**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to accurately assess a critical clinical sign (Battle sign) and implement their change in condition policy by failing to immediately activate EMS (emergency medical services) 911 to transport a resident with an acute change in mental status. This affected one of three residents R366 reviewed for change in condition and delay of treatment. This failure resulted in R366 being transported to the hospital and diagnosed with a large traumatic subdural bleed (collection of blood between the covering of the brain and the surface of the brain) with midline shift (displacement of the brain tissue across the midline) causing herniation. Findings include: On [DATE] at 10:10 AM, V17 LPN (Licensed Practical Nurse) stated that V17 worked day shift on the second-floor nursing unit on [DATE]. V17 stated that during initial rounds V17 saw R366 in room and talked to her. V17 stated that R366 was in bed with her face covered up with a sheet; V17 did not see R366's face. V17 stated that when R366 walked to the dining room for breakfast V17 called R366 to come get her medications. V17 stated that is when he observed R366's left eye and left posterior ear discolorations. V17 stated that V17 asked R366 what happened with the left side of her face; R366 rubbed face and informed V17 that she fell last night in her room. V17 stated that R366 stated she tripped and hit the left side of her face on her dresser. V17 stated that V17 asked if R366 told the nurse, R366 stated 'no, she just went back to sleep'. V17 stated that V17 assessed R366 for any other injuries, gave R366 an ice pack, initiated neurological checks, and paged V32 (physician). V17 stated that V32 called and was informed of the incident. V17 stated that V32 ordered a routine facial x-ray. V17 stated that R366 was still walking around during V17's shift. V17 stated that V17 informed staff that R366 cannot leave the nursing unit without a staff member. V17 stated that V17 informed on-coming nurse, V15 RN (Registered Nurse), to not let R366 leave the nursing unit alone. V17 stated that the skin surrounding R366's left eye was black. V17 stated that V17 also observed discoloration behind R366's left ear. On [DATE] at 10:50 AM, dietary mealtimes posted on the second-floor nursing unit notes breakfast is delivered 6:45-6:55 AM. On [DATE] at 10:52 AM, V17 stated that the meal trays are brought up between 6:45 and 6:55 AM and the trays are passed out in the dining room around 7:00 AM. V17 stated that is when V17 observed R366's facial bruising. R366's medical record, dated [DATE] at 9:35 AM, V17 LPN noted R366 was observed with discolorations around left eye and behind left ear. Upon interview with R366, R366 stated that she fell last night in the room and got herself up. R366 stated that she thought that she was fine and didn't report to anyone. V17 encouraged R366 to report incidents timely and to be mindful of her environment to prevent tripping, stated okay. R366 was assessed from head to toe and no other injury noted apart from the discolorations mentioned. R366 denied any pain or discomfort at this time. R366 was placed on observation with staff. Neurological checks were initiated and were normal. Active range of motion was completed with no issue. R366's neurological checks documentation notes it was initiated on [DATE] at 9:45 AM. R366's POS (physician order sheet), dated [DATE] at 9:50 AM, notes an order for facial x-ray due to fall. On [DATE] at 3:30 PM, V12 (smoke monitor) stated that he was working on [DATE] from 2:30 PM until 10:00 PM. V12 stated that R366 got a cigarette and sat down to smoke. V12 stated that R366 was on the patio until her smoke break was over at 5:20 PM. V12 stated that when R366 was finished smoking, R366 got up, walked over and placed cigarette butt in the discard container. V12 stated that R366 then walked around garbage can, staggered and fell to the ground hitting head. On [DATE] at 8:53 AM, V31 (Outside Program Employee) stated that V31 works for a program that assists residents to move back into the community. V31 stated that V31 was at the facility on [DATE] at 5:40 PM to visit with two residents. V31 stated that as V31 was signing the logbook at the reception desk, a security guard approached the receptionist and asked for a wheelchair and to have the nurse called because somebody fell on the patio. V31 stated that the receptionist said she would call nurse but did not know where to find a wheelchair. V31 stated that V31 informed them to get a wheelchair from the skilled therapy department. V31 stated that V31 observed R366 being pushed to the elevator; R366 had a dark red purple discoloration to left eye and was complaining her head hurt. V31 stated that V31 rode in the elevator with R366 and got off with R366 on the second-floor nursing unit. V31 stated that staff parked wheelchair with R366 at the nurses' station and the nurse was attempting to obtain R366's blood pressure. V31 stated that V31 visited one resident for 20 minutes. V31 stated that R366 was still in wheelchair at nurses' station with the nurse. V31 stated that V31 left the nursing unit to see another resident. V31 stated that about 6:15 PM V31 heard a code blue paged overhead. V31 stated that afterwards V31 approached the receptionist desk to sign out before leaving facility. V31 stated that V31 saw EMS (emergency medical services) crew arriving at facility. V31 stated that V31 asked the receptionist if the crew was here to get R366 and was informed 'yes'. On [DATE] at 12:35 PM, V16 CNA (Certified Nurse Aide) stated that he worked evening shift on [DATE]. V16 stated that R366 went down to the patio for smoke break. V16 stated that R366 can leave the nursing unit independently to smoke on the patio. V16 denied any staff member that accompanied R366 on that day. V16 stated that V16 does not recall what time it was when V15 RN (Registered Nurse) assessed R366 and screamed call EMS 911. V16 denied calling 911. V16 was unsure who did call 911. V16 denied any other staff coming to the nursing unit to assist V15. On [DATE] at 3:12 PM, V15 RN stated that V15 was coming out of the medication room and escorted R366 to R366's room and immediately assessed R366; R366 had a gash to the left side of her head. V15 stated that V15 obtained vital signs, R366 was lethargic. V15 stated that R366's vital signs were abnormal, oxygen saturation level was decreasing to 87% on room air. V15 stated that she placed R366 on oxygen 2 liters via nasal cannula and oxygen saturation level increased to 95%. V15 stated that EMS crew arrived 10 minutes later. R366's vital sign documentation, dated [DATE] at 5:55 PM, notes blood pressure 104/68, pulse 104 beats/minute, respirations 18 per minute, and oxygen saturation level 87% on room air. At 5:58 PM, oxygen saturation level 95% on oxygen. R366's EMS run sheet, dated [DATE] notes the facility contacted EMS at 6:12 PM for an unresponsive resident. EMS crew was en route to the facility at 6:14 PM, arrived at 6:18 PM, and were at R366's bedside at 6:21 PM. The narrative notes crew dispatched to patient unresponsive with CPR (cardiopulmonary resuscitation) in progress. Upon arrival, R366 laying supine in bed unresponsive with CPR being performed by nursing home staff. Crew advised staff to pause CPR and perform a pulse check on R366. Crew noted R366 had a pulse and was breathing. Crew placed defibrillator pads on R366 and cardiac monitor showed sinus rhythm. CPR discontinued. Staff reported R366 was downstairs outside of facility when she fell and hit her head. Staff reported they brought R366 back to her room in a wheelchair while she was alert and orientated x3 per her normal. Staff reported R366 became unresponsive when getting back to room. Staff reported they put R366 on the bed and initiated CPR because R366 was not breathing. Crew noted hematoma to back of R366's head. R366 presented with battle sign behind left ear. Crew noted R366 had swelling with black and blue discoloration to left eye. Staff reported R366 had a previous fall approximately one day prior to crew arrival. R366 transferred to ambulance. ALS (advanced life support) care initiated. Cardiac monitor showed sinus rhythm. Crew administered oxygen via nasal cannula at 6 liters/minute. Crew noted decreased lung sounds in lower fields bilaterally and some snoring respirations bilaterally in upper fields. R366 presented with dilated pupils. R366 arrived at closest hospital at 6:48 PM. R366's hospital record, dated [DATE] at 6:51 PM, R366 presented unresponsive to the hospital. R366 was noted to have bruising around left eye and around left mastoid. R366 noted