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