) stated that resident who smoke will be evaluated for any unsafe smoking behaviors by completing smoking risk assessment upon admission, quarterly, annually, and as needed. V14 stated that the purpose of smoking assessment is to determine unsafe smoking behaviors and the risk factors for safety of the residents and staff. V1 (Administrator) stated that smoking policy was ruled out 3 weeks ago, discussed the process and slowly implement it. V1 stated that facility should keep all smoking materials for safety. Reviewed R113's electronic health record (EHR) with V14 and confirmed that smoking assessment was last completed on 1/27/21. R113's care plan dated 1/9/23 reviewed with V14 and V1 and confirmed that smoking care plan interventions included but not limited to smoking materials should be kept by facility; Assess Consumer's ability to adhere to smoking program per facilities guidelines. V14 confirmed that R413 uses oxygen and is an active smoker. V14 stated that R413 was educated regarding smoking cessation or safe smoking. V14 confirmed that no care plan for smoking found in R413's EHR. MDS (Minimum Data Set) dated 8/3/23 showed that R113's cognition was intact. R113 needed supervision with bed mobility, transfer, walk in room and corridor, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. MDS showed that R113 with current tobacco use. R113's Smoking Risk assessment dated [DATE] documented in part: Safe smoker. Monitor per facility safe smoking guidelines. Care plan dated 1/9/23 documented in part: R113 makes the choice to continue to smoke. Care plan interventions included but not limited to assess consumer's ability to adhere to smoking program per facilities guidelines. Care plan intervention: Cigarette lighters are to be kept with cigarettes was deleted when facility provided the printout care plan dated 8/17/23. Care plan dated 8/15/23 included interventions not limited to provide R113 with smoking materials during smoke time. MDS (Minimum Data Set) dated 8/3/23 showed that R413's cognition was intact. R413 needed supervision with bed mobility, transfer, walk in room and corridor, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. MDS showed that R413 with current tobacco use. R413's Smoking Risk assessment dated [DATE] documented in part: safe smoker. Monitor per facility safe smoking guidelines. 46342 On 08/15/23 at 3:13 PM, observed pack of cigarettes at R82's bedside. On 08/16/23 at 12:52 PM, observed R118 waiting in hallway outside smoking patio for 1:00 PM smoke break. R118 showed surveyor that R118 was carrying cigarettes by showing surveyor cigarettes in a bag. On 08/15/23 at 1:31 PM, V5 (Psychosocial Aide) stated that the residents right now are allowed to keep their cigarettes and lighters on them in their room. On 08/16/23 at 1:58 PM, V1 stated the policy provided to surveyors is the policy the facility is currently following. R82's diagnosis included but not limited to Malignant Neoplasm of Hypopharynx, Chronic Obstructive Pulmonary Disease, Encounter for Attention To Tracheostomy, Encounter For Attention To Gastrostomy, Solitary Pulmonary Nodule, Cognitive Communication Deficit, Nicotine Dependence Insomnia, Protein Calorie Malnutrition, Dysphasia. R82's Care Plan documents in part smoking preference R82 continues to smoke and interventions include but not limited to keep resident's cigarettes in the medication room or activity closet. R82's MDS (Minimum Data Set) dated 08/01/23 indicates intact cognition, supervision required with bed mobility, transfer, walking, locomotion, dressing, personal hygiene, and R82 is a smoker. R118's diagnosis included but not limited to Pulmonary Embolism Without Acute Cor Pulmonale, Abnormalities of Gait And Mobility, Weakness, Lack Of Coordination, Chronic Systolic Congestive Heart Failure, Ascites, Peripheral Vascular Disease, Anemia, Thrombocytosis, Schizophrenia, Schizoaffective Affective Disorder, Malaise, History Of Falling, Symptoms And Signs Involving The Musculoskeletal System. R118's care plan dated 10/13/22 documents in part R118 makes the choice to continue to smoke. R118's Smoking Risk Assessment last completed 10/13/22. R118's MDS (Minimum Data Set) from 06/26/23 indicates intact cognition, extensive assistance required with bed mobility, transfer, locomotion, toilet use, dressing, and personal hygiene, limited range of motion to lower extremities on both sides, uses a wheelchair for mobility and R118 is a smoker. Facility's smoking safety policy dated August 2023 documented in part: - Designated staff members will hold resident's cigarettes and distribute during designated smoking times only. - It is against facility policy to carry a lighter (and other smoking materials i.e. cigarettes, tobacco, etc). Being caught in possession with a lighter and / or cigarettes / smoking materials will be considered a violation of the policy and consequences will be reviewed on an individual basis. - Residents who smoke will be evaluated at admission (within the first 72 hours of admittance), quarterly, and annually, as well as if unsafe smoking behaviors / cognitive decline that affects smoking behaviors occur, to determine their ability to comply with safety rules.

Based on interview and record review, the facility failed to ensure that a resident was free from physical abuse which affected one (R1) of three residents reviewed (R1, R2, R4) reviewed for physical abuse. This deficient practice resulted in R1 experiencing new left shoulder pain and limited range of motion which required R1 to be transferred to the hospital with left shoulder musculoskeletal strain. Findings include: R1's Admission Record documents, in part, diagnoses of dementia, muscle weakness, bilateral hearing loss, dysphagia, cachexia, and severe protein calorie malnutrition. R1's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 11 which indicates that R1 has moderate cognitive impairment. On 5/16/23 at 10:34 am, when asked about the physical altercation with V4 (Former Staffing Coordinator) on 4/17/23, R1 stated, I (R1) was just there in the hallway. R1 stated, Why (V4) put (V4's) hands on me, I (R1) don't know. I (R1) wasn't doing nothing. R1 stated that V4 said, Go to your room. R1 stated that R1 was in the hallway, and then (V4) grabbed (R1's) my left arm to make me (R1) go. R1 then demonstrated on R1's arm where V4 grabbed R1 directly above R1's left wrist. R1 stated, (V4) grabbed my arm and pulled me. I (R1) pulled my arm back. When asked where this incident took place with V4, R1 stated it was by nurse's station while R1 was standing there. R1 stated that that R1 then fell in the hallway. When asked if R1 told any other staff member in the facility about this incident with V4, R1 stated, No because that nurse (V7, Licensed Practical Nurse, LPN) didn't do nothing. R1 stated that R1 saw V5 (Certified Nursing Assistant, CNA) and V7 at the nurse's station when it happened. R1 stated that it was around 9:00 to 10:00 pm that night (4/17/23). R1 stated that R1 did not have pain directly after the physical altercation with V4. R1 stated that R1 started to feel pain in R1's left shoulder the next day or two, and it (left shoulder) was hard to move. R1 stated, It was bad enough for me (R1) to know that something was wrong when I (R1) would try to move my (left) arm, pain would shoot down from my shoulder. R1 stated that R1 told V17 (Social Services Director, SSD) about R1's left shoulder pain and limited range of motion. R1 stated that R1 was then transferred to the hospital for pain and not being able to move it (left shoulder) only at a certain angle. R1's ambulance transportation record, dated 4/20/23, documents, in part, (Ambulance) dispatched to (facility) for an Emergency Transport of (R1) to (hospital) for left shoulder pain . Crew initiates assessment, finds (R1) with pain in (R1's) upper left shoulder . Crew inquires about (R1's) fall, (R1) notes that 2 days ago, a staff member tried to force (R1) into bedroom . (R1) notes that as of today, (R1) cannot raise left arm above (R1's) head . inspects and palpates shoulder and notes tenderness upon asking (R1), as well as a small bruise the size of a quarter. In R1's hospital records, V20 (Hospital Emergency Physician) documents, in part, R1 presenting the hospital emergency department for left should pain after witnessed fall 3 days ago after a staff member at (facility) pulled (R1) causing (R1) to fall and hit left shoulder. V20 documents, in part, that R1 has limited ROM with left shoulder abduction with a differential diagnosis of musculoskeletal strain. R1's hospital emergency Discharge Instructions, dated 4/20/23, documents, in part, Diagnoses from today's visit: Left shoulder pain, Shoulder injury, Elder abuse. On 5/16/23 at 2:59 pm, V4 (Former Staffing Coordinator) stated that V4 no longer works at the facility and had been hired as staffing coordinator with responsibilities of ensuring that the facility has sufficient nursing staffing. V4 stated that V4 is not a nurse or certified nursing assistant (CNA). V4 stated that on 4/17/23, during the evening shift, V4 was in the facility on the 4th floor at the nurse's station trying to get staff to pick up shifts to work, and R1 made sexual comments towards V5 (CNA). V4 stated that V5 (CNA) said to R1, Go to your room. You all heard (R1) right. V4 stated that V4, V5 (CNA) and V7 (Licensed Practical Nurse, LPN) were at the nurse's station at this time. V4 stated that V4 instructed R1 to go to R1's room. V4 stated, I said, (R1), go to your room. V4 stated, (R1) said (R1's) not going nowhere. V4 stated that V4 then walked from behind the nurse's station, and R1 was walking to dining room. V4 stated, I (V4) said, 'You (R1) can't go in there.' V4 explained that the dining room door was closed, and the dining room is on one side of the nurse's station. V4 stated that V4 put V4's hand on the dining room's doorknob, and I (V4) put my hands out to block the doorway. V4 said, I redirect (R1) with other hand. (R1) is pushing my hand down with R1 saying, I am not going nowhere. V4 stated that R1 was trying to move me (V4). V4 stated I (V4) pointed to direct (R1) then R1 pushed V4's pointer arm down. V4 said, Let's move. Go to your room. V4 stated, From there, we (R1 and V4) became physical, more of me (V4) placing my hand on (R1's) back or on (R1's) arm, not grabbing. (R1) was shrugging me (V4) off. When this surveyor asked V4 if it's either R1's arm or back, V4 stated, It was (R1's) arm. Back of arm. I (V4) had it (R1's arm). V4 stated that at this time, R1 and V4 were in front of the elevators in front of the nurse's station. When asked if R1 is moving voluntarily when V4 had R1's arm, V4 stated, No, I (V4) was guiding (R1). I (V4) would stop, and (R1) will then stop and start talking. V4 stated that V4 is moving R1 a little past nurse's station, headed towards (R1's) room and (R1) tried to turn back. I (V4) was right there. V4 stated, I (V4) was behind (R1). (R1) slid to floor. V4 confirmed with this surveyor that V4 hand wrote a statement and was interviewed by V3 (Former Administrator) on 4/21/23 about this incident with R1. Facility transcript of V4's interview, dated 4/21/23, titled (V4), Staffing Coordinator), and signed by V4, documents, in part, After I (V4) told (R1) to go to (R1's room), (R1) said no and wen (went) towards the dayroom. I (V4) got up closed the door and blocked the door with my body. I (V4) continue to tell (R1) go to (R1's) room and (R1) refused to so I (V4) started to redirect (R1) with my body and then from there I (V4) had my hand up and (R1) grabbed me (V4) to move me (V4) out of the way, so after that I (V4) grabbed (R1's) arm and started moving (R1) towards (R1's) room. (R1) was struggling and slid to the floor. On 5/17/23 at 3:03 pm, V3 (Former Administrator) stated that on 4/20/23, V3 was the administrator and abuse coordinator of the facility. V3 stated, on 4/20/23, R1's physical abuse allegation was reported to V3 by V17 (Social Services Director, SSD) after their morning meeting around 10 am. V3 stated, V3 brought R1 into V3's office, and R1 said, I (R1) was roughed up. V3 stated, V2 (Director of Nursing, DON) and V15 (Assistant DON, ADON) then come into the office with R1. V3 stated, R1 said R1 was roughed up by man worker. V3 stated, R1 complained of R1's left arm hurting and couldn't lift R1's arm higher than R1's shoulder level while V2 and V15 were assessing R1. V3 stated, V2 and V3 were viewing the video coverage of the 4th floor nurse's station camera (which is above room [ROOM NUMBER]) after identifying V4 (Former Staffing Coordinator) as the alleged abuser towards R1. V3 stated, V2 and V3 could see and hear the incident with R1 and V4 on 4/17/23 on the camera surveillance. This surveyor then asked V3 what V3 saw and heard while viewing this video coverage. V3 stated, it showed at 10:00 pm on 4/17/23 as follows: V6 was out of camera's view. V4 comes up to R1. R1 had come and leaned on the corner of the nurse's station. Then R1 backed up. V7 was sitting over here at nurse's station by room [ROOM NUMBER]. V5 was standing next to V4 behind the nurse's station on other side by 417. V4 comes over and around the nurse's station. R1 comes out from the dining room. V3 can hear V4 say, '(R1), it's time to go to bed.' R1 said, 'I (R1) told you I am not going to bed.' R1 walks around trying to go to the dining room. R1 puts R1's hands up, and V4 grabs R1's arm and pulled R1's arm. V4 was grabbing R1's left arm. R1's right arm was flaying. The dining lights were off. (V4) treated R1 like R1 don't have rights. Enough people are there (and they) didn't stop it. R1 and V4 tussled. V5 moves out the way, and they (R1 and V4) are continuing with V4 pushing and R1 pulling. At end of nurse's station, they turned in the hallway with V4 and R1. And then (R1) breaks free and slides down wall. V3 stated that V3 performed a thorough abuse investigation of R1's physical abuse allegation. When asked if V3's investigation for R1's physical abuse allegation towards V4 was substantiated, V3 stated, It was. On 5/17/23 at 12:19 pm, V16 (Nurse Practitioner, NP) stated, V16 is assigned to R1, who has a diagnosis of dementia, and sees R1 monthly in the facility. V16 stated, V16 is in the facility daily from Monday through Friday and will check in with residents for updates. V16 stated, on 4/20/23, V16 received a phone call from a facility staff member about R1's complaint of left shoulder pain. V16 stated, V16 returned to the facility in the afternoon on 4/20/23 and assessed R1 in-person. V16 stated, V3 (Former Administrator) had made V16 aware of R1's physical abuse allegation towards V4. V16 stated, (R1) was not able lift arm, was limited ROM (range of motion) and was guarding shoulder. V16 stated, this was new onset pain in R1's left shoulder. V16 stated, R1 said R1 got into it with a staff member (V4). V16 stated, Pain can cause the limited range of motion. When asked what effect on a resident if someone has the resident's arm and is moving the resident by that arm, V16 stated, It could be dislocated or fracture. When asked could an affect on the resident (being moved by someone grabbing the arm) be musculoskeletal strain of the shoulder, V16 stated, Yes, it could occur from moving resident with (that) arm. Torque the shoulder. When asked if having a person with their hand on a resident's arm and moving the resident with that arm, could it cause a musculoskeletal strain of the shoulder? V16 stated, Yes especially for the elderly. (R1) had weight loss and deconditioning too. When asked does pain from a musculoskeletal strain occur right away, V16 stated, No, it would cause some people to take a few days for pain. V16 stated, the previous date that V16 assessed R1 in the facility (on 4/11/23), (R1) had no pain or ROM deficits. In R1's Progress Note, dated 4/20/23 at 5:15 pm, V16 (NP) documents, in part, Left shoulder xray not completed. (R1) c/o (complains of) pain with limited ROM. Send (R1) to (hospital emergency department) for evaluation and treatment. R1's Care Plan, dated 10/8/22, documents, in part, a focus of (R1) may be at risk for potential abuse r/t (related to) mental/emotional challenges as evidenced by: Dementia, with a goal of (R1) will free from harm, with interventions of: Assure (R1) that they are in a safe and secure environment with caring professionals; If (R1) is increasingly upset or agitated ruing care, ensure resident is safe. Politely excuse yourself and then report situation to supervisor and re-approach (R1) with assistance or alternative staff; and Utilize behavior approaches that attempt to keep (R1) safe and calm by reassurance, redirection, task segmentation, cueing, reminders, re-approaching, reality orientation during care. R1's document, dated 4/21/23 and titled Head to Toe Skin Assessment, documents, in part a body diagram with the left shoulder circled with skin abrasion hand written for R1's left shoulder, and for the comments, Old skin abrasion to (R1's) L (left) shoulder. Facility policy dated 11/22/2017 and titled Abuse Prevention Program - Policy, documents, in part, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment . Purpose: the purpose of this policy and the Abuse Prevention Program is to describe the process for identification, assessment, and protection of residents from abuse, neglect, misappropriation of property, and exploitation. This will be accomplished by: . Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation, and misappropriation of property; establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; identifying occurrences and patterns of potential mistreatment; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property . The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents, including verbal, mental, sexual or physical abuse . The facility has a no tolerance philosophy; persons found to have engaged in such conduct will be terminated. Definitions: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means . Abuse is also the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish to a resident . Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention . Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to supervise R6 who is assessed as high risk for falls and resides on a memory care unit. This failure resulted in R6 being left unattended, falling, and sustaining 3 sutures to the back right side of the head. This failure affected R6 in a sample of 11 residents reviewed for falls. Findings include, Facility's incident report (2/17/23) to state agency documents in part: R6 with diagnosis of Hypertension, Major Depressive Disorder, Dementia, Epilepsy, Cirrhosis of Liver, Cardiomegaly, Multiple Sclerosis, Osteoarthritis. Location of incident: Resident's Bathroom. Description of incident: R6 is a [AGE] year-old that admitted to facility in September 2015. She requires extensive assist from staff for bed mobility, transfers, dressing, toileting activities, and personal hygiene. Her fall risk assessment indicates she is a high risk for falls due to medication regimen, incontinence, and gait imbalance. R6 has not had any falls in nearly a year. The interdisciplinary team routinely reviews her fall prevention care plan based on her personal fall risks. The care plan includes keeping her call light in reach, maintaining her bed in the lowest position, staff providing redirection as needed to prevent impulse changes and time of day as needed. On February 16, 2023, R6 was assisted to the bathroom by V5 CNA. After assisting R6 to the restroom and toilet, V5 instructed R6 not to get up until she returned to assist her to which R6 replied, Okay. V5 informed R6 that she would be right back. V5 then left the room to go get something from the Clean Utility Closet and immediately returned to assist R6. Upon her return to the bathroom to assist R6, V5 observed R6 on the floor. She immediately informed R6's Nurse, V9. V9 immediately assessed R6 and noted a small amount of blood to the back of her head on the right side. MD notified of the fall and assessment findings. New orders received to transfer R6 to the Emergency Department for further evaluation. R6's state guardian was notified of the incident and hospital transfer. R6 was transferred to Hospital via Ambulance. CT of head resulted negative; 3 sutures were placed to a small laceration on the back right side of her head. On 3/28/2023 at 11:46am, R6 said she hit her head when she fell and does not remember what hit R6 on the head. R6 said, she got stitches on her head and is now healed. R6 pointed to the middle of her head and said I am ok, they take good care of me. R6 said she sometimes tries to get up without staff assistance and staff keep reminding her not to get up without help. R6 said, she knows how to use the call light. On 3/28/2023 at 11:56am, V6 (Licensed Practical Nurse) said R6 has MS (Multiple sclerosis) and is impulsive and thinks she can do a lot for herself and be independent and she cannot. V6 said, R6 knows how to use the call light but sometimes R6 thinks she can do things for herself without staff assistance and will not use the call light, therefore, staff keep an eye on R6 to keep her safe. On 3/28/2023 at 12:59pm, V5 (Certified Nurse ' s Assistant-CNA) said she took R6 to the bathroom on 2/16/2023 and told R6 to not move without V5 helping R6. V5 said, R6 is able to use the call light, and V5 stepped out of the bathroom to go to the clean utility, which was right opposite R6's bathroom, and as V5 was going out of the room, V5 heard a noise, V5 went back to the washroom room and found R6 on the floor by the toilet sitting on the floor. V5 said, she went to get the nurse, and the nurse came in and assessed R6 and laid R6 on the bed. V5 said, V5 then left out of the room and left the nurse to complete assessments. V5 said, R6 is getting weaker due to diagnosis of MS and that is why R6 needs to be assisted and monitored while she is in the bathroom, but R6 is able to use the call light. V5 said, R6 is impulsive and will do what she wants to do, therefore staff must keep reinforcing to R6 that R6 cannot perform ADLs (Activities of Daily Living) by herself. On 3/29/2023 at 11:36am, V15 (Restorative Director/Falls Coordinator-LPN) said, when a resident is extensive assist for toileting, it means it's more of a hands on because the resident may not be able to do the task on their own. V15 further said, that extensive assists like R6 have to be physically assisted with toileting and transferring, and staff have to be near R6 when R6 is using the bathroom so that staff can assist if needed, to prevent falls. V15 said, R6 has some cognitive deficits but understands what she is being told, however, R6 is impulsive and does what she wants to do. V6 said you could turn your back and R6 will do what she wants, even when you tell her not to try to stand. V15 said, most of the times staff stay with R6 and R6's room is near the nursing station. V15 said, staff were in-serviced to bring all the necessary stuff needed for changing a resident when they take a resident to the bathroom. V15 said, staff were also in-serviced on giving residents privacy when they use the bathroom, but still keep an eye on residents like R6 who are on the memory care unit because of dementia. On 3/29/2023at 1:02pm, V2 (Director of Nursing-DON) said, as long as the resident has been assessed for call light use and the assessment shows they can use the call light, they can be left in the bathroom by themselves for privacy, even if they are in the memory loss unit. V2 said, R6 was assessed for call light use and assessment documented R6 is able to use call light to get staff attention. R6's last call light assessment was completed in 7/10/2022. R6 was not assessed for Call light use post falls. V2 said after the fall on 2/16/2023, R6 has had two more falls on 2/28/2023. On 4/05/2023 at 3:35pm, V24 (Nurse Practitioner) said, for a resident with a diagnosis of dementia, is impulsive, and has been assessed for extensive, one person assist for toilet use, that resident should not be left alone in the bathroom. V24 said, even if R6 had been assessed for call light use, R6 can forget to use the call light since R6 has a diagnosis of dementia and is impulsive. V24 said, potential harm for residents who are assessed as needing extensive one person assistance for bathroom use is falls with injury if left alone in the bathroom. V24 also said, the facility staff should follow their policy on resident supervision, however V24 was not aware what the policy was. R6's Brief Interview for Mental Status (BIMS) dated 2/08/2023, documents score of 12, R6 has slight cognitive impairment. R6's MDS (Minimum Data Set) dated 2/20/2023 documents R6 needs extensive assistance with one person physical assist for Bed mobility, Dressing, Transfer, Locomotion on unit, Locomotion off unit and Toilet use. Review of R6's progress notes document R6 fell again on 2/28/2023 at 15:54 and again at 20:14. R6's care plan revised on 2/16/2023 documented R6 had an actual fall, and further documents R6's interventions, dated 2/17 to prevent falls include: Encourage R6 to sit in a supervised area as tolerated when out of bed. Staff documented to supervise R6 include: CNAs (certified Nurse Assistant) and RN/LPN (Registered Nurse/Licensed Practical Nurse), redirection as needed to prevent impulsive changes. R6's care plan continue to document that R6 has a HX (history) of being observed throwing herself on the ground and attempting to get up without staff assistance. Goals for this focus is documented as: CNAs (certified Nurse Assistant) and PLN (Licensed Practical Nurse), to assess and anticipate R6's needs: food thirst, toileting needs, comfort level, body positioning, pain, etc. Another care plan focus area for R6 is dated 5/24/2022 documents: R6 is alert to surrounding with some long- and short-term memory deficits, cognitive skills are somewhat impaired due to a diagnosis of Dementia. R6 enjoys listening to music, watching westerns, reminiscing this and that trivia. Facility policy (10/21) Safety and Supervision of Residents documents in part: 2. Staff shall use various sources to identify risk factors of residents, including the information obtained from the medical history, physical exam, observation of the residnet and the MDS. Facility policy titled Fall management, dated 8/14, 6/21, 6/22, 2/23 documents: This facility is committed to maximizing each resident's physical, mental and psychosocial wellbeing. While preventing all fall is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Facility Assessment tool dated 01/04/2023 documents in part: Provide person centered/directed care, Psycho/social/spiritual support: Identify hazards and risks for residents