to have a large scalp hematoma (swelling). R366 is minimally responsive. R366 is breathing on own but does not respond to pain or voice, does not open eyes. Pupils are fixed and dilated. Given exam, signs of trauma to the head, Battle sign, bruising over the mastoid, R366 was emergently taken for CT (computerized tomography) of head. R366 noted to have a large traumatic subdural with shift causing herniation. There was concern for catastrophic injury. At 7:00 PM, neurological checks noted corneal reflex absent to both eyes. R366 was seen by neurosurgeon who deemed that R366's prognosis was very poor without any chance for any significant functional outcome. The CT scan of R366's head showed a large right cerebral convexity acute subdural hematoma measuring up to 3 cm (centimeters) with severe 1.7cm leftward midline shift, subfalcine and uncal herniation and enlargement of the left lateral ventricle concerning for developing entrapment. R366 expired on [DATE] at 4:40 PM. R366's death certificate was not available for review during this survey. On [DATE] at 3:05 PM, V3 DON (director of nursing) stated that R366's facial Xray was not completed prior to R366 being transferred to the hospital. V3 stated that it was not ordered to be done urgently. V3 acknowledged that given the bruising to R366's left eye and posterior left ear, R366 should have been transferred to the hospital when staff first noted injury earlier in the day. The National Library of Medicine, dated [DATE], notes Battle sign is bruising over the mastoid process and typically requires significant head trauma and may indicate significant internal injury to the brain. It takes Battle sign 1-2 days for the sign to appear. Battle sign is a clinical sign. The facility's change in resident's condition or status policy, undated, notes except in medical emergencies, physician notification will be made within 24 hours of a change occurring in the resident's condition or status. During medical emergencies 911 will be notified for transport to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that staff provide timely assessment and adequate intervention for a resident who was experiencing complications with an indwelling urinary catheter. This failure affected one (R2) of two residents reviewed for urinary catheter care. This failure resulted in R2 experiencing a delay in assessment and treatment while experiencing a leaking urinary catheter, abdominal fullness, and pain before being transferred to hospital and being treated for urinary retention secondary to malfunctioning urinary catheter and (UTI) urinary tract infection. Findings include: R2 is a [AGE] year-old male admitted to the facility on [DATE], medical diagnosis includes, but not limited to Multiple Sclerosis, quadriplegia, cardiomyopathy, bipolar disorder, other specified myopathies, abnormal posture, vitamin D deficiency, major depressive disorder, essential primary hypertension, acute cholecystitis, epilepsy, hyperlipidemia etc. Minimum Data Set (MDS) assessment dated [DATE] section C (cognitive) documented that resident is cognitively intact with a BIMs score of 15; Section H (bowel and bladder) stated that resident is always incontinent of bowel; Section GG (functional status) documented that R2 requires substantial/maximal assistance to total dependence on staff for all activities of daily living (ADL) care. Care plan initiated 2/9/2024 stated that R2 is at risk for complications related to catheter use, interventions include monitor indwelling catheter and change urinary bag as needed, observe intake and output, monitor urine for increase sediment, cloudy urine, odor, etc. 6/24/2024 at 11:45AM, R2 was observed in his room, awake and alert sitting in his motorized wheelchair. R2 stated that he has been at the facility since February 2024. The day he went to the hospital, his urinary bag was leaking, bladder was very full, urine was backing up to his bladder and causing him a lot of pain. R2 went to the nurse at the nursing station and told the nurse that he would like his bag to be changed and she told him to go back to his room. R2 said he went to the nurse again because he was in a lot of pain and asked the nurse to call 911 and she told him to call 911 himself after all he has a phone. R2 called 911 and was taken to a local hospital where they drained a large amount of urine from him and he felt better immediately, the hospital told him that he had a bladder infection, and he was started on antibiotics. Hospital record dated 6/23/2024 to 6/24/2024 states in part: patient's presentation seems most consistent with acute urinary tract infection and urinary retention secondary to malfunctioning urinary catheter, urinalysis seems consistent with infection. Patient's urinary catheter was replaced, and he had decompression of his bladder with resolution of his lower abdominal discomfort. Patient received an IV dose of ceftriaxone in the emergency room and to be discharged with 10-day course of Keflex. emergency room physical assessment of the abdomen documents the following: there is tenderness, palpable suprapubic fullness, tenderness to palpation. Bladder scan on 5/23/2024 at 23:44 showed 1358 ml of urine. Medication administration record (MAR) documented that R2 was receiving Keflex 500mg, 1 tablet by mouth three times a day for UTI starting 5/24/2024 and completed on June 2, 2024. On 6/24/2024 at 10:16AM, V5 (Registered Nurse/RN) said that she was the nurse that took care of the resident at the hospital, resident was crying and stated that he asked numerous nurses at the nursing home to change his urinary catheter, he was in so much pain and felt like his bladder is full. V5 said that it took them 5 minutes to change the resident's urinary catheter and he felt immediate release. V5 added that R2 was also treated with oral antibiotics for urinary tract infection, she stated that all these could have been avoided if the facility just changed the resident's urinary catheter. 6/24/24 at 3:50PM, V2 (Director of Nurses/DON) said that the day R2 went to the hospital, he called 911 because he said that his urinary catheter was leaking and needed to be changed, the nurse told him to wait until after medication pass because it is not an emergency. V2 stated that resident's urinary catheter was changed in the emergency room, and he was treated for urinary tract infection (UTI). V2 added that UTI can be caused by lack of proper urinary catheter care, not being changed on time or urine output not being emptied, poor hygiene etc. 6/24/2024 at 12:45P, V3 (RN) said that she was off for two days, came back to work the day R2 went to the hospital and worked double shift that day. Resident came to her and stated that he has been asking nurses to change his urinary catheter for the past three days, his catheter was leaking. V3 checked the catheter, and it was not leaking, resident still wanted his catheter changed and V3 told the resident to wait until after medication pass. V3 stated that this happened around 4 to 5PM, resident never told her to call 911, the next thing she saw was the paramedics that came to take resident to the hospital around 10:00pm. 6/25/2024 at 1:50PM, V7 (Certified Nursing Assistant/CNA), said that she was assigned to R2 the day he had an issue with his urinary catheter. R2 stated that his urinary catheter was pulling and leaking, that was before lunch and the nurse was aware. V7 added that she did not empty any urine from resident's bag on her shift (7am to 3pm) because his bag was leaking and all the urine was in the incontinence brief, resident was also complaining of pain. V7 added that the CNAs are supposed to tell the nurse how much urine they emptied from the urinary catheter bag, the nurses document them in medical record. 6/26/2024 at 11:46AM, V6 (Attending Physician) said that that nurses are supposed to change resident's catheter every month and as needed and this should be documented. V6 added that some factors that could contribute to the development of UTI in residents with urinary catheter include lack of routine care with aseptic technique, making sure the catheter is in place, monitoring intake and output, etc. Physician order dated 2/9/2024 reads as follows: Change urinary catheter bag monthly and as needed every night shift starting on the 10th and ending on the 10th every month for infection control. Urinary catheters care every shift and as needed for soilage, Monitor and record amount/character of urine every shift for urinary catheter, Monitor and Record Color of urine. A document presented by V2 (DON) (undated), titled, Urinary Catheter Care states in its purpose: a resident with an indwelling catheter is susceptible to urinary tract infection. Under standards, the document states in part: catheter care should be provided every shift and any time incontinent episode occurs .urinary bags will be changed monthly and PRN (as needed). Intake and output will be monitored via physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop an individualized plan of care for a resident identified to be at risk for aspirations and assessed to have impairments while eating. The facility also discharged resident from speech therapy before reaching the short-term goals identified in evaluation. This affected one of one resident (R13) reviewed for safe oral intake. This failure resulted in R13 becoming unconscious, CPR (cardiopulmonary resuscitation) being initiated, excessive amount of food found in R13's airway, and resident being admitted to hospital. Findings include: R13's face sheet shows diagnosis of alcohol dependence with alcohol induced persisting dementia, induced by alcohol dependence, heart failure, atherosclerotic heart disease of native coronary artery. R13's MDS (Minimum Data Set) dated 7/19/2023 section C for cognition denotes a score of 9 (cognitive impairments). Section G for functional status denote in part eating, self-performance is extensive assist (resident involved staff provide weight bearing support), support denotes 2 (one-person physical assist). Police report dated 8/12/2023 denotes in-part ambulance call, to nursing home name listed, victim is R13, date of birth noted, other individual denotes V40 name and date of birth , call in at 12:34pm, In brief on 8/12/2023 at 12:34 pm, r/o (responding officer) was dispatched to (facility address noted) 4th floor (facility name noted) in regard to an ambulance call. Upon arrival r/o spoke with V40 Nurse (name is noted in police report) advise that patient identified as R13 was observed on the ground in the hallway in the middle of the hallway unresponsive and not breathing. Staff immediately began CPR (cardiopulmonary resuscitation) on R13 and called paramedics. R13 was seen eating lunch prior to this incident and believed that may have been choking. FD (fire department) arrived on scene and began working on patient. Patient was transported to (hospital name) for further treatment. R13's emergency room records denote in-part, prior to seeing patient review of triage note, vitals. This is a [AGE] year-old male presenting as a cardiac arrest, patient was at the nursing home today was eating lunch walked out of the dining room, had jerky movements was lowered to the to the ground, turned blue, arrested. Patient often walked around all day long, staff did CPR for 10 minutes. EMS (emergency medical services) arrived and did additional 20 minutes of CPR. Patient initially pulseless, had 2 defibrillations for ventricle tachycardia. He receives epinephrine 4 times prior to arrival and his second shock was just prior to arrival. On arrival his first pulse check he had a pulse. Patient had a LMA (laryngeal mask airway) placed. They noted in route that there was some foreign material in his airway, but they were able to bag with that with slight difficulty. Resuscitation cardiac arrest. I spoke with patient's sister and nursing home. Per the family patient was at the nursing home, he has dementia in the setting of alcohol abuse. He was eating in the dining hall, got up and walked out to the hallway. Began to have choking, staff came to assist, they lowered him to the ground where he continued to choke and went unresponsive and turned blue. He started CPR. Suspected hypoxic arrest. Here with occlusion of airway, able to bag with removal of significant foreign body. Impression and plan; cardiac arrest. Chief complaint; cardiac arrest. R13 is a [AGE] year-old at (nursing home name) presenting for cardiac arrest. History per EMS (emergency medical services), NH (nursing home) staff, chart review based on clinical condition. Per EMS, they were called for cardiac arrest to NH. Witnessed, bystanders EMS chest compressions. There were concerns about a choking episode. EMS removed a significant amount of food from his airway upon arrival. They placed a supraglottic device. They were able to use BVM (bag valve mask) without resistance. Downtime prior to EMS arrival at the nursing home was 12 minutes. EMS remained on scene for 19 minutes. They administered a total of 3 rounds of epinephrine. Initially patient was PEA, asystole. V-fib, PEA, V-fib, PEA. A total of 3 rounds of epinephrine. Two defibrillations. Antiarrhythmics not given. Normal accu-check. Patient arrives to us with I-gel in place. Repeated accu-check in the 200s. Definitive airway established, see MDM. Additional history obtained from nursing home staff. Patient has resided at nursing home x 4 years. He is admitted for severe alcohol induced dementia. The patient was in the dining room, ate lunch. Walked out of the dining room into the hallway and started making chocking noises. They immediately went to attend to him and then the patient collapsed, was cyanotic. CPR was initiated. Full code. ED course, based on history and airway findings, concerns for aspiration event, hypoxia, cardiac arrest. ED diagnosis; cardiac arrest. R13 fire department report dated 8/12/2023 denotes in part in summary: was dispatched to the nursing home to assist fire department for [AGE] year-old male for the reported cardiac arrest, U/A (upon arrival) to the scene pt (patient) was found lying supine on the ground unresponsive, pulseless, and apneic with (fire department) crew actively performing CPR with BVM (bag valve mask) ventilation. Healthcare staff on scene stated the patient was eating when he walked into the hallway gasping for air and was witnessed collapsing to the ground inro cardiac arrest. Nursing home staff originally began CPR and applied AED, patient had been down approximately ten minutes when crew arrived. When visualized the vocal cords via laryngoscope crew noted an excessive amount of food in the patient's airway. Crew began to remove the debris, via forceps from patient airway intermittently between ventilations. Number 4 I-gel inserted after vocal cords were still unable to be visualized due to aspiration, confirmed by other crew members. Continues CPR began. On 4/23/24 at 10:56am V40 (Licensed Practical Nurse/LPN) said she was in the dining room when she observed R13 with jerky movements. V40 said she went over to R13 and R13 became unconscious. V40 said a code blue was called and R13 was lowered to the floor. V40 said R13 did not have a pulse nor did R13 have any respirations. V40 said she don't know why she was in the dining room; she just knows she was there. V40 said she don't know how long she was in the dining room. V40 said she did not see R13 eat his lunch. V40 said R13 was finished with lunch when she observed him. V40 said she don't remember if R13 needed assist with meals. V40 said she don't know who she told to call a code blue; she doesn't know who she told to call 911. V40 said she don't know if R13 had issues with chewing or swallowing, she doesn't know if R13 had all his teeth. V40 said she started chest compression on R13 when R13 was observed unconscious. V40 said she may have talked to the paramedics when they arrived on the scene. V40 said she did not tell the medics that R13 was found in the hallway unconscious. R13 Fire department report reviewed with V40. V40 said she don't know why the paramedics stated that in their report. V40 denied telling the paramedics that R13 was in the hallway collapsed. V40 said sometimes the hospital do call the facility when they want more information on the resident. V40 said she don't remember if she talked to the emergency room regarding R13. V40 denied knowing if R13 was at risk for choking, V40 denied that R13 was at risk for aspiration. On 4/23/24 at 1:38pm V43 (Certified Nursing Assistant/CNA) said she was R13's aide on 8/12/2023. V43 said R13 spoke Spanish but was able to understand English when she communicated with him. V43 said she passed R13 his tray lunch tray on 8/12/23, but she did not assist R13 with his meal. V43 said she only cut R13's food up. V43 said she was in the dining room doing a one-to-one observation with a resident that was experiencing a behavior episode. V43 said lunch was over, trays had been picked up. V43 said she looked over and saw R13 shrugging his shoulders. V43 said she did not hear R13 making any coughing sounds. V43 said she thought R13 was exercising. V43 said V40 was in the dining room, and she got V40 attention and told her to check on R13. V43 said V40 was in the dining room covering for another aide that was