Based on interview and record review, the facility failed to ensure that two residents (R5 and R6) were free from resident-to-resident physical abuse. This failure affected R5 who sustained a laceration to the left eyebrow that required stitches. Findings include: On 01/03/23 at 11:20 am, V1 (Administrator), who is the abuse coordinator, provided the surveyor with the initial and final incident reports that were sent to the state agency for the alleged incident that occurred on 11/27/2022 between R5 and R6. The final report faxed to the state agency on December 2, 2022, documents, in part, (R5) was warming up his (R5) food when (R6) walked up behind him (R5). When (R5) turned around, (R6) struck him (R5) with his cane. (R5) then took (R6's) cane and hit (R6) with it. On 01/03/23 at 12:35 PM, due to a history of traumatic brain injury, bilateral hearing loss and selective mutism, the surveyor had to interview R6 by writing the questions on a piece of paper to which R6 was able to reply yes or no by shaking his (R6) head. At times, R6 would answer with simple sentences but as the dialogue progressed, it became incomprehensible. When the surveyor inquired if R6 hit R5 with his (R6) cane, R6 shook his head Yes and stated, He (R5) put his (R5) hands on me (R6) first. When asked why, R6 replied, I (R6) don't know. The surveyor inquired if R6 was hurt. R6 replied, Not at all. On 01/03/23 at 1:03 PM, the surveyor used the facility's language interpreting service to interview R5 who is mostly Spanish speaking. When asked about the alleged altercation with R6, R5 kept responding, I don't remember. The surveyor inquired if R5 had gone to the hospital recently. R5 stated, I (R5) went to the hospital once, but it was nothing. It was like a month ago. I (R5) hit my eyebrow. When the surveyor inquired if R5 was hit by another resident, R5 stated, I (R5) don't remember if someone hit me. On 01/03/23 at 12:11 pm, V12 (LPN/Licensed Practical Nurse) stated, I (V12) was at my medication cart at the nurses' station and heard a lot of commotion, so I (V12) ran over to where the microwave is at. I (V12) saw (R5) had (R6's) cane and was hitting (R6) with it. He (R5) told me that he (R5) was at the microwave trying to warm food up. (R6) came to him (R5) and put his (R6) finger in his (R5) face and hit him (R5) with the cane. I asked (R6) if he (R6) hit (R5) first, he (R6) said yes. So, he (R6) initiated the fight. V12 added that R5 was bleeding from above one of his (R5) eyes (V12 could not remember which eye but stated that it's documented). On 01/04/23 at 9:34 AM, V26 CNA stated that she (V26) didn't see when the altercation started because she (V26) was in a resident's room. V26 added, When I got to it, (R6) was on the floor and (R5) was hitting him (R6) with (R6's) cane. I grabbed (R5) and walked him (R5) to the nurse because his (R5) head was bleeding. On 01/04/23 at 10:31 AM, V1 (Administrator) stated, (R5) was sent out to the hospital to ensure that there was no internal injury since he (R5) received a blow to the head. On 01/04/23 at 1:07 PM, the surveyor inquired what type of injury, in your professional opinion, is possible if a resident is hit in the head with a cane? V32 (R5's Primary Physician) replied, Well it could be no injury, it could be a minor abrasion, a superficial hematoma, underlying subdural bleed, brain contusion, possible death. All of that is possible. R5's 11/27/22 Emergency Department Discharge Summary documented, in part, Discharge Diagnoses: Laceration of face. R5's Nursing Progress Note authored by V12 on 11/27/22 at 3:54 PM documents, in part, Patient (R5) arrived back to the facility. Patient (R5) has dissolvable stitches to his (R5) left lower eyebrow. R5's face sheet documents diagnoses including but not limited to personality disorder, convulsions, alcohol abuse, schizophrenia, osteoporosis, and anxiety disorder. R5's 12/08/22 BIMS (Brief Interview for Mental Status) determined a score of 13, indicating that R5's cognition is intact. R6's face sheet documents diagnoses including but not limited to traumatic brain injury, cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, bilateral hearing loss, selective mutism, major depressive disorder, psychosis, schizoaffective disorder and anxiety disorder. R6's 11/01/22 BIMS determined a score of 9, indicating that R6's cognition is moderately impaired. R6's 12/24/2019 care plan documents, in part, The resident has the potential to demonstrate physically aggressive behaviors. The facility Abuse Prevention Program-Policy dated 11/22/17 documents, in part, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment .Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to ensure the safety of residents by not monitoring and preventing a resident (R4) from receiving and using an illegal drug. This failure resulted in R4 overdosing on heroin, requiring transfer and treatment at local hospital for treatment. Findings include: R4's current medical record (Face Sheet, Progress Notes, MDS-Minimum Data Set) documents: R4 is a cognitively intact [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: Opioid Abuse, Opioid Dependence, Cocaine Use, Acute Respiratory Failure with Hypoxia and Congestive Heart Failure. Progress note dated 11/8/2022 at 3:20 AM documents in part: Nurse on duty notified by CNA to come to check to room to check on R4. Writer immediately rushed in resident('s) room and observed resident unresponsive, no movement of the entire body. Eyes rolled to back of head, extremely diaphoretic, unresponsive to sternal rub, and with agonal respirations. Code blue/rapid response initiated immediately, and staff responded. 911 called. Resident was taken to (local hospital). Facility's investigation (undated) documents in part: 11/8/22, (R4) noted to be unresponsive at 03:20 (AM). Code Blue called, Narcan administered and effective. Evidence of substance abuse note by nurse-small blue empty bag with whitish brown powder and rolled up bill/powdery residue. Transferred to ER for evaluation. Resident returned to the facility with no new orders. Hospital paperwork indicates that drug screen was positive for opioids. Progress note dated 11/08/2022 at 3:15 AM documents in part: Writer was told by staff that resident(R4) was in room, unresponsive and then a code blue/rapid response was overheard in speakers. Upon entering room, resident(R4) observed with eyes rolled to back of head, extremely diaphoretic, unresponsive to sternal rub, and with agonal respirations. 911 already called. Open carrier bag sitting on top of resident while code ongoing and all staff responding. Writer found a blue small empty drug bag with only a residual whitish brown powder and rolled up bill also with powdery residual. He(R4) was given multiple rounds of Narcan. Slowly, resident(R4) began to come out of stupor and respirations increased. He(R4) soiled himself and began to vomit. 911 EMTs and police arrived and were given report on his(R4's) status and presentation. Progress Note dated 11/08/2022 at 7:02 AM documents in part: Received a telephone call from (local hospital) regarding resident(R4), spoke with RN, who stated resident will be returning back to facility. DX (diagnosis) Opioid overdose. emergency room Record Note 11/08/2022 documents: opiate OD s/p Narcan in (is) bedridden resident(R4) of nursing facility. Unexplained access to heroin. 12/08/2022 at 12:21 PM, V6 (LPN-Licensed Practical Nurse) said, when I called R4's name there was no response, no rising/fall of chest. I shook R4, checked pulse. There was no response to sternal rub. I called 911, called code blue. Nurse Supervisor (V10) responded, requested Narcan because V10 knows R4 has history of drug overdose. I remembered small black pouch or purse next to resident on bed, V10 saw the bag. There was a little, small plastic clear bag on top R4 with a whitish residue. I did see a male resident go into R4's room an hour or so before R4 was (found unresponsive). I don't know the resident's name; he is no longer at the facility. V6 stated their bags are not checked by security when they come to work. 12/07/2022 at 9:13 PM, V10 (Registered Nurse/Evening Nurse Supervisor) said, I was the manager on duty, they called rapid response/code blue. When I got there, R4 was extremely diaphoretic, sweating bullets, agonal respirations of 2-3 per minute, eyes rolled to back of head, and was non-responsive to sternal rub. I saw a black bag in bed by the resident, it was open. I saw a blue baggy with white residue and a rolled-up bill. I called for nasal Narcan; I gave it but R4 didn't respond. I couldn't appreciate pulse, or it was faint. I gave second round up Narcan. At that point we thought we were going to have to start compressions. Then 30-40 seconds later, R4 took a deep breath, like R4 was coming out of the water. R4 started breathing normally. R4's respirations gradually returned to normal. Then R4 just woke up. 12/09/2022 at 10:20 AM, R4 said R11 sold R4 heroin. R11 came into my room. I gave R11 $20 dollars for two bags of heroin. The next thing I remember is the paramedics in my room. Everyone knew R11 was the go-to guy (to get heroin). V1 (Administrator) met with me after I returned to the facility from the hospital. V1 asked me, who gave you the heroin? I told V1, I had it with me. V1 said, no you didn't. I saw (on the camera) R11 coming out of your room. I said to V1, then why are you asking if you already know? They knew R11 was selling it, R11 kept coming to my room. Drugs are still coming in (to facility), residents are still using (did not provide any additional information). 12/07/2022 at 3:52 AM, V1 said they didn't know how R4 got the heroin. V1 said they did not review tape and that V11 (Regional Nurse Consultant) completed an investigation. 12/09/2022 at 4:44 PM, V11 (Regional Nurse Consultant) said, I completed the investigation. I don't feel that I could come up with a concrete way that R4 got the heroin. For this situation, we suspect that something may have come over the patio (fence). I did not review tape. 12/08/22 at 4:13 PM, V12 (Licensed Practical Nurse/3rd Floor Nurse Supervisor) said, What I know is that R11 visited R4's room that night. I was told by my night nurse (V6). V6 was working the 3rd floor that night. I was told R1 visited R4's room at approximately 1 or 2 in the morning and approximately 30 minutes to an hour after R11 went into R4's room, R4 was found unresponsive. R4's care plan for substance abuse (created and initiated on 11/09/2022) documents under focus: resident has a history of substance abuse while in the community; under goal: resident will address chemical dependency by attending program as well as external chemical dependency treatment through next review. There are no interventions documented. Facility did not provide documentation that R4 attended programs.

Based on observation, interview and record review, the facility failed provide care and services for the management of a resident's diabetes by not following physician orders to administer insulin medication as ordered, failed to document insulin administration and glucose level, and failed to have staff knowledgeable about the use of an insulin pen. These failures affected 1 of 38 residents (R6) diagnosed with diabetic mellitus receiving insulin. As a result of this failure R6 was administered 300 units of insulin and R6's blood sugar measured 205 mg/dl when insulin was administered. This facility failure has the potential for R6 experiencing adverse effects and complications of unstable blood sugar including but not limited to: Diabetic ketoacidosis, [CONDITION(S)] and [CONDITION(S)]. This was identified as an immediate jeopardy which began on 8/30/2022 when surveyor observed V10 (LPN) drawing up the incorrect dosage of insulin with an insulin syringe from the insulin pen and administering to R1. The immediacy was removed on 09/06/2022. V1 (Administrator) was informed of the immediate jeopardy and the immediate jeopardy template was presented on 09/01/22 at 3:29pm. The facility provided an initial removal plan on 09/2/2022 and was not accepted on 09/02/2022. The facility presented a modified removal plan on 09/08/2022 and the plan was accepted on 09/08/2022. Although the immediacy was removed, the deficiency remains at the second level of harm until the facility can determine the effectiveness of the implementation of removal plan. Findings include: R6's medical record showed that R6 was admitted to the facility originally on 06/08/2020 and initial admission of 03/15/2021. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Minimum Data Set (MDS) dated [DATE], Section C-brief interview for mental status summary score is (15) indicating R6 is cognitively intact. R6's Diabetes Mellitus plan of care with initiated date of 03/28/2021 documented interventions include but not limited to blood glucose monitoring per MD (Medical Doctor) order and document. Diabetes medication as ordered by doctor. Monitor /document for side effects and effectiveness. On 08/30/22 at 12:30 p.m. on the 3rd floor, surveyor observed R6 sitting in a wheelchair at the nurse's station asking for V10 (LPN) to check her (R6) glucose level. V10 LPN told R6 to go and eat and that R6's blood sugar was fine. R6 stated, my (R6) glucose monitoring has not been done. V10 proceeded to obtain R6's blood glucose in view of other residents and visitors at the nurse's station despite V12 (LPN) asking V10 to take R6 to R6's room for privacy. R6's blood glucose measured 205mg/dl. V10 went to the medication cart and obtained R6's insulin pen. V10 then came back to the medication cart and obtained an insulin syringe. V10 opened the insulin syringe and inserted the insulin syringe (U100) needle into the rubber stopper of the insulin pen and withdrew insulin from the insulin pen into the insulin syringe. As V10 prepared to administer R6 the insulin at the nurses' station, V5 (SSD) came and assisted R6 to her (R6's) room and stated to V10, Medication administration should be done in the resident's room for privacy. Upon R6 returning to (R6's) room, the surveyor observed V10 preparing to administer the insulin in R6's abdomen. Prior to V10 administering the insulin to R6, the surveyor intervened and asked V10 to clarify the dose of insulin in the syringe. V10 stated, 60 units of [MEDICATION(S)] R. V10 showed the surveyor the syringe. The surveyor observed the insulin syringe at the 60 units measurement mark. Again, the surveyor asked V10 to clarify the amount (dose) of insulin that was supposed to be administered with the medication order since the surveyor did not observe V10 verify the physician order with the EMAR prior to preparing the insulin for administration. V10 stated, I know the order. R6 is supposed to get 120 units but I'm given (R6) 60 units half of what is ordered. The surveyor asked V10 why she (V10) was giving R6 half of the dose of insulin ordered by the physician. V10 replied, Personally, I don't believe R6 should be getting that much (referring to ordered insulin), so I (V10) am giving half of the dose. The surveyor asked V10 why she (V10) withdrew the insulin from the insulin pen using an insulin syringe. V10 stated, I (V10) don't usually like the pen (referring to the insulin pen) because the insulin is usually stronger when it's used with the pen. The surveyor immediately asked V10 to stop the insulin administration and to clarify the physician order. V10 disregarded the surveyor's request and administered the insulin to R6 using the insulin syringe with the measured amount of 60 units observed on the insulin syringe. After V10 administered the insulin to R6, V10 stated to the surveyor, I (V10) know the order. On 8/30/2022 at 12:56pm, V10 and the surveyor checked the EMAR (electronic medication administration record) and the POS (physician's order sheet) for R6's insulin order. R6's POS dated 1/22/2022 showed an order of [MEDICATION(S)] R U-500 K*** Pen Solution Pen-injector 500 UNIT/ML (Insulin Regular Human (Conc) to Inject 140 unit subcutaneously in the morning related to TYPE 2 DIABETES MELLITUS WITH [CONDITION(S)] (E11.65) With breakfast AND Inject 140 unit subcutaneously in the afternoon related to TYPE 2 DIABETES MELLITUS WITH [CONDITION(S)] (E11.65) With lunch AND Inject 125 unit subcutaneously in the evening related to TYPE 2 DIABETES MELLITUS WITH [CONDITION(S)] (E11.65) With dinner. There was no physician order to inject 60 units of insulin to R6. The order showed that R6 should have received 140 units of insulin [MEDICATION(S)] R via insulin pen (Pen-injector). On 8/30/2022 at approximately 12:59pm, surveyor asked V10 about the facility protocol regarding insulin administration and withdrawing insulin from the insulin pen. V10 replied, You (referring to surveyor) want the book knowledge form or what I (V10) do in real world. V10 stated, I don't think using the pen hits the same or works well for (R6) and I'm trying to study (R6) to see what works well for (R6) so that's why. The surveyor further asked V10, what is the facility policy on medication administration regarding physician orders, notification of physician and clarification of medication orders. V10 stated, The physician order should be carried out and medication pass should be passed one hour before and one hour after. Medication should be given as ordered by the physician. Surveyor asked V10 if she (V10) administrated R6's insulin medication as ordered. V10 replied, No because I'm (V10) still trying to get the coverage (referring to insulin) and let the physician know about it. During this time, the surveyor did not observe V10 notify the MD of the medication error nor did V10 document notification of the medication error at the time the error was made. V10 was aware she did not administer R6 the ordered dose of insulin. On 8/30/2022 at approximately 1:03pm, V2 DON (Director of Nurse's) walked out of the elevator and overheard V10 explaining V10's actions regarding insulin administration to surveyor. V2 stated to surveyor, I can't believe the explanation of whatever question you asked her (referring to V10). On 08/30/22 at 2:02pm V2 (DON) stated, medication is to be given as physician ordered, if it says (referring to the order) insulin pen it should be given via insulin pen. Surveyor asked V2 can the nurses change a physician order. V2 stated, They (referring to nurses) are not physicians so they cannot change the order. All orders are to be given as physician ordered. On 8/30/22 at 2:13pm Surveyor asked V2, what can happen to residents if medication (referring to insulin) is not administered as prescribed. V2 stated, It means the resident can go into Hypo or Hyperglycemic reaction depending on what is going on with them (referring to resident). On 08/30/22 at 4:00pm the facility was unable to present any documentation that showed V10 informed R6's physician of the insulin medication error. MAR dated 8/30/2022 at 1730 (5:30pm) R6's BS (blood sugar) documented 182. On 09/01/22 at 11:55am, surveyor conducted interview with V25 NP (Nurse Practitioner) regarding the significance of following the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/03/22 at 10:12am, interview with V27 (Pharmacist) regarding the amount of insulin administered to R6, and the use of an insulin syringe instead of the insulin pen. V27 stated that the amount of insulin administered to R6 via an insulin syringe equals 300 units and that is 160 units more than the 140 units ordered. V27 stated, the amount in the pen is of a large concentration 500 units/ml (Milliliters), and the way the nurse used the insulin pen defeats the purpose of how the pen was designed to be used. Facility Charge Nurse Job Description dated 2003 in part states: Purpose of Your Job Position - The primary purpose of your job position is to provide direct nursing care to the residents. Such supervision must be in accordance with current federal, state, and local standards, guidelines and regulations that govern our facility to ensure that the highest degree of quality care is maintained at all times. Delegation of Authority - As Charge Nurse you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Duties and Responsibilities - Ensure all nursing personnel assigned to you comply with the written policies and procedures established by this facility. Periodically review department's policies, procedure manuals. Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manual. Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting etc., as necessary. Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident as well as the resident's response to the care. Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures. Prepare and administer medications as ordered by the physician. Consult with the resident's physician in providing the resident's care, etc. as necessary. Review the resident's chart for specific medication orders, etc. as necessary. Facility policy regarding Insulin Pen Usage dated 06/2021 documented in part, the policy is to provide the staff with guidance on accuracy of insulin administration and dosing. Listed responsible party are RN (Registered Nurse) or LPN (Licensed Practical Nurse). Policy statements includes but not limited to never use syringe to draw insulin out of an insulin pen cartridge. Administer insulin as ordered. Listed procedure includes but not limited to documenting each insulin dosage, site, time, in the EMAR (Electronic Medication Administration Record). The facility Medication administration policy presented with review date 11/2021 documented in part: all medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Listed responsible party are RN (Registered Nurse) or LPN (Licensed Practical Nurse). Listed guideline includes but not limited to an order is required for administration of all medication. Checking medication administration record prior to administering medication for rights that includes the dose. Following special instruction written on the label. Document as each medication is prepared in the MAR (Medication Administration Record). If medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider and resident representative if applicable. Facility presented the manufacture's undated Instructions for the use of the [MEDICATION(S)] R U-500 K***Pen which included the following: Important: Know your dose of [MEDICATION(S)] R U-500 insulin. The pen delivers your dose in insulin units. Insulin units may not be the same as syringe markings. Your [MEDICATION(S)] R U-500 is a concentrated insulin. Do not transfer [MEDICATION(S)] R U-500 insulin from Pen into a syringe. A severe overdose can happen, causing very low blood sugar, which may put your life in danger. Based on the evidence the facility did not follow established policies and the manufacturer's instructions for the use of an insulin pen. The surveyor on 09/12/2022 via observation, interview and record review confirmed the following removal plan was implemented by the facility: 1. R6 and POA (Power of Attorney) were notified of R6 receiving incorrect dose of Insulin. 2. R6, NP (Nurse Practitioner) and POA were notified that insulin from the U500 insulin pen was administered with a U100 Insulin syringe rather than the insulin pen as ordered. 3. Follow up blood glucose of 188 4. All resident with insulin administration and blood glucose monitoring reviewed for compliance to assure no other resident is affected. 5. Facility nurses were being educated on: Facility policy regarding medication administration including the rights of medication administration including correct dose, time, patient, medication and route as well as notifying the physician or NP when error occurs. Nurses are being educated on proper use of insulin pens with return demonstration. Nurses are being educated on proper medication management of diabetes including potential adverse effect of complications including diabetes including potential adverse effects of complications including diabetic ketoacidosis, [CONDITION(S)] and [CONDITION(S)]. Nurses are being educated on difference between U-100 insulin and U-500 insulin concentration with the information provided in a red binder on each nurse's station. Revision made to Insulin Pen policy. Pharmacy to place a red sticker on insulin to indicate that it is high-alert medication with the potential to cause patient harm if used in error. Education of nurses initiated 08/30/22 and completion of removal plan target date 09/02/22. 6. V10 has been terminated. Last day of work 08/30/22. 7. The facility will monitor with QA (Quality Assurance) tool developed and DON (Director of Nurses) with target date 09/06/22.