completing patient care at that time. V43 said V40 went to R13 and placed him on the floor from the chair. V43 said V40 told her to call code blue. V43 said she don't know who called 911. V43 said all the staff came to assist V40. V43 said she don't know who came, she doesn't recall. V43 said she don't know what happened after that because she was removing the resident from the dining room. V43 said she often worked with R13 and R13 did not need any assistance with meals. V43 said she has never assisted R13 with any meals. V43 said she only cut up R13's food (set up tray). V43 said she cut the food up because that's what they do for all the residents on the 4th floor because they have dementia. V43 said R13 does have dementia. V43 said some residents on the 4th floor be gobbling their food down, V43 said the residents eat fast. V43 omitted reporting her observations of residents gobbling there food down to the nurse or the Director of Nursing. V43 denied knowing if the resident that was gobbling their food down were at risk for aspiration. V43 said she only observed R43 being assisted with meals once. V43 said the residents were served pork on 8/12/23. V43 denied that R13 was at risk for choking/ aspiration. During a follow up interview on 4/24/24 at 3:56pm V43 said she documented 3, 2 for eating for R13 on 8/12/24 for breakfast and lunch. Review of the documentation denotes 3 is for extensive assist, and 2 is for one-person physical assist. V43 said she thought she was documenting for set up only. V43 said she received training on documentation in the system. V43 said she knows the difference in extensive assist and set up because she helps R3 get dressed and R13 needs extensive assist with dressing. Review of V43 documentation for R13, denotes V43 documented 3, 2 for eating for R13 on multiple days that week for multiple meals. V43 then said R13 does need a lot of cueing when eating, V43 said R13 was constantly reminded to eat his food. V43 said she puts R13's hand on the spoon and guide R13 to put the food in his mouth also when she had to cue him. V43 described R13 would stop eating and began to stare, that's why he needs constant reminders to eat. V43 said she cuts R13's food up because he has dementia. V43 said V40 was responsible for monitoring the dining room on 8/12/23 and V40 was responsible to monitor the residents for safety. V43 said V40 was to monitor to make sure the residents were eating, monitor the residents for choking, and assist and cue the residents as needed. V43 said usually there are 3 to 4 staff (activity aides and social worker) monitoring the big dining room, and all CNAs would monitor the small dining room during meals times. V43 restated that she did not assist R13 with lunch on 8/12/2023. V43 denied that she spoke to the paramedics when the arrived at the facility on 8/12/2023. Review of the facility 4th floor dining room time for 8/12/23 denotes V40 name listed for the 12:30pm time. There is no name or time listed for the 12:00pm time. V43 name is listed for the 11:30am time. On 4/23/24 at 2:28pm V51 (Rehab Director) said R13 was referred to speech therapy on 3/9/2023 for a swallow assessment due to weight loss and increased need for assistance/ cues required to complete meals for adequate and safe oral intake. V51 said she did not conduct the evaluation, V51 said she was not sure of some of the language in the evaluation and discharge summary. V51 agreeable to have a speech pathologist assist with review of R13's speech evaluation and discharge summary. On 4/26/24 V51 said R13 did not have dysphagia, and the diagnosis dysphagia is a treatment diagnosis to allow for the speech evaluation. V51 said R13's last speech treatment date was 3/22/23, and that 6/2/23 was not correct. On 4/26/24 at 12:25pm am V56 (Speech Pathologist) said she did not complete the assessment for R13 in March 2023 however was agreeable to review the evaluation and discharge summary. V51 was present. V56 said R13 was referred per MD orders and facility dietary tech for evaluation for swallow assessment due to recent decline in weight and increase need for assistance/ cues required to complete meals for adequate and safe oral intake. V56 said R13's evaluation denotes labial closure for solids, mild (difficulties). V56 described R13 had difficulties with bring the lips to a closure, R13 ate with his mouth open. V56 said R13 noted with rapid mastication (R13 ate fast). Bolus formation - moderate (difficulty). V56 said R13's evaluation denotes R13 was found to have swallow disorder involving the oral phase. Patient presents with mild oral dysfunction, evidenced by difficulty initiating oral stage, anterior spillage of solids, incomplete bolus formation, inadequate mastication/ rotary chew pattern, effortful mastication, oral residue, and poor attention to task. V56 said R13 had behaviors, the therapist documented R13 would get up walk away, R13 would eat fast. V56 explained that difficulty initiating oral phase could be getting R13 started with the meal, anterior spillage is food falling out the mouth, R13 had difficulty chewing the food and forming a bolus of the food (that's when chew the food and mixing it with saliva making it a bolus, inadequate mastication is inadequate chewing of the food, oral residue is when some food remains in the mouth after swallowing, and poor attention to task.) V56 said the recommendations was for dysphagia treatment. Supervision was distant supervision. Strategies to facilitate safety and efficiency, it is recommended the patient use the following strategies and or maneuvers during oral intake, general swallow techniques/precautions, alterations of liquids/solids and bolus size modifications, upright posture during meals and upright posture for greater than 30 minutes after meals, environmental modifications via reduction of distraction, setup and food cutting up assistance, supervision. V56 said general swallow techniques and precautions as listed. V56 described alternating between solids and liquids would be taking a sip of water/liquids after swallow food. V56 described cutting the food into small sizes would be bolus size modifications, sitting upright during meals and sitting up after meals for greater than 30 minutes would aide in digestion of food. During the evaluation short term goals are developed based on the identified issues. Review of R13's goals, patient will improve oral clearance during meals in response to cues/strategies provided by ST (speech therapist) and trained caregivers at 80% of opportunities. Patient will improve bolus control and labial seal to reduce bolus loss in response to cues/strategies provided by ST and trained caregivers at 80% of opportunities. Patient will improve attention to meals in response to cues/strategies and environmental modification provided by ST and trained caregivers. V56 said R13's discharge recommendations were that prognosis was good with consistent staff follow through. R13's recommended diet was regular texture, thin liquids, swallow strategies/position: to facilitate a safety and efficiency, it is recommended patient use the following strategies and maneuvers during oral intake; general swallow techniques/ precautions, alterations of liquids/solids, rate modification and bolus size modifications, upright posture during meals and upright posture for greater than 30 minutes after meals, meal intake in dining room. Supervision for oral intake; distance supervision. V56 said she don't know how the facility planned to ensure swallow techniques/precautions, alternating between liquids and solids, rate modifications and bolus size if the recommendation is distance supervision. V56 said the discharge report denotes R13 was discharged prior to meeting his goal for oral clearance at 80% of opportunities. V56 said R13 was discharged meeting goal at 50-60% of opportunities. R13 did not meet his goal for improving bolus control and labial seal to reduce oral bolus loss in response to cues/strategies, and R13 continued to need for redirection and attention to meal. V56 said R13 was at risk for aspiration due to the swallowing difficulties identified, eating with mouth open, incomplete bolus formation, inadequate bolus control, inattention, fast eating, and difficulty with oral clearing. V56 said upon review of the evaluation and discharge, she would have questions as to why was R13 discharged before meeting his short-term goal. On 4/23/24, V13 (Director of Nursing) said he was not at the facility during the code blue for R13. V13 said the nurse documented what happened. V13 was asked if R13 choked on food. V13 said the nurse documented what happened. V13 said the facility did not complete an incident report for R13. V13 said he is aware that R13 was admitted to the hospital for aspiration. V13 said he is aware that R13 expired. On 4/26/24 at 2:00pm V50 (Restorative Nurse) said she was the restorative nurse, she was not employed in 2023, review of R13's care with V50, V50 said R13 required extensive assist of one-person physical assist with meals. Review of R13's annual restorative review with V50, V50 said R13 required extensive assist with eating, support of one-person physical assist with eating. 4/30/24 at 1:57pm V10 (Prior Restorative Nurse) said she is familiar with R13. V10 said she was the restorative Nurse in 2023. V10 said R13 required extensive assist of one-person physical assist with meals. V10 said the staff should be assisting with feeding by sitting with R13, cutting up R13's food, cueing R13 as needed, assisting R13 with eating. V10 said the aides are aware of the level of care the resident need because it's listed on the (electronic) charting. V10 said the aides also document the level of assist that's provided during ADLs and eating in the (electronic) charting. On 4/30/24 at 2:20pm V52 (Assistant Administrator) said she completed R13's restorative assessment on 7/19/2023 for R13. V52 said R13 needed extensive assist of one-person physical assist with eating. V13 explained that she was helping the Director of Nursing when she completed R13's assessment. V52 said she completed a physical assessment and she also review the 7-day look back for R13 and it was documented that R13 needed extensive assist of one-person physical assist greater than 3 times. V52 said the staff did not inform her of any issues, concerns with R13's eating abilities. R13's progress note dated 8/12/23 completed by V40 at 1:05pm denotes in-part resident was noted at approximately 12:30pm in the dining room and had finished eating (per staff), he started to have some jerky movements and was lowered by staff to the floor. Resident loss consciousness and code blue was called. CPR was initiated and 911 was called. Resident was taken to hospital via stretcher, resident sister was notified, MD (Medical doctor) was also called, and supervisor made aware. At 1:55pm hospital called back, and stated resident was admitted to hospital with diagnosis of aspiration. All parties made aware and resident belongings remain in his room, at this time meds placed in proper storage. R13's physician order sheet dated 3/9/2023 denotes in-part ST (speech therapy) to evaluate and treat 5 times a week for 4 weeks for dysphagia management s/p (status post) weight loss and increased need for assistance at meals. R13's care plan dated 7/19/23 denotes in-part R13 requires assist with ADL's (activities of daily living) to maintain highest possible level of functioning as evidence by the following limitations and potential contributing diagnosis, schizophrenia, heart failure, dementia, weakness, abnormalities of gait and mobility, hyperlipidemia, chronic kidney disease, anemia, anxiety disorder, unsteadiness on feet abnormal posture. Bed mobility up to EXT-X1 (extensive assist x1), transfer up to EXT-X1 (extensive assist x1), toileting up to EXT-X1 (extensive assist x1), eating up to EXT-X1 (extensive assist x1), transfer. R13 will maintain present level of function without decline by next review. Assist with meals as needed, bathing dressing transfers as needed, explain all tasks prior to starting, ensure proper positioning while in bed/chair, encourage resident to participate in all areas of care we are involved in exercise program as tolerated, rest periods as needed, involve social services as needed, turn and reposition every 2 hours, all meal trays to be set up with milk and other container open. R13's care plan for alteration in nutrition denotes in part receives therapeutic diets or mechanically altered diet, receives double portion with all meals, staff supervision with all meals. R13's care plan dated 7/19/23 denotes in part R13 has some or all-natural tooth loss, R13 will tolerate diet as ordered through next review. Monitor for chewing difficulty, monitor for mouth, or tooth pain, refer to dentist as needed encourage good oral care and/or assist with oral care as needed, encourage resident to wear dentures and/or bridges if applicable and that food serves as appropriate. R13's death certificate denotes date of death [DATE], cause of death complications of choking, how injury occurred choked on food bolus. Facility policy titled Care Plan Policy and Procedures, no effective or review date noted, denotes in-part each resident will have a comprehensive assessment completed that will assist in the development of an individualized plan of care that will include goals and interventions and to improve or maintain the residents highest level of function prevent decrease the complications of medical conditions medications and diagnosis decrease risk of injury or to promote comfort at end of life. Each resident will have a comprehensive assessment completed by the interdisciplinary team upon admission quarterly and with significant changes and an individualized care plan will be developed and updated as needed with readmissions and changes in condition. Weather care plans will be reviewed and updated as needed with readmissions quickly and with any significant changes in condition. The MDS nurse will be the primary lead of the care conference but in the absence of MDS the nurse, Social Services or other designee may conduct the meeting. The care plan will also be updated with any additional identified problems or approaches. Review of R13 care plan there is not documentation denoting the identified issues observed during the speech evaluation had resolved, there is no documentation of reevaluation of identified issues for safe oral intake for R13. Upon exit of this survey the facility failed to present the plan to ensure safe oral intake for R13, and or plan to reduce risk for aspiration for R13. Facility failed to present documentation denoting R13 was discharged from speech therapy before he met his short-term goals. Facility failed to present documentation for plan for aspiration for R13.

Based on observation, interview, and record review the facility failed to develop, implement, evaluate, and reevaluate a plan to prevent a continued insidious unplanned weight loss for one of three residents (R14) reviewed for unplanned weight loss. This failure resulted in R14 having a continued weight loss resulting in a significant weight loss of 18.55% in 90 days. Findings include: On 4/11/25 at 4:30pm V25 (R14's family) said R14 has lost a lot of weight. V25 said R14 lost about 30 pounds. V25 said she knows this because R14 would visit her home from time to time and she could recognize the difference in R14's weight. V25 said R14 has told her that the facility doesn't feed him. On 4/9/24 at 12:08pm R14 observed awake, alert, unable to be interviewed. R14 observed with non-sensical speech, very low tone. R14 cannot be interviewed. R14's physician order sheet dated 11/07/23 denotes orders for no added salt and concentrated sweets diet, regular texture, thin liquids consistency, add double portions at breakfast and sandwich at HS (nighttime). R14 weight record dated 4/8/24 denotes R14 weighed 179.2 pounds. R14 weighed 220 pounds on 1/5/2024. On 4/23/24 at 2:12pm with assist from V42 (Restorative Aide) and V50 (Restorative Nurse), R14 observed to weigh 175.3 pounds. On 4/9/24 at 12:58pm V26 (Dietary Assistant) said the resident's meal is served based on the information on the meal ticket. V26 said the dietary staff do not inform nursing staff if a resident does not come down for meals. Request was made to review R14's meal ticket. On 4/9/24 at 2:24pm V26 (Dietary Assistant) presents R14's diet slip. V26 reviewed the diet slip and stated she do not see any orders for double portion for breakfast and sandwich at night-time. R14's diet slip presented by V26 does not denote double portions and sandwich at HS as noted in the physician order sheet. On 4/11/24 at 8:46am V47 (Certified Nursing Assistant) said he was R14's CNA. V47 said he works with R14 often. V47 said he is familiar with R14. V47 said R14 was finished with breakfast, request was made to observed R14 breakfast tray. V47went to the food cart, retrieved R14's tray, R14's meal ticket observed on tray. R14's meal ticket did not denote double portions for breakfast and sandwich at HS. V14 said R14 ate 50% of meal. There was a half of a biscuit and sausage gravy observed on R14 tray. V47 said R14 did not have double portions for breakfast. V47 was asked if R14 should have