Based on interview and record review the facility failed to supervise and monitor three residents (R2) in the dining room and (R4 and R5) during resident smoke time. These failures resulted in R2 falling and sustaining a laceration to left eyebrow and suspicious complex ligamentous injury with potential cord compression and R5 sustaining injury/wounds to both knees, left eye swelling and redness, and a scratch under left eye. These failures have the potential to affect all 61 residents at risk for falls and all 34 smokers residing in the facility. Findings include: R2's medical record documented date admission as 06/29/22, with diagnosis information that includes but not limited to unspecified Dementia without behavioral disturbances, Displaced fracture of Proximal phalanx of the left index finger, subsequent encounter for fracture and routine healing , Pain Left hand, presence of unspecified Artificial Knee Joint, Vascular Dementia without behavioral disturbance, Primary Generalized (Osteo) Arthritis, Heart Failure and Unilateral primary [CONDITION(S)], right knee. R2's medical record showed that R2 had a fall on 07/14/22 and was sent to a local community hospital for further evaluation and treatment. R2 was then transferred to another community hospital for further evaluation and treatment. R2's medical record dated 07/13/22 timed 2:02pm (14:02) documented that R2 is confused needs redirecting, staff gave a full body shower resident complied, skin assessed, skin intact staff will continue to monitor. R2's MDS (Minimum Data Set) dated 07/06/22 coded R2 BIMS 00 indicating that R2 is severely cognitively impaired. R2's progress note dated 7/14/2022 17:26 (5:26pm) Health Status/Progress Note Note Text: Writer (V16 - RN) observed resident in dining room and heard a noise. Writer (V16) seen resident on her left side laying on the floor. Writer (V16) assessed resident and noted open area to the left side with minor bleeding. V/S taken B/P 114/69, RR 18, pulse 73, T 98.0, SPO 98 RA. Writer (V16) and CNA (V17) help resident back in chair. Resident voiced no pain. Writer (V16) asked how you fell resident stated, I was trying to get my shoes. Daughter in the building she made aware. MD called awaiting on call back. R2's potential fall plan of care initiated 06/29/22 documented that R2 is at risk for injury from falls with goals to reduce the likelihood of the resident experiencing a fall with target date 10/12/2022. R2's plan of care for ADL's documented that R2 has an ADL self-care performance deficit initiated 07/12/22, interventions documentation listed showed that R2 needs total assistance with staff participation with toilet use, transfer, bed mobility bathing, personal hygiene / oral care dressing and eating On 08/24/22 at 1:48pm, V15 NP (Nurse Practitioner) was asked if she (V15) was made aware that R2 had any injury with the fall that occurred on 7/14/2022. V15 stated, I was not notified of any injury between 8am to 6pm. I'm not on duty after 6pm. The facility nurses will have to call either the PCP (Primary Care Physician) or the NP on call. I (V15) was not notified of R2 having any injury. V15 further stated, The facility staff are supposed to monitor and supervise the residents to prevent falls. On 08/24/2022 at 3:39pm V17 CNA (Certified Nurse's Aide) identified herself as helping to get R2 up off the floor after R2 had a fall on 7/14/2022. V17 stated, she (V17) remembers R2 and worked on the floor the day R2 fell . V17 stated, R2 was found on the floor in the dining area, and she (V17) was not the CNA assigned to R2. V17 stated, She (V17) did not witness R2's fall, but the nurse told her that R2 fell . V17 stated, She makes rounds every two to two and half hours because when they assume duty at 3pm to 11pm shift, almost all of the residents are usually up out of the bed. V17 stated, She (V17) helped in getting R2 off the floor and they (V16 and V17) physically lifted R2 of the floor. On 08/24/22 at 3:47pm, V18 (CNA) stated, I worked on the floor the day of the incident (7/14/2022), but I (V18) did not work with R2, and I (V18) do not remember what happened to R2 on 07/14/22. When asked how often V18 makes rounds, V18 replied, every one to one and a half hours (1 - 1 1/2). On 08/24/22 at 3:52pm, V19 (CNA) was identified as working with R2 on 07/14/22 when R2 fell . V19 stated, She (V19) was on duty but did not witness the fall and did not know where she was at the time of the fall. V19 further stated, I (V19) do not remember the last time I saw R2 before the fall on 07/14/22. On 08/24/22 at 4:02pm, surveyor asked V2 regarding the fall with injury R2 had on 7/14/2022. V2 stated, The facility did not get any report from the hospital about any injury. Originally R2 was sent to a local hospital and was later transferred to another local hospital. V2 stated, R2's family member wanted R2 to be sent to another hospital and then to another LTC. R2's emergency hospital record dated 7/14/2022 at 23:33 (11:33 pm) showed R2 was admitted on [DATE]. The report documented that R2 fell at the facility, had a 3cm (Three centimeter) superficial laceration on the left eyebrow used Dermabond on the area and there was no more bleeding at the site. Under reexamination/reevaluation imaging reviewed CT head showing no acute intracranial processes. CT neck showing concerns for cord compression currently. Given imaging result recommend need for emergent MRI to rule out cord compression at this time. Patient (referring to R2) will require escalation of care, spoke with (another hospital trauma center) who accepted patient (R2). Superficial laceration Dermabond shut with approximation of laceration. Diagnostic test result CT (Computer Tomography) Spine Cervical w/o contrast dated 07/14/22 at 20:48 (8:48pm) documented under impression that C1/C2/basion findings as described suspicious for complex ligamentous injury and potential cord compression. Question age-indeterminate atlantoaxial/rotatory subluxation and even low-grade occipital-axial dissociation. Recommend MRI and comparison to priors. The reason for the exam was for neck trauma. The report addendum documentation pointed out that this report containing critical findings was discussed with (Doctor on 07/14/22 at 10:37pm). R4's medical record showed that R4 was admitted to the facility initially 11/18/2021. Last admitted was 08/22/22. R4's listed diagnosis includes but not limited to other specified Abnormal Immunological findings in serum, [CONDITION(S)] Uncomplicated, Nicotine dependence, cigarettes uncomplicated, Other Psychoactive Substance Abuse in remission, and Major Depressive Disorder Recurrent, mild, Opioid Dependence uncomplicated, and Opioid use unspecified, uncomplicated. R4's Minimum Data Set (MDS) dated [DATE], Section C-brief interview for mental status summary score is (06) indicating R4 is cognitively impaired. R5's medical record documented that R5 was last admitted [DATE]. Diagnosis list includes but not limited to Epileptic Seizures related to external causes not intractable without status Epilepticus, Unilateral primary [CONDITION(S)] Left Knee, [CONDITION(S)], Effusion Left Knee, Acute Embolism and [CONDITION(S)] of Right Femoral Vein, Other [CONDITION(S)] Right Knee. R5's Minimum Data Set (MDS) dated [DATE], Section C-brief interview for mental status summary score is (11) indicating R5 is severely cognitively impaired. Review of R5's medical record progress notes showed the following documentation: V16 documented on 8/15/2022 between 2130 and 2140 (9:30pm and 9:45pm) R4 started to get physically aggressive and came up to another resident and started to punch repeatedly and pull R5 off the wheelchair. V26 LPN (Licensed Practical Nurse) documented at 2210 (10:10pm) in part R5 had a physical altercation with peer (R4) on the courtyard. Resident (R5) was assessed by writer, Writer (V26) noted swelling to the left eye and a small scratch under left eye. Left eye is red. No other bruise noted. V4 (Wound Care Nurse) documented that on 08/17/22 at 1:07pm that R5 had a skin tear to left and right knee with wound care department will be monitoring. R1 medical record documents admitted [DATE]. R1's diagnosis includes but not limited to Obesity, unspecified, Type 2 Diabetes Mellitus with [CONDITION(S)], Essential Hypertension R1's Minimum Data Set (MDS) dated [DATE], Section C-brief interview for mental status summary score is (14) indicating R1 is cognitively intact. On 8/24/2022 at approximately 4:29pm Surveyor asked R1 what staff were on patio. R1 stated, There was no staff out there to help. We all could have been attacked, and I'm not staying here. I (R1) want to leave. V12's Progress Note dated 8/22/2022 documents R1 is A+O (Alert and Oriented) x 3. On 8/25/2022 at approximately 12:16pm surveyor asked R5 if staff were present on the patio. R5 stated, No, staff were there. On 8/25/2022 at 12:29pm surveyor asked R4 if staff were present on the patio. R4 stated, No body (referring to staff) were there. On 8/25/2022 at 2:03pm V1 (Administrator) stated, The security guard on duty did not see them (R4 and R5) have any contact with each other (R4 and R5). He (V24) was the one supervising the smoking patio at the time (referring to incident). On 8/30/2022 at 9:41am V12 (LPN) stated, I (V12) was called downstairs that there was an altercation between two residents (R4 and R5). R4 was not downstairs, he (R4) was back on the unit in his (R4's) room. R4 did not give me (V12) any details about the altercation. Surveyor asked V12 was staff supervising or monitoring the residents on the patio. V12 stated, That is a good question, I (V12) will have to find out about that. V12 was unable to state who was supervising residents on patio at the time of the incident. On 08/30/22 at 12:23pm R6 stated There was no staff present at the time, but the other resident went and called the security guard (V24). R6's medical record showed that R6 was admitted to the facility originally on 06/08/2020 and initial admission of 03/15/2021. Diagnosis includes but not limited to Type 2Diabetes Mellitus with [CONDITION(S)], Type2 Diabetes Mellitus with Diabetic [CONDITION(S)] unspecified, other seizures, Shortness of breath, Acute [CONDITION(S)], Wheezing, Chest pain, other visual disturbances, Acute Embolism and [CONDITION(S)] of unspecified Deep Veins of Right Lower Extremity. R6's Minimum Data Set (MDS) dated [DATE], Section C-brief interview for mental status summary score is (15) indicating R6 is cognitively intact. On 08/30/22 at 12:24pm, interview conducted with R7 regarding the physical altercation between R4 and R5. R7 stated, The residents were on the smoking patio smoking when R4 attacked R5. R4 was hitting R5 and throwing R5 out of the wheelchair to the floor. R7 stated, R4 was kicking R5 on the head and the body and because the staff was not around the other resident had to hold R4 away from R5. R7 stated, There was no security guard at the time so one of the residents had to run and called the security staff. R7 asked surveyor how did you (surveyor) know I (R7) was there during the incident. Surveyor told R7 that V1 told surveyor. R7 then stated, V1 told R7 that V1 saw him in the video. R7's medical record showed that R7 was admitted to the facility on [DATE]. Diagnosis includes but not limited to Essential Hypertension, Post Traumatic Stress Disorder, unspecified, Major Depressive Disorder, Fracture of Orbital Floor, Left Side. R7's Minimum Data Set (MDS) dated [DATE], Section C-brief interview for mental status summary score is (12) indicating R7 is mildly impaired. On 8/30/2022 at approximately 1:30pm survey asked V1 to see the video from the incident on 8/15/2022. V1 stated, There was no video. According to facility investigation, documented during investigation by V1 (Administrator) on 8/15/2022, V24 stated, V24 heard yelling in the patio and when he approached, he observed (R4 and R5) getting into an altercation and R4 was standing beside R5. V24 did not see R4 had any physical contact with peer (R5) but peer (R5) was the one that told him (V24) that R4 assaulted him (R5). During this survey V2 made attempts to call V16 (RN) and V26 (LPN) with no response. V2 stated V16 was on vacation. Surveyor attempted to call V26 on 8/31/2022 and 9/1/2022 with no response and attempted to call V24 on 8/31/2022 with no response. On 9/1/2022 when surveyor call V24, V24 identified himself as V24 and when surveyor identified self as surveyor, V24 hung up the phone. Surveyor called V24 back and there was no answer. The facility Falls Management policy presented with revised date 6/21 documented in part that the facility is committed to maximizing each resident's physical, mental and psychosocial wellbeing while preventing all falls is not possible, the facility will plan for preventive strategies and facilitate as safe an environment as possible. Facility guideline following a fall incident includes but not limited to completing a fall event. This event includes the circumstances surrounding the fall devices in use, full body observation of injury, pain, range of motion and neuro checks as needed. All incident and accident with serious physical injury will be initially reported as required to the Health Department. A final written investigation is required by the Department of Public Health within seven days of incident. The facility policy on Smoking presented with review date of 6/21 documented in part that smoking is a right for our residents. Residents are allowed to smoke only in designated places. Responsibly Party: All facility staff. Guideline: includes but not limited to: 8. The designated smoking areas will be supervised during the designated smoking times. 10. Residents will be supervised during smoking unless the IDT determines the resident can safely smoke unsupervised during non-designated smoking times. Facility documented Smoking times: listed includes but not limited 9pm to 10pm.