double portions for breakfast. V47 said he does not know. V47 said he do not know if R14 had a significant weight loss. V47 said he is not aware of R14 having a weight loss. V47 said he does not know if R14 is currently on a calorie count. On 4/9/2024 at 3:12pm V49 (Psych Physician) said he did not have much time to speak with surveyor as he had to pick his children up from day care. V49 said he does not deal with weight loss. V49 said psych medications do not cause weight loss but in-fact will result in weight gain. V49 was made aware that one of R14's recommendations for weight loss was to consult the psych provider. V49 said he will assess R14 in front of surveyor, surveyor made V49 aware that, that was not necessary. V49 said he will speak to the Director of Nursing regarding the recommendations for him to see R14 due to weight loss. On 4/24/2024 V48 (Dietitian) said R14 is reviewed during the NARS (Nutrition at Risk) meeting in February 2024, V48 said R14 is reviewed for unplanned weight loss. V48 said R14 has had a significant weight loss in 6 months. V48 said initially in 2023, R14 had a desirable weight loss. V48 said the plan was to implement double portions at breakfast and a sandwich at HS, consult with the psych physician, and weekly weights. V48 did not respond when asked when did the planned weight loss become unplanned weight loss. V48 said usually the facility serve the resident meal based on the information on the diet slip. R14's diet slip from 4/11/24 (retrieved from meal tray) and 4/9/24 (presented by dietary assistant) reviewed with V48. V48 confirmed that there is not documentation denoting that R14 should have double portions for breakfast and a sandwich at HS. V48 said she believes she knows why but she does not want to discuss that with the surveyor. V48 made aware that surveyor retrieved the tickets on different days and surveyor cannot conclude that the physician orders and dietitian recommendations was followed for R14 for weight loss interventions. V48 was made aware that the psych physician said he does not see residents for weight loss, and that psych medications do not cause weight loss but in fact will result in weight gain. V48 said the double portion and sandwich is to increase calorie intake to stop weight loss. R14's dietary progress note dated 4/8/2024 denotes in-part weight warning, 7.5%, 10%, diet NCS/NAS (no concentrated sweets, no added salt) regular thin liquids, double at B (breakfast), sandwich at HS, plan recommendations continue current nutritional management. R14's care plan for weight loss denotes in part, resident has experienced weight loss, resident will not have any sig (significant) wt. (weight) until next review. Intervention refers to MD/RD if there is a 5% wt. loss x 1 mo. (month) or 10%, wt. loss over 6 months. Weight resident monthly per facility protocol, weekly weights/ NARs review. Provide diet as ordered. Notify MD of weight change greater than 5% x 1 month. Double portions at breakfast, sandwich at HS, refer to SS(social services)/psych, weight monitoring/NARS review refer to RD (Registered Dietitian). Facility policy titled care plan and procedures, no effective, review or revised date noted denotes in-part each resident will have a comprehensive assessment completed and will assist in the development of an individualized plan of care that will include goals and interventions aimed to improve or maintain the resident highest level of function prevent decline decrease risk of complications of medical conditions medications and diagnosis, decrease risk of injury or to promote comfort and end of life. Each resident will have a comprehensive assessment completed by the interdisciplinary team upon a mission quarterly and with significant changes and in individualized care plan will be developed and updated as needed with quarterly assessment, readmissions, and changes in condition. Resident care plans will be reviewed and updated as needed with readmissions quarterly reassessment annually and with significant changes in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to keep a resident free from involuntary seclusion by not allowing a resident to discharge from the facility against medical advice immediately after the resident expressed the desire to discharge from the facility. This failure applied to one (R569) of one resident reviewed for discharge and resulted in R569 being kept in the facility against her will for two days and experiencing anxiety and psychosocial harm as a result of not being allowed to leave the facility. Findings include: R569 was admitted to the facility on [DATE] with primary diagnosis of congestive heart failure and admitting diagnoses of lupus and anemia. Other diagnoses include essential hypertension, hypokalemia, and long term (current) use of anticoagulants. On 8/16/22 at 9:01 AM R569 was asked about her experience surrounding her admission and discharge to the facility and stated the following: I have my own apartment. I have CHF (congestive heart failure) and I don't have a vent (in my apartment) and only have fans. My neighbors smoke and everything comes in here. I was feeling sick and called 911, and the ambulance took me to (local hospital). Thinking that the hospital social worker would help me find a better place, I agreed to go to the facility. When I went into the room, I saw all these men running around, God knows what was going on. I asked what kind of place is this? I'm not mentally ill, why did they bring me here? I'm supposed to be at an independent living place. The hospital social worker told me that I am free to leave whenever I want. When I tried to leave, the security guard came and then called the med team and said they were going to give me a shot. I told them they weren't going to give me anything and they better not touch me. They wouldn't let me leave so I called the police; they came, and the ambulance came. The police came and said I couldn't leave because the medical record said I was drunk and using drugs, I never used drugs in my life. The facility must have given them false information from my medical record, so they told me I couldn't go anywhere. After the police left, I went back into my room. They had such a nasty attitude and said no, I have to talk to the social worker tomorrow. My mind was in shock, I stayed up half the night and waited until the morning. I told the lady I was on my monthly and they still didn't give me anything to take a shower or nothing. Social work director or something like that came into my room in the morning and asked me why I was in this facility. I told him that I didn't know why I was here. He looked at the computer and said my record said I had meth and something in my system, I don't know what that is, I don't use drugs. They said I had alcohol in my system and slobbering at the mouth; I told him I never did any of those things. Then he looked and said that is not me, that's a man. I offered to show him my driver's license so he could see that it wasn't me. They treated me like a dog. They didn't feed me. I couldn't take a shower and I was on my cycle. The same way they are treating me, they are treating all of those people in there. The staff talk to people like they are dogs. I have no mental illness. I have lupus and heart problems. My niece had to sign me out of that place. It felt like a dream, or a movie, something that is not real. It's so sad. I cried and cried and cried. I have video and you can hear how they are talking to me, and you can hear me just crying. R569 became very emotional and crying during interview; she stated that she always cries when she talks about this experience because she can't believe it actually happened. Local Police Department - Event Report dated 8/8/22 20:26:40 documents the following information: Nature: Assist Citizen Caller: (Resident Name) R569 Notes: Caller is in (room#), would like to leave and is hysterical [8/8/22 20:28:10] SAYS HER FRIEND IS ENRT TO GET HER, AND THEY ARE TELLING HER SHE CAN'T LEAVE [8/8/22 20:28:52] Subject is calm and was advised by staff that she cannot leave until she is evaluated by social worker tomorrow morning [8/8/22 20:46:30] Call Received: 8/8/22 20:26:40 Call Routed: 8/8/22 20:28:35 1st Dispatch: 8/8/22 20:31:20 1st En-Route: 8/8/22 20:31:20 1st Arrive: 8/8/22 20:41:36 On 8/18/22 at 4:39 PM, V19 (Social Service Coordinator) was asked about interaction with R569 since he had written a note in the medical record, documenting that resident had behaviors when redirected off the elevator. V19 stated that the resident was not on his caseload. V19 continued to explain that the resident was not allowed to leave as she requested because she needed to have someone sign her out and would not provide them with her address or the name of her landlord or phone number. It's part of the policy and procedure for residents to provide this information if they are leaving. She did not have a guardian or POA that I'm aware of. When asked why R569 had to provide the name and phone number of her landlord to discharge if she is her own decision maker. V19 said, we just want to make sure that residents have a safe discharge. We needed to make sure that someone is here to pick her up for her safety and her health. Surveyor asked V19 why a resident who is their own decision maker, has no guardian or POA, no diagnoses of mental illness or developmental disability, and no apparent skilled care needs was not allowed to leave AMA as requested? Further, why does someone need to sign this individual out? V19 stated that the situation was brought to the attention of his supervisor, V17 (Social Service Director). On 8/18/22 at 4:51 PM, V17 (Social Service Director) was asked the same questions as were asked to V19. V17 said, R569 came in the day before and so I saw her the next day - we basically tried to see what she was here for and what we could do to help her. When I found out that she wanted to be discharged we called the doctor and informed him that she wanted to be discharged . I wanted to make sure that she had a safe ride and could make it to her destination. We tried to know where she was going to make sure that she had a legitimate ride for a safe discharge. From my understanding her ride didn't show up to pick her up. When her ride didn't show up, she needed a dial-a-ride to come and get her so the next day she left. There wasn't really a delay - her transportation didn't come to get her. Our number one concern was her safety. She was her own decision maker that I know of and did not have a POA. She just did not have transportation. When asked why transportation was a requirement for discharge? V17 stated that it was to ensure the resident's safety. On 8/18/22 at 5:07 PM V1 (Administrator) said, I spoke to the social services team on the 9th when they were trying to assist her, when they told me that a family member was going to pick her up. Social service wanted someone to be aware that she would be leaving. We gave her $5 and allowed her to go. She waited patiently for her family to come but they never arrived. There was conflicting information with the paperwork that we received from the hospital versus the packet that the patient arrived with, in social services trying to dissect that, they discovered the discrepancy. V1 was asked what the admissions process is in determining that a resident is appropriate for skilled nursing care and their facility. V1 responded that the resident was appropriate because the PASRR showed that the resident was eligible for skilled care. When asked again what specific, skilled care needs the resident had, V1 stated that she had congestive heart failure. When asked if a diagnosis alone is sufficient to require skilled care, V1 referred to the clinical team that makes the determination if a resident is appropriate for medical care. V1 confirmed that R569 had no psychiatric diagnoses but was in the facility for medical care. V1 was asked what were the medical needs of the resident that caused her to be admitted and V1 did not answer the question and referred to V2 (Assistant Administrator), who is part of the clinical team that makes admission decisions. On 8/18/22 at 10:56 AM, R569 continued with interview and stated, that the facility wanted her to be signed out by someone when she told them she wanted to leave. I told them I have no family members in Chicago, and I have only been here for two years. If I had no one to sign me out, I would have had to stay there. They weren't going to let me leave without anyone. My niece in Louisiana had to email them back the form with a copy of her driver's license so that I could get signed out. Then (dial-a-ride) service came to pick me up. I had to pay (dial-a-ride) service $3.25 to come and pick me up (when I finally was allowed to leave). The first night a friend of mine paid someone she knows $40 to come and pick me up. My friend was there when the police came, and they told her too that I couldn't leave. The second night I called (dial-a-ride) service and the supervisor opened a case because it wasn't a 24-hour notice, and you are supposed to call 24 hours in advance, but when they came to pick me up, the facility still wouldn't let me leave with them. I have no care needs. I am fully independent and need no assistance with anything. I have no problem taking my medication or accessing care or other needs. I have no pain management issues. I only have pain when my lupus flairs up and my skin gets irritated, but I just keep it clean and wash it. I just try to rest as much as I can. I never saw a doctor or nurse practitioner while I was in the facility. When they (facility staff) came toward me, I told them don't put your hands on me and they didn't touch me, but it felt like it came close. It's like a movie, I never seen such a thing in my life. I didn't even think anything like this ever existed. I told them they are holding me against my will, and they were just telling me that I wasn't going anywhere. I thought my life was gone. I'm in the medical field, I'm a lupus advocate and I know that they really give people shots to knock them out. They wouldn't take me to the hospital because they said, they will just bring me right back. On 8/21/22 at 1:19 PM, (post survey exit) surveyor received a return call from V44 (Hospital Social Worker). Surveyor asked V44 if she was familiar with (R569) and V44 recalled the resident well. When asked why R569 was admitted to a skilled nursing facility if her hospital discharge paperwork documents that resident was waiting for placement at an assisted living facility (ALF). V44 responded that the resident was ready to be discharged and it was taking long for any ALF facilities to get back to her and it was much faster to discharge the patient to a nursing home. She had gotten a response back from one other nursing home in the city. Also, they were waiting for the resident's toxicology screen to come back (which came back negative). When asked what care needs the resident had that needed to be provided by a nursing home, V44 responded that R569 did not have any care needs as she was very independent. R569 seemed to just want to get out of the basement apartment that she was living in at the time. V44 also confirmed that R569 is her own decision maker and has no impairment in regard to making decisions on her own. On 8/18/22 at 3:46 PM V45 (Admissions Director) stated that she mostly works outside of the facility, meeting with residents and working on screening for admissions. When asked if she had met with R569 prior to admission, V45 stated that since COVID, she can't always go to the hospital to see the patient before admitted them. In that case, she will just go off the paperwork received from the hospital and will do an initial assessment and then forward it to the clinical team to decide about whether they can meet the residents care needs and if they are appropriate for the facility. V45 confirmed that she did not meet with R569 or provide her with any information about the type of facility this was. On 8/18/22 at 5:18 PM V2 (Assistant Administrator) was asked why R569 was admitted to the facility. V2 stated that the hospital paperwork said that she was admitted for smoke inhalation, she has diagnosis of congestive heart failure, and chest pain. The day that she came, she had a packet from the hospital. I think the hospital gave her the idea that she was going to an assisted living facility. The record says that she was cleared by cardiology for discharge and was awaiting placement at an assisted living facility. Asked how the determination is made to accept a resident. V2 said, we review the packet sent over from the hospital and if they have the PASRR. When asked what medical care needs or activities of daily living the resident needed assistance with, which required skilled nursing care. V2 responded that (R569) had pain and did not provide any further details as to why the resident was admitted or what skilled care needs the resident had. Review of care plans and physician orders provided, do not include any orders for pain medication or any diagnoses related to any psychiatric disorders. Facility provided the following care plans (including but not limited to): - Discharge Potential / Discharge Planning Care Plan dated 