Based on interview and record review, the facility failed to keep one resident (R5) free from physical abuse. This failure affected one of three residents (R5) reviewed for physical abuse that sustained injury/wounds to both knees, swelling and redness of left eye and a small scratch under left eye. This failure has the potential to affect all 180 residents residing in the facility. Findings include: R4's medical record showed that R4 was admitted to the facility initially 11/18/2021. Last admitted was 08/22/22. R4's listed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Minimum Data Set (MDS) dated [DATE], Section C-brief interview for mental status summary score is (06) indicating R4 is cognitively impaired. R5's medical record documented that R5 was last admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Minimum Data Set (MDS) dated [DATE], Section C-brief interview for mental status summary score is (11) indicating R5 is moderately impaired. R5's medical record progress notes and POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1.Review of R5's progress noted documentation dated 08/15/22 timed 22:43 (10:43pm) V12 LPN (Licensed Practical Nurse) documented in part that R4 struck peer (referring to R5) several times in the face. R4 was assessed and marks were noted to left elbow. 2.V16 documented on 08/15/22 that the reason for report was due to Aggressive and threatening behavior towards other specific resident escalated when (R4) started to get physically aggressive. At 2130-2140 (9:30pm-9:40pm) R4 came up to another resident and started to punch repeatedly and pull (R5) off the wheelchair. 3.V26 LPN (Licensed Practical Nurse) for R5 on the day of incident documented that writer was informed by staff that resident (R5) had a physical altercation with peer (R4) on the courtyard. Resident (R5) was immediately separated and placed on 1:1. Resident (R5) was assessed by writer(V26) upon entering the courtyard. Writer (V26) noted swelling to the left eye and a small scratch under left eye. Left eye is red. No other bruise noted. 4.V20's documentation in R5's progress note dated 08/16/22 timed 8:50am documented that this writer did body assessment this morning on resident. Resident (R5) only noted to have sores on both knees no other injury noted. 5. V4 (wound care Nurse) documented that on 08/17/22 at 1:07pm that R5 had a skin tear to left and right knee with wound care department will be monitoring. According to facility investigation reviewed, V1 (Administrator) documented on 8/18/2022 in part that V24 (Security guard) heard the yelling and when V24 approached, V24 immediately intervened and called for backup. V24 did not observe any physical contact between R4 and R5. V1 documented that based on known facts, the following conclusions have been determined that the allegation of physical abuse is unsubstantiated because R4 did not have any physical contact with R5. On 08/24/22 at 3:14pm, interview conducted with V1 regarding the facility investigation of physical abuse on 8/15/2022. V1 stated R1 was a witnessed to an abuse situation and R1 was not abused but saw the altercation between R4 and R5. R1 medical record documents admitted [DATE]. R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Minimum Data Set (MDS) dated [DATE], Section C-brief interview for mental status summary score is (14) indicating R1 is cognitively intact. On 08/24/22 at 4:27pm, R1 was asked regarding the incident R1 witnessed between R4 and R5 on 8/15/2022. R1 explained that some of the residents were on the patio (Smoking Area) smoking. R1 stated, I (R1) witnessed R4 and R5 arguing and R4 started hitting R5 in the head, face and (R4) threw (R5) on the floor from the wheelchair. R1 stated, R4 continued to hit R5 while on the floor. R1 stated, There was no staff around at the time, so I (R1) had to call other residents that were present to assist me (R1) in separating R4 and R5 while one resident was yelling for the staff. R1 stated, By the time the staff showed up, R5 was on the floor bruised on the knees, face punched and swollen. On 08/25/22 at 12:12pm, interview with R5 regarding the physical altercation with R4. R5 stated that someone (referring to R4) turned me over from my wheelchair and I (R5) fell and hurt my legs. R5 touching the face and forehead said (R4) hit me in my face my head and knock me on the floor. At 12:17pm R5 pulled his pants leg up and showed the surveyor his bilateral knees with V20 LPN (Licensed Practical nurse) present at the time. Surveyor observed dressings on both knees of R5. V20 then told the surveyor that (R5) was in an altercation with another resident (referring to R4) and was thrown on the floor from his wheelchair and R5 got injured on both knees. When V20 tried to touch the left knee R5 clinched and stated it hurts. R5 showed facial grimaces that reflect pain and told the surveyors that it is not fair for (R4) to hit me like that. On 08/25/22 at 12:25pm, interview conducted with R4 regarding physical altercation with R5. R4 stated that, I (R4) was sitting there on the patio talking. R4 stated, He (R5) came over there, and things don't look right anymore, no one hits me and gets away. R4 stated, R5 picked up this big plastic yellow cone (referring sign used by housekeeping) so I blocked him (R5), and I lost my temper when R5 hit me. R4 stated, I (R4) really did not hit him as hard as I could, but I gave him one on his mouth and I threw him out of the wheelchair. (R5) was in a wheelchair which doesn't matter to me. I (R4) then see paramedics and they said the police is coming and I (R4) should follow them to the hospital. They (referring to paramedics) said they will bring me back after seeing the doctor. R4 stated, they (paramedics) said they will strap me (R4) up if I (R4) don't follow them. On 08/25/22 at 2:51pm, V4 (wound care Nurse) presented R5's bilateral knee wound care assessment dated [DATE] timed 1:07pm. V4 documented in part that he (V4) was notified by the floor nurse of a possible wound on (R5) Legs. Upon assessment noted skin tear to (R5) left and right knee. V4 stated the knees were not done until 08/17/22 because the wound care department was not notified until 08/17/22. Left knee Measurement 1.00cm (Centimeter) in length, 0.80cm width and 0.10cm in depth. Right knee Measurement 2.00cm length x 2.00cm width x 0.10cm depth. R5's treatment order dated 8/17/2022 showed orders for right knee to Cleanse with NSS (Normal Saline Solution) or wound cleanser, pat dry, skin prep peri wound, apply xeroform, and cover with a dry dressing 3x week / PRN (As needed) every day shift every Mon, Wed, Fri for To Promote Wound Healing and as needed for To Promote Wound Healing. Left knee order read to cleanse with NSS or wound cleanser, pat dry, skin prep peri wound, apply xeroform, and cover with a dry dressing 3x week / PRN every day shift every Mon, Wed, Fri for To Promote Wound Healing On 08/30/22 at 12:21pm, R6 was in her room in a wheelchair. Surveyor asked R6 regarding the 08/15/22 physical altercation between R4 and R5. R6 stated, R4 was the aggressive one and he hit R5 in the head and kicked R5 while R5 was lying on the floor. R6's Minimum Data Set (MDS) dated [DATE], Section C-brief interview for mental status summary score is (15) indicating R6 is cognitively intact. On 08/30/22 at 12:24pm, interview conducted with R7 regarding the physical altercation between R4 and R5. R7 stated, The residents were on the smoking patio smoking when R4 attacked R5. R4 was hitting R5 and throwing R5 out of the wheelchair to the floor. R7 stated, R4 was kicking R5 on the head and the body and because the staff was not around the other resident had to hold R4 away from R5. R7 stated, There was no security guard at the time so one of the residents had to run and called the security staff. R7's Minimum Data Set (MDS) dated [DATE], Section C-brief interview for mental status summary score is (12) indicating R7 is mildly impaired. During this investigation calls were placed to V16 (RN), V24 (Security Guard), and V26 (LPN) with no return phone call. The facility Abuse Prevention Program policy presented documented in part that residents have the right to be free from abuse and this includes but not limited to any physical abuse. The purpose of this policy and abuse program is to describe the process for identification, assessment, and protection of residents from abuse, to be accomplished by establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. Abuse is defined in part as a willful infliction of injury or punishment that which resulted in physical harm. Physical abuse is defined as infliction of injury on a resident other than by accidental means. Physical abuse includes but not limited to hitting, slapping and kicking. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on observation, interview, and record review, the facility failed to supervise a resident who had a history of falls to prevent repeated falls; and failed to implement individualized progressive fall prevention interventions for a resident who was identified to be at risk for falls. These failures affected one resident (R2), out of 2 residents, reviewed for falls. R2 fell three times within two weeks and had a fourth fall with injury to the head and face, that required hospitalization , with a diagnosis of Closed Head Injury and Fall. Findings include: R2's hospital records dated 5/19/2022, page 13, under Diagnosis and Plan/Problem List, written by V20 (Hospital Physician) states: #1. Close Head Injury; #2. Fall. In addition, page 16 shows that R2 had Traumatic Ecchymosis of Face and Facial Laceration. Page 12, under Diagnosis and Plan shows that R2's hospital admitting diagnoses were Closed Head Injury and Fall. On 6/6/22 at 10:45am, the facility's reported incident that was sent to state agency was reviewed. The final report dated 5/26/22 shows that R2 was found on the floor with two hematomas and a laceration above the left eye. This report also shows that was in the hospital from 5/19/22 to 5/23/22. R2's admission diagnoses include but are not limited to Hypertension, Diabetes, [CONDITION(S)] Disorder, [CONDITION(S)], Anxiety, Depression, [CONDITION(S)] and Collapse, [CONDITION(S)], Dementia, and History of Falling. On 6/6/22 at 10:40am during observation of residents on the fourth floor, R2 was observed in the wheelchair several times moving around in hallway unsupervised, far away from the nursing station, and not within view of any staff member. Facility's Falls Incident Reports presented by V3(Restorative Nurse) shows that R2 recently had falls as follows: Dated 1/7/22; Location: Resident's room; Nursing Description; resident was noted sitting on her buttock by her bed on the floor. Dated 1/9/22; Location: Resident's Room; Nursing Description; CNA (Certified Nursing Assistant) informed writer that resident was on the floor; writer observed resident lying on her left side on floor next to bed. Dated 1/20/22; Location: Resident's Room; Nursing Description; Resident was observed on the floor with bleeding noted to the right side of her forehead. Dated 5/19/22; Location: Resident's Room; Sent to emergency room . R2's Fall care plan dated 11/09/2019 documents in part - Focus: Resident is unable to use call light due to cognitive status. Interventions: Resident will be evaluated for specific safety alert device. R2's Fall Risk Screen dated 5/23/22, documents in part, Category: Moderate Risk. 3. History of Falls within last six months, 5. Multiple Falls. R2's Minimum Data Set (MDS), dated [DATE], documents that R2 has a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicates that R2 has severe impairment. Section G. Functional Status: Bed Mobility, Transfer, Locomotion on unit, requires extensive assistance. On 6/7/22 at 1:07pm, V8 (Social Worker) was interviewed regarding R2's fall that resulted in hospitalization . V8 stated that V8 was walking down the hall and heard someone yelling for help and went into R2's room and saw that R2 was on the floor. V8 explained that V8 ran to get the nurse and we both came into the room and assisted (R2) to the wheelchair. On 6/7/22 at 12:00pm, V4 (License Practical Nurse, LPN) was interviewed regarding R2's fall. V4 stated that the social worker (V8) notified V4 that R2 was on the floor. V4 stated that R2 was lying face down on the floor when V4 came into the room. V4 explained that V4 assessed R2 before moving R2 off the floor. V4 added that the social worker helped V4 get R2 up off the floor. V4 explained that R2 had a mark on R2's head and a laceration on the left side of R2's face. V4 added that the Nurse Practitioner came to the floor to do an assessment and ordered to send R2 to out for an evaluation. On 6/7/22 at 1:45pm, V10 (Nurse Practitioner, NP) was interviewed regarding R2's several falls and her professional opinion about preventing repeated falls. V10 stated that V10 was aware of previous falls of R2. Regarding the fall on 5/19/22, V10 stated that V10 assessed R2 and observed a hematoma above R2's left eye. V10 explained that when V10 was asking R2 questions, R2 would not answer any questions. V10 added that V10 sent R2 to hospital for evaluation. The Surveyor inquired from V10 about the Interventions dated 11/9/2019 on R2's care plan to evaluate resident for specific safety alert device. V10 stated, I do not know what device they are talking about. V10 stated that she (V10) will follow up on it and get back with the surveyor. V10 did not get back to the Surveyor. On 6/7/22 at 2:08pm, V19(Care Plan Nurse) was interviewed about R2's care plan. V19 stated that R2 cannot use call light because of R2's cognition. The Surveyor Inquired from V19 about the intervention in R2's care plan regarding resident being evaluated for specific safety alert device. V19 responded, That's not supposed to be there, that's wrong. V19 stated that R2 needs to be closer to the nursing station. R2's Progress Notes dated (5/19/22) at 3:17pm written by V4 (LPN) states: Writer notified by the social worker that the resident was in the room on the floor next to the bed. After lifting the resident back to the bed, noted a hematoma x 2 and a laceration above the left eye with minimal drainage. Completed head to toe assessment. BP (Blood Pressure) 125/74, P(Pulse) 72, 02(Oxygen) 96% RR (Respiration Rate) 20. NP (Nurse Practitioner) and PCP (Primary Care Physician) notified. Unable to reach her daughter POA (Power of Attorney). NP spoke with the son on POC (Plan of Care). Ambulance has been called to transport resident to Local Hospital ED (Emergency Department) for CT (Cat Scan) of head. Facility's Policy with review date 6/21 and titled, Falls Management, documents, in part, under General: The facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe and environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

Based on observation, interviews and record review, the facility failed to have a system in place to alert staff when an illegal drug enters the facility, if a resident uses illegal drugs within the facility and discourage the possession of an illegal drug by a resident and failed to have a care plan and implement interventions to decrease a resident's repeated use of an illegal drug. This applies to one of three residents (R11) reviewed for illegal substances and has the potential to affect 56 residents who are known drug users. As a result, R11 with a known history of illegal drug use, had repeated overdose from illegal drugs while in the facility. This was identified as an immediate jeopardy situation which began on 02/07/2022, when R11 was found on the floor unresponsive. On 02/16/2022 the administrator was notified of the immediate jeopardy. The immediate jeopardy was removed on 02/18/2022. 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, R11 is a 58-year resident admitted to the facility on [DATE]. According to physician assistant note dated 09/25/2022, R11 has a history of drug and alcohol use. Nursing progress note dated 11/26/2021, documents R11's active use of drugs and drug overdose. R11's Minimum Date Set assignment dated 01/06/2022 indicated R11 has a Brief Interview for Mental Status (BIMS) score of 15, which indicates resident has intact cognitive response. R11's care plan dated 02/08/2022 indicated resident has a history of substance abuse and interventions for monitoring and supervision listed are for resident to provide urine sample, resident to address chemical dependency by actively participate in group treatment program. A facility incident Report dated 02/07/2022 documented: Writer (V15 a licensed practical nurse / LPN) was informed by another resident that R11 was found lying on the floor in his room unresponsive and sweating. Nursing Progress Note dated 02/07/2022 authored by V15 documented: Writer was informed by another resident that R11 was found lying on the room floor unresponsive and sweating. Writer knows that the resident has a drug history and writer administered 4mg x4 Narcans in nostrils. Resident(R11) became responsive, and resident stated, what all the staff in here for. Writer contacted (NP/Nurse Practitioner) about resident overdosing and NP stated, resident is medically cleared to be discharged home and to revoke all passes. R11's progress note dated 11/26/2021 documented: On rounding, resident was noted to be slumped over on a corner, food tray and debris all over clothes. He was breathing very heavily, unable to respond by name or touch, even sternal rub. He was sweating profusely and drooling at the mouth. Writer recognized signs of overdose and administered a total of 4 narcans intranasally with full response after about 8 to 10 minutes. Writer attended to other roommate in same state, other staff members witnessed resident holding same yellow baggies found on roommate that contained the drugs. When resident got back to his feet and back to baseline, AOx4, he was able to hide drugs. Resident denied having them or turning them over even after staff witnessed him in possession of them. MD notified of overdose with new order to stop all passes, discontinue narcotic pain medications. Staff continuing to monitor resident closely. Will be referred to SSD/Social Services Director in AM. On 02/08/2022 at 12:32pm, V1 (administrator) stated, I am aware a resident, R11, overdosed inside the facility yesterday. I met with social services this morning to make sure things are put into place. I met with V7 (social worker) and V9 (social worker), our social services. The room search, behavioral contract and reassessment for community pass have not been done but we will do it. This resident is known to have problems with drug use. R11 has overdosed in the past, so we are aware that R11 has an issue with drug use. On 02/09/2022 at 10:54am V15 (LPN) stated, R11 has an order for [MEDICATION(S)] because R11 has overdosed in the past. I was the nurse for R11 on the night that R11 overdosed. I was working during the 3-11 shift on 02/07/2022. R11 was out on pass on 02/07/2022 and returned about an hour before R11 was found unresponsive. I did my rounds at 4:10pm and R11 was not back yet because he was out on pass. I'm really not sure how long R11 was back for before R11 overdosed. I don't remember what time R11 returned, but it's possible that R11 returned between 5 and 6 pm. I was getting ready to start passing my 7pm medication and I found R11 lying flat, face down on the floor in his room. I found R11 lying face down on the floor, around 7:30pm. I assessed R11 and R11 was sweaty, and the other CNAs helped me turn the resident over and that's when I administered [MEDICATION(S)]. I administered a total of 8 mg into each nostril. R11 received a total of 16mg of [MEDICATION(S)]. After I administered the [MEDICATION(S)], a CNA and myself were giving R11 chest rubs and R11 came out of it and became responsive. I called 911. The ambulance came and the resident refused to go with them to the hospital. So R11 refused hospitalization . The supervisor on duty stated that R11 has the right to refused going to the hospital. This is not the first time that R11 overdosed, so R11 had the order for [MEDICATION(S)] in place. R11 is not a resident that is safe to go out on pass because R11 has a drug use problem and R11 has overdosed in the past. On 02/09/2022 at 2:34pm, R11 stated, I was out on Monday, and I was drinking and then I passed out. I did use drugs on Monday, and I was drinking alcohol. I took cocaine. I used other drugs before, but I didn't like it. I used cocaine on Monday, and I passed out and they brought me back. I used to do a lot of drugs. I used cocaine couple times recently and I was drinking on Monday as well. They gave me a pass to go out and I was out on pass on Monday. I did overdose few months ago and they brought me back. On 02/09/2022 at 2:45pm, V14 (receptionist) stated, R11 left out of the facility at 10:30am on 02/07/2022. R11 signed R11 out at 10:30am but never signed back in so we don't know what time R11 actually returned. On 02/09/2022 at 3:35pm, V10 (social worker) stated, R11 overdosed on 02/07/2022 and they revoked his community pass privilege. R11 had his pass revoked in December 2021 because R11 overdosed on drugs. R11 had his pass reinstated after that just recently. The other social worker reinstated the community pass by the end of January. So R11 just had his pass reinstated. R11 did not have any behaviors recently, except drug use in November or December. We have to revoke resident's pass privilege for a specified amount of time. I did not reinstate R11's community pass privileges, that was the other social worker that used to work here. I know that R11 has a drug use problem, and I was not the one who reinstated R11's community pass. The nurse practitioner and the doctor also help to determine if the resident is safe to go out into the community. R11 has overdosed in the past and I was not the one who reinstated R11's community pass. I'm not sure why they allowed R11 to go back out into the community unsupervised. On 02/10/2022 at 11:11am, V25(NP) stated, I am the nurse practitioner for R11. R11 has a history of drug use, and R11 did overdose on 02/07/2022. R11 is usually a quiet resident and a stable resident. R11 did overdose. R11 does have a standing order for [MEDICATION(S)] which was ordered on 12/15/2022. R11 was prescribed [MEDICATION(S)] because it helps to bring the resident back when they overdose on drugs. [MEDICATION(S)] is generally prescribed to counter the effect of the opioid, it is used to save someone's life when they overdose on drugs. On 11/26/2022 R11 overdosed also. That's why the [MEDICATION(S)] was prescribed because this is not the first time that R11 overdosed. R11 is not safe to be out in the community not supervised. R11 will not be given permission to go out into the community unsupervised. R11 was not safe to be out in the community independently because R11 is a known drug used and R11 did overdose in the past, so R11 was not safe to be in the community. R11 was out on pass on 02/07/2022, but R11 was not supposed to be out on pass because of R11's drug and overdose history. I don't remember giving R11 a pass to go out into the community, because R11 is not safe to be out in the community unsupervised. I am not sure why R11 was out in the community, but I did not give R11 a pass because R11 is not safe given R11's drug history. If R11 was not on pass, this drug overdose which occurred on 02/07/2022 could have been avoided. On 02/18/2022 at 9:41am, V1 (administrator) stated, I don't know how R11 was able to get into the building, I have to check with the receptionist. When the resident is returning into the building, the receptionist must make sure that the resident is signing back in. R11 does not have a pass to go back out into the community. When the pass is reinstated for R11, R11 will be searched when returning into the facility, as well as room searches. We will be searching the residents who are returning into the facility from pass. The residents are aware now that when they go out on pass, they will be searched upon return to the facility. We will also monitor the visits in the facility, and we have to make sure that we report any suspicious activity. We will search the visitors if they are brining bags into the building to make sure that drugs are not being brought into the facility. Front Desk Sign Out Book documents that R11 went out on pass on 02/07/2022 at 10:30am. R11 signed self out. R11 failed to sign self-back in when returned to the facility on [DATE]. Social Service: Behavioral Contract signed by R11 on 1/29/2022. Behavior Contract explains the nature of resident's behavior that presents an infringement to the health, safety, welfare, and rights of other individuals. Social Service: Behavioral Contract signed by R11 on 02/08/2022. Behavior Contract explains the nature of resident's behavior that presents an infringement to the health, safety, welfare, and rights of other individuals. 2. According to social service interview on 02/15/2022 at 1:47pm, V7 (social service director) stated that the facility has a total of 56 residents with a known history or current use of illegal drugs. On 02/08/2022, surveyor informed V1 (administrator) that R8 identified R10 as the resident who sells the illegal street drugs inside the facility. V1 informed surveyor that V1 will inform two social workers, V7 and V9, and a search will be conducted with the assistance of the police department. On 02/08/2022 at 1:05pm, surveyor observed V4 (staffing coordinator) warning and informing the resident, R10, that the police is on the way and that the resident will be searched for possession of drugs. This incident was corroborated by video surveillance which captured the visual and audio evidence of V4 impeding on the investigation by informing R10 of the upcoming search. Employee Report (dated 02/08/2022) documents: V4 (staffing coordinator) was suspended due to providing information to a resident of an investigation, therefore, impeding on the investigation. On 02/09/2022 at 11:10am and 2:30pm, contraband policy was requested. Facility failed to provide contraband policy. On 02/09/2022 at 2:45pm, surveyor requested resident admission packet which provides notification for non-use or possession of illegal drug within the facility. Facility failed to provide resident admission packet. When asked if the facility allow a resident to have possession of illegal drug, the administrator responded, The residents are not allowed to use or possess illegal drugs or alcohol in the facility. Residents are made aware of this strict non-tolerance policy on admission into the facility. The surveyor confirmed through observations, interviews, and record reviews that the facility took the following actions to remove the Immediate Jeopardy: 1. On 02/16/2022, V1 (administrator) has educated V7 (social service director) on the room search policy which indicates that in the event that a resident gives the facility just cause for suspicion, the resident's room may be searched for unauthorized medication, weapons or illegal substances. 2. On 02/18/2022 the facility has completed an investigation launched to identify staff members potentially involved in aiding resident's usage of drugs or possession. A confidential questionnaire has been distributed to staff members to report any concerns or suspicions they may have in the facility. They have been advised to hand form only to the Administrator to maintain confidentiality. 3. On 02/18/2022V26 (Director of Nursing) started providing an in-service to all staff on the need to immediately report to Director of Nursing and Social Service Director any suspicious or suspected drug activity. Staff members will be contacted by phone if not scheduled to work to provide verbal education. If staff member is unattainable, the staff member who has not been educated will not be allowed to work in facility until education is completed. 4. On 02/18/2022, V7 (social service director) created a monitor list to identify residents who need supervised visits when visitors enter the facility. 5. On 02/18/2022, the receptionist has been in-serviced by V7 (social service director), to notify Social Service Director if a resident on the monitor list receives a visitor and requires supervised visits. 6. On 02/18/2022, V7 (Social Services Director) started to reassess all residents with history of substance abuse with the Community Skills Determination and complete updated Behavioral Contracts. Behavioral Contracts indicate that the resident will 'agree to a room search, if requested by the interdisciplinary team. 7. On 02/18/2022, V7 (Social Services Director) implemented complete room searches on all residents with history of substance abuse, as stated in the facility's Room Search Policy. 8. V4 (staffing coordinator), the staff member who was identified in impeding in the facility's drug investigation by forewarning R10, the resident who was identified as having possession of illegal substances in the facility, was suspended on 02/08/2022, for the dates 2/9, 2/10 and 2/11/2022 and permanently released from Chicago West on 2/17/2022. 9. On 02/18/2022, the facility implemented a procedure where the front desk receptionist will search all items insides bags being brought into the facility, if resident is suspected of potential substance abuse or dealing illegal drugs. their visits will be supervised by a staff member. 10. On 02/18/2022, the facility implemented a policy, if resident is suspected of potential substance abuse or dealing illegal drugs, their visits will be supervised by a staff member. If any illegal drugs are identified, V1 (administrator) will be notified immediately to handle situation and notify the police. 11. On 02/18/2022, a QA Tool was developed to ensure room searches are being completed 2x/weekly to identify any illegal drugs or drug paraphernalia. This will be completed on all residents with known substance abuse. 2x/week and will continue until QAPI has identified facility remains in continued compliance, no less than 90 days. The QA tool will be reviewed weekly by V1 (administrator), V26 (director of nursing) and V7 (director of social services).

Based upon record review and interview the facility failed to ensure that staff are aware of resident assignments, failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R1's not being monitored as ordered by physican and ([DATE]) death. Findings include; R1 was [AGE] years old. The ([DATE]) progress notes state R1's ([DATE]) Covid test result was positive. R1's ([DATE]) POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor vital signs (full vitals) every 4 hours for 14 days. Observe for evidence of deterioration. Call medical doctor/nurse practitioner as indicated. On [DATE] at 2:14pm, R10 (R1's roommate) stated on New Year's eve (2021) and New Year's day (2022) the Nurse said she was the only nurse on the floor, cause of the Covid a lot of nurses called off. Surveyor inquired about R1's status on or about [DATE] R10 responded I (R10) used to help him (R1) go out and smoke but when they (staff) moved him (R1) in the room ([DATE]) I didn't even recognize him (R1). When he (R1) talked you couldn't even hear him he (R1) talked so soft. His (R1's) face was grey, he looked like his skin sunk in like bones and everything. They should have sent him (R1) to the hospital. Every time he (R1) would call the Nurses they would come in, turn his light off and go away. He couldn't talk and tell em what he needed. The day before he died ([DATE]) she (Nurse) didn't even come in the room for vital signs or meds our door was closed all night. The next day I (R10) called the nurse, told her something was wrong with him and he was dead. R10's ([DATE]) BIMS (Brief Interview of Mental Status) determined a score of 15 (cognitively intact). R1's ([DATE]) Certificate of Death states death occurred in a nursing home. Cause of Death Novel Corona (Covid 19) [CONDITION(S)] Infection. Time of Death: 9:03am. The ([DATE]/[DATE]) MARS (Medication Administration Records) affirm that R1's vital signs were last documented on [DATE] at 3:00pm therefore on [DATE] (7:00pm & 11:00pm) and [DATE] (3:00am & 7:00am) vital signs were not documented. R1's vitals summary affirms no additional vital signs were documented on or about aforementioned dates as stated. [R2's Covid 19 monitoring evaluations for [DATE] and [DATE] were entered by V2 (DON/Director of Nursing) on [DATE], approximately a week after he expired]. R1's progress notes state; ([DATE]) 8:36am, Upon making morning rounds writer observed resident unresponsive, pupils dilated, no pulse palpated and no vital signs obtained. No response to verbal or tactile stimuli. CPR (Cardiopulmonary Resuscitation) initiated. 911 called. Paramedics in facility take over CPR. Resident still no vital signs at this time. Paramedics informed writer resident has expired. On [DATE] at 11:19am, surveyor inquired about R1's ([DATE]) 7am-3pm status V9 (Licensed Practical Nurse) stated Upon coming onto shift I was doing my rounds and I found him unresponsive. He was laying on his stomach, he was cold and his eyes was fixed. I checked for vital signs there were none so I called a code blue and initiated CPR (Cardiopulmonary Resuscitation). Surveyor inquired why R1's 7:00am vital signs were not obtained V9 responded I started at like 8:30 cause they was short a nurse so they asked me to come in. On [DATE] at 11:42am, surveyor inquired about the facility protocol for residents who acquired Covid 19. V2 (DON) stated, We put in orders for vital signs and the monitoring. Surveyor inquired where vital signs are documented V2 responded, They're documented on the MAR (Medication Administration Record) they're also documented in the monitoring tool for like a change in condition. It's under forms, Covid monitoring. Surveyor inquired about the required frequency for Covid monitoring V2 replied Everyone (re: Covid positive residents) should be having it (referring to the electronic Covid 19 monitoring evaluation) every shift. V2 subsequently accessed R1's electronic Covid 19 Monitoring Evaluations and affirmed that she (V2) entered the ([DATE], [DATE], [DATE]) 7am-3pm assessments however additional assessments (for other shifts) were not documented. Upon further inspection all aforementioned assessments were entered on [DATE] ( a week later). On [DATE] at 10:02am, surveyor inquired about R1's ([DATE]) status on the 11pm-7am shift V13 (Registered Nurse) stated I was assigned to rooms ,d+[DATE] he (R1) was assigned to someone else. Surveyor inquired which nurse R1 was assigned to V13 responded I don't remember. R1 resided on the 2nd floor. On [DATE] at 10:16am, V2 presented the 2nd floor ([DATE]) 11pm-7am daily assignment sheet (as requested) which states V13 was assigned to rooms ,d+[DATE]. Surveyor inquired if V13 was assigned to the entire 2nd floor on [DATE] (11pm-7am) V2 stated Yes. Surveyor advised that V13 stated he was not assigned to R1 on [DATE], therefore R1's assessments were not documented on or about said date/time, and R1's vital signs were not documented for 16 hours (prior to his death) which were supposed to be monitored every 4 hours. V2 responded I know he told you that but he was the nurse assigned for that night. On [DATE] at 3:00pm, surveyor inquired about potential harm to a Covid 19 positive resident if not monitored for change in condition and/or vital signs are not obtained as ordered. V14 (Medical Director) responded, If the vital signs are all stable and the condition is the same than not reporting to the Physician wouldn't cause any harm but not reporting to the Physician that the condition is different or the vital signs have changed than the implications may be different depending on the circumstance. Change in condition can be anything it would depend on what the vitals was. Not having vitals is not good, we should have the vitals to make sure they are stable. We can only assess the viability if they (vital signs) are stable. The coronavirus 2019 policy (revised [DATE]) states if patients have been screened and their testing is positive for Covid 19: cohort with another symptomatic/positive patient. Vitals (temperature, heart rate, respirations) and pulse oximetry every 4 hours. Blood pressure every 8 hours. The change in resident's condition (reviewed ,d+[DATE]) 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. The coronavirus 2019 policy (revised [DATE]) states if patients have been screened and their testing is positive for Covid 19: cohort with another symptomatic/positive patient. Vitals (temperature, heart rate, respirations) and pulse oximetry every 4 hours. Blood pressure every 8 hours.