8/8/22 includes: My discharge potential is: Fair My tentative plan is for me to move to: Not applicable Approaches/Interventions: As necessary, meet with me/my representative on a regular basis to help me with the mental preparation for discharge. Provide me with an opportunity to express my thoughts or feelings. Address my concerns prior to discharge. -R569 has a care plan for Specialized Psychiatric Programming dated 8/8/22 includes: I have a diagnosis and history of severe mental illness (SMI). The symptoms that I have are manifested by: Need for on-going psychoactive medication. Approaches/Interventions: Utilize assessment data (i.e., MDS, CAA's, Psychiatric Evaluation, Level of Functioning and Psychosocial History) to help determine my present needs, deficits, abilities and strengths. -Care plan for History of Suspected Abuse/Neglect/Trauma dated 8/8/22 and includes: I have the following Strengths and Abilities: Able to make needs and wants known. Hospital records document an admit date of 7/22/22 and admitting diagnosis of Chest Pain, R/O ACS. - Assessment: Atypical chest pain, Lupus, Anemia, and Cardiology consult: 2D ECHO normal; non-coronary ischemia - Plan: Cleared by cardiology for discharge, Anemia workup as outpatient - Social worker paid a visit and will be reverting to the patient regarding an assisted living facility. Awaiting placement in an assisted living facility. - UDS (urine drug screen): Negative 8/5/22 - Discussed with ER MD - Apparently patient is waiting for placement History of present illness: 49yo F with PMH SLE and CHF presented to the ED with non-radiating left chest pain that woke her up from sleep this morning after smelling smoke coming from the units above her basement. She also reports having some palpitations and mild dyspnea earlier, but they are now subsided. No fever, chills, cough/URI symptoms, N/V, leg swelling/pain, back pain, or other acute physical complaints. No recent travel or sick contact. Denies tobacco or illicit drug use. Pt denies any chest pain now. Review of New admission packet for R569 includes (but not limited to) the following information: Approved by V2 (Assistant Administrator). admission packet also includes copy of PASRR Screen Outcome which documents PASRR Level I Determination: No Level II Required - No SMI/ID/RC .Your Level I screen does not show that you have a serious mental illness or an intellectual/developmental disability (IDD). You do not need more screenings unless you have or may have a serious mental illness or an IDD and experience a significant change in treatments needs. Please note admission to a nursing facility is a choice made by you or the legal entities that have the authority to make decisions for you. This nursing facility screening notice does not require you to admit to a nursing facility. Typical Living Situation: Home alone Mental Health Diagnoses: No mental health diagnosis is known or suspected Substance Related Diagnoses - Does the individual have a substance related disorder (abuse or dependency)? Yes, Opioids, When was the last known use - Less than 7 days Is the request for nursing facility in any way associated with or resulting from the substance related disorder? No Dementia/Neurocognitive Disorders - Does the individual have a diagnosis of dementia/neurocognitive disorder? No Behaviors & Symptoms - Interpersonal Behaviors There are no known mental health behaviors which affect interpersonal interactions There are no known mental health symptoms affecting the individual's ability to think through or complete tasks which she/he should be physically capable of completing. There are no known recent or current mental health symptoms Behavioral Health Services - Has the individual received any of the following mental health services now or in the past? NO Behavioral Health Impact - Has there been legal intervention due to mental health symptoms/behaviors? NO Has the individual had to move to another setting because of mental health symptoms? NO Has the individual even been homeless? NO Are there other examples where the individual's life has been seriously affected because of mental health symptoms? NO Does the individual have a diagnosis of an intellectual disability? NO Is the individual suspected to have an intellectual disability that has not been diagnosed? NO Recommended Services - No recommendations at this time Recommended Supports - No recommendations at this time On 8/18/22 at 12:44 PM V3 (Director of Nursing) was asked about the procedure for residents wanting to discharge AMA (against medical advice). V3 stated that if they are their own responsible party, they call the physician and get orders. As long as the resident is stable, we provide education and have them sign AMA paperwork. On 8/19/22 at 2:39 PM, V43 (Medical Director) was asked if he was made aware that R569 requested to be discharged against medical advice. V43 confirmed that he was made aware. V43 said, I advise them that you have to consider the resident's mental condition but there is consideration for the patient's medical and psychiatric condition; but we investigate every allegation of abuse. Whenever the allegations come thru, they take it extremely serious no matter what time of day; they call me at my cell phone at any time of day. A lot of the patients' say that they are being abused so that they get attention. There is no shot except for COVID testing and shot for vaccination; that's not a threat. This is a free country and people can leave; there is free will. The resident could not be held at the hospital any longer, so we found the fastest way to get her out of there. We asked her to bring a family member to sign her out for her safety. I told them to give her a day or two, sometimes the resident's say they want to leave but need time to adjust. Review of AMA (Against Medical Advice) Form - Release of Responsibility for Discharge (completed for R569) Dated 8/10/22, Time: 1pm Form is signed by R569 and witnessed by V17 (Social Services Director) Form reads: Authorization must be signed by the resident, or by the nearest relative when the resident is physically or mentally incompetent. Facility AMA - Against Medical Advice Policy (undated) reads: It is the policy of the facility to administer care and treatment to the residents according to physician orders and care plans based on assessments and observations of the nursing home staff and other appropriate providers. If the resident decided to leave the facility for whatever reason while at a time in the course of their stay where their physician and other disciplines in the facility feel that it is not recommend as being in the best interest or welfare of the resident, this is considered leaving AMA or Against Medical Advice. Should this desire on the part of the resident be expressed, the following should happen: Procedure: 1) As soon as the resident expresses a desire to leave AMA, appropriate leadership staff to include the Administrator/DON/SSD and the physician or Nurse Practitioner as available should meet with the resident in an effort to discover the reason why the resident is wanting to leave. Note: Examples of reasons residents might choose to leave AMA include, but are not limited to .b) they change their mind about being a nursing home resident . 2) When possible to discern the reason they desire to leave, the appropriate facility staff will help them formulate a plan that can address and lessen or even possibly solve their issue of concern. 3) If they are adamant on leaving, be sure that the risks of their leaving against medical advice are clearly explained to include possible negative outcomes when the services, care, treatments and whatever they will not be receiving if they leave - are no longer available to them. This must be clearly documented. 4) If they are not their own representative, their representative should be involved in a care plan meeting prior to the resident leaving . 5) The resident has the right to leave the facility. The facility will ensure that leaving is an informed decision as much as possible. The facility will be respectful of the resident's decisions. 6) All discharge paperwork will be completed to include the discharge summary information. The related doctor's orders will be followed. This will include assisting in making any follow up appointments arranging for any ordered Home Health and disposition of meds/prescriptions per policy . Note: Detailed timely and accurate documentation must be done on any resident who chooses to leave AMA. The AMA form must be completed and copies of all documents given to the resident must be kept on file at the facility.