1. Based upon observation, interview and record review the facility failed to follow and maintain infection prevention and control by providing a safe and sanitary environment to prevent the spread of infecion specifically Covid-19. These failures resulted in a Covid 19 outbreak throughout the facility on or about [DATE] which affected 166 residents and 51 staff that tested positive for Covid 19, and resulted in R3 who was Covid negative being cohorted with a known Covid positive and R3 becoming Covid positive. Findings include; The ([DATE]) census includes 187 residents. The census affirms that R3 has resided in current room since [DATE]. R4 was moved to R3's room on [DATE] [2 days after confirmed Covid 19 infection]. The Covid 19 resident tracking affirms R3 sustained covid acquired in facility date of symptom onset [DATE] [4 days after aforementioned room change]. R3's ([DATE]) POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . If positive call MD (Medical Doctor/NP (Nurse Practitioner). Monitor vital signs (full vitals) every 4 hours for 14 days. Observe for evidence of deterioration. Call MD/NP as indicated. R3's vitals summary affirms vital signs were obtained on [DATE] at 3:24pm however they were not documented on [DATE] (7pm and 11pm) and on [DATE] (3am, 7am, and 11am) as ordered therefore roughly 23 hours transpired without an assessment. R3's ([DATE]) 2:08pm progress notes state upon entering the room resident observed wheezing stating I can't breathe. Writer applied oxygen 2 liters per nasal cannula, saturation 87%. Nurse Practitioner called gave order to send resident out 911. Resident admitted for [CONDITION(S)] related to Covid positive and [MEDICATION(S)] [CONDITION(S)] (R3's pulse was 52 at 2pm per vitals summary). On [DATE] at approximately 1:00pm, surveyor inquired if any residents in the facility are Covid positive V1 (Administrator) affirmed there was a recent Covid outbreak that affected 2nd, 3rd and 4th floor residents which are currently positive. Surveyor inquired about the required PPE (Personal Protective Equipment) for staff V1 stated N95 and the face shields. Full PPE; gloves, gown and N95 if we go into the rooms. On [DATE] at 2:01pm, V5 (CNA/Certified Nursing Assistant) was observed in the 4th floor hallway wearing 2 surgical masks. Surveyor inquired why an N95 mask was not in use V5 stated I sometimes feel like I can't breathe with that one on so I just put 2 masks on. Surveyor inquired if V5 was mask fit tested V5 responded I didn't get fitted yet. I missed my day to get it fit so I guess they'll do em again. The ([DATE]) log of current Covid positive residents includes rooms [ROOM NUMBERS] however there were no contact/droplet precaution signs posted on and/or near either door. Surveyor inquired if the residents in room [ROOM NUMBER] and/or 430 were Covid positive V5 responded No, nobody told me they was isolation. On [DATE] at 2:07pm, V6 (CNA) was observed in the 4th floor hallway wearing 2 surgical masks. Surveyor inquired which masks she (V6) was wearing V6 stated The regular mask. Surveyor inquired which mask she (V6) was required to wear due to Covid outbreak throughout the facility V6 responded I know we supposed to have the N95. I can't breathe with it on. I have 2 of the other one (referring to the surgical mask) though. V6 then proceeded to open the (closed) double doors and entered the quarantined area without an N95 mask on. On [DATE] at 2:10pm, R7 was observed ambulating throughout the 4th floor hallway without wearing a mask. Surveyor inquired why R7 was in the hallway without a mask on V5 stated He just walked outta his room and he ain't gonna put it on anyway. When somebody ask him, he say no and provided no redirection and/or mask to R7. R8 subsequently exited the elevator with V7 (LPN/Licensed Practical Nurse) however R8's mask was on her chin. Surveyor inquired about the location of R8's mask V7 stated We encourage them (residents) as much as possible to keep em on and provided no redirection to R8. R9 was subsequently observed in the hallway without wearing a mask. Surveyor inquired why R9 was in the hallway without a mask on V8 (LPN) stated She's had one on 4 times. She keeps taking it off, that's what she does and provided no redirection and/or mask to R9. On [DATE] at 2:26pm, 3 residents were observed in the 4th floor dining room not wearing masks. Surveyor inquired about infection control concerns with the residents currently in the dining room V4 (Infection Control Nurse) stated They're not masked. Surveyor inquired about required PPE for residents while not in their rooms V4 responded They need to keep their mask on but nobody up here is going to keep their mask on. Surveyor inquired why none of the 3 residents (currently in the dining room) have a mask available V4 replied We constantly offer them masks however masks were not provided to said residents at this time. On [DATE] at 2:28pm, surveyor inquired if anyone posted contact/droplet precaution signs on and/or near the door of rooms [ROOM NUMBERS] (as warranted) V4 inspected both rooms and stated No, we did not. On [DATE] at 2:30pm, a Doffing Station sign was observed on the (4th floor hallway) wall with 2 red bins below it however the designated area was (outside) the closed double doors (quarantined area). Surveyor inquired where staff are required to doff PPE V4 stated We enter one way and exit the other (referring to the quarantined area), they are supposed to be doing it here in the soiled utility room. Surveyor inquired about the location of the doffing station and red bins V4 responded They're supposed to be back there (referring to the soiled utility room) however the soiled utility room was also located outside the quarantined area. On [DATE] at 2:33pm, a sign stating Please practice social distancing, maintain 6 feet from others was posted (outside the elevator) however V4 entered the elevator with 2 people already in it and stood approximately 2 feet away from them. Surveyor inquired how many people are allowed in the elevator if maintaining 6 feet social distancing V4 stated It's 3 people that's allowed for the building. On [DATE] at 2:36pm, surveyor inquired where (3rd floor) staff doff PPE V10 (LPN) stated You go in (referring to the quarantined area) with your PPE on and there's a doffing over there (referring to the hallway outside the plastic sheets/quarantined area). Surveyor inquired about infection control concerns with the location of the 3rd floor doffing station V10 replied It's in the hallway and affirmed it was outside the quarantined area. On [DATE] at 2:44pm, surveyor inquired about the location of (2nd floor) Covid positive residents V9 stated I believe it's certain rooms in the back and front units and affirmed there was no specific quarantined area on 2nd floor due to recent outbreak. [The [DATE] log of current Covid positive residents includes twelve 2nd floor rooms throughout the unit]. Surveyor inquired where (2nd floor) staff doff PPE V9 responded The doffing station is over there (referring to 2 red bins located in the hallway near room [ROOM NUMBER]). Surveyor inquired about infection control concerns with the location of the 2nd floor doffing station V9 replied We're coming outside in the hall however the contact precaution signs posted on quarantined residents doors state Discard gown before room exit. R4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's ([DATE]) care plan states resident has confirmed Covid 19 infection, intervention: Place in private room or cohort with resident with same symptoms/Covid 19 confirmation. The census affirms that R3 has resided in current room since [DATE]. R4 was moved to R3's room on [DATE] [2 days after confirmed Covid 19 infection]. R4's ([DATE]) care plan states resident has confirmed Covid 19 infection, intervention: follow policy & procedure for contact and droplet precautions. Place in private room or cohort with resident with same symptoms/Covid 19 confirmation however he was placed in R3's room. The census affirms that R3 has resided in current room since [DATE]. R4 was moved to R3's room on [DATE] [2 days after confirmed Covid 19 infection]. The Covid 19 resident tracking affirms R3 sustained covid acquired in facility date of symptom onset [DATE] [4 days after aforementioned room change]. On [DATE] at 2:51pm, contact/droplet precaution signs were posted on R4's door however the door was wide open. On [DATE] at 3:00pm, contact/droplet precaution signs were posted on R5's door however the door was wide open. On [DATE] at 3:12pm, a sign posted (inside the elevator) stated attention use of the elevator is limited to 3 people however there were 4 people observed inside the elevator. Surveyor inquired how many people are allowed on the elevator V11 (CNA) stated 3. On [DATE] at 2:00pm, V1 (Administrator) presented the facility elevator measurements; length: 7 feet, width: 5 feet 6 inches, diagonal: 8 feet 9 inches. Surveyor inquired if 3 people are allowed in the elevators V1 stated Right now were allowing 2 diagonally in the elevator. On [DATE] at 12:50pm, surveyor inquired if Covid positive residents room doors are supposed to be open or closed V4 (Infection Control Nurse) stated closed. Surveyor inquired when the Covid outbreak started V4 responded The 1st case we got was [DATE] (2021). Surveyor inquired how many people tested positive for Covid 19 V4 replied Almost everyone 166 residents and 51 staff. On [DATE] at 12:56pm V4 stated, R3 (he) came back yesterday (from the hospital). There was an incident initially ([DATE]) when we were trying to move (R3) because he wasn't covid positive his roommate was. He (R3) declined movement, said no that was his room, and didn't want to move. I (V4) have to look back over the notes because I got like 56 (covid +) residents at one time (,d+[DATE]). The next day 42. Almost everyone 166 residents and 51 staff. We have like 4 people (staff) out (off) still. (R3) became positive I think on the 4th (from [DATE] test). He requested a rapid and it came back negative. R4 was positive [DATE]. R3 it was collected on [DATE] we got results [DATE]. Surveyor asked why was R4's room not changed? V4 stated, because the whole 2nd floor became the covid unit, that's where most cases were. On [DATE] at 1:41pm surveyor inquired about R3's room assignment V12 (Social Service) stated He's been in that room since basically when he was admitted . Surveyor inquired why R4 was placed in (R3's room) on [DATE]. V12 responded He (R4) was likely positive for Covid 19 that's why he was likely moved. Surveyor inquired why R4 (who was Covid positive) was placed in R3's room V12 replied I believe he (R3) was positive too. Surveyor inquired who was responsible for making room assignments V12 stated We (staff) all worked as a team we put people who were positive together and tried to take people that were negative and put them together. I did talk to some of the residents who refused rooms but we did talk to them educated them about the importance of moving rooms because of the protocols. Surveyor inquired if it was appropriate for R4 to be placed in R3's room on [DATE] knowing that he (R4) was positive for Covid and R3 was asymptomatic V12 replied We can't make them move, it's their right. Surveyor inquired about resident safety V12 replied Safety is important but rights supersede safety. On [DATE] at 2:57pm, surveyor inquired about potential harm if a Covid 19 positive resident is placed in a room with an asymptomatic resident V14 (Medical Director) stated The asymptomatic patient would have the potential risk for exposure and may contract the infection. The coronavirus 2019 policy (revised [DATE]) states facility is focused on containing the spread and mitigating the impact of Coronavirus. Covid 19 is spread from person to person by respiratory droplets between people who are in close contact with one another (about 6 feet). Outbreak definition of Covid 19 (one lab confirmed case of Covid 19). Procedure: while at work, the employee must don a facemask. All employees must wear a mask during their shift to protect residents [N95 is not inclusive]. Facility will follow its policies and procedures developed related to Coronavirus 2019 prevention and management based on State Health Department and or CDC (Centers for Disease Control) Interim guidance. 2. Based upon record review and interview the facility failed to follow policy & procedures, failed to ensure that assessments were documented accurately, failed to ensure that (R4's) physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include; On [DATE] and [DATE], IDPH (Illinois Department of Public Health) received allegations that Covid 19 positive residents were placed in rooms with Covid 19 negative residents. The following was identified; R4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's ([DATE]) care plan states resident has confirmed Covid 19 infection, intervention: Place in private room or cohort with resident with same symptoms/Covid 19 confirmation. The census affirms that R3 has resided in current room since [DATE]. R4 was moved to R3's room on [DATE] [2 days after confirmed Covid 19 infection]. The Covid 19 resident tracking affirms R3 sustained covid acquired in facility date of symptom onset [DATE] [4 days after aforementioned room change]. On [DATE] at 1:41pm surveyor inquired about R3's room assignment V12 (Social Service) stated He's been in that room since basically when he was admitted . Surveyor inquired why R4 was placed in (R3's room) on [DATE]. V12 responded He (R4) was likely positive for Covid 19 that's why he was likely moved. Surveyor inquired why R4 (who was Covid positive) was placed in R3's room V12 replied I believe he (R3) was positive too. Surveyor inquired who was responsible for making room assignments V12 stated We (staff) all worked as a team we put people who were positive together and tried to take people that were negative and put them together. I did talk to some of the residents who refused rooms but we did talk to them educated them about the importance of moving rooms because of the protocols. Surveyor inquired if it was appropriate for R4 to be placed in R3's room on [DATE] knowing that he (R4) was positive for Covid and R3 was asymptomatic V12 replied We can't make them move, it's their right. Surveyor inquired about resident safety V12 replied Safety is important but rights supersede safety. On [DATE] at 2:57pm, surveyor inquired about potential harm if a Covid 19 positive resident is placed in a room with an asymptomatic resident V14 (Medical Director) stated The asymptomatic patient would have the potential risk for exposure and may contract the infection. R3's ([DATE]) POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . If positive call MD (Medical Doctor/NP (Nurse Practitioner). Monitor vital signs (full vitals) every 4 hours for 14 days. Observe for evidence of deterioration. Call MD/NP as indicated. R3's vitals summary affirms vital signs were obtained on [DATE] at 3:24pm however they were not documented on [DATE] (7pm and 11pm) and on [DATE] (3am, 7am, and 11am) as ordered therefore roughly 23 hours transpired without an assessment. R3's ([DATE]) 2:08pm progress notes state upon entering the room resident observed wheezing stating I can't breathe. Writer applied oxygen 2 liters per nasal cannula, saturation 87%. Nurse Practitioner called gave order to send resident out 911. Resident admitted for [CONDITION(S)] related to Covid positive and [MEDICATION(S)] [CONDITION(S)] (R3's pulse was 52 at 2pm per vitals summary). R1's progress notes state ([DATE]) Covid test result was positive. R1's ([DATE]) POS states monitor patient with Covid 19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor vital signs (full vitals) every 4 hours for 14 days. Observe for evidence of deterioration. Call medical doctor/nurse practitioner as indicated. The ([DATE]/[DATE]) MARS (Medication Administration Records) affirm that R1's vital signs were last documented on [DATE] at 3:00pm therefore on [DATE] (7:00pm & 11:00pm) and [DATE] (3:00am & 7:00am) vital signs were not documented. R1's vitals summary affirms no additional vital signs were documented. On [DATE] at 11:42am, surveyor inquired about the facility protocol for residents who acquired Covid 19 V2 (DON/Director of Nursing) stated We put in orders for vital signs and the monitoring. Surveyor inquired where vital signs are documented V2 responded They're documented on the MAR (Medication Administration Record) they're also documented in the monitoring tool for like a change in condition. It's under forms, Covid monitoring. Surveyor inquired about the required frequency for Covid monitoring V2 replied Everyone (re: Covid positive residents) should be having it (referring to the electronic Covid 19 monitoring evaluation) every shift. Surveyor requested R1, R3, R4, R5 and R6's Covid 19 monitoring evaluations however nothing was received for R4, R5, and/or R6. R1's ([DATE], [DATE] and [DATE]) evaluations were entered by V2 on [DATE] (a week later) additional entries (for evening and night shifts) were not documented. R3's ([DATE] and [DATE]) Covid 19 monitoring evaluations were entered by V2 on [DATE] (days later) additional entries for night shift were not documented. On [DATE] at 10:52am, V2 affirmed that there were no Covid 19 monitoring evaluations documented for R4, R5 and R6 (prior to inquiry). Surveyor relayed concerns with the assessments V2 documented roughly a week after (R1) expired. V2 replied I know I made a mistake and entered something in there. The Covid 19 tracking log affirms R4 sustained facility acquired Covid 19 on [DATE]. R4's ([DATE]) POS states monitor vital signs (full vitals) every 4 hours for evidence of deterioration for 14 days (end date [DATE]). R4's ([DATE]) MAR was reviewed however every 4 hour vital sign orders were not inclusive. R4's ([DATE]-[DATE]) vital signs summary affirms vital signs were not documented. The Covid 19 tracking log affirms R5 sustained facility acquired Covid 19 on [DATE]. R5's ([DATE]) POS states monitor vital signs (full vitals) every 4 hours. Observe for evidence of deterioration (end date [DATE]). R5's ([DATE]-[DATE]) vital sign documentation includes one (1) entry on [DATE] for pulse, respiration and temperature [blood pressure and oxygen saturation is not inclusive]. No additional entries were documented. The Covid 19 resident tracking log affirms R6 sustained facility acquired Covid 19 on [DATE]. R6's ([DATE]) POS states monitor vital signs (full vitals) every 4 hours. Observe for deterioration (end date [DATE]). R6's ([DATE]-[DATE]) vital sign documentation includes one (1) entry on [DATE] for blood pressure, pulse, respiration and temperature [oxygen saturation is not inclusive]. No additional entries were documented. On [DATE] at 12:54pm, surveyor inquired why R6's vital signs were not documented every 4 hours as ordered. V4 (Infection Control Nurse) stated I was just looking back to see what happened because the orders are definitely there. The coronavirus 2019 policy (revised [DATE]) states if patients have been screened and their testing is positive for Covid 19: cohort with another symptomatic/positive patient. Vitals (temperature, heart rate, respirations) and pulse oximetry every 4 hours. Blood pressure every 8 hours. The change in resident's condition (reviewed ,d+[DATE]) 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 on observation, interview and record review, the facility failed to provide sufficient nursing staff and failed to follow their medication policy to ensure residents received essential medications to treat their medical conditions as ordered by their physician. There was no nurse to pass medications on one portion of a resident hallway and as a result, 26 residents (R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32) did not receive their scheduled medications on 5/15/2021 and 5/16/2021 on the day shift (7:00 AM - 3:00 PM). These failures had the potential to cause negative medical outcomes for all 26 residents. These failures resulted in an Immediate Jeopardy. On 6/9/2021 at 10:30 AM, V1 (Administrator), V2 (DON), V6 (Nurse Consultant) were notified of the Immediate Jeopardy. The Immediate Jeopardy was noted to start on 05/15/2021. The surveyors confirmed by observation, interview and record review, that the immediacy was removed on 6/15/2021. However, the facility remains out of compliance at a Level 2 because additional time is needed to evaluate implementation and effectiveness of their plan. Findings include: During interview on 5/20/21 at 2:51 PM, R7 stated the weekend was bad. R7 stated I did not get my morning medication at all this weekend. No one got their medication on this end of the hall. There was only one nurse and I asked her if she could give me my medication and she said no. R7 stated I don't feel good about not getting my medication. It makes me angry. After speaking with R7, surveyor immediately went down stairs to conference room and reviewed the electronic medication administration records for R7 and other resident's on the same end of the third floor and obtained time stamped copies. All of the resident's electronic medication administration records reviewed were missing medications on Saturday 5/15/2021 and Sunday 5/16/2021 (the spaces were blank). Surveyor requested from V1, Administrator the electronic Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 5/20/21 at 4:35 PM, with V1, V7, DON (Director of Nursing) and V4 (House Supervisor), V7 stated she was getting the information requested and before she gives information she looks at it. V7 stated that she noticed that medication was missing for all the residents on half the floor for the weekend. V7 stated she spoke to V8, LPN (Licensed Practical Nurse) about not passing the medications. V7 stated that V8 told her she did not give any medication to the other half of the floor. V7, V1, and V4 all stated that they were unaware that the residents on the 3rd floor did not receive their medication until just now when they spoke with V8. V7 stated that they just learned that no one passed medications to the other half of the 3rd floor on Saturday and Sunday. On 5/20/21 at 4:55 PM, V8 stated that there wasn't a nurse scheduled for the other half of the 3rd floor on the weekend. I was the only nurse on the schedule. I was the only nurse on the 3rd floor morning shift. I just heard today when I was called down to see the DON that if there is no other nurse on the floor that I am responsible for passing medication to everyone on the floor. I only passed medications for rooms 301 - 314. V8 stated, I did not tell anyone that medications had not been passed or that I was the only nurse on the floor because they knew I was the only nurse on the schedule. I know that for 2 days no one received their medications on the other side of the third floor because I worked both days. On 5/20/21 at 5:15 PM, V6 (Staffing Coordinator) stated that on the 3rd floor there was only one nurse for Saturday and Sunday 5/15 and 5/16 and no other nurses or supervisors helped out on that floor those days. Surveyor requested staffing record for 5/15/2021 and 5/16/2021 and only one nurse (V8) was scheduled to work on the 3rd floor. On 5/21/21 at 9:56 AM, R23 stated there was no nurse on the weekend day shift. I don't get my medication every day. I didn't feel good on the weekend. I felt sick because I need my insulin. I should get insulin three times a day at breakfast, lunch and dinner. I told the nurse on the other side that I needed my medication and she said I had to wait for my nurse to get here. I take medication for seizures. On 5/21/2021 at 11:40 AM, V13 (Primary Care Physician for R23) stated that [MEDICATION(S)] (to prevent blood clots) and [MEDICATION(S)] (to treat seizures) are significant medications. [MEDICATION(S)] and [MEDICATION(S)] are the most important medications. It is not good if a resident missed those medications because it could reduce the therapeutic level. Resident is at risk for compromised patient care if medications were missed. The facility Medication Administration policy documents the following: General: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. An In-service, Education, and Staff Development Attendance Record dated 4/26/2021 documents: Topic: Sufficient Nursing Staff; Summary of Contents: RN/LPN's are running behind with administering medications, the RN/LPN will contact house supervisor/VM/Nursing Supervisor to assist with medication pass. On 6/3/21 at 12:43 PM, R7 stated, I don't feel good when I don't get my medication. I feel physically off. My blood pressures was 179. I get [MEDICATION(S)] for my liver in the morning and in the evening. When I don't get my morning medication by 10:00 AM or 11:00 AM that is not acceptable. 6/3/2021 at 1:06 PM, R28 stated that he has not been getting his medications. R28 stated I have a [CONDITION(S)]. I am not getting my pain pills 3 times per day. I'm getting it twice a-day. When they miss my morning medication I'm in a lot of pain. They ask me if pain is 1-10, but when I do not get my pain medication my right hip hurts and the pain is more than a 10. 6/3/2021 1:20 PM, R35 stated we are always missing medications. R35 stated I have a heart condition and when I don't get my water pill 2 times a day I feel short of breath. I am really short of breath when I walk around, because the fluids build up. I have told V1 (Administrator) and the old DON numerous times that we are not getting our medication. When you complain about not getting your medication most of the staff are mean and curse you out. They talk to us like we are in-humane. They say they will get to you when they can. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An Employee Education and Employee Report documents V8's acknowledgment that she failed to administer medication to the residents on an entire section of the 3rd floor. Staffing schedules were reviewed for 5/15/21 and 5/16/21, surveyor verified that on the 3rd floor unit only one nurse was working but there should be two nurses working on all units/floors. Current face sheet documents the following: 27 residents (R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29 R30, R31, R32, R35 [Interviewed on 6/3/2021] have the following medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R7- essential hypertension ([CONDITION(S)]), Metabolic [CONDITION(S)], Liver [CONDITION(S)], right and left knee pain. Missed medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . R8- Essential hypertension, [CONDITION(S)], unspecified convulsions, [CONDITION(S)], seizures. Missed medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . R9 - Essential Hypertension, Gout. Missed medication(s): [MEDICATION(S)] R10 - Essential Hypertension, Chest pain, Dyspnea. Missed medication(s): [MEDICATION(S)] R11 - [CONDITION(S)] of left lower limb, essential hypertension, diabetes. Missed medication(s): [MEDICATION(S)] Monitrate, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)]. R12 - Essential Hypertension, Amnestic Disorder. Missed medication(s): [MEDICATION(S)], [MEDICATION(S)] R13- Pain left hip, Essential hypertension, [CONDITION(S)]. Missed medication(s): [MEDICATION(S)], [MEDICATION(S)] HCTZ R14 - Chronic Obstructive Pulmonary Disease ([CONDITION(S)]), Heart failure, [CONDITION(S)]. Missed medication(s): [MEDICATION(S)], [MEDICATION(S)] R15 - History of venous [CONDITION(S)] and embolism, Pulmonary embolism, [CONDITION(S)], Peripheral vascular disease (PVD). Missed medication(s): [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] R16 - Seizures, [CONDITION(S)]. Missed medication(s): [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] R17 - [CONDITION(S)], Cerebral Infarction (CVA) Missed medication(s): [MEDICATION(S)], Losartan, [MEDICATION(S)] R18 - [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)]; Missed medication(s): [MEDICATION(S)]-[MEDICATION(S)], [MEDICATION(S)] R19 - [CONDITION(S)], Cerebral atherosclerosis, PVD, Anxiety disorder, Delusional disorder; Missed medication(s): Clopidogril Bisulfate, [MEDICATION(S)] R20 - [CONDITION(S)], Glaucoma; Missed medication(s): [MEDICATION(S)], HCTZ R21 - Diabetes, CVA, [CONDITION(S)], [CONDITION(S)], Pain in leg; Missed medication(s): [MEDICATION(S)], [MEDICATION(S)], Aspirin, [MEDICATION(S)], [MEDICATION(S)] diskus, [MEDICATION(S)], [MEDICATION(S)] tartate R22 - [CONDITION(S)], [CONDITION(S)], Congestive Heart Failure (CHF) , [CONDITION(S)], Asthma, Diabetes, [CONDITION(S)]. Missed medications: [MEDICAL RECORD OR PHYSICIAN ORDER] R23 - [CONDITION(S)], Diabetes, [CONDITION(S)], Deep Vein [CONDITION(S)] (DVT) of right lower extremity Missed medications: [MEDICAL RECORD OR PHYSICIAN ORDER] R24- [CONDITION(S)], [CONDITION(S)]; Missed medication(s): [MEDICATION(S)] [MEDICATION(S)] Aerosol, Carvedolol R25 - [CONDITION(S)] Flutter, Diabetes, [CONDITION(S)]; Missed medication(s): [MEDICATION(S)], [MEDICATION(S)], HCTZ, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] R26 - [CONDITION(S)], [CONDITION(S)], Venous [CONDITION(S)] and embolism, [CONDITION(S)], pain in back, right and left hip; Missed medication(s): Losartan/HCTZ, Potassium, Diclofinac R27 - PVD, [CONDITION(S)], [CONDITION(S)]; Missed medication(s): [MEDICATION(S)], HCTZ, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] R28 - [CONDITION(S)] of hip, PVD, Pain right hip, [CONDITION(S)], CHF. Missed medications: [MEDICAL RECORD OR PHYSICIAN ORDER] R29 - [CONDITION(S)] of hip, PVD; Missed medication(s): Nifediac, [MEDICATION(S)], [MEDICATION(S)] R30 - Unspecified convulsion, Venous [CONDITION(S)] and Embolism, [CONDITION(S)] Missed medication(s): [MEDICATION(S)], Levetracetam, [MEDICATION(S)] R31- Low back pain, [CONDITION(S)], Malignant Neoplasm of the bone; Missed medication(s): [MEDICATION(S)], [MEDICATION(S)] R32 - Chronic [CONDITION(S)], [CONDITION(S)], asthma; Missed medication(s): [MEDICATION(S)] aerosol The Facility document Resident-Centered Medication Administration Policy dated 5/2021 documents: Purpose: To provide each patient with an evidence-based, person-centered care approach across the entire medication use process in the facility. To help accomplish this goal, the facility will use a liberalized block-style medication administration schedule, when appropriate, for each patient. Definitions: Time-Critical Scheduled Medication, as defined by Institute of Safe Medication Practice (ISMP), is a medication where early or delayed administration of maintenance doses of greater than 30 minutes before or after the scheduled dose may cause harm or result in substantial sub-optimal therapy or pharmacological effect. On 6/8/2021 at 12:32 PM, V3 (Medical Director) stated they have Quality Assurance Performance Improvement (QAPI) meeting monthly and he attends. V3 stated, in regards to medication administration in the meeting 2 weeks ago, there was a concern that one staff member did not give medication to half of the unit. V3 stated this was the first time he has heard of anything like this happening and that In the March and April meetings they discussed medication administration but there were no major concerns. Surveyor asked if V3 has heard of any other occasions of residents not receiving medication or not receiving their medication in a timely manner. V3 stated he has not heard that any residents outside of the regular 1 or 2 a month that call, were not getting medications or not getting them in a timely manner. V3 stated he does not remember the plan discussed in the meeting to address this issue, but V1 (Administrator) and the new DON (V2) are handling it. V3 stated he has not heard of any of the previous tags in regards to this. V3 stated, in regards to medication pass, I do not see a pattern. On 6/8/2021 at 1:30 PM -1:55 PM, V2 (DON) stated she has been working at the facility since 5/17/21. V2 stated she did not know the severity and level of tags when she arrived. I knew facility had annual and complaint. I didn't get around to seeing what was what until around Wednesday or Thursday. I started working on staffing and medication pass issues. The facility was working on building the staff, which they had been working on for a while, and making sure medications were being passed to residents as ordered. The facility has gotten some new staff. Our focus and management team focus is to make sure that medications are being passed. I took on the responsibility to get more staff and make sure medication is being passed in a timely manner. There has been a big improvement in medication pass and staffing. The previous DON wasn't doing what she should have. She had no checks and balances. V2 further stated, we had QAPI (Quality Assurance and Performance Improvement) meeting the week after I got here. Everyone who should have been there was there including administrator and medical director. To address the issues we have done in-services: we had 2 hours to get medications pass completed and nurses were running late. We have now transitioned to a liberalized medication pass and block charting that started about 10 days ago. I had to get orders from the medical director and individual doctors to tell them we were switching to block charting and asked if it was okay with them. V2 stated all the nurses like the new charting. I have gotten positive feedback. Nurses have told me that it gives them time to assess their patients, and provide care because now they are not rushed by the medication time. We have managers on floor to assist. Surveyor asks what they are doing on the weekends for staffing. V2 stated nurse manager on duty is coming in, manager on duty that is non-clinical, and I am on call I've been here the last 2 weekends. We are still using same staffing grid. Nursing is not calling off too much. Staffing is doing much better. On 6/8/2021 at 1:55 PM, R37 stated he is the vice president of resident council meeting. R37 stated the facility has not been having resident council meetings because of COVID-19. R37 stated that residents have complained that medications are not on time. Residents have said that they have not gotten their medications. People want medications right away as soon as they are due. On 6/8/2021 2:00 PM, V1 stated that once she got back from leave, in order to address medication pass issue, the facility had to get a new DON. The previous DON probably needed to get more DON training. We brought back nurses and CNA's who didn't want to work with previous DON. We started in April 2021 a temporary program. V1 stated QAPI is always the last Wednesday of the month at 11:00 AM in person (not a zoom) 5/26/21. We had April one on 4/28/21. V1 stated she scans everyone's reports and put them on the screen during the QAPI meeting. Surveyor asked when did QAPI team discuss the tags on medication administrations? V1 stated I will get back to you. I'm not sure if it was in the April meeting because of the date we received the 2567. V1 stated the QAPI meeting on 5/26/21 was attended by DON, Medical records, Medical Director, Pharmacy representative, [CONDITION(S)] tries to come, Administrator, Human Resources, Admissions, V4 LPN (House Supervisor). We have a Quality Assurance (QA) audit tool to check if residents are getting medication at scheduled time. Review of Resident council minutes documents that for March and April of 2021 V5 (Ombudsmen) was on site. On 6/11/21 at 10:30 AM, V5 (Ombudsman) stated there has been chronic confirmed complaints all year of lack of staffing and residents not getting their medications especially on the weekends and night shift. There has been a massive turnover of staff. V5 stated he is in the facility 3-4 times a week. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy on 6/15/21. 1. Nurses have been educated on notifying the Nurse Manager when they are running late with medication administration so Nurse Manager can provide support ensuring medications are administered as ordered by Health Care Provider. DON will be responsible. 2. Nurses have been educated on the expectation any medications that is scheduled at a specific time will be passed as ordered or within 60 minutes before or after the scheduled administration time by Health Care Provider and the Health Care Provider will be notified of late administration. Nurses on vacation or on leave of absence will be educated prior to returning to work. These would include orders from Health care Providers specifying a specific time for a medication to be given (ie: insulins, IV's [intravenous], anticoagulants, etc). 3. Facility has changed medication pass from standard timed pass to a Resident-Centered Medication Pass. Health Care Providers have been notified and orders received. Any medications that are ordered at specific times (ie: insulins, IV's, anticoagulants, etc) will be considered a timed medication pass and not fall under the Resident Centered Medication Pass. Health care providers have provided orders for Resident-Centered Medication Pass for Residents R7, R8, R9, R10, R11, R12, R13, R14, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, and R35. R15 has discharged to the community. 4. Nurses have been educated on the Resident-Centered Medication Pass, also known as Liberated Medication pass. 5. Nurse Practitioner have reviewed the affected Residents and documented adverse/no adverse reactions due to not receiving medications as prescribed by health care provider. Given the date of the occurrences, NP's have since seen and/or reviewed their Residents to ensure if there were any adverse reactions. This was completed on 6/9/2021. 6. Staffing is reviewed daily after morning meeting for the next day by Administrator and DON with Staffing Coordinator to ensure adequate nursing staff to pass medications. Staffing schedule is provided by Staffing Coordinator by end of day for next day. Any concerns are addressed throughout the day to ensure staffing is at minimum requirements. Currently staffing a minimum of 2 nurses per floor per shift. In addition, there are Unit Nurse Managers to assist as needed to ensure medications passed as ordered by Health Care Providers. 7. Random Medication Audits are completed daily to ensure medication pass is completed and passed as ordered by Health Care Providers. In addition, A Medication Administration Audit is completed from the previous day to ensure there were no missed or late administrations. If there are any missed or late administrations, the Nurse responsible will be addressed with education and/or disciplinary action. The Health Care Provider will be notified. This process is completed daily and will continue until QAPI has identified that the facility remains in substantial compliance, no less than 90 days. This is the responsibility of the DON. 8. A QA Tool was developed to ensure medication administration was being completed as ordered by Health Care Provider. This continues to be completed 3x/week and will continue until QAPI has identified facility remains in continued compliance, no less than 90 days. This is the responsibility of the DON. 9. The QA Tool will be reviewed by the DON and Medical Director weekly. 10. The Administrator and DON will continue to monitor staffing to ensure appropriate nursing staff onsite to pass medications as ordered by Health Care Provider. 11. The QA Tool has been presented to QAPI and continues to be reviewed for on-going compliance and for any further recommendations and or resolutions

Based on interviews and record reviews, the facility failed to ensure an effective pain management program. The facility failed to follow facility policy on pain management by: 1. Failing to determine and address the underlying cause of the pain 2. Failing to ensure that outside physician referrals were carried out 3. Failing to reassess, re-evaluate and implement individualized care plan interventions addressing new onset of pain 4. Failing to monitor effectiveness of treatment and interventions These failures affected one resident (R1), out of 6 residents reviewed for pain in a sample of 7. R1 had a significant weight loss of 6.4% in one month, which, R1 had attributed to loss of appetite due to abdominal pain and discomfort. R1 was brought to the hospital by V9 (family) due to ongoing and unresolved abdominal pain for one month, was admitted , and had innumerable liver [MEDICAL CONDITION] with morphology consistent with metastatic disease, and abdominal and retroperitoneal lymphadenopathy per ultrasound and magnetic resonance cholangiopancreotopography (MRCP) results. Findings include: According to medical records, R1 is diagnosed with [REDACTED]. R1's 11/15/18 hospital records documented that R1 presented with abdominal pain for 1 month and had intermittent vomiting for 1 week. It documented that SNF has given (R1) [MEDICATION NAME] with no relief; R1 endorses occasional subjective night sweats, decreased appetite. Right upper quadrant ultrasound on 11/14/18 shoes mild common bile duct dilatation, pericholecystic fluid and gallbladder thickening. MRCP showed innumerable liver masses and retroperitoneal lymphadenopathy concerning for metastatic disease versus primary multifocal liver malignancy. 11/19/18 - (R1) patient with known [MEDICAL CONDITION], constipation. R1's facility medical records were reviewed. R1's nursing and medical progress notes documented R1's nursing/medical progress notes documented the following: On 9/14/18 at 19:41, [MEDICATION NAME] sodium administered for pain for complains of abdominal pain, tenderness in bilateral lower quadrants on either side of the naval. At 22:28, V6 (Primary Physician) was notified regarding monitoring of abdominal pain. On 9/15/18 at 5:56, [MEDICATION NAME] sodium administered as needed for pain. On 9/26/18, V7 (Nurse Practitioner) documented, R1 having intermittent nausea with 1 small episode of emesis 3-4 days ago and ongoing central/upper abdominal pain. V7 documents, (Calcium [MEDICATION NAME] and peptobismol) taken without relief. V7 documented that R3's abdomen was slightly distended, possibly heartburn versus possible [MEDICAL CONDITION] ulcer and discontinued use of [MEDICATION NAME] and started on PPI (proton pump inhibitor) and [MEDICATION NAME], if ongoing or symptoms worsen will set up gastrointestinal appointment. R1's medical records documented that R1 was given omerprazole daily and [MEDICATION NAME]. On 9/30/18 at 23:50, [MEDICATION NAME] administered was administered for R1 but did not document location and type of pain and pain scale at time of medication administration. On 10/1/18, V7 documented improvement in nausea but with ongoing decreased appetite and worsening abdominal pain, (R1) stating sharp shooting intermittent 7/10 pain to right upper quadrant that started yesterday morning. V7 documented that abdominal pain to right upper quadrant stabbing and (R1) very sensitive to light palpation; abdomen with slight distention, positive bowel sounds, possibly related to constipation. V7 documented that was unable to assess for hepatomegaly due to pain. V7 had ordered for KUB (Kidney Ureter Bladder) x-rays, CBC, CMP. On 10/1/18, V8 (Dietary) also documented in dietary notes, will follow up abdominal pain discomfort with (V7). On 10/3/18, V7 documented x-ray results = ileus. V7 documented that R1 stated minimal improvement in pain with pain medications, no change in type of pain and no change in decreased appetite. V7 documented, no change, slight improvement with [MEDICATION NAME], (R1) notified of kidneys, ureter and bladder x-ray results for mild colonic ileus and most likely cause of pain. It also documents that R3 was started on medication - [MEDICATION NAME] to address the nausea/vomiting. On 10/5/18, V7 documented that (R1) states improvement in abdominal pain but denies resolution. V7 documented R1 requesting for stronger pain medicine to eliminate abdominal pain. V7 documented abdominal pain ongoing but improved; described as discomfort instead of stabbing pain, tolerating clear liquids. V7 documented that (R1) was educated that stronger pain medication cannot be provided due to side effects of mobility paralysis, and to continue with [MEDICATION NAME], clear liquid diet and [MEDICATION NAME]. On 10/10/18, V7 documented that (R1's) abdominal pain is ongoing but continues to slowly improve and is tolerating clear liquid diet. No additional orders made. On 10/10/18 at 20:26, [MEDICATION NAME] administered was administered for R1 but did not document location and type of pain and pain scale at time of medication administration. On 10/14/18 at 06:01, [MEDICATION NAME] administered was administered for R1 but did not document location and type of pain and pain scale at time of medication administration. On 10/26/18 at 18:52, V6 documented that (R3) complained of mild abdominal pain; Gastrointestinal system - slight distension, tender to light palpation in right upper quadrant On 11/2/18 at 14:53, [MEDICATION NAME] administered was administered for R1 but did not document location and type of pain and pain scale at time of medication administration. On 11/3/18 at 22:04, [MEDICATION NAME] administered was administered for R1 but did not document location and type of pain and pain scale at time of medication administration. On 11/5/18 at 5:26, [MEDICATION NAME] administered was administered for R1 but did not document location and type of pain and pain scale at time of medication administration. On 11/12/18 at 16:01, V8 documented weight history: (11/7/18) 158.4 pounds, (10/4/18) 169.3 pounds reflective of a 10.9 pound decline past month which triggers at of 64% significant weight decline. V8 documented that R1 attributes weight decline to abdominal pain which at times on right side and other times left side and not much of an appetite due to abdominal discomfort. On 11/14/18, R1 while out on pass with V9 (R1's family), R1 went to a (local hospital) emergency room and was admitted for unknown abdominal pain. R1's medical records documented an order for [REDACTED]. V7's progress notes documented on 8/17/18 notes [MEDICAL CONDITION] previously managed at outpatient unit - instructed nurses for follow up with hepatology. On 9/26/18, 10/1/18, 10/3/18, 10/5/18, V7 documents - (Appointment) Pending. V1 (Administrator) and V2 confirmed during an interview on 12/5/18 at 2:00 pm that there was no evidence of going to hepatology appointments as ordered after (MONTH) (YEAR), V2 stated that staff did not remember anything regarding hepatology appointments. R1's medical record did not document that R1 was referred to any [MEDICATION NAME] (GI) specialist. V7 was interviewed and confirmed that V7 had wrote on NP notes regarding referral for R1 to be seen by GI but don't know how staff schedules these referrals. V7 also stated that it is staff who schedules appointments for hepatology referral and not sure how they (staff) do that. R1's current plan of care was reviewed. R1's care plan addresses hip pain and has identified interventions. R1's care plan did not identify R1's abdominal pain and did not document any related abdominal pain care plan goals and interventions. V2 confirmed that the care plan was not revised to include interventions addressing onset of abdominal pain, as care plan should have updated and revised. R1's medical records documented comprehensive pain evaluations on 11/28/17 and 11/20/18. There were no documented pain assessments during on quarterly and with new pain onset. V2 stated that per facility policy, comprehensive pain evaluations should be completed on admission, readmission, quarterly, during change of condition and with new onset of pain but did not find any other documented comprehensive pain assessments for R1, other than the ones provided. R1's 9/4/18 Minimum Data Set Assessment under section C0500 BIMS (Brief Interview of Mental status) result of 15/15 (Cognitively intact). According to V5 (Licensed Practical Nurse), R1 is alert and oriented to person, place, time and situation. R1 was interviewed in the room on 12/3/18 at 2:30 pm. R1 verbalized, They (facility) are now much better with addressing my pain. On 11/28/18 at 9:40 am, V9 (R1's family) was interviewed via telephone that R1 had been consistently complaining about abdominal pain for a long time and that it was not addressed and that the facility staff kept telling R1 that the x-ray result was negative. V9 stated that R1 informed V9 that R1 wanted to go to the hospital because pain is not going away and facility staff is not addressing it. V9 stated that V9 brought R1 to a local emergency room and after extensive testing, R1 was diagnosed with [REDACTED]. On 12/5/18 at 3:30 pm, V7 (Nurse Practitioner) was interviewed via telephone. V7 stated that R1 is alert and oriented x 3 and currently being treated for [REDACTED]. V7 stated that R1 complained of abdominal pain and an x-ray of abdomen was done which showed a result of ileus - which is a partial blockage of colon tract. V7 confirmed that x-ray will not reveal [DIAGNOSES REDACTED]. V7 stated that while assessing R1, R1 was having abdominal pain, slightly relieved but not improving. V7 stated that V7 had wrote for a referral R1 to be seen by GI for further evaluation and management of abdominal pain, but didn't know what had happened and don't know how staff schedules these. V7 also stated that it is staff who schedules appointments for hepatology referral and not sure how they (staff) do that. V7 confirmed that R1 did ask for stronger pain medications to alleviate the pain but V7 stated that R1 could not have stronger medication due to [DIAGNOSES REDACTED]. V7 was asked what the treatment plan was and stated that the plan at that time was to continue with clear liquid diet and pain control with [MEDICATION NAME]. V7 stated that the next step would have been to do an ultrasound of the abdomen, which was not done because by the time V7 was going to see R1, R1 already went to the hospital. The facility's revised 7/2014 policy on pain management documents under guidelines: 1. Pain management program is based on a facility wide commitment to resident comfort. Pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. 2. Pain management is defines as the process of alleviating the resident's pain a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Observing for the potential for pain b. Effectively recognizing the presence of pain c. Identifying the characteristics of pain d. Addressing the underlying causes of the resident's pain e. Developing and implementing approaches to pain management f. Identifying and using specific strategies for different levels and sources of pain g. Monitoring for the effectiveness of interventions h. Modifying approaches as necessary 5. Conduct an admission pain management observation upon admission to the facility, then complete the pain form if pain is identified and whenever there is a change in condition, and when there is onset of new pain and at least in stable chronic pain Guideline: 1. The pain form and corresponding documentation is completed by nursing upon admission and readmission. The quarterly pain screen is completed quarterly. 6. Development of the care plan - based on the documentation, a pain management care plan will be developed, maintained or updated. 7. If pain has not been managed consistent with the resident's goals and needs, the interdisciplinary team may need to reconsider current interventions and revise those interventions as needed; or if pain has been maintained or resolved, the nursing staff will work with the physician to taper or discontinue [MEDICATION NAME].

Based on observation, interview and record review, the facility failed to implement a policy and procedure to restrict weapons in the building and secure razors to ensure resident safety for five residents (R2, R8, R9, R10, R11) of five residents reviewed for supervision in a total sample of 29. This failure resulted in one resident (R1) being stabbed multiple times and requiring hospitalization . Findings Include; On 9/13/17 at 10:30 AM R1 is observed to have a laceration with multiple sutures on the anterior neck, three superficial lacerations on the upper abdomen, and lacerations on the right upper arm and left elbow. On 9/13/17 at 10:30 AM with E3 CNA (Certified Nursing Assistant) interpreting Spanish to English, R1 stated that R1 called to R2 because R1 thought R2 stole money, 26 dollars, from R1. R2 came over with the knife and started stabbing me. I never had problems with R2 before this, we got along fine. R2 also hit me with a cane, and I hit R2 back with my cane. I never saw the knife before. This happened early in the morning. I don't want to be here (facility). R1 is crying during conversation. The facility Incident Report time line documents in part; on 9/11/17 at 4:10 AM (R1) exited room actively bleeding from upper torso and neck , (R2) sitting on floor in doorway of room with laceration on forehead, 911 was called, rapid response initiated, first aid rendered. 4:30 AM police in facility and conducted an investigation, statements taken, residents taken to the hospital. Facility swept for weapons. Confiscated any weapons found, (care planned and documented) by end of day . Updates from hospital stating R2 fractured wrist and R1 multiple sites requiring sutures. R1 and R2 are roommates in a three bed room. The third roommate R29 was not interviewable. On 9/13/17 at 2:30 PM E1 Administrator, E2 Director of Nursing,and E7 Facility Nurse Consultant stated that there is no facility policy for weapons. If we see something dangerous we take it, but there is no policy. We are in the process of putting together a policy. Inventory of resident items is taken at admission. In orientation we train staff to take away unsafe items and call the E1 Administrator and E2 DON (Director of Nursing). We do not have a list or any documentation for weapons not allowed in the building. We have a no gun sign in the lobby. On 9/14/17 at 9:50 AM E8 CNA (Certified Nurse's Assistant) stated, I was working the on the fourth floor, I always work the fourth floor. I was on the other side of the unit when E6 LPN (Licensed Practical Nurse) called me to the nurses station and handed me some 4x4's (dressing) and told me to go down to R1's room and help E9 CNA . E1 was standing in the hallway covered in blood. R1 yelled (Resident's name) (R2) has a knife. (Resident's name) (R2) said I took (Resident's name) (R2) 26 dollars. I was assigned to both R1 and R2. R2 was sitting on the floor in the doorway; R2 had a towel holding it to the eye. R2 didn't say anything. This happened between 3:30 and 4:00AM. About an hour before this, during rounds, I saw R2 sitting in bed shaving. I thought that was strange. I don't know where R2 got the razor and I didn't take it away. The nurses keep razors in the drawer at the nurse's station, they are not locked. The rest are in the med (medication) room locked. Some residents shave themselves; they sometimes give it back to me or keep it and use it again. R1 and R2 shave themselves; I'm not sure what happens to the razor when they are done. We decide who can shave independently by observation. If there is a list, I don't know about it. We confiscate things if we see them. I'm not aware of any policy for searching or weapon possession. On 9/13/17 at 10:10 AM E1 Administrator and E2 DON stated in part; that R2 was the assaulter. R2 has mental illness [DIAGNOSES REDACTED]. R1 and R2 were roommates in a 3 bed room. R2 said R2 was missing money. The nurse at the time of the incident said R2 had a pocket knife. The police have it now. R2 goes out on pass with family, R2 cannot go out alone. A family member of R2's said he doesn't know where R2 got the knife. Before this incident we did not search anyone. Some residents have behavioral contracts that allow search if there is suspicion. We do search resident's room but no standard or time table. We do not know how R2 got the knife. After this incident we did a building search and found some scissors, a razor, pocket knives and a butcher knife. R2 was always quiet with no behaviors. On 9/14/17 at 9:25 AM one razor was observed in the second floor nurses station unlocked top drawer. E10 LPN Unit Manager stated That should not be there. The razors should be kept in the med room locked. On 9/14/17 at 9:30 AM one razor was observed in the fourth floor nurses station unlocked drawer. E2 DON stated, That (razor) should not be there, it should be in the med room locked up. On 9/14/17 E2 DON stated, There is no shaving log. The CNA and nurses give the razors to the residents. We tell the resident to let us know when they're done, so we can dispose of it, but there is no in and out log. The facility search (swept of building) done on 9/11/17 documents R8 had a pocket knife, R9 had a razor, R10 had a pocket knife and R11 had a butcher knife. On 9/26/17 at 12:10 PM R8 stated I was never told I couldn't have a pocket knife, scissors, or anything. R11's care plan dated 5/24/17 documents in part, R11 has a [DIAGNOSES REDACTED]. Care Plan dated 5/22/17 documents in part R11 has a history of criminal behavior while residing in the community, in 1974 resident was charged with burglary, theft and aggravated battery. R10 has a [DIAGNOSES REDACTED].

Based on interview and record review, the facility failed to prevent physical abuse for one resident (R1) of four residents reviewed for abuse in a total sample of 29 residents. This failure resulted in R1 receiving multiple stab wounds from another resident (R2), that required hospitalization . Findings Include; On 9/13/17 at 10:30 AM R1 is observed to have a laceration with multiple sutures on the anterior neck, three superficial cuts on the upper abdomen, a cut on the right upper arm and left elbow. R1 stated that he called to R2 because he thought R2 stole money, 26 dollars, from him. R2 came over with the knife and started stabbing me. I never had problems with R2 before this, we got along fine. R2 also hit me with a cane, and I hit R2 back with my cane. I never saw the knife before. The facility Incident Report time line documents in part; on 9/11/17 at 4:10 AM (R1) exited room actively bleeding from upper torso and neck , (R2) sitting on floor in doorway of room with laceration on forehead, 911 was called, rapid response initiated, first aid rendered. 4:30 AM police in facility and conducted an investigation, statements taken, residents taken to the hospital. Facility swept for weapons. Confiscated any weapons found, (care planned and documented) by end of day . Updates from hospital stating R2 fractured wrist and R1 multiple sites requiring sutures. R1 and R2 are roommates in a three bed room. The third roommate R29 was not interviewable. On 9/13/17 at 2:30 PM E1 Administrator, E2 Director of Nursing,and E7 Facility Nurse Consultant stated that there is no facility policy for weapons. If we see something dangerous we take it, but there is no policy. We are in the process of putting together a policy. Inventory of resident items is taken at admission. In orientation we train staff to take away unsafe items and call the E1 Administrator and E2 DON (Director of Nursing). We do not have a list or any documentation for weapons not allowed in the building. We have a no gun sign in the lobby. On 9/13/17 at 10:10 AM E1 Administrator and E2 DON stated in part; that R2 was the assaulter. R2 has mental illness [DIAGNOSES REDACTED]. R1 and R2 were roommates in a 3 bed room. R2 said R2 was missing money. The nurse at the time of the incident said R2 had a pocket knife. The police have it now. R2 goes out on pass with family, R2 cannot go out alone. A family member of R2's said he doesn't know where R2 got the knife. Before this incident we did not search anyone. Some residents have behavioral contracts that allow search if there is suspicion. We do search resident's room but no standard or time table. We do not know how R2 got the knife. After this incident we did a building search and found some scissors, a razor, pocket knives and a butcher knife. R2 was always quiet with no behaviors. On 9/14/17 at 9:50 AM E8 CNA (Certified Nurse's Assistant) stated, I was working the on the fourth floor, I always work the fourth floor. I was on the other side of the unit when E6 LPN (Licensed Practical Nurse) called me to the nurses station and handed me some 4x4's (dressing) and told me to go down to R1's room and help E9 CNA . E1 was standing in the hallway covered in blood. R1 yelled (Resident's name) (R2) has a knife. (Resident's name)(R2) said I took (Resident's name) (R2) 26 dollars. I was assigned to both R1 and R2. R2 was sitting on the floor in the doorway; R2 had a towel holding it to the eye. R2 didn't say anything. This happened between 3:30 and 4:00AM. About an hour before this, during rounds, I saw R2 sitting in bed shaving. I thought that was strange. I don't know where R2 got the razor and I didn't take it away. The nurses keep razors in the drawer at the nurse's station, they are not locked. The rest are in the med (medication) room locked. Some residents shave themselves; they sometimes give it back to me or keep it and use it again. R1 and R2 shave themselves; I'm not sure what happens to the razor when they are done. We confiscate things if we see them. I'm not aware of any policy for searching or weapon possession.

Based on observation, record review and interview the facility failed to supervise and monitor a resident with a known unsafe smoking behavior. This failure applies to one of three residents (R6) reviewed for behaviors, in a sample of eight. As a result, R6 while smoking a cigarette during oxygen therapy, sustained facial burns and smoke inhalation Findings include: Medical record for R6 noted [AGE] year old admitted to facility on 7/8/2014 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated 7/15/2014 for R6 scored 7 out of a possible 15 on the Brief Intelligence Mental Status (BIMS). This indicated R6 had a impaired cognitive status. physician's orders [REDACTED]. On 2/18/2015 at 2:30PM and on 2/19/2015 at 10:00AM, residents were seen smoking outside the facility's building with staff supervision. R6's smoke risk assessment done upon admission 7/11/2014 scored 0-9 indicative of a safe smoker. The following was documented in R6's record regarding the resident behavior and facility's actions: -On 11/4/2014 medical record for R6 documented social worker spoke with R6 in relation to report of him smoking in his room. Actions post Smoking event by facility included counseling, education and signing of smoking contract by R6. Along with the above action by facility, smoking materials were removed from R6's room. Care plan noted education for R6. On 11/19/2014 at 10:35AM, Z2(Psychiatrist) documented (R6) smokes in room with oxygen and with interdisciplinary observations (R6) can be impulsive and forgetful. Behavior for R6 noted with impaired judgment and impaired insight. -On 1/23/2015 at 13:56PM, nurse wrote, " nurse manager informed per staff housekeeper resident smoking in room with oxygen present. Upon entering room, resident sitting on side of bed and stated that he was smoking. Writer provided education regarding hazard of smoking while oxygen in use and /or present. Resident stated, " it won't happen again that was my last one anyway " . Actions post smoking event by facility on 1/23/2015 included education, and daily discussions with administrator along with search for alternative placement. No new intervention was documented in care plan to ensure behavior was not repeated. No other smoke assessment was done after two occurrences of smoking in room by R6. According to E1(Administrator) the smoke risk assessment is done yearly. -An incident report of 2/15/2015 at 11:30PM documented, CNA (certified nurse aide) noted black around resident's nose and mouth. R6 stated "was trying to take a quick hit off his cigarette and it blew up in his face." The resident was assessed and noted with burns to resident's nose, lips, hair and blisters forming on his jaw. R6's nurses notes for 2/16/2015 at 11:03AM noted, "Spoke with charge nurse at hospital, made aware that resident was admitted with facial burns and smoke inhalation. " On 2/18/2015 at 10:00AM, E1 (Administrator) said constant education was provided for R6 in relation to smoking rules. When asked what was done by the facility after the first and even after the second occurrence of (R6) smoking in room with oxygen present, E1 said a smoking contract was signed by R6 on both occasions and alternative placement was sought. E1 also said it was one person with two occurrences. According to E1 residents could have smoked in designated areas between 7:00AM and 10:00PM daily. No additional policy regarding supervision of residents smoking was presented, when requested by the surveyor. Upon request the facility failed to provide the surveyor with any written interventions regarding monitoring and supervising R6's non-compliant behavior to the facility's smoking policy implemented between 7/8/2014 and 2/15/2015. On 2/19/2015 at 1:00PM, E1 presented new smoking supervision process which according to him was initiated after the incident of 2/15/2015. On 2/20/ at 11:55AM, Z2 (psychiatrist) said she could not remember when she saw R6 and she could not have done anything about his smoking in room. According to her, the facility had the responsibility to prevent the resident from obtaining cigarettes if they did not want him to smoke in room. Smoking Policy for facility documented "Smoking is confined to designated areas of the building and at designated times". and " Residents are allowed to smoke in designated places, never in their rooms or hallways". On 2/18/2015 at 9:30AM and 2/19/2015 at 1:30PM, tour of facility noted no smell of cigarette smoke. Random check of residents' drawer in room with E2(Director of Nurses, DON) noted no cigarettes or lighter.

Based on observation, interview and record review, the facility failed to ensure that fall prevention interventions were implemented for 1 resident (R5), of 3 residents , reviewed for falls. This failure resulted in R5 sustaining bi-lateral leg fractures. Findings Include: R5 is a [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 9-23-14 at 7:30PM, R5 was lying in a bariatric bed. R5 was alert and slow to respond verbally to simple questions. R5 had bilateral soft cast and immobilizers on both legs and requires extensive assistance with bed mobility. R5's Minimum Data Set (MDS) assessment dated [DATE] notes; bed mobility extensive assist and two person physical assist, transfer assessed ; total dependence with two person physical assist. R5's care plan dated 12-15-13 notes;" potential for falls related to the [DIAGNOSES REDACTED]. Incident on 2-8-14, witnessed by staff, R5 rolled to floor from bed no injury. Interventions to increase to a 2 person assist with transfers and bed mobility. R5's Fall Risk assessment dated [DATE] is noted to be at a level of 13. The fall risk assessment notes any scores above ten puts the resident at high risk for fall. Incident report dated 9-6-14 notes the following: " R5 rolled off the bed and onto the floor, full body assessment completed. Resident complaining of bilateral lower extremity pain. Medical Doctor (Z4) called and pain management provided. Order obtained to send to local hospital for medical evaluation. Resident was subsequently admitted with [DIAGNOSES REDACTED]." The facilities investigation of the incident concluded that on 9/6/14, E7 (Certified Nursing Assistant), while performing ADL ( Activities Daily Living) care while R5 was in bed , E7 turned R5, which resulted in R5 rolling off the bed and landing on the floor. E7 was without staff assist. R5's hospital x-rays reports dated 9-7-14 notes the following, " An acute fracture is present at the distal aspect of the right femoral shaft. X-ray of left lower leg notes an acute transverse non-displaced fracture of the proximal shaft of the tibia is demonstrated." On 10-17-13 E11 (Falls Coordinator) stated," R5 was assessed at a 13, high risk for falls. R5's high risk for falls was documented in the care plan for all to see." On 9-23-14 at 5:30PM E6(Staff Nurse) stated," R5 is legally blind and has left sided hemi paresis, alert and oriented to self and place at times. Since R5's admission, R5 has always been a two person assist because of her weight (obese) and immobility. After the fall on 9/6/14, R5 returned from the hospital with bilateral soft cast on and splint immobilizers on both legs and very apprehensive and fearful with bed mobility and transfers. " E1 (Director of Nursing) on 9-23-14 at 8:00PM stated," R5 was assessed as a two person assist based on the 6-16-14 MDS assessments with all activities of daily living. " E4 (Administrator) on 9-23-14 at 8:30PM stated," E7 no longer works at the facility." Z4 on 10-17-14 at 12:15 stated," The facility explained that they lost control of R5 while doing care and she rolled out of the bed onto the floor. This is how she sustained fractures of both legs. " Facilities policy regarding transfers and fall prevention indicates that the individualized plan of care are to be followed.

Based on observation, interviews and record reviews, the facility failed to follow up on family members' concerns about the physical condition of a resident, assess potential causative factors for swelling, pain and change in daily activity and immediately notified a physician of a resident's change of condition. This failure applies to one of four residents (R13) reviewed for incontinence and activities of daily living (ADL) in a sample of four. As a result, the facility delayed the discovery of a foreign object within R13 urinary tract (penal area) which required surgery to be removed. R13's physical condition became critical and needed treatment in a hospital. Findings include: On 7/24/14 at 3:32PM, Z3 and Z4 were interviewed during a two way phone call. Z3 and Z4 (Family Members of R13) stated they use to go to the nursing home on a regular basis. Z4 stated a week before R13 was hospitalized ; he was in the bed at the nursing home, very weak and sickly looking could not get up and expressed not feeling well although he could not talk that good. Z4 said, "I could see he did not feel good, as a mother, I know my son well." Z4 and Z3 commented this was not like him to be in bed because he never stays in bed and had not been sick like this before. Z4 said, "I told the nurse about my concerns (did remember nurses name but described him as heavy set male on the evening shift). The nurse said, "He (R13) probably got a cold or something, he will be okay." Z3 and Z4 said, "The supervisor was made aware as well. They didn't do anything to help him when we told them he was very sick almost a week before he was sent to the hospital. The nursing home did not notify us he was sent to the hospital on [DATE]. We got a call from the hospital's doctor on 7/20/14 informing us that he was in the hospital and they needed consent for a procedure. We went there right away. R13 was on a life support machine, hooked up to IVs (intravenous tubes)" Z3 said, " We found out from the doctor R13 had a piece of a urinary catheter tube that was left in him at the nursing home but we never knew he had a urinary catheter. The nurses didn't check it. The doctor at the hospital told us they removed a urinary catheter tube from him and it was infected. They had to surgically place a Tube ([MEDICATION NAME]) in him at the hospital so he could pass urine. Also, they said he had pneumonia." On 7/24/14 at 3:35PM, the surveyor visited R13 at the local hospital. R13 was in critical care unit on Ventilation machine, IV s for antibiotic, pain and various medications to maintain blood pressure. R13 was non- responsive. On 7/24/14 at 4:10PM, Z8 (Critical Care Nurse) said, " R13 came in from ER (emergency room ) very compromised, severely dehydrated. He received 5 liters of IV fluids. He was in pain, could hear him moaning. Patient (R13) had coded yesterday but he's more stable today." R13's POS(Physician order [REDACTED]. Nursing Care Plan dated 3/31/14 documents potential for incontinence of bowel and bladder. Nurse's notes dated 7/19/14 at 6:55PM E11(nurse) documents, R13 was noted with right foot swollen with 2 plus [MEDICAL CONDITION], leg elevated on a pillow. There are no documented vital signs. Nurses ' notes dated 7/20/14 at 12:48AM, E10(NURSE) documents, "Received report from 2nd shift nurse that she had noted a change in resident and that she called the house supervisor to assess resident to see if he should be sent to hospital. Resident vital signs: temperature=94.7, Pulse=119, BP(blood pressure)=55/41 and resident skin was cold to touch. Noted resident was responding but not able to stay awake. (This was noted at 11:30PM). Doctor(Z9) was called at 11:45PM and condition reported to him. He gave order to send to local community hospital for evaluation, stated to send to closest hospital due to condition. Local hospital called and informed of resident condition and that he will be coming to ER(emergency room ). 911 was called at 11:55PM. Ambulance Report dated 7/20/14 at 12:08AM, called to transfer patient to hospital for Mental Status change, abnormal vital signs. R13 received from nursing home weak, pale and hypotensive. Shallow breathing, alert, and unable to obtain IV access. Resident transferred to community hospital at 12:11AM. Hospital emergency room Physician notes dated 7/20/14 at 7:30AM to 4:20PM, remarks: R13(Patient) "[AGE] year old male with past medical history of [REDACTED]. Nursing home resident sent for [MEDICAL CONDITION] and altered mental status. Received resident with right sided weakness, lower extremity [MEDICAL CONDITION]. Skin is cold, and cyanosis. Contact family for consents. Insertion of Central Lines. Start transfusion of one unit of platelets. Patient received 5 liters of fluids and his mentation improved. BP-still low. It is not clear what happened in the nursing home (questioned diarrhea, bleeding). As per ER report, he was profoundly dehydrated when he came and now looks much better. Labs is significant for [MEDICAL CONDITION], elevated BUN and [MEDICATION NAME] which is disproportionate. Chest x-ray for right sided pleural effusion, possible hemothorax, start on [MEDICATION NAME] (antibiotics)." Hospital physician notes dated 7/20/14 at 8:00PM, remarks," Patient incontinent of large amounts of pinkish fluid, 2 plus [MEDICAL CONDITION] noted to extremities. Attempted Texas Catheter(external catheter) but unable to as Penis is Swollen and will not fit with standard size. At 5:30AM, attempted three way indwelling catheter placement was unsuccessful due to blood clots and pain. Patient yelling out, checked for incontinence of urine, almost pure blood from penis, [MEDICATION NAME] 2.5 mg given for pain. Found to have 3 to 4 inches of indwelling catheter protruding in his penis area." Hospital Physician notes dated 7/21/14 documents resident was sent to OR(Operating Room) for surgical cystoscopy and placement of suprapubic tube. Physician notes dated 7/22/14 documents, "Chest x-ray results indicate patient with Left Lower lung Pneumonia and Para Pneumonic effusion. Thoracentesis procedure done at bedside. Bloody fluid came out." Hospital chemistry lab results report dated 7/20/14 remarks: [MEDICATION NAME] normal range (0.6-1.3mg/dl) result= {1.8 High} Plasma BUN normal range(7-18mg/dl) result= {101 High} Estimated GFR(62 mL/min) result= {41 Low} Kidney function Lab result indicate resident with Dehydration. On 8/11/14 at 9:50AM, E11(nurse) said, "It was brought to my attention on 7/20/14 R13 was moaning when you touched him. His legs were swollen, (vital signs not recorded). I had the Nursing Supervisor (Z10) come and assess him. She told me to elevate his legs so he would be comfortable. I gave report and concerns to the night shift nurse(E10). On 8/11/14 at 10:00AM, Z9(Attending Physician) said, " I was notified for the first time about R13's change in condition on 7/19/14 close to midnight. The nurse told me the patient was almost comatose, almost unresponsive. I ordered accuchecks due to resident being diabetic but his blood sugar was okay and gave verbal order to send R13 to hospital stat. Z9 said, "The nurse commented to me she wandered why nobody had noticed resident was so sick before." Z9 stated he had never received a call before that night resident had a change in vital signs or sick. If a resident was dehydrated, he does not become like that in a few hours. However, a diabetic patient could become dehydrated due to drop in blood sugar(hypoglycemic) in about 2-3 days, if he does not receive fluids or has a (high) temperature. The nurses did not tell me he was sick. I last visited R13 on 7/18/14 and the nurses said he was fine. A physician assessment note dated 7/18/14 at 7:11PM documents, "No new complaints; doing well per nursing staff. Hydration-adequate. Clinically stable." On 8/7/14 at 12:15PM, E9/NURSE said, "R13 had paralysis on right side. I did speak with mother. I Told her he was not in bed sick. He sometimes did not want to get up. R13 did not have a urinary catheter or an order for [REDACTED]." On 8/11/12 at 12:40PM (second interview with E9), E9 said, "I worked the day shift. A lot of times the mother would come in and inquire why R13 would be in the bed." E9 commented R13 was never a person who stayed in bed all the time or even 2 days in a row. He could not talk but respond by nodding head to say "yes" or "no." E9 said, "I told her I don't know why he was in bed and he will probably be out of bed today. I never told the family he probably had the flu or cold and would be okay. R13 did not have a urinary catheter" During an interview with E12(nurse assistant) on 8/11/14 at 9:40AM, "R13 had days when he was not feeling good. He would say his stomach was hurting or something and did not want to get up. I would report this to the nurse." On 8/11/14 at 10:45AM, Z10(Supervisor/ Weekends) said, "I only work weekends. The nurse (E11) reported R13 had a low blood pressure and was [MEDICAL CONDITION]. I did not see swelling in his legs. I saw him very briefly. I took a manual reading and his pulse was okay. I told the nurse to monitor him. He was sent out to hospital later on that night. The resident had to be sick before that night." On 8/11/14 at 3:15PM, E2 (director of nurses/DON) said, "Nurse's only document if there is something significant that happens with a resident. I take full responsibility for nursing communication about resident care. I expect nurse's to report any change in condition right away." R13's nurse's notes for June and July 2014 did not address any of Z3 and Z4's concern about R13's condition. R13's attending physician (Z9) was not informed of the onset (7/19/14 at 6:55PM) of R13's swelling and later pain. R13 had no continuous monitoring of symptoms after a nurse's assessment of physical changes.

Based on observation, interview and record review, the facility failed to follow pressure ulcer policy for monitoring skin condition and implement pressure relieving methods, completing accurate measurement for pressure ulcer and provide pressure ulcer treatments as ordered for two of seven residents ( R3 and R5), in the sample of fourteen residents reviewed for pressure ulcers. As a result of these failures R3 developed stage II, III and IV pressure ulcers, resulting in the need for debridement of the stage IV ulcer at a hospital. R5 development a stage III pressure ulcer that had increased in size just seven days after being admitted to the facility. Findings Include: 1. R3 was readmitted into the facility on [DATE]. R3's admission records for bodily assessment indicate that R3 had no open pressure areas. R3's risk assessment scale for skin breakdown indicated that R3 was scored 14 which is moderate risk. Review of the facilities policy for pressure ulcer prevention state that all residents assessed and treated. The facility's wound care notes indicate that on 9/16/12, R3 had developed four new pressure ulcer areas. The wound summary sheets with date of 9/16/2012 indicated a stage three pressure ulcer to the right buttock, stage three pressure ulcer to the coccyx, stage two pressure ulcer to the left buttock and stage two pressure ulcer to the anal area. The comprehensive assessment of the pressure ulcers did not include measurement for the depth for any of the stage three pressure ulcers identified at this time. Further review of the wound care notes indicated R3's had a sacrum ulcer stage IV in which was not assessed until 10/29/2012 after treatment was started 10/27/12. There was no documentation when this pressure ulcer was developed. The facility's wound assessment details report date 10/30/12 denotes 5.5 cm X 3.5 cm X 2.0 cm with exudates and moderate amount serosanguineous drainage on the sacrum area. The hospital physician progress notes [REDACTED]. The hospital physician progress notes [REDACTED]. The facility's pressure ulcer prevention policy and procedures included but not limited: "All residents assessed to be at risk for breakdown should be placed on a pressure reducing bed or mattress. Based on the results of the pressure risk assessment, all residents at-risk for pressure ulcer development will receive a documented daily visual inspection of their skin by the RN/LPN (register/licensed nurse) or CNA (certified nurse aide)delivering care." This policy also denotes: "a Stage 3 pressure ulcer has a full thickness tissue loss and the depth varies and Stage 4 pressure ulcer has full thickness tissue loss with exposed bone, tendon, or muscle and the depth varies. " R3's physician's order sheet reflected no use of a pressure relief mattress until 9/16/12, when facility staff acknowledged R3 developed new pressure ulcers. In addition, the wound assessment notes does not include measurements of depth for the identified stage 3 pressure ulcers during the period of 9/16 to 9/27/12. E2 (Director of Nursing) on 11/7/12 at 10:45 A.M. stated, " the certified nurse's aides are to do daily skin checks on all residents during bath or shower days, note any unusual observations on the skin assessment sheets and inform the nurse in charge". E2 was unable to supply documentation of the skin assessment sheets for R3 from 9/12 to 9/16/12. E2 continued to state that the treatment nurse is to check the skin assessment sheets on a daily basis for follow up on any concerns regarding resident's skin issues. E4 (treatment nurse) stated on 11/5/12 at 11:50 A.M., "She was not notified of R3's pressure ulcer until 9/16/12." R3 was observed on 01/10/13 at 10:05 A.M. in bed. R3 was observed with sacrum pressure ulcer length 3.0 cm X 2.5 cm, pink tissue, scanty amount sangerious drainage and no odor. E5 (nurse-wound care coordinator) on 01/28/13 at 10:28 A.M. stated, "It was the right buttock but it extended to the sacrum. I didn't assess the sacrum ulcer or treat the sacrum." E5 was unable to show where this change in R3's skin condition was documented by any of the wound care staff. 01/28/13 at 2:30 P.M. E12 (nurse consultant) in the presence of E5, acknowledged it was true that a stage 3 and stage 4 would have a depth measurement included in the assessment. 2. R5 closed record documented R5 as total care resident admitted to facility on 7/20/12. R5's skin assessment dated [DATE] indicated that R5 had only small scratches and a skin tear, both to the sacrum upon admission. R5's wound care notes dated 7/20/12 and initial minimum data set (MDS) assessment dated [DATE] both documented R5 having a pressure ulcer on admission. The wound care notes stated, R5 had a previous pressure ulcer noted to right ischium/ sacrum noted with stage 2 with measurement of 2.5 cm (long) X 1.8 cm (wide) X 0.2 cm (depth). On the MDS the same measurement was recorded but it was indicated as a stage 3 pressure ulcer. In addition, it indicated R5 was incontinent of bowel and bladder. -R5's nurses notes dated 7/24/12 at A.M. stated, R5's indwelling catheter was removed this AM (morning). R5's comprehensive care plan dated 7/20/12 for the pressure ulcer indicated R5 was to be kept clean and dry as possible to minimize skin expose to moisture. The care plan had no details how the staff members would accomplish this take. The care plan also identified the use of a low air loss mattress (pressure relief mattress). -On 1/28/13 at 2:30 P.M. E5 (wound care coordinator) and E12 (nurse consultant) were asked what was the plan for reducing the moisture or keeping R5 as dry as possible to decrease the risk for development for further pressure. E12 initially reported it was documented on the wound care notes 7/20/12, R5 had a indwelling catheter. The surveyor asked for a physician order for [REDACTED]. R5's physician's order did not have any orders for the use of a pressure relief mattress and indwelling catheter. R5 had order dated 7/20/12 for treatment of [REDACTED]. Also, treatment orders dated 7/27/12 for the right buttock on Monday, Wednesday and Friday and as needed and sacrum everyday and as needed. R5's treatment administration records (TAR) were reviewed to confirm the treatments were done as ordered. R5's TAR between 7/20 and 7/27/12 denoted one treatment (7/20/12) for R5's sacrum area. The treatment that should have been scheduled for 7/23 and 7/25/12 were not documented as being done. Next, R5's TAR between 7/27 and 8/09/12 had undocumented treatments for R5's sacrum area for 8 of 14 days before being transferred out. The treatments that should have been scheduled for 7/30, 8/3 and 8/06/12 were not document as being done. R5's wound care notes dated 7/27/12 documented upon dressing change R5 had an open area to the right buttock measuring 2.5 cm X 3.5 cm, and sacrum wound 5.0 cm X 6.0 cm X 0.2 cm. This was a newly developed pressure ulcer and an increase of the pressure ulcer identified on admission. R